Yes - Susan G. Komen Twin Cities Race for the Cure

Transcription

THE SUSAN G. KOMEN BREAST CANCER FDN, GROUP
75-2462834
Form 990 (2012)
Page
Part III
1
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III
Briefly describe the organization's mission:
mmmmmmmmmmmmmmmmmmmmmmmm
2
X
TO END BREAST CANCER BY FUNDING RESEARCH & COMMUNITY HEALTH OUTREACH
FOCUSED ON EDUCATION AND ACCESS TO SCREENING AND TREATMENT PRIMARILY
AIMED AT LOW-INCOME AND MEDICALLY UNDERSERVED PEOPLE.
2 Did the organization undertake any significant program services during the year which were not listed on the
X No
prior Form 990 or 990-EZ?
Yes
If "Yes," describe these new services on Schedule O.
3 Did the organization cease conducting, or make significant changes in how it conducts, any program
X No
services?
Yes
If "Yes," describe these changes on Schedule O.
4 Describe 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.
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
4a (Code:
) (Expenses $
46,792,281.
including grants of $
14,325,951.
) (Revenue $
609,819.
)
4b (Code:
) (Expenses $
51,315,683.
47,305,654.
) (Revenue $
0
)
4c (Code:
) (Expenses $
25,964,111.
0
) (Revenue $
0
)
PUBLIC HEALTH EDUCATION PROGRAMS AND GRANTS: SEE SCHEDULE O FOR
ADDITIONAL DETAILS.
HEALTH SCREENING PROGRAMS AND GRANTS: SEE SCHEDULE O FOR
ADDITIONAL DETAILS.
RESEARCH PAYMENTS TO PARENT: OUR PLAN IS STRAIGHTFORWARD: WE FUND
CUTTING-EDGE RESEARCH TO FIND THE CURES. REMAINING NET MONIES (A
MINIMUM OF 25%) FROM KOMEN AFFILIATE EVENTS LIKE THE RACE FOR THE
CURE SERIES HELP SUPPORT THE KOMEN RESEARCH AND TRAINING GRANT
PROGRAM CONDUCTED BY THE KOMEN PARENT ORGANIZATION, WHICH PROVIDES
FUNDING FOR INNOVATIVE BREAST CANCER RESEARCH AND A VARIETY OF
MERITORIOUS AWARDS. SEE SCHEDULE O FOR ADDITIONAL DETAILS.
4d Other program services (Describe in Schedule O.)
(Expenses $
16,133,624. including grants of $
14,804,158.
140,205,699.
4e Total program service expenses
JSA
2E1020 2.000
I
87855E 1385
) (Revenue $
0
)
Form
V 12-7.10
GROUP
990
(2012)
75-2462834
Form 990 (2012)
Part IV
Page
Checklist of Required Schedules
Yes
1
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmm
2
3
4
5
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If "Yes,"
complete Schedule A
Is the organization required to complete Schedule B, Schedule of Contributors (see instructions)?
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to
candidates for public office? If "Yes," complete Schedule C, Part I
Section 501(c)(3) organizations. Did 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,
assessments, or similar amounts as defined in Revenue Procedure 98-19? If "Yes," complete Schedule C,
Part III
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors
have the right to provide advice on the distribution 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, historic land areas, or historic structures? If "Yes," complete Schedule D, Part II
Did the organization maintain collections of works of art, historical 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 negotiation services? If "Yes," complete Schedule D, Part IV
Did the organization, directly or through a related organization, hold assets in temporarily restricted
endowments, permanent endowments, or quasi-endowments? If "Yes," complete Schedule D, Part V
If the organization’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 securities in Part X, line 12 that is 5% 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 is 5% 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
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
6
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmm
7
8
9
mmmmmmm
10
11
a
b
c
d
mmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmm
e
f Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses
mmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmm
mmmmmmmmmm
mmmmmmmmmmmmm
the organization's liability for uncertain tax positions under FIN 48 (ASC 740)? If "Yes," complete Schedule D, Part X
12 a Did the organization obtain separate, independent audited financial statements for the tax year? If "Yes,"
complete Schedule D, Parts XI and XII
b 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 D, Parts XI and XII is optional
13 Is the organization a school described in section 170(b)(1)(A)(ii)? If "Yes," complete Schedule E
14 a Did the organization maintain an office, employees, or agents outside of the United States?
b Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking,
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
15 Did 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
16 Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance
to individuals located outside the United States? If "Yes," complete Schedule F, Parts III and IV
17 Did 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 instructions)
18 Did the organization report more than $15,000 total of fundraising event gross income and contributions on
Part VIII, lines 1c and 8a? If "Yes," complete Schedule G, Part II
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
20 a Did the organization operate one or more hospital facilities? If "Yes," complete Schedule H
b If "Yes" to line 20a, did the organization attach a copy of its audited financial statements to this return?
mmmmmmmmmmm
mmmmmmm
mmmmmmmmmmm
mmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmm
mmmmmm
1
2
2E1021 1.000
87855E 1385
V 12-7.10
GROUP
X
X
5
X
6
X
7
X
8
X
9
X
10
X
11a
X
11b
X
11c
X
11d
11e
X
X
11f
X
X
12a
12b
13
14a
X
X
X
14b
X
15
X
16
X
17
X
18
X
19
20a
20b
X
Form
JSA
No
X
X
3
4
3
990
X
(2012)
75-2462834
Form 990 (2012)
Part IV
Page
Checklist of Required Schedules (continued)
Yes
21
Did the organization report more than $5,000 of grants and other assistance to any government or organization
in the United States 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 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
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
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 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 during the year?
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction
with a disqualified person during the year? If "Yes," complete Schedule L, Part I
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior
year, and that the transaction has not been reported on any of the organization's prior Forms 990 or 990-EZ?
If "Yes," complete Schedule L, Part I
Was a loan to or by a current or former officer, director, trustee, key employee, highly compensated employee, or
disqualified person outstanding as of the end of the organization's tax year? If "Yes," 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 with one of the following parties (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 contributions? If "Yes," complete Schedule M
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified
conservation contributions? 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, Part 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-charitable
related organization? If "Yes," complete Schedule R, Part V, line 2
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
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11b and
19? Note. All Form 990 filers are required to complete Schedule O
mmmmmmmmmmmm
22
23
24 a
b
c
d
25 a
b
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmm
mmmmmmm
mmmmmmmmmmmmmmmmmmm
m
26
27
mmmmmmmmmmmmmmm
28
a
b
c
29
30
31
32
33
34
35 a
b
36
37
38
mmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmm
mmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmm
21
X
22
X
23
X
JSA
87855E 1385
V 12-7.10
GROUP
No
X
24a
24b
24c
24d
25a
X
25b
X
26
X
27
X
28a
X
X
28b
28c
29
X
X
X
30
31
X
32
X
33
X
34
35a
X
X
35b
36
X
37
X
38
Form
2E1030 1.000
4
X
990 (2012)
75-2462834
Form 990 (2012)
Part V
Page
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V
mmmmmmmmmmmmmmmmmmmmmmm
845
mmmmmmmmmm
2
mmmmmmmmm
X
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
*
698
m
X
mmmmmmm
X
mmmmmmmmmm
mmmmmmmmmmmmm
Yes
1a
1 a Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable
1b
b Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable
c Did the organization comply with backup withholding rules for reportable payments to vendors and
reportable gaming (gambling) winnings to prize winners?
2 a Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax
2a
Statements, filed for the calendar year ending with or within the year covered by this return
b 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)
3 a Did the organization have unrelated business gross income of $1,000 or more during the year?
b If "Yes," has it filed a Form 990-T for this year? If "No," provide an explanation in Schedule O
4 a At any time during 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)?
b If “Yes,” enter the name of the foreign country:
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5 a Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?
b Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
c If "Yes" to line 5a or 5b, did the organization file Form 8886-T?
6 a 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 contributions?
b If "Yes," did the organization include with every solicitation an express statement that such contributions or
gifts were not tax deductible?
7 Organizations that may receive deductible contributions under section 170(c).
a 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?
b If "Yes," did the organization notify the donor of the value of the goods or services provided?
c Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was
required to file Form 8282?
7d
d If "Yes," indicate the number of Forms 8282 filed during the year
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
I
mmmmmmmm
mmmmmmmmmmm
e
f
g
h
8
9
a
b
10
a
b
11
mmmmmmmmmmmm
mmmmmmmmmmmmmmmm
mmm
mmm
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?
If the organization received a contribution 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. Did the supporting organization, or a donor advised fund maintained by a sponsoring
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 distribution to a donor, donor advisor, or related person?
Section 501(c)(7) organizations. Enter:
10a
Initiation fees and capital contributions included on Part VIII, line 12
10b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
mmmmmmmmmmmmmmmm
mmmmmmmmmmmmmm
mmmm
mmmmm
mmmmmmmmmmmmmmmmmm
Section 501(c)(12) organizations. Enter:
11a
a Gross income from members or shareholders
b Gross income from other sources (Do not net amounts due or paid to other sources
11b
against amounts due or received from them.)
12 a Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12b
b If "Yes," enter the amount of tax-exempt interest received or accrued during the year
13
5
Section 501(c)(29) qualified nonprofit health insurance issuers.
a 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.
b Enter the amount of reserves the organization is required to maintain by the states in which
the organization is licensed to issue qualified health plans
13b
13c
c Enter the amount of reserves on hand
mmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
m m m m m m m mm mm mm mm mm mm
14 a Did the organization receive any payments for indoor tanning services during the tax year?
b If "Yes," has it filed a Form 720 to report these payments? If "No," provide an explanation in Schedule O
JSA
* AMOUNT REPRESENTS TOTAL NUMBER OF EMPLOYEES REPORTED ON FORM W-3 FOR
2E1040 1.000
ALL AFFILIATES. EMPLOYEES ARE EMPLOYED
AND PAID AT THE AFFILIATE
87855E 1385
V 12-7F
GROUP LEVEL.
SALARY EXPENSE REPORTED ON PART IX IS PAID FROM THE AFFILIATES.
No
1c
2b
3a
3b
4a
X
5a
5b
5c
X
X
6a
X
6b
7a
7b
X
X
7c
X
7e
7f
7g
7h
X
X
8
9a
9b
12a
13a
14a
14b
Form
X
990 (2012)
Page 5 Page 5
75-2462834
Page 6
Part VI Governance, Management, and Disclosure For each "Yes" response to lines 2 through 7b below, and for a "No"
Form 990 (2012)
response to line 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI
Section A. Governing Body and Management
1a Enter the number of voting members of the governing body at the end of the tax year.
mmmmmmmmmmm
1a
Yes
1,267
X
No
If there are material differences in voting rights among members of the governing body, or if the governing
mmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmm
mmmmmmm
mmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
1,264
1b
b Enter the number of voting members included in line 1a, above, who are independent
2
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?
3
Did 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?
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed?
5
Did the organization become aware during the year of a significant diversion of the organization's assets?
6
Did the organization have members or stockholders?
7a 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?
b Are any governance decisions of the organization reserved to (or subject to approval by) members,
stockholders, or persons other than the governing body?
8
Did the organization contemporaneously document the meetings held or written actions undertaken during
the year by the following:
a The governing body?
b Each committee with authority to act on behalf of the governing body?
9
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 O
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmm
X
2
3
4
5
6
X
mmmm
mm
mmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmm
Section C. Disclosure
7b
X
8a
8b
X
X
X
9
Yes
No
10a
X
10b
11a
X
12a
X
12b
X
12c
13
14
X
X
X
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
15a
15b
X
X
16a
I ATTACHMENT 1
X
X
X
7a
Section B. Policies (This Section B requests information about policies not required by the Internal Revenue Code.)
10 a Did the organization have local chapters, branches, or affiliates?
b If "Yes," did the organization have written policies and procedures governing the activities of such chapters,
affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes?
11 a 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 O the process, if any, used by the organization to review this Form 990.
12 a 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
rise to conflicts?
c Did the organization regularly and consistently monitor and enforce compliance with the policy? If "Yes,"
describe in Schedule O how this was done
13
Did the organization have a written whistleblower policy?
14
Did 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 decision?
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, describe the process in Schedule O (see instructions).
16 a Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement
with a taxable entity during the year?
b If "Yes," did the organization follow a written 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 arrangements?
X
X
16b
17
18
List the states with which a copy of this Form 990 is required to be filed
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.
X Own website
X Upon request
Another's website
Other (explain in Schedule O)
19
Describe in Schedule O 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.
State the name, physical address, and telephone number of the person who possesses the books and records of the
972-855-1600
organization: MARK NADOLNY, CFO 5005 LBJ FREEWAY, SUITE 250 DALLAS, TX 75244-6125
Form 990 (2012)
20
JSA
I
2E1042 1.000
87855E 1385
V 12-7.10
GROUP
75-2462834
Page 7
Compensation of Officers, Directors, Trustees, Key Employees, Highest Compensated Employees, and
Independent Contractors
Check if Schedule O contains a response to any question in this Part VII
Form 990 (2012)
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 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 (D), (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 organization compensated any current officer, director, or trustee.
(C)
(A)
Name and Title
(B)
(do not check more than one
Average
hours per box, unless person is both an
week (list any officer and a director/trustee)
DIR-FIN & ADMIN - GTR NYC
(4) MICHELE OSTRANDER
EXEC. DIRECTOR - DENVER METRO
(5) CHERYL SHAW
EXEC. DIRECTOR - PUGET SOUND
(6) BOBBI MEYERS (4/1/12-11/8/12)
EXEC. DIRECTOR - MIAMI
(7) ROBIN PROTHRO
(8)
CEO - MARYLAND
X
Former
CEO - GREATER NYC (THRU 8/12)
(3) JACQUELINE SAM
55.00
0
45.00
0
50.00
0
50.00
0
50.00
0
60.00
0
Highest compensated
employee
(1) SEE ATTACHMENT 2A FOR PART VII
Key employee
line)
Officer
below dotted
Institutional trustee
related
organizations
Individual trustee
or director
hours for
(2) DARA RICHARDSON-HERON
Position
(D)
(E)
Reportable
Reportable
compensation
compensation from
from
related
the
organizations
organization
(W-2/1099-MISC)
(W-2/1099-MISC)
(F)
Estimated
amount of
other
compensation
from the
organization
and related
organizations
X
12,000.
0
0
X
136,230.
0
0
X
135,563.
0
8,641.
X
145,800.
0
0
X
137,970.
0
16,700.
X
149,836.
0
0
X
143,222.
0
0
(9)
(10)
(11)
(12)
(13)
(14)
Form
JSA
2E1041 1.000
87855E 1385
V 12-7.10
GROUP
990
(2012)
75-2462834
Form 990 (2012)
Part VII
Page
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and title
(B)
(C)
Average
Position
(do not check more than one
box, unless person is both an
officer and a director/trustee)
hours per
week (list any
hours for
Former
Highest compensated
employee
Key employee
Officer
line)
Institutional trustee
below dotted
Individual trustee
or director
related
organizations
(D)
(E)
Reportable
Reportable
compensation
compensation from
from
related
the
organizations
organization
(W-2/1099-MISC)
(W-2/1099-MISC)
m m m m m m m m m m m m m m m m m m m m m m m m m mm mm mm mm mm mm mm mm mm mm mm mm mm I
m m m m m m m m m m m m m m m m m m m m m m m m m m m m II
I
(F)
Estimated
amount of
other
compensation
from the
organization
and related
organizations
1b
c
d
2
860,621.
Sub-total
0
Total from continuation sheets to Part VII, Section A
860,621.
Total (add lines 1b and 1c)
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of
reportable compensation from the organization
27
3
Did 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
3
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 $150,000? If “Yes,” complete Schedule J for such
individual
4
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmm
5
0
0
0
25,341.
0
25,341.
Yes No
X
X
Did 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
5
Section B. Independent Contractors
1 Complete this table for your five highest compensated independent contractors that received more than $100,000 of
compensation from the organization. Report compensation for the calendar year ending with or within the organization's tax
year.
(A)
Name and business address
(B)
Description of services
8
X
(C)
Compensation
ATTACHMENT 2
2
Total number of independent contractors (including but not limited to those listed above) who received
more than $100,000 in compensation from the organization
4
JSA
2E1055 3.000
I
87855E 1385
V 12-7.10
Form
GROUP
990
(2012)
Form 990 (2012)
Part VIII
Statement of Revenue
Check if Schedule O contains a response to any question in this Part VIII
Contributions, Gifts, Grants
Program Service Revenue and Other Similar Amounts
(A)
Total revenue
mmmmmmmm
mmmmmmmmm
mmmmmmmmm
mmmmmmmm
mm
m
m m m m m m m m m m m m m m m m m m mI
Federated campaigns
1a
b
Membership dues
1b
1a
Fundraising events
Related organizations
1d
e
Government grants (contributions)
1e
f
All other contributions, gifts, grants,
1f
39,683,906.
9,130,438.
Total. Add lines 1a-1f
Business Code
2a
(B)
Related or
exempt
function
revenue
(C)
Unrelated
business
revenue
(D)
Revenue
excluded from tax
under sections
512, 513, or 514
MISSION RELATED REVENUE
116,609,198.
900099
129,084.
129,084.
b
c
d
e
f
g
3
m m m m m m mm mm mm mm mm m m m m m m m m I
m m m m m m m m m m m m m m m m m m mI
m m m m m m m m m m m m m m m m m m m m m m mm mm mm II
mmmmmmmm
mmm
m mm m m m m m m m m m m m m m m m m
I
All other program service revenue
Total. Add lines 2a-2f
129,084.
Investment income (including dividends, interest, and
287,482.
other similar amounts)
4
Income from investment of tax-exempt bond proceeds
5
Royalties
6a
Less: rental expenses
c
d
Rental income or (loss)
Net rental income or (loss)
b
(i) Real
(ii) Personal
(i) Securities
(ii) Other
Gross amount from sales of
assets other than inventory
8a
423,747.
423,747.
0
10.
mmmm
m m mm mm mm mm mm m m m m m m m m m m m m m m m m
Less: cost or other basis
15,064.
and sales expenses
c
d
287,482.
0
Gross rents
b
7a
Other Revenue
9
76,404,233.
Noncash contributions included in lines 1a-1f: $
and similar amounts not included above
g
h
Page
521,059.
1c
c
d
75-2462834
-15,054.
Gain or (loss)
Net gain or (loss)
I
-15,054.
-15,054.
25,214,742.
25,214,742.
185,508.
185,508.
Gross income from fundraising
events (not including $
76,404,233.
mmmmmmmmmmm
mmmmmmmmmm mmmmmmmm
I
mmmmmmmmmmm
mmmmmmmmmmmmmmmmmmm
I
mmmmmmmmm
mmmmmmmmmmmmmmmmmm
I
of contributions reported on line 1c).
a
37,300,224.
Less: direct expenses
b
Net income or (loss) from fundraising events
12,085,482.
See Part IV, line 18
b
c
9a
b
c
10a
b
c
11a
Gross income from gaming activities.
See Part IV, line 19
Less: direct expenses
Net income or (loss) from gaming activities
Gross
sales
of
inventory,
returns and allowances
195,575.
b
10,067.
less
Less: cost of goods sold
Net income or (loss) from sales of inventory
Miscellaneous Revenue
INTERCOMPANY REVENUE
a
a
989,039.
b
508,304.
480,735.
Business Code
900099
480,735.
5,189,398.
5,189,398.
b
c
12
m m m m mm mm mm mm mm mm mm mm mm m m m m m m m m
m m m m m m m m m m m m m m II
d
All other revenue
e
Total. Add lines 11a-11d
Total revenue. See instructions
JSA
2E1051 1.000
87855E 1385
5,189,398.
148,504,840.
609,819.
31,285,823.
Form
V 12-7.10
GROUP
990
(2012)
Part IX Statement of Functional Expenses
Form 990 (2012)
75-2462834
Page
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A).
Check if Schedule O contains a response to any question in this Part IX
Do not include amounts reported on lines 6b, 7b,
8b, 9b, and 10b of Part VIII.
1
m
mmmmmm
Grants and other assistance to governments and
organizations in the United States. See Part IV, line 21
2
Grants and other assistance to individuals in
the United States. See Part IV, line 22
3
Grants and other assistance to governments,
organizations, and individuals outside the
United States. See Part IV, lines 15 and 16
4
Benefits paid to or for members
5
Compensation of current officers, directors,
trustees, and key employees
6
Compensation not included above, to disqualified
mmmm
mmmmmmmmm
mmmmmmmmmm
76,412,774.
76,412,774.
22,989.
22,989.
(D)
Fundraising
expenses
X
0
0
8,894.
20,752.
0
25,035,654.
16,577,844.
5,141,269.
3,316,541.
292,442.
1,765,444.
2,060,041.
208,110.
1,108,477.
1,358,871.
35,598.
443,953.
424,267.
48,734.
213,014.
276,903.
3,752.
28,493.
140,781.
3,221.
76,477.
266.
4,647.
906,843.
2,043,142.
5,329,545.
268,126.
162,709.
1,422,111.
195,302.
352,289.
3,651,292.
1,689,039.
668,489.
859,157.
230,052.
225,520.
113,538.
0
326,802.
2,883.
25,964,111.
155,983.
10,155.
259,385.
205.
25,964,111.
34,396.
5,338.
25,379.
2,644.
42,038.
34.
68,338.
3,751.
53,249.
1,066.
Total functional expenses. Add lines 1 through 24e
2,422,614.
5,987,165.
958,806.
592,222.
578,457.
161,288,856.
1,632,283.
4,421,191.
697,341.
245,916.
327,800.
140,205,699.
330,406.
36,875.
119,648.
100,438.
207,839.
9,971,152.
459,925.
1,529,099.
141,817.
245,868.
42,818.
11,112,005.
mIm m m m m m
19,561,964.
13,430,677.
m m m m m m mm mm mm mm mm mm
mmmmmm
mmmmmmmmmmmm
mmmmmmmmmmmmmmmmmm
m m m m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm
mmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmm
mmmmmmmmm
mmmmmm
m
m
m
m
m
m m m m m m m m m m mm mm mm mm mm mm
mmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmm
persons described in section 4958(c)(3)(B)
Other salaries and wages
8
Pension plan accruals and contributions (include section
401(k) and 403(b) employer contributions)
11
(C)
Management and
general expenses
118,584.
7
10
(B)
Program service
expenses
148,230.
persons (as defined under section 4958(f)(1)) and
9
(A)
Total expenses
10
Other employee benefits
Payroll taxes
Fees for services (non-employees):
a Management
b Legal
c Accounting
d Lobbying
e Professional fundraising services. See Part IV, line 17
f Investment management fees
g Other.
(If line 11g amount exceeds 10% of line 25, column
(A) amount, list line 11g expenses on Schedule O.)
12
Advertising and promotion
13
Office expenses
14
Information technology
15
Royalties
16
Occupancy
17
Travel
18
Payments of travel or entertainment expenses
for any federal, state, or local public officials
19
Conferences, conventions, and meetings
20
Interest
21
Payments to affiliates
22
Depreciation, depletion, and amortization
23
Insurance
24
Other
mmmm
mmmmmmmmmmmmmm
mmmm
mmmmmmmmmmmmmmmmmmm
expenses.
Itemize
expenses
not
0
7,239.
109,617.
140,781.
177,293.
0
1,370,271.
2,558,140.
10,402,948.
0
0
2,773,716.
1,012,079.
177,293.
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 Schedule O.)
a CONSULTING
& PROF SERVICES
PRODUCTION
c FOOD AND BEVERAGE
d GIFTS AND RECOGNITION
b RACE
e All other expenses
25
26
Joint costs. Complete this line only if the
organization reported in column (B) joint costs
from a combined educational campaign and
X if
fundraising solicitation. Check here
following SOP 98-2 (ASC 958-720)
JSA
2E1052 1.000
87855E 1385
6,131,287.
Form
V 12-7.10
GROUP
990 (2012)
75-2462834
Form 990 (2012)
Part X
1
2
3
4
5
Net Assets or Fund Balances
Liabilities
Assets
6
Page
Balance Sheet
Check if Schedule O contains a response to any question in this Part X
Cash - non-interest-bearing
Savings and temporary cash investments
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.
Complete Part II of Schedule L
(A)
Beginning of year
m m m m m m m m m m m m m m mm mm mm mm mm mm mm mm mm mm mm
m m m m m m m m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm
Notes and loans receivable, net
Inventories for sale or use
Prepaid expenses and deferred charges
Land, buildings, and equipment: cost or
1,983,646.
10a
other basis. Complete Part VI of Schedule D
1,580,750.
10b
b Less: accumulated depreciation
11 Investments - publicly traded securities
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 through 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
22 Loans and other payables to current and former officers, directors,
trustees, key employees, highest compensated employees, and
disqualified persons. Complete Part II of Schedule L
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 through 25
X and
Organizations that follow SFAS 117 (ASC 958), check here
complete lines 27 through 29, and lines 33 and 34.
mmmmmmmmmm
mmmmmmmmmmmmmmm
mmmmmmmmmmmmmm
m m m m m m m m m m m m m m mm mm mm mm mm mm mm mm mm mm
mmmm
27
28
29
Unrestricted net assets
Temporarily restricted net assets
Permanently restricted net assets
Organizations that do not follow SFAS 117 (ASC 958), check here
complete lines 30 through 34.
30
31
32
33
34
Capital stock or trust principal, or current funds
Paid-in or capital surplus, or land, building, or equipment fund
Retained earnings, endowment, accumulated income, or other funds
Total net assets or fund balances
Total liabilities and net assets/fund balances
and
V 12-7.10
23,824.
110,307,188.
23,326,561.
0
0 5
0
6
7
8
9
476,095. 10c
18,297,500. 11
0 12
0 13
0 14
131,442. 15
182,374,000. 16
1,780,245. 17
85,111,273. 18
2,071,550. 19
0 20
0 21
0
0
155,638.
429,435.
402,896.
14,087,310.
0
0
0
8,514,470.
157,247,322.
1,946,765.
71,744,697.
2,471,935.
0
0
0 22
0 23
0 24
0
0
0
10,726,176. 25
99,689,244. 26
9,208,907.
85,372,304.
56,680,745. 27
26,004,011. 28
0 29
42,160,844.
29,714,174.
0
30
31
32
82,684,756. 33
182,374,000. 34
JSA
2E1053 1.000
87855E 1385
1
2
3
4
0
0
139,882.
523,612.
mmmmmmmmmmmmmm
mmmmmmm
mmmmmmmmm
m m m m m m m m m m m m m m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm
I
mmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm
I
mmmmmmmmmmmmmmmm
mmmmmmmm
mmmm
m m m m m m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm
(B)
End of year
22,905.
134,079,514.
28,703,050.
0
Loans and other receivables from other disqualified persons (as defined under section
4958(f)(1)), persons described 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
7
8
9
10 a
11
GROUP
71,875,018.
157,247,322.
Form 990 (2012)
75-2462834
Form 990 (2012)
Part XI
1
2
3
4
5
6
7
8
9
10
Page
Reconciliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI
m m m m m m m m m m m m m m 148,504,840.
mmmm X
161,288,856.
-12,784,016.
82,684,756.
mmmmm
33,340.
-1,690,888.
0
0
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
3,631,826.
mmmmmmmmmmmmmmmm
71,875,018.
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII m m m m m m m m m m m m m m m m m
Total revenue (must equal Part VIII, column (A), line 12)
Total expenses (must equal Part IX, column (A), line 25)
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))
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 O)
Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line
33, column (B))
Part XII
12
1
2
3
4
5
6
7
8
9
10
X Accrual
Accounting method used to prepare the Form 990:
Cash
Other
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2 a 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:
Yes
No
1
Separate basis
Consolidated basis
mmmmmm
2a
mmmmmmmmmmmmmm
2b
X
2c
X
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 financial statements for the year were audited on a
separate basis, consolidated basis, or both:
X Consolidated basis
Separate 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 its financial statements and selection of an independent accountant?
If the organization changed either its oversight process or selection process during the tax year, explain in
Schedule O.
3 a 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
required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
JSA
87855E 1385
V 12-7.10
GROUP
X
3a
3b
Form
2E1054 1.000
X
990
(2012)
SCHEDULE A
(Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Name of the organization
Public Charity Status and Public Support
OMB No. 1545-0047
À¾µ¶
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
I
Attach to Form 990 or Form 990-EZ.
I
Open to Public
Inspection
See separate instructions.
Employer identification number
75-2462834
Reason for Public Charity Status (All organizations must complete this part.) See instructions.
Part I
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
A church, convention of churches, or association of churches described in section 170(b)(1)(A)(i).
2
A school described in section 170(b)(1)(A)(ii). (Attach Schedule E.)
3
A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii).
4
A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the
hospital's name, city, and state:
5
An organization operated for the benefit of a college or university owned or operated by a governmental unit described in
section 170(b)(1)(A)(iv). (Complete Part II.)
6
A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v).
7 X An organization that normally receives a substantial part of its support from a governmental unit or from the general public
described in section 170(b)(1)(A)(vi). (Complete Part II.)
8
A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.)
9
An organization that normally receives: (1) more than 33 1/3 % of its support from contributions, membership fees, and gross
receipts from activities related to its exempt functions - subject to certain exceptions, and (2) no more than 33 1/3% of its
support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
An organization organized and operated exclusively to test for public safety. See section 509(a)(4).
11
An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the
purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section
509(a)(3). Check the box that describes the type of supporting organization and complete lines 11e through 11h.
a
Type I
b
Type II
c
Type III-Functionally integrated
d
Type III-Non-functionally integrated
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified
persons other than foundation managers and other than one or more publicly supported organizations described in section
509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II, or Type III supporting
organization, check this box
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the
following persons?
Yes No
(i) A person who directly or indirectly controls, either alone or together with persons described in (ii)
11g(i)
and (iii) below, the governing body of the supported organization?
11g(ii)
(ii) A family member of a person described in (i) above?
11g(iii)
(iii) A 35% controlled entity of a person described in (i) or (ii) above?
h
Provide the following information about the supported organization(s).
(i) Name of supported
organization
(ii) EIN
(iii) Type of organization
(described on lines 1-9
above or IRC section
(see instructions))
(iv) Is the
organization in
col. (i) listed in
your governing
document?
Yes
No
(v) Did you notify
(vi) Is the
the organization
organization in
in col. (i) of
col. (i) organized
your support?
in the U.S.?
Yes
No
Yes
(vii) Amount of monetary
support
No
(A)
(B)
(C)
(D)
(E)
Total
For Paperwork Reduction Act Notice, see the Instructions for
Form 990 or 990-EZ.
Schedule A (Form 990 or 990-EZ) 2012
JSA
2E1210 1.000
87855E 1385
V 12-7.10
GROUP
75-2462834
Page
Part II
2
Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under
Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year (or fiscal year beginning in)
1
2
I
Gifts,
grants,
contributions,
and
membership fees received. (Do not
include any "unusual grants.")
mmmmmm
4
Total. Add lines 1 through 3
5
The portion of total contributions by
each
person
(other
than
a
governmental
unit
or
publicly
supported organization) included on
line 1 that exceeds 2% of the amount
shown on line 11, column (f)
Public support. Subtract line 5 from line 4.
mmmmmmm
mmmmmmm
11
12
13
145,170,788.
(e) 2012
141,884,451.
116,609,198.
(f) Total
680,674,467.
0
0
139,225,891.
137,784,139.
145,170,788.
141,884,451.
116,609,198.
680,674,467.
36,521,888.
644,152,579.
m m m m m m m m Im m
139,225,891.
137,784,139.
145,170,788.
141,884,451.
116,609,198.
680,674,467.
mmmmmmmmmmmmmmmmm
1,920,816.
935,902.
812,504.
794,412.
711,229.
5,174,863.
Net income from unrelated business
activities, whether or not the business
is regularly carried on
0
0
0
10
137,784,139.
(d) 2011
mmmmmmm
Section B. Total Support
9
139,225,891.
(c) 2010
mmmmmmm
The value of services or facilities
furnished by a governmental unit to the
organization without charge
7
8
(b) 2009
Tax
revenues
levied
for
the
organization's benefit and either paid
to or expended on its behalf
3
6
(a) 2008
Amounts from line 4
Gross income from interest, dividends,
payments received on securities loans,
rents, royalties and income from similar
sources
(a) 2008
mmmmmmmmmm
Other income. Do not include gain or
loss from the sale of capital assets
(Explain in Part IV.) ATCH 1
mmmmmmmmmmm
mm
(b) 2009
(c) 2010
(d) 2011
33,526.
(e) 2012
0
8,812.
Total support. Add lines 7 through 10
(f) Total
42,338.
685,891,668.
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmI
Section C. Computation of Public Support Percentage
93.91
mmmmmmmm
93.71
mmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmI X
mmmmmmmmmmmmmmmmmI
12
Gross receipts from related activities, etc. (see instructions)
230,549,718.
First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3)
organization, check this box and stop here
14
14 Public support percentage for 2012 (line 6, column (f) divided by line 11, column (f))
15
15 Public support percentage from 2011 Schedule A, Part II, line 14
16a 33 1/3 % support test - 2012. If the organization did not check the box on line 13, and line 14 is 33 1/3 % or more, check
this box and stop here. The organization qualifies as a publicly supported organization
b 33 1/3 % support test - 2011. If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3 % or more,
check this box and stop here. The organization qualifies as a publicly supported organization
17a 10%-facts-and-circumstances test - 2012. If the organization did not check a box on line 13, 16a, or 16b, and line 14 is
10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here. Explain in
Part IV how the organization meets the "facts-and-circumstances” test. The organization qualifies as a publicly supported
organization
b 10%-facts-and-circumstances test - 2011. If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly
supported organization
18 Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions
%
%
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmI
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmI
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmI
JSA
2E1220 1.000
87855E 1385
V 12-7.10
GROUP
75-2462834
Page
Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II.
If the organization fails to qualify under the tests listed below, please complete Part II.)
Section A. Public Support
Part III
1
I
(a) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(f) Total
(a) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(f) Total
3
Gifts, grants, contributions, and membership fees
received. (Do not include any "unusual grants.")
