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OMB No 1545-1150

Short Form

Return of Organization Exempt From Income Tax


Form

99^^EZ

Department of the Treasury


internal Revenue Service

A For the 2008 calendar year, or tax year beginning


B Check if applicable
Address change

Name change
Ind
retur n

Tenmauon

Amended ratan

Appr

onpendng

Please
use IRS

1=

Website : ^

D Employer identification number


--

_ ^E MEDICINE

SiE_QF__-CIE

pdM or
t ype'
see
specific
Instruc

1475 Mt. Hood Avenue

Sons.

Woodburn , OR 97071

Number and street (or P.O

x:.32

F Group Exemption

Number .
G Accounting method,

not
reCheck Do- 0 if
quired toattachtSchedule Bfi(Form

H
4947 a 1 or

t (insert no. )

Cash Accrual

Other (specify) 10-

Ilfestylemedicme.org
6

5 =>= =''

(pr

E Telephone number

Room/suite

box, if mail is not delivered to street address

City or town, state or country, and ZIP + 4

J Organization type (check only one)- 501 c

, 20

C Name of organization

label or 4^

, 2008, and ending

Section 501 (c)(3) organizations and 4947(a)(1) nonexempt charitable trusts must attach
a completed Schedule A (Form 990 or 990-EZ).

2008

Under section 501 ( c), 527 , or 4947(a)(1) of the Internal Revenue Code
(except black lung benefit trust or pirate foundation)
^ Sponsoring org anizations of donor advised funds and controlling organizations as defined in section
512(bx13) must file Form 990 All other organizations vnth gross receipts less than $1 , 000 , 000 and total
assets less than $2 , 500,000 at the end of the year may use this form.
^ The organiz ation may have to use a copy of this return to satisfy state r ortng requirements.,

990-EZ. or 990-PF)

527

K Check ^ if the organization is not a section 509(aX3) supporting organization and its gross receipts are normally not more than $25,000 A return is
not required, but if the organization chooses to file a return, be sure to file a complete return.
L Add lines 5b 6b, and 7b, to line 9 to determine gross receipts; if $1,000,000 or more, file Form 990 instead of Form 990-EZ

33237

^ $

Revenue, Expe nses, and Chan ges in Net Assets or Fund Balances (See the instruct ions for Part I.
Contributions , gifts , grants , and similar amounts received . . . . . . . . . . . . . .
Program service revenue including government fees and contracts . . . . . . . . .
Membership dues and assessments
. . . . . . . . . . . . . . . . . . . .
Investment income . . . . . . . . . . . . . . .
. . . . .
5a
Gross amount from sale of assets other than inventory . . .
5b
Less: cost or other basis and sales expenses . . . . _ .
Gain or (loss) from sale of assets other than inventory (Subtract line 5b from line 5a) (attach schedule) .
Special events and activities (complete applicable parts of Schedule G). If any amount is from gaming , check here ^
of contributions
Gross revenue (not including $
6a
reported on line 1 )
. . . . . . . . . . . . . . . .
6b
b Less: direct expenses other than fundraising expenses . . .
c Net income or (loss) from special events and activities (Subtract line 6b from line 6a) . .
7a
7a Gross sales of inventory , less returns and allowances
. . . .
7b
b Less: cost of goods sold . . . . . . . . . . . . . .

I
2
3
4
5a
b
c
6
a
cc

8
9
10
11
12
13

14

15
16
17

c
18
19
a
20
21

'a

L -22
23
t24
25
26
27

c Gross profit or (loss) from sales of inventory (Subtract line 7b from line 7a)
Other revenue (describe ^
Total revenue . Add lines 1, 2, 3, 4, 5c, 6c, 7c, and 8.
Grants and similar amounts paid (attach schedule)
. . . . .
Benefits paid to or for members . . . . . . . . . . . .
Salanes, other compensation , and employee benefits
. . . .
Professional fees a
other payments to independent contractors
Occupancy , rent , ilities , p- s
Printing
g , publicatlo s ,
e
T
Other expenses ( `r' be ^ S
Total expenses. ad lin
h
16

.
.
.

.
.
.

.
)
. ^

.
.
.

.
.
.

.
.
.

.
.
.

.
.
.

.
.
.

10000

2
3
4
-

23065
172

5C

6c

7c
8
9
10
11

33237

10013

12
13

14
)
110-

Excess or (deficit fbi the year (Sub


e 1
m line 9) . .
Net assets or fu d b
t^egi
n of
r (from line 27, column (A)) (must agree
end-of-year figu
y
etu ) . . . . . . . . . . . . . .
Other changes in net assets or
a ach explanation) . . . . . . . .
Net assets or fund balances at end of year. Combine lines 18 through 20 .
Balance Sheets . If Total assets on line 25, column (B) are $2,500,000 or more, file Form

(See the instructions for Part II.)


. . . . . . . .
Cash , savings , and investments
Land and buildings . . . . . . . . . . . . .
Other assets (describe ^
Total assets . . . . . . . . .
. . .
Total liabilities (describe ^ SEE STATEMENT
Net assets or fund balances (l ine 27 of colum n ( B) must

5403
15416
17821

16
17
18

with -----336
19
. .
.
17485
^
21
990 instead of Form 990-EZ.
(B) End of year

(A) Beginning of year

4664 22

.
)

.
)

24
4664 25
5000 26
-336 27

agree with line 21)

For Privacy Act and Paperwork Reduction Act Notice , see the Instruction for Form 990.

20485

231

Cat No 106421

20485
3000
17485
Form 99U -LZ (2008)

Page 2

From 99n-EZ 120081

ON=

Expenses

Statement of Prog ram Service Accom plishments (See the instructions for Part III.

What is the organization's primary exempt purpose? Bus. Asso. of Doctors


Describe what was achieved in carrying out the organization ' s exempt purposes. I n a c l ear an d conc i se manne r ,

describe the services provided, the number of persons benefited, or other relevant information for each program title.
;
28 Training, educating physician in health medicine techniques __________________________________

(Required for 501(cx3)


and (4) organizations
an d 4947(aXl) trusts ;
optional for others.)

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------^
Grants $
If this amount includes foreign grants , check here

28a

29 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------^
If this amount includes forei g n g rants , check here
Grants

29a

30 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------^
Grants $
If this amount includes forei gn grants , check here 31 Other program services (attach schedule) . . . . . . . . . . . . . . . . . . . . .
^
(Grants $
If this amount includes foreign grants , check here
. ^
32 Total program service expenses (add lines 28a through 31a)
JZMMt

15416

30a
31a
32

15416

List of Officers. Directors, Trustees, and Key Employees. List each one even if not compensated. (See the Instructions for Part IV)
(e) Expense
(d) Contributions to
(c) Compensation
(b) Title and average
(a) Name and address

hours per week


devoted to position

Of not paid,
enter -0-.)

mployee benefit plans 8


deterred compensation

account and
other allowances

See List

Form 990 EZ (2ooe)

Page 3

Form 990-EZ (2008)

statement requirements in the instructions for Part VI


33 `Did the organization engage in any activity not previously reported to the IRS? If "Yes," attach a detailed
description of each activity
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
34 Were any changes made to the organizing or governing documents but not reported to the IRS? If "Yes,"
attach a conformed copy of the changes
. . . . . . . . . . . . . . . . . . . . . .
35 If the organization had income from business activities, such as those reported on lines 2, 6a, and 7a (among others), but
not reported on Form 990-T, attach a statement explaining your reason for not reporting the income on Form 990-T.
a Did the organization have unrelated business gross income of $1,000 or more or section 6033(e) notice, reporting,
and proxy tax requirements ? . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b If "Yes," has it filed a tax return on Form 990-T for this year?
. . . . . . . . . . . . . . .
36
37a
b
38a
b
39
a
b
40a
b

c
d

33

34

35a
b

Was there a liquidation, dissolution, termination, or substantial contraction during the year? If "Yes,"
36

complete applicable parts of Schedule N


. . . . . . . . . . . . . .
37a
0
i
Enter amount of political expenditures, director indirect, as described in the instructions . ^
37b

Did the organization file Form 1120-POL for this year? . . . . . . . . . . . . . . . . . . .


Did the organization borrow from, or make any loans to, any officer, director, trustee, or key employee or were
any such loans made in a prior year and still unpaid at the start of the period covered by this return? . . .

If "Yes," complete Schedule L, Part II and enter the total amount involved
. . . . 38113
Section 501(c)(7) organizations. Enter
Initiation fees and capital contributions included on line 9
:
Gross receipts, included on line 9, for public use of club facilities
..!
. . . . . . . .
Section 501(c)(3) organization Enter amount of tax imposed on the organization during the year under:
section 4911 ^
;section 4912 ^
; section 4955 ^
Section 501 (c)(3) and (4) organizati s. Did the organization engage in any section 4958 excess benefit transaction
during the year or did it become awar of an excess benefit transaction from a prior year? If Yes," complete Schedule
T4Obr
L, Part I . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . .
Enter amount of tax imposed on orga ation managers or disqualified persons during
the year under sections 4912, 4955, an 4958 . . . . . . . . . . . . .
^
Enter amount of tax on line 40c reimburs
by the organization . . . . . . . . ^

e All organizations. At any time during the


ear, was the organization a party to a prohibited tax shelter
.
40e
transaction? If `Yes," complete Form 8886. . . . . . . . . . . . . . . . . . . . .
41
List the states with which a copy of this return is filed ^ California
42a The books are in care of ^ _ Dr.-Braman
Telephone no. ^ ------ ----------__-----__
Located at ^ Addresspa9e I-------------------------------------------------------------ZIP + 4 ^ ----------------------------------------------------------------------------b At any time during the calendar year, did the organization have an interest in or a signature or other authonty
Yes No
over a financial account in a foreign country (such as a bank account, securities account, or other financial
42b

account)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Y
If "Yes," enter the name of the foreign country: ^
See the instructions for exceptions and filing requirements for Form TD F 90-22.1, Report of Foreign Bank
and Financial Accounts.
42c

c At any time during the calendar year, did the organization maintain an office outside of the U.S.?
. .
43

If "ryes," enter the name of the foreign country: ^


Section 4947(a)(1) nonexempt charitable trusts filing Form 990-EZ in lieu of Form 1041 -Check here
. . .
and enter the amount of tax-exempt interest received or accrued during the tax year . . . . . ^ 143 I

Yes No
44
45

Did the organization maintain any donor advised funds? If "Yes," Form 990 must be completed instead of
Form 990-EZ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Is any related organization a controlled entity of the organization within the meaning of section 512(b)(13)? If
"y'es." Form 990 must be completed instead of Form 990-EZ
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

-44

45

Form 990-EZ (2008)

Form g90-EZ (2008)

Page 4

must answer quest

Section 501 (b (3) organizations only. All section 501


and complete tke tables for lines 50 and 51.

in direct or indirect political campaign activities on behalf of or in opposition to


Did the organization enga
candidates for public office f "Yes," complete Schedule C, Part
47 Did the organization engage i obbying activities? If "Yes," Complete Schedule C, Part II . . . . . .
48 Is the organization operating a s' ool as described in section 170(b)(1)(A)()? If "Yes," complete Schedule E
. . . . .
49a Did the organization make any tra fens to an exempt non-charitable related organization?
b If "Yes," was the related organizatio s) a section 527 organization ?
. . . . . . . . . . . . .
50 Complete this table for the five high
compensated employees (other than officers, directors, trustees and
pensation from the organization. If there is none, enter "None."
each received more than $100,000 of

Yes No

4,6

(a) Name and address of each employee paid more


than $ 100,000

(c) Compensation

(b) Title and average


hours per week
devoted to position

47
48
49a
49b

.
.
key employees) who

(d) Contributions to
employee benefit plans &
deferred compensation

(e) Expense
account and
other allowances

--------------------------------------------------------------

--------------------------------------------------------------

--------------------------------------------------------------

--------------------------------------------------------------

---------------------------------------------------------------

Total number of other employees paid over $100,000 ^


51

Complete this table for the five highest compensated independent oo


compensation from the organization . If there is none, enter "None."

ctors who each received more than $100,000 of

(a) Name and address of each independent contractor paid more than $ 100,000

(b) Type of service

(c) Compensation

------------ ------------------------------------------------------------------------------- ----

------------ ------------------------------------------------------------------------------- --------

------------ ------------------------------------------------------------------------------- --------

------------ ------------------------------------------------------------------------------- --------

------------ ------------------------------------------------------------------------------- --------

Total number of other independent contractors each receiving over $ 100,000

. ^

Under penalties of pequry, I declare that I have examined this return , including accompanying schedules and statements, and to the best of my knowledge
and belief , it i

true, correct , and complete . Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge-

Sign
signatu re of officer

Here

W"AW
' Type or pnnt name and tit le.
Preparer's
signature

Paid
Pmm
Use Only

nrm 's name (or yours


if self-employed).
address, and ZIP + 4

34629 Q=ina Tr,


Ca .
63$

Ia MLrada

May the IRS discuss this return with the oreoarer shown above?

Page 1 of 3

LCarl Corsi
From:

Kathy Cater [kcater@fifestylemedicine.org]

Sent:

Friday, February 27, 2009 3:52 PM

To:

Carl Corsi

Subject : ACLM requested information

Dear Mr. Corsi,


Here is the information you requested for our tax statement. I have not heard from all of our board
members. Can we use an average time for them?

We had an election in May that was finalized in June. At that point, some members were added, and in
the case of John Kelly, his official status changed from President to Immediate Past President.
John Kelly

Presidendlmmediate Past President


For 2008
Jan - 8h
Feb - 8h
Mar-8h
Apr - 9h
May - 10h
Jun - 9h
Jul - 9h
Aug-12h.
Sep - 20h
Oct - 8h
Nov - l0h
Dec - 9h

Total 120h
467 Misty Lane
Boones Mill, VA 24065
Marc Braman
Secretary/President
Estimated hours per month: 50
1475 Mt. Hood Ave
Woodburn, OR 97071
Wayne Dysinger
President Elect

Estimated hours per month: 8


24785 Stewart Street. EH 101

Page 2 of'3

Gordon Betting
Treasurer

401 Taylor Blvd


Pleasant Hill , CA 94523
Hans Diehl
Director
Estimated hours per month: 15
11538 Anderson Street
Loma Linda, CA 92354
Joel Fuhrman
Director
22 Buchanan Way
Flemington , NJ 08822
Wes Youngberg
Director
43183 Corte Cabrera
Temecula , CA 92592
John Westerdahl
Director
Estimated hours per month: 3
Bragg Health Foundation
199 Winchester Canyon Rd
Santa Barbara, CA 93117

Ron Stout
Director (added in June election)
Estimated hours per month: 8
8700 Mason Montgomery Rd
Mason , OH 45040

Greg Steinke
Young Director (added in June election)

25231 La Mar Rd Apt C


Loma Linda, CA 92354
Liana Lianov
Director ('added in June election)
Estimated hours per month: 2

rage 1 01 r

.Carl Corsi
From :

Kathy Cater [kcater@lifestylemedicine.org]

Sent:

Sunday, March 01 , 2009 4:03 PM

To:

Carl Corsi

Subject : Fwd: ACLM tax statement information needed from 2008 board members

Hi Mr Corsi,
Here is one more board member's estimate of hours spent.
Kathy
Begin forwarded message:
From : Greg Steinke <greg_steinke@gmail com>
Date : March 1, 2009 11:10:15 AM PST
To: Kathy Cater <kcater@ifestylernedicine_ org>
Subject : Re: ACLM tax statement information needed from 2008 board members

I estimate 2 hours per month so far.

