Form Schedule D (Form 9 Schedule D (Form 9 Supplemental Financial Statements

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SCHEDULE D
(Form 990)

OMB No. 1545-0047

Supplemental Financial Statements

2012

▶ Complete

Department of the Treasury
Internal Revenue Service
Name of the organization

if the organization answered “Yes,” to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b.
▶ Attach to Form 990. ▶ See separate instructions.

Open to Public
Inspection

Employer identification number

DRAFT AS OF
June 5, 2012
DO NOT FILE

Part I

Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the
organization answered “Yes” to Form 990, Part IV, line 6.
(a) Donor advised funds

(b) Funds and other accounts

1
2
3
4
5

Total number at end of year . . . . .
Aggregate contributions to (during year) .
Aggregate grants from (during year) . .
Aggregate value at end of year . . . .
Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization’s property, subject to the organization’s exclusive legal control? . . . . . .

Yes

No

6

Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be used
only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose
conferring impermissible private benefit? . . . . . . . . . . . . . . . . . . . . . .

Yes

No

Part II
1

2

Conservation Easements. Complete if the organization answered “Yes” to Form 990, Part IV, line 7.

Purpose(s) of conservation easements held by the organization (check all that apply).
Preservation of land for public use (e.g., recreation or education)
Preservation of an historically important land area
Protection of natural habitat
Preservation of a certified historic structure
Preservation of open space
Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation
easement on the last day of the tax year.
Held at the End of the Tax Year

a
b
c
d
3
4
5
6

Total number of conservation easements . . . . . . . . . . . . . . . . .
2a
Total acreage restricted by conservation easements . . . . . . . . . . . . . .
2b
2c
Number of conservation easements on a certified historic structure included in (a) . . . .
Number of conservation easements included in (c) acquired after 8/17/06, and not on a
historic structure listed in the National Register . . . . . . . . . . . . . . .
2d
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during the
tax year ▶
Number of states where property subject to conservation easement is located ▶
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of
violations, and enforcement of the conservation easements it holds? . . . . . . . . . . . . .

Yes
Staff and volunteer hours devoted to monitoring, inspecting, and enforcing conservation easements during the year

No

▶

7
8
9

Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
▶$
Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)
(i) and section 170(h)(4)(B)(ii)? . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes
No
In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes the
organization’s accounting for conservation easements.

Part III
1a

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered “Yes” to Form 990, Part IV, line 8.

If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet
works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of
public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items.

b If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet
works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of
public service, provide the following amounts relating to these items:

2

(i) Revenues included in Form 990, Part VIII, line 1 . . . . . . . . . . . . . . . . ▶ $
(ii) Assets included in Form 990, Part X . . . . . . . . . . . . . . . . . . . . ▶ $
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958) relating to these items:

a Revenues included in Form 990, Part VIII, line 1
b Assets included in Form 990, Part X . . . .

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For Paperwork Reduction Act Notice, see the Instructions for Form 990.

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Cat. No. 52283D

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▶
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$
$
Schedule D (Form 990) 2012

Page 2
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)

Schedule D (Form 990) 2012

Part III
3

Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its
collection items (check all that apply):
a
b
c

4
5

Public exhibition
Loan or exchange programs
d
Scholarly research
Other
e
Preservation for future generations
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in Part
XIII.
During the year, did the organization solicit or receive donations of art, historical treasures, or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection? . .
Yes
No

DRAFT AS OF
June 5, 2012
DO NOT FILE

Part IV
1a

Escrow and Custodial Arrangements. Complete if the organization answered “Yes” to Form 990, Part IV,
line 9, or reported an amount on Form 990, Part X, line 21.

Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? . . . . . . . . . . . . . . . . . . . . . . . . . .

b If “Yes,” explain the arrangement in Part XIII and complete the following table:
c
d
e
f
2a
b

No

Yes
.

No

Amount

Beginning balance . . . . . . . . . . . . . . . . . . . . . .
1c
Additions during the year
. . . . . . . . . . . . . . . . . . .
1d
Distributions during the year
. . . . . . . . . . . . . . . . . .
1e
Ending balance . . . . . . . . . . . . . . . . . . . . . . .
1f
Did the organization include an amount on Form 990, Part X, line 21? . . . . . . . . . . . . .
If “Yes,” explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII .

Part V

Yes

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Endowment Funds. Complete if the organization answered “Yes” to Form 990, Part IV, line 10.
(a) Current year

(b) Prior year

(c) Two years back

(d) Three years back

(e) Four years back

1a Beginning of year balance . . .
b Contributions . . . . . . .
c Net investment earnings, gains, and
losses . . . . . . . . . .
d Grants or scholarships . . . .
e Other expenditures for facilities and
programs . . . . . . . . .
f
g
2
a
b
c
3a

Administrative expenses . . . .
End of year balance . . . . .
Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:
%
Board designated or quasi-endowment ▶
Permanent endowment ▶
%
Temporarily restricted endowment ▶
%
The percentages in lines 2a, 2b, and 2c should equal 100%.
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

(i) unrelated organizations . . . . . . . . . . . . . . . . . .
(ii) related organizations . . . . . . . . . . . . . . . . . . .
b If “Yes” to 3a(ii), are the related organizations listed as required on Schedule R?
4
Describe in Part XIII the intended uses of the organization’s endowment funds.