2
Gross receipts from admissions, merchandise
sold
or
services
performed,
or
facilities
furnished in any activity that is related to the
organization's tax-exempt purpose
3
mmmmmm
m
Gross receipts from activities that are not an
unrelated trade or business under section 513
4
Tax
revenues
levied
for
the
organization's benefit and either paid
to or expended on its behalf
5
The
value
of
services
mmmmmmm
or
facilities
furnished by a governmental unit to the
organization without charge
6
Total. Add lines 1 through 5
mmmmmmm
mmmmmmm
mmmm
7 a Amounts included on lines 1, 2, and 3
received from disqualified persons
b Amounts included on lines 2 and 3
received
from
other than
disqualified
persons that exceed the greater of $5,000
or 1% of the amount on line 13 for the year
mmmmmmmmmmm
mmmmmmmmmmmmmmmmm
Section B. Total Support
m m m m m m m m m m Im
8
c Add lines 7a and 7b
Public support (Subtract line 7c from
line 6.)
9 Amounts from line 6
10 a Gross income from interest, dividends,
payments received on securities loans,
rents, royalties and income from similar
sources
mmmmmmmmmmmmmmmmm
b Unrelated business taxable income (less
section 511
taxes) from businesses
mmmmmm
mmmmmmmmm
acquired after June 30, 1975
c Add lines 10a and 10b
11
Net income from unrelated business
activities not included in line 10b,
whether or not the business is regularly
carried on
Other income. Do not include gain or
loss from the sale of capital assets
(Explain in Part IV.)
mmmmmmmmmmmmmmm
12
mmmmmmmmmmm
mmmmmmmmmmmmmmmm
13
Total support. (Add lines 9, 10c, 11,
14
First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3)
and 12.)
organization, check this box and stop here
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mI
m m m m m m m m m mm mm mm mm mm mm mm mm mm mm mm mm mm mm
Section C. Computation of Public Support Percentage
15
Public support percentage for 2012 (line 8, column (f) divided by line 13, column (f))
15
16
Public support percentage from 2011 Schedule A, Part III, line 15
16
Section D. Computation of Investment Income Percentage
mmmmmmmmmm
17
Investment income percentage for 2012 (line 10c, column (f) divided by line 13, column (f))
17
18
Investment income percentage from 2011 Schedule A, Part III, line 17
18
19 a 33 1/3 % support tests - 2012. If the organization did not check the box on line 14, and line 15 is more than 33 1/3 %, and line
17 is not more than 33 1/3 %, check this box and stop here. The organization qualifies as a publicly supported organization
b 33 1/3 % support tests - 2011. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3 %, and
20
line 18 is not more than 33 1/3 %, check this box and stop here. The organization qualifies as a publicly supported organization
Private foundation. If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions
JSA
2E1221 1.000
%
%
%
%
I
I
I
87855E 1385
V 12-7.10
GROUP
75-2462834
Page
Part IV
Supplemental Information. Complete this part to provide the explanations required by Part II, line 10;
Part II, line 17a or 17b; and Part III, line 12. Also complete this part for any additional information. (See
instructions).
ATTACHMENT 1
SCHEDULE A, PART II - OTHER INCOME
DESCRIPTION
2008
2009
2010
2011
2012
TOTAL
OTHER REVENUE
33,526.
8,812.
42,338.
TOTALS
33,526.
8,812.
42,338.
JSA
2E1225 1.000
4
87855E 1385
V 12-7.10
GROUP
Schedule B
(Form 990, 990-EZ,
or 990-PF)
I
Schedule of Contributors
OMB No. 1545-0047
À¾µ¶
Attach to Form 990, Form 990-EZ, or Form 990-PF.
75-2462834
Organization type (check one):
Filers of:
Section:
Form 990 or 990-EZ
X
501(c)( 3
) (enter number) organization
4947(a)(1) nonexempt charitable trust not treated as a private foundation
527 political organization
Form 990-PF
501(c)(3) exempt private foundation
4947(a)(1) nonexempt charitable trust treated as a private foundation
501(c)(3) taxable private foundation
Check if your organization is covered by the General Rule or a Special Rule.
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See
instructions.
General Rule
For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, $5,000 or more (in money or
property) from any one contributor. Complete Parts I and II.
Special Rules
X
For a section 501(c)(3) organization filing Form 990 or 990-EZ that met the 33 1/3 % support test of the regulations
under sections 509(a)(1) and 170(b)(1)(A)(vi) and received from any one contributor, during the year, a contribution of
the greater of (1) $5,000 or (2) 2% of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1.
Complete Parts I and II.
For a section 501(c)(7), (8), or (10) organization filing Form 990 or 990-EZ that received from any one contributor,
during the year, total contributions of more than $1,000 for use exclusively for religious, charitable, scientific, literary,
or educational purposes, or the prevention of cruelty to children or animals. Complete Parts I, II, and III.
For a section 501(c)(7), (8), or (10) organization filing Form 990 or 990-EZ that received from any one contributor,
during the year, contributions for use exclusively for religious, charitable, etc., purposes, but these contributions did
not total to more than $1,000. If this box is checked, enter here the total contributions that were received during the
year for an exclusively religious, charitable, etc., purpose. Do not complete any of the parts unless the General Rule
applies to this organization because it received nonexclusively religious, charitable, etc., contributions of $5,000 or
more during the year
$
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm I
Caution. An organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer "No" on Part IV, line 2 of its Form 990; or check the box on line H of its Form 990-EZ or on
Part I, line 2 of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990, 990-EZ, or 990-PF).
For Paperwork Reduction Act Notice, see the Instructions for Form 990, 990-EZ, or 990-PF.
Schedule B (Form 990, 990-EZ, or 990-PF) (2012)
JSA
2E1251 1.000
87855E 1385
V 12-7.10
GROUP
Page 2
Name of organization
75-2462834
Part I Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(a)
No.
1
(b)
Name, address, and ZIP + 4
(c)
Total contributions
CONTRIBUTIONS OVER 2% - SEE ATTACHMENT 3
$
17,947,157.
(d)
Type of contribution
Person
Payroll
Noncash
X
(Complete Part II if there is
a noncash contribution.)
(a)
No.
2
(b)
(c)
Total contributions
NONCASH CONTRIB OVER 2%-SEE ATTACHMENT 3
$
4,035,885.
(d)
Person
Payroll
Noncash
X
X
(a)
No.
(b)
(c)
Total contributions
(d)
Person
Payroll
Noncash
$
(a)
No.
(b)
(c)
Total contributions
(d)
Person
Payroll
Noncash
$
(a)
No.
(b)
(c)
Total contributions
(d)
Person
Payroll
Noncash
$
(a)
No.
(b)
(c)
Total contributions
(d)
Person
Payroll
Noncash
$
JSA
2E1253 1.000
87855E 1385
V 12-7.10
GROUP
Part II
3
75-2462834
Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
(a) No.
from
Part I
2
Page
(c)
FMV (or estimate)
(see instructions)
(b)
Description of noncash property given
(d)
Date received
VARIOUS ITEMS - SEE ATTACHMENT 3
4,035,885.
$
(a) No.
from
Part I
(b)
VARIOUS
(c)
FMV (or estimate)
(see instructions)
(d)
Date received
(c)
FMV (or estimate)
(see instructions)
(d)
Date received
(c)
FMV (or estimate)
(see instructions)
(d)
Date received
(c)
FMV (or estimate)
(see instructions)
(d)
Date received
(c)
FMV (or estimate)
(see instructions)
(d)
Date received
$
(a) No.
from
Part I
(b)
$
(a) No.
from
Part I
(b)
$
(a) No.
from
Part I
(b)
$
(a) No.
from
Part I
(b)
$
JSA
2E1254 1.000
87855E 1385
V 12-7.10
GROUP
Page
4
75-2462834
Part III Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
that total more than $1,000 for the year. Complete columns (a) through (e) and the following line entry.
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.)
$
Use duplicate copies of Part III if additional space is needed.
I
(a) No.
from
Part I
(b) Purpose of gift
(c) Use of gift
(d) Description of how gift is held
(e) Transfer of gift
Transferee's name, address, and ZIP + 4
(a) No.
from
Part I
(b) Purpose of gift
Relationship of transferor to transferee
(c) Use of gift
(a) No.
from
Part I
(b) Purpose of gift
(c) Use of gift
(a) No.
from
Part I
(b) Purpose of gift
(c) Use of gift
JSA
2E1255 1.000
87855E 1385
V 12-7.10
GROUP
NOT FOR PUBLIC DISCLOSURE
SUSAN G. KOMEN BREAST CANCER FOUNDATION - GROUP
YEAR ENDED MARCH 31, 2013
SCHEDULE B, PART I and II
Contributor Name
EIN # 75-2462834
2012 FORM 990
Street Address
City
State
Zip
Contribution
Amount
Cash or
Non-cash
Date of Noncash
FMV of Noncash
Non-cash property description
Acadiana Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
5,000 Food & Beverage
-
10,000
5,000
10,000
10,000
5,000
5,000
5,047
5,000
Cash
Noncash
Cash
Cash
Cash
Cash
Cash
Cash
2/25/13
-
-
2,500
60,000
50,000
35,000
Cash
Noncash
Cash
Cash
7/16/12
-
-
60,000 Mascara
-
-
-
-
-
The Arkansas Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
The Aspen Chapter of the Susan G. Komen Breast Cancer Foundation
20,000 Cash
8,000 Cash
Austin Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
75,000
50,149
44,966
5,000
28,080
Cash
Cash
Cash
Cash
Noncash
Various
-
28,080 Venue Expenses, Tent, Medical experts
37,500
5,000
8,750
10,000
Cash
Cash
Noncash
Noncash
Various
3/31/13
-
8,750 FOOD, TENTS, TABLES, WATER
10,000 Coffee
10,000
200
8,243
10,000
6,765
5,047
5,000
5,000
Cash
Noncash
Cash
Noncash
Cash
Cash
Cash
Cash
10/1/12
10/1/12
-
-
200 Food and beverage
10,000 Food and beverage
-
65,585
30,000
5,000
35,000
5,000
7,800
30,000
14,298
12,290
Cash
Cash
Noncash
Cash
Cash
Noncash
Cash
Cash
Noncash
1/27/13
2/12/13
3/8/13
-
Baton Rouge Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
Bayou Region Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
-
Boise, Idaho Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
-
5,000 Gifts
7,800 Bagels & Fruit
12,290 Coffee
Central and South Jersey Affiliate of Susan G. Komen Breast Cancer Foundation, Inc.
126,856 Cash
50,000 Cash
50,000 Cash
-
-
6/15/12
-
-
-
Central Oklahoma Chapter of the Komen Foundation, Inc.
40,000
20,000
19,350
10,000
25,000
Page 1 of 14
Cash
Cash
Cash
Noncash
Cash
-
10,000 food, goodie bags
-
ATTACHMENT 3
Contributor Name
EIN # 75-2462834
2012 FORM 990
Street Address
City
State
Zip
Contribution
Amount
15,000
7,000
20,000
Cash or
Non-cash
Cash
Noncash
Cash
Date of Noncash
10/3/12
-
FMV of Noncash
-
7,000 food
-
Central Florida Affiliate of the Susan G. Komen Breast Cancer Foundation
-
24,760 WATER, JUICE & GRANOLA BARS FOR RACE
-
2,500 Cash
24,760 Noncash
15,000 Cash
10/16/12
-
51,109
5,000
5,000
5,000
5,000
5,000
5,000
Cash
Noncash
Cash
Cash
Cash
Cash
Cash
11/15/12
-
-
20,000
10,000
5,837
8,000
Cash
Noncash
Cash
Cash
2/4/13
-
-
Cash
Cash
Cash
Cash
Cash
Cash
Cash
-
-
-
124,500 Cash
25,000 Cash
-
-
-
5/31/12
8/16/12
-
-
-
-
6/12/12
-
-
-
-
-
Central Georgia Affiliate of the Susan G. Komen Breast Cancer Foundation
-
5,000 Food and Beverage
-
Central Mississippi Steel Magnolias Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
-
10,000 FOOD AND BEVERAGE
-
Central New Mexico Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
30,000
125,000
25,000
20,000
24,180
15,000
12,280
Central New York Affiliate of the Susan G. Komen Breast Cancer Foundation
Central Texas Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
10,000
10,000
15,000
10,115
5,000
Cash
Noncash
Cash
Noncash
Cash
25,365
20,748
10,866
10,000
10,000
10,000
10,000
Cash
Cash
Cash
Cash
Cash
Cash
Cash
35,000
25,948
5,000
5,000
5,000
5,000
5,000
Cash
Noncash
Cash
Cash
Cash
Cash
Cash
-
10,000 BEVERAGES
10,115 Food
-
Central Valley Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
-
Central Wisconsin Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
-
25,948 Gifts
-
Charlotte Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
45,000 Cash
40,928 Cash
Page 2 of 14
ATTACHMENT 3
Contributor Name
EIN # 75-2462834
2012 FORM 990
Street Address
City
State
Zip
Contribution
Cash or
Amount
Non-cash
38,000 Noncash
Date of Noncash
6/26/12
FMV of Noncash
38,000 Water
Chattanooga Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
50,000
20,000
10,000
2,000
Cash
Cash
Cash
Noncash
6/15/12
-
160,000
5,000
120,000
40,000
130,000
124,588
4,000
60,360
Cash
Noncash
Cash
Noncash
Cash
Cash
Noncash
Cash
Various
VARIOUS
Various
-
-
11,500
20,059
50,000
11,000
13,295
8,840
1,080
16,200
Cash
Cash
Cash
Noncash
Noncash
Cash
Noncash
Cash
VARIOUS
9/9/12
VARIOUS
-
-
30,000
35,752
20,000
40,000
100,000
27,436
23,064
30,000
60,000
48,500
41,497
Cash
Noncash
Cash
Cash
Cash
Cash
Noncash
Noncash
Cash
Cash
Noncash
3/20/13
Various
8/3/12
5/19/12
2,000 Bagels
The Chicagoland Area Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
-
5,000 Bags
40,000 Food
4,000 Beverages
-
Colorado Springs Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
-
11,000 Food
13,295 Food
1,080 GIFT CERTIFICATES
-
Columbus Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
-
-
35,752 food and giftcards
23,064 GIFT BAGS, GIFT BASKETS
30,000 COFFEE COUPONS
41,497 Food
Connecticut Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
95,000 Cash
48,000 Cash
-
-
-
Dallas County Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
63,539
74,873
100,177
5,150
100,000
Cash
Cash
Cash
Noncash
Cash
1/14/13
-
-
235,000
166,274
510
90,000
7,709
66,510
Cash
Cash
Noncash
Cash
Cash
Noncash
10/12/12
Various
-
-
-
-
5,150 Products, gifts
-
The Denver Metropolitan Affiliate of Susan G. Komen Breast Cancer Foundation
-
510 TICKETS TO BOTANIC GARDENS
Survivor gifts, fundraiser gifts, Rafe NY Karolina
66,510
Flat Clutch
The Des Moines Chapter of the Susan G. Komen Breast Cancer Foundation
19,792 Cash
21,618 Cash
20,000 Cash
Page 3 of 14
ATTACHMENT 3
Contributor Name
EIN # 75-2462834
2012 FORM 990
Street Address
City
State
Zip
Contribution
Cash or
Amount
Non-cash
31,862 Cash
12,410 Cash
Date of Noncash
-
FMV of Noncash
-
-
Eastern Washington Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
21,460
30,000
1,500
30,000
65,585
15,000
11,600
11,000
Noncash
Noncash
Cash
Noncash
Cash
Cash
Cash
Cash
14,606
10,000
5,000
5,000
Cash
Cash
Cash
Cash
20,000
7,500
10,000
15,000
14,500
15,315
1,100
8,600
Cash
Cash
Cash
Cash
Noncash
Cash
Cash
Noncash
Various
Various
Various
-
-
-
-
3/26/13
12/10/12
-
-
-
5/31/12
9/21/12
5/23/12
-
-
-
21,460 Water cups for race
30,000 Coffee for Race
30,000 Charms for Survivors
-
Elmira Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
-
El Paso Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
-
14,500 Gifts
8,600 Food and Medals for Race
Florida Suncoast Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
24,500 Cash
20,733 Cash
-
Grand Rapids Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
30,000
18,180
11,500
5,000
10,001
10,000
10,000
10,000
8,000
Cash
Cash
Cash
Noncash
Cash
Cash
Noncash
Noncash
Cash
-
-
5,000 Trucks, lifts, ice, water, skids
10,000 Custard
10,000 Bagels, coffee, breakfast
-
Greater Amarillo Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
10,000 Cash
7,500 Cash
6,500 Cash
-
-
-
The Greater Atlanta Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
521,900
386,662
180,000
76,000
62,817
Cash
Cash
Cash
Cash
Cash
-
-
-
192,955
28,980
40,000
43,530
Cash
Cash
Cash
Cash
-
-
-
50,000
15,000
15,000
12,500
Cash
Cash
Cash
Cash
-
-
-
Greater Cincinnati Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
Greater Evansville Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
Page 4 of 14
ATTACHMENT 3
Contributor Name
EIN # 75-2462834
2012 FORM 990
Street Address
City
State
Zip
Contribution
Amount
Cash or
Non-cash
Date of Noncash
FMV of Noncash
Greater Lansing Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
48,870
30,000
25,000
22,500
9,268
8,859
18,005
16,000
15,270
Cash
Cash
Cash
Noncash
Noncash
Cash
Noncash
Cash
Noncash
3/5/12
8/4/12
VARIOUS
3/5/13
-
152,514
66,500
1,000
31,500
25,263
Cash
Cash
Noncash
Noncash
Cash
2/15/13
7/13/12
-
-
201,491
311,124
85,000
40,000
Cash
Cash
Noncash
Cash
6/20/12
-
-
-
-
-
22,500
9,268
18,005
15,270
WATER
GIFT AND SPA CERTIFICATES
chocolate milk, ice, onsite staff
Gift cards, jackets, bibs, socks, store space,
packet, pickup trucks
The Greater Nashville Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
-
1,000 Water
31,500 COFFEE, HOT CHOCOLATE, GIFT CARDS
-
Greater New York City Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
-
85,000 Aquafina and Addl Products
-
Greater Richmond, Virginia Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
41,320
30,000
29,365
20,117
19,943
17,145
Cash
Cash
Cash
Cash
Cash
Cash
-
Greater Roanoke Valley Area Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
100,000 GIFT - LIP SHIMMER
15,540 Food
47,985
100,000
20,000
62,461
15,540
Cash
Noncash
Cash
Cash
Noncash
3/31/13
3/31/13
25,000
20,000
10,000
10,000
Noncash
Cash
Noncash
Cash
6/25/12
7/16/12
192,797
160,000
119,000
20,000
95,000
Cash
Cash
Noncash
Cash
Cash
6/7/12
-
25,000
50,000
50,000
50,000
40,000
10,000
Noncash
Cash
Noncash
Cash
Cash
Noncash
4/11/12
Various
3/13/2013
25,000 Food
50,000 Coffee
10,000 GIFT BASKETS AND LOTTO TICKETS
50,000
11,257
45,000
30,000
Cash
Noncash
Noncash
Cash
8/20/12
6/5/12
-
11,257 Food
45,000 Gift cards
-
-
Hawaii Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
-
25,000 food and water
10,000 PASSES, MEMBERSHIPS TO CLUB
Houston Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
-
119,000 Gifts
-
Indianapolis Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
Inland Empire Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
Page 5 of 14
-
-
ATTACHMENT 3
Contributor Name
EIN # 75-2462834
2012 FORM 990
Street Address
City
State
Zip
Contribution
Amount
27,992
25,000
22,500
22,500
21,600
12,252
8,100
21,377
30,876
27,474
Cash or
Non-cash
Noncash
Cash
Noncash
Cash
Noncash
Cash
Noncash
Cash
Cash
Cash
Date of Noncash
6/4/12
6/4/12
7/18/12
Various
-
FMV of Noncash
27,992 GYM MEMBERSHIPS
22,500 Gift cards
-
21,600 Gift cards
8,100 Food
-
Knoxville Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
-
16,000 Gift Certificates
8,091 Snacks, Water, Carnations
-
-
17,500 Food & Beverage
-
50,000
43,884
16,000
46,762
8,091
24,000
25,000
Cash
Cash
Noncash
Cash
Noncash
Cash
Cash
12/26/12
8/31/12
-
-
17,500
99,729
20,000
30,248
Noncash
Cash
Cash
Cash
8/1/12
-
15,000
14,700
18,000
19,120
25,000
1,500
Cash
Cash
Cash
Noncash
Cash
Cash
Various
-
85,000
35,000
115,000
84,000
40,000
50,000
15,250
Cash
Cash
Cash
Noncash
Noncash
Cash
Noncash
9/12/12
9/18/12
3/23/13
26,650
25,000
33,000
6,500
12,850
25,000
Noncash
Cash
Cash
Cash
Noncash
-
8/31/12
6/7/12
-
54,000 Noncash
4/1/12
25,000
5,000
35,500
30,900
17,500
6,500
10,000
6,500
29,106
4/4/12
4/5/12
6/20/12
4/3/12
4/5/12
-
-
-
-
-
-
-
-
The Las Vegas Chapter of the Susan G. Komen Breast Cancer Foundation
Lexington Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
-
19,120 Smoothie Cards
-
The Los Angeles County Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
-
-
84,000 Gift Certificates for Gala
40,000 Catered meal packages for Gala
15,250 Food for Race, Gifts
Louisville, Kentucky Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
-
26,650 Food, prizes, coupons
12,850 Bottled water for race, survivors, coffee for race
-
Lowcountry Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
Cash
Noncash
Noncash
Noncash
Cash
Noncash
Cash
Noncash
Cash
-
54,000 watches,socks.Cehon scarves, hats, Bears,
bracelets 400 each item
5,000 food/fruits, water for race,employees
35,500 decorations
30,900 gift certificates Race and pledge program
6,500 Food/catered
6,500 Gift Cards
Lubbock Area Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
20,000 Cash
Page 6 of 14
ATTACHMENT 3
Contributor Name
EIN # 75-2462834
2012 FORM 990
Street Address
City
State
Zip
Contribution
Amount
10,000
25,000
10,000
15,000
Cash or
Non-cash
Noncash
Cash
Cash
Cash
Date of Noncash
5/3/12
-
FMV of Noncash
10,000 Décor and flowers
-
Madison Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
-
20,000 Breakfast food for Race
27,500
25,205
60,000
20,000
Cash
Cash
Cash
Noncash
1/12/13
10,000
15,796
6,000
7,500
10,000
Noncash
Cash
Cash
Noncash
Cash
Various
Various
-
60,000 Cash
32,800 Noncash
62,505 Cash
Various
-
-
57,437 Cash
-
-
-
40,000 Cash
65,000 Cash
20,000 Cash
-
-
-
Maine Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
-
10,000 food for races
7500 Food for Survivor Reception
-
Maryland Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
-
32,800 Gift Cards, Race Day Food
-
Massachusetts Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
Memphis-Midsouth Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
Miami Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
80,000
35,000
22,500
6,200
Cash
Cash
Cash
Noncash
9/12/12
-
6,200 Merchandise & Gifts
38,000
4,000
38,000
10,000
4,000
Cash
Noncash
Cash
Cash
Noncash
1/23/12
9/29/12
-
4,000 Survivor breakfast, ad, water, granola bars
4,000 Vans, trucks, pace car, flatbed
11,525
10,000
10,000
2,500
2,500
2,500
2,500
5,000
Noncash
Cash
Cash
Cash
Noncash
Cash
Noncash
Cash
9/30/12
10/1/12
9/1/12
-
50,000
43,209
34,500
6,140
23,537
Cash
Cash
Cash
Noncash
Cash
Various
-
-
60,000
20,000
50,000
12,000
58,177
Cash
Noncash
Cash
Noncash
Cash
5/23/12
4/20/12
-
-
Mid-Kansas Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
-
Mid-Missouri Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
-
11,525 Breakfast
2,500 Water, bananas
2,500 Bottles of water, bananas
-
Milwaukee Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
-
6,140 Gifts
-
Minnesota Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
Page 7 of 14
-
20,000 Food
12,000 Hair products
ATTACHMENT 3
Contributor Name
EIN # 75-2462834
2012 FORM 990
Street Address
City
State
Zip
Contribution
Cash or
Amount
Non-cash
51,876 Cash
50,000 Noncash
Date of Noncash
4/1/12
FMV of Noncash
-
50,000 Coffee
5/1/12
-
-
5,000 Food
-
-
-
Montana Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
10,000
10,000
5,100
5,000
5,000
5,000
Cash
Cash
Cash
Noncash
Cash
Cash
9,378
10,000
5,000
11,471
Cash
Cash
Cash
Cash
-
North Carolina Foothills Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
-
North Carolina Triad Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
463,600
50,000
38,094
31,691
31,584
Cash
Cash
Cash
Cash
Noncash
1/9/13
-
31,584 Water
68,350
48,000
30,000
5,000
35,000
34,450
33,500
30,000
3,000
32,000
Cash
Noncash
Cash
Noncash
Cash
Noncash
Cash
Cash
Noncash
Cash
4/17/13
Various
Various
12/10/12
-
-
48,000 WATER AND 2 REFILLING STATIONS
5,000 Gift cards, incentive gifts
34,450 Breakfast, food, flowers, gift cards
3,000 Gift cards
-
50,060
8,000
40,000
34,886
24,402
20,000
108,411
Cash
Noncash
Cash
Cash
Cash
Cash
Cash
Various
-
25,000
18,987
5,000
9,500
Cash
Cash
Cash
Noncash
10/8/12
-
44,553 Cash
17,000 Noncash
15,000 Cash
8/1/12
-
-
10/20/12
10/20/12
-
-
-
NC Triangle Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
-
Nebraska Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
-
8,000 Water
-
New Orleans Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
9,500 Coffee
North Central Alabama Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
-
17,000 Gift cards
-
North Florida Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
50,000
28,632
15,000
9,154
8,750
Cash
Cash
Cash
Noncash
Noncash
9,154 WATER AND CUPS
8,750 Bagels
The North Jersey Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
223,877 Cash
117,210 Cash
Page 8 of 14
ATTACHMENT 3
Contributor Name
EIN # 75-2462834
2012 FORM 990
Street Address
City
State
Zip
Contribution
Cash or
Amount
Non-cash
60,000 Cash
Date of Noncash
-
FMV of Noncash
-
-
North Mississippi Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
Cash
Cash
Cash
Cash
Noncash
7/19/12
-
6,957 CLOTHING
30,000 Cash
44,245 Cash
9,500 Noncash
2/21/13
-
9,500 Water, fruit, gift cards
11,260
7,900
7,500
4,000
1,061
5,000
5,000
5,000
9/29/12
5/25/12
9/29/12
-
7,900 Gifts
1,061 Beverage
5,000 Food
-
-
10/6/12
12/20/12
-
-
6/6/12
-
9,784 Food
-
35,000
10,000
13,000
3,438
6,957
North Texas Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
The Northeast Louisiana Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
Cash
Noncash
Cash
Cash
Noncash
Cash
Cash
Noncash
-
The Northeast Ohio Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
75,000 Cash
-
Northeastern New York Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
14,105
10,000
10,000
10,000
10,000
10,000
3,927
5,000
6,386
Cash
Noncash
Cash
Cash
Cash
Cash
Cash
Noncash
Cash
-
10,000 Beverage
-
The Northeastern Pennsylvania Chapter of the Susan G. Komen Breast Cancer Foundation
17,519 Cash
9,784 Noncash
Northern Indiana Affiliate of the Susan G. Komen Breast Cancer Foundation
30,000
15,000
12,500
10,000
2,500
10,500
10,000
5,677
Cash
Cash
Cash
Cash
Noncash
Cash
Cash
Cash
12/31/12
-
-
14,000
8,000
10,400
7,000
7,000
Cash
Noncash
Noncash
Cash
Cash
Various
10/31/12
-
-
39,384
17,605
10,000
20,000
20,000
20,000
20,000
Cash
Cash
Noncash
Cash
Cash
Cash
Cash
2/28/13
-
-
-
Northern Nevada Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
-
8,000 Food & Beverage / Survivor Gifts
10,400 FOOD AND GIFTS
-
Northwest Ohio Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
Page 9 of 14
-
10,000 FOOD & RACE FOR CURE VENUE
ATTACHMENT 3
Contributor Name
EIN # 75-2462834
2012 FORM 990
Street Address
City
State
Zip
Contribution
Cash or
Amount
Non-cash
13,320 Noncash
Date of Noncash
2/28/13
FMV of Noncash
13,320 FOOD & RACE FOR CURE VENUE
Ozark Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
62,000 Cash
30,000 Cash
23,750 Cash
-
-
-
The Peoria Memorial Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
35,000
35,000
25,000
17,500
Cash
Cash
Cash
Noncash
12/19/12
-
233,758
100,000
55,000
115,755
148,000
60,000
50,000
Cash
Noncash
Cash
Noncash
Noncash
Cash
Noncash
Various
2/22/13
3/31/13
Various
-
203,304
29,000
60,530
51,990
25,000
16,794
Cash
Noncash
Cash
Cash
Noncash
Cash
11/14/12
7/31/12
-
-
100,071
11,178
60,000
55,000
45,000
5,620
49,200
40,629
Cash
Noncash
Cash
Cash
Noncash
Cash
Noncash
Cash
1/2/13
5/14/12
3/31/13
-
-
33,549 Cash
19,194 Cash
10,375 Noncash
3/31/13
-
17,500 Food
Philadelphia Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc
-
-
100,000 Food and beverage
115,755 Food and beverage, tent
148,000 Food
50,000 Food
Phoenix Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
-
29,000 FOOD AND BEVERAGE, GIFT CARDS
25,000 Food
-
Pittsburgh Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
-
11,178 OPAL EARRINGS
45,000 Food, prizes
49,200 Food
-
Quad Cities Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
9,750
9,150
9,000
8,970
7,823
5,735
Noncash
Cash
Cash
Cash
Cash
Cash
Various
-
-
120,000 Noncash
202,500 Cash
31,459 Cash
12/1/12
-
-
10,375 500 cases of water, 15 cases of soda, 10 cases
gatorade, 8 tubs
-
Sacramento Valley Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
120,000 FOOD FOR THE 2013 RACE
-
Salt Lake City Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
42,500
23,640
15,820
12,000
Noncash
Cash
Noncash
Cash
4/5/12
3/31/13
-
45,500 Cash
18,152 Noncash
42,293 Cash
3/12/12
-
-
42,500 FOOD AND GIFT CARDS
15,820 T-SHIRTS
-
The San Antonio Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
Page 10 of 14
-
ATTACHMENT 3
Contributor Name
EIN # 75-2462834
2012 FORM 990
Street Address
City
State
Zip
Contribution
Cash or
Amount
Non-cash
33,534 Cash
Date of Noncash
-
FMV of Noncash
-
-
The San Diego Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
99,472
53,750
50,000
7,000
38,000
Cash
Noncash
Cash
Noncash
Noncash
26,553
76,590
31,459
37,694
25,000
25,000
Cash
Cash
Cash
Cash
Cash
Cash
12,639
6,000
7,500
5,000
1,248
5,551
Cash
Cash
Cash
Cash
Noncash
Noncash
13,015
5,000
11,781
5,000
137,500
25,000
15,000
13,000
53,750 Prizes
6/12/12
11/4/12
10/6/12
-
-
-
5/31/12
6/6/12
-
Cash
Cash
Cash
Cash
-
-
-
Cash
Cash
Cash
Cash
-
-
-
1/2/13
-
-
-
The San Francisco Bay Area Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
-
Shreveport Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
1,248 WATER AND FRUIT FOR RACE
5,551 FOOD FOR SURVIVOR LUNCH AND RACE DAY
Siouxland Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
South Dakota Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
The South Florida Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
175,000 Noncash
90,000 Cash
50,000 Cash
175,000 GIFTS AND RECOGNITION
-
Southeast Georgia Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
30,242
20,000
30,000
20,198
17,300
15,650
10,000
10,000
Cash
Cash
Cash
Cash
Cash
Noncash
Cash
Cash
3/22/2013
-
-
10,000
11,200
5,000
5,000
5,000
Cash
Cash
Noncash
Cash
Cash
2/14/13
-
-
53,512
9,000
12,500
5,000
20,000
65,562
Cash
Noncash
Cash
Noncash
Cash
Cash
10/30/12
3/1/13
-
-
-
15,650 CONTINENTAL BREAKFAST FOR RACE FOR VIP
-
Southeast Iowa Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
-
-
Southern Arizona Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
Page 11 of 14
-
9,000 WATER, FRUIT, YOPLAIT, REFRIG VAN FOR
5,000 Ice
-
ATTACHMENT 3
Contributor Name
Street Address
Southwest Florida Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 75-2462834
2012 FORM 990
City
State
Zip
Contribution
Amount
Cash or
Non-cash
69,160
50,000
24,000
35,000
Cash
Cash
Cash
Cash
13,040
3,200
10,000
10,000
10,000
10,000
18,180
7,000
60,000
51,282
50,000
7,500
Date of Noncash
FMV of Noncash
-
-
Cash
Cash
Cash
Cash
Cash
Cash
Cash
Noncash
3/31/13
-
Cash
Noncash
Cash
Cash
1/24/13
-
-
34,500 Cash
30,000 Cash
9,369 Noncash
11/30/12
-
-
-
-
The Southwest Michigan Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
7,000 FOOD FOR VOLUNTEERS, SURVIVORS, &
VIPS
St. Louis Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
-
51,282 GRANOLA BARS, ROSES
-
Tarrant County Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
64,245 Cash
9,369 BANANAS, APPLES, GIFT CARDS, WATER,
FERNS CAKE
-
Texarkana Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
30,000
5,000
15,000
50,000
9,281
1,438
10,000
9,185
10,000
Cash
Noncash
Cash
Cash
Cash
Noncash
Noncash
Noncash
Noncash
10/18/12
7/30/12
8/24/12
7/12/12
6/20/12
-
130,198
212,500
75,000
135,418
23,000
5,000
81,600
71,680
Cash
Cash
Cash
Cash
Noncash
Cash
Noncash
Cash
11/28/12
5/1/12
-
-
93,000
48,040
58,932
60,000
6,000
Noncash
Cash
Cash
Cash
Cash
-
5,000 COFFEE FOR PP AND RACE
1,435 FOUR LUNCHEONS
10,000 Floral Arrangement for VIP
9,185 LADIES/MENS WATCHES FOR AUCTION
10,000 FOOD FOR PASTA PARTY
The Orange County Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
-
23,000 GIFT CARDS
81,600 GIFT CARDS
-
4/4/12
-
-
93,000 Food and goody bags
-
-
-
-
The Oregon and Southwest Washington Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc
The Puget Sound Chapter of the Susan G. Komen Foundation, Inc.