Greg.
On Wed, Feb 25 , 2009 at 2 :27 PM. Kathy Cater <kcater0a lifcstylemedicine _ org> wrote:
Greetings,
Mr. Carl Corsi is preparing our tax statement, and needs an estimate of time spent on
ACLM from each of our 2048 board members . He suggested a monthly estimate/average
number of hours spent.
If you would send your best approximation to tne, I will compile it with all the
information Mr. Corsi has requested.
Thank you,

Kathy

kcatcrtc lifcstylcmedicinc.org
American Collc L c of Lifestyle Medicine
c/o Wellspring Medical Centci
1475 Mt Hood Ave.
Woodbuni. OR 9707 i
9 71-9S I-538_;

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Home

What Is Lifestyle Medicine?

Baard of P.d V11^L5

Abcu: ACIM

Find a Memoer

Membership

Education

Events

^n^,. ^.A

ACLM News

Contact

I ors-2Lett4L5

About ACLM
The American College of Ufestyle Medicine (ACLM) Is a new national medical specialty
society. It has been formed In answer to the need for quality education and certification of
the practice In clinical lifestyle medidne.
As the ffnt national specialty society for clinicians emphasizing the use of lifestyle
interventions In the treatment and management of disease , the ACLM Is currently working
to develop formal recognition for this important field of medical practice and research. In
the future, It Is the goal of the ACLM to establish an official Board of Lifestyle Medicine that
wi'I grant board certification In Ufestyle Medfdne.
Formed in 2004 in California, the ACLM has member's across the United States and international membership Is growing
rapIdly. The value of Ufestyle Medicine is becoming recognized by all aspects of medical practice. and ACIM members
represent the broad diversity of the medical profession. Members Include primary care physicians, specialists, researchers,
professors, students, public spokespersons, hospital administrators, nutritionists, pu'Jtic health professionals, and many
others.

;rl, ti AC.'

American College of Lifestyle Medicine


I',.veied by s/I d Apnr;'t - Membe,sh c nan^oe'r'.^nt datah.I c' Online event renistratia.,
mteqra.ed wt'[)-, to fo ^,noc nt c, s cI^ h5, rhr.lirirs and other non-p outs

http ://www.lifestylemedicine . org/aboutA.CLM

2/25/2009

Amrican 00 lege of T i festy a MBdicine:

501 (c) (6) entity.

32

0204851

SIYXIDM RE OIHER FMS:

1 fees, serums:(
riaa.irg, gr hics

Tn site

1080
1048
2400

Various fees, aaypal, lark etc

312

Office sullies, voice nail

563

total casts

5403

SDi'IE tEN OF PLUOCNIS PA)ME LM: $ 3000. Involves a loan frmn an officer of
this entity, which is being said laic by AQM at $ 10M per month.
It is an in^t free lean, nada wIm the entity was in effect
area, and men ri smL- flans.
starting up in a r

Fonn

Short Form
Return of Organization Exempt From Income Tax

990-EZ

A For the 2011 calendar year, or tax year beginning


C Nameof orqamzatcn
B Checkd applicable,

Imtlal return

Termmated

~(Q)11

Under section 501(c), 527, or 4947(a)(1)of the Internal Revenue Code


(except black lung benefit trust or private foundation)
... Sponsoringorganizationsof donor advisedfunds, organizationsthat operateone or more hospitalfacllllles,
and certain controllingorganizationsas defined In section 512(b)(13)mustfile Form990 (see instructions)
All other orqsmzanonawith gross receiptsless than $200,000and total assets less than $500,000
at the end of the year may use this form
... The 0 emzsuon ma have to use a co of this return to ssns state re ortm re uuements

Departmentof theTreasury
InternalRevenueService

o Addresschange
o Namechange
D
o
oo Amended
return
Application
pending

OMB No 1545-1150

American

Open to Public
Inspection

,2011, and ending

,20

o Employer

College of Lifestyle

Medicine

Numberand street (or PObox, If mau is not deliveredto street address)

Identification number

32-0208451

Room/SUite

E Telephone number

612 Glatt Circle

971-983-5383

City or town, state or country,and ZIP + 4

F Group Exemption
Number

Woodburn,

G Accounting Method,

IX! Cash

...

Oregon 97071

o Accrual

Other (specify) ...

I Website: ... lifestylernedicine.org


J Tax-exempt status (check only one) - 0 501 (c)(3) 00501 (c)(

6 )....
(Insert no ) 0

4947(a)(1) or

0527

H Check ... 00 if the organization IS not


required to attach Schedule B
(Form 990, 990-EZ, or 990-PF),

K Check"
0
If the crqaruzatron IS not a section 509(a)(3) supporting organization or a section 527 organization and its gross receipts are normally
not more than $50,000, A Form 990-EZ or Form 990 return IS not required though Form 990-N (e-postcard) may be required (see instructions) But If
the organization chooses to file a return, be sure to file a complete return,
L Add lines 5b, 6c, and 7b, to line 9 to determine gross receipts If gross receipts are $200,000 or more, or If total assets (Part II,
line 25, column (8) below) are $500,000 or more, file Form 990 Instead of Form 990-EZ

Id.1
1
2
3
4
5a
b
c
S
a
(II

::::I

e
GI
>
(II

a::

III
(II

III

e
(II

Q.
)(

III
III

...

18
19

20
21

hk(:

1,~~1~
.

'1

;\t
Sd
h

'E 0' ,',


ocr.F\V, '"

,'w,

Gross sales of inventory, less returns and allowances


7a
"
I';
Less' cost of goods sold
I 7b I
Gross profit or (loss) from sales of inventory (Subtract line 7b from line 7a) , ,
7c
,
8
Other revenue (descnbe In Schedule 0) , , , , , "
Total revenue. Add lines 1,2,3,4, 5c, 6d, 7c, iaa a
9
Grants and Similar amounts paid (list in Schedu e O~:--:-, ,
10
11
Benefits paid to or for members , , , , , -g,
, , 1 S 20W, '
12
Salaries, other compensation, and employee be t!{fj~"
~
13
Professional fees and other payments to indepe ~ t contrastgrs ,14
Occupancy, rent, utilities, and maintenance
\
Printing, publications, postage, and shippmq
._
15
Other expenses (describe In Schedule 0)
1S
Total expenses. Add lines 10 through 16
17
Excess or (deflcit) for the year (Subtract line 17 from line 9)
18
Net assets or fund balances at beginning of year (from line 27, column (A (must agree with ~,~
end-of-year figure reported on prior year's return)
19
Other changes in net assets or fund balances (explain In Schedule 0) ,
20
Net assets or fund balances at end of year, Combine lines 18 through 20
.... 21

For Paperwork
ISA

>

I
I

c(

(II

"

Gross income from fundrarsmq events (not including $


of contributions
from fundraising events reported on line 1) (attach Schedule G if the
sum of such gross income and contributions exceeds $15,000) ,
ISb
c Less: direct expenses from gaming and fundraislng events
I Sc I
d Net income or (loss) from gaming and fundraising events (add lines 6a and 6b and subtract
-line 6c)

17
.I!l
(II

sal

7a
b
c
8
9
10
11
12
13
14
15
1S

14 1, 84 6

... $

Revenue, Expenses, and Changes in Net Assets or Fund Balances (see the instructions for Part I.)
Ch ec k Ilf th e orgamza
izat Ion use d Sc he d ue
lOt o respon d to any ques tion
Ion iIn thiIS Pa rt I
IX!
Contributions, gifts, grants, and Similaramounts received
1
93,271
Program service revenue including government fees and contracts
2
46,278
Membership dues and assessments ,
3
Investment income
4
Gross amount from sale of assets other than inventory
l
. (~';
~...\(~.:,'
Less: cost or other basis and sales expenses ,
I 5b I
0
Gain or (loss) from sale of assets other than inventory (Subtract line 5b from line 5a)
5c
4",:--tt,'''''
Gaming and fundraising events
Gross Income from gaming (attach Schedule G if greater than
Y, }
"' ).
$15,000) ,
I Sa

....

0
2,297
141,846

U1 ,- '1 '
OGOE\\\'. ' - ,

....

Reduction

Act Notice, see the separate instructions.

38,128
9,317
6,728
497
82,871
137,541
4,305
9,040
13,345
Form 990-EZ

(2011)

-r.

Page 2

Form990EZ(2011)

IGIII

Balance
Sheets. (see the instructions
Check if the organization
used Schedule

for Part II.)


0 to respond

to any ques Ion in this Part II


(A) Beginningof year

22
Cash, savings, and investments
23
Land and buildings
24
Other assets (describe in Schedule 0)
25
Total assets
26
Total liabilities (describe in Schedule 0)
27
Net assets or fund balances (line 27 of column (8) must agree with line 21)
1::F.T11111
Statement
of Program Service Accomplishments
(see the instructions

9,040
9,040
9,040

(8) Endof year

22
23
24
25
26
27

13,345
13,345
13,345

for Part III.)

Expenses
____
....:C:..:h..:.:e:..:c..:.:k~if:....;t:..:h.=.e...:o..:"rg"'"'a:..:n....:lz::.:a....:ti:..:o....:n...:u:..:s.=.e.:;_d...:S...:c....:h.:;_ed.:...u:..:l,:_e...:O_t....:o-:,r.::..e..::.Jsp,,-lo=-:n_:d_t:..:o...
(Requiredfor section
What is the organization's primary exempt purpose?
Medical education
501(c)(3)and501(c)(4)
organizationsand section
Describe the organization's
program service accomplishments
for each of its three largest program services,
4947(a)(1)trusts;optional
as measured by expenses, In a clear and concise manner, desenbe the services provided, the number of
for others.)
persons benefited, and other relevant information for each program title.
28

29

30

31 Other program services (describe in Schedule 0)


(Grants $
) If this amount includes foreign grants, check here
.... D
31a
32 Total program service expenses (add lines 28a through 31a)
....
32
1:lffiIL'JI
List of Officers, Directors, Trustees, and Key Employees. List each one even If not compensated. (see the instructions for Part IV)
Check If the organization
used Schedule 0 to respond to an" question In this Part IV
. . . . . .
D
(e) Reportable
(d) Healthbenefits,
(b)Title and average
compensation
contributionsto employee (e) Estimatedamountof
(a) Nameand address
hoursperweek
devotedto positron (FormsW211099MISC) benefitplans,and
othercompensation
(If not paid, enter 0) deferredcompensation

Liana Lianov
--------------------------------------------------------------------------

President

David L. Katz
--------------------------------------------------------------------------

Pres Elect

1
~.i?:y.I].~
...Qy.~.~!!_g~E........................................Pas t Pre s
1

.~~E.g~
...~.~!:bEJ:.E?........................................ Sec /Trea s
1

o
o
o
o

o
o
o
o

o
o
o
o

Form 990-EZ (2011)

'C"

Form 990-EZ (2011)

Page

Other Information (Note the Schedule A and personal benefit contract statement requirements in the
instructions for Part V.) Check if the organization used Schedule 0 to respond to any question in this Part V

IX!

Yes No
33

Old the organization engage in any significant activity not previously reported to the IRS? If "Yes," provide a
detailed description of each activity in Schedule 0

Were any significant changes made to the organizing or governing documents? If "Yes," attach a conformed
copy of the amended documents If they reflect a change to the organization's name. Otherwise, explain the
change on Schedule 0 (see Instructions)
35a Did the organization have unrelated business gross income of $1,000 or more during the year from business
activities (such as those reported on lines 2, 6a, and 7a, among others)?

33

34

35a

34

b
C

36

If "Yes,"to line35a,hasthe organizationfileda Form990-T for the year?If UNo,"providean explanationin Schedule0
1-'3;_;5;.;;:b+-_-I-_
Was the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization subject to section 6033(e) notice,
reporting, and proxy tax requirements during the year? If "Yes," complete Schedule C, Part III
35c
X
Did the organization undergo a liquidation, dissolution, termination, or significant disposition of net assets
during the year? If "Yes," complete applicable parts of Schedule N
36
X

37a Enter amount of political expenditures,direct or Indirect,as describedIn the instructions. .... 1'-'3:....:7....:a:...JI 0-l
37b
b Did the organization file Form 1120-POL for this year?
38a Did the organization borrow from, or make any loans to, any officer, director, trustee, or key employee or were
any such loans made in a prior year and stili outstanding at the end of the tax year covered by this return?
38a
b
39
a
b
40a
b

d
e
41

_j
X

_j
X

If "Yes," complete Schedule L, Part II and enter the total amount involved
38b
1--;------1
Section 501(c)(7) organizations. Enter:
__
Initiation fees and capital contributions included on line 9
1-'3:....:9:.=a+--I
Gross receipts, included on line 9, for public use of club facihties
'-'3:....:9;.;;:b:...J.... --I
Section 501(c)(3) organizations. Enter amount of tax Imposed on the organization during the year under:
section 4911 ....
, section 4912....
, section 4955 ....
Section 501(c)(3) and 501(c)(4) organizations Did the organization engage in any section 4958 excess benefit ----transaction dunng the year, or did It engage In an excess benefit transaction in a pnor year that has not been
reported on any of Its prior Forms 990 or 990-EZ? If "Yes," complete Schedule L, Part I
40b
Section 501(c)(3) and 501(c)(4) organizations. Enter amount of tax imposed on
organization managers or disqualified persons during the year under sections 4912,
4955, and 4958 .
....
Section 501(c)(3) and 501(c)(4) organizations. Enter amount of tax on line 40c
reimbursed by the organization
....
All organizations. At any time during the tax year, was the organization a party to a prohibited tax shelter
----transaction? lf 'Yes." complete Form 8886-T.
40e
List the states with which a copy of this return ISfiled. ....

-----------------~~~~~~~~
2~7~Q-7T::-96-7-5-----

The organization's books are in care of ....!'::1-'?:E_<?:.


