Form 990 Questionnaire

Please be sure to provide a complete questionnaire (we get a lot of incomplete questionnaires).
Unless stated otherwise, all questions relate to the fiscal year reported on this Form 990.
This info will get us started. It is possible we will need additional info as the process goes forwardif so, well contact you.
The filing deadline is the 15th day of the fifth month after the end of your fiscal year (May 15 if you operate on a calendar year basis); we need your
data as soon after your fiscal year-end as possible but not later than 10 days before the filing deadline. Otherwise, we will probably need to apply for
a three-month filing extension.
Send the requested material to MCG: (We strongly prefer you send documents like this that contain sensitive info via our secure web portal)
MCGs web portal https://mcgtax.securefilepro.com/portal/login.aspx?ReturnUrl=%2fportal%2ffiles%2ffilesmain.aspx
Forgot your password? Click the Lost Password link. Dont have a web portal account? Contact us.
Or mail to MCG; 107 W Main St; Fulton OH 43321-9702; or fax to: 614-340-7909.
If you have questions, please call 614-743-2106.
By submitting this questionnaire to MCG, you are certifying that the information it contains is accurate and complete and that it may be
relied upon for the purpose of preparing Form 990 or Form 990EZ or Form 990-N for the period indicated herein.

A. Info about your organization:

Federal ID number
Organizations name
Organizations address
Check here if this is a change of address from last year
Organizations phone Organizations web site
Organization is a Corporation Trust Association
Date incorporated State where incorporated
Month fiscal year ends
Principal officer's name Principal officer's phone
Did your organization cease operations this year? Yes No
Did your organization engage in significant program services this year not reported on any
Yes No
previous Form 990? (if yes, provide a complete explanation).
Did your organization cease conducting or make significant changes to any program services? (if
Yes No
yes, provide a complete explanation).

B. Who will sign the Form 990? Name: Position:

C. This info was provided by: Name: Phone:

E-mail:

D. Has your organization filed Form 1023 (application for IRS recognition of tax-exempt status)?

Yes, we have received an approval letter from the IRS

Yes, it has been submitted to the IRS but we are awaiting final approval
No, our revenue is low enough (less than $5000/year) that we are not required to file Form 1023
No, we need MCG's assistance in preparing Form 1023 (MCG will send another questionnaire to get the necessary info)
No, we plan to prepare/file Form 1023 on our own before the filing deadline
E. In a sentence or two (220 or fewer characters), describe your organization's mission:

F. Who has custody of the bookkeeping records? Name:

Address: Phone:

H. Did you receive more than $1000 of unrelated business income (UBI). Income is UBI if the activity that produced it is not related to
your exempt purpose, even if the income it generated is used exclusively to advance your exempt purpose. Note that regularly
carried-on internet sales are almost always considered UBI.

Yes (provide details in the explanation section) No

I. Is your organization required to file a year-end report with one of more states?
Yeswith the following state(s) and:
we want MCG to prepare it
we will prepare it ourselves.
If yes, ignore the rest of this page and complete the remainder of this questionnaire
No
J. Complete this chart:
Gross Income
(from all sources)
Current report year
First previous year
Second previous year
Average income *

* Average Income is the total of the three years divided by the number of years that had a balance greater than zero.
Was your organizations average gross income greater than:

$75,000 if this was your very first year, or

$60,000 if your organization has existed 1-3 years, or
$50,000 if your organization has existed more than 3 years?

If yescomplete the remainder of the questionnaire

If noyou do not need to complete the remainder of this questionnaire; return only pages 1 and 2 of the questionnaire.

2
1. Board Members & Corporate Officers include former members/officers if they served at any time during the report year
Check here if any board member or officer can NOT be reached at the organizations' address and provide their address on the last page.

OrgHrs/Week This

OrgsHrs/Wk Related

from This Org

Annual Comp

Related Orgs

Benefits from
Board Mbr?