193,389
188,891
117,615
90,000
74,514
61,000
Cash
Cash
Cash
Cash
Cash
Cash
-
Tidewater Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
Page 12 of 14
ATTACHMENT 3
Contributor Name
EIN # 75-2462834
2012 FORM 990
Street Address
City
State
Zip
Contribution
Cash or
Amount
Non-cash
52,391 Cash
Date of Noncash
-
FMV of Noncash
-
-
Tri-Cities Affiliate of the Susan G. Komen Breast Cancer Foundation
5,000 FOOD & BEVERAGE
8,676 MCCAFE TRUCK, TEA (SUV CELB),TRAY LINE
55,102
25,000
10,000
5,000
8,676
Cash
Cash
Cash
Noncash
Noncash
10/21/12
10/21/12
-
15,740
15,000
2,940
12,060
18,000
45,000
15,000
25,000
Cash
Cash
Noncash
Cash
Noncash
Cash
Cash
Cash
7/30/12
7/21/12
-
-
1,875
6,000
12,000
8,000
25,000
13,000
10,000
Noncash
Cash
Cash
Cash
Cash
Cash
Cash
2/1/13
-
-
-
-
Cash
Noncash
Cash
Noncash
Cash
8/15/12
5/2/12
-
-
10,000 Cash
5,000 Noncash
6/26/12
-
5,000 AUCTION PRIZES
2,500 Food
-
Tulsa Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
-
2,940 Jewelry items
-
Tyler Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
1,875 Gift Cards
-
Upper Cumberland Affiliate of the Susan G. Komen Breast Cancer Foundation
10,000 Cash
6,960 Cash
5,000 Cash
-
Upstate South Carolina Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
30,000
250,000
20,000
10,000
24,131
-
250,000 Chapstick
10,000 WATER AND FRUIT FOR RACE
-
Vermont-New Hampshire Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
Wabash Valley Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
5,000
5,000
2,500
5,000
Cash
Cash
Noncash
Cash
Various
-
-
20,000
2,300
16512
16000
Cash
Noncash
Cash
Cash
Various
-
-
5,000
35,000
41,000
23,515
Cash
Cash
Noncash
Noncash
1/16/13
3/25/13
-
12,500 Cash
-
-
-
30,000 Cash
-
-
-
-
West Virginia Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
-
2,300 Fruit
-
The Western New York Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
41,000 Food for Race
23,515 FOOD FOR RACE
Wichita Falls Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
Wyoming Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
Page 13 of 14
ATTACHMENT 3
Contributor Name
EIN # 75-2462834
2012 FORM 990
Street Address
City
State
Zip
Contribution
Amount
15,000
10,000
8,493
16,000
30,000
10,000
10,000
17,000
Cash or
Non-cash
Cash
Cash
Cash
Noncash
Cash
Cash
Cash
Cash
Date of Noncash
10/31/12
-
FMV of Noncash
-
16,000 FOOD FOR RACE 12 AND 13
-
TOTALS
21,983,042
4,035,885
Less Noncash
Total Cash over 2%
(4,035,885)
17,947,157
5,094,553 Total Noncash contrib under 2%
9,130,438 Total Noncash Contributions
Page 14 of 14
ATTACHMENT 3
Political Campaign and Lobbying Activities
SCHEDULE C
I
OMB No. 1545-0047
For Organizations Exempt From Income Tax Under section 501(c) and section 527
Complete if the organization is described below.
I
I
À¾µ¶
Open to Public
Inspection
If the organization answered "Yes," to Form 990, Part IV, line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
%
%
%
%
%
%
Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Section 527 organizations: Complete Part I-A only.
If the organization answered "Yes," to Form 990, Part IV, line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)): Complete Part II-A. Do not complete Part II-B.
Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered "Yes," to Form 990, Part IV, line 5 (Proxy Tax) or Form 990-EZ, Part V, line 35c (Proxy Tax), then
Section 501(c)(4), (5), or (6) organizations: Complete Part III.
75-2462834
Part I-A
Complete if the organization is exempt under section 501(c) or is a section 527 organization.
1
2
3
Provide a description of the organization's direct and indirect political campaign activities in Part IV.
$
Political expenditures
Volunteer hours
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mIm
Part
I-B
4
Complete if the organization is exempt under section 501(c)(3).
mmmmmm I
mm I
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm
1
2
3
4a
b
Enter the amount of any excise tax incurred by the organization under section 4955
Enter the amount of any excise tax incurred by organization managers under section 4955
If the organization incurred a section 4955 tax, did it file Form 4720 for this year?
Was a correction made?
If "Yes," describe in Part IV.
1
Enter the amount directly expended by the filing organization for section 527 exempt function
$
activities
Enter the amount of the filing organization's funds contributed to other organizations for section
$
527 exempt function activities
Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL,
$
line 17b
Did the filing organization file Form 1120-POL for this year?
Yes
No
Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization's funds. Also enter
the amount of political contributions received that were promptly and directly delivered to a separate political organization, such
as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.
Part I-C
2
3
4
5
$
$
Yes
No
Yes
No
Complete if the organization is exempt under section 501(c), except section 501(c)(3).
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm I
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm I
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm I
(a) Name
(b) Address
(c) EIN
(d) Amount paid from
filing organization's
funds. If none, enter -0-.
(e) Amount of political
contributions received and
promptly and directly
delivered to a separate
political organization. If
none, enter -0-.
(1)
(2)
(3)
(4)
(5)
(6)
Schedule C (Form 990 or 990-EZ) 2012
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
JSA
2E1264 1.000
87855E 1385
V 12-7.10
GROUP
75-2462834
Page 2
Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under
section 501(h)).
X if the filing organization belongs to an affiliated group (and list in Part IV each affiliated group member's
name, address, EIN, expenses, and share of excess lobbying expenditures).
if the filing organization checked box A and "limited control" provisions apply.
Part II-A
I
Check I
A Check
B
1a
b
c
d
e
f
Limits on Lobbying Expenditures
(The term "expenditures" means amounts paid or incurred.)
mmmmm
mmmmmm
mmmmmmmmmmmmmmmm
(a) Filing
organization's totals
Total lobbying expenditures to influence public opinion (grass roots lobbying)
Total lobbying expenditures to influence a legislative body (direct lobbying)
Total lobbying expenditures (add lines 1a and 1b)
Other exempt purpose expenditures
Total exempt purpose expenditures (add lines 1c and 1d)
Lobbying nontaxable amount. Enter the amount from the following table in both
columns.
If the amount on line 1e, column (a) or (b) is: The lobbying nontaxable amount is:
g
h
i
j
Not over $500,000
20% of the amount on line 1e.
Over $500,000 but not over $1,000,000
$100,000 plus 15% of the excess over $500,000.
Over $1,000,000 but not over $1,500,000
$175,000 plus 10% of the excess over $1,000,000.
Over $1,500,000 but not over $17,000,000
$225,000 plus 5% of the excess over $1,500,000.
Over $17,000,000
$1,000,000.
(b) Affiliated
group totals
83,839.
56,942.
140,781.
151,176,923.
151,317,704.
83,839.
60,995.
144,834.
302,332,256.
302,477,090.
1,000,000.
1,000,000.
mmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
250,000.
Grassroots nontaxable amount (enter 25% of line 1f)
0
Subtract line 1g from line 1a. If zero or less, enter -00
Subtract line 1f from line 1c. If zero or less, enter -0If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720
reporting section 4911 tax for this year?
250,000.
0
0
Yes
No
4-Year Averaging Period Under Section 501(h)
(Some organizations that made a section 501(h) election do not have to complete all of the five
columns below. See the instructions for lines 2a through 2f on page 4.)
Lobbying Expenditures During 4-Year Averaging Period
Calendar year (or fiscal year
beginning in)
2 a Lobbying nontaxable amount
b Lobbying ceiling amount
(a) 2009
1,000,000.
(b) 2010
1,000,000.
(c) 2011
1,000,000.
(d) 2012
1,000,000.
(e) Total
4,000,000.
6,000,000.
(150% of line 2a, column (e))
c Total lobbying expenditures
295,135.
552,301.
656,218.
144,834.
1,648,488.
d Grassroots nontaxable amount
250,000.
250,000.
250,000.
250,000.
1,000,000.
e Grassroots ceiling amount
1,500,000.
(150% of line 2d, column (e))
f
Grassroots lobbying expenditures
219,954.
439,745.
519,831.
JSA
2E1265 1.000
87855E 1385
V 12-7.10
GROUP
83,839.
1,263,369.
75-2462834
Page
Part II-B
For each "Yes," response to lines 1a through 1i below, provide in Part IV a detailed
description of the lobbying activity.
1
a
b
c
d
e
f
g
h
i
j
2a
b
c
d
(a)
Yes
(b)
No
Amount
During the year, did the filing organization attempt to influence foreign, national, state or local
legislation, including any attempt to influence public opinion on a legislative matter or
referendum, through the use of:
Volunteers?
Paid staff or management (include compensation in expenses reported on lines 1c through 1i)?
Media advertisements?
Mailings to members, legislators, or the public?
Publications, or published or broadcast statements?
Grants to other organizations for lobbying purposes?
Direct contact with legislators, their staffs, government officials, or a legislative body?
Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means?
Other activities?
Total. Add lines 1c through 1i
Did the activities in line 1 cause the organization to be not described in section 501(c)(3)?
If "Yes," enter the amount of any tax incurred under section 4912
If "Yes," enter the amount of any tax incurred by organization managers under section 4912
If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year?
Part III-A
1
2
3
3
Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768
(election under section 501(h)).
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mm
mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm
mmmmmm
mmmm
m m m m m m m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm
mmm
mmmmmmmmmmmmmmmm
m m m mm mm
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section
501(c)(6).
mmmmmmmmmmmmmmmmmmm
m m m m m m m m mm mm mm mm mm mm mm mm mm mm
Were substantially all (90% or more) dues received nondeductible by members?
Did the organization make only in-house lobbying expenditures of $2,000 or less?
Did the organization agree to carry over lobbying and political expenditures from the prior year?
Part III-B
Dues, assessments and similar amounts from members
Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of
political expenses for w hich the section 527(f) tax was paid).
a Current year
b Carryover from last year
c Total
3
Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues
4
If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the
excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying
and political expenditure next year?
5
Taxable amount of lobbying and political expenditures (see instructions)
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmm
Part IV
No
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section
501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2, are answered "No," OR (b) Part III-A, line 3, is
answered "Yes."
1
2
Yes
1
2
3
m m m m m m m m m m m m m m m m m m m m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm
Supplemental Information
1
2a
2b
2c
3
4
5
Complete this part to provide the descriptions required for Part I-A, line 1; Part I-B, line 4; Part I-C, line 5; Part II-A (affiliated group
list); Part II-A, line 2; and Part II-B, line 1. Also, complete this part for any additional information.
JSA
2E1266 1.000
87855E 1385
V 12-7.10
GROUP
Part IV
Page
Supplemental Information (continued)
4
JSA
2E1500 1.000
75-2462834
87855E 1385
V 12-7.10
GROUP
SCHEDULE D
(Form 990)
I
OMB No. 1545-0047
Supplemental Financial Statements
À¾µ¶
Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b.
Attach to Form 990.
I
I
Open to Public
Inspection
75-2462834
Part I
Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the
organization answered "Yes" to Form 990, Part IV, line 6.
(a) Donor advised funds
mmmmmmmmmmm
mmmm
mmmmmmm
mmmmmmmmmm
1
2
3
4
5
(b) Funds and other accounts
Total number at end of year
Aggregate contributions to (during year)
Aggregate grants from (during year)
Aggregate value at end of year
Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization’s property, subject to the organization's exclusive legal control?
Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be used
only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose
conferring impermissible private benefit?
6
Yes
No
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
Yes
No
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
Part II
1
mmmmmmmmmmm
Purpose(s) of conservation easements held by the organization (check all that apply).
Preservation of land for public use (e.g., recreation or education)
Preservation of an historically important land area
Protection of natural habitat
Preservation of a certified historic structure
Preservation of open space
Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation
easement on the last day of the tax year.
2
a
b
c
d
mmmmmm
Held at the End of the Tax Year
6
2a
Total number of conservation easements
2b
Total acreage restricted by conservation easements
2c
Number of conservation easements on a certified historic structure included in (a)
Number of conservation easements included in (c) acquired after 8/17/06, and not on a
2d
historic structure listed in the National Register
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during the
tax year
Number of states where property subject to conservation easement is located
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of
violations, and enforcement of the conservation easements it holds?
Yes
No
Staff and volunteer hours devoted to monitoring, inspecting, and enforcing conservation easements during the year
7
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
8
Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)
(i) and section 170(h)(4)(B)(ii)?
Yes
In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes the
organization’s accounting for conservation easements.
3
I
4
5
I
I
I
$
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
9
Part III
1a
b
2
a
b
No
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.
If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet
works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of
public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items.
If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet
works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of
public service, provide the following amounts relating to these items:
(i) Revenues included in Form 990, Part VIII, line 1
$
(ii) Assets included in Form 990, Part X
$
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958) relating to these items:
Revenues included in Form 990, Part VIII, line 1
$
Assets included in Form 990, Part X
$
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m II
m m m m m m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm II
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
JSA
2E1268 1.000
87855E 1385
V 12-7.10
Schedule D (Form 990) 2012
GROUP
75-2462834
Page 2
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
Part III
3
Using the organization's acquisition, accession, and other records, check any of the following that are a significant use of its
collection items (check all that apply):
Public exhibition
Loan or exchange programs
a
d
Scholarly research
Other
b
e
Preservation for future generations
c
4 Provide a description of the organization's collections and explain how they further the organization's exempt purpose in Part
XIII.
5 During the year, did the organization solicit or receive donations of art, historical treasures, or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization's collection?
Yes
No
Part IV
mmmmmm
Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990, Part IV,
line 9, or reported an amount on Form 990, Part X, line 21.
1a Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X?
b If "Yes," explain the arrangement in Part XIII and complete the following table:
Amount
c Beginning balance
1c
d Additions during the year
1d
e Distributions during the year
1e
f Ending balance
1f
2a Did the organization include an amount on Form 990, Part X, line 21?
b If "Yes," explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII
Part V
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
m m m m m m m m m m m m m m m m m m mm mm mm mm m m m m m
Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
(a) Current year
mmmm
mmmmmmmmmmm
mmmmmmmmmmmmm
mmmmmm
mmmmmmmmmmm
mmmmm
mmmmmmmm
(b) Prior year
(c) Two years back
(d) Three years back
Yes
No
Yes
No
(e) Four years back
1a Beginning of year balance
b Contributions
c Net investment earnings, gains,
and losses
d Grants or scholarships
e Other expenditures for facilities
and programs
f Administrative expenses
g End of year balance
2
a
b
c
Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:
Board designated or quasi-endowment
%
Permanent endowment
%
Temporarily restricted endowment
%
The percentages in lines 2a, 2b, and 2c should equal 100%.
3a Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:
(i) unrelated organizations
(ii) related organizations
b If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R?
4 Describe in Part XIII the intended uses of the organization's endowment funds.
I
I
I
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmmmmmm
Part VI
3a(i)
3a(ii)
3b
Yes
No
Land, Buildings, and Equipment. See Form 990, Part X, line 10.
Description of property
mmmmmmmmmmmmmmmmmm
mmmmmmmmmm
mmmmmmmmmmmmmmmmm
(a) Cost or other basis
(b) Cost or other basis
(c) Accumulated
(investment)
(other)
depreciation
1a Land
b Buildings
459,818.
327,671.
c Leasehold improvements
1,334,037. 1,103,286.
d Equipment
189,791.
149,793.
e Other
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)
mmmmmmI
JSA
2E1269 1.000
87855E 1385
V 12-7.10
GROUP
(d) Book value
132,147.
230,751.
39,998.
402,896.
75-2462834
Part VII
Page
Investments - Other Securities. See Form 990, Part X, line 12.
(a) Description of security or category
(including name of security)
(b) Book value
mmmmmmmmmmmmmmmmm
mmmmmmmmmmmmm
(1) Financial derivatives
(2) Closely-held equity interests
(3) Other
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
(I)
Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)
Part VIII
(c) Method of valuation:
Cost or end-of-year market value
I
Investments - Program Related. See Form 990, Part X, line 13.
(a) Description of investment type
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Part IX
(b) Book value
(c) Method of valuation:
Cost or end-of-year market value
I
Other Assets. See Form 990, Part X, line 15.
(a) Description
(1) DUE FROM KOMEN PARENT
(2) OTHER ASSETS
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Part X
1.
3
(b) Book value
7,959,842.
554,628.
mmmmmmmmmmmmmmmmmmmmmmmmmm I
Other Liabilities. See Form 990, Part X, line 25.
(a) Description of liability
(1) Federal income taxes
(2) DUE TO KOMEN PARENT
(3) ACCRUED EXPENSES
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
8,514,470.
(b) Book value
9,180,954.
27,953.
I
9,208,907.
2. FIN 48 (ASC 740) Footnote. In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's
liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII
JSA
2E1270 1.000
87855E 1385
mmmmmmmmmmm
V 12-7.10
GROUP
75-2462834
Part XI
1
2
a
b
c
d
e
3
4
a
b
c
5
a
b
c
d
e
3
4
a
b
c
5
mmmmmmmmmmmmmmmmm
m m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm
2e
3
mmmmmmm
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mm mm mm mm mm mm mm mm mm mm mm mm mm mm
4c
5
Total revenue, gains, and other support per audited financial statements
Amounts included on line 1 but not on Form 990, Part VIII, line 12:
Net unrealized gains on investments
Recoveries of prior year grants
Other (Describe in Part XIII.)
Add lines 2a through 2d
Subtract line 2e from line 1
Amounts included on Form 990, Part VIII, line 12, but not on line 1 :
Investment expenses not included on Form 990, Part VIII, line 7b
Add lines 4a and 4b
Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.)
Part XII
1
2
Page
Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1
2a
2b
2c
2d
4a
4b
Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
m m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm
mmmmmmm
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mm mm mm mm mm mm mm mm mm mm mm mm mm mm
Total expenses and losses per audited financial statements
Amounts included on line 1 but not on Form 990, Part IX, line 25:
Prior year adjustments
Other losses
Add lines 2a through 2d
Subtract line 2e from line 1
Amounts included on Form 990, Part IX, line 25, but not on line 1:
Investment expenses not included on Form 990, Part VIII, line 7b
Add lines 4a and 4b
Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.)
Part XIII
4
1
2a
2b
2c
2d
2e
3
4a
4b
4c
5
Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part IV, lines 1b and 2b;
Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional
information.
FIN 48 (ASC 740) FINANCIAL STATEMENT DISCLOSURE
SCHEDULE D, PART X, LINE 2
THE ORGANIZATION IS SUBJECT TO A RECOGNITION THRESHOLD AND MEASUREMENT
ATTRIBUTE FOR FINANCIAL STATEMENT RECOGNITION AND MEASUREMENT OF A TAX
POSITION TAKEN OR EXPECTED TO BE TAKEN IN A TAX RETURN. THERE WERE NO
UNCERTAIN TAX POSITIONS IN THE FINANCIAL STATEMENTS AT MARCH 31, 2013 OR
MARCH 31, 2012.
JSA
2E1271 1.000
87855E 1385
V 12-7.10
GROUP
Supplemental Information (continued)
Part XIII
75-2462834
Page
5
JSA
2E1226 2.000
87855E 1385
V 12-7.10
GROUP
SCHEDULE G
OMB No. 1545-0047
Supplemental Information Regarding
Fundraising or Gaming Activities
Complete if the organization answered "Yes" to Form 990, Part IV, lines 17, 18, or 19, or if the
organization entered more than $15,000 on Form 990-EZ, line 6a.
I
I
À¾µ¶
Open to Public
Inspection
75-2462834
Fundraising Activities. Complete if the organization answered "Yes" to Form 990, Part IV, line 17.
Part I
Form 990-EZ filers are not required to complete this part.
1
a
b
c
d
Indicate whether the organization raised funds through any
X Mail solicitations
e X
X Internet and email solicitations
f X
X Phone solicitations
g X
X In-person solicitations
of the following activities. Check all that apply.
Solicitation of non-government grants
Solicitation of government grants
Special fundraising events
2 a Did the organization have a written or oral agreement with any individual (including officers, directors, trustees
X Yes
or key employees listed in Form 990, Part VII) or entity in connection with professional fundraising services?
No
b If "Yes," list the ten highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is to be
compensated at least $5,000 by the organization.
(i) Name and address of individual
or entity (fundraiser)
1
J.C. GEEVER INC.
2
EXTRAORDINARY EVENTS, LLC
3
W. STEWART MCKEOUGH
4
(ii) Activity
(iii) Did fundraiser have
custody or control of
contributions?
Yes
FOUNDATION
GRANTS
SOLICIT
SPONSORS
SOLICIT
SPONSORS
(iv) Gross receipts
from activity
(v) Amount paid to
(or retained by)
fundraiser listed in
col. (i)
(vi) Amount paid to
(or retained by)
organization
No
X
14,400.
X
910,686.
37,364.
873,322.
X
1,390,000.
125,529.
1,264,471.
5
6
7
8
9
10
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmI
2,300,686.
177,293. 2,137,793.
Total
3 List all states in which the organization is registered or licensed to solicit contributions or has been notified it is exempt from
registration or licensing.
AL,AZ,AR,CA,CO,CT,DE,FL,GA,HI,ID,IL,IN,
IA,KS,KY,LA,ME,MD,MA,MI,MN,MS,MO,MT,NE,NV,NH,NJ,NM,NY,NC,ND,OH,
OK,OR,PA,SC,SD,TN,TX,UT,VT,WA,WV,WI,WY,
Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
JSA
2E1281 1.000
87855E 1385
V 12-7.10
Schedule G (Form 990 or 990-EZ) 2012
GROUP
75-2462834
Part II
Page
Fundraising Events. Complete if the organization answered "Yes" to Form 990, Part IV, line 18, or reported more
2
than $15,000 of fundraising event contributions and gross income on Form 990-EZ, lines 1 and 6b. List events with
gross receipts greater than $5,000.
RACE
(a) Event #1
(b) Event #2
(c) Other events
(event type)
(total number)
PINK TIE BALL
Revenue
(event type)
mmmmmmmmmmmm
mmmmmmmmm
mmmmmmmmmmmmmmmmm
mmmmmmmmmmmmmm
mmmmmmmmmmmm
mmmmmmmmmm
mmmmmmmmm
mmmmmmmmmmmm
mmmmmmmm
1 Gross receipts
2 Less: Contributions
3 Gross income (line 1 minus
line 2)
(d) Total events
(add col. (a) through
col. (c))
220.
103,511,141.
2,880,319.
7,312,997.
113,704,457.
68,987,144.
1,690,411.
5,726,678.
76,404,233.
34,523,997.
1,189,908.
1,586,319.
37,300,224.
3,406,572.
9,170.
362,989.
3,778,731.
77,667.
264,136.
341,803.
371,295.
454,803.
5,581,065.
27,245.
16,025.
43,270.
20,288.
31,381.
2,340,613.
4 Cash prizes
Direct Expenses
5 Noncash prizes
6 Rent/facility costs
7 Food and beverages
4,754,967.
8 Entertainment
9 Other direct expenses
2,288,944.
mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm I 12,085,482.
25,214,742.
I
Gaming. Complete if the organization answered "Yes" to Form 990, Part IV, line 19, or reported more
10 Direct expense summary. Add lines 4 through 9 in column (d)
11 Net income summary. Combine line 3, column (d), and line 10
Part III
(
)
Direct Expenses
Revenue
than $15,000 on Form 990-EZ, line 6a.
(b) Pull tabs/instant
bingo/progressive bingo
(a) Bingo
mmmmmmmmmmmm
mmmmmmmmmmmmmm
mmmmmmmmmmm
mmmmmmmmmm
mmmmmmmm
mmmmmmmmmmm
1 Gross revenue
2 Cash prizes
3 Noncash prizes
195,575.
195,575.
9,186.
9,186.
732.
732.
149.
95.0000 %
149.
4 Rent/facility costs
5 Other direct expenses
6 Volunteer labor
Yes
Yes
%
No
No
7 Direct expense summary. Add lines 2 through 5 in column (d)
%
(d) Total gaming (add
col. (a) through col. (c))
(c) Other gaming
X
Yes
No
mmmmmmmmmmmmmmmmmmmmm I
mmmmmmmmmmmmmmmmmm I
(
8 Net gaming income summary. Combine line 1, column d, and line 7
9
Enter the state(s) in which the organization operates gaming activities: SEE SUPPLEMENTAL PAGE
a Is the organization licensed to operate gaming activities in each of these states?
b If "No," explain:
mmmmmmmmmmmmmmmmm
THE AFFILIATES ARE REGISTERED IN EACH STATE WHERE A LICENSE IS KNOWN TO
BE REQUIRED.
10 a Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year?
b If "Yes," explain:
mmmm
10,067.)
185,508.
Yes
X No
Yes
X No
JSA
2E1282 1.000
87855E 1385
V 12-7.10
GROUP
75-2462834
11
12
Does the organization operate gaming activities with nonmembers?
Is the organization a grantor, beneficiary or trustee of a trust or a member of a partnership or other entity
formed to administer charitable gaming?
13
Indicate the percentage of gaming activity operated in:
a The organization's facility
13a
b An outside facility
13b
14
Enter the name and address of the person who prepares the organization's gaming/special events books and
records:
Name
I
Address
15 a
I
%
100.0000 %
Yes X No
I
I
Gaming manager information:
Name
I
NONE
Gaming manager compensation
Description of services provided
Director/officer
17
Yes X No
SAME ADDRESS AS KOMEN AFFILIATE ,
I
I
Address
16
3
No
THE TREASURER OF EACH INDIVIDUAL KOMEN AFFILIATE
Does the organization have a contract with a third party from whom the organization receives gaming
revenue?
b If "Yes," enter the amount of gaming revenue received by the organization
$
and the
amount of gaming revenue retained by the third party
$
.
c If "Yes," enter name and address of the third party:
Name
Page
X Yes
I
I
$
Employee
Independent contractor
Mandatory distributions:
Is the organization required under state law to make charitable distributions from the gaming proceeds to
X Yes
retain the state gaming license?
b Enter the amount of distributions required under state law to be distributed to other exempt organizations
185,508.
or spent in the organization's own exempt activities during the tax year
$
a
Part IV
I
No
Supplemental Information. Complete this part to provide the explanation required by Part I, line 2b,
columns (iii) and (v), and Part III, lines 9, 9b, 10b, 15b, 15c, 16, and 17b, as applicable. Also complete this
part to provide any additional information (see instructions).
FUNDRAISING EVENTS
SCHEDULE G, PART II - NET INCOME SUMMARY
GROSS RECEIPTS ARE REDUCED BY THE AMOUNT OF CONTRIBUTIONS PER IRS
INSTRUCTIONS. THE CONTRIBUTIONS FOR FYE 3/31/13 WERE $76,404,233.
DOES THE ORGANIZATION OPERATE GAMING ACTIVITIES WITH NON-MEMBERS SCHEDULE
G, PART III, LINE 11
JSA
2E1503 1.000
87855E 1385
V 12-7.10
GROUP
75-2462834
11
12
13
13a
13b
14
records:
Name
revenue?
$
and the
$
.
I
I
No
%
%
Yes
No
Yes
No
I
Address
I
Name
I
Director/officer
17
Yes
I
15 a
16
3
No
I
Address
Name
Page
Yes
I
I
$
Employee
$
a
I
Part IV
THE AFFILIATES DO NOT HAVE ANY MEMBERS WHICH COULD CONDUCT GAMING
ACTIVITIES.
HOWEVER, THE MAJORITY OF GAMING ACTIVITIES WERE CONDUCTED BY
VOLUNTEERS.
MANDATORY DISTRIBUTIONS
PART III, LINE 17
REGARDLESS OF STATE REQUIREMENTS, ALL FUNDS FROM GAMING ACTIVITIES SUCH
JSA
2E1503 1.000
87855E 1385
V 12-7.10
GROUP
75-2462834
11
12
13
13a
13b
14
records:
Name
15 a
I
I
No
%
%
Yes
No
Yes
No
I
Address
I
Name
I
Director/officer
17
Yes
I
revenue?
$
and the
$
.
16
3
No
I
Address
Name
Page
Yes
I
I
$
Employee
$
a
Part IV
I
AS CHARITABLE RAFFLES ARE EITHER DISTRIBUTED TO OTHER EXEMPT
ORGANIZATIONS OR SPENT ON THE AFFILIATE'S OWN EXEMPT ACTIVITIES DURING
THE TAX YEAR.
JSA
2E1503 1.000
87855E 1385
V 12-7.10
GROUP
75-2462834
11
12
13
13a
13b
14
records:
Name
15 a
I
I
No
%
%
Yes
No
Yes
No
I
Address
I
Name
I
Director/officer
17
Yes
I
revenue?
$
and the
$
.
16
3
No
I
Address
Name
Page
Yes
I
I
$
Employee
$
a
Part IV
I
SCHEDULE G, PART III-STATES IN WHICH ORG. OPERATES GAMING ACTIVITIES
AZ,CA,CO,FL,ID,IL,IN,
IA,KY,LA,ME,MI,MO,MT,NE,NJ,NM,NY,OH,OK,PA,SC,TX,VT,VA,WV,WI,
JSA
2E1503 1.000
87855E 1385
V 12-7.10
GROUP
SCHEDULE I
(Form 990)
Grants and Other Assistance to Organizations,
Governments, and Individuals in the United States
2
À¾µ¶
Open to Public
Inspection
Complete if the organization answered "Yes" to Form 990, Part IV, line 21 or 22.
Attach to Form 990.
I
Part I General Information on Grants and Assistance
1
OMB No. 1545-0047
75-2462834
Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance?
Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
X Yes
No
Part II Grants and Other Assistance to Governments and Organizations in the United States. Complete if the organization answered "Yes" to Form 990,
Part IV, line 21, for any recipient that received more than $5,000. Part II can be duplicated if additional space is needed.
1
(1)
(a) Name and address of organization
or government
(b) EIN
(c) IRC section
if applicable
(d) Amount of cash
grant
(e) Amount of noncash assistance
(f) Method of valuation
(book, FMV, appraisal,
other)
(g) Description of
non-cash assistance
(h) Purpose of grant
or assistance
SEE SCHEDULE I ATTACHMENT
87,493,338.
(2)
SEE SCH I ATTACHED
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
m m m m m m m m m m m m m m m m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm II
2 Enter total number of section 501(c)(3) and government organizations listed in the line 1 table
3 Enter total number of other organizations listed in the line 1 table
JSA
2E1288 1.000
87855E 1385
V 12-7.10
GROUP
1,353.
Schedule I (Form 990) (2012)
75-2462834
Part III
(a) Type of grant or assistance
1
Page
Grants and Other Assistance to Individuals in the United States. Complete if the organization answered "Yes" on Form 990, Part IV, line 22.
Part III can be duplicated if additional space is needed.
EDUCATION
(b) Number of
recipients
20.
(d) Amount of
non-cash assistance
(c) Amount of
cash grant
(e) Method of valuation (book,
2
(f) Description of non-cash assistance
FMV, appraisal, other)
16,273.
2
3
4
5
6
7
Supplemental Information. Complete this part to provide the information required in Part I, line 2, Part III, column (b), and any other additional
information.
FORM 990, SCHEDULE I
Part IV
DESCRIPTION OF ORGANIZATION'S PROCEDURES FOR MONITORING THE USE OF GRANTS
AFFILIATES REQUIRE GRANTEES TO SUBMIT PROGRESS AND FINAL REPORTS THAT
PROVIDE INFORMATION ABOUT PROGRESS MADE TOWARD THE FUNDED PROGRAM'S GOALS
AND OBJECTIVES AND A FINANCIAL REPORT ON THE EXPENDITURE OF FUNDS
AWARDED.
FUTURE PAYMENTS UNDER THE GRANT ARE CONTINGENT UPON AFFILIATES'
RECEIPT OF SATISFACTORY REPORTS. IF THE REPORTS DO NOT REFLECT
SATISFACTORY PROGRESS OR THERE IS A CONCERN ABOUT THE EXPENDITURE OF
FUNDS, AFFILIATES MAY EITHER TERMINATE THE GRANT OR REFUSE TO ISSUE
ADDITIONAL PAYMENTS UNTIL CORRECTIVE ACTION IS TAKEN. AFFILIATES ALSO MAY
JSA
2E1504 2.000
87855E 1385
V 12-7.10
GROUP
75-2462834
Part III
Page
Grants and Other Assistance to Individuals in the United States. Complete if the organization answered "Yes" on Form 990, Part IV, line 22.
Part III can be duplicated if additional space is needed.
(a) Type of grant or assistance
(b) Number of
recipients
(c) Amount of
cash grant
(d) Amount of
non-cash assistance
(e) Method of valuation (book,
2
(f) Description of non-cash assistance
FMV, appraisal, other)
1
2
3
4
5
6
7
Supplemental Information. Complete this part to provide the information required in Part I, line 2, Part III, column (b), and any other additional
information.
CONDUCT SITE VISITS IN ORDER TO BUILD STRONGER RELATIONSHIPS WITH
Part IV
GRANTEES, TO GAIN A BETTER UNDERSTANDING OF THEIR WORK, AND TO ADDRESS
ANY CHALLENGES OR PROBLEMS THE GRANTEES MAY BE FACING.
JSA
2E1504 2.000
87855E 1385
V 12-7.10
GROUP
Compensation Information
SCHEDULE J
(Form 990)
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
Complete if the organization answered "Yes" to Form 990,
Part IV, line 23.
Attach to Form 990.
I
OMB No. 1545-0047
I
I
À¾µ¶
Open to Public
Inspection
Part I
Questions Regarding Compensation
75-2462834
Yes
No
1a Check the appropriate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
First-class or charter travel
Travel for companions
Tax indemnification and gross-up payments
Discretionary spending account
Housing allowance or residence for personal use
Payments for business use of personal residence
Health or social club dues or initiation fees
Personal services (e.g., maid, chauffeur, chef)
b If any of the boxes on line 1a are checked, did the organization follow a written policy regarding payment
or reimbursement or provision of all of the expenses described above? If "No," complete Part III to
explain
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all officers,
directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a?