__.!?_~~~!._l_________________________________ Telephone no. ....97 1- 9 8 3 - 5 3 8 3
Located at ....
f_~E_<?:.~._L __~~s?_s!~_I}._~!._l_!_ Q~._g~_I)_______________ ZIP + 4....
------b At any time dunng the calendaryear, did the organizationhave an interest in or a signatureor other authority over
Yes No
a financial account in a foreign country (suchas a bank account,secunnesaccount,or other financial account)?
X
42b

42a

_?J~ ~J~!:_t

If "Yes," enter the name of the foreign country: ....


See the instructions for exceptions and filing requirements for Form TO F 90-22.1, Report of Foreign Bank
and Financial Accounts.

_J

-- --At any time dunng the calendar year, did the organization maintain an office outside the U.S.? .
X
42c
If "Yes," enter the name of the foreign country ....
43
Section 4947(a)(1) nonexempt charitable trusts filing Form 990-EZ in lieu of Form 1041-Check here
....
.... 0
and enter the amount of tax-exempt interest received or accrued during the tax year
.... 143
Yes No
Did
the
organization
maintain
any
donor
advised
funds
dunnq
the
year?
If
"Yes,"
Form
990
must
be
44a
--- -- _j
completed instead of Form 990-EZ
X
44a
Old
the
organization
operate
one
or
more
hospital
facilities
during
the
year?
If
"Yes,"
Form
990
must
be
b
--- -completed instead of Form 990-EZ
X
44b
X
c Old the organization receive any payments for indoor tanning services during the year?
44c
d If "Yes" to line 44c, has the organization filed a Form 720 to report these payments? If "No," provide an -_j
-explanation in Schedule 0
44d
45a Did the organization have a controlled entity within the meaning of section 512(b)(13)?
X
45a
45b Did the organization receive any payment from or engage in any transaction with a controlled entity within the
meaning of section 512(b)(13)? If "Yes," Form 990 and Schedule R may need to be completed instead of
-- -Form 990-EZ (see instructions) .
45b
X
c

_I

___
J

Form

990-EZ

(2011)

Form990-EZ(2911)

Page4
Yes

46

Old the organization engage, directly or indirectly, in political campaign activities on behalf of or in opposition
to candidates for public office? If "Yes," complete Schedule C, Part I . . . . . .

No

,,~

ITs--

Section 501(c)(3) organizations


and section 4947(a)(1) nonexempt
charitable
trusts only. All section
501 (c)(3) organizations
and section 4947(a)(1) nonexempt charitable trusts must answer questions 47-49b
and 52, and complete the tables for lines 50 and 51.
Ch ec k If t h e orqaruza
. tlIon use d S c he d uelOt o respon d t o any ques tion
Ion lIn thiIS P a rt VI
D
Yes No
Did the organization engage in lobbymq activities or have a section 501 (h) election in effect during the tax
year? If "Yes," complete Schedule C, Part II
47
Is the organization a school as descnbed in section 170(b)(1)(A)(ii)? If "Yes," complete Schedule E
48
Did the organization make any transfers to an exempt non-charitable related organization?
49a
If "Yes," was the related organization a section 527 organization?
49b
Complete this table for the organization's five highest compensated employees (other than officers, directors, trustees and key
employees) who each received more than $100,000 of compensation from the organization. If there IS none, enter "None."
(d)Healthbenefits,
(b)Titleandaverage
(c)Reportable
contnbunons to employee (e)Estimatedamountof
(a)Nameandaddressof eachemployee
hoursperweek
compensation
paidmorethan$100,000
(FormsW-2/1099-MISC)benefitplans,anddeferred othercompensation
devotedto posinon
compensation

l::Iffiia'JI

47
48
49a
b

50

51

Total number of other employees paid over $100,000


. . . . ...
_
Complete this table for the organization's five highest compensated independent contractors who each received more than
$100,000 of compensation from the organization If there IS none, enter "None."

(a)Nameandaddressof eachIndependent
contractorpaidmorethan$100,000

(b)Typeof service

(e) Compensation

d Total number of other independent contractors each receiving over $100,000


. . ...
_
52
Old the organization complete Schedule A? Note' All section 501 (c)(3) organizations and 4947(a)(1)
nonexempt charitable trusts must attach a completed Schedule A . . . .
. ... DYes
D No
Underpenaltiesof perjury, I declarethatI haveexaminedthiSretum,includingaccompanying
schedulesandstatements,andto thebestof myknowledgeandbelief,It IS
true,correct,andcompleteDeclaration of preparer(otherthanofficer)ISbasedonall informationof whichpreparerhasanyknowledge

S-/~-I:;2..
Sign
Here

~ Signatureof officer

Paid

Pnnvrypepreparer'sname

Executive
~ Marc
Braman,
Typeor pnntnameandtitle

Date
Director
PTIN

Preparer~T~h~e~o~d~o~r~e~R~._A~h~r~e-=
__ ~~~~~~
__ ~~~~~~~~~~~~~P~0~0~0~6~4~0~8~2~
UseOnly~F~lr~m~'s~n=am~e~~~_T~h~e~o~d~o_r~e~~~_~r_e_,~~_~
~=-~~~ __ ~~~~~~~~~~~
__
Flrm'saddress~576 Glatt
rcle,
Woodburn,
OR 97071
May the IRS discuss this return With the preparer shown above? See instructions
Form990-EZ

(2011)

SCHEDULED
(FonY:I990 or 990-EZ)
Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ


Complete to provide information
for responses to specific questions
Form 990 or 990-EZ or to provide any additional information.

~(Q)11
Open to Public
Inspection

~ Attach to Form 990 or 990-EZ.

Name of the orqaruzanon

Employer Identification number

American Colle e of Lifest le Medicine

32-0208451

9_!:0_~_~~~.P.~!l_?.~_~_:_
Y..V_~_~~b__~p

?._~_~.!?_?

Publications

6.291

~_~~X~_~~_~~
~~_!__~!l_9~_I2~_~

~_~};?_?

Insurance
Licenses

_
_

267
54

~_~_~~~_~~_9..

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~_~~_~~_~_~~_I2~9_~~

~_~_Qg_Q

~-~~~---~~-I!~~--~~~~-~~-~----------~~-!-~.:?-!----------

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
ISA

on

OMB No 1545-0047

Schedule 0 (Form 990 or 990-EZ) (2011)

203907/0212013907

AM

990

'Fo~

Return of Organization

A For th e 2012 ca en d ar vear or tax~_ar besinruns


B Check
Ifapplicable C4 Nameof orqaruzauon

Terrmnated

Tax-exempt

Telephone
number

32-0208451
Room/sUite

Woodburn

OR

97071

G Gross
receipts
$

206,180

F Nameandaddress
ofpnncipal officer

I I

status

501(c)(3)

IXI

PartJ

Employer
identificationnumber

971-983-5383

501(c) (

6 )<IlII (Insertno)

lifestylemedicine.org
Website:~
Formoforqamzauon
IXI CorporationI Trust I Assocrauon

612 Glatt Circle

Applicabon
pending

City,townorpostoffice,state,andZIPcode

D Amended
return
D

an d en d'ma

OolngBusiness
As
Number
andstreet(orPObox Ifmaillsnotdelivered
tostreetaddress)

Name
change
Imbalretum

Open to Public
Inspectlc)n

American College of Lifestyle Med

D Address
chan~e

2012

Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung
benefit trust or private foundation)
~ The organization may have to use a copy of this return to satisfy state reporting requirements

Department
oftheTreasury
tntemal
Revenue
Service

OMBNo 154~047

Exempt From Income Tax

I I 4947(a)(1)
or

H(a) IsthiSagroupreturn
foraffiliates? DYes

No

Dyes
H(b) Areallaffiliates
Included?
If"No,"attachalist (seemstrucuons)

No

I I 527

I I Other~

IL

H(c) Groupexemption
number
~
Yearofformaaon
I M StateofleQaldomicile

5 ummary

1 Bnefly descnbe the organization's mission or most significant activities

To offer quality education and certification


lifestyle medicine.

GI

c
ca
c

..
GI

>

0
C!)

011
1/1
GI

:;:;

's
u
<

:;:;

GI

:::I

c
GI

>
GI
a::

6~~

IhrouQ~;r.k.t

GI

D.
)C

~'"
0'"