Part VI

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Yes No
3a(i)
3a(ii)
3b

Land, Buildings, and Equipment. See Form 990, Part X, line 10.
Description of property

(a) Cost or other basis
(investment)

(b) Cost or other basis
(other)

(c) Accumulated
depreciation

(d) Book value

1a
b
c
d
e

Land . . . . . . . . . . .
Buildings . . . . . . . . . .
Leasehold improvements
. . . .
Equipment . . . . . . . . .
Other . . . . . . . . . . .
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)

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▶
Schedule D (Form 990) 2012

Page 3

Schedule D (Form 990) 2012

Part VII

Investments—Other Securities. See Form 990, Part X, line 12.
(a) Description of security or category
(including name of security)

(1) Financial derivatives
. . .
(2) Closely-held equity interests .
(3) Other
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
(I)

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(b) Book value

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DRAFT AS OF
June 5, 2012
DO NOT FILE

Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)

Part VIII

▶

Investments—Program Related. See Form 990, Part X, line 13.

(a) Description of investment type

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)

(c) Method of valuation:
Cost or end-of-year market value

Total. (Column (b) must equal Form 990, Part X, col. (B) line 13.)

Part IX

(b) Book value

(c) Method of valuation:
Cost or end-of-year market value

▶

Other Assets. See Form 990, Part X, line 15.
(a) Description

(b) Book value

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)

Total. (Column (b) must equal Form 990, Part X, col. (B) line 15.) .

Part X

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▶

Other Liabilities. See Form 990, Part X, line 25.

1.
(a) Description of liability
(1) Federal income taxes

(b) Book value

(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)

Total. (Column (b) must equal Form 990, Part X, col. (B) line 25.) ▶
2. FIN 48 (ASC 740) Footnote. In Part XIII, provide the text of the footnote to the organization’s financial statements that reports the organization’s
liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII . . . . .
Schedule D (Form 990) 2012

Page 4

Schedule D (Form 990) 2012

Part XI

Reconciliation of Revenue per Audited Financial Statements With Revenue per Return

1
2

Total revenue, gains, and other support per audited financial statements . .
Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains on investments . . . . . . . . . . . .
2a
b Donated services and use of facilities
. . . . . . . . . . .
2b
c Recoveries of prior year grants . . . . . . . . . . . . . .
2c
d Other (Describe in Part XIII.) . . . . . . . . . . . . . . .
2d
e Add lines 2a through 2d . . . . . . . . . . . . . . . . . .
3
Subtract line 2e from line 1 . . . . . . . . . . . . . . . . .
4
Amounts included on Form 990, Part VIII, line 12, but not on line 1 :
a Investment expenses not included on Form 990, Part VIII, line 7b . .
4a
b Other (Describe in Part XIII.) . . . . . . . . . . . . . . .
4b
c Add lines 4a and 4b . . . . . . . . . . . . . . . . . . .
5
Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.)

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1

DRAFT AS OF
June 5, 2012
DO NOT FILE

Part XII
1
2

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2e
3

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4c
5

Reconciliation of Expenses per Audited Financial Statements With Expenses per Return

Total expenses and losses per audited financial statements . . . . . .
Amounts included on line 1 but not on Form 990, Part IX, line 25:
2a
a Donated services and use of facilities
. . . . . . . . . . .
b Prior year adjustments . . . . . . . . . . . . . . . .
2b
c Other losses . . . . . . . . . . . . . . . . . . . .
2c
d Other (Describe in Part XIII.) . . . . . . . . . . . . . . .
2d
e Add lines 2a through 2d . . . . . . . . . . . . . . . . . .
3
Subtract line 2e from line 1 . . . . . . . . . . . . . . . . .
4
Amounts included on Form 990, Part IX, line 25, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b . .
4a
b Other (Describe in Part XIII.) . . . . . . . . . . . . . . .
4b
c Add lines 4a and 4b . . . . . . . . . . . . . . . . . . .
5
Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.)

Part XIII

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2e
3

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4c
5

Supplemental Information

Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part IV, lines 1b and 2b;
Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional
information.

Schedule D (Form 990) 2012

Page 5

Schedule D (Form 990) 2012

Part XIII

Supplemental Information (continued)

DRAFT AS OF
June 5, 2012
DO NOT FILE

Schedule D (Form 990) 2012