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
mmmmmmmmmmm
3
X
X
W ritten employment contract
Compensation survey or study
Approval by the board or compensation committee
During the year, did any person listed in Form 990, Part VII, Section A, line 1a, with respect to the filing
organization or a related organization:
a Receive a severance payment or change-of-control payment?
b Participate in, or receive payment from, a supplemental nonqualified retirement plan?
c Participate in, or receive payment from, an equity-based compensation arrangement?
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
mmmmmmmmmmmmmm
mmmmmmmmmmmmmmm
5
a
b
6
a
b
7
8
9
2
Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods used by a
related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
Compensation committee
Independent compensation consultant
Form 990 of other organizations
4
1b
4a
4b
4c
X
X
X
5a
5b
X
X
6a
6b
X
X
7
X
8
X
Only section 501(c)(3) and 501(c)(4) organizations must complete lines 5-9.
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
The organization?
Any related organization?
If "Yes" to line 5a or 5b, describe in Part III.
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
The organization?
Any related organization?
If "Yes" to line 6a or 6b, describe in Part III.
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III
Were any amounts reported in Form 990, Part VII, paid or accrued pursuant to a contract that was subject
to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in
Regulations section 53.4958-6(c)?
JSA
2E1290 1.000
87855E 1385
V 12-7.10
9
Schedule J (Form 990) 2012
GROUP
75-2462834
Part II
Page
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.
2
For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that
individual.
(B) Breakdown of W-2 and/or 1099-MISC compensation
(A) Name and Title
CHERYL SHAW
(i) Base
compensation
(i)
1 EXEC. DIRECTOR - PUGET SOUND
(ii)
2
(ii)
3
(ii)
4
(ii)
5
(ii)
6
(ii)
7
(ii)
8
(ii)
9
(ii)
10
(ii)
11
(ii)
12
(ii)
13
(ii)
14
(ii)
15
(ii)
16
(ii)
(i)
(ii) Bonus & incentive
compensation
137,970.
0
(C) Retirement and
other deferred
compensation
(iii) Other
reportable
compensation
0
0
0
0
(D) Nontaxable
benefits
16,700.
(E) Total of columns
(B)(i)-(D)
(F) Compensation
reported as deferred in
prior Form 990
154,670.
(i)
(i)
(i)
(i)
(i)
(i)
(i)
(i)
(i)
(i)
(i)
(i)
(i)
(i)
JSA
2E1291 1.000
87855E 1385
V 12-7.10
GROUP
75-2462834
Page
3
Part III Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II.
Also complete this part for any additional information.
SUPPLEMENTAL COMPENSATION INFORMATION
SUPPLEMENTAL COMPENSATION INFORMATION
SUPPLEMENTAL INFORMATION
SEE THE SCHEDULE O DETAIL FOR PART VI, QUESTIONS 15A AND 15B FOR MORE
INFORMATION.
JSA
2E1505 1.000
87855E 1385
V 12-7.10
GROUP
SCHEDULE L
Transactions With Interested Persons
OMB No. 1545-0047
I
À¾µ¶
Complete if the organization answered
"Yes" on Form 990, Part IV, line 25a, 25b, 26, 27, 28a, 28b, or 28c,
or Form 990-EZ, Part V, line 38a or 40b.
I
I
Open To Public
Inspection
75-2462834
Part I
Excess Benefit Transactions (section 501(c)(3) and section 501(c)(4) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.
1
(a) Name of disqualified person
(b) Relationship between disqualified person
and organization
(d)
(c) Description of transaction
Corrected?
Yes No
(1)
(2)
(3)
(4)
(5)
(6)
2
3
Enter the amount of tax incurred by the organization managers or disqualified persons during the year
under section 4958
Enter the amount of tax, if any, on line 2, above, reimbursed by the organization
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmI
mmmmmmmmmmmmmmI
Part II
$
$
Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990-EZ, Part V, line 38a or Form 990, Part IV, line 26; or if the
organization reported an amount on Form 990, Part X, line 5, 6, or 22.
(a) Name of interested person
(b) Relationship
with organization
(c) Purpose of
loan
(d) Loan to or
from the
organization?
To
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Total
(e) Original
principal amount
(f) Balance due
Yes
From
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmI
Grants or Assistance Benefiting Interested Persons.
(g) In default? (h) Approved (i) Written
No
by board or
committee?
agreement?
Yes
Yes
No
No
$
Part III
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.
(b) Relationship between interested (c) Amount of assistance
(d) Type of assistance
(e) Purpose of assistance
person and the organization
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Schedule L (Form 990 or 990-EZ) 2012
JSA
2E1297 1.000
87855E 1385
V 12-7.10
GROUP
75-2462834
Page 2
Part IV
Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.
(b) Relationship between
interested person and the
organization
(c) Amount of
transaction
(d) Description of transaction
(e) Sharing of
organization's
revenues?
Yes
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
No
MORESOURCE, INC.
KAT CUNNINGHAM OWNS MORES
59,586. SEE SCHED L, PART V
X
TURNKEY DIRECT, INC.
TERRI BORG OWNS COMPANY
56,963. SEE SCHED L, PART V
X
Part V
Complete this part to provide additional information for responses to questions on Schedule L (see instructions).
BUSINESS TRANSACTIONS WITH INTERESTED PERSONS
SCHEDULE L, PART IV
THE MID-MISSOURI AFFILIATE LEASES THEIR OFFICE EMPLOYEE FROM MORESOURCE,
INC.
KAT CUNNINGHAM, MID-MISSOURI AFFILIATE'S PRESIDENT OWNS MORESOURCE,
INC.
TURNKEY DIRECT, INC. PROVIDED MARKETING, T-SHIRTS AND OTHER ITEMS FOR THE
SALT LAKE CITY AFFILIATE RACE.
TERRI BORG, SALT LAKE AFFILIATE BOARD
MEMBER OWNS TURNKEY DIRECT, INC.
SOME BOARD MEMBERS OF SUSAN G. KOMEN'S AFFILIATES ARE ALSO EMPLOYEES OF
ORGANIZATIONS THAT QUALIFY TO RECEIVE GRANTS FROM THE KOMEN AFFILIATES.
THE KOMEN AFFILIATES HAVE STRICT POLICIES REGARDING THE REVIEW AND GRANT
AWARD APPROVAL PROCESS WHICH INCLUDES THE PROCESSING OF GRANT
APPLICATIONS THROUGH AN INDEPENDENT AND OBJECTIVE KOMEN AFFILIATE REVIEW
PROCESS. A VOLUNTEER REVIEW PANEL IS FORMED FOR THE PURPOSE OF EVALUATING
AND RECOMMENDING WHICH ORGANIZATIONS SHOULD RECEIVE GRANT FUNDS. THE
MEMBERS OF THIS PANEL MUST CONFIRM THAT THEY HAVE NO CONFLICT OF INTEREST
IN THESE DECISIONS.
JSA
2E1507 1.000
87855E 1385
ONCE THEIR RECOMMENDATIONS ARE SENT TO THE
V 12-7.10
GROUP
75-2462834
Page 2
Part IV
Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.
(b) Relationship between
interested person and the
organization
(c) Amount of
transaction
(d) Description of transaction
(e) Sharing of
organization's
revenues?
Yes
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Part V
No
Complete this part to provide additional information for responses to questions on Schedule L (see instructions).
INDIVIDUAL KOMEN AFFILIATE BOARD FOR APPROVAL, ANY KOMEN AFFILIATE BOARD
MEMBERS WHO ARE ALSO MEMBERS OF THE ORGANIZATIONS BEING RECOMMENDED TO
RECEIVE GRANT FUNDS ABSTAIN FROM ANY DISCUSSION OR VOTING ON THE APPROVAL
OF GRANT AWARDS.
SOME KOMEN AFFILIATE BOARD MEMBERS ARE ALSO EMPLOYEES OF KOMEN EVENT
SPONSORS, RACE FOR THE CURE SPONSORS, OR VENDORS.
EACH AFFILIATE HAS
PROCESSES TO ENSURE TRANSACTIONS UNDERTAKEN WITH COMPANIES AND
INDIVIDUALS ASSOCIATED WITH BOARD MEMBERS ARE NEGOTIATED AT ARMS LENGTH
AND REPRESENT FAIR MARKET VALUE.
JSA
2E1507 1.000
87855E 1385
V 12-7.10
GROUP
SCHEDULE M
(Form 990)
I
I
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
(a)
Check if
applicable
75-2462834
(b)
Number of contributions or
items contributed
(c)
Noncash contribution
amounts reported on
Form 990, Part VIII, line 1g
Art - Works of art
Art - Historical treasures
Art - Fractional interests
Books and publications
Clothing and household
goods
Cars and other vehicles
Boats and planes
Intellectual property
Securities - Publicly traded
Securities - Closely held stock
Securities - Partnership, LLC,
or trust interests
Securities - Miscellaneous
Qualified conservation
contribution - Historic
structures
Qualified conservation
contribution - Other
Real estate - Residential
Real estate - Commercial
Real estate - Other
Collectibles
Food inventory
Drugs and medical supplies
Taxidermy
Historical artifacts
Scientific specimens
Archeological artifacts
573.
9,130,438.
Other ( ATCH 1
)
Other (
)
Other (
)
Other (
)
Number of Forms 8283 received by the organization during the tax year for contributions for
which the organization completed Form 8283, Part IV, Donee Acknowledgement
I
I
I
I
Open To Public
Inspection
Types of Property
Part I
mmmmmmmmmm
mmmmmm
mmmmmm
mmmmmm
mmmmmmmmmmmmmmmm
mmmmmm
mmmmmmmmmm
mmmmmmmm
mmmm
mmm
mmmmmmmmmm
mmmmm
À¾µ¶
Complete if the organizations answered "Yes" on Form
990, Part IV, lines 29 or 30.
Attach to Form 990.
1
2
3
4
5
OMB No. 1545-0047
Noncash Contributions
(d)
Method of determining
noncash contribution amounts
mmmmmmmmmmmmm
mmmmmmmm
mmmmmm
mmmmm
mmmmmmmmm
mmmmmmmmmmmmm
mmmmmmmmmmm
mmmm
mmmmmmmmmmmmm
mmmmmmmmm
mmmmmmmm
mmmmmmm
mmmmmmmmm
29
Yes
30 a During the year, did the organization receive by contribution any property reported in Part I, lines 1-28 that
it must hold for at least three years from the date of the initial contribution, and which is not required to be
used for exempt purposes for the entire holding period?
b If "Yes," describe the arrangement in Part II.
31
Does the organization have a gift acceptance policy that requires the review of any non-standard
contributions?
32 a Does the organization hire or use third parties or related organizations to solicit, process, or sell noncash
contributions?
b If "Yes," describe in Part II.
33
If the organization did not report an amount in column (c) for a type of property for which column (a) is checked,
describe in Part II.
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
JSA
2E1298 1.000
87855E 1385
V 12-7.10
No
X
30a
31
X
32a
X
Schedule M (Form 990) (2012)
GROUP
75-2462834
Page
Part II
2
Supplemental Information. Complete this part to provide the information required by Part I, lines 30b, 32b,
and 33, and whether the organization is reporting in Part I, column (b), the number of contributions, the
number of items received, or a combination of both. Also complete this part for any additional information.
SCHEDULE M
FORM 990, LINE 32A
IN CONJUNCTION WITH MAJOR EVENTS, AFFILIATES EMPLOY SERVICES OF THIRD
PARTIES TO HELP PRODUCE THE EVENT. THE SERVICES MAY INCLUDE OBTAINING
IN-KIND GOODS AND SERVICES RELATED DIRECTLY TO THESE EVENTS.
JSA
2E1508 2.000
87855E 1385
V 12-7.10
GROUP
75-2462834
Part II
Page
2
Supplemental Information. Complete this part to provide the information required by Part I, lines 30b, 32b,
and 33, and whether the organization is reporting in Part I, column (b), the number of contributions, the
number of items received, or a combination of both. Also complete this part for any additional information.
ATTACHMENT 1
SCHEDULE M, PART I - OTHER NONCASH CONTRIBUTIONS
DESCRIPTION
EVENT-RELATED ITEMS
TOTALS
(A) CHECK
X
(B) NUMBER OF
CONTRIBUTIONS
(C) REVENUES
REPORTED
573.
9,130,438.
573.
9,130,438.
FMV OF DONATED PROP
JSA
2E1508 2.000
(D) METHOD OF
DETERMINING
87855E 1385
V 12-7.10
GROUP
SCHEDULE N
Liquidation, Termination, Dissolution, or Significant Disposition of Assets
I
OMB No. 1545-0047
À¾µ¶
Complete if the organization answered "Yes" to Form 990, Part IV, lines 31 or 32; or Form 990-EZ, line 36.
I
Attach certified copies of any articles of dissolution, resolutions, or plans.
I
Open to Public
Inspection
Attach to Form 990 or 990-EZ.
75-2462834
Part I
Liquidation, Termination, or Dissolution. Complete this part if the organization answered "Yes" to Form 990, Part IV, line 31, or Form 990-EZ, line 36.
Part I can be duplicated if additional space is needed.
1
(a) Description of asset(s)
distributed or transaction
expenses paid
(b) Date of
distribution
(c) Fair market value of
asset(s) distributed or
amount of transaction
expenses
(d) Method of
determining FMV for
transaction expenses
(e) EIN of recipient
(f) Name and address of recipient
(g) IRC section of
recipient(s) (if
tax-exempt) or type
of entity
SUSAN G. KOMEN BREAST CANCER FOUNDATION
NORTH DAKOTA AFFILIATE ASSETS
07/09/2012
141,386.
ACTUAL COST
75-1835298
5005 LBJ FREEWAY,STE 250,DALLAS,TX 75244
501(C)(3)
BOISE, IDAHO AFFILIATE OF SUSAN G. KOMEN
COEUR D'ALENE AFFILIATE
04/01/2012
41,007.
ACTUAL COST
75-2854965
1412 W IDAHO, STE 200 BOISE,ID 83702
501(C)(3)
Yes
2
Did or will any officer, director, trustee, or key employee of the organization:
a Become a director or trustee of a successor or transferee organization?
mmmmmmmmmmmmmmmmmmm
I
b Become an employee of, or independent contractor for, a successor or transferee organization?
2a
2b
c Become a direct or indirect owner of a successor or transferee organization?
2c
d Receive, or become entitled to, compensation or other similar payments as a result of the organization's liquidation, termination, or dissolution?
2d
e If the organization answered "Yes" to any of the questions in this line, provide the name of the person involved and explain in Part III.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or Form 990-EZ.
JSA
2E1302 1.000
87855E 1385
V 12-7.10
No
X
X
X
X
Schedule N (Form 990 or 990-EZ) (2012)
GROUP
75-2462834
Part I
Page
Liquidation, Termination, or Dissolution (continued)
Note. If the organization distributed all of its assets during the tax year, then Form 990, Part X, column (B), line 16 (Total assets), and line 26
(Total liabilities), should equal -0-.
3
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm
mmmmmmmmmmm
Did the organization distribute its assets in accordance with its governing instrument(s)? If "No," describe in Part III
4 a Is the organization required to notify the attorney general or other appropriate state official of its intent to dissolve, liquidate, or terminate?
b If "Yes," did the organization provide such notice?
5
Did the organization discharge or pay all of its liabilities in accordance with state laws?
6 a Did the organization have any tax-exempt bonds outstanding during the year?
b Did the organization discharge or defease all of its tax-exempt bond liabilities during the tax year in accordance with the Internal Revenue Code and state laws?
Yes
3
4a
4b
5
6a
X
X
X
X
6b
2
No
X
c If "Yes" to line 6b, describe in Part III how the organization defeased or otherwise settled these liabilities. If "No," explain in Part III.
Part II
1
Sale, Exchange, Disposition, or Other Transfer of More Than 25% of the Organization's Assets. Complete this part if the organization answered
"Yes" to Form 990, Part IV, line 32, or Form 990-EZ, line 36. Part II can be duplicated if additional space is needed.
(a) Description of asset(s)
distributed or transaction
expenses paid
(b) Date of
distribution
(c) Fair market value of
amount of transaction
expenses
(d) Method of
determining FMV for
transaction expenses
(e) EIN of recipient
(f) Name and address of recipient
(g) IRC section of
recipient(s) (if
tax-exempt) or type
of entity
Yes
2
No
Did or will any officer, director, trustee, or key employee of the organization:
a Become a director or trustee of a successor or transferee organization?
I
b Become an employee of, or independent contractor for, a successor or transferee organization?
2a
2b
c Become a direct or indirect owner of a successor or transferee organization?
2c
d Receive, or become entitled to, compensation or other similar payments as a result of the organization's significant disposition of assets?
2d
e If the organization answered "Yes" to any of the questions in this line, provide the name of the person involved and explain in Part III.
JSA
2E1303 1.000
87855E 1385
V 12-7.10
GROUP
75-2462834
Schedule N (Form 990 or 990-EZ) 2012
Part III
Page
3
Supplemental Information. Complete to provide the information required by Part I, lines 2e and 6c, and Part
II, line 2e. Also complete this part to provide any additional information.
SCHEDULE N, PART I
THE NORTH DAKOTA AFFILIATE AUTHORIZED THE DISSOLUTION OF THE AFFILIATE ON
JULY 9, 2012.
THE NORTH DAKOTA AFFILIATE'S CERTIFICATE OF DISSOLUTION
WAS SUBSEQUENTLY FILED WITH THE STATE OF DELAWARE ON
APRIL 1, 2013.
THE COEUR D'ALENE AFFILIATE WAS MERGED WITH THE BOISE, IDAHO AFFILIATE
APRIL 1, 2012 PURSUANT TO ITS GOVERNING DOCUMENTS AND STATE LAW.
JSA
2E1509 1.000
87855E 1385
V 12-7.10
GROUP
SCHEDULE O
Supplemental Information to 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.
Attach to Form 990 or 990-EZ.
I
OMB No. 1545-0047
À¾µ¶
Open to Public
Inspection
75-2462834
FORM 990 SUPPLEMENTAL INFORMATION
FORM 990, PART III - PROGRAM SERVICE ACCOMPLISHMENTS
NANCY G. BRINKER PROMISED HER DYING SISTER, SUZY, THAT SHE WOULD DO
EVERYTHING IN HER POWER TO END BREAST CANCER. SUSAN G. KOMEN WORKS TO END
BREAST CANCER IN THE U.S. AND THROUGHOUT THE WORLD BY INVESTING IN BREAST
CANCER RESEARCH AND COMMUNITY OUTREACH PROGRAMS, WITH A FOCUS ON
MEDICALLY UNDERSERVED PEOPLE. KOMEN, AND ITS AFFILIATES, ADVOCATES FOR
CANCER RESEARCH AND ACCESS TO CANCER CARE.
KOMEN WORKS GLOBALLY IN MORE
THAN 30 COUNTRIES.
A - EDUCATION
KOMEN IS A TRUSTED SOURCE OF BREAST HEALTH AND BREAST CANCER INFORMATION
FOR PEOPLE ALL OVER THE WORLD AND IS INSTRUMENTAL IN CONNECTING PEOPLE
WITH THE RESOURCES THEY NEED IN THEIR FIGHT AGAINST BREAST CANCER.
KOMEN AFFILIATES DISTRIBUTE KOMEN'S SCIENCE-BASED, EASY-TO-READ
EDUCATIONAL MATERIALS. NEARLY 5 MILLION EDUCATIONAL MATERIALS WERE
DISTRIBUTED IN FISCAL YEAR 2013. EXAMPLES OF KOMEN EDUCATIONAL MATERIALS
INCLUDE THE FOLLOWING:
- BREAST SELF-AWARENESS CARDS IN 21 LANGUAGES FOR 22 SPECIFIC AUDIENCES
- GENERAL BREAST HEALTH AWARENESS AND BREAST CANCER SPECIFIC BROCHURES
AND FACT SHEETS
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
JSA
2E1227 1.000
87855E 1385
V 12-7.10
GROUP
Schedule O (Form 990 or 990-EZ) (2012)
Schedule O (Form 990 or 990-EZ) 2012
Page
2
75-2462834
- BOOKLETS WITH SUPPORT INFORMATION FOR SURVIVORS AND CO-SURVIVORS
I AM THE CURE® IS AN EDUCATIONAL PROGRAM THAT TEACHES SIMPLE,
ACTION-ORIENTED, BREAST HEALTH INFORMATION TO PARTICIPANTS IN THE SUSAN
G. KOMEN RACE FOR THE CURE® SERIES.
LAST YEAR, NEARLY 1.5 MILLION PEOPLE
PARTICIPATED IN A RACE FOR THE CURE EVENT.
A FORMAL EVALUATION SHOWED
THAT 82% OF PARTICIPANTS RECALLED THE MESSAGE THAT EARLY DETECTION IS KEY
TO SURVIVAL.
IN COMMUNITIES AROUND THE UNITED STATES, KOMEN AFFILIATES SUPPORT
PROGRAMS THAT RAISE AWARENESS ABOUT BREAST CANCER, ITS RISK FACTORS, AND
WHERE TO GO FOR HELP. LISTED BELOW ARE THREE EXAMPLES:
THE NORTHWEST GEORGIA HEALTHCARE PARTNERSHIP RECEIVED A GRANT FROM THE
CHATTANOOGA AFFILIATE TO EQUIP A PROMOTORA DE SALUD (BILINGUAL AND
CULTURALLY COMPETENT COMMUNITY HEALTH WORKER) TO PROVIDE BREAST HEALTH
EDUCATION AND IMMIGRANT OUTREACH IN NORTHWEST GEORGIA. THE BREAST HEALTH
PROMOTORA DE SALUD WILL PROVIDE PATIENT NAVIGATION AND CASE MANAGEMENT
FOR LATINO WOMEN REQUIRING MAMMOGRAMS, OTHER DIAGNOSTIC SCREENINGS, AND
FOR THOSE DIAGNOSED WITH BREAST CANCER. THE INDIGENT AND MEDICALLY
UNDERSERVED WILL BE TARGETED. THE NORTHWEST GEORGIA HEALTHCARE
PARTNERSHIP INITIATED THE PROMOTORAS DE SALUD INITIATIVE TO SERVE THE
INFLUX OF LATINO RESIDENTS IN WHITFIELD AND MURRAY COUNTIES. PROMOTORAS
DE SALUD ARE NATURAL LEADERS WITHIN THEIR COMMUNITY WHO ARE ABLE TO
IDENTIFY INDIVIDUALS AND GROUPS AND PROVIDE HEALTH CARE ADVICE AND
JSA
2E1228 1.000
87855E 1385
V 12-7.10
GROUP
Page
SUPPORT IN SPANISH.
2
75-2462834
THEY HELP TO IMPROVE HEALTH CONDITIONS THROUGH
EDUCATION, ADVOCACY, AND EMPOWERING THEM TO TAKE CONTROL OF THEIR HEALTH
BY TEACHING THEM HOW TO ACCESS APPROPRIATE HEALTH CARE AND COMMUNITY
RESOURCES.
THE VERMONT-NEW HAMPSHIRE AFFILIATE PROVIDED A GRANT TO THE VERMONT
CANCER CENTER - UNIVERSITY OF VERMONT COLLEGE OF MEDICINE TO SUPPORT THE
CENTER'S 16TH ANNUAL BREAST CANCER CONFERENCE AT THE SHERATON CONFERENCE
CENTER IN BURLINGTON, VT. THIS FREE COMMUNITY BREAST HEALTH EVENT
PROVIDES PATIENTS, SURVIVORS, THEIR FAMILIES AND FRIENDS IN VT, NH, AND
NORTHERN NY WITH THE LATEST INFORMATION ON BREAST CANCER RESEARCH,
CLINICAL TRIALS, PREVENTION, SCREENING, TREATMENT, AND SURVIVORSHIP.
RESIDENTS OF THIS RURAL REGION FACE OBSTACLES WHEN ACCESSING HEALTH CARE
RESOURCES AND MAY EXPERIENCE CHALLENGES IN FINDING RELIABLE INFORMATION
ABOUT CURRENT BREAST CANCER RESEARCH, PREVENTION AND SCREENING,
COUNSELING AND DIAGNOSTICS, AND THERAPEUTICS, WARRANTING A SIGNIFICANT
NEED FOR THIS FREE REGIONAL BREAST HEALTH EDUCATIONAL EVENT.
CONFERENCE
GOALS INCLUDE INCREASING AWARENESS OF THE SCREENING FACILITIES IN
CHITTENDEN AND NEARBY COUNTIES OF VT, NH AND IN NORTHERN NY, AS WELL AS
INCREASING AWARENESS AND ATTENDANCE OF THE CONFERENCE AMONG RURAL,
ECONOMICALLY CHALLENGED, AND MEDICALLY UNDERSERVED POPULATIONS IN THE
REGION, PARTICULARLY THOSE WHO ARE NEWLY DIAGNOSED OR HAVE NOT YET
ATTENDED THE CONFERENCE.
THE MASSACHUSETTS AFFILIATE PROVIDED A GRANT TO THE YWCA OF SOUTHEASTERN
JSA
2E1228 1.000
87855E 1385
V 12-7.10
GROUP
Page
2
75-2462834
MASSACHUSETTS THAT SUPPORTED EDUCATIONAL OUTREACH TO WOMEN IN
SOUTHEASTERN MASSACHUSETTS.
THE YWCA PROGRAM EXPANDS BREAST HEALTH
EDUCATION, LINKAGE TO SCREENING AND PATIENT NAVIGATION TO LOW-INCOME
UNDERSERVED WOMEN OVER 40 IN SOUTHEASTERN MASSACHUSETTS, CAPE COD,
MARTHA'S VINEYARD AND NANTUCKET. THIS GROUP WAS IDENTIFIED BY KOMEN
MASSACHUSETTS AS NEEDING BREAST CANCER EDUCATION AND SCREENING, AS THERE
IS A HIGH INCIDENCE IN THIS AREA. APPROPRIATE EDUCATION AND REFERRALS CAN
INCREASE THE BREAST CANCER DETECTION RATE FOR MANY OF THESE WOMEN TO THE
POINT THAT THEY CAN BE CURED IN ITS EARLIEST STATE, INCREASING THE
SURVIVAL RATE SIGNIFICANTLY.
B - SCREENING
GETTING REGULAR SCREENING TESTS, ALONG WITH TREATMENT IF DIAGNOSED,
LOWERS THE RISK OF DYING FROM BREAST CANCER. SCREENING TESTS CAN FIND
BREAST CANCER EARLY, WHEN IT'S MOST TREATABLE. KOMEN AFFILIATES SUPPORT
FREE AND LOW-COST MAMMOGRAM PROGRAMS IN COMMUNITIES FOR WOMEN WITHOUT
HEALTH INSURANCE OR THOSE WITH HIGH CO-PAYS AND DEDUCTIBLES THAT MAKE
GETTING A MAMMOGRAM TOO COSTLY.
LISTED BELOW ARE EXAMPLES OF SUCH
PROGRAMS:
THE NC FOOTHILLS AFFILIATE PROVIDED A GRANT TO FUND THE GOOD SAMARITAN
CLINIC- THE PRIMARY CARE PROVIDER AND SAFETY NET FOR BURKE COUNTY'S
LOW-INCOME, UNINSURED RESIDENTS.
THE CLINIC WORKS CLOSELY WITH COMMUNITY
PARTNERS TO INCREASE CAPACITY OF CARE AND MAXIMIZE EFFICIENCY.
JSA
2E1228 1.000
THE
87855E 1385
V 12-7.10
GROUP
Page
2
75-2462834
GRANT AWARDED TO GOOD SAMARITAN CLINIC WILL BE USED TO SUPPORT THE
SCREENING AND REFERRAL OF PATIENTS RECEIVING A CLINICAL BREAST EXAM AND
OFTEN, THE SUBSEQUENT SCREENING OR DIAGNOSTIC MAMMOGRAM.
THIS FUNDING
WILL BE USED TO COVER THE COST OF PERFORMING THE EXAMS, REVIEWING THE
TESTS AND COORDINATING ADDITIONAL TESTING.
EVALUATION WILL INCLUDE A
COMBINATION OF QUANTITATIVE DATA AND CLINICAL QUALITY IMPROVEMENT CYCLES
TO IMPROVE PATIENT FLOW AND SUBSEQUENT IMPACT.
IT IS ANTICIPATED THAT A
DEDICATED BREAST HEALTH CLINIC HELD MONTHLY WILL NOT ONLY YIELD A
SIGNIFICANT NUMBER OF SCREENINGS BUT WILL RESULT IN INCREASED EDUCATION
AND AWARENESS AMONG THE UNINSURED.
THE
MEMORIAL AFFILIATE FUNDED A GRANT TO ST. JOHN'S HOSPITAL
(SPRINGFIELD), ST. FRANCIS HOSPITAL (LITCHFIELD), AND ST. MARY'S HOSPITAL
(STREATOR); ALL PARTNERING HOSPITALS IN THE HOSPITAL SISTERS HEALTH
SYSTEM.
THESE HOSPITALS WILL PROVIDE AT LEAST 82 LOW-INCOME WOMEN FROM
LA SALLE, MONTGOMERY, AND SANGAMON COUNTIES WITH ACCESS TO A FREE ANNUAL
SCREENING MAMMOGRAM.
THROUGH COLLABORATION WITH THE COORDINATED ACCESS
TO COMMUNITY HEALTH PROGRAM IN SANGAMON COUNTY, THEY WILL PROVIDE THE
NECESSARY RESOURCES THAT THESE PATIENTS NEED TO OVERCOME THE BARRIERS TO
ACCESSING REGULAR MAMMOGRAMS.
UNINSURED WOMEN WILL BE SCHEDULED FOR A
BREAST SCREENING MAMMOGRAM, IN ADDITION TO RECEIVING BREAST HEALTH
INFORMATION.
EVALUATION OF THE PROGRAM WILL BE TRACKED BY THE NUMBER OF
WOMEN RECEIVING A SCREENING MAMMOGRAM AND BREAST HEALTH EDUCATION.
THE
POTENTIAL IMPACT OF THIS PROGRAM IS GREATER ACCESS TO BREAST SCREENING
SERVICES AVAILABLE TO THE TARGET POPULATION THAT DO NOT HAVE A REGULAR
JSA
2E1228 1.000
87855E 1385
V 12-7.10
GROUP
Page
2
75-2462834
MAMMOGRAM, INCREASING COLLABORATION AMONG HOSPITALS FOR BREAST HEALTH
SERVICES, INCREASING BREAST HEALTH AWARENESS, AND COLLABORATION WITH
LOCAL AGENCIES IN PROVIDING ACCESS TO HEALTH SERVICES.
THE SC MOUNTAINS TO MIDLANDS AFFILIATE PROVIDED A GRANT TO THE FOUNDATION
OF MONONGALIA GENERAL HOSPITAL TO HELP FUND 60 (OR MORE) FREE MAMMOGRAMS
TO WOMEN AGE 36 AND OLDER WITH NO HEALTH INSURANCE AND A FAMILY HISTORY
OF BREAST CANCER.
THEY WILL TARGET THE COUNTIES OF PRESTON, GRANT,
HARDY, TAYLOR, MINERAL, TUCKER, RANDOLPH, BARBOUR, LEWIS AND UPSHUR.
WITHIN THIS AREA RESIDE MORE THAN 100,000 WOMEN FITTING THE CRITERIA.
THIS AREA ALSO HAS RELATIVELY LOW HEALTH INSURANCE COVERAGE COMPARED TO
THE MORE METROPOLITAN AREA OF MONONGALIA COUNTY. THE RESULTS WILL BE
SHOWN IN HOW MANY WOMEN SIGN UP FOR THE FREE MAMMOGRAM SCREENINGS.
THE
EXPECTED CHANGE FOR THE COMMUNITY WILL BE MORE WOMEN GETTING SCREENINGS
WHO OTHERWISE WOULD NOT.
C - RESEARCH AND TRAINING
KOMEN HAS CONTRIBUTED TO MAJOR ADVANCES IN BREAST CANCER RESEARCH OVER
THE PAST 30 YEARS.
KOMEN'S RESEARCH AND TRAINING PROGRAMS ARE DESIGNED
TO ADVANCE THE TRANSLATION OF RESEARCH DISCOVERIES INTO NEW WAYS TO
DIAGNOSE, TREAT, AND PREVENT BREAST CANCER, LEADING TO A REDUCTION OF
BREAST CANCER INCIDENCE AND MORTALITY WITHIN THE NEXT DECADE.
TO ENSURE
MAXIMUM IMPACT FOR ITS RESEARCH DOLLARS, KOMEN IS GUIDED BY A SCIENTIFIC
ADVISORY BOARD, A GROUP OF INTERNATIONALLY RECOGNIZED DOCTORS, SCIENTISTS
JSA
2E1228 1.000
87855E 1385
V 12-7.10
GROUP
Page
2
75-2462834
AND ADVOCATES, AND CONSULTS WITH THE KOMEN SCHOLARS, A GROUP COMPRISED OF
70 SCIENTISTS AND ADVOCATES.
KOMEN AWARDS GRANTS TO INDIVIDUAL SCIENTISTS, RESEARCH TEAMS, AND
ORGANIZATIONS AROUND THE WORLD THROUGH COMPETITIVE, REVIEW PROCESSES THAT
ENSURE MAXIMUM IMPACT FOR OUR RESEARCH DOLLARS.
WHILE AFFILIATES DO NOT FUND RESEARCH GRANTS DIRECTLY, A PORTION OF THE
NET FUNDS RAISED BY EVERY AFFILIATE (APPROXIMATELY 25%) GOES TO SUPPORT
THE RESEARCH AND TRAINING GRANTS PROGRAMS AT KOMEN HEADQUARTERS.
IN
FISCAL YEAR 2013, KOMEN MADE 124 GRANTS THROUGH ITS RESEARCH AND TRAINING
GRANTS PROGRAM TO SUPPORT RESEARCH AND TRAINING IN THE UNITED STATES AND
OTHER COUNTRIES, INCLUDING AUSTRALIA, BELGIUM, AND CANADA.