,!!g

",,,,

:Cii

CfV';,C(~

""'"'-c;:

~~~

VlII,,"" .. ;~~

G""" and"mol" amountspaid(P~\~:'''3\W~

14 Benefits paid to or for members (Part I,


c

in clinical

2 Check this box ~


if the organization discontinued its operations or disposed of more than 25% of Its net assets.
3 Number of voting members of the governing body (Part VI, line 1a)
3
4 Number of Independent voting members of the governing body (Part VI, line 1b)
4
5 Total number of Individuals employed In calendar year 2012 (Part V, line 2a)
5
6 Total number of volunteers (estimate If necessary)
6
7a Total unrelated business revenue from Part VIII, column (C), line 12
7a
b Net unrelated business taxable income from Form 990-T, line 34
7b
PriorYear
8 Contnbutions and grants (Part VIII, line 1h)
9 Proqram service revenue (Part VIII. II,e 29)
_- ~
10 Investment income (Part VIII, column ~ lines 3
11 Other revenue (Part VIII, column (A) lin ~
, Oc, and 1
I
ecual Part
ti,e 12)
12 Total revenue - add lmes
13

1/1
GI
1/1

of the practice

umn (A), lin

\.fr'

15 Salanes, other compensation, empIOye~~~


rrn
, lines 5-10)
16aProfessionai fundraising fees (Part IX, co umn ~11e)
b Total fundraising expenses (Part IX, column (0), line 25) ~
17 Other expenses (Part IX, column (A), lines 11a-11d, 11f-24e)
18 Total expenses Add lines 13-17 (must equal Part IX, column (A), line 25)
19 Revenue less expenses, Subtract line 18 from line 12

0
0
CurrentYear

0
197,068
0
9,112
206,180
0
0
46,381
0

0
163,645
210,026
-3,846
Beginningof CurrentYear

20 Total assets (Part X, line 16)


21 Total liabilities (Part X, line 26)
22 Net assets or fund balances. Subtract line 21 from line 20

0
0
0
0

EndofYear

13,345
0
13,345

9,499
0
9,499

medthis retum, includingaccompanyingschedulesand statements,and to the best of my knowledgeand belief,It IS


arer otherthanofficer)ISbasedon all Informationof which preparerhas any knowledge.

--~'-------r.----.~'_~
__------~-n~~~--~------------------------------------------------,-----~~~-----------~ign
~Here

~
~

George Guthrie

secretary-treasurer

TypeorpnntnameandbUe

~.------~~~----~-------------------,~--~--~---------------------,~-----r----~-r==~---PnnVType
preparer's
name
Preparer's
signature
PTIN

c;;{

OPaid
OOPreparer
Use Only

TheodoreR. Ahre, CPA


Firm'sname

Theodore R. Ahre, CPA

Theodore R. Ahre, CPA


576 Glatt Circle
Woodburn, OR 97071- 9675

Firm'saddress ~
May the IRS diSCUSSthiS return With the preparer shown above? (see Instructions)
For Paperwork Reduction Act Notice, see the separate Instructions.
DAA

P00064082

Phoneno

503-982-5201
DYes

eO

Form

DNo
(2012),f

------------------------------------------------------------------------------203907/0212013907

Form 990(2012)

Part III
1

AM

American College of Lifestyle Med

32-0208451

Page

Statement of Program Service Accomplishments


Check if Schedule 0 contains a response to any question in this Part III

Briefly describe. the organization's mission:

To offer quality education and certification


lifestyle medicine.
2

of the practice

in clinical

Did the organization undertake any significant program services dunng the year which were not listed on the
pnor Form 990 or 990-EZ?

---------

If "Yes," descnbe these new services on Schedule O.


Did the organization cease conducting, or make significant changes in how It conducts, any program
services?
If "Yes," descnbe these changes on Schedule 0

DYes

[!]

No

DYes

[!]

No

Descnbe the organization's program service accomplishments for each of ItS three largest program services, as measured by
expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others,
the total expenses, and revenue, If any, for each program service reported.

4a (Code:

) (Expenses $

210 ,026

Including grants of $

) (Revenue $

Provide workshops

4b (Code.

) (Expenses $

including grants of $

) (Revenue $

4c (Code:

) (Expenses $

including grants of $

) (Revenue $

4d Other program services. (Descnbe in Schedule 0.)


(Expenses $
4e Total program service expenses ~
OM

including grants of $

) (Revenue $

210 ,026
Form

990 (2012)

203907/0212013907

AM

Form 990 (2012)

Part IV

American College

of

Lifestyle

Med

32-0208451

Page
Yes

Is the organizaijon described In section 501(c)(3) or 4947(a)(1) (other than a pnvate foundation)? If "Yes,"
complete Schedule A

2
3

Is the organization required to complete Schedule B, Schedule of Contnbutors (see instructions)?


Old the organization engage in direct or Indirect pohtical campaign activities on behalf of or In opposmon to
candidates for public office? If "Yes," complete Schedule C, Part I
Section 501(c)(3) organizations. Old the organization engage In lobbYing activities, or have a section 501(h)
election in effect during the tax year? If "Yes," complete Schedule C, Part II
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues,

4
5

No

1
2

X
X

assessments, or similar amounts as defined In Revenue Procedure 98-19? If "Yes," complete Schedule C,
Part III

Old the organization maintain any donor advised funds or any similar funds or accounts for which donors
have the nght to provide advice on the distribution or investment of amounts In such funds or accounts? If
"Yes," complete Schedule 0, Part I

Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, hrstonc land areas, or hrstonc structures? If "Yes," complete Schedule 0, Part II
Old the organization maintain collections of works of art, rustoncal treasures, or other Similar assets? If "Yes,"
complete Schedule 0, Part III
Old the organization report an amount In Part X, line 21, for escrow or custodial account liability, serve as a
custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or
debt negotiation services? If "Yes," complete Schedule 0, Part IV
Old the organization, directly or through a related organization, hold assets in temporarily restricted
endowments, permanent endowments, or quasi-endowments? If "Yes," complete Schedule 0, Part V
If the organization's answer to any of the followmq questions IS "Yes," then complete Schedule 0, Parts VI,
VII, VIII, IX, or X as applicable
Old the organization report an amount for land, buildings, and equipment In Part X, line 10? If "Yes,"
complete Schedule 0, Part VI
Did the organization report an amount for investments--other secunties in Part X, line 12 that is 5% or more
of ItStotal assets reported In Part X, line 16? If "Yes," complete Schedule 0, Part VII
Old the organization report an amount for Investments--program related In Part X, line 13 that IS 5% or more
of ItStotal assets reported in Part X, line 16? If "Yes," complete Schedule 0, Part VIII
Old the organization report an amount for other assets in Part X, line 15 that IS 5% or more of its total assets
reported In Part X, line 16? If "Yes," complete Schedule 0, Part IX
Old the organization report an amount for other liabilities in Part X, line 25? If "Yes," complete Schedule D, Part X
Old the organization's separate or consolidated financial statements for the tax year Include a footnote that addresses
the organization's liability for uncertain tax positions under FIN 48 (ASC 740)? If "Yes," complete Schedule 0, Part X
Old the organization obtain separate, Independent audited financial statements for the tax year? If "Yes," complete
Schedule 0, Parts XI and XII
Was the organization included In consolidated, Independent audited financial statements for the tax year? If "Yes," and If
the organization answered "No" to line 12a, then completing Schedule 0, Parts XI and XII ISoptional
Is the organization a school descnbed In section 170(b)(1)(A)(II)? If "Yes," complete Schedule E
Did the organization maintain an office, employees, or agents outside of the United States?
Old the organization have aggregate revenues or expenses of more than $10,000 from grantmaklng,

10

11a

11b

11c

11d
11e

X
X

11f

12a

12b
13
14a

X
X
X

14b

15

16

8
9

10
11
a
b
c
d
e
f
12a
b
13
14a
b

15
16
17

fundraising, business. Investment, and program service activities outside the United States, or aggregate
foreign investments valued at $100,000 or more? If "Yes," complete Schedule F, Parts I and IV
Old the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any
organization or entity located outside the United States? If "Yes," complete Schedule F, Parts II and IV
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance
to lndivrduals located outside the United States? If "Yes," complete Schedule F, Parts III and IV
Old the organization report a total of more than $15,000 of expenses for professional fundraising services on
Part IX, column (A), lines 6 and 11e? If "Yes," complete Schedule G, Part I (see instrucbons)

17

18

Did the organization report more than $15,000 total of fundratsmq event gross Income and contnbutlons on
Part VIII, lines 1c and 8a? If "Yes," complete Schedule G, Part II

18

19

Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a?
If "Yes," complete Schedule G, Part III
Did the organization operate one or more hospital facilities? If "Yes," complete Schedule H
If "Yes" to line 20a did the orqanlzatlon attach a COpy of its audited financial statements to this return?

19
20a
20b

X
X

20a
b

Form

OM

Checklist of ReQUiredSchedules

990 (2012)

203907/0212013907

AM

Form 990 (2012)

Part IV

American College

of Li festyle

Med

32-0208451

Paqe
Yes

21

Did the orqaruzanon report more than $5,000 of grants and other assistance to any govemment or organization
in the tinited States on Part IX, column (A), line 1? If "Yes," complete Schedule I, Parts I and II

22

Did the organization report more than $5,000 of grants and other assistance to individuals In the United States
on Part IX, column (A), line 2? If "Yes," complete Schedule I, Parts I and III
Did the organization answer "Yes" to Part VII, Section A, line 3, 4, or 5 about compensation of the
organization's current and former officers, directors, trustees, key employees, and highest compensated
employees? If "Yes," complete Schedule J

23

24a

Did the organization have a tax-exempt bond Issue With an outstanding principal amount of more than
$100,000 as of the last day of the year, that was issued after December 31, 2002? If "Yes," answer lines 24b
through 24d and complete Schedule K. If "No," go to line 25

b
c

Did the organization Invest any proceeds of tax-exempt bonds beyond a temporary period exception?
Did the organization maintain an escrow account other than a refunding escrow at any time dunng the year
to defease any tax-exempt bonds?
d Did the organization act as an "on behalf of" issuer for bonds outstanding at any time during the year?
25a Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage In an excess benefit transaction
With a disqualified person dunng the year? If "Yes," complete Schedule L, Part I
b Is the organization aware that it engaged In an excess benefit transaction With a disqualified person In a pnor
year, and that the transaction has not been reported on any of the organization's pnor Forms 990 or 990-EZ?
If "Yes," complete Schedule L, Part I
26
Was a loan to or by a current or former officer, director, trustee, key employee, highest compensated employee, or
disqualified person outstanding as of the end of the organization's tax year? If "Yes," complete Schedule L, Part II
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee,
substantial contnbutor or employee thereof, a grant selection committee member, or to a 35% controlled
entity or family member of any of these persons? If "Yes," complete Schedule L, Part III
28
Was the organization a party to a business transaction With one of the follOWingparties (see Schedule L,
Part IV Instructions for applicable filing thresholds, conditions, and exceptions)
a A current or former officer, director, trustee, or key employee? If "Yes," complete Schedule L, Part IV
b A family member of a current or former officer, director, trustee, or key employee? If "Yes," complete
Schedule L, Part IV
c An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof)
was an officer, director, trustee, or direct or indirect owner? If "Yes," complete Schedule L, Part IV
29
Did the organization receive more than $25,000 in non-cash contributions? If "Yes." complete Schedule M
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified
conservation contnbunons? If 'Yes," complete Schedule M
31
Did the organization hquidate, terminate, or dissolve and cease operations? If "Yes," complete Schedule N,
Part I
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of ItS net assets? If "Yes,"
complete Schedule N, Part II
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations
sections 301.7701-2 and 301.7701-3? If Yes," complete Schedule R, Part I
34 Was the organization related to any tax-exempt or taxable entity? If "Yes," complete Schedule R, Parts II, III,
or IV, and Part V, line 1
35a Did the organization have a controlled entity within the meaning of section 512(b)(13)?
b If "Yes" to line 35a, did the organization receive any payment from or engage In any transaction with a
36
37

38

controlled entity Within the meaning of section 512(b)(13)? If "Yes," complete Schedule R, Part V, line 2
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable
related organization? If "Yes," complete Schedule R, Part V, line 2

22

23

24a
24b

24c
24d
25a

25b
26

27

28a

28b

28c
29

X
X

30

31

32

33

34

X
X

35a
35b
36

Did the organization conduct more than 5% of ItS activities through an entity that IS not a related organization
and that is treated as a partnership for federal Income tax purposes? If "Yes." complete Schedule R,
Part VI

37

Did the organization complete Schedule 0 and provide explanations


19? Note. All Form 990 filers are reauired to complete Schedule 0

38

In

No

21

Schedule 0 for Part VI, lines 11b and


Form

OM

Checklist of Required Schedules (continued)

990 (2012)

203907/0212013907

AM

Fdrm 990 (2012)

PiilrtV

1a
b
c
2a
b
3a
b
4a

b
5a
b
c
6a
b
7
a

American College

of Lifestyle

Med

32- 0208451

Enter the number reported In Box 3 of Form 1096 Enter -0- If not applicable
Enter the number of Forms W-2G Included in line 1a. Enter -0- If not applicable
Did the organization comply with backup Withholding rules for reportable payments to vendors and
reportable gaming (gambling) Winnings to pnze Winners?
Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax

1c

Statements, filed for the calendar year ending With or Within the year covered by this return
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?
Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file (see instructions)
Old the organization have unrelated business gross Income of $1,000 or more during the year?
If "Yes: has it filed a Form 990-T for this year? If "No: provide an explanation In Schedule 0
At any time dunng the calendar year, did the organization have an interest in, or a signature or other authority
over, a financial account In a foreign country (such as a bank account, securities account, or other financial
account)?
If "Yes: enter the name of the foreign country ....

If "Yes: Indicate the number of Forms 8282 filed dunng the year
7d
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?
If the organization received a contribution of qualified Intellectual property, did the organization file Form 8899 as required?

a
b
10

If the organization received a contnbution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting
organizations. Old the supporting organization, or a donor advrsed fund maintained by a sponsonng
organization, have excess business holdings at any time during the year?
Sponsoring organizations maintaining donor advised funds.
Did the organization make any taxable distributions under section 4966?
Did the organization make a distnbution to a donor, donor advisor, or related person?
Section 501(c)(7) organizations. Enter:

a
b
11

Initiation fees and capital contnbunons included on Part VIII, line 12


Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facmties
Section 501(c)(12) organizations. Enter:

Gross income from members or shareholders


Gross income from other sources (Do not net amounts due or paid to other sources
against amounts due or received from them.)

b
13
a
b
c

3a

4a

5a
5b
5c
6a

x
x
x
x

6b

7a
7b
7c
7e
7f
7a
f-'7:..:h.=....f
__ r-_

8
9a
9b

l10a I
10b
11a
L...:1..:.1=b...L..

Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 In lieu of Forml1041?
If "Yes: enter the amount of tax-exempt interest received or accrued dunng the year
L...:1.=2=b-LI
Section 501(c)(29) qualified nonprofit health insurance issuers.
Is the organization licensed to issue qualified health plans in more than one state?
Note. See the Instructions for additional information the organization must report on Schedule O.
Enter the amount of reserves the organization is required to maintain by the states in which
the organization ISlicensed to issue qualified health plans
Enter the amount of reserves on hand

3b

2b

See instructions for filing requirements for Form TO F 90-22 1, Report of Foreign Bank and Financial Accounts.