Comp from
Position(s) (e.g., board

This Org
Former?
Officer?
Name member, President, etc.)
(List all that apply)

1)

2)

3)

4)

5)

6)

7)

8)

9)

10)
2. List any other person or entity (other than corporations) to whom you paid $100,000 or more for services rendered during the report
year
Note: these entities should have received Form 1099-MISC for these payments. Compensation includes salaries, wages, housing allowances, bonuses, stipends,
contractor payments, etc; do not include purchases of merchandise; do include the cost of parts if they were associated with services rendered.
Name Position Address Compensation Benefits
1)
2)
3)
4)
5)

ReceivedGrants
Revenue **Direct
UtilizedVolunteers
Impacted# People

3. In no more than 1-3 brief sentences each, describe your top program service Expenses *
accomplishment(s).

1)

2)

3)

4)

5) All other programs

Total expenses (this total must equal the Program Expense total in #35 below)
* Dont forget to include the value of donated services in program expenses if those expenses are included in the program expenses column of question #35 below.
** Direct revenue includes any revenue derived directly from the activity, such as fees for services or from the sale of goods that directly relate to the listed activity. This
revenue includes program service revenue investment income, royalties, rents, net sales of inventory, and fundraising event income.

3
Question Yes No Explanation and/or Response
prepared by MCG
Not preparednot required to file
4. Last year's Form 990 was. . . Not preparedrequired to file but did not do
so
Prepared elsewheresend a copy of last
TWO years Forms 990
Religious Charitable
5. Check the exempt purpose(s) for which the organization exists as
stated in your Articles of Incorporation, Code of Regulations, Educational Scientific
Constitution, or By-Laws (check all that apply; if you are not sure, Literary Testing for public safety
refer to your Articles of Incorporation or to a previous Form 990 or to Amateur sports
Form 1023):
Prevention of cruelty to children or animals
6. Are any board members or corporate officers related to one another

(by blood, marriage, or significant business/financial dealings)? Explain

7. How many times did the board of directors meet?

8. Were all board and committee meetings and decisions
contemporaneously documented (i.e., did you keep minutes)?
9. a. Number of voting board members a.
b. Number of independent voting board members (i.e., not related to
another board member; not on the organization's payroll) b.

10. Does any board member or officer (or anyone related to them) also
serve on the board of any entity with whom this organization has a
Explain
business or other significant relationship?
11. Did the organization make any loans to or receive loans from any
board member, officer or other person with whom it has a significant
Explain
business/financial relationship (or anyone related to them)?
12. Did any person or entity receive an economic benefit OR use any of
the organizations resources that was: a. a. a.
Explain
a. Not formally authorized by the organization
b. b. b.
b. Not reasonable in nature or amount Explain
c. Not properly reported for tax purposes c. c. c.
Explain
Form 1099-MISC
From W2G
13. How many of these tax forms did you issue for the report year?
Form W2 (if greater than 0, check here if you
filed all required employment tax returns )
14. Did the organization have an interest in or signature authority over a

financial account (of any type) in a foreign country? Explain

15. Did the organization receive non-cash contributions (not including the
value of donated services or donated facilities) with an aggregate
Explain
value over $25,000 during the year?
16. Did the organization invest in, contribute assets to, or participate in a

joint venture or similar arrangement with a taxable entity? Explain

17. Was the organization involved a partnership or other joint venture for
which Schedule K-1 (Form 1065) was received? If yes, send a copy of Sch K-1; K-1 income usually
Explain
must be treated as unrelated business income.
18. Did the organization lobby any legislative body (Congress, state

legislature, city council, school board, etc)? Explain

19. Did you make significant changes to what you do or to your governing
documents since the latter of a) the date your Form 1023 was Explain

4
 approved or b) filing your most recent Form 990?
Question Yes No Explanation and/or Response
20. Do you have a written conflict of interest policy? If no, check here if you desire to hire MCG to assist
in creating one
21. Do you have a written whistle blower policy? If no, check here if you desire to hire MCG to assist
in creating one
22. Do you have a written document retention and destruction policy? If no, check here if you desire to hire MCG to assist
in creating one
23. Are officers, directors and key employees required to annually report

any interests that could result in a conflict of interest? Explain

24. Did the organization engage in a business transaction with any

current or former (who served in the previous five years) board

member, officer or key employee, or any person related to such a Explain
person or any business in which such a person is involved?
25. Is all compensation for officers, directors and key employees subject
to each of the following (hint: it must be!): a) review and approval by
the board independent of undue influence from the affected
employee, b) a review of compensation data for people in comparable
positions with other organizations, and c) written documentation of
the entire decision making process and final result.
26. Did you solicit any donations that were not tax deductible?
27. Did you receive one or more payments in excess of $75 made partly
as a contribution and partly in exchange for goods or services
provided to the payer? Explain