D - TREATMENT
COUNTLESS NUMBERS OF PATIENTS DELAY OR FOREGO BREAST CANCER TREATMENT
EACH YEAR, AND AS A RESULT, THESE WOMEN ARE LESS LIKELY TO SURVIVE. FOR
THIS REASON, KOMEN SUPPORTS PROGRAMS THAT CONNECT PEOPLE WITH LOCAL
RESOURCES, PSYCHOSOCIAL SUPPORT, AND PROVIDE CRITICAL FINANCIAL
ASSISTANCE.
THE IOWA AFFILIATE FUNDS THE BREAST CANCER ASSISTANCE PROGRAM OF VISITING
NURSES ASSOCIATION OF POTTAWATTAMIE COUNTY, WHICH SEEKS TO EASE THESE
HARDSHIPS BY ALLEVIATING IMMEDIATE FINANCIAL NEEDS ARISING FROM A BREAST
JSA
2E1228 1.000
87855E 1385
V 12-7.10
GROUP
Page
2
75-2462834
CANCER DIAGNOSIS, PROVIDING EMOTIONAL SUPPORT, AND CONNECTING PATIENTS
WITH COMMUNITY RESOURCES. SERVICES TO THE CLIENT ARE TAILORED TO THEIR
PARTICULAR NEED. EVALUATION INCLUDES THE USE OF SATISFACTION SURVEYS, AND
COLLECTION OF DATA REGARDING SERVICE PROVISION AND IMPACT. IT IS EXPECTED
THAT THE KOMEN GRANT WILL HELP FUND TRANSPORTATION SERVICES AND OTHER
SUPPORT FOR APPROXIMATELY 20-30 WOMEN IN IOWA, ENABLING THEM TO FOCUS
THEIR ENERGY ON RECOVERY.
THE TEXARKANA AFFILIATE PROVIDES A GRANT TO THE HOSPICE OF TEXARKANA
WHICH SUPPORTS PATIENTS WITH BREAST CANCER WHO ARE IN NEED OF END-OF-LIFE
SUPPORT, REGARDLESS OF THEIR GENDER, AGE, OR ABILITY TO PAY. THE HOSPICE
PROVIDES PROVIDE COMPREHENSIVE SERVICES AND DOES NOT SEND A BILL TO
PATIENTS, WHETHER OR NOT THEY HAVE INSURANCE BENEFITS.
PATIENTS ARE
TYPICALLY REFERRED BY THEIR PHYSICIANS WHEN CURATIVE OPTIONS HAVE BEEN
EXHAUSTED AND SYMPTOMS NEED TO BE CONTROLLED SO THEY CAN HAVE QUALITY
TIME WITH FAMILY. ALSO, THE HOSPICE'S BEREAVEMENT DEPARTMENT OFFERS
CONSOLATION TO THE PATIENT'S FAMILY FOR A YEAR BEYOND THE DEATH.
THE CHICAGOLAND AFFILIATE PROVIDED A GRANT TO THE ROSELAND COMMUNITY
HOSPITAL (RCH) TO SUPPORT THE OPERATION OF A PATIENT NAVIGATION PROGRAM
THAT ASSISTS LOW-INCOME AFRICAN-AMERICAN WOMEN IN THE GREATER ROSELAND
COMMUNITY AREA
RECEIVING BREAST HEALTH SERVICES. THE FIVE COMMUNITIES
COMPRISING GREATER ROSELAND COMMUNITY ARE ROSELAND, PULLMAN, WEST
PULLMAN, WASHINGTON HEIGHTS, AND RIVERDALE.
THE COMMUNITIES ARE
APPROXIMATELY 95 PERCENT AFRICAN-AMERICAN AND AMONG THE MOST IMPOVERISHED
JSA
2E1228 1.000
87855E 1385
V 12-7.10
GROUP
Page
OF THE 77 COMMUNITY AREAS IN CHICAGO.
2
75-2462834
THE KOMEN GRANT WILL SUPPORT A
PATIENT NAVIGATION PROGRAM FOR WOMEN RECEIVING MAMMOGRAPHY SCREENING,
DIAGNOSIS AND TREATMENT SERVICES IN THE HOSPITALS' NEWLY ESTABLISHED
"WOMEN'S MAMMOGRAPHY CENTER".
WOMEN WITH POSITIVE FINDINGS WILL RECEIVE
THE SUPPORT AND GUIDANCE NEEDED TO NAVIGATE THROUGH AN OFTEN COMPLEX
MEDICAL SYSTEM FOR DIAGNOSIS AND TREATMENT IN A TIMELY MANNER. EVALUATION
WILL ASSURE THAT THE PATIENT NAVIGATION PROGRAM HAS THE DESIRED IMPACT BY
MEASURING OUTCOMES INCLUDED IN THE WORK PLAN, SUCH AS, THE NUMBER OF
WOMEN ASSISTED BY THE PATIENT NAVIGATION SERVICES RECEIVING TREATMENT.
NUMBER OF VOTING MEMBERS OF THE GOVERNING BODY
FORM 990, PART VI, LINE 1A
THIS 1,267 REPRESENTS THE TOTAL NUMBER OF BOARD MEMBERS THAT SERVE ON THE
BOARDS OF THE 119 AFFILIATES THAT COMPRISE THE KOMEN GROUP RETURN.
DESCRIPTION OF RELATIONSHIPS
FORM 990, PART VI, QUESTION 2
INLAND EMPIRE AFFILIATE:
DEBBIE GILLIGAN, SECRETARY AND HERB KILLIAN, BOARD MEMBER HAVE A FAMILY
RELATIONSHIP
HERB KILLIAN, BOARD MEMBER AND BARB KILLIAN, BOARD MEMBER HAVE A FAMILY
RELATIONSHIP
NORTH DAKOTA AFFILIATE:
KELLY QUINTUS, BOARD MEMBER AND ERIN GREEN-GROM, BOARD MEMBER HAVE A
FAMILY RELATIONSHIP
JSA
2E1228 1.000
87855E 1385
V 12-7.10
GROUP
Page
2
75-2462834
SOUTH DAKOTA AFFILIATE:
BETH O'TOOLE, BOARD MEMBER AND SHANE MINER, BOARD MEMBER HAVE A FAMILY
RELATIONSHIP
UPPER CUMBERLAND AFFILIATE:
EILEEN STUBER, PRESIDENT AND HARRY STUBER, BOARD MEMBER HAVE A FAMILY
RELATIONSHIP
WABASH VALLEY AFFILIATE:
PATRICIA WILEY, BOARD MEMBER AND MICHELLE MCCREA, BOARD MEMBER HAVE A
FAMILY RELATIONSHIP.
EXPLANATION OF SIGNIFICANT CHANGES MADE TO THE BYLAWS OF SELECTED
AFFILIATES OF SUSAN G. KOMEN FOR THE CURE IN FY2013
ONE KOMEN AFFILIATE MADE SIGNIFICANT CHANGES TO ITS BYLAWS IN FY2013
("BYLAWS" SHALL MEAN THE GOVERNING BYLAWS OF THE RESPECTIVE AFFILIATE.):
1.
DENVER METROPOLITAN AFFILIATE OF THE SUSAN G. KOMEN BREAST CANCER
FOUNDATION
- THE POSITION OF PRESIDENT-ELECT WAS ADDED TO THE BYLAWS.
DECISIONS OF GOVERNING BODY SUBJECT TO APPROVAL BY OTHER PERSONS
JSA
2E1228 1.000
87855E 1385
V 12-7.10
GROUP
Page
2
75-2462834
FORM 990, PART VI, LINE 7B
IN ADDITION TO RECEIVING APPROVAL FROM ITS BOARD OF DIRECTORS, A KOMEN
AFFILIATE MUST RECEIVE THE APPROVAL OF KOMEN PARENT PRIOR TO AMENDING ITS
ARTICLES/CERTIFICATE OF INCORPORATION AND BYLAWS.
A KOMEN AFFILIATE IS
ALSO SUBJECT TO ITS AFFILIATION AGREEMENT WITH KOMEN PARENT AND OTHER
POLICIES PROMULGATED BY KOMEN PARENT.
DESCRIBE THE PROCESS USED BY MANAGEMENT &/OR GOVERNING BODY TO REVIEW
990
FORM 990, PART VI, QUESTION 11B
AS PART OF THE YEAR END FINANCIAL STATEMENT AND 990 PREPARATION PROCESS,
THE MANAGEMENT OF EACH AFFILIATE PREPARES A WORKBOOK DETAILING KEY
INFORMATION NECESSARY TO ACCURATELY COMPLETE THE GROUP FORM 990.
THIS
INFORMATION IS REVIEWED BY THE PARENT ORGANIZATION'S MANAGEMENT AND USED
TO PREPARE THE MATERIALS FOR THE FORM 990 WITH THE ASSISTANCE OF AND
REVIEW BY EXTERNAL ACCOUNTANTS. SENIOR LEVELS OF THE PARENT
ORGANIZATION'S MANAGEMENT REVIEW AND COMMENT ON THE FINAL DRAFT OF THE
FORM 990 WHICH IS THEN PRESENTED TO THE KOMEN PARENT AUDIT COMMITTEE OF
THE BOARD OF DIRECTORS. THE AUDIT COMMITTEE OF THE BOARD OF DIRECTORS
REVIEWS AND APPROVES THE FORM 990 PRIOR TO FILING. THE PUBLIC DISCLOSURE
COPY OF THE GROUP 990 IS ALSO MADE AVAILABLE TO EACH AFFILIATE BOARD
PRIOR TO FILING.
DESCRIPTION OF PROCESS TO MONITOR TRANSACTIONS FOR CONFLICTS OF INTEREST
JSA
2E1228 1.000
87855E 1385
V 12-7.10
GROUP
Page
2
75-2462834
FORM 990, PART VI, QUESTION 12C
THE ORGANIZATION PRODUCES AN ANNUAL SURVEY REQUIRING ALL EMPLOYEES, BOARD
MEMBERS, COMMITTEE MEMBERS AND KEY VOLUNTEERS TO INFORM ON CONFLICTS. ANY
REPORTED CONFLICTS ARE REVIEWED BY KOMEN AFFILIATE STAFF AND REPORTED TO
EACH RESPECTIVE KOMEN AFFILIATE BOARD OF DIRECTORS FOR REVIEW AND
APPROPRIATE ACTION, SUCH AS RECUSAL FROM DECISIONS IMPACTED BY A CONFLICT
OF INTEREST.
IN ADDITION, THOSE SAME PEOPLE HAVE THE OBLIGATION TO
UPDATE THE CONFLICT OF INTEREST STATEMENTS DURING THE YEAR.
OFFICES & POSITIONS FOR WHICH PROCESS WAS USED, & YEAR PROCESS WAS BEGUN
FORM 990, PART VI, QUESTION 15A & 15B
EACH KOMEN AFFILIATE IS INDEPENDENTLY RESPONSIBLE FOR DETERMINING THE
COMPENSATION FOR ITS CEO, EXECUTIVE DIRECTOR, TOP MANAGEMENT OFFICIALS,
OTHER OFFICERS OR KEY EMPLOYEES OF THE ORGANIZATION.
THE GENERAL PROCESS IS AS FOLLOWS:
THE INDEPENDENT MEMBERS OF THE BOARD, COMMITTEE OR DESIGNEE OF THE BOARD
RESEARCHES SALARY RANGES FOR COMPARABLE DESCRIPTIONS AND ACCORDINGLY SETS
THE SALARY TO A REASONABLE AND COMPARABLE LEVEL, TAKING INTO
CONSIDERATION FACTORS SUCH AS GEOGRAPHIC LOCATION, SKILL SET, EXPERIENCE
AND JOB REQUIREMENTS.
THE INDEPENDENT MEMBERS OF THE BOARD BASE THEIR
FINAL DECISION ON THIS INFORMATION, SUCH DECISION BEING MADE PRIOR TO THE
PAYMENT OF ANY COMPENSATION.
AS AN ADDITIONAL RESOURCE, THE SALARY
SURVEY INFORMATION OBTAINED BY THE SUSAN G. KOMEN BREAST CANCER
FOUNDATION, INC. ("THE PARENT") IS MADE AVAILABLE TO KOMEN AFFILIATES
UPON REQUEST.
JSA
2E1228 1.000
87855E 1385
V 12-7.10
GROUP
Page
2
75-2462834
AVAIL OF GOV DOCS, CONFLICT OF INTEREST POLICY, & FIN STMTS TO GEN
PUBLIC
THE ORGANIZATION'S AUDITED FINANCIAL STATEMENTS AND THE GROUP FORM 990
ARE PUBLICLY AVAILABLE AT WWW.KOMEN.ORG.
THE ARTICLES OF INCORPORATION
ARE AVAILABLE IN THE STATE EACH AFFILIATE IS INCORPORATED AND OTHER
GOVERNING DOCUMENTS ARE MADE AVAILABLE AS REQUIRED BY STATE LAW.
FORM
1023 IS NOT ONLINE BUT AVAILABLE TO THE PUBLIC UPON REQUEST.
PAYMENTS TO AFFILIATES
FORM 990, PART IX, LINE 21
THE SUSAN G. KOMEN BREAST CANCER FOUNDATION AFFILIATES (THE KOMEN
AFFILIATES) PAY A PREDETERMINED PERCENTAGE (MINIMUM OF 25%) OF THEIR NET
MONIES RAISED TO THE FOUNDATION (THE KOMEN PARENT) TO HELP FUND THE KOMEN
PARENT RESEARCH AND TRAINING GRANT PROGRAM.
THESE FUNDS ARE EARMARKED BY
THE KOMEN PARENT TO BE USED SPECIFICALLY FOR THE RESEARCH AND TRAINING
GRANT PROGRAM, WHICH PROVIDES FUNDING FOR INNOVATIVE BREAST CANCER
RESEARCH.
THE KOMEN PARENT ADHERES TO A REVIEW PROCESS WHEN DETERMINING
WHO RECEIVES GRANT FUNDS.
FOR FURTHER INFORMATION, SEE FORM 990, PART
III, PRIMARY EXEMPT PURPOSE AND PROGRAM SERVICE ACCOMPLISHMENTS.
OTHER CHANGES IN NET ASSETS
PART XI RECONCILIATION OF NET ASSETS
JSA
2E1228 1.000
87855E 1385
V 12-7.10
GROUP
Page
2
75-2462834
PART XI, LINE 6
IN KIND SERVICE REVENUE
47,561,825
IN KIND SERVICE EXPENSE
(49,252,713)
NET IN KIND SERVICES
(1,690,888)
PART XI, LINE 9:
RESCINDED GRANTS
3,631,824
ROUNDING
TOTAL
2
3,631,826
ATTACHMENT 1
FORM 990, PART VI, LINE 17 - STATES
AL,AZ,AR,CA,CO,CT,
FL,GA,HI,IL,IN,KS,KY,ME,MD,MA,MI,
MN,MS,NH,NJ,NM,NY,NC,ND,OH,OK,OR,PA,
SC,TN,UT,VA,WA,WI,
ATTACHMENT 2
990, PART VII- COMPENSATION OF THE FIVE HIGHEST PAID IND. CONTRACTORS
DESCRIPTION OF SERVICES
NAME AND ADDRESS
COMPENSATION
APPLE EVENTS
8189 S. CENTRAL EXPRESSWAY
DALLAS, TX 75241
RFTC & CHIP TIMING
108,742.
LEAD DOG PRODUCTION
159 WEST 25TH STREET
NEW YORK CITY, NY 10001
RACE PRODUCTION
121,200.
THE STAR GROUP
VOORHEES TOWN CENTER, 220 LAUREL ROAD
VOORHEES, NJ 08043
CONSULTING
238,278.
JSA
2E1228 1.000
87855E 1385
V 12-7.10
GROUP
Page
2
75-2462834
ATTACHMENT 2 (CONT'D)
990, PART VII- COMPENSATION OF THE FIVE HIGHEST PAID IND. CONTRACTORS
DESCRIPTION OF SERVICES
NAME AND ADDRESS
CHRIS TATREAU CONSULTING, LTD
PO BOX 139
GWYNEDD VALLEY, PA 19437
CONSULTING
112,250.
JSA
2E1228 1.000
COMPENSATION
87855E 1385
V 12-7.10
GROUP
PART VII - COMPENSATION OF OFFICERS, DIRECTORS, KEY EMPLOYEES, AND FIVE HIGHEST COMPENSATED EMPLOYEES
EIN# 75-2462834
2012 FORM 990
C Position - Mark All That Apply
Filing Organization
(A) Name
(A) Title
(B) AVG
HOURS/
WEEK
Individual
Trustee or
Director
Institutional
Trustee
Officer
Key
Employee
HighestCompensated
Employee
Former
(D) Reportable
Compensation
from the
Organization
(F) Estimated
amount of other
compensation
from the
organization and
related orgs
(E) Reportable
compensation
from related
organizations
Acadiana Affiliate
Toni Guillotte
Alice Dukes
Susan Allardyce
Liz Cole
Shalondra Hite-Lewis
Roxan Goudeau
Mellisa Bowers
Tyshaun James-Hart MD
Kylie Tahana
Susan Boudreaux
Mallory Acrey
Ayesha Martin
Lori Tursic
Courtney Blanchard
Tori Theriot
President (Thru 3/27/13)
Board Member (Thru 12/1/12)
Secretary
President (Beg 3/13)
Treasurer
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
17
3
3
3
3
3
17
3
3
3
3
3
3
3
3
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
The Arkansas Chapter
Ellen Kreth
Lisa Love
Isabelle Monroe
Alesa Garner
Mike Gavigan
Leila Alston
Tjuana Byrd
Errin Dean
Hope Keiser
Lynelle Lehman
Vickey Metrailer
Angela Parker
Matt Propst
Mattye Willis
Kristi Moody
President
Treasurer
Vice President/Secretary
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
4
4
12
8
4
4
4
4
4
4
4
4
4
4
4
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
The Aspen Chapter
Marcia Goshorn
Barbara Newton
Liz Siegel
Lolly Kelly
Nancy Pickard
Sandra Menter
Denise Rock
RJ Gallagher
Chris George
David Eisenstat
Melissa Cook
Rebecca Leutke
Maurie Wolff
Board President
Vice President
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Treasurer (Thru 6/7/12)
3
3
3
1
4
1
3
1
2
1
1
1
1
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
The Austin Chapter
Robert Notley
Justin Krost
Rick Reeder
Julie Sanders
Jennifer Stevens (Lustina)
Robin Thigpin
Courtney Dickey
T. Harper
Valerie Shaw
Kathleen Lucente
Karen Shultz
Deb Hastings
Sadaf Kahn
Deborah O'Connell, MD
Treasurer
Board Member
President
Board Member
Vice President
Board Member
Secretary
Board Member
Board Member
Board Member
Board Member
Board Member
8
2
8
2
2
2
2
2
2
2
2
2
2
2
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Page 1 of 27
ATTACHMENT 2A
EIN# 75-2462834
2012 FORM 990
Filing Organization
Karen Quintos
Christie Barany
(A) Name
(A) Title
Baton Rouge Affiliate
Angela Miller
Toni Douglas
Eulanda Batiste
Wendy Reeves
Danielle Bayham
Victoria Cooper
Laura Soileau
Lauren Modenback
Renee Andre'
Nancy Jones
Ashley Bowers
Susan Mittenforf
President
Treasurer
Secretary
Board Member
Board Member
Board Member
Board Member
Bayou Region Affiliate
Steve Gaubert
Laura Roger
Greg Stock
Susan Guidry
Dr. Alice Pecoraro
Marlo Tibbs
Earl Hernandez
Donna Callahan
Brenda Hansen
Wayne Arboneaux
Rachel Becnel
Monica Sanchez
Boise, Idaho Affiliate
(B) AVG Individual
HOURS/ Trustee or
WEEK
Director
2
X
2
X
Institutional
Trustee
-
Officer
-
Key
Employee
-
HighestCompensated
Employee
-
Former
-
(D) Reportable
Compensation
from the
Organization
0
0
(F) Estimated
amount of other
(E) Reportable
compensation
compensation
from the
from related
organization and
organizations
related orgs
0
0
0
0
40
15
5
2
2
2
2
2
2
2
2
2
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Treasurer
Secretary
President
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member (Beg 12/6/12)
2
6
2
1
1
1
6
1
6
1
1
6
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Jodi Brawley
Vicki Masterson
Cindy Baker
Judy Murray
Michelle Edmonds
Dr. Mark Wigod
Allison Bender
Kathy Winn
President
Treasurer
Secretary
Board Member
Board Member
Board Member
1
1
1
1
1
1
1
1
X
X
X
X
X
X
X
X
-
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Central and South Jersey Affiliate
Jay Turchin
Marcia Cohen
Kathy Kivelson Hecht
Ken Berlin
Joe Cavone
Rachel Dultz MD
Ann Marie Hill
Brian Markison
Jon Pearson
Michael Schaff
Eduardo Schur
President
Treasurer
Secretary
Board Member
Board Member (Thru 11/12)
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
6
4
5
2
2
2
4
2
2
2
2
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Central Oklahoma Chapter of the
Sherry Barton
Kevin Fosbenner
Kyle Shoemaker
Mandy Hansen
Cristi Reiger
Natalie Rice
Phyllis Wahahrockah-Tasi
Dustin Davis
President
Treasurer
Secretary
Board Member
Board Member
Board Member
Board Member
Board Member
5
5
5
5
1
1
1
1
X
X
X
X
X
X
X
X
-
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Central Florida Affiliate
Jeri Francoeur
Jesica Anderson
Board President
Board Vice-President
25
15
X
X
-
X
X
-
-
-
0
0
0
0
0
0
Page 2 of 27
ATTACHMENT 2A
EIN# 75-2462834
2012 FORM 990
Filing Organization
(B) AVG Individual
HOURS/ Trustee or
WEEK
Director
5
X
7
X
5
X
2
X
2
X
10
X
2
X
15
X
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
(F) Estimated
amount of other
compensation
from the
organization and
related orgs
0
0
0
0
0
0
0
0
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
X
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
X
X
X
-
-
-
0
0
0
0
0
0
0
0
0
Institutional
Trustee
-
Officer
X
X
-
Key
Employee
-
HighestCompensated
Employee
-
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
-
-
-
3
3
3
3
3
3
3
3
3
X
X
X
X
X
X
X
X
X
-
X
X
X
X
-
-
Secretary
Treasurer
President
Board Member
Board Member
3
3
3
3
3
3
3
X
X
X
x
X
X
X
-
X
X
X
-
Elaine Jacobs
Louise Hofmann
Catherine Shamlian
Susan St.Amour
Jeff Camanici
Mary Ann Drumm
Kim Hunter
Kristine Keeney, MD
Candice Lucas
Mary Market
Susan Meath
Karen Nasoni
Phil Reagan
Susan Swift
Kelly Vaccaro
Sheri Cohen
President, Board Member
Secretary,Board Member
Vice President, Board Member
Treasurer, Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
5
5
5
5
1
1
1
1
1
1
1
1
1
1
1
1
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
x
-
Kay Huggins
Gregory Barton
Jennifer Manning
President
Vice President
Treasurer
5
1
5
X
X
X
-
(A) Name
Donna-Sue Sanders
Rachel Cataline
George Kastroulis
Tracy Jacim
Tammy Marcotte
Cher Keller-Bodnar
Donna Todd
Paula Cariazzai
(A) Title
Board Member
Board Treasurer/Secretary
Board Member
Board Member
Central Georgia Affiliate
Nicole Rinehart
Carole Radney
Jeff Harris
Dawn Cole
Sarah Jones
Natasha Graddick
Susan Fry
Kristi Minor
Kalin Richardson
Shelia Henderson
Barbara Marshall
Amy Tarpley
Dennis Whitaker
President
Secretary
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Treasurer (6/1/12 - 11/1/12)
5
2
2
2
2
2
2
2
2
2
5
2
2
Central Mississippi Steel Magnolias Affiliate
Dr. Wilma Mosley Clopton
Jeanne Fortenberry
Michael Anthony Davis
Dr. Emma Brooks Smith
Mrs. Odessa Hawkins
Christy Moore
Kimberly Sweet
Georganna Kennum
Dr. Urseline Hawkins
Board President
Vice President
Treasurer
Board Member
Board Member
Secretary (6/1/12 - 12/1/12)
Board Member (5/1/12 - 12/1/12)
Board Member (6/1/12 - 12/1/12)
Board Member (6/1/12 - 12/1/12)
Central New Mexico Affiliate
Shannon Adragna
Julia Chong
Michele Conners
Reina Luna
Mike Rico
Cindy Adams
David Baker
Central New York Affiliate
Central Texas Affiliate
Page 3 of 27
Former
-
(D) Reportable
Compensation
from the
Organization
(E) Reportable
compensation
from related
organizations
ATTACHMENT 2A
EIN# 75-2462834
2012 FORM 990
Filing Organization
(A) Name
Jane Allen
Cecilia Pena
Libby Cain
April Pullen
Sherry Lynn Trainer-Guardiola
(A) Title
Secretary
Board Member
Board Member
Board Member
Central Valley Affiliate
Lisa Quiroz
Kim Fletcher
Kim Kaiser
Darrellyn Colldar
DeLaine Pereida
Rowena Chu-Bacher
Marilyn Hickman
Summer Johnson
Lindsey Scully
Samantha Carroll
Jamie Ledezma
Eric Frazier
Jen Thomas
Jen Williams
Debbie Young
Lorenzo Neal
Secretary
Treasurer (5/15/12 - 3/31/13)
President Elect (3/19/13 - 3/31/13)
Board Member
Board Member
Board Member
Board Member (5/15/12 - 3/31/13)
President (5/15/12 - 8/21/12)
Central Wisconsin Affiliate
Jennifer Smith
Sandy Draeger
Tricia Nielson
Deb Clements
Kathy Frierson
Tara Schessler
Patty Krug
John Willems Van Dijk
Tina Frey
Rick Reyer
Amanda Patterson
Carrie Sukup
Pam Galloway
Susan Ford-Hoffert
Jill Depke
Ann Jacobson
John Prey
Judi Coppock
Linda Grilley
Charlotte Affiliate
Chattanooga Affiliate
(B) AVG Individual
HOURS/ Trustee or
WEEK
Director
1
X
X
1
1
X
1
X
1
X
Institutional
Trustee
-
Officer
X
-
Key
Employee
-
HighestCompensated
Employee
-
Former
-
0
0
0
0
0
0
0
0
0
0
(F) Estimated
amount of other
compensation
from the
organization and
related orgs
0
0
0
0
0
(D) Reportable
Compensation
from the
Organization
(E) Reportable
compensation
from related
organizations
5
8
6
2
5
3
1
2
2
8
4
2
2
2
2
1
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Secretary
President
Treasurer
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
3
20
5
4
1
4
3
1
2
2
5
2
1
1
1
2
1
1
1
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Mike Smiley
Kathi Lucchesi
Joyce Reto
Park Williams
Vetta Higgs
Curt Shaw
Lisa Crockett Moon
William Miller
Carin Ross Johnson
Sharon Matthews
Susan Stuppnig
Beatriz Suris
President
Vice President
Treasurer
Secretary
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
10
2
5
3
1
1
1
1
1
1
1
1
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Barbara Marshall
Kimberly Hutchinson
Sarah E. Bowen
Carolyn Money
Muna Wagner
Secretary
Treasurer
President
Board Member
Board Member
1
2
2
1
1
X
X
X
X
X
-
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Page 4 of 27
ATTACHMENT 2A
EIN# 75-2462834
2012 FORM 990
(B) AVG Individual
HOURS/ Trustee or
WEEK
Director
1
X
X
1
1
X
1
X
X
1
1
X
1
X
0
0
0
0
0
0
0
0
0
0
0
0
0
0
(F) Estimated
amount of other
compensation
from the
organization and
related orgs
0
0
0
0
0
0
0
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
X
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
X
X
-
-
-
0
0
0
0
0
0
Institutional
Trustee
-
Officer
X
-
Key
Employee
-
HighestCompensated
Employee
-
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
-
-
-
2
1
2
1
1
1
0.5
1
1.5
1
1
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
-
-
Board member
President
Secertary
Board member
Board member
Board member
Treasurer
Board member
Board member
Board member
Board member
Board member
Board member (Thru 2/28/13)
Board member (Thru 7/1/12)
Board member (1/1/12 - 7/1/12)
1
4
2
1
1
3
4
1
1
1
1
1
1
1
1
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
x
x
X
-
Gail Marcus
Nancy Meyer
Donna Gilbert
Kia Murrell
Richard Orr
Lillian Cruz
Reem Nouh
David Gruen
Christa Allen
Sonja Larkin-Thorne
Ann Hogan
President
Vice President
Treasurer
Secretary
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
2
2
2
2
1
1
1
1
1
1
1
X
X
X
X
X
X
X
X
X
X
X
-
Terri Swain
Sharla Myers
President
President Elect
5
2
X
X
-
Filing Organization
Becky Reeves
Chris Hennen
Jay Hudson
Patty Holmes
Patti Sanders
Laura Reid
Dora Coker
(A) Name
(A) Title
Board Member
Board Member
Board Member
Board Member
Board Member
The Chicagoland Area Chapter
Bonnie Gordon
Brad Schneider
Dr. Robert Maganini
Joan Bailar
Linda Borton
Liz Calhoun
Renee Blank
Richard Biller
Ruth Todd
Sean Tenner
Secretary
Board Member
Board Member
Vice President / Governance Chair
Board Member
Board Member
Treasurer
Board President
Board Member
Board Member
2
2
2
2
20
8
2
5
6
3
Colorado Springs Affiliate of the
Dr. Laura Pomerenke
Sharon McDermott
Debbie Griffin-Strickland
Lyrae Williams
Mike Ensiminger
Doug Gibson
Sloan Maes
Joan Schulz
Joyce-Anne Velez
Jim Young
Zelna Joseph
President
Vice President
Secretary
Treasurer
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Columbus Affiliate
Angela An
Connie Browning
Yvonne Burry
Susan Hosket
Dr. Doug Knutson
Darlene Matthews
Holly Merry
Judy Mobley
Mark Rickel
Tammy Weis
Michelle Wong-Halabi
AJ Poole
Dr. Mysheika Williams Roberts
Joanne Pickrell
Brian King
Connecticut Affiliate
Dallas County Affiliate
Page 5 of 27
Former
-
(D) Reportable
Compensation
from the
Organization
(E) Reportable
compensation
from related
organizations
ATTACHMENT 2A
EIN# 75-2462834
2012 FORM 990
Filing Organization
(A) Name
Linda Wilkins
Elsa Grivas
Irvin Ashford Jr.
Stephanie Bowman
Linda Hardy
Elizabeth Hardy
Dr. Edwin Harrison
Dr. Cheryl Harth
Wendeline Jongenburger
Henda Salmeron
Perry Stephenson
Rebecca Whitacre
Secretary
Treasurer
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
(A) Title
The Denver Metropolitan Affiliate
Sylvia Church
Hollen Ferrendelli
Chris Armijo
Lora D Barke
Kristen Battenfield
Andres Chaparro
John DellaSalle
Dave Fisher
Brian Jumps
Mary McBride
Rhonda Mickelson
Carolyn Paul
Dianne Primavera
Jacquelynn McDaniel
Treasurer
President/Secretary
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
The Des Moines Chapter
Roni Schuling
Greg Edwards
Tami Synder
Wendy Wall
Carma Herring
Giulia Jackson
Leslie Malcom
Kelly Schuler
Kara Urlis
Becki Brommel
Lori Howe
Greg Shireman
Eastern Washington Affiliate
Elmira Affiliate
(B) AVG Individual
HOURS/ Trustee or
WEEK
Director
2
X
X
2
X
1
X
1
1
X
1
X
X
1
1
X
1
X
X
1
1
X
X
1
Institutional
Trustee
-
Officer
X
X
-
Key
Employee
-
HighestCompensated
Employee
-
Former
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
(F) Estimated
amount of other
compensation
from the
organization and
related orgs
0
0
0
0
0
0
0
0
0
0
0
0
(D) Reportable
Compensation
from the
Organization
(E) Reportable
compensation
from related
organizations
4
4
4
4
4
4
10
4
4
4
4
4
4
1
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Board President
President-Elect
Treasurer
Secretary
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
2
1
2
1
1
1
1
1
1
1
1
1
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Shelley Ripley
Rancy Schwaegler
Kim Weller
Sarah Beito
Cindy Corbett
Jennifer Miley
Stephanie Aden
Jara DeAugustino
Stephanie Moline, M.D.
Shae Fasbender
Shelly Barton
Stephanie Klein (aka Stephanie Bast)
Kim Koch
Bailee Neyland
Joni Nichols, M.D.