Was the organization a party to a prohibited tax shelter transaction at any time dunng the tax year?
Old any taxable party notify the organization that It was or IS a party to a prohibited tax shelter transaction?
If "Yes" to line 5a or 5b, did the organization file Form 8886-T?
Does the organization have annual gross receipts that are normally greater than $100,000, and did the
organization solicit any contributions that were not tax deductible as charitable contnbutions?
If "Yes: did the organization Include with every solicitation an express statement that such contributions or
gifts were not tax deductible?
Organizations that may receive deductible contributions under section 170(c).
Did the organization receive a payment In excess of $75 made partly as a contnbunon and partly for goods
and services provided to the payor?

No

1b

d
e
f
g

12a

Yes

I 1a I

If "Yes," did the organization notify the donor of the value of the goods or services provided?
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which It was
required to file Form 8282?

b
c

Page

Statements Regarding Other IRS Filings and Tax Compliance


Check if Schedule 0 contains a response to any Question In this Part V

--I
1-=-1=2a=-+-_-4__
-{
13a

13c

14a

Old the organization receive any payments for Indoor tanning services during the tax year?

b
OM

If "Yes," has it filed a Form 720 to report these pavments? If "No," provide an explanation In Schedule 0

14a
14b
Form

x
990 (2012)

203907/0212013907

AM

Fdrm990(2012)

Part VI

American College

of Lifestyle

Med

32-0208451

Page

Governance, Management, and Disclosure For each "Yes" response to lines 2 through 7b below, and for a "No"
response to line 8a, 8b, or 1Db below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule 0 contains a response to any question in this Part VI
[L

Section A Governmg Body and Management


Yes
1a

No

1a

Enter the number of voting members of the governing body at the end of the tax year
If there are matenal differences in voting nghts among members of the governing body, or
if the governing body delegated broad authority to an executive committee or similar
committee, explain In Schedule O.

2
3
4
5

6
7a
b

a
b
9

Enter the number of voting members included In line 1a, above, who are Independent
1b
Did any officer, director, trustee, or key employee have a family relationship or a business relationship With
any other officer, director, trustee, or key employee?
Did the organization delegate control over management duties customanly performed by or under the direct
supervision of officers, directors, or trustees, or key employees to a management company or other person?
Did the organization make any Significant changes to ItS governing documents since the prior Form 990 was filed?
Did the organization become aware dunng the year of a Significant diversion of the organization's assets?
Did the organization have members or stockholders?
Did the organization have members, stockholders, or other persons who had the power to elect or appoint
one or more members of the governing body?
Are any governance decisions of the organization reserved to (or subject to approval by) members,
stockholders, or persons other than the governing body?
Did the organization contemporaneously document the meetings held or wntten actions undertaken during the year by the following:
The governing body?
Each committee With authority to act on behalf of the governing body?
Is there any officer, director, trustee, or key employee listed In Part VII, Section A, who cannot be reached at
the organization's mailing address? If "Yes," provide the names and addresses In Schedule 0

3
4
5

X
X
X
X

7a

7b

X
X
X

8a
8b

Section B. Policies (This Section B reauests information about policies not required by the Internal Revenue Code.)
Yes
10a
b

Did the organization have local chapters, branches, or affiliates?


If "Yes," did the organization have wntten policies and procedures governing the activities of such chapters,
affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes?
11a Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form?
b Descnbe in Schedule 0 the process, If any, used by the organization to review thiS Form 990
12a Did the organization have a written conflict of Interest policy? If "No,' go to line 13
b Were officers, directors, or trustees, and key employees required to disclose annually interests that could give nse to conflicts?
c Did the organization regularly and consistently monitor and enforce compliance With the policy? If "Yes,"
describe In Schedule 0 how this was done
13
Did the organization have a wntten whlstleblower policy?
14
Did the organization have a wntten document retention and destruction policy?
15 Did the process for determining compensation of the follOWingpersons Include a review and approval by
Independent persons, comparability data, and contemporaneous substantiation of the deliberation and decrslon?
a The organization's CEO, Executive Director, or top management official
b Other officers or key employees of the organization
If "Yes' to line 1Sa or 1Sb, descnbe the process in Schedule 0 (see instructions).
16a Did the organization Invest in, contribute assets to, or participate In a [omt venture or Similar arrangement
with a taxable entity dunng the year?
b

No

10a

10b
11a

12a

12b
12c
13
14

X
X

15b

X
X

16a

15a

If "Yes," did the organization follow a wntten policy or procedure requiring the organization to evaluate its
participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the
organization's exempt status With respect to such arranqements?

16b

Section C. Disclosure
None

17

List the states with which a copy of thrs Form 990 is required to be filed ~

18

Section 6104 requires an organization to make ItS Forms 1023 (or 1024 If applicable), 990, and 990-T (Section S01(c)(3)s only)
available for public inspection. Indicate how you made these available. Check all that apply.

o
19
20

State the name, physical address, and telephone number of the person who possesses the books and records of the
organization: ~
Marc Braman
612 Glatt Circle

Woodburn
DM

Own website
Another's website
Upon request
Other (explain In Schedule 0)
Descnbe in Schedule 0 whether (and if so, how), the organization made ItS governing documents, conflict of interest policy,
and financial statements available to the public during the tax year

OR 97071

971-983-5383
Form

990 (2012)

203907/0212013907
AM
Form 990(2012)

Part VII

American

College

of

Lifestyle

32-0208451

Med

Page

Compensation of Officers, Directors, Trustees, Key Employees, Highest Compensated Employees, and
Independent Contractors
Check if Schedule 0 contains a response to any question in this Part VII

Section A.'

Officers, Directors, Trustees, Key Employees, and Highest Compensated

Employees

1a Complete trus table for all persons required to be listed. Report compensation for the calendar year ending with or within the
organization's tax year
List all of the organization's current officers, directors, trustees (whether individuals or organizations), regardless of amount of
compensation. Enter -0- in columns (0), (E), and (F) If no compensation was paid
List all of the organization's current key employees, If any. See Instructions for definition of "key employee."
List the organization's five current highest compensated employees (other than an officer, director, trustee, or key employee)
who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the
organization and any related organizations.
List all of the organization's former officers, key employees, and highest compensated employees who received more than
$100,000 of reportable compensation from the organization and any related organizations.
List all of the organization's former directors or trustees that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.
List persons In the folloWing order: Individual trustees or directors; institutional trustees; officers; key employees, highest
compensated employees; and former such persons
~

Check this box If neither the organization nor any related organizations compensated any current officer, director, or trustee.
(A)
Name and Tltle

(8)
Average
hours per
week
(list any
hours for
related
organizations
below dotted
line)

~
c.
al

51

(C)

(0)

Position
(do not check more than one
box, unless person IS both an
officer and a director/trustee)

Reportable
compensation
from
the
orqarnzatron

~
~

~ 3~::r

-e
CD

"C

0"
'<
CD
CD

"T1
0

o~ 3~

"0

(E)
Reportable
compensabon from
related
organizations

(F)
Esbmated
amount of
other
compensation
fromtlhe
organization
and related
organizations

(W-211099-MISC)

(W-211099-MISC)

mS

"0
CD
::>

en

'"

!D

0.

(1)Liana

Lianov

President
(2) David

0.50
0.00

3.00
0.00

4.00
0.00

Dysinger

Past President
(4) George

Katz

President Elect
(3) Wayne

4.00
0.00

Guthrie

Secretary/Treasurer
(5)

(6)

(7)

(8)

(9)

(10)

(11)

DAA

Fonm

990 (2012)

203907/0212013907
AM
Fonn 99.0(2012) American
Part
Section A. Officers

VIr

(A)
Nameandutle

College of Lifestyle
Med
, Directors , Trustees , Key Employees , and Highest
(8)

Average
hoursper
week
(lostany
hoursfor
related
orqaruzatrons

belowdotted
lone)

(0)

(C)
Posmon

Reportable

(donotcheckmorethanone
box.unlesspersonISbothan
officeranda director/trustee)
CD:!:
"T1
a :;0<;
::0
0
CD
3c5

s:0
::0

!!!.

2"

~
CD

3l
n

!!!

"<
CD

3
0
-e

'"
CD
CD

32 - 0208451
Compensated

om

"0 :T

mg

compensation

from
the
orqaruzatron

Page

Employees (continued)
(E)
Reportable
cornpensanon from
related
orqaruzauons

(W-211099-MtSC)

(W-211099-MtSC)

(F)

EstImated
amount
of
other
compensahon
fromthe
orqaruzanon

andrelated

!!!

orqaruzanons

"0

CD
::0

'"
a;
Q)

c.

(12)

(13)

(14)

(15)

(16)

(17)

(18)

(19)

1b

Sub-total

c
d
2

Total from continuation sheets to Part VII, Section A


~
Total (add lines 1band 1c)
~
Total number of tndividuals (including but not limited to those listed above) who received more than $100,000 In
reportable compensation from the orcaruzanon ~ 0
Yes

Old the organization list any former officer, director, or trustee, key employee, or highest compensated
employee on line 1a? If "Yes," complete Schedule J for such individual
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the
organization and related organizations greater than $150,OOO?If "Yes," complete Schedule J for such
individual
5
Old any person listed on line 1a receive or accrue compensation from any unrelated organization or lndrvrdual
for services rendered to the orqaruzanon? If "Yes," complete Schedule J for such person
Section B. Independent Contractors

No

2
OM

Complete this table for your five highest compensated independent contractors that received more than $100,000 of
cornoensanon from the organization. Report compensation for the calendar year ending WIth or within the organization's tax vear.
(A)
(8)
Name
andbusiness
address
Descl1Qbon
ofservices

Total number of independent contractors (including but not limited to those listed above) who
received more than $100,000 of compensation from the organization ~

(e)

Cornrerisanon

Form990 (2012)

203907/0212013907

AM

Foim 990 (~!o12)

Part VIII

American College

of Lifestyle

(A)
Total revenue

-(/)m

1a Federated campaigns
b Membership dues
~E
c Fundralsmq events
~~
d Related organizations
(!)~
uiE
e
Government grants (conlnbubons)
1:'I:I:
ftI::::J
"0

..

.011)
-G)

1:"
01:

Oftl

and similar amounts not Included above

9 Noncash contnbubons Included In lines 1a-1t


h Total. Add lines 1a-1f

G>

2a

Conference

Membership

Workshop

G>

u
.~
G>

VJ

E
E
C)

a..

(B)
Related or
exempt
function
revenue

(C)
Unrelated
business
revenue

(D)
Revenue
exduded from tax
under sections
512.513. or 514

1f

~
Busn Code

0:::

>
G>

Page

1a
1b
1c
1d
1e

G>
::::I

c:

32 - 0208451

f All other conlnbubons. gifts. grants

::::J.e:
..a_

EO

Med

Statement of Revenue
Check if Schedule 0 contains a response to any question in this Part VIII.

127,818
61,315
7,935

dues

d
e
f All other program service revenue
Q Total. Add lines 2a-2f
~
3 Investment Income (including dividends, interest,
and other Similar amounts)
~
4 Income from Investment of tax-exempt bond proceeds ~
5 Royalties
~
(I) Real

6a
b
c
d
7a

127,818
61,315
7,935

197,068

(II) Personal

Gross rents
Less rental exps
Rental me or (loss)

Net rental Income or (loss)


Gross amount from
sales of assets
other than Inventof'l

(I) secunnes

(II) Other

b Less cost or other


bass & sales exps

G)

::::J
I:
G>

>
G)

..

0::

G)

s:

c Gain or (loss)
d Net gain or (loss)
8a GrossIncomefromfundraisingevents
(notIncluding$
of contnbuttonsreportedon line 1c)
SeePartIV,line 18
a
b Less: direct expenses
b
c Net income or (loss) from fundraisin events
9a GrossIncomefromgamingactivities
SeePartIV,line 19
a
b Less: direct expenses
b
c Net Income or (loss) from gaming activities
10a Gross sales of inventory, less
returns and allowances
a
b Less: cost of goods sold
b
c Net Income or (loss) from sales of Inventory
Miscellaneous Revenue

11a

~
Busn Code

Other

Refunds

Trainin!f

d All other revenue


e Total. Add lines 11a-11d
12 Total revenue. See instructions.

~
~

8,431
586
95

8,431
586
95

9,112
206,180

206,180

0
Form

OM

0
990 (2012)

203907/0212013907

AM

American College

Fohn 990(2012)

Part IX

of Lifestyle

Med

32-0208451

Section 501(c)(3) and 501 (c)(4) orcarnzanons must complete all columns All other orcamzanons
Check if Schedule 0 contains a response to any question in this Part IX
Do not inc!lude amounts reported on lines 6b,
7b 8b 9b and 10b of Part VIII.
1 Grants and other assistance to governments and
organizations In the U S See Part IV, hne 21
2 Grants and other assistance to Individuals In
3

5
6

7
8
9
10
11
a
b
c
d
e
f

9
12
13
14
15
16
17
18
19
20
21
22
23
24

Page

10

Statementof Functional Expenses

the U.S. See Part IV, line 22


Grants and other assistance to governments,
orqaruzanons. and individuals outside the
U.S. See Part IV, lines 15 and 16
Benefits paid to or for members
Compensation of current officers, directors,
trustees, and key employees
Compensation not Includedabove, to disquahfled
persons (as defined under secnon 4958(1)(1))and
persons descnbed in section 4958(c)(3)(8)
Other salanes and wages
Pension plan accruals and contnbunons (Include
section 401(k) and 403(b) employer contributions)
Other employee benefits
Payroll taxes
Fees for services (non-employees):
Management
Legal
Accounting
LobbYing
Professional fundralsing services. See Part IV, hne 17
Investment management fees
Other(Ifline119 amounlexceeds10% ofline25, column
(A) amount,listline119 expenses
onSchedule
0)
Advertising and promotion
Office expenses
Information technology
Royalties
Occupancy
Travel
Payments of travel or entertainment expenses
for any federal, state, or local public officials
Conferences, conventions, and meetings
Interest
Payments to affiliates
Depreciation, depletion, and amortization
Insurance

(A)

Totalexpenses

must complete column (A)


(C)

(8)

Programservice
expenses

46,381

46,381

818

818

10,953

10,953

6,000

6,000

839

839

118,672
8,891
6,322
5,827
5,323
210,026

118,672
8,891
6,322
5,827
5,323
210,026

(0)

Managementand
generalexpenses

rl

Fundralsmg
expenses

Other expenses Itemize expenses not covered


above (List miscellaneous expenses In hne 24e If
hne24e amount exceeds 10% of hne25, column
(A) amount, hst line 24e expenses on Schedule 0 )

a
b

c
d

Workshop
Conference attendance
Bank charges
Administrative Asst

e All other expenses


25
26

expenses. Add lines1 through24e


Joint costs. Complete thiS hneonly If the
organization reported in column (8) JOintcosts
from a combined educational campaign and
fundraismq sohcitaton Check here....
if
followmo SOP 98-2 IASC 958-720)
Total functional

OM

Form

990 (2012)

203907/0212013907

AM

Form 990 (2012)

PartX

American College

of Lifestyle

Med

32-0208451

Page

I I

Check If Schedule 0 contains a response to any question in this Part X


(A)
Beginning of year
1
2
3
4

11

BalanceSheet
(B)
End of year

13,345

Cash-rion-Interest bearing
Savings and temporary cash investments
Pledges and grants receivable, net
Accounts receivable, net

9,499

1
2
3
4

Loans and other receivables from current and former officers, directors,
trustees, key employees, and highest compensated employees.
Complete Part II of Schedule L
6 Loans and other receivables from other disqualified persons (as defined under section
4958(f)(1 , persons descnbed In section 4958(c)(3)(B), and contributing employers and
sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary
organizations (see instructions). Complete Part II of Schedule L
J!l
II)
(I)
7
Notes and loans receivable, net
(I)
oCt
8 Inventories for sale or use
9 Prepaid expenses and deferred charges
10a Land, buildmqs, and equipment: cost or
other baSIS.Complete Part VI of Schedule D
10a
10b
b Less: accumulated deprecation
11 Investments-publicly traded secuntles
12 Investments-other securities. See Part IV, line 11
13 Investments-program-related