If yes, did you notify the donor of the value of the goods or services
provided and include only the net amount in the donation receipt?
28. Did all donation acknowledgments include all five of the following: a)
your organization's name, b) your organization's address, c) the
donor's name, d) a list itemized by date of all donations (i.e., not just
a total), e) a disclaimer statement (such as, 'Donor received no goods
or services in exchange for these donations'.
29. a. Did you receive a donation of an airplane, boat or car? a. a. a.
Explain
b. If yes, did you issue Form 1098-C to the donor and to the IRS? b. b.

30. a. Did you sell, exchange, or otherwise dispose of any donated car a. a. a.
(valued at $500 or more) or any other item (valued at $5000 of Explain
more) within two years of receiving the donated item? b. b.
b. If yes, did you issue Form 8282 to the donor and to the IRS?
31. Were any changes made to beginning net assets (other than

recording current year net income)? Explain

5
Financial Data
We were a MCG' AdMinistry client at the end of the report year: you do not need to complete the Items in red. Responses to all other
questions are still required.
We were NOT a MCG' AdMinistry client at the end of the report year: ALL of the financial data questions on the following pages must be
completed. We cannot complete Form 990 without this information!
In lieu of providing this financial data you can send a balance sheet, income statement, and donor summary (including address info);
however, that will probably require more of our time to parse the data which could result in a commensurately greater preparation fee. We
are happy to do that; we just want to make you aware of this potentially cost saving option.
Report all income and expenses for the report period (i.e., your fiscal year). If your fiscal year is not a calendar year, your payroll expenses
may be different than the amount reported on your Forms W-2 (which must be reported on a calendar year basis).
32. Accounting basis: Accrual Cash Modified cash

33. Income for the report year (prior year data needed only if MCG did not prepare your Form 990 last year). Please round all amounts to the
nearest dollar (no cents)
First Second
Income Categories Report Year
Previous Year Previous Year
Federal campaigns
Membership dues
Fundraising events; if the amount is $15,00 or more please provide

below a description and income/expense report for each event
Direct expenses for fundraising events
Income from related organizations
Government grants
All other donations, gifts, & grants
Value of donated high-end professional services not included above *
Value of other non-cash donations received *
Program fees:
Program fees:
Program fees:
Program fees:
Interest & other investment income
Royalty income
Gross rental income
Less: rental expenses
Gross proceeds from sales of assets other than inventory
Less: costs basis of assets sold
Sales of inventory items
Cost of inventory items purchased (whether sold or still in inventory)
Total Income
* Include only if you use the accrual basis of accounting; if you record non-cash amounts also complete #40 below.

34. Fundraising events. Please round all amounts to the nearest dollar (no cents)
Included in
Gross Income

Donations

Other Costs
Cash Prizes

Beverages

Entertain-
Noncash

Facility

Food &
Prizes

ment

Description
Gross Inc.

6
35. Expenses for the report year (prior year data needed only if MCG did not prepare your Form 990 last year).
If gross income exceeds $200,000 or if net assets exceed $500,000, expenses MUST be allocated between Program Services,
Management & General, and Fundraising (the lavender section). Further, the Program Services total MUST be equal to the program
initiatives expense total in item #1 (on page 2).