Laura Hill
President
Board Member
Treasurer
Secretary
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Past President (Thru 12/31/12)
8
8
8
4
4
4
4
4
4
4
4
8
8
4
4
4
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Ann Campbell
Mila Meier
Mary Tucker
Board President
Board Vice President
Board Secretary
40
5
6
X
X
X
-
X
X
X
-
-
-
0
0
0
0
0
0
0
0
0
Page 6 of 27
ATTACHMENT 2A
EIN# 75-2462834
2012 FORM 990
Filing Organization
(B) AVG Individual
HOURS/ Trustee or
WEEK
Director
10
X
6
X
X
5
X
3
3
X
3
X
X
3
X
5
5
X
6
X
5
X
0
0
0
0
0
0
0
0
0
0
0
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
0
0
0
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
X
X
-
-
-
0
0
0
0
0
0
Institutional
Trustee
-
Officer
X
-
Key
Employee
-
HighestCompensated
Employee
-
X
X
X
X
X
X
X
X
X
-
X
X
X
X
X
-
-
1
X
-
-
-
2
1
2
1
1
1
3
1
2
1
2
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
-
2
12
2
2
2
10
2
2
2
12
2
X
X
X
X
X
X
X
X
X
X
X
-
President
Secretary
Treasurer
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
5
1
3
1
1
1
1
5
5
1
1
X
X
X
X
X
X
X
X
X
X
X
President
Treasurer
3
3
X
X
(A) Name
Domenica Harris
Susan Berry
Marché Brown
Kendra Castello
Diana Hughes
Mary Pat Learned
Charlette Smith
Jennifer Warner
Meg Aiosa
Colleen Hurd
Brooke Sherman-Schmieg
(A) Title
Board Treasurer
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Christina Velasco
Roseanne Rueda
Shelley King-D'Souza
Davina Heredia
Cindy Aguilar-Davis
Carlos Dube
Robert Halter
Susie Stowe
Amanda Morrison
Board President
Treasurer
President-Elect
Secretary
Board Member
Board Member
Board Member
Board Member
Secretary (Thru 7/1/12)
1
2
1
1
1
1
1
1
1
Bill Young
Florida Suncoast Affiliate
Susan Brown
Gail Clark
Anne Hochsprung
John Kiluk
Patrick Meehan
Lalitha Degala
Cauney Bamberg
Pat Dupar
Teresa Honeycutt
Wayne Lewis
Catherine McGarry
President
Vice President
Treasurer
Secretary
Board Member
Board Member
Board Member
Board Member
Board Member
Grand Rapids Affiliate of the
Chuck Christmas
Carol Perschbacher
Anna Konging-Ogg
Gregory Kilby
Melinda Tobias
Susan Hoppough
Bev Wall
Brian Behler
Dennis Zoet
Cara Ontiveros
Sylvia James
Treasurer/Secretary
President
Board Member
Vice President
Board Member
Board Member
Board Member
Board Member
Board Member
Past-President (thru 7/27/12)
Greater Amarillo Affiliate of the
Amy_Beth Morrison
Sarah Caviness
Lizzie Mason
Shannon Williams
Natalie Mahlberg
Kelly Whittenburg
Richard Walton
Betsy Kelley
Fararr Mansfield
Marjorie Chelly
Whitney Kelly
The Greater Atlanta Affiliate
Karen Bragman
Kim Hartsock
El Paso Affiliate
0
0
0
0
0
0
0
0
0
0
0
(F) Estimated
amount of other
compensation
from the
organization and
related orgs
0
0
0
0
0
0
0
0
0
0
0
Page 7 of 27
Former
-
(D) Reportable
Compensation
from the
Organization
(E) Reportable
compensation
from related
organizations
ATTACHMENT 2A
EIN# 75-2462834
2012 FORM 990
Filing Organization
Greater Cincinnati Affiliate
(A) Name
Connie Dotzenrod
Joel Ballantyne
Lynn Baxter, MD
Karyn Cerulli
Tom Coley
Tricia Dempsey
Susan Hannan
Lila Hertz
Laurie King
Cam Teems
Sue Williams
Reinaldo Padua
Loretta Walker
(A) Title
Secretary
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
(B) AVG Individual
HOURS/ Trustee or
WEEK
Director
3
X
3
X
3
X
3
X
3
X
3
X
X
3
X
3
3
X
X
3
X
3
3
X
3
X
Institutional
Trustee
-
Officer
X
-
Key
Employee
-
HighestCompensated
Employee
-
Former
-
Karyn Ganaway
President
5
X
X
Secretary
5
X
X
Jackie Sweeney, MD
X
Gene Barber
Board Member
2
Angela Norman
Board Member
2
X
X
Diane Schneider
Board Member
2
Board Member
2
X
Megan McElheney
Board Member
2
X
Tracey Johnson
10
X
X
* Diana Veid
Treasurer/CPA
10
X
Karen Naber
Immediate Past President
*Diana Veid serves as the treasurer of the Greater Cincinnati Affiliate. The compensation reported is for accounting services rendered to the Affiliateand not for her role as a board member
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
(F) Estimated
amount of other
compensation
from the
organization and
related orgs
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
12,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
(D) Reportable
Compensation
from the
Organization
(E) Reportable
compensation
from related
organizations
Greater Evansville Affiliate
Carolyn Beck
Elissa Shetler
Julie Jarvis
Marty Custis
Georgiann Leonard
Deb McKinney-Huff
Marcia Minton
Brenda Phelps
Doris Razzano
Pilar Tirado
Kathy Dockery
Joan Finch
Sheila Hauck
Kelly Howard
Steve Newman
Jill Trautvetter
President
Secretary
Treasurer
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member (11/1/12 - 12/31/12)
Board Member (11/1/12 - 12/31/12)
Board Member (1/1/12 - 10/30/12)
2
1
2
1
1
1
1
1
1
1
1
1
1
1
1
1
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Greater Kansas City Affiliate
Laurie Roberts
Sharon Latimer
Debbie Schulte
George Verschelden
Denise Gilmore
Cheryl Jernigan
Shalina Gupta-Burt
Mary Buschmann
Katie Linden
Pam Mahoney
President
Secretary/Treasurer
Vice President
Board Member
Board Member
Board Member
Board Member
Board Member
4
4
4
1
1
1
1
1
4
1
X
X
X
X
X
X
X
X
X
X
-
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Greater Lansing Affiliate
Kristin St. Marie
Susan Schanski
Barbara Fulton
Mary Jo Schultz
Lisa Dancsok
James Epolito
Ann Verhey-Henke
Julie Barrons
President
Treasurer
Secretary
Board Member
Board Member
Board Member
Board Member
Board Member
1
1
1
1
1
1
1
1
X
X
X
X
X
X
X
X
-
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Page 8 of 27
ATTACHMENT 2A
EIN# 75-2462834
2012 FORM 990
Filing Organization
(A) Name
(B) AVG Individual
HOURS/ Trustee or
WEEK
Director
1
X
(D) Reportable
Compensation
from the
Organization
(F) Estimated
amount of other
(E) Reportable
compensation
compensation
from the
from related
organization and
organizations
related orgs
0
0
Institutional
Trustee
-
Officer
-
Key
Employee
-
HighestCompensated
Employee
-
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
2
1.5
1
0.5
0.5
0.5
0.5
0.5
1
0.5
0.5
0.5
0.5
0.5
0.5
2
0.5
0.5
1
0.5
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
3
3
2
5
1
1
1
1
X
X
X
X
X
X
X
X
-
X
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
4
10
4
5
3
3
3
8
3
3
X
X
X
X
X
X
X
X
X
X
-
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Kim Hartman
(A) Title
Board Member (thru 6/1/12)
The Greater Nashville Chapter
Lynn Edwards
Nancy Mullen
Melissa Smith
Lisa Zindel
Margaret P. Barker
Karen Fleming
Mike Gould
Lisa Tunstall
Kimberly Songy
Haden McWhorter
Julie Boswell
Evelyn Zerfoss
Dana Coleman
DeWayne Olive
Barb Sawyer
Shana Alford
Julie Walker
President
Treasurer
Secretary
Vice President
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
4
3
2
2
2
2
2
2
2
2
2
1
2
2
2
2
1
Greater New York City Affiliate
Laila Worrell
Ivy Gamble Cobb
Grant Bokerman
Ayala Deutsch
Maurice DuBois
Joe Gold
Amy Tsui Luke
William Shelton
Sandra Kozlowski
Ahalya Nava
Nikki Tippins
Katherine Park
Martha Beard
Kathy Wilson
Renee N. Garbus
Blythe Masters
Jeanne Mullgrav
Linda Sage
Dr. Ruth Oratz
Dr. Robert Schneider
Chairperson
Board Member
Board Member
Treasurer / Secretary
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Greater Richmond, Virginia Affiliate
Carla Harris
Lynn Jordan
Lynn Kirk
Meredith Beadles
Melissa Damiano
Melissa Monk
Vivian Robles
Wanda Johnson
Secretary
Treasurer
Vice President
President
Board Member
Board Member
Board Member
Board Member
Greater Roanoke Valley Area Affiliate
ETHAN COOK
JANET FRANTZ
HEATHER FERGUSON
LIZ FRANKL
MARTHA GLASS
ALICIA MULLINS
LISA MITCHELL
JOEY BECK
ELLEN DEHAVEN
DECCA KNIGHT
Treasurer
President
Secretary
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Page 9 of 27
Former
-
0
ATTACHMENT 2A
EIN# 75-2462834
2012 FORM 990
Filing Organization
(B) AVG Individual
HOURS/ Trustee or
WEEK
Director
3
X
X
3
X
3
10
X
3
X
3
X
3
X
3
X
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
(F) Estimated
amount of other
compensation
from the
organization and
related orgs
0
0
0
0
0
0
0
0
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Institutional
Trustee
-
Officer
-
Key
Employee
-
HighestCompensated
Employee
-
X
X
X
X
X
X
X
X
-
X
X
X
-
-
-
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
-
-
1
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
-
15
22
10
25
15
15
2
3
5
X
X
X
X
X
X
X
X
X
-
X
X
X
X
-
(A) Name
MARGARET NELSON
JOHN ROGERS
BOB WILLIAMS
JANET SCHEID
KATHLEEN WERNER
RUTH ELLEN KUHNEL
JANET LEMONS
VICKI LIONBERGER
(A) Title
Board Member
Board Member
Board Member
Vice President
Board Member (Thru - 9/23/12)
Secretary (Thru - 12/31/12)
Hawaii Affiliate
Anne Harpham
Camonia Long
Kim Huber
Chimaine Pouteau
Paulette Williams
Miriam Loui
Linda Mitchell
Nina Rappeline
President
Secretary
Treasurer
Board Member
Board Member
Board Member
Board Member
Board Member (4/1/12 - 2/1/13)
5
5
5
5
5
5
5
5
Houston Affiliate
Betsy Kamin
Carol Helliker
Jill Cude
Cal Leeke
Jayne Homco
Anne Meyn
Debbie Scanlon
Molly Bobrow
Debbie Kearns
Jan Miller
Margo Scholin
Margaret Cazalot
Ann Masel
Kathy Nicholson
Allen Wilson
President
Secretary
Vice President
Treasurer
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Indianapolis Affiliate
Julie Meek
John Papageorge
Amadou Yattassaye
Terri Bendes
Lyle Browne
Tory Callaghan Castor
Robort Goulet
Lynnette Hanes
Hammoudeh Fuad
Larry Keyler
Christina Kim
Beth Lux
Mike Marker
Annmarie Novotney
Patrick Wooten
Ann Hamilton
James Burnes
Vice President
President
Secretary
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Treasurer
Board Member
Inland Empire Affiliate
Sandy Finestone
Jacquin Davidson
Cindy Golden
Debbie Gilligan
Barb Killian
Herb Killian
Dorcy Bowman Rose
Craig Webber
Aimee Salzmann
President
Treasurer
Secretary
President Elect
Board Member
Board Member
Board Member
Board Member (6/27/12 - 3/31/13)
Board Member (7/25/12 - 3/31/13)
Page 10 of 27
Former
-
(D) Reportable
Compensation
from the
Organization
(E) Reportable
compensation
from related
organizations
ATTACHMENT 2A
EIN# 75-2462834
2012 FORM 990
(B) AVG Individual
HOURS/ Trustee or
WEEK
Director
2
X
2
X
10
X
2
X
3
X
0
0
0
0
0
0
0
0
0
0
(F) Estimated
amount of other
compensation
from the
organization and
related orgs
0
0
0
0
0
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
X
X
X
-
-
-
0
0
0
0
0
0
0
0
0
Institutional
Trustee
-
Officer
-
Key
Employee
-
HighestCompensated
Employee
-
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
-
-
-
2
4
2
1
2
1
1
1
3
1
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
-
-
President
Board Member
Secretary
Board Member
Board Member
Board Member
Vice President
Board Member
Board Member
Treasurer
Board Member
Board Member
Board Member
4
4
2
4
2
1
2
2
2
4
2
2
1
2
1
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
-
Elizabeth Berger
Patricia Buske
Lisa Demsky
Linda Pura
Kelli Brooks
Paulette Pasciuti
Nancy Miller
Leslie Haas
Lee Halarewicz
Jerri Johnson
Andrea Scott
President
Treasurer
Secretary
Board Member
Board Member
Board Member
3
3
3
3
1.5
1.5
1
1
1
3
1
X
X
X
X
X
X
X
X
X
X
X
-
Bob Silverthorn
Karen Blaiklock
Christopher Hatcher
President
Vice-President
Treasurer
15
2
7
X
X
X
-
Filing Organization
Johnny Montes
Allison De Tal
Cindy Fitch
Micki Greenspan
Natalee Boggs
(A) Name
(A) Title
Board Member (6/27/12 - 3/31/13)
Board Member (6/27/12 - 3/31/13)
Board Member(12/1/12 - 3/31/13)
Knoxville Affiliate
Lynn W. Akers
Lytle Brown IV
Katie Coffey
Kathy Cummins
Allison Dooley
Kelly Fletcher
Misty Monday
Pat Murphy
Lisa Stearns
Kristi Sykes
Rosa Thomas
Michele Wall
President
Board Member
Board Member
Treasurer
Board Member
Board Member
Secretary
Board Member
Board Member
Board Member
Board Member
Board Member
2
1
1
1
1
1
1
1
1
1
1
1
The Las Vegas Chapter
Rachelle Crupi
Diane Allison
Kelly Tate
Dr. James Sanchez
Jennifer Lazovich
Tonya Carpenter
Aimee Romero
Sharice Lance
Karen Zehner
Tanya Flanagan
President
Treasurer
Board Member
Board Member
Board Member
Board Member
Board Member
Secretary
Board Member
Lexington Affiliate
Stuart Hurt
Billie Dollins
Linda Gilker
Cathryn Gibson
Nancy Elliott
Pam Nystrom
Chris Young
Cindy Hicks
Yajaira West
Morgan Daulton
Mary Layton
Shana Carr
Bret Melrose
Wayne Thompson
Adam English
The Los Angeles County Chapter
Louisville, Kentucky Affiliate
Page 11 of 27
Former
-
(D) Reportable
Compensation
from the
Organization
(E) Reportable
compensation
from related
organizations
ATTACHMENT 2A
EIN# 75-2462834
2012 FORM 990
Filing Organization
(A) Name
(B) AVG Individual
HOURS/ Trustee or
WEEK
Director
X
2
X
1
X
1
X
1
X
3
X
2
X
1
X
1
X
3
X
1
X
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
(F) Estimated
amount of other
compensation
from the
organization and
related orgs
0
0
0
0
0
0
0
0
0
0
0
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Institutional
Trustee
-
Officer
X
-
Key
Employee
-
HighestCompensated
Employee
-
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
-
-
-
2
3
5
1
1
15
2
2
1
4
2
1
1
1
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
-
-
President
Immediate Past President
Vice Pres., Board President Elect
Secretary
Treasurer
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member (Thru 12/31/12
Board Member (Thru 12/31/12
3
1
1
2
3
1
1
1
1
1
1
2
3
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
-
Board Member
Treasurer
Board Member
President
Secretary
Board Member
3
5
3
5
3
3
3
X
X
X
X
X
X
X
-
X
X
X
-
Mike Woerner
John Applegate
Judy Breitenstein
Linda Goss
Sabrina Hackett
Melinda McKinley
Art McLaughlin
Brian Nochols
Mary Schneider
Gerina Whethers
Sarah Malone
(A) Title
Secretary
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Lowcountry Affiliate
Patricia Simon
Jennifer Fiorini
Paulette Van Fleet
Shirly Nilsen
Elizabeth Ricciardone
Bonnie Hancock
Leslie Haywood
Helena Bastian
Loretta Mozon
Jack Hensel
Lynn Anne Gillen
Laura Simons Greavy
President
President Elect
Treasurer
Secretary
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
2
1
2
1
2
2
1
1
1
1
1
1
Lubbock Area Affiliate
Jennifer Bell Riley
Cindy Best
Renee Davis
Nancy Drerup
Linda Greetstreet
Julie Holladay
Becky Jones
Amy McCallister
Ronda Menefee
Sandy Muff
Christie Pare
Bruce Sifrit
Joe Velasquez
Brenda Wilson
Board Member
Secretary
Vice President
President
Board Member
Board Member
Board Member
Treasurer
Board Member
Board Member
Board Member
Board Member
Madison Affiliate
Mike Fahey
Mary Carr Lee
Toni Gnewuch
Rebecca Orvick
Tim Koechel
Pamela Bean
Emilie Fedorov
Alexander Herring
Laura Jelle
Linda Plourde
Dr. Gale Sisney
Melissa Warner
Mary Pat Berry
Maine Affiliate
Victoria Abbott
Cathy Dow
Denise Hodsdon
Holly Korda
Noreen Patient
Jeff Bennett
Patsy Wiggins
Page 12 of 27
Former
-
(D) Reportable
Compensation
from the
Organization
(E) Reportable
compensation
from related
organizations
ATTACHMENT 2A
EIN# 75-2462834
2012 FORM 990
Filing Organization
(A) Name
(A) Title
Carrie Meo
Board Member
Maryland Affiliate
Amy Heinrich
Bryant Cargile
Kelly Swoope-Holloway
Julie Thomas
Elaine Bonneau
Lisa Adkins
Susan Forlifer
Sharon Mirabelle
Neil Christ
Aliza Rothenberg
Nicholas Geier
Kimberly Neal
Ann Musser
Michelle Levin
President
VP Finance-Treasurer
VP Board Governance-Secretary
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Massachusetts Affiliate
Margery Cole
Tracy Curley
Ann Donner
Phil Graceffa
Alison Kennedy
Karen Sundermier Mankes
Rich Meagher
Christian Megliola
Jane Mendez
Chris O’Connor
Linda Ruberto
Joan Schloss Delena
Christine George
Memphis-Midsouth Affiliate
(B) AVG Individual
HOURS/ Trustee or
WEEK
Director
X
3
Institutional
Trustee
-
Officer
-
Key
Employee
-
HighestCompensated
Employee
-
Former
-
(D) Reportable
Compensation
from the
Organization
0
(F) Estimated
amount of other
(E) Reportable
compensation
compensation
from the
from related
organization and
organizations
related orgs
0
0
10
10
1
1
1
1
1
1
1
1
1
1
1
1
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Treasurer
Secretary
Board Member
Board Member
Board Member
Board Member
Board Member
President
Board Member
Vice President
2
3
2
2
2
3
2
2
3
8
2
3
5
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Alyssa Throckmorton
Billie White
Eric Lucka
Jeanette O'Bryant
Lorraine Wolf
Meredith Williams
Michael Thannum
Michelle Epps
Mollie Baltimore
Nikk Huffman
Sara Thatcher
Cheri Rudner
Holly Ford
President
Secretary and IT Chair
Treasurer
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
President - Elect
1
1
1
1
1
1
1
1
1
1
1
1
1
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Miami Affiliate
Kim Heard
Monica Cepero
Jennifer Jarema
Grace Lopez
Felicity Fang
Sharon Philip
Pat Thomson
Odalys Smith
Sherri Martens-Curtis
Alison Pages
Diane Danois
Board Member
Board Member
Secretary
President
Treasurer
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
8
1
3
10
1
3
2
4
20
2
2
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Mid-Kansas Chapter
Pam Palmer
Brian Clark
Debbie Christiansen
Vicki Carter
President
Secretary
Treasurer
Board Member
1
1
1
1
X
X
X
X
-
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
Page 13 of 27
ATTACHMENT 2A
EIN# 75-2462834
2012 FORM 990
Filing Organization
(B) AVG Individual
HOURS/ Trustee or
WEEK
Director
1
X
1
X
1
X
X
1
X
1
1
X
1
X
0
0
0
0
0
0
0
0
0
0
0
0
0
0
(F) Estimated
amount of other
compensation
from the
organization and
related orgs
0
0
0
0
0
0
0
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
X
X
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
X
X
X
X
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
Institutional
Trustee
-
Officer
-
Key
Employee
-
HighestCompensated
Employee
-
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
-
-
-
6
3
1
1
1
1
1
1
0
2
2
1
0
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
-
-
10
4
10
2
4
2
2
2
X
X
X
X
X
X
X
X
-
X
X
X
-
2
4
2
2
2
2
2
2
2
2
1
2
1
X
X
X
X
X
X
X
X
X
X
X
X
X
-
1
2
1
15
X
X
X
X
-
(A) Name
Jan Davis
Karla Goewert
Nancy Harman
Rob Burton
Steve Carr
Sara Monger
Teresa Wallweber
(A) Title
Board Member
Board Member
Board Member
Board Member
Board Member (5/21/12 - 8/31/12)
Mid-Missouri Affiliate
Susan McClintic
Johanna Cox-Littrell
Jane McElroy
Kim Oxenhandler
Mitzi Clayton
Kat Cunningham
Robin Corderman
Matt Melton
Pam Neugeberger
Laura Lewis
Julie Hampton
Secretary
Vice President
President
Treasurer
Board Member
Board Member
Board Member
Board Member
Board Member
2
2
5
3
2
2
3
3
2
2
2
Milwaukee Affiliate
Meghan Shannon
Rebecca Gottfried
Anne Ballentine
Lisa Gingerich
Laurie Stencel
Guillermo Martinez-Torres
Ryan Johnson
Cynthia Hooker
Wendy Carlson
Suzanee Rapp
Debra Tews
Dawn Regner
Floyd Breztman
President
Treasurer
Secretary
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Minnesota Affiliate
Val Hallgren
Susan Klasen Albrecht
Beth Pulsipher
Drew Backstrand
Larry Berg
Peter Hasselquist
Doug Yee
Tufia Haddad
President
Treasurer
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Montana Affiliate
Eddie Black
Jullie Heller
Katherine Berry
Dianne Page
Debera Charlton
Kevin Skaalure
Mary George
Kari Parmer
Cynthia Gustafson
Anastasia Burton
Casy Kyler-West
Molly Mosness
Marilyn Aberle
President
Treasurer
Vice-President
Secretary
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member(Beg 11/30/12)
Board Member
North Carolina Foothills Affiliate
Angie Glazebrooks
Libby Stroud
Susan Secrest
Teresa Jarrett
Secretary
Treasurer
Board Member
President
Page 14 of 27
Former
-
(D) Reportable
Compensation
from the
Organization
(E) Reportable
compensation
from related
organizations
ATTACHMENT 2A
EIN# 75-2462834
2012 FORM 990
Filing Organization
(A) Name
Brenda Putnam
Deborah Burgess
JoAnn Smith
Pamela Hemphill
Patricia Kokoszka
Regina Kilby
Sandra Holman
Suan Dickens
Susan Ratcliff
Wanda Mace
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
(A) Title
North Carolina Triad Affiliate
Natasha Gore
Stephanie Billings
JoAnn Gibson
Mary T. Perkins
Karen Jarvis
Whitney Webster
Chrystal Parnell
Jan Knox
Leslie Conway
Mike Reeves
Carla Strom
Ashley Kohlrus
Roberta King Latham
Marissa McNatt
Enid Bonilla
President
Vice President
Treasurer
Secretary
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
NC Triangle Affiliate
Becky George
Carlyn Sue Haney
Kathy Barger
Ted Smyth
Bill Roberts
John Eastman
Julie McQueen
Kathy O'Brien
Keith Amos
Kevin Sowers
Kolby Sidhu, MD
Marian Johnston-Thompson
Jessie Wei
Treasurer
Secretary
Vice President
President
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Assistant Treasurer
Nebraska Affiliate
Angie Miller
Andrea Heffelfinger
Robert Langdon
Natalie Mandolfo
Kate Sommer
Janet Osborn
Paula Porzelt
Madeline Roebke
Stephen Jackson
Cristina Castro-Matukewicz
Deidra Andrews
Geneva Dourisseau
Susan Westcott
Mike Demman
Renee Franklin
New Orleans Chapter
Frank Liantonio
Christina Chifici
Lori Barthelemy
Paula Brown
(B) AVG Individual
HOURS/ Trustee or
WEEK
Director
3
X
5
X
X
1
X
1
X
2
1
X
X
2
X
1
1
X
X
1
Institutional
Trustee
-
Officer
-
Key
Employee
-
HighestCompensated
Employee
-
Former
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
(F) Estimated
amount of other
compensation
from the
organization and
related orgs
0
0
0
0
0
0
0
0
0
0
(D) Reportable
Compensation
from the
Organization
(E) Reportable
compensation
from related
organizations
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
5
5
5
10
5
5
5
5
5
5
5
5
5
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
President
Secretary
Board Member
Board Member
Board Member
Treasurer
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
3
2
1
2
3
3
1
1
1
3
1
1
1
1
2
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
President
Treasurer
Secretary
Board Member
10
15
12
6
X
X
X
X
-
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
Page 15 of 27
ATTACHMENT 2A
EIN# 75-2462834
2012 FORM 990
(B) AVG Individual
HOURS/ Trustee or
WEEK
Director
6
X
6
X
6
X
6
X
X
6
0
0
0
0
0
0
0
0
0
0
(F) Estimated
amount of other
compensation
from the
organization and
related orgs
0
0
0
0
0
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
X
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
-
-
-
0
0
0
0
0
0
0
0
0
Institutional
Trustee
-
Officer
-
Key
Employee
-
HighestCompensated
Employee
-
X
X
X
X
X
X
X
X
X
-
X
X
X
X
-
-
1
1
1
1
1
1
1
1
1
X
X
X
X
X
X
X
X
X
-
X
X
-
-
President
Treasurer
Board Member
Fund Development
Board Development
Board Member
Board Member
Board Member
Board Member
Treasurer
Board Member
5
4
4
4
4
5
5
5
2
5
2
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
-
Robin Bloink Ventura
Karen Meleta
Kristen Olson
Charles Wolf
Shawn Leyden
Frank D. Isoldi
Wendy Lemke
Kristin Wenger
President
Vice President
Secretary
Treasurer
Board Member
Board Member
Board Member
Board Member
2
1
1
1
1
1
1
1
X
X
X
X
X
X
X
X
-
North Mississippi Affiliate
Ellen Friloux
Janie Lee
Paula Turner
Pam Hadley
Mike Tapscott
Mary Walden
Shannon Fryery
Patsy Brandon
Liz Dawson
Sergio Warren
Secretary
Treasurer
President
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
2.0
3.0
0.5
1.0
0.5
0.5
1.0
0.5
3.0
0.5
X
X
X
X
X
X
X
X
X
X
North Texas Affiliate
David Aiello
Debbie Thomas
James Polfreman
Board Member
Board Member
Board Member
1
1
1
X
X
X
Filing Organization
(A) Name
Jennifer Greene
Henry Kothmann
Elly Zakris
Bridgette Collins-Burow
Joe Briand
Board Member
Board Member
Board Member
Board Member
Board Member
(A) Title
North Central Alabama Affiliate
Claudia Hardy
Rebecaa DiPiazza
Kay Wilburn
Lori Elrod
Thelma Perry Brown
Jeannine Jersey Bailey
Kerry McInerney
Joe O'Donnell
Beverly Laird
President
Board Member
Board Member
Secretary/Treasurer
Board Member
Vice President
5
2
2
1
3
2
1
1
5
North Dakota Affiliate
Shari Hahn
Lori Finken
Melanie Carvell
Julie Jeske
Beth Schoenbeg
Linda Pahlke
Nicole Poolman
Kelly Quintus
Erin Green-Grom
North Florida Affiliate
Linda Hansen-Allen
Scott Mattson
Dr. John Murray
Dr. Ankit Desai
Henry R. Maly
Benivia Forester
Michelle Kargbo
Tammy Molter
Trishna Patel
Christopher Quevedo
B. Tyler White
The North Jersey Affiliate
Page 16 of 27
Former
-
(D) Reportable
Compensation
from the
Organization
(E) Reportable
compensation
from related
organizations
ATTACHMENT 2A
EIN# 75-2462834
2012 FORM 990
Filing Organization
(B) AVG Individual
HOURS/ Trustee or
WEEK
Director
1
X
1
X
X
1
X
1
X
1
X
1
1
X
X
1
X
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
(F) Estimated
amount of other
compensation
from the
organization and
related orgs
0
0
0
0
0
0
0
0
0
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Institutional
Trustee
-
Officer
X
X
X
X
-
Key
Employee
-
HighestCompensated
Employee
-
X
X
X
X
X
X
X
X
-
X
X
X
-
-
-
2
15
2
2
3
2
2
2
2
2
3
2
5
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
X
-
-
Board President
Board Vice President
Board Treasurer
Board Member
Board Member
Board Member
Board Member
Secretary
Board Member
Board Member
Board Member
3
2
3
1
1
1
1
2
1
1
1
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
-
Richard G. Emanuelson, M. D.
Marion L. Farrell, Ph.D.
Daniel J. West., Ph.D.
Joann Marsili
Laurie LaMaster
Sister Ruth Neely
Maria E. Scopelliti
John R. O'Brien Esq.
President
Vice President
Board Member
Secretary/Treasurer
Board Member
Board Member
Board Member
Board Member
2
1
1
1
1
1
1
1
X
X
X
X
X
X
X
X
-
Pam Jarrett
Cathy Lance
Sandi Rousseve
Fr. Austin Collins
Lisa Martell
Patty Brady
Bonnie Raine
President
Treasurer
Secretary
Board Member
Board Member
Board Member
Board Member
15
5
1
1
3
3
1
X
X
X
X
X
X
X
-
(A) Name
Jean Evans
Kevin Housing
Mackenzie DeWerff
Nat Cohen
Robbie Collins
Rozalind Dickerson
Sherri Bishop
Steve Watten
Jennifer Edwards
Secretary
Board Member
Board Member
Treasurer
Board Member
Past President
Vice President
President
Board Member
(A) Title
The Northeast Louisiana Chapter
Rachel Riser
Lacy Miletello-McCarthy
Tomi Tharp
James Adams
Donna Nolan
Tommi Bratton
Pamela Bratton
Kelli Blakely
President
Board Member
Board Member
Treasurer
Board Member
Secretary
Board Member
Board Member
2
2
2
2
2
2
2
2
The Northeast Ohio Chapter
Adam Chafe
Denise Grcevich
Eileen Korey
Greg Boone
Jennifer Boland
Jennifer Deutsch
John Ertz
Kelly Linson
Lee Giller
Lolita McDavid
Mike Gall
Najeebah Shine
Sue Kurzweil
Board Member
President
Vice President
Board Member
Vice President
Board Member
Board Member
Treasurer
Secretary
Board Member
Board Member
Board Member
Board Member
Northeastern New York Affiliate
Nancy Sciocchetti
Deb Sottolano
Barbara Wayman
Arsyl DeJesus
Francesca Durand
Monica Minor
Ryan Burke
Pam Demers
Jan Opal
Katie Slater
Rodi Marcelle
Northeastern Pennsylvania Chapter
Northern Indiana Affiliate
Page 17 of 27
Former
-
(D) Reportable
Compensation
from the
Organization
(E) Reportable
compensation
from related
organizations
ATTACHMENT 2A
EIN# 75-2462834
2012 FORM 990
Filing Organization
(B) AVG Individual
HOURS/ Trustee or
WEEK
Director
1
X
X
3
1
X
1
X
1
X
1
X
X
10
1
X
10
X
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
(F) Estimated
amount of other
compensation
from the
organization and
related orgs
0
0
0
0
0
0
0
0
0
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
-
0
0
0
0
0
0
Institutional
Trustee
-
Officer
-
Key
Employee
-
HighestCompensated
Employee
-
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
X
-
-
1
5
1
1
1
1
1
1
1
1
1
1
1
1
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
-
-
President
Treasurer
Secretary
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
2
4
2
2
2
2
2
2
2
2
2
2
2
2
2
X
X
X
X
X
X
X
X
X
X
X
X
X
X
x
-
X
X
X
-
Board Member
Board Member
1
2
X
X
-
-
(A) Name
Christopher Kiefer
Linda Herter
Lynn Kachmarik
Danny Conroy
Glynda Harris
Sharon Simmons
Mikki Dobski
Mindy McIntire
Sheri Miller Story
(A) Title
Board Member
Board Member
Board Member
Board Member
Northern Nevada Affiliate
Emily Nelson
Leslie Bittleson
Fran Culverhouse
Cindy Lain
Amanda Parks
Janet Ravey
Amber Barnes
Heather Goulding
Shannon Hogan
Bianca Ayala
Amanda Horn
Abbi Whitaker
Tina Davis
Rhonda Walker
Nancy O'Neal
Sue Leaonard
Melanie Richard
President
Secretary
Treasurer
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Vice-President (Thru 7/12)
Secretary (Thru 7/12)
7
1
1
2
2
1
2
2
1
1
1
2
1
4
2
1
4
Northwest Ohio Affiliate
Mark Evans
Mary Chris Skeldon
Karen Cline
Anne Loochtan, Ph.D.
Christy Contardi Stone
Deborah Barnett
Lori Decker
Shaneli Fernando, M.D.
Brian Fink Ph. D.
Teresa McHugh
Phillip Platz
Michele Rice
Judge Lynn Howard Schaefer, Retired
Robin Shermis, M.D.