See Part IV, line 11
14 Intangible assets
15 Other assets. See Part IV, line 11
16 Total assets. Add lines 1 throuqh 15 (must equal line 34)
17 Accounts payable and accrued expenses
18 Grants payable
19 Deferred revenue
20 Tax-exempt bond liabilities
21 Escrow or custodial account liability. Complete Part IV of Schedule D
(I)
22 Loans and other payables to current and former officers, directors,
II)
trustees, key employees, highest compensated employees, and
~
disqualified persons Complete Part II of Schedule L
ca
:::i 23 Secured mortgages and notes payable to unrelated third parties
24 Unsecured notes and loans payable to unrelated third parties
25 Other liabilities (including federal income tax, payables to related third
parties, and other liabilities not Included on lines 17-24). Complete Part X
of Schedule D
26 Total liabilities. Add lines 17 throuch 25
Organizations that follow SFAS 117 (ASC 958), check here ~
and
(I)
II)
complete
lines
27
through
29,
and
lines
33
and
34.
U
I:
ca 27 Unrestricted net assets
iii
IX! 28 Temporarily restricted net assets
"C
Permanently restncted net assets
I: 29
::::I
II..
Organizations that do not follow SFAS 117 (ASC 958), check here ~
and
0
complete
lines
30
through
34.
(I)
II)
30 Capital stock or trust pnncipal, or current funds
II)
II)
-e 31 Paid-in or capital surplus, or land, bUilding, or equipment fund

6
7
8
9

13,345

:c

II)

9,499

22
23
24

25
26

27
28
29

00

...

10c
11
12
13
14
15
16
17
18
19
20
21

32
33
34

Retained earnings, endowment, accumulated income, or other funds


Total net assets or fund balances
Total liabilities and net assets/fund balances

30
31

13,345
13,345
13,345

9,499
9,499
9,499

32
33
34
Form

DM

990 (2012)

203907/0212013907

AM

Form 990 (2012)

Part XI
1
2
3
4

5
6

7
8
9
10

American

Collecre

of

Lifestyle

Med

32-0208451

Page

Reconciliation of Net Assets

Check if Schedule 0 contains a response to any question in this Part XI


Total revenue (must equal Part VIII, column (A), line 12)

2
3
4

Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A
Net unrealized gains (losses) on investments

Donated services and use of facilities


Investment expenses

Prior period adjustments


Other changes In net assets or fund balances (explain in Schedule 0)
Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line
33, column (B))

8
9

1 Accounting method used to prepare the Fonn 990

Cash

0 Accrual

Yes
Other

2a

2b

recurred audit or audits, ~xplaln why in Schedule 0 and descnbe any steps taken to undem_osuch audits

2c

3a
3b
Form

OM

No

Separate basis
Consolidated baSIS
Both consolidated and separate baSIS
b Were the organization's financial statements audited by an Independent accountant?
If "Yes," check a box below to indicate whether the flnancral statements for the year were audited on a
separate baSIS,consolidated baSIS,or both:
Separate baSIS
Consolidated baSIS
Both consolidated and separate basis
c If "Yes' to line 2a or 2b, does the organization have a committee that assumes responsibility for oversight
of the audit, review, or compilation of ItSfinancial statements and selection of an independent accountant?
If the organization changed either ItS oversight process or selection process dunng the tax year, explain In
Schedule O.
3a As a result of a federal award, was the organization required to undergo an audit or audits as set forth in
the Single Audit Act and OMB Circular A-133?
b If "Yes," did the organization undergo the required audit or audits? If the organization did not undergo the

to any question in this Part XII

If the organization changed Its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a Were the organization's financial statements compiled or reviewed by an Independent accountant?
If "Yes," check a box below to indicate whether the financial statements for the year were compiled or
reviewed on a separate baSIS,consolidated baSIS,or both

9,499

10

Financial Statementsand Reporting


Check if Schedule 0 contains a response

206,180
210,026
-3,846
13,345

Total e'Xpenses(must equal Part IX, column (A), line 25)


Revenue less expenses. Subtract line 2 from line 1

Part XU

12

990 (2012)

203907/0212013907 AM

.
SCHEDULE 0

OMS No 1545-0047

Supplemental Information to Form 990 or 990-EZ

(Form 990 or 990-EZ)

2012

Complete to provide information for responses to specific questions on


Form 990 or 990-EZ or to provide any additional information.
~ Attach to Form 990 or 990-EZ.

Department of th~ Treasury


Internal Revenue Service

Open to Public
Ins lion

Employer IdentificatIon

Name of the orqaruzauon

number

32-0208451

American Colle e of Lifest 1e Med


Form 990, Part III, Line 4d - All Other Accomplishment
Provide workshops

Form 990, Part VI, Line 11b - Organization's

Process to Review Form 990

No review was or will be conducted.

Form 990, Part VI, Line 19 - Governing Documents Disclosure

Explanation

No documents available to the public

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
OM

Schedule 0 (Form 990 or 990-EZ) (2012)

2039"OJ7I21f2014
1. 24PM

OMBNo 1545-0047

Return of Organization Exempt From Income Tax

990

Form

2013

Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private foundations)
... Do not enter Social Security numbers on this form as it may be made public.
Open to Public
Ins ection
... Information about Form 990 and its instructions is at www irs. ovlform990.
and end ina
A For the 2013 calendar vear or tax year beainnina
EmployerIdenllfieatlonnumber
0
B Check
Ifapplicable C Nameof orgaOlzallon
Oepartmenl
of!heTreasury
Inlern.;lRevenueService

American College of Lifestyle Med

Address
change

Name
change

lrnhal retum

Terminated

Amended
return

DOingBUSiness
As
Numberandstreel(orPObox ~ rnailrs not dehvered
10 slreeladdress)

314-398-7343

PO Box 6432
Chesterfield

MO

63006

295,748

Grossreceipts
$

F Nameandaddressofpnncopal
officer

(Insertno I
Tax-exempt status
I I 501(e)(31 IXI 501(el ( 6 ).....
lifestylemedicine.orq
WebSite:...

32-0208451
Telephone
number

Room/SUite

C,lyor town, state orprovince.country,andZIPorforeignpostalcode

Apphca~on
pending

/XI

Formof0!l!amza~on
Coroora~on l Trust
Part I ,
Summary

r l Assocaaon r l

l4947(a)(1)or

H(., IsthiSagroupreturnforsubordinates?
D Yes ~

No

Dyes
H(b)Areallsubordinates
Included?
If"No,"altacha hsl (seeInstructions)

No

l 527
H(e)GrOUD
exernonon number...

IL

Other'"

IM

Yearoffomna~on

StateoflegaldomICile

1 Bnefly descnbe the organization's mission or most Significant acnvitres:

To offer quality education and certification of the practice in clinical


lifestyle medicine.

GI

r:
10
r:
LCD

>
0

If the organization discontinued ItS operations or disposed of more than 25% of ItS net assets
2 Check this box'"
3 Number of voting members of the governmg body (Part VI, line 1a)
4 Number of Independent voting members of the governing body (Part VI, hne 1b)
5 Total number of mdividuals employed m calendar year 2013 (Part V, hne 2a)
6 Total number of volunteers (estimate If necessary)

o
05

rn
GI

;;

's
;;
u
-c

7a Total unrelated busmess revenue from Part VIII, column (C), line 12
b Net unrelated business taxable income from Form 990-T tn;;;
"

8 Contnbutions and grants (Part YIII, hne 1h)


9 Program service revenue (Part YIII, line 2g)

GI

::l

r:
CIJ

>
GI
fJ) a::

z
m

rn
GI
rn
)::0' e
CIJ

c:

en

Q.
)(

~
c:>

c:>

..
....

~
0"
!!g

6
7a
7b

{-;L'(~~'~~-'I~r"lj
-'

,...

~(!); AUl:i

10 Investment mcome (Part VII', column (A), hnes 3, 4, and

- " - ~-~ ~
~----"-;r/)~

'(i)'

3
4

{i;:L,_.._

PriorYear

0
0
0
0
0
0
CurrentYear

0
295,748
0
0
295 748
0
0
2 989
0

_,

oM.

2014

11 Other revenue (Part YIII, column (A), lines 5, 6d, 8c, 9c, Oc,anO~DEN
~
12 Total revenue - add lines B throuah 11 (must eaual Part l,u..column4A1":-hne+:h
13 Grants and Similar amounts paid (Part IX, column (A), hnes 1-3)
14 Benefits paid to or for members (Part IX, column (A), lme 4)
1S Salanes, other compensation, employee benefits (Part IX, column (A), hnes 5-10)
16a Professional fundraismq fees (Part IX, column (A), line 11e)
b Total fundralslng expenses (Part IX, column (D), line 25) ...
17 Other expenses (Part IX, column (A), lines 11a-11d, 11f-24e)
18 Total expenses Add hnes 13-17 (must equal Part IX, column (A), line 25)
19 Revenue less expenses Subtract line 18 from hne 12

;a::'!

_J J

UT

197 068
9,112
206.180
46,381

0
163 645
210.026
-3 846

244,589
247,578
48,170

Be!llnnln~01CurrentYear

End01Year

57_/
670
0
57,670

9 500
0
9 500

20 Total assets (Part X, line 16)


21 Total habilltles (Part X, hne 26)
~-g
z:>
u.. 22 Net assets or fund balances Subtract line 21 from line 20
"'i;

"co

Signature Block

Part II

Under penalties of penury, I declare that I have examined trns retum, includingaccompanying schedules and statements,and 10 the best of my knowledge and belief, It IS
true correct and complete Declarallon.,.-of preparer (other than officer) ISbased on all mtormanon of Whichpreparerhas any knowledge
"

Sign
Here

Ignatureofofficer

BII

17-;l..!"'- l'f

d"

Dale

Susan Benigas
Typeorprontname end uue
PnnVType
preparer's name

Executive Director

I,

Preparer's signature
Paid
Theodore R. Ahre, CPA
Theodore R. Ahre, CPA
Preparer
Theodore R. Ahre, CPA LLC
~
Fum's nama
Use Only
576 Glatt Circle

Woodburn, OR 97071-9675
Flmn'saddress ~
May the IRS diSCUSStms return With the preparer shown above? (see instructions)
For Paperwork Reduction Act Notice, see the separate Instructions.
OM

"' Dale
07/21/14

DI

Check
of PTIN
self-employed POO0640B2

Firm'sEIN~
Phoneno

46-1648641
503-982-5201

nNo

ilves
Form990 (2013)

203907/2112014924

'

Fonn990(2013)

Part III
1

AM

American College of Lifestyle Med

32-0208451

Page

'Statement of Program Service Accomplishments


Check if Schedule 0 contains a response or note to any line in this Part III

Briefly describe the orqamzation's mission:

To offer quality education and certification of the practice. in clinical


lifestyle medicine.
2

Did the organizatJonundertake any significant program services dunng the year which were not listed on the

pnor Fonn 990 or 990-EZ?


If "Yes," descnbe these new services on Schedule O.
Did the orqaruzauoncease conductJng,or make significant changes In how It conducts, any program
services?
If "Yes." descnbe these changes on Schedule 0
Descnbe the organization's program service accomplishments for each of ItSthree largest program services, as measured by
expenses. SectJon501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others,
the total expenses, and revenue, if any, for each program service reported.

4a (Code:

) (Expenses $

247

57 8

Including grants of $

) (Revenue $

D Yes

No

D Yes

No

Provide workshops

4b (Code:

) (Expenses $

including grants of $

) (Revenue $

4c (Code

) (Expenses $

including grants of $

) (Revenue $

4d Other program services. (Describe in Schedule 0.)


(Expenses $
4e Total program service expenses jOM

including grants of $

) (Revenue $

247,578
Form

990 (2013)

203907/21/2014924

'

AM

Form 990 (2013)

American College

of Li festy1e

Med

32-0208451

Page 3

Part IV . Checklist of Reauired Schedules


Yes
1

Is the organizallon descnbed in secuon 501(c)(3) or 4947(a)(1) (other than a private foundation)? If "Yes,"
complete Schedule A

2
3

Is the organization required to complete Schedule B, Schedule of Contributors (see instructions)?


Did the organization engage in direct or indirect political campaign acuvitres on behalf of or in opposmon to
candidates for public office? If "Yes," complete Schedule e, Part I

Section 501(c)(3) organizations. Did the organization engage In lobbying acuvitres, or have a section 501(h)
election in effect dunng the tax year? If "Yes," complete Schedule C, Part II
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues,
assessments, or Similar amounts as defined In Revenue Procedure 98-19? If "Yes," complete Schedule c,
Part III

7
8
9

10
11
a
b
c
d
e
f
12a
b
13
14a
b

15
16
17
18

Did the organization maintain any donor advised funds or any similar funds or accounts for which donors
have the nght to provide advice on the drstnbution or Investment of amounts in such funds or accounts? If
"Yes," complete Schedule D, Part I
Did the organization receive or hold a conservation easement, Including easements to preserve open space,
the environment, histonc land areas, or histone structures? If "Yes," complete Schedule D, Part II
Did the organization maintain collections of works of art, histoncal treasures, or other similar assets? If "Yes,"
complete Schedule D, Part III
Did the organization report an amount in Part X, line 21, for escrow or custodial account liability; serve as a
custodian for amounts not listed In Part X; or provide credit counseling, debt management, credit repair, or
debt negotlallon services? If "Yes," complete Schedule D, Part IV
Did the organization, directly or through a related organization, hold assets in temporanly restncted
endowments, permanent endowments, or quasi-endowments? If "Yes," complete Schedule D, Part V
If the organizallon's answer to any of the following questions IS"Yes," then complete Schedule D, Parts VI,
VII, VIII, IX, or X as applicable.
Did the organization report an amount for land, buildings, and equipment in Part X, line 10? If "Yes,"
complete Schedule D, Part VI
Did the organization report an amount for investments-other secunues In Part X, line 12 that IS5% or more
of its total assets reported In Part X, line 16? If "Yes," complete Schedule D, Part VII
Did the organization report an amount for investments-program related In Part X, line 13 that is 5% or more
of Its total assets reported In Part X, line 16? If "Yes," complete Schedule D, Part VIII
Did the organization report an amount for other assets In Part X, line 15 that IS5% or more of its total assets
reported In Part X, line 16? If "Yes," complete Schedule D, Part IX
Did the organization report an amount for other liabilities in Part X, line 25? If "Yes," complete Schedule D, Part X
Did the organization's separate or consolidated financal statements for the tax year include a footnote that addresses
the orqaruzanon's liability for uncertain tax positions under FIN 48 (ASe 740)? If "Yes," complete Schedule D, Part X
Did the organization obtain separate, independent audited financial statements for the tax year? If "Yes," complete
Schedule D, Parts XI and XII
Was the organization included In consolidated, Independent audited financral statements for the tax year? If "Yes," and If
the orqaruzauon answered "No" to line 12a, then completing Schedule D, Parts XI and XII is optional
Is the organization a school descnbed in section 170(b)(1)(A)(ii)? If "Yes," complete Schedule E
Did the organization maintain an office, employees, or agents outside of the United States?
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaklng,
fundraising, business, investment, and program service activrnes outside the United States, or aggregate
foreign investments valued at $100,000 or more? If "Yes," complete Schedule F, Parts I and IV
Did the orqaruzation report on Part IX, column (A), line 3, more than $5,000 of grants or other assistance to or
for any foreign organizallon? If "Yes," complete Schedule F, Parts" and IV
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or other
assistance to or for foreign Individuals? If "Yes," complete Schedule F, Parts III and IV
Did the orqaruzation report a total of more than $15,000 of expenses for professional fundraising services on
Part IX, column (A), lines 6 and 11e? If 'Yes," complete Schedule G, Part I (see instructions)
Did the organization report more than $15,000 total of fundraising event gross Income and contnbullons on
Part VIII, lines 1c and 8a? If "Yes," complete Schedule G, Part II

Did the organization report more than $15,000 of gross income from gaming activities on Part VIII,line 9a?
If "Yes," complete Schedule G, Part III
20a Did the organization operate one or more hospital faohues? If "Yes," complete Schedule H
b If "Yes" to line 20a, did the oroamzanon attach a copy of its audited financral statements to this retum?

No

1
2

X
X

10

11a

11b

11c

11d
11e

X
X

11f

12a

12b
13
14a

X
X
X

14b

15

16

17

18

19
20a
20b

X
X

19

Fonn

OM

990 (2013)

203907/2112014924

'

AM

Form 990(2013)

Part IV

American College

of Lifestyle

Med

32-0208451

Paqe4

Checklist of Required Schedules (continued)


Yes

No

21

Did the organization report more than $5,000 of grants or other assistance to any domestic organization or
government on Part IX, column (A), line 1? If "Yes," complete Schedule I, Parts I and II
Did the organization report more than $5,000 of grants or other assistance to Individuals In the United States

21

22

on Part IX, column (A), line 2? If "Yes," complete Schedule I, Parts I and III
Did the organization answer "Yes" to Part VII, Section A, line 3, 4, or 5 about compensation of the
organization's current and former officers, directors, trustees, key employees, and highest compensated

22

employees? If "Yes," complete Schedule J