Please round all amounts to the nearest dollar (no cents)

Allocation of Total Expense

required only if your gross income was Required if MCG did not
$200k or greater or net assets were $500k or prep Form 990 last year
greater
Program Managemen Fund 1st Prev 2nd Prev
Expense Categories Annual Total
Services t & General Raising Year Year
Grants paid from donor advised funds
Other grants paid; if > $5000 provide a list of

recipients, addresses & amounts
Assistance to individuals; if > $5000 provide

a list of recipients, addresses & amounts
Benefits paid to or for members
Compensation: current officers & directors
Compensation: former officers & directors
Compensation: all others
Pension plan contributions
Other employee benefits
Payroll taxes paid by employer
Management fees
Legal fees
Accounting fees
Lobbying fees
Professional fundraising fees
Investment management fees
Other professional fees
Advertising & promotion
Office expenses
Information technology
Royalties paid
Occupancy costs (rent/util/insurance/etc)
Travel
Conferences, conventions & meetings
Interest expense
Payments to affiliates
Depreciation & depletion
Insurance
Value of non-cash donations received
Value of donated professional services*
Other:
Other:
Other:
Other:
Other:
Other:
Program Services Total This total must equal the expense total in #3 above

7
* Include only if you use the accrual basis of accounting

8
36. Balance sheet as of the last day of the fiscal year (prior year data needed only if MCG did not prepare your Form 990 last year). Please
round all amounts to the nearest dollar (no cents)

Assets Beginning End of Liabilities Beginning

End of Year
* accrual based accounting only of Year Year * accrual based accounting only of Year
Checking accounts & cash on hand * Accounts payable
Savings accounts * Grants payable
Amounts receivable from directors, Loans payable to officers, directors,

officers and key employees and key employees
* Other accounts receivable * Deferred revenue
* Other notes and loans receivable * Tax-exempt bond liability
* Inventories * Mortgages/other notes payable
* Pre-paid expenses * Other liability:
* Fixed assets other than real estate * Other liability:
* Accumulated depreciation * Other liability:
* Real estate Net Assets
* Accumulated depreciation Complete this section if you follow SFAS 117
* Other asset: Unrestricted net assets
* Other asset: Temporarily restricted net assets
* Other asset: Permanently restricted net assets
* Other asset: Complete this section if you do not follow SFAS 117
* Other asset: Capital stock/trust principal
* Other asset: Paid-in or capital surplus
* Other asset: Retained earnings
* Other asset: Total net assets/fund balance

Beginning total net assets/equity +

Total income (question #33 above) +
Total expenses (question #35 above) -
Ending total net assets/equity =
Please note: Beginning net assets plus total income minus total expenses MUST equal ending net assets. A discrepancy in this
computation is the most common financial data errors we encounter. Form 990 cannot be completed until these figures agree.

37. List here any items reported on previous Forms 990 as assets that were sold (or otherwise disposed of) during the report year)

Depreciation Expense
Description Original Cost Net Sales Price
Previously Taken

9
38. Donors: Check here if no donor gave $5000 or more
List each person, business or other entity (include grants) whose cash and non-cash donations totaled $5000 or more. You can ignore any
individual donation that was less than $1000 (i.e., include only those donations that were $1000 or higher). Round all amounts to the nearest
dollar.
Non-
Name Address Amount Given
Cash?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.

39. Substantial Donors This computation is a little tricky. Just follow the instructions. Hint: if you made this computation if previous years you can
simply copy those previous year amounts to the appropriate column on this years questionnaire.

3rd Prev Year 2nd Prev Year 1st Prev Year Report Year
1. Gifts, grants, contributions and membership fees received
2. 2% of the amount on line 1
3. Add up the total donations for all donors whose individual
donations for the year exceeded the amount on line 2. Do not
include governmental units or publicly supported organizations.
4. How many donors are included in the amount recorded on line 3?
5. Line 2 times line 4
6. Line 3 minus line 5

40. Non-Cash Donors: list any person, business or other entity who made non-cash donations with a fair-market value that is more than the greater
of a) $5000 or b) 2% of donations, gifts, grants and similar receipts. Do not include any of the following: a) reimbursements or b) items that were
negligible in value or c) the value of donated services.
1 Name Address Value of item given
Description Date
2 Name Address Value of item given
Description Date
3 Name Address Value of item given
Description Date

10
41. Explanations (use this section to provide explanations for any item(s) recorded in this questionnaire)
Item # Explanation

11