Treaurer
President
Board Member
Board Member
Board Member
Board Member
Secretary
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Ozark Affiliate
Kari Nikolish
Larry Shackelford
Kathleen Dalton
Rich Reaves
Dr. Stephen Rosenfeld
Dr. Danna Grear
Michelle Gloeckler
Betsy Reithemeyer
De De Priest
Sara Lilygren
Adriana Wilhelm
Sean Keith
Mike Turner
Mary Zettle
Sissy Pederson
The Peoria Memorial Affiliate
Craig Gilson
Helene Peterson
Page 18 of 27
Former
-
(D) Reportable
Compensation
from the
Organization
(E) Reportable
compensation
from related
organizations
ATTACHMENT 2A
EIN# 75-2462834
2012 FORM 990
Filing Organization
(B) AVG Individual
HOURS/ Trustee or
WEEK
Director
2
X
2
X
1
X
1
X
X
1
1
X
1
X
X
1
X
1
1
X
X
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
(F) Estimated
amount of other
compensation
from the
organization and
related orgs
0
0
0
0
0
0
0
0
0
0
0
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
Institutional
Trustee
-
Officer
X
X
-
Key
Employee
-
HighestCompensated
Employee
-
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
-
-
-
8
8
4
4
4
4
2
2
2
2
2
2
2
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
-
-
1
2
1
1
1
1
4
1
1
1
1
1
1
1
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
-
15
1
1
1
X
X
X
X
-
X
X
-
(A) Name
Lisa Hansen
Nick Esser
Dr. Denise Mammolito
Dr. John Miller
Greg Miller
Jeanne Buysee
Jennifer Robin
Kate Van Beek
Linda Washkuhn-Sutkowski
Margo Rozell
Wilma Bates
(A) Title
Secretary/Treasurer
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
President
Board Member
Board Member
Board Member
Philadelphia Affiliate
Joanne Calabria
Lisa Wollan
Ronald B Morris, CPA
Barbara A Orr
Ellen M Cavanuagh
Rabbi Jerome P. David
Tangee E. Gibson
Judy Kellem
Sue Schick
Sloane R. Six
Lawrence A. Smith
Fred Stein
Meryl Weinreb
Harris Bock
President
Vice President
Treasurer
Secretary
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
5
3
4
3
5
2
2
2
2
2
2
2
2
2
Phoenix Affiliate of the
Dan Costello
Luisa Salcedo
Anabell Casto-Thompson
Barbara Watson-Riley
Carolyn Evani
Lisa Levi-Schmidke
Cristina Lenko
Jeff Gauvin
Jill Bray
Katherine Yu
Michael Sherman
Pam Giannonatti
Tonsa Price-Edwards
Board Member
Secretary / Treasurer
Board Member
Board Member
President
Board Member
Board Member
Board Member
Vice President
Board Member
Board Member
Board Member
Board Member
Pittsburgh Affiliate
Sue Ely
Judy Herstine
Holly Wald
Michael Barfield
Annette Dudash Boyer
Karen Hartley
Jeremy Hartzell
Dina Johnson
Eric Kulikowski
Debbi Linhart
Carmelle Nickens
Gina Pferdehirt
William Poller
Lynda Saxon
Board First Vice President
Board Secretary/Treasurer
Board Second Vice President
Board Member
Board Member
Board Member
Board President
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Quad Cities Affiliate
Martha Watters
Sheila Soltow
Amy Westfall
Andrea Schelin
Treasurer
President
Board Member
Board Member
Page 19 of 27
Former
-
(D) Reportable
Compensation
from the
Organization
(E) Reportable
compensation
from related
organizations
ATTACHMENT 2A
EIN# 75-2462834
2012 FORM 990
Filing Organization
(A) Name
Cathie Whiteside
Karen Roebuck
Kathy Daily
Shelly Rosa-Gastaldo
Cyndi Ashmun
Jodi Scharer
Laura Erntzen
Wendy Meyer
(A) Title
Board Member
Board Member
Board Member
Board Member
Past President (Thru 8/9/12)
Board Member
Sacramento Valley Affiliate
Diane Pearson-Brown
Karen Moreno
Ann Yoshimoto
Jennifer Glass
Jennifer Solorio
Emily Leff
President
Secretary
Vice President
Treasurer
Board Member
Board Member (4/1/12 - 6/1/12)
Salt Lake City Affiliate
Lisa Schneider
Kimberly Neville
Coralie Alder
Terri Borg
Susan Couch
Christina DeVore
David Gaffney, M.D.
Gail Winterfeld
Sally Brown
Patricia Thompson
Rebecca Chambers
Thomas Tsai
Megan Corrent
Patricia Bair
David Goldsmith
The San Antonio Chapter of the
The San Diego Chapter of the
(B) AVG Individual
HOURS/ Trustee or
WEEK
Director
10
X
X
1
1
X
1
X
1
X
1
X
X
10
1
X
Institutional
Trustee
-
Officer
-
Key
Employee
-
HighestCompensated
Employee
-
Former
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
(F) Estimated
amount of other
compensation
from the
organization and
related orgs
0
0
0
0
0
0
0
0
(D) Reportable
Compensation
from the
Organization
(E) Reportable
compensation
from related
organizations
10
4
8
15
2
1
X
X
X
X
X
X
-
X
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
President
Treasurer
Board member
Board member
Board member
Board member
Board member
Board member
Board member
Board member
Treasurer (Thru 7/12)
Treasurer
Secretary (Thru 7/12)
6
1
2
5
3
3
1
4
2
2
1
2
1
1
1
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Jessica Huff
Irene Hahn
Susan Schott
Tanya Sammis
Debra Acosta
Kathy Humphries
Sandra San Miguel
Lauren McLaughlin
Eileen Lundin
Tyler Davies
Brian Mathers
Anne Blantyne
Elsa Perez
Joan Lawhon
President
Vice President
Treasurer
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
5
1
1
1
1
2
1
2
1
5
1
1
1
1
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Linda Amaro
Susan Halliday
Risto Mitrovich
Catherine Blair
Irene Oberbauer
Elle Peji
Jenee Peevy
Craig Pobst
Dinah Smith
Jeremy Ross
Nykia Wilson
Drew Scholssberg
Elaine Bellock
Carolyn Clark
President
Treasurer
Secretary
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member (4/1/12 - 10/17/12)
Board Member (4/1/12 - 9/12/12)
6
2
2
6
1
1
1
1
1
1
1
1
1
2
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Page 20 of 27
ATTACHMENT 2A
EIN# 75-2462834
2012 FORM 990
Filing Organization
(A) Name
(B) AVG Individual
HOURS/ Trustee or
WEEK
Director
2
X
2
X
(D) Reportable
Compensation
from the
Organization
(F) Estimated
amount of other
(E) Reportable
compensation
compensation
from the
from related
organization and
organizations
related orgs
0
0
0
0
Institutional
Trustee
-
Officer
-
Key
Employee
-
HighestCompensated
Employee
-
X
X
X
X
X
X
X
X
X
-
X
X
X
X
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
2
3
2
2
2
2
2
1
1
1
1
1
1
1
1
2
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
5
5
2
5
5
5
5
1
1
1
5
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
10
10
5
1
1
1
1
1
1
1
1
5
1
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
2
2
2
2
X
X
X
X
-
X
X
X
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
Theresa Fox
Patty Alvarez
(A) Title
Board Member (4/1/12 - 10/17/12)
Board Member (4/1/12 - 2/20/13)
The San Francisco Bay Area Affiliate
Anita Brink
Patrick Barber
Claudia Owen
Carol Benz
Caolyn Chang, MD
Jenner Morrison
Charles Rashall
Amanda Peters
Jackie Schneider
President
Vice President
Treasurer
Board Member
Board Member
Board Member
Board Member
Board Member
2
2
2
1
1
1
1
1
2
Shreveport Affiliate
Alice Jett
Sarona Snyder
Catherine Jones
Deborah Roberts
Sherin Mercer
Suzanne Sims
Rhonda McIssac
Julia Watson
Julie Mook
Karin Oathout
Kathy Crow
Lyndsay Catlett
Mark Kraemer
Michelle Jobe
Paula Rembert
Melissa Washington
Board Member
Vice President
Board Member
Treasurer
Board Member
President
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Secretary
Board Member (5/15/12 - 7/31/12)
Siouxland Affiliate
Angie Schneiderman
Michelle Holmes
Deena Townley
Birgit Flom
Cindy Brewer
Stephanie Myres
Teresa Ramold
Gary Richardson
Lynn Peterson
Marcia Moore
Barb Pieper
President
Treasurer
Secretary
Board Member
Board Member
Board Member
President Elect
Board Member
Board Member
Board Member
South Dakota Affiliate
Kathy A Manning
Daisy Halvorson
Rod Goeman
Paul Clemments
Julie Hanisch
Beth O'Toole
Shane Miner
Colleen Schurrer
Vanessa Shortbull
April Sorrensen
Sherri Basley
Heather Keeler
Tinka Duran
President
Treasurer
Vice-President
Secretary
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member (4/26/12 - 1/11/13)
The South Florida Chapter
George M Bachman
Kathleen Bocek
Teresa A. Licamara
P. Kristen Pressly
Board Member
Vice-President
Treasurer
Secretary
Page 21 of 27
Former
-
0
0
ATTACHMENT 2A
EIN# 75-2462834
2012 FORM 990
Filing Organization
(B) AVG Individual
HOURS/ Trustee or
WEEK
Director
2
X
1
X
X
1
X
1
1
X
X
1
X
1
1
X
X
1
X
1
1
X
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
(F) Estimated
amount of other
compensation
from the
organization and
related orgs
0
0
0
0
0
0
0
0
0
0
0
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
-
0
0
0
0
0
0
0
0
0
Institutional
Trustee
-
Officer
X
-
Key
Employee
-
HighestCompensated
Employee
-
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
-
-
-
20
20
10
10
10
5
5
2
2
2
2
1
2
1
1
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
X
-
-
President
Board Member
Secretary
Treasurer
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member (4/1/12 - 11/27/12)
2
1
1
1
1
1
1
1
1
1
1
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
-
President
Vice President
Secretary
2
2
2
X
X
X
-
X
X
X
(A) Name
Dave Ragsdale
Michael Becker
Carlos Berrocal
Fern Duberman
Jane Herring-Choate
Dr. Fausta Nazaire
Dr. Carisa Pearce
Dr. Marilyn Raymond
Jill G. Weiss
Deborah Wienke
Marc Yavinsky
President
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
(A) Title
Southeast Georgia Affiliate
Susie Massey
Sue Adler
Pam Cowart
Laura Hagan
Amy Hughes
Caroline Keller
Jennifer Mafera
Elizabeth Myers
Russ Toal
Amos Timna
Julie Cyr
Sarah Denmark
Julie Grimm
Nikki Troxclair
Andres Montes
Donna Williams
DelRia Baisden
Treasurer
President
Secretary
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
8
5
2
6
2
8
2
2
2
8
2
2
2
2
2
2
2
Southeast Iowa Affiliate of the
Pam Kesselring
Laurie Hornback
Janet Paulson
Eve Schindler
Krista Burton
Gayla Harrison
Marie Zoromski
Tracy Hatfield
Cecile Van Winkle
Debbie Maloy
Camilla Crumes
Maggie Fuller
Amber Kephart
Mabel Hart
Ashley Marshall-Lowenberg
President
Board Member
Treasurer
Board Member
Treasurer
Vice-President
Board Member
Board Member
Board Member
Board Member
Board Member
Secretary
Southern Arizona Affiliate of the
Bimi Huebner
Deborah Friedman
Elaine Walsh
Mark Channell
Debbie Bush
Tay Fitzgerald
Marian LaLonde
Ali Madani
Pearle Merriner
Gigi Schneppat
Catrina Baird
Southwest Florida Affiliate of the
Mariann MacDonald
Heather Turco
Dorothy Taylor
Page 22 of 27
Former
-
(D) Reportable
Compensation
from the
Organization
(E) Reportable
compensation
from related
organizations
ATTACHMENT 2A
EIN# 75-2462834
2012 FORM 990
Filing Organization
(B) AVG Individual
HOURS/ Trustee or
WEEK
Director
2
X
2
X
X
1
1
X
X
3
X
1
X
1
1
X
X
1
X
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
(F) Estimated
amount of other
compensation
from the
organization and
related orgs
0
0
0
0
0
0
0
0
0
0
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
X
X
X
-
-
-
0
0
0
0
0
0
0
0
0
Institutional
Trustee
-
Officer
X
X
-
Key
Employee
-
HighestCompensated
Employee
-
X
X
X
X
X
X
X
-
X
X
X
X
-
-
-
2
1
1
1
1
1
1
1
1
1
1
1
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
-
-
Board Member
Board Member
President
Board Member
Board Member
Board Member
Treasurer
Board Member
1
1
2
3
2
10
4
2
1
2
1
2
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
-
Ashley Loftin
Bruce Ramsey
Julie Sanderson
Katie Andrus
DeAnn Goins
William Wright
Buddy Allen
Pam Beck
Jeanie Conway
Don Morriss
Randy Sarrett, MD
Melinda Vammen
Treasurer
Board Member
President
Secretary
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
10
6
5
5
5
2
1
1
1
1
1
1
X
X
X
X
X
X
X
X
X
X
X
X
-
Sue Parks
Gretchen Valentine
Carrie Bollwinkle
President
Treasurer
Secretary
3
2
2
X
X
X
-
(A) Name
Robert Mangene
Janus King
Thomas Fabian, MD
Gayla Wright
Noreen Thomas
David Rock, MD
Connie Dillon
Steve Ershowsky
Marci Sanders
Deborah Solomon
(A) Title
Secretary (4/1/12 - 7/13/12)
Treasurer (4/1/12 - 1/15/13)
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
The Southwest Michigan Affiliate of the
Lucinda Stinson
Patricia Adams
Kristin Sauerhoff
Nathan Bolton
Terry McKay
Denise Stewart
Janet Miles
President
Vice President
Secretary
Treasurer
Board Member
Board Member
2
2
2
2
1
1
1
St. Louis Affiliate of the
DEDE HOFFMANN
CARRIE BUCHANAN
DAN BINDLER
JENNIFER KINGSTON
JOAN SEHL
KATE WALL
LILLIE THOMAS
MIKKI BREWSTER
PAUL LOVELL
PHYLECCIA REED COLE
RENEE HALL
SUSIE KNOPF
President
Board Member
Board Member
Board Member
Secretary
Board Member
Board Member
Board Member
Board Member
Board Member
Treasurer
Board Member
Tarrant County Affiliate
Julie Porter-Mayfield
Sarah Erekson
Gynna Harlin
Barbara Lander
Jackie Meeks
Tracy Reed
Michael Rendon
Beth Rivers
Joan Mason
Dori Boone-Constantino
Steve Peglar
Kara Rariden
Texarkana Affiliate
The Orange County Affiliate
Page 23 of 27
Former
-
(D) Reportable
Compensation
from the
Organization
(E) Reportable
compensation
from related
organizations
ATTACHMENT 2A
EIN# 75-2462834
2012 FORM 990
Filing Organization
(B) AVG Individual
HOURS/ Trustee or
WEEK
Director
1
X
1
X
X
2
X
2
2
X
3
X
1
X
0
0
0
0
0
0
0
0
0
0
0
0
0
0
(F) Estimated
amount of other
compensation
from the
organization and
related orgs
0
0
0
0
0
0
0
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Institutional
Trustee
-
Officer
X
-
Key
Employee
-
HighestCompensated
Employee
-
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
-
-
-
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
-
-
President
Treasurer
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
2
2
2
2
2
2
2
2
X
X
X
X
X
X
X
X
-
X
X
-
President
Secretary
Board Member
Board Member
Board Member
Treasurer
8
2
1
1
1
1
X
X
X
X
X
X
-
X
X
X
(A) Name
Lynn Jolliffe
Regino Diaz
Lisa E. Guerra
Dennis Kuhl
Sora Park Tanjasiri
Sol Reyes Roberts
Lynn Salo
(A) Title
President Elect
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
The Oregon and Southwest Washington Aff
Marta Monetti
Michael Phillips
Shirley Cry
Alec Vesely
Celia Austin
Chery Pape
Don Pearson
Gale Castillo
Gloria Coronado
Jen Williamson
Josh Kermisch
Laurie Reser
Lillian Nail
Nathalie Johnson
Pat Brown
Robert Dove
Sarah Couey
Tina Foster
Gail Houck
Cynthia Grant
Linda Williams
President
Vice President
Treasurer
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
1
2
5
1
2
1
1
1
1
1
1
1
1
1
1
1
1
2
2
1
1
The Puget Sound Chapter
Jim Havens
Stephen Sommerville
Nancy Koeper
Kathy Bressler
Nicole Grogan
Juli Farris
Kathleen Hogan
Michael Hunter
Brenda Glasgow
Dilip Wagle
Wendy Grover
Camila Santistevan
Albert Shen
Kathi Malone
Lisa Wissner-Slivka
President
Treasurer
Secretary
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Tidewater Affiliate
Maria Williamson
Sheena Boston
Barb Geraghty
Cliff Yellen
Grace Pearson
Dr. Mike Petruschak
Marcus Calabrese
Jodi Butler
Tri-Cities Affiliate
Curt Rose
Leslie Gilliam
Vanessa Bramble
Martha Chill
Beth Cox
Stephanie D. Werner
Page 24 of 27
Former
-
(D) Reportable
Compensation
from the
Organization
(E) Reportable
compensation
from related
organizations
ATTACHMENT 2A
EIN# 75-2462834
2012 FORM 990
Filing Organization
(A) Name
Pat Hale
Ken Harris
Sue Lindenbusch
Sandra McGlothlin
Mara Owens
Board Member
Board Member
Board Member
Board Member
Board Member
(A) Title
Tulsa Affiliate
Dawne Stafford
Diana Lowe
Tony Otto
Debbie Ritchie
Kristen Turley
Kim Tryon
Dr. Melisa Boersma
Melody McCloud
David Losacco
LToya Knighten
Patrice Brown
Michael Allen
Andrew Malati
President
Secretary
Treasurer
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Tyler Chapter
Connie Greenberg
Kristy Everitt
Anna Malone
Chelli Warren
Suzanne Booher
Ellen Peirce
Steve Countryman
Jo Ellen Callahan
Mike Hines
Karla Hutchison
Regina Davis
Wendy Johnston
Ed Sauter
Autumn King
Upper Cumberland Affiliate
Upstate South Carolina Affiliate
(B) AVG Individual
HOURS/ Trustee or
WEEK
Director
1
X
X
1
X
1
X
1
1
X
Institutional
Trustee
-
Officer
-
Key
Employee
-
HighestCompensated
Employee
-
Former
-
0
0
0
0
0
0
0
0
0
0
(F) Estimated
amount of other
compensation
from the
organization and
related orgs
0
0
0
0
0
(D) Reportable
Compensation
from the
Organization
(E) Reportable
compensation
from related
organizations
4
2
2
2
1
1
1
1
1
1
1
1
1
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
President
Treasurer
Secretary
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
15
15
10
5
5
5
5
5
5
5
5
5
5
5
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Pam Cummins
Robert N. Spence
Ashley Wright
Marie Ferran
Nancy Himmel
Nancy Judd
Marty Lewis
Lora Looper
Vickie Wilson
Laura Wolf
Heather Mullinix
Eileen Stuber
Jane Gray
Angela Regikto
Harry Stuber, MD
Gay McNab
Secretary
Treasurer
Board Member
President
Board Member
Vice President
Board Member
Board Member
Board Member
Board Member
Board Member
Vice President (Thru 1/31/13)
4
15
4
10
1
8
7
5
4
5
3
20
12
5
2
5
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Cynthia Fryer
Diana Ivankovic
Glen Innman-Williamson
Liza Owens West
Roger Beasley
Tammy Van Gieson
Mei Au
Donna Winbrenner
Barbara Rhodes
President
Board Member
Board Member
Board Member
Board Member
Board Member
Treasurer
Board Member
Board Member
5
1
1
2
1
5
3
3
2
X
X
X
X
X
X
X
X
X
-
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Page 25 of 27
ATTACHMENT 2A
EIN# 75-2462834
2012 FORM 990
(B) AVG Individual
HOURS/ Trustee or
WEEK
Director
2
X
(D) Reportable
Compensation
from the
Organization
(F) Estimated
amount of other
(E) Reportable
compensation
compensation
from the
from related
organization and
organizations
related orgs
0
0
Institutional
Trustee
-
Officer
X
Key
Employee
-
HighestCompensated
Employee
-
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
X
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
5
5
5
5
10
1
5
1
1
1
10
20
1
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
President
Board Member
Board Member
Board Member
Treasurer
Board Member
Board Member
Board Member
Vice President
Board Member
Board Member
President (8/11/12 - 12/11/12)
Secretary (thru 1/11/13)
15
8
8
5
20
8
10
8
15
8
5
37
7
5
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
X
X
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Colleen Nossavage
Dr. Stephen Edge
Patricia Stewart
Marylou Borowiak
Althea Luehrsen
James Kincaid
Dr. Robert Moskowitz
Donna Perna
Angel Beiter
Gerry Glose
Heather Ochs-Balcom
Mary Montani
President
Board Member
Board Member
Board Member
Vice-President
Secreatry/Treasurer
Board Member
Board Member
Board Member
Board Member
Board Member (5/1/12 - 9/1/12)
10
3
3
3
5
5
3
3
3
3
3
3
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Laura Schlager
Tamara Bowersock
Andy Stanford
James Johnston
Jeff Killion
Janice Sons
Board Member
Secretary
Board Member
Board Member
Board Member
Board Member
1
1
1
1
1
1
X
X
X
X
X
X
-
X
-
-
-
-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Filing Organization
(A) Name
(A) Title
Katrina Daniel
Secretary
Vermont-New Hampshire Affiliate
Becky Burke
Judi Fox
Valerie Rochon
Maureen Stannard
Lois Whidden
Kathy Murphy
Wendy Gawlik
Kimberly Luebbers
Terri Hathaway
Debbie Peretz
President
Treasurer
Board Member
Secretary
Board Member
Vice President
Board Member
Board Member
20
5
5
5
5
5
10
5
10
15
Wabash Valley Affiliate
Jana James
Jill Ferres
Leesa Nesty
Lorrie Heber
Phylis Fouts
Sally Roetker
Stan Hobbs
Terry Hogan
Michelle McCrea
Vickie Wallace
Barbara Lloyd
Jeri Humphrey
Patricia Wiley
Board Member
Vice President
Board Member
Board Member
Treasurer
President
Board Member
Board Member
Board Member
Treasurer
West Virginia Affiliate
Cathy McAlister
Pastor Bob Wood
Angela Brown
Kari Clark
Adam Carr
Natalie Luppold
Shanen Wright
Dennie Large
Rachel Schmidt
Holly Cowie
Kim Couch
Rebecca Newhouse
Jennifer Greenlief President
Kim Johnson
The Western New York Affiliate
Wichita Falls Affiliate
Page 26 of 27
Former
-
0
ATTACHMENT 2A
EIN# 75-2462834
2012 FORM 990
Filing Organization
Wyoming Chapter
(A) Name
(A) Title
Linda Boyd
Fran Lindemann
Mark Henderson
Stormi Bryant
Board Member
Co-Treasurer
President
Treasurer
Suzanne Esquibel
Mark Hicks
Whitney Swieter - Lamb
Antoinette Brown
Keith Howard
Jan Drury
Nancy Knaub
Jayne Mockler
Laurie Heath
Charlotte Carr
Roxanne Homar
Sandy Pederson
Stacey Caesar
Caryn Young
Michelle Kren
Vicki Sopr
President
Treasurer
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
President (4/1/12 - 6/27/12)
Secretary (4/1/12 - 6/28/12)
Treasurer (4/1/12 - 7/1/12)
Board Member (4/1/12 - 6/28/12)
Board Member (4/1/12 - 6/28/12)
Board Member (4/1/12 - 6/28/12)
Secretary (8/27/12 - 3/15/13)
(B) AVG Individual
HOURS/ Trustee or
WEEK
Director
1
X
X
1
X
5
5
X
2
3
2
2
2
2
2
2
6
8
2
5
2
2
2
2
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Totals
Page 27 of 27
Institutional
Trustee
-
Officer
X
X
X
Key
Employee
-
HighestCompensated
Employee
-
-
X
X
X
X
X
X
-
-
Former
-
0
0
0
0
0
0
0
0
(F) Estimated
amount of other
compensation
from the
organization and
related orgs
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
12,000
0
0
(D) Reportable
Compensation
from the
Organization
(E) Reportable
compensation
from related
organizations
ATTACHMENT 2A
The Susan G. Komen Breast Cancer Foundation, Inc. - Group Return
Year Ended March 31, 2013
EIN: 75-2462834
2012 Form 990
Form 990, Schedule C, Part II-A - Lobbying Expenditures by Electing Public Charities
Grassroots
Expenditures
Direct Lobbying
Expenditures
Total Lobbying
Expenditures
Other Exempt
Expenditures
Total Exempt Purpose
Expenditures
-
-
-
860,297
860,297
-
-
2,152,161
2,152,161
Susan G. Komen Breast Cancer Foundation Address for parent and all affiliates is:
5005 LBJ Freeway, Suite 250, Dallas, Texas 75244
1
Acadiana Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN #72-1436764
2
The Arkansas Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 71-0724439
3
The Aspen Chapter of the Susan G. Komen Breast Cancer Foundation
EIN# 84-1160739
-
-
-
453,102
453,102
4
Austin Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 75-2854966
-
-
-
1,846,203
1,846,203
5
Baton Rouge Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 75-2854972
-
-
-
698,601
698,601
6
Bayou Region Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 75-2854976
-
-
-
229,943
229,943
7
Boise, Idaho Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 75-2854965
-
-
-
726,407
726,407
8
Central Florida Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 75-2854957
7,441
1,106
8,547
805,594
814,141
9
Central Georgia Affiliate of the Susan G. Komen Breast Cancer Foundation
EIN # 75-2881536
1,051
-
1,051
327,871
328,922
10
Central Mississippi Steel Magnolias Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 75-2875174
1,674
-
1,674
378,310
379,984
11
Central New Mexico Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 85-0462625
-
-
-
475,284
475,284
12
Central New York Affiliate of the Susan G. Komen Breast Cancer Foundation
EIN# 16-1389666
-
-
-
894,004
894,004
13
Central Oklahoma Chapter of the Komen Foundation, Inc.
EIN# 73-1372249
-
-
-
910,385
910,385
14
Central and South Jersey Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 43-2052349
-
-
-
2,206,673
2,206,673
15
Central Texas Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 74-2906528
661
-
661
224,430
225,091
16
Central Valley Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 75-2854970
127
-
127
373,273
373,400
-
Page 1 of 8
Page 106
EIN: 75-2462834
2012 Form 990
Grassroots
Expenditures
Direct Lobbying
Expenditures
Total Lobbying
Expenditures
Other Exempt
Expenditures
Expenditures
17
Central Wisconsin Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 56-2613151
-
-
-
243,021
243,021
18
Charlotte Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 75-2854959
-
231
231
3,458,914
3,459,145
19
Chattanooga Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 75-2875175
-
-
-
630,642
630,642
20
The Chicagoland Area Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 36-4111723
1,317
-
1,317
2,866,388
2,867,705
21
Colorado Springs Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2844654
-
-
-
640,853
640,853
22
Columbus Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2844651
2,320
2,500
4,820
2,849,988
2,854,808
23
Connecticut Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2844629
-
-
-
2,483,998
2,483,998
24
Dallas County Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2444724
-
-
-
3,350,526
3,350,526
25
The Denver Metropolitan Affiliate of the Susan G. Komen Breast Cancer Foundation
EIN# 84-1199858
85
884
969
4,463,894
4,464,863
26
The Des Moines Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 42-1438018
-
-
-
1,079,206
1,079,206
27
Eastern Washington Affiliate of the Susan G. Komen Foundation, Inc.
EIN# 81-0578449
-
-
-
605,730
605,730
28
Elmira Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2844630
-
-
-
254,968
254,968
29
El Paso Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 74-2723408
-
-
-
551,788
551,788
30
Florida Suncoast Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2870702
5,392
-
5,392
1,297,407
1,302,799
31
The Greater Atlanta Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 58-1959763
-
-
-
3,042,800
3,042,800
32
Grand Rapids Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2844631
669
5
674
580,328
581,002
33
Greater Amarillo Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 72-1562627
-
-
-
434,731
434,731
Page 2 of 8
Page 107
EIN: 75-2462834
2012 Form 990
Grassroots
Expenditures
Direct Lobbying
Expenditures
Total Lobbying
Expenditures
Other Exempt
Expenditures
Expenditures
34
Greater Cincinnati Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 75-2855038
-
-
-
1,635,127
1,635,127
35
Greater Evansville Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 75-2844632
-
-
-
923,021
923,021
36
Greater Kansas City Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 75-2844634
42
4,087
4,129
1,955,951
1,960,080
37
Greater Lansing Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2915870
-
-
-
675,601
675,601
38
The Greater Nashville Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 62-1671774
-
-
-
1,225,090
1,225,090
39
Greater New York City Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 91-2049420
4,988
-
4,988
4,797,421
4,802,409
40
Greater Richmond, Virginia Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2844659
-
-
-
1,011,857
1,011,857
41
Greater Roanoke Valley Area Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 56-2619425
-
-
-
622,036
622,036
42
Hawaii Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 75-2844635
-
-
-
632,840
632,840
43
Houston Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 76-0360372
-
73
73
5,087,496
5,087,569
44
Indianapolis Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2941627
-
-
-
2,387,717
2,387,717
45
Inland Empire Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 33-0802964
-
-
-
1,218,642
1,218,642
46
Knoxville Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 75-2854955
-
-
-
989,448
989,448
47
The Las Vegas Chapter of the Susan G. Komen Breast Cancer Foundation
EIN# 88-0372386
-
-
-
1,156,850
1,156,850
48
Lexington Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 75-2854969
-
-
-
668,575
668,575
49
The Los Angeles County Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 95-4582064
5,270
4,436
9,706
1,313,086
1,322,792
50
Louisville, Kentucky Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 75-2855046
-
-
-
1,019,765
1,019,765
Page 3 of 8
Page 108
EIN: 75-2462834
2012 Form 990
Grassroots
Expenditures
Direct Lobbying
Expenditures
Total Lobbying
Expenditures
Other Exempt
Expenditures
Expenditures
51
Lowcountry Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2844655
-
-
-
1,069,410
1,069,410
52
Lubbock Area Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2509762
-
-
-
547,041
547,041
53
Madison Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 75-2855043
-
-
-
1,003,491
1,003,491
54
Maine Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN #75-2844637
-
89
89
523,282
523,371
55
Maryland Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 52-2053491
-
-
-
2,694,823
2,694,823
56
Massachusetts Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2854961
6,296
25
6,321
1,253,025
1,259,346
57
Memphis-Midsouth Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 75-2942859
-
-
-
1,159,235
1,159,235
58
Miami Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 75-2844638
4,806
25
4,831
1,956,955
1,961,786
59
Mid-Kansas Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 48-1120492
-
-
-
747,919
747,919
60
Mid-Missouri Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 56-2583638
-
-
-
277,629
277,629
61
Milwaukee Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2844639
-
-
-
2,220,830
2,220,830
62
Minnesota Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 41-1924790
-
-
-
2,568,722
2,568,722
63
Montana Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2845067
-
-
-
253,831
253,831
64
Nebraska Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 26-0056671
-
-
-
1,289,497
1,289,497
65
New Orleans Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 72-1222127
-
28
28
957,955
957,983
66
North Carolina Foothills Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 75-2875177
-
-
-
278,707
278,707
67
North Carolina Triad Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 75-2891104
-
-
-
1,082,415
1,082,415
Page 4 of 8
Page 109
EIN: 75-2462834
2012 Form 990
Grassroots
Expenditures
Direct Lobbying
Expenditures
Total Lobbying
Expenditures
Other Exempt
Expenditures
Expenditures
2,444
-
2,444
2,174,004
2,176,448
68
NC Triangle Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2845066
69
North Central Alabama Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2844656
-
-
-
1,198,144
1,198,144
70
Northeastern New York Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2854968
13
-
13
402,136
402,149
71
The Northeastern Pennsylvania Chapter of the Susan G. Komen Breast Cancer Foundation
EIN# 23-2657570
-
-
-
534,757
534,757
72
The Northeast Louisiana Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 93-1225877
2,382
-
2,382
341,313
343,695
73
The Northeast Ohio Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 34-1793460
114
3
117
1,838,247
1,838,364
74
Northern Indiana Affiliate of the Susan G. Komen Breast Cancer Foundation
EIN # 56-2583682
-
-
-
364,004
364,004
75
Northern Nevada Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 75-2855035
-
287
287
483,603
483,890
76
North Dakota Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 26-4810260
-
-
-
168,158
168,158
77
North Florida Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2844636
-
18,851
18,851
528,472
547,323
78
The North Jersey Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 22-3528454
-
-
-
1,716,274
1,716,274
79
North Mississippi Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2844621
-
-
-
292,060
292,060
80
North Texas Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2356437
-
-
-
1,440,854
1,440,854
81
Northwest Ohio Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2845063
7,701
4,243
11,944
1,428,670
1,440,614
82
The Orange County Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 33-0487943
896
3,632
4,528
3,602,392
3,606,920
83
The Oregon and Southwest Washington Affiliate of the Susan G. Komen Breast Cancer Foundation, In
EIN# 93-1068897
250
1,919
2,169
2,932,048
2,934,217
84
Ozark Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2845062
-
-
-
1,284,018
1,284,018
Page 5 of 8
Page 110
EIN: 75-2462834
2012 Form 990
Grassroots
Expenditures
Direct Lobbying
Expenditures
Total Lobbying
Expenditures
Other Exempt
Expenditures
Expenditures
-
-
-
4,506,790
4,506,790
375
-
375
2,661,504
2,661,879
85
Philadelphia Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc
EIN# 75-2949264
86
Phoenix Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2845061
87
Pittsburgh Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 81-0665396
-
1,817
1,817
2,263,838
2,265,655
88
The Peoria Memorial Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 37-1286285
-
-
-
1,596,135
1,596,135
89
The Puget Sound Chapter of the Susan G. Komen Foundation, Inc.
EIN# 91-1624040
-
-
-
3,624,474
3,624,474
90
Quad Cities Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2844660
-
-
-
495,597
495,597
91
Sacramento Valley Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 94-3169358
16,854
7,023
23,877
1,621,882
1,645,759
92
Siouxland Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 86-1102587
-
-
-
244,962
244,962
93
St. Louis Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2844650
-
-
-
3,535,966
3,535,966
94
The San Francisco Bay Area Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 94-3047626
2,282
1,523
3,805
1,017,299
1,021,104
95
Salt Lake City Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 75-2855032
-
-
-
911,431
911,431
96
The San Antonio Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 74-2856696
-
-
-
1,481,872
1,481,872
97
The San Diego Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 33-0638911
4,565
1,062
5,627
2,089,558
2,095,185
98
Shreveport Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2844653
-
-
-
467,624
467,624
99
Southeast Georgia Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 56-2583644
-
-
-
567,258
567,258
100
Southeast Iowa Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 75-2854980
-
-
-
204,808
204,808
101
Southern Arizona Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2844652
-
-
-
727,740
727,740
Page 6 of 8
Page 111
EIN: 75-2462834
2012 Form 990
Grassroots
Expenditures
Direct Lobbying
Expenditures
Total Lobbying
Expenditures
Other Exempt
Expenditures
Expenditures
102
South Dakota Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 33-1114233
-
-
-
436,696
436,696
103
The South Florida Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 65-0254225
-
256
256
1,691,060
1,691,316
104
Southwest Florida Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 68-0523074
1,452
-
1,452
1,152,212
1,153,664
105
The Southwest Michigan Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 38-3437505
-
504
504
397,281
397,785
106
Tarrant County Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2445070
41
-
41
1,835,919
1,835,960
107
Texarkana Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2844649
-
-
-
542,871
542,871
108
Tidewater Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 75-2875178
2,332
2,332
4,664
1,152,320
1,156,984
109
Tri-Cities Affiliate of the Susan G. Komen Breast Cancer Foundation
EIN # 84-1689067
-
-
-
564,055
564,055
110
Tulsa Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2854974
-
-
-
901,833
901,833
111
Tyler Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 74-2764235
-
-
-
416,834
416,834
112
Upper Cumberland Affiliate of the Susan G. Komen Breast Cancer Foundation
EIN# 20-5956855
-
-
-
241,294
241,294
113
Upstate South Carolina Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 75-2854973
-
-
-
665,931
665,931
114
Vermont-New Hampshire Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2844657
-
-
-
686,659
686,659
115
Wabash Valley Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2844615
-
-
-
240,314
240,314
116
The Western New York Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 75-2875179
-
-
-
628,412
628,412
117
West Virginia Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN # 75-2885304
-
-
-
498,669
498,669
118
Wichita Falls Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 75-2844658
-
-
-
206,080
206,080
Page 7 of 8
Page 112
EIN: 75-2462834
2012 Form 990
119
Grassroots
Expenditures
Direct Lobbying
Expenditures
Total Lobbying
Expenditures
-
-
-
567,581
567,581
83,839
56,942
140,781
151,176,923
151,317,704
-
4,053
4,053
151,155,333
151,159,386
83,839
60,995
144,834
302,332,256
302,477,090
Wyoming Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
EIN# 84-1387410
Totals - Affiliates
Susan G. Komen Breast Cancer Foundation, Inc. (Parent)
EIN# 75-1835298
Totals for Parent and Affiliates
Other Exempt
Expenditures
Expenditures
Page 8 of 8
Page 113
EIN # 75‐2462834
2012 Form 990
Susan G. Komen Breast Cancer Foundation ‐ Group
Schedule I, Part II
Street Address
F
Recipient Name
AL100 ‐ North Central Alabama Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
3201 1st Ave. South, AB 990 UAB‐Deep South Network for Cancer Contro
1530 3rd Ave. South, AB1170 UAB‐University of Alabama at Birmingham
1530 3rd Ave. South, NP2510 UAB‐University of Alabama at Birmingham
1675 University Blvd., Webb346 UAB‐University of Alabama at Birmingham
3601 CCI Drive Russell Hill Cancer
RSA Tower, 201 Monroe St Suite 1364 Alabama Dept. of Public Health
1100 Ireland Way, Suite 201 American Cancer Society
City
Birmingham
Birmingham
Birmingham
Birmingham
Huntsville
Montgomery
Birmingham
AL
AL
AL
AL
AL
AL
AL
35294‐0109
35294
35294
35294
35805
36130‐3017
35205
16‐3605396
16‐3605396
16‐3605396
16‐3605396
20‐5015568
63‐1106545
74‐1185665
501c3
501c3
501c3
501c3
501c3
501c3
501c3
54,000 Education
28,000 Education
25,000 Education
25,546 Treatment
50,000 Education
412,532 Screening
40,000 Treatment
635,078
AR100 ‐ Ozark Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
Michelle Bonds 7301 Rogers Ave
St. Edward Mercy Foundation
Michelle Bonds 7301 Rogers Ave
St. Edward Mercy Foundation
PO Box 650 Skaggs Foundation/Skaggs Regional Medica
Attn: Chanita Neal 614 E Emma Street Suit 300
Community Clinic Rogers Medical
Attn: Chanita Neal 614 E Emma Street Suit 300
Community Clinic Rogers Medical
Attn: Chanita Neal 614 E. Emma Avenue, Suite 300
Community Clinic Springdale Medical
Attn: Chanita Neal 614 E. Emma Avenue, Suite 300
Community Clinic Springdale Medical
500 Mount Olive, Suite 200 Community Clinic‐Siloam Springs
500 Mount Olive, Suite 200 Community Clinic‐Siloam Springs
Attn: Gay Prescott 5835 W Sunset Ave
Hope Cancer Resources
Attn: Gay Prescott 5835 W Sunset Ave
Hope Cancer Resources
3101 SE 14th Street Mercy Health System
East Main & S. 20th Streets Summit Medical Center Auxilliary
East Main & S. 20th Streets Summit Medical Center Auxilliary
1515 Pioneer Drive North Arkansas Partnership for Health Ed
PO Box 2406 Sparks Health System Foundation
PO Box 2406 Sparks Health System Foundation
1101 N. Woolsey Avenue Washington Regional
Dr. Merlin Leach 12825 Hwy 412
The Merlin Foundation
Donna Graham PO Box 336
Madison County Health Coalition
Fort Smith
Fort Smith
Branson
Springdale
Springdale
Springdale
Springdale
Siloam Springs
Siloam Springs
Springdale
Springdale
Bentonville
Bentonville
Bentonville
Van Buren
Van Buren
Harrison
Harrison
Harrison
Fort Smith
Fort Smith
Fayetteville
Fayetteville
Fayetteville
Fayetteville
Fayetteville
Fayetteville
Alpena
Alpena
Alpena
Huntsville
Huntsville
Huntsville
AR
AR
MO
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
72903
72903
65615‐0650
72764
72764
72764
72764
72761
72761
72762
72762
72712
72712
72712
72956
72956
72601
72601
72601
72902
72902
72703
72703
72703
72703
72703
72703
72611
72611
72611
72740
72740
72740
23‐7330425
23‐7330425
30‐0107007
31‐1553455
31‐1553455
31‐1553455
31‐1553455
31‐1553455
31‐1553455
31‐1637431
31‐1637431
39‐0816848
39‐0816848
39‐0816848
45‐0593476
45‐0593476
62‐1682626
62‐1682626
62‐1682626
71‐0236920
71‐0236920
71‐0664687
71‐0664687
71‐0664687
71‐0664687
71‐0664687
71‐0664687
71‐0747717
71‐0747717
71‐0747717
71‐0842427
71‐0842427
71‐0842427
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
15,120 Screening
8,880 Education, Treatment
20,000 Education, Screening
20,400 Treatment
20,400 Treatment
23,400 Treatment
8,800 Screening
71,200 Treatment
15,960 Education
13,020 Screening
13,020 Treatment
7,500 Education
17,500 Screening
18,270 Education
41,760 Screening
26,970 Treatment
25,900 Treatment
17,280 Education
15,360 Screening
15,360 Treatment
13,430 Education
55,300 Screening
10,270 Treatment
13,300 Education
41,300 Screening
15,400 Treatment
14,950 Education
28,600 Screening
21,450 Treatment
750,000
AR101 ‐ The Arkansas Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
9601 Interstate 630, Exit 7 Baptist Health Medical Center
9601 Interstate 630, Exit 7 Baptist Health Women's Resource Center
9601 Interstate 630, Exit 7 Baptist Health Women's Resource Center
1200 Westpark Drive, Suite 400 Encore for Women's Health
2729 Highway 65 & 82 South Greater Delta Alliance for Health
2729 Highway 65 & 82 South Greater Delta Alliance for Health
1309 West Main St. Lawrence Memorial Hospital
2 St. Vincent Circle St. Vincent Health System
623 North 9th Street Arcare
624 Hospital Drive Baxter Regional Medical Center
624 Hospital Drive Baxter Regional Medical Center
1600 West 40th St. Jefferson Regional Medical Center
1710 Harrison St. White River Health System
530 W. Atkins Blvd. Lee County Cooperative Clinic
400 East Street St. Bernards Medical Center
400 East Street St. Bernards Medical Center
P.O. Box 55011 CARTI
1300 Creason Road; P.O. Box 83 Corning Area Healthcare, Inc
1300 Creason Road; P.O. Box 83 Corning Area Healthcare, Inc
Little Rock
Little Rock
Little Rock
Little Rock
Little Rock
Little Rock
Lake Village
Lake Village
Walnut Ridge Little Rock
Augusta
Augusta
Augusta
Mountain Home
Mountain Home
Pine Bluff
Batesville
Marianna
Jonesboro
Jonesboro
Little Rock
Corning
Corning
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
AR
72205
72205
72205
72204
72204
72204
71653
71653
72476
72205
72006
72006
72006
72653
72653
71603
72501
72360
72401
72401
72215
72422
72422
23‐7169407
23‐7169407
23‐7169407
26‐2680239
26‐2680239
26‐2680239
26‐3424681
26‐3424681
37‐1080255
51‐0169537
58‐1666179
58‐1666179
58‐1666179
58‐1805265
58‐1805265
71‐0329353
71‐0411459
71‐0413798
71‐0563245
71‐0563245
71‐0589907
71‐0715998
71‐0715998
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
10,000 Screening
19,313 Treatment
46,523 Education
40,683 Screening
54,242 Treatment
16,216 Education
127,963 Screening
8,390 Screening
112,500 Treatment
10,302 Education
134,228 Screening
11,495 Treatment
5,500 Treatment
30,280 Education
269,512 Screening
66,485 Treatment
29,329 Screening
6,196 Treatment
Page 1 of 34
State
Zip
EIN #
IRS
Total Amount of
Purpose of Grant
ATTACHMENT 5
EIN # 75‐2462834
2012 Form 990
Schedule I, Part II
F
Recipient Name
Boston Mountain Rural Health Center
Quachita County Medical Center
Healthy Connections, Inc.
Healthy Connections, Inc.
CrossRidge Community Hospital
Arkansas Department of Health
BreastCare
Univ of Arkansas for Medical Sci
Univ of Arkansas for Medical Sci
Street Address
P.O. Box 1030 638 California Avenue P.O. Box 1848 P.O. Box 1848 310 South Falls Blvd. Geray Pickle 4815 West Markham, Slot 6
4815 West Markham, Slot 11 Treasurer's Office 4301 West Markham, #812
Treasurer's Office 4301 West Markham, #812
City
State
Zip
EIN #
IRS
Total Amount of
Purpose of Grant
Marshall
Camden
Mena
Mena
Wynne
Little Rock
Little Rock
Little Rock
Little Rock
AR
AR
AR
AR
AR
AR
AR
AR
AR
72650
71701
71953
71953
72396
72205
72205
72205
72205
71‐0717967
71‐0766341
71‐0807744
71‐0807744
71‐0835247
71‐0847443
71‐0847443
71‐6003252
71‐6003252
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
9,116 Screening
5,819 Education
37,004 Screening
197,500 Screening
103,097 Screening
9,364 Treatment
1,781,530
AZ100 ‐ Phoenix Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
1800 E Florence Blvd Casa Grande Regional Med Ctr Foundation
Laura Dreier Breast Center 2025 N. 3rd Street
Banner Health Foundation
Laura Dreier Breast Center 2025 N. 3rd Street
Banner Health Foundation
6741 N 7th St Asian Pacific Community in Action
P.O. Box 1390 Navajo Nation Division of Health
2833 N. Third Street Arizona's Children Assoc. ‐ Golden Gate
9100 North 2nd Street Desert Mission
9100 N 2nd Street, Suite 301 John C. Lincoln Health Network
5651 N 7th St Planned Parenthood of Central & Northern
2505 N. Central Avenue Junior League of Phoenix, Inc.
1200 W Mohave Rd La Paz Regional Hospital
6300 E Bell Rd La Casa De Cristo Lutheran Church
2702 N 3rd St,Ste 4020 Mountain Park Health Cntr.
2702 N 3rd St,Ste 4020 Mountain Park Health Cntr.
P.O. Box 3630 North Country Community Health Center
PO Box 38 Gila River Health Care Corporation
Attn: Abby Maestas 4041 N. Central Ave,Suite 700
Maricopa County Dept.of Public Health
Attn: Abby Maestas 4041 N. Central Ave,Suite 700
Maricopa County Dept.of Public Health
1090 Commerce Drive Yavapai Community Health Services
Casa Grande
Phoenix
Phoenix
Phoenix
Window Rock
Phoenix
Phoenix
Phoenix
Phoenix
Phoenix
Phoenix
Phoenix
Parker
Scottsdale
Phoenix
Phoenix
Flagstaff
Sacaton
Phoenix
Phoenix
Prescott
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
85122
85004
85004
85014‐1004
86515
85004
85020
85020
85020
85020
85014‐2500
85004
85344
85254
85004
85004
86003‐3630
85147
85012
85012
86305
31‐1726569
45‐0233470
45‐0233470
75‐3040117
86‐0092335
86‐0096772
86‐0096941
86‐0096941
86‐0096941
86‐0096941
86‐0146520
86‐0178631
86‐0260959
86‐0326047
86‐0498020
86‐0498020
86‐0663432
86‐0810876
86‐6000472
86‐6000472
86‐6000561
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
75,000 Screening
74,250 Screening
200,750 Treatment
47,135 Education
25,000 Education
44,000 Screening
24,225 Screening
50,270 Education
80,431 Screening
120,647 Treatment
21,430 Screening
7,030 Screening
49,832 Screening
12,000 Screening
75,000 Screening
150,000 Treatment
150,000 Treatment
66,870 Screening
75,000 Screening
150,000 Treatment
54,911 Screening
1,553,781
AZ101 ‐ Southern Arizona Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
140 W Speedway Blvd, Suite 100 St. Elizabeth's Health Center
2424 N. Wyatt Drive, Suite 130 Arizona Orthopaedic Research Center
2424 N. Wyatt Drive, Suite 130 Arizona Orthopaedic Research Center
7717 N Hartman Lane Breast Assured Foundation
2400 S. Ave A Foundation of Yuma Regional Medical Ctr
1636 N. Swan Rd, Suite 151 American Cancer Society
1501 N. Campbell Ave. Arizona Board of Regents, Univ.of Arizon
2100 N. Rosemont Ave., Suite 100 Tucson Medical Center
1852 N. Mastick Way Mariposa Community Health Center
P.O. Box 617 214 W Main St
Regional Center for Border Health
1205 F Avenue Chiricahua Comm Health Centers, Inc.
332 S. Freeway Pima County Health Department
332 S. Freeway Pima County Health Department
3838 N. Campbell Ave.,Room #129 U of A Foundation for Arizona Cancer Ctr
Tucson
Tucson
Tucson
Tucson
Tucson
Tucson
Yuma
Tucson
Tucson
Tucson
Nogales
Somerton
Douglas
Tucson
Tucson
Tucson
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
85705
85705
85705
85712‐6113
85712‐6113
85743
85364‐7170
85712
85724
85712‐2805
85621
85350
85607‐1920
85745
85745
85719
08‐0100880
08‐0100880
08‐0100880
20‐0301903
20‐0301903
27‐2194906
51‐0179146
74‐1185665
74‐2652689
86‐0137567
86‐0524321
86‐0561847
86‐0814898
86‐6000543
86‐6000543
86‐6050388
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
57,373 Education
57,373 Screening
59,112 Treatment
7,500 Education
14,200 Treatment
40,000 Screening
40,000 Screening
8,000 Treatment
40,000 Screening
40,000 Screening
48,530 Treatment
45,000 Education
90,000 Treatment
20,000 Screening
50,000 Treatment
44,987 Education
662,076
Santa Ana
Santa Ana
Santa Ana
Garden Grove
Santa Ana
Irvine
Irvine
Tustin
Brea
Garden Grove
Fountain Valley
Fountain Valley
Fullerton
Fullerton
Laguna Beach
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
92705
92701
92701
92841
92701
92606
92606
92782
92821
92843
92708
92708
92832
92832
92651
Los Angeles
CA
90040
14‐1911866
27‐0421556
33‐0396096
33‐0477323
33‐0562943
33‐0765783
33‐0765783
33‐0906866
33‐1143366
91‐2047245
91‐2170415
91‐2170415
95‐1687482
95‐1687482
95‐2637633
95‐2810095
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
13,365 Education
108,412 Screening
30,000 Education
107,720 Screening
67,500 Education
18,150 Education
100,000 Treatment
119,263 Screening
41,250 Education
25,000 Screening
75,000 Education
18,750 Screening
75,000 Education
25,000 Screening
80,000 Screening
150,000 Screening
CA100 ‐ The Orange County Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
1505 E. 17th Street, Suite 220 Pacific Islander Health Partnership
1206 E. 17th Street, Suite 101 Serve the People Community Health Center
850 N. Birch St. Asian American Senior Citizens Service
7761 Garden Grove Blvd. Nhan Hoa Comprehensive Health Care Clini
450 W Fourth Street Suite130
Latino Center for Prevention and Action
2691 Richter Avenue, Suite 114 Breast Cancer Solutions
2691 Richter Avenue, Suite 114 Breast Cancer Solutions
1 Hope Drive Hurtt Family Health Clinic, Inc
c/o Ernesta Wright P.O. Box 82
The G.R.E.E.N. Foundation
12900 Garden Grove Blvd., Suite 214A Orange County Asian & Pacific Islander
17150 Newhope St. Suite #502 Vietnamese American Cancer Foundation
17150 Newhope St. Suite #502 Vietnamese American Cancer Foundation
215 East Commonwealth Ave., Suite E YWCA of North Orange County
215 East Commonwealth Ave., Suite E YWCA of North Orange County
362 Third Street Laguna Beach Community Clinic
Attn: Aggie Williams, Finance Dept. 2040 Camfield Avenue
AltaMed Health Services Corporation
Page 2 of 34
ATTACHMENT 5
EIN # 75‐2462834
2012 Form 990
Schedule I, Part II
F
Recipient Name
AltaMed Health Services Corporation
Share Our Selves (SOS) Corporation
Central City Community Health Center
Planned Parenthood of Orange & SB County
Regents of UC ‐ UC Irvine Medical Center
Street Address
City
State
Zip
EIN #
95‐2810095
95‐3222316
95‐4492570
95‐6152773
Attn: Aggie Williams, Finance Dept. 2040 Camfield Avenue
Los Angeles
CA
90040
1550 Superior Avenue 5233 E. Beverly Blvd. 700 S. Tustin St. 101 The City Drive Building #23
Costa Mesa
Los Angeles
Orange
Orange
CA
CA
CA
CA
92627
90022
92866
92868
CA101 ‐ Sacramento Valley Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
2715 K Street, Suite D Clara's House
2715 K Street, Suite D Clara's House
Attn: Kimberly Parker PO Box 1810
Sierra Nevada Memorial Hospital
Attn: Kimberly Parker PO Box 1810
Sierra Nevada Memorial Hospital
7275 E. Southgate Drive, Suite 306 Hmong Women's Heritage Association
5730 Packard Ave, Suite 600 Peach Tree Healthcare
5730 Packard Ave, Suite 600 Peach Tree Healthcare
900 East Main Street, Suite 301 Sierra Nevada Community Health Plan
900 East Main Street, Suite 301 Sierra Nevada Community Health Plan
1800 N. California Street St. Joseph's Medical Center of Stockton
1800 N. California Street St. Joseph's Medical Center of Stockton
Attn: Kim Cramer 1095 Marshall Way 2nd Floor
Marshall Medical Center
1700 McHenry Village Way, #11 Center for Human Services
1700 McHenry Village Way, #11 Center for Human Services
Attn: Robin Affrime P.O. Box 1260
Communicare Health Centers
Attn: Robin Affrime P.O. Box 1260
Communicare Health Centers
11670 Atwood Road Chapa‐De Indian Health Program, Inc.
11670 Atwood Road Chapa‐De Indian Health Program, Inc.
1680 West Shaw Avenue California Health Collaborative
Barbara Clifford 25 Jan Ct., Suite 130
California Health Collaborative
Barbara Clifford 25 Jan Ct., Suite 130
California Health Collaborative
UC Davis Cancer Center 4501 X Street, Ste. 3016
University of California‐Davis
1320 Arnold Drive, Suite 170 YWCA of Contra Costa County, Sac
417 V Street The Regents of University of California
P.O. Box 221417 Healing Journeys
Sacramento
Sacramento
Grass Valley
Grass Valley
Sacramento
Marysville
Marysville
Grass Valley
Grass Valley
Stockton
Stockton
Placerville
Placerville
Placerville
Modesto
Modesto
Davis
Davis
Auburn
Auburn
Fresno
Fresno
Fresno
Chico
Chico
Sacramento
Sacramento
Sacramento
Martinez
Sacramento
Sacramento
Sacramento
Sacramento
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
95816
95816
95945
95945
95823
95901
95901
95945
95945
95204
95204
95667
95667
95667
95350
95350
95616
95616
95603‐9522
95603‐9522
93711‐3504
93711‐3504
93711‐3504
95928
95928
95817
95817
95817
94553
95818
95817
95817
95822
61‐1591265
61‐1591265
68‐0005939
68‐0005939
68‐0350323
68‐0371679
68‐0371679
68‐0482483
68‐0482483
94‐1196203
94‐1196203
94‐1450151
94‐1450151
94‐1450151
94‐1725620
94‐1725620
94‐2188574
94‐2188574
94‐2583156
94‐2583156
94‐2862660
94‐2862660
94‐2862660
94‐2862660
94‐2862660
94‐6036494
94‐6036494
94‐6036494
CA102 ‐ Central Valley Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
1616 W. Shaw Ave, C‐1 Hinds Hospice
Out Patient Physical Therapy Dept. 688 Medical Ctr Drive East, Ste 101
Clovis Comm. Medical Ctr‐Lymphedema Clin
302 Fresno Street Ste 205 West Fresno Health Care Coalition
2115 Kern Street, Suite 1 Central California Legal Services
2115 Kern Street, Suite 1 Central California Legal Services
800 S Figueroa St. #1120 Disability Rights Legal Center
Fresno
Clovis
Fresno
Fresno
Fresno
Fresno
Fresno
Fresno
Los Angeles
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA103 ‐ Inland Empire Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
536 S. 2nd Ave., Suite L Kommah Seray Inflammatory Breast
The Pink Ribbon Place 1737 Atlanta Ave. Suite H5
Inland Agency
The Pink Ribbon Place 1737 Atlanta Ave. Suite H5
Inland Agency
2101 North Waterman Avenue St. Bernardine Medical Center Foundation
815 W. Sixth Street, Suite 110 Foundation for Community & Family Hlth
25400 Alessandro Boulevard, Suite 101 Quinn Community Outreach Corporation
74091 Larrea Street Desert Cancer Foundation
P.O. Box 880969 Community Clinics Health Network
130 McCormick Ave., Suite 102 Breast Cancer Solutions
67‐625 E. Palm Canyon Drive #7A Gilda's Club Desert Cities
Attn: Kim Goodnough 27645 Jefferson Ave, #117
Michelle's Place
Attn: Kim Goodnough 27645 Jefferson Ave, #117
Michelle's Place
999 San Bernardino Road San Antonio Community Hospital
350 Terracina Blvd., P.O. Box 3080 Redlands Community Hospital
605 W. Olympic Blvd., Suite 600 SSG/PALS for Health
Covina
Riverside
Riverside
San Bernardino
Corona
Moreno Valley
Palm Desert
San Diego
Costa Mesa
Cathedral City
Temecula
Temecula
Upland
Redlands
Los Angeles
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Page 3 of 34
95-2585792
IRS
501c3
501c3
501c3
501c3
501c3
Total Amount of
Purpose of Grant
43,750 Screening
117,500 Screening
12,500 Screening
153,713 Screening
60,078 Screening
1,441,950
94‐6036497
94‐6036494
94‐6036494
77‐0379046
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
15,000 Education
35,000 Screening
58,752 Education
18,449 Screening
37,500 Education
36,500 Screening
13,500 Treatment
11,924 Education
35,771 Screening, Treatment
11,000 Education
7,500 Education
25,000 Screening
17,500 Treatment
10,000 Education
40,000 Screening
7,500 Education
68,012 Screening
35,000 Education
7,500 Education
48,840 Screening
22,500 Treatment
45,858 Screening
33,750 Treatment
20,000 Education
10,000 Screening
20,000 Treatment
75,000 Screening, Education
27,300 Education
10,000 Education
877,364
93711
93611‐6800
93706
93721
93721
93711‐3504
93711‐3504
93711‐3504
90017‐2759
77‐0071360
77‐0191730
77‐0577093
94‐1631809
94‐1631809
94‐2862660
94‐2862660
94‐2862660
95‐2960607
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
45,601 Treatment
48,041 Education
33,742 Education
11,247 Screening
7,396 Education
31,897 Screening
6,934 Treatment
47,090 Education
280,000
91723
92507
92507
92404‐4836
92882‐3289
92553
92260‐4466
92168‐0969
92626‐3316
92234‐5462
92590
92590
91786‐4992
92373‐4897
90015
20‐5968227
23‐7058717
23‐7058717
23‐7440086
33‐0071575
33‐0637525
33‐0648823
33‐0759107
33‐0765783
33‐0911108
33‐0951216
33‐0951216
95‐1183919
95‐1643347
95‐1716914
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
33,400 Treatment
28,047 Education
51,726 Treatment
25,000 Treatment
23,650 Treatment
36,998 Education
45,000 Treatment
12,500 Treatment
60,000 Treatment
14,237 Treatment
24,530 Education
45,000 Treatment
40,000 Treatment
30,622 Education
94-1156364
ATTACHMENT 5
EIN # 75‐2462834
2012 Form 990
Schedule I, Part II
F
Community Connect
Street Address
Recipient Name
2060 University Ave., Suite 212 City
State
Zip
EIN #
IRS
Total Amount of
Purpose of Grant
Riverside
CA
92507
95‐2287250
501c3
13,369 Education
554,079
CA104 ‐ The Los Angeles County Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
923 S. San Gabriel Blvd. Herald Christian Health Center
923 S. San Gabriel Blvd. Herald Christian Health Center
1050 Linden Avenue St Mary Med Ctr Found‐Fam in Good Health
1050 Linden Avenue St Mary Med Ctr Found‐Fam in Good Health
P. O. Box 3272 My Sister My Friend Breast Cancer Suppor
2200 W. Third Street, Suite 200 St. Vincent Medical Center
300 West Huntington Drive Methodist Hospital
1420 S. Central Ave Glendale Memorial Health Hospital
1420 S. Central Ave Glendale Memorial Health Hospital
8405 Beverly Blvd The Saban Free Clinic
604 Rose Ave Venice Family Clinic
604 Rose Ave Venice Family Clinic
800 S. Figueroa St., Suite 1120 Disability Rights Legal Center
23929 McBean Parkway, Suite 101 Henry Mayo Newhall Memorial Health Fndtn
23929 McBean Parkway, Suite 101 Henry Mayo Newhall Memorial Health Fndtn
San Gabriel
San Gabriel
Long Beach
Long Beach
Long Beach
Los Angeles
Arcadia
Glendale
Glendale
Los Angeles
Venice
Venice
Los Angeles
Valencia
Valencia
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
91776
91776
90813
90813
90807
90057
92834
91204
91204
90048
90291
90291
90017
91355
91355
20‐3492620
20‐3492620
23‐7153876
23‐7153876
30‐0315743
91‐2154438
95‐1643336
95‐1648194
95‐1648194
95‐2539105
95‐2769432
95‐2769432
95‐2960607
95‐3849903
95‐3849903
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
16,455 Education
24,682 Screening
11,000 Education
29,000 Screening
9,925 Education
36,329 Education
19,250 Education
8,250 Education
24,750 Screening
9,880 Education
29,639 Screening
16,000 Education
10,000 Education
30,000 Screening
295,158
CA105 ‐ The San Diego Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
Jewish Family Service of San Diego 8804 Balboa Ave
Jewish Family Service
3960 Home Avenue Mama's Kitchen
4060 Fairmount Ave La Maestra Family Clinic, Inc.
7535 Metropolitan Drive Community Clinics Health Network
7535 Metropolitan Drive Community Clinics Health Network
2691 Richter Avenue, #114 Breast Cancer Solutions
P.O. Box 420039, 5251 Viewridge Court 2‐1‐1 San Diego
Somali Family Service of San Diego 6035 University Avenue #6
Somali Family
9500 Gilman Drive #0696 The Regents of University of California
237 Church Ave. Scripps Mercy Hospital Chula Vista
1275 30th Street San Ysidro Health Center
1000 Vale Terrace Vista Community Clinic
823 Gateway Center Way Family Health Centers of San Diego
Sharp Rehabilitation Services, SCVMC Lorna McGrory
Sharp Chula Vista Medical Center
511 G Street Chula Vista Community Collaborative
3855 Health Sciences Drive #0850 Moore's UCSD Cancer Ctr,Patient & Family
San Diego
San Diego
San Diego
San Diego
San Diego
Irvine
San Diego
San Diego
La Jolla
Chula Vista
San Diego
Vista
San Diego
Chula Vista
Chula Vista
La Jolla
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
92123‐1506
92105
92104
92108
92108
92606
92123
92115
92093‐0696
91910
92154
92084
92102
91911
91910
92037‐0658
22‐2119902
33‐0434246
33‐0473171
33‐0759107
33‐0759107
33‐0765783
33‐1029843
91‐2065038
94‐6036497
95‐1684089
95‐2801772
95‐2815615
95‐2833205
95‐3492461
95‐6000613
95‐6006144
CA106 ‐ The San Francisco Bay Area Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
4271 Mission Street, 2nd Floor Latina Breast Cancer Agency
12 Grace Street, Suite 300 Breast Cancer Emergency Fund
39500 Liberty Street Tri‐City Health Center
39500 Liberty Street Tri‐City Health Center
1511 S. Claremont Street Samaritan House
1511 S. Claremont Street Samaritan House
2450 Ashby Ave. Alta Bates Summit Foundation
2601 Mission Street, Suite 702 Circulo de Vida Cancer Support & Resourc
2601 Mission Street, Suite 702 Circulo de Vida Cancer Support & Resourc
1650 S. Amphlett Blvd., Ste. 105 Taulama for Tongans
1650 S. Amphlett Blvd., Ste. 105 Taulama for Tongans
2055 Sunnydale Ave. Samoan Community Development Center
P O Box 245 Asociacion Hispana del Cancer
P O Box 245 Asociacion Hispana del Cancer
PO Box 22210 La Clinica de la Raza, lead agency: Lati
PO Box 22210 La Clinica de la Raza, lead agency: Lati
240 Shotwell Street Mission Neighborhood Health Center
240 Shotwell Street Mission Neighborhood Health Center
730 Polk Street, Floor 3 Shanti Project Inc.
1333 Meridian Avenue Indian Health Cntr of Santa Clara Valley
1748 Market Street, #201 Lyon‐Martin Health Services
1748 Market Street, #201 Lyon‐Martin Health Services
710 Fourth Street Marin Center for Independent Living
710 Fourth Street Marin Center for Independent Living
222 West 39th Ave. San Mateo County Health Foundation
5741 Telegraph Avenue Women's Cancer Resource Center
San Francisco
San Francisco
Fremont
Fremont
San Mateo
San Mateo
Berkeley
Berkeley
Berkeley
San Francisco
San Francisco
San Mateo
San Mateo
San Francisco
Walnut Creek
Walnut Creek
Oakland
Oakland
San Francisco
San Francisco
San Francisco
San Jose
San Francisco
San Francisco
San Rafael
San Rafael
San Mateo
San Mateo
San Mateo
Oakland
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
94112
94103
94538
94538
94402
94402
94705
94705
94705
94110
94110
94402
94402
94134
94597‐0245
94597‐0245
94623
94623
94110
94110
94109
95125
94102
94102
94901
94901
94403
94403
94403
94609
01‐0628124
20‐3203899
23‐7255435
23‐7255435
23‐7416272
23‐7416272
51‐0160184
51‐0160184
51‐0160184
51‐0471693
51‐0471693
68‐0488293
68‐0488293
77‐0290646
84‐1690144
84‐1690144
94‐1744108
94‐1744108
94‐2284365
94‐2284365
94‐2297147
94‐2476242
94‐2597707
94‐2597707
94‐2605669
94‐2605669
94‐3116070
94‐3116070
94‐3116070
94‐3131204
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
Page 4 of 34
50,000 Education
50,000 Treatment
89,561 Education
325,850 Screening
80,150 Treatment
125,000 Education
50,000 Education
39,100 Education
50,000 Education
40,000 Education
90,000 Education
40,000 Education
100,000 Education
69,010 Education
40,000 Education
40,000 Education
1,278,671
27,000 Education, Treatment, Screening
275,000 Treatment
19,531 Education
5,695 Education
8,542 Screening
8,261 Education
41,305 Screening
5,507 Treatment
7,200 Education
10,800 Treatment
36,800 Education
9,200 Screening
27,607 Education
20,698 Education
13,799 Treatment
8,515 Education
32,033 Screening
11,690 Treatment
8,969 Education
70,405 Screening
22,500 Education
22,500 Treatment
26,496 Education
26,496 Screening
13,248 Treatment
13,500 Education
ATTACHMENT 5
EIN # 75‐2462834
2012 Form 990
Schedule I, Part II
F
Recipient Name
Women's Cancer Resource Center
Women's Cancer Resource Center
Street Address
City
State
Zip
EIN #
IRS
Total Amount of
Purpose of Grant
Oakland
Oakland
Larkspur
East Palo Alto
East Palo Alto
CA
CA
CA
CA
CA
94609
94609
94939
94303
94303
94‐3131204
94‐3131204
94‐2890791
94‐3372130
94‐3372130
501c3
501c3
501c3
501c3
501c3
13,500 Screening
18,000 Treatment
8,000 Treatment
10,000 Education
15,000 Treatment
957,236
CO100 ‐ The Aspen Chapter of the Susan G. Komen Breast Cancer Foundation
PO Box 11799 Pathfinders for Cancer
7155 E 38th Ave Planned Parenthood of the Rocky
Attn: Tazi Lutgring 0405 Castle Creek Rd. #6
Community Health Services
Attn:Debby Essex 0401 Castle Creek Road
Aspen Valley Hospital
PO Box 1529 Eagle Care Medical
1905 Blake Ave., Suite 101 Mountain Family Health
Attn: Saundra Swanson PO Box 1845
Family Visitor
4300 Cherry Creek Drive South CO Dept. of Public Health & Environment
Aspen
Denver
Aspen
Aspen
Vail
Glenwood Springs
Glenwood Springs
Denver
CO
CO
CO
CO
CO
CO
CO
CO
81612
80207
81611
81611
81658
81601
81602
80246
20‐1710899
84‐0404253
84‐0609057
84‐0643721
84‐0742145
84‐0742145
84‐1001484
84‐0644739
45,000 Education
37,615 Screening
51,543 Screening
47,645 Screening
52,847 Screening
58,535 Screening
10,000 Education
21,405 Screening
324,590
CO101 ‐ Colorado Springs Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
722 S. Wahsatch Ave. Peak Vista Community Health Ctrs
722 S. Wahsatch Ave. Peak Vista Community Health Ctrs
1008 Minnequa Avenue St Mary‐Corwin Health Foundation
Attn: Bernadete Lujan 110 E Routt Ave
Pueblo