24a Did the organization have a tax-exempt bond Issue Withan outstanding pnncipal amount of more than
$100,000 as of the last day of the year, that was issued after December 31, 2002? If "Yes," answer lines 24b
through 24d and complete Schedule K. If "No," go to line 25a
b Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?

23

24a
24b

23

c
d
25a
b

26

27

28
a
b
c
29
30
31
32
33

34
35a
b
36
37

38

Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?
Did the organization act as an "on behalf of issuer for bonds outstanding at any time dunnq the year?
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage In an excess benefit transaction
with a disqualified person dunnq the year? If "Yes," complete Schedule L, Part I
Is the organization aware that It engaged In an excess benefit transaction Witha disqualified person In a pnor
year, and that the transaction has not been reported on any of the organization's pnor Forms 990 or 990-EZ?
If "Yes," complete Schedule L, Part I
Did the organization report any amount on Part X, line 5, 6, or 22 for receivables from or payables to any
current or former officers, directors, trustees, key employees, highest compensated employees, or
disqualified persons? If so, complete Schedule L, Part II
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee,
substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled
entity or family member of any of these persons? If "Yes," complete Schedule L, Part III
Was the organization a party to a business transaction Withone of the follOWingparties (see Schedule L,
Part IV Instructions for applicable filing thresholds, conditions, and exceptions)
A current or former officer, director, trustee, or key employee? If "Yes," complete Schedule L, Part IV
A family member of a current or former officer, director, trustee, or key employee? If "Yes," complete
Schedule L, Part IV
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof)
was an officer, director, trustee, or direct or indirect owner? If "Yes," complete Schedule L, Part IV
Did the organization receive more than $25,000 In non-cash contnbunons? If 'Yes," complete Schedule M
Did the organization receive contnbunons of art, historical treasures, or other Similar assets, or qualified
conservation contnbunons? If "Yes," complete Schedule M
Did the organization liquidate, terminate, or dissolve and cease operations? If "Yes," complete Schedule N,
Part I
Did the organization sell, exchange, dispose of, or transfer more than 25% of ItS net assets? If "Yes,"
complete Schedule N, Part II
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations
sections 301 7701-2 and 301.7701-3? If Yes," complete Schedule R, Part I
Was the organization related to any tax-exempt or taxable entity? If "Yes," complete Schedule R, Parts II, III,
or IV, and Part V, line 1
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
If "Yes" to line 35a, did the organization receive any payment from or engage In any transaction with a
controlled entity within the meaning of section 512(b)(13)? If "Yes," complete Schedule R, Part V, line 2
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-chantable
related organization? If "Yes," complete Schedule R, Part V, line 2
Did the organization conduct more than 5% of ItSactivities through an entity that ISnot a related organization
and that is treated as a partnership for federal income tax purposes? If "Yes," complete Schedule R,
Part VI
Did the organization complete Schedule 0 and provide explanations in Schedule 0 for Part VI, lines 11b and
19? Note. All Form 990 filers are required to complete Schedule 0

24c
24d
25a

25b

26

27

28a

28b

28c
29

X
X

30

31

32

33

34

X
X

35a

35b
36

37
38
Form

OM

X
X
990 (2013)

203907/21/2014924

Fonn990(2013)

Part V

1a
b
c
2a
b
3a
b
4a

AM

American College

of Lifestyle

Med

32-0208451

Page

Statements Regarding Other IRS Filings and Tax Compliance


Check if Schedule 0 contains a response or note to any line In this Part V

Enter the number reported in Box 3 of Fonn 1096. Enter -0- If not applicable
Enter the number of Fonns W-2G included In line 1a. Enter -0- if not applicable
Did the organization comply with backup withholding rules for reportable payments to vendors and
reportable gaming (gambling) winnings to pnze winners?
Enter the number of employees reported on Fonn W-3, Transmittal of Wage and Tax

o
Yes

I 1a I

b
7
a
b
c
d
e
f
g
h

9
a
b
10
a
b
11
a
b
12a
b
13
a
b
c
14a
b
OM

No

1b
1c

Statements, filed for the calendar year ending with or within the year covered by this return
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?
Note. If the sum of lines 1a and 2a ISgreater than 250, you may be required to e-file (see Instructions)
Did the organization have unrelated busmess gross Income of $1,000 or more dunng the year?
If Yes," has it filed a Fonn 990-T for trus year? If "No" to line 3b, provide an explanation in Schedule 0
At any time dunng the calendar year, did the organization have an Interest in, or a signature or other authonty
over, a financial account In a foreign country (such as a bank account. securities account, or other financial
account)?
If "Yes," enter the name of the foreign country. ~

3a
3b

4a

5a
5b
5c

Did any taxable party notify the organization that It was or ISa party to a prohibited tax shelter transaction?
If Yes" to line 5a or 5b, did the organization file Fonn 8886-T?
Does the organization have annual gross receipts that are nonnally greater than $100,000, and did the
organization sohcrt any contnbutlons that were not tax deductible as charitable contributions?
If "Yes," did the organization include with every sohotanon an express statement that such contnbuuons or
gifts were not tax deductible?
Organizations that may receive deductible contributions under section 170(c).
Did the organization receive a payment In excess of $75 made partly as a contribution and partly for goods
and services provided to the payor?
If "Yes," did the organization notify the donor of the value of the goods or services provided?
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which It was
required to file Fonn 8282?
If 'Yes." indicate the number of Fonns 8282 filed dunng the year
Did the organization receive any funds, directly or Indirectly, to pay premiums on a personal benefit contract?
Did the organization, dunng the year, pay premiums, directly or Indirectly, on a personal benefit contract?
If the organization received a contnbunon of quahfied Intellectual property, did the organization file Fonn 8899 as required?
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Fonn 1098-C?
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting
organizations. Did the supporting organization, or a donor advised fund maintained by a sponsonng
organization, have excess business holdings at any time dunng the year?
Sponsoring organizations maintaining donor advised funds.
Did the organization make any taxable drstnbutions under section 4966?
Did the organization make a distnbution to a donor, donor advisor, or related person?
Section 501(c)(7) organizations. Enter:
Initiation fees and capital contributions included on Part VIII, line 12
110a 1
Gross receipts, included on Fonn 990, Part VIII, hne 12, for pubhc use of club facihties
10b
Section 501(c)(12) organizations. Enter:
Gross income from members or shareholders
11a
Gross income from other sources (Do not net amounts due or paid to other sources
against amounts due or received from them.)
L.-:.1..:.1b::..L.
Section 4947(a)(1) non-exempt charitable trusts. Is the organization fihng Fonn 990 in heu of Fonn 1041?
If "Yes," enter the amount of tax-exempt interest received or accrued dunng the year
1L.-:.1:2b::.I.l-I
Section 501(c)(29) qualified nonprofit health insurance issuers.

2b

See Instructions for filing requirements for Fonn TD F 90-22.1, Report of Foreign Bank and Fmancial Accounts
5a Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?
b
c
6a

6a

x
x
x

x
x

6b

7a
7b
7c
7e
7f
7g
7h

8
9a
9b

--1
1-1.:..:2::=a=+-_-+__
-I

Is the organization licensed to issue quahfied health plans In more than one state?
1-'-13;;.;a,,+_--+
__
Note. See the instructions for additional infonnation the orqaruzauon must report on Schedule O.
Enter the amount of reserves the organization is required to maintain by the states in which
the organization ISlicensed to issue quahfied health plans
Ir1.::.3b:.t-I
-I
Enter the amount of reserves on hand
13c
~~--------------~r_~--_+~Did the organization receive any payments for indoor tanning services dunng the tax year?
14a
X
If "Yes has it filed a Fonn 720 to report these payments? If "No," provide an explanation in Schedule 0
14b
Form

990 (2013)

---------------------------------------------------------------------

---

-----

203907/2112014924 AM

Form 990(2013)

American

College

of

Lifestyle

Med

32-0208451

Page

Part Vl

Governance, Management, and Disclosure For each "Yes" response to lines 2 through 7b below, and for a "No"
response to line 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule 0 contains a response or note to any line in this Part VI
[L
Section A Governing Bodv and Management
Yes
1a

Enter the number of voting members of the governing body at the end of the tax year
If there are matenal differences In votmg nghts among members of the governing body, or

No

1a

if the governing body delegated broad authonty to an executive committee or Similar


committee, explain in Schedule 0
b

Enter the number of voting members included In line 1a, above, who are Independent
Old any officer, director, trustee, or key employee have a family relationship or a business relationship With

1b

any other officer, director, trustee, or key employee?


Old the organization delegate control over management duties customarily performed by or under the direct
supervision of officers, directors, or trustees, or key employees to a management company or other person?
Did the organization make any Significantchanges to ItSgoverning documents since the prior Form 990 was filed?

3
4
5
6
7a
b
8
a
b
9

Old the organization become aware dunng the year of a Significant diversion of the organization's assets?
Did the organization have members or stockholders?
Old the organization have members, stockholders, or other persons who had the power to elect or appoint
one or more members of the governing body?
Are any governance decisions of the organization reserved to (or subject to approval by) members,
stockholders, or persons other than the governing body?
Old the organization contemporaneously document the meetings held or written actions undertaken dunng the year by the follOWing:
The governing body?
Each committee with authority to act on behalf of the governing body?
Is there any officer, director, trustee, or key employee listed In Part VII, Section A, who cannot be reached at
the organization's mailing address? If "Yes," prOVidethe names and addresses in Schedule 0

Section B. Policies

3
4
5
6

X
X
X
X

7a

7b

X
X
X

8a
8b

9
(This Section B requests information about coheres not required by the Internal Revenue Code.)
Yes

10a
b

Old the organization have local chapters, branches, or affiliates?


If "Yes," did the organization have written policies and procedures governing the acuvities of such chapters,
affiliates, and branches to ensure their operations are consistent With the organization's exempt purposes?
11a Has the organization provided a complete copy of this Form 990 to all members of Its governing body before filing the form?
b Describe in Schedule 0 the process, If any, used by the organization to review thiS Form 990.
12a Old the organization have a written conflict of Interest policy? If "No," go to line 13
b Were officers, directors, or trustees, and key employees required to disclose annually interests that could give rise to conflicts?
c Did the organization regularly and consistently monitor and enforce compliance Withthe policy? If "Yes,"
descnbe in Schedule 0 how ttus was done
13
Old the organization have a wntten wtllstleblower policy?
14
Old the organization have a written document retention and destruction policy?
15
Did the process for determining compensation of the following persons Include a review and approval by
Independent persons, comparability data, and contemporaneous substantiation of the deliberation and decrslon?
a The organization's CEO, Executive Director, or top management official
b Other officers or key employees of the organization
If "Yes" to line 15a or 15b, descnbe the process in Schedule 0 (see instructions)
16a Old the organization invest in, contnbute assets to, or participate in a jomt venture or Similar arrangement
Witha taxable entity dunng the year?
b If "Yes," did the organization follow a wntten policy or procedure requmnq the organization to evaluate its
paruopanon in joint venture arrangements under applicable federal tax law, and take steps to safeguard the
organization's exempt status Withresp_ectto such arrangements?

No

10a

10b
11a

X
X

12a
12b
12c
13
14

X
X

15a
15b

X
X

16a

16b

Section C. Disclosure

17

List the states Withwhich a copy of this Form 990 ISrequired to be filed....

18

Section 6104 requires an organization to make ItS Forms 1023 (or 1024 If applicable), 990, and 990-T (Section 501(c)(3)s only)
available for public inspection. Indicate how you made these available Check all that apply.

o
19
20

Own website
Another's website
Upon request
Other (explain in Schedule 0)
Describe in Schedule 0 whether (and if so, how) the organization made ItSgoverning documents, conflict of interest policy, and
financial statements available to the public dunng the tax year.
State the name, physical address, and telephone number of the person who possesses the books and records of the
organization.... Susan Benigas
PO Box 6432

Chesterfield
OM

None

MO 63006
Form

990

(2013)

203907/2112014924

AM

Form990(2013)

Part VII

American

College

of

Lifestyle

Med

32-0208451

Page 7

Compensation of Officers, Directors, Trustees, Key Employees, Highest Compensated Employees, and
Independent Contractors
Check if Schedule 0 contains a response or note to any line in this Part VII

Section A.

Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees

1a Complete this table for all persons required to be listed Report compensation for the calendar year ending Withor Within the
organization's tax year
List all of the organization's current officers, directors, trustees (whether Individuals or organizations), regardless of amount of
compensation Enter -0- in columns (0), (E), and (F) If no compensation was paid.
List all of the organization's current key employees, If any. See instructions for definition of "key employee"
List the organization's five current highest compensated employees (other than an officer, director, trustee, or key employee)
who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the
organization and any related organizations.
List all of the organization's former officers, key employees, and highest compensated employees who received more than
$100,000 of reportable compensation from the organization and any related organizations.
List all of the organization's former directors or trustees that received, In the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.
List persons In the follOWingorder: individual trustees or directors, institutional trustees; officers, key employees; highest
compensated employees; and former such persons

[!] Check this box If neither the organization nor any related organizations compensated any current officer, director, or trustee
(A)
Name and TItle

(8)
Average
hours per
week
(hst any
hours for
related
orqamzauons
below dotted
hne)

(C)
Position
(do not check more than one
box, unless person IS both an
officer and a director/trustee)
0

3i

"!!l

"':':
3<5

'T1
0

~~

!!l

'"

'0 =r

3
"!2.

mg

CD
'<
CD

-c
CD
CD

(0)

(E)

(F)

Reportable
compensation
from
the
organization

Reportable
compensation from
related
orqamzauons

Esbmated
amount of
other
compensabon
from the
organlzabon
and related
orqaruzauons

(W2Jl0GGMISCj

(W-2Jl099-MISC)

'0

~
II>

10

Co.

(1)David

Katz

President
(2) George

Treasurer

4.00
0.00

4.00
0.00

4.00
0.00

Edshteyn

secretary
(4) Wayne

Guthrie

President Elect
(3) Ingrid

4.00
0.00

Dysinger

(5)

(6)

(7)

(8)

(9)

(10)

(11)

OM

Form

990 (2013)

203907/21/2014924AM
Form 990 ~2013) American College
of
Part
Section A. Officers, Directors, Trustees,

vn

(A)
NameandbUe

(8)

Lifestyle
Key Employees,

Med

32 - 0208451

and Highest Compensated

Page

Employees

(0)

(C)

Average
Posruon
hoursper
(donotcheck morethanone
week
box,unlesspersonIS bothan
(listany
officeranda director/trustee)
hoursfor
g
'":1: "T'I
0
e 3<i5 0
related
3;
-c
"'"0::.CD
orgamzabons ~
g
o~ 3!!l
"
3
a
"0
belowdolled
g
c- 3
-c
line)
1il

'"

..

(F)

(E)

Reportable
compensabon
from
the
organlzabon
(W-211099-MISC)

(continued)

Reportable
compensabon
from
retated

Esbmated
amountof
other
compensabon
fromthe
orgamzabon
andrelated
orgaOlzabons

orqaruzaucne

(W-211099-MtSC)

i8
a

'"

'"

C1.

(12)

(13)

(14)

(15)

(16)

(17)

(18)

(19)

1b
c
d
2

....
Sub-total
....
Total from continuation sheets to Part VII, Section A
Total (add lines 1b and 1cl
....
Total number of individuals (including but not limited to those listed above) who received more than $100,000 In
reporta bIe compensation fr am th e organization .... 0

Old the organization list any former officer, director, or trustee, key employee, or highest compensated
employee on line ta? If "Yes," complete Schedule J for such mdividual
For any Individual listed on line 1a, IS the sum of reportable compensation and other compensation from the
organization and related organizations greater than $150,000? If "Yes," complete Schedule J for such
individual
Old any person listed on line 1a receive or accrue compensation from any unrelated organization or Individual
for services rendered to the organization? If "Yes," complete Schedule J for such person

Yes

..

No

Section B. Independent Contractors


1 Complete this table for your five highest compensated independent contractors that received more than $100,000 of
. .
..
s tax year.
Report compensation ~or the ca Ien dar year en dmowith
Ing Wit or Within th e organization
compensation fr am the orqanlzation.
(A)
Name andbusiness address

2
OM

Total number of independent contractors (including but not limited to those listed above) who
received more than $100,000 of compensation from the orqarnzanon ....

(8)
Descnpbon of services

(C)
Comliensabon

0
Form

990 (2013)

AM

203907/21/2014924

Form990(2013)

American College

of Lifestyle

Med

32-0208451

Page

Part VIII . Statement of Revenue


Check if Schedule 0 contains a response or note to any line in this Part VIII
(A)

Total revenue

....
..

.:::I.e
.0 ..
:sO
C-c

d Related organizations
e Governmentgrants (contnbulJons)

Oc
CI>
:::3
I:
CI>

i;
0::
CI>

u
.~
CI>

en

E
I!!

0..

Revenue
exduded from tax
under sections

revenue

512514

1d
1e

f All other contnbubons,giftS,grants,

"QI

0111

(0)

1a
1b
1c

Cc 1a Federated campaigns
111:::1
b Membership dues
"0
~E
c Fundratsmq events
CI=
uiE
coCl)

D
(C)
Unrelated
business

revenue

(1)(1)

~~
.- III

(B)
Related or
exempt
function

and similar amounts not Includedabove

1f

9 NoncashcontnbubonsIncludedIn lines la-It


h Total. Add lines 1a-11

...
Busn. Code

2a
b
C

211,210
85,716
-1,178

Membership fees
Conference Sponsorship
Refunds

211,210
85,716
-1,178

d
e
f All other program service revenue
9 Total. Add lines 2a-2f
3 Investment income (Including dividends, Interest,
and other similar amounts)
4 Income from investment of tax-exempt bond proceeds ...
5 Royalties

...
...

295,748

...

(I) Real

(II) Personal

6a Gross rents
b Less rental exps
C Rental me or (loss)

d Net rental Income or (loss)


7a Gross amountfrom
(I) Secunbes
sales of assets
other than Inventor.

...
(II) Other

b Less cost or other


basrs & sales exps
C Gain or (loss)

QI

:::I

c
GI
>
GI

..

0::
GI

s:

d Net gain or (loss)


8a GrossIncomefromfundraisingevents
(notincluding$
of contnbuttons
reportedon line1c)
SeePartIV,line18
a
b
b Less: direct expenses
c Net income or (loss) from fundraisin events
9a GrossIncomefromgamingacnvmes,
SeePartIV,line19
a
b
b Less. direct expenses
c Net Income or (loss) from gaming activities
10a Gross sales of inventory, less
returns and allowances
a
b
b Less' cost of goods sold
c Net income or (loss) from sales of Inventory
Miscellaneous Revenue

...

...
...
...
Busn. Code

11a
b
c
d All other revenue
e Total. Add lines 11a-11d
12 Total revenue. See Instructions.

...
...

295,748

295,748

0
Form

OM

990 (2013)

2039 07/2112014 9 24 AM

Form 990(2013)

Part IX

American College

of Lifestyle

32-0208451

Med

Section 501(c)(3) and 501 (c)(4) organizations must complete all columns All other organizations
Check If Schedule 0 contains a response or note to any line in this Part IX
Do not include amounts reported
7b, 8b, 9b, and 10b of Part VIII.
1
2
3

(A)

on lines 6b,

T otal

Grants and other assistance to govemments and


organizations In the U S See Part IV, line 21
Grants and other assistance to indiViduals

Compensationnot Included above, to disqualified


persons (as defined under section 4958(n(1)) and
persons descnbed In section 4958(c)(3)(B)
Other salanes and wages
Pension plan accruals and contnbutlons (Include
section 401(k) and 403(b) employer contnbutlons)
Other employee benefits
Payroll taxes
Fees for services (non-employees)
Management
Legal
Accounting
Lobbying
Professionalfundraising services See Part IV, line 17
Investment management fees
Other(Ifhne119 amountexceeds10% ofhne25, column
(A) amount hsthne119 expenses
onSchedule
0)
Advertismq and promotion
Office expenses
Information technology
Royalties
Occupancy
Travel
Payments of travel or entertainment expenses
for any federal, state, or local public officials
Conferences, conventions, and meetings
Interest
Payments to affiliates
Depreciation, depletion, and amortization
Insurance
Other expenses. Itemize expenses not covered
above (List miscellaneous expenses In line 24e If
line 24e amount exceeds 10% of line 25, column
(A) amount, list line 24e expenses on Schedule0.)

c
d
e
f
9
12
13
14
15
16
17
18
19
20
21
22
23
24

a
b

(C)

(0)

Management
and
generalexpenses

r1

Fundralsong
expenses

In

9
10
11
a

expenses

(8)
Programservice

the U.S See Part IV, line 22


Grants and other assistance to govemments,
organizations, and Individuals outside the
US See Part IV, lines 15 and 16
Benefits paid to or for members
Compensation of current officers, directors,
trustees, and key employees

10

must complete column (A)

expenses

4
5

Page

. Statement of Functional Expenses

Workshop
B~k charges
Newsletter
Telephone

d
e All other expenses
25 Totalfunctionalexpenses.Add hnes1 through24e
26 Joint costs. Complete this line only if the
organization reported in column (B) joint costs
from a combined educational campaign and
fundralslng sonctaaon Check here ~
if
following SOP 98-2 (ASC 958-720)
OM

2,989

2,989

1,147

1,147

12,945

12,945

2,000

2,000

212,984
12,103
735
666
2,009
247,578

212,984
12,103
735
666
2,009
247,578

Fcnn 990 (2013)

2039 07/2112014 9 24 AM

Form 990 (2013)

Pari X

American College

of Lifestyle

32-0208451

Med

Page

11

. Balance Sheet
Check if Schedule 0 contains a response or note to any line in this Part X
(B)
End of year

(A)
Beginning of year

9,500

Cash--non-Interest bearing
Savings and temporary cash investments

3
4

Pledges and grants receivable, net


Accounts receivable, net
Loans and other receivables from current and former officers, directors,
trustees, key employees, and highest compensated employees

3
4

Complete Part II of Schedule L


Loans and other receivables from other disqualified persons (as defined under section
4958(f)(1)), persons descnbed in section 4958(c)(3)(8), and contnbutmq employers and
sponsonng organizations of section 501(c)(9) voluntary employees' beneficiary

VI
VI

7
8
9
10a

26
VI
G)

o
c::

ftI

iii

III
"tI

c::

..

27
28
29

::::I
u,
0
VI

GiVI 30

..
VI

<
G)

31
32
33
34

of Schedule D
Total liabilities. Add lines 17 tnrouoh 25
Organizations that follow SFAS 117 (ASC 958). check here ~
and
complete lines 27 through 29. and lines 33 and 34.
Unrestncted net assets
Temporanly restncted net assets
Permanently restricted net assets
Organizations that do not follow SFAS 117 (ASC 958). check here ~
~
complete lines 30 through 34.
Capital stock or trust princtpal, or current funds
Paid-in or capital surplus, or land, buildmq, or equipment fund
Retained eamings, endowment, accumulated Income, or other funds
Total net assets or fund balances
Total liabilities and net assets/fund balances

57,670

6
7
8
9

organizations (see instructions). Complete Part II of Schedule L


Notes and loans receivable, net
<
Inventones for sale or use
Prepaid expenses and deferred charges
Land, buildmqs, and equipment: cost or
10a
other basis. Complete Part VI of Schedule D
10b
b Less: accumulated depreciation
11 Investments-publicly traded secunnes
12 Investments-other secunnes. See Part IV, line 11
13 Investments-program-related See Part IV, line 11
14 Intangible assets
15 Other assets See Part IV, line 11
16 Total assets. Add lines 1 throuqh 15 (must equal line 34)
17 Accounts payable and accrued expenses
18 Grants payable
19 Deferred revenue
20 Tax-exempt bond liabilities
21 Escrow or custodial account liability. Complete Part IV of Schedule D
VI
22 Loans and other payables to current and former officers, directors,
G)
trustees, key employees, highest compensated employees, and
~
:E
disqualified persons. Complete Part II of Schedule L
ftI
:::i 23 Secured mortgages and notes payable to unrelated third parties
24 Unsecured notes and loans payable to unrelated third parties
25 Other liabilities (including federal Income tax, payables to related third
parties, and other liabilities not Included on lines 17-24). Complete Part X

J!l
G)

1
2

1
2

9,500

10c
11
12
13
14
15
16
17
18
19
20
21

57,670

22
23
24

25
26

27
28
29
and

9,500
9,500
9,500

30
31
32
33
34

57,670
57,670
57,670
Form

OM

990 (2013)

203907/2112014924 AM

Form 990 (2013)

Part Xl

American College

of Lifestyle

Med

32-0208451

Page

. Reconciliation of Net Assets

Check if Schedule 0 contains a response or note to any line in this Part XI


1
2
3
4

Total revenue (must equal Part VIII, column (A), line 12)
Total expenses (must equal Part IX, column (A), line 25)

Net unrealized gains (losses) on Investments


Donated services and use of facilitJes
Investment expenses
Pnor period adjustments

5
6
7

Other changes In net assets or fund balances (explain In Schedule 0)


Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line
33, column (B

6
7

8
9
10

Part XU

295,748
247,578
48,170
9,500

1
2
3
4

Revenue less expenses. Subtract line 2 from line 1


Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A))

57,670

10

Flnancial Statements and Reportmg

Check If Schedule 0 contains a response or note to any line In this Part XII
1

AccountJngmethod used to prepare the Form 990

Cash

D Accrual

Yes
Other

If the organization changed Its method of accounting from a pnor year or checked "Other," explain in
Schedule O.
2a Were the organization's financial statements compiled or reviewed by an Independent accountant?
If "Yes," check a box below to indicate whether the financral statements for the year were compiled or
reviewed on a separate basis, consolidated basis, or both:

2a

2b

required audit or audits, explain why in Schedule 0 and describe any steps taken to undergo such audits

2c

3a

3b
Form

OM

No

Separate basis
Consolidated basis
Both consolidated and separate basts
b Were the organization's financial statements audited by an independent accountant?
If "Yes." check a box below to indicate whether the financial statements for the year were audited on a
separate basis, consolidated basis, or both.
Separate basis
Consolidated basis
Both consolidated and separate basis .
c If "Yes" to line 2a or 2b, does the organization have a committee that assumes responsibility for oversight
of the audit, review, or compilation of ItSfinancial statements and selection of an independent accountant?
If the organization changed either ItSoversight process or selection process dunng the tax year, explain in
Schedule O.
3a As a result of a federal award, was the orqaruzation required to undergo an audit or audits as set forth In
the Single Audit Act and OMB Circular A-133?
b If "Yes," did the organization undergo the required audit or audits? If the organization did not undergo the

12

990 (2013)

..

2039 07/2112014924 AM

SCHEDUL 0

Supplemental Information to Form 990 or 990EZ

OMS No 1545-004 7

(Form. 990 or 990-EZ)

Complete to provide information for responses to specific questions on


Form 990 or 990-EZ or to provide any additional information.

2013

Department of the Treasury


tntemal Revenue Service

... Attach to Form 990 or 990-EZ.


... Information about Schedule 0 (Form 990 or 990-EZ) and its instructions Is at www.irs.gov/form990.

Name of the orqaruzauon

Open to Pubnc
Inspection

Employer Identification number

American Colle e of Lifest 1e Med

32-0208451

Form 990, Part III, Line 4d - All Other Accomplishment


Provide workshops

~orm 990, Part VI, Line 11b - Organization's Process to Review Form 990
No review was or will be conducted.

~orm 990, Part VI, Line 19 - Governing Documents Disclosure Explanation


No documents available to the public

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
DM

Schedule 0 (Form 990 or 990-EZ) (2013)

---------------------------------------------------------------------------------------.,

20390511312014900 AM

,.

8868

Form

Application for Extension of Time To File an


Exempt Organization Return

(Rev. January 2014)

OMB No 1545-1709

.... File a separate application for each return.


....Information about Form 8868 and its Instructions is at www.irs.gov/form8868.

Department of the Treasury


Intemal Revenue ServIce

.... X

If you are filing for an Automatic 3-Month Extension, complete only Part I and check thrs box
If you are filing for an Additional (Not Automatic) 3-Month Extension, complete only Part II (on page 2 of this form)
Do not complete Part II unless you have already been granted an automatic 3-month extension on a previously filed Form 8868.
Electronic filing (e-file). You can electronically file Form 8868 If you need a 3-month automatic extension of time to file (6 months for
a corporation required to file Form 990-T), or an additional (not automatic) 3-month extension of time You can electronically file Form
8868 to request an extension of time to file any of the forms listed In Part I or Part II with the exception of Form 8870, Information
Return for Transfers ASSOCiated
With Certain Personal Benefit Contracts, whtch must be sent to the IRS In paper format (see
mstrucnons) For more details on the electromc filing of tms form, VISitwww.lrs gov/efile and dick on e-file for Chanties & Nonprofits

Part I

Automatic 3-MonthExtension of Time. Only submit anginal (no copies needed).

A corporation required to file Form 990-T and requesting an automatic 6-month extension - check thrs box and complete
Part I only
All other corporations (including 1120-C filers), partnerships, REMICs, and trusts must use Form 7004 to request an extension of time
to file income tax returns
Enter filer's identifying number see instructions
Employer Identification number (EIN) or

Name of exempt orqaruzation or other filer, see instructions

Type or
print
FIle by the
due dale lor
filing your
relum See
Instructions

American Colleqe of Lifestvle Med

32-0208451

Number, street, and room or suite no If a PObox,

Social secunty number (SSN)

see mstrucnons

612 Glatt Circle


City, town or post office, state, and ZIP code For a foreign address, see instructions

Woodburn

OR 97071

Enter the Return code for the return that thrs application ISfor (file a separate application for each return)
Return
Code
01
02

Application
Is For
Form 990 or Form 990-EZ
Form 990-BL
Form 4720 (IndiVidual)
Form 990-PF
Form 990-T (sec 401(a) or 408(a) trust)
Form 990-T (trust other than above)

03
04
05
06

Application
Is For
Form 990-T (corporation)
Form 1041-A

Return
Code
07
08
09
10
11
12

Form 4720 (other than individual)


Form 5227
Form 6069
Form 8870

Marc Braman
612 Glatt Circle
Thebooksaremthecareof ....Woodburn

Telephone No ....

971-983-5383

OR 97071
FAX No ....

If the organization does not have an office or place of business In the United States, check ttus box
If ttus ISfor a Group Return, enter the organization's four digit Group Exemption Number (GEN)
for the whole group, check ttus box
....
If It ISfor part of the group, check thrs box
....

If thrs IS

0 and attach

a list Withthe names and EINs of all members the extension ISfor
1
I request an automatic 3-month (6 months for a corporation required to file Form 990-T) extension of time
until 08/15/14 ,to file the exempt orqaruzatron return for the organization named above The extension IS
for the organtzation's return for
.... ~ calendar year 2013
or

....
0

tax year beginning


, and ending
If the tax year entered In line 1 ISfor less than 12 months, check reason
chance In accounnnq penod

0 lrutral return 0 Final return

If tms apphcanon ISfor Forms 990-BL, 990-PF, 990-T, 4720, or 6069, enter the tentative tax, less any
nonrefundable credits See instructions

3a

If tlus apphcauon ISfor Forms 990-PF, 990-T, 4720, or 6069, enter any refundable credits and
esltmated tax payments made. Include any pnor year overpayment allowed as a credit

3b

Balance due. Subtract line 3b from nne 3a Include your payment Withttus form, If required, by usmq
EFTPS (Electronic Federal Tax Payment System). See instructions

3a

3c
$
Caution. If youaregomgto makeanelectronicfundswithdrawal(directdebrt)WiththiSFonn8868,seeFonn8453-EOandFonn8879EOforpaymentinstructions
For Privacy Act and Paperwork Reduction Act Notice, see Instructions.
Fonn 8868 (Rev
OM

0
1-2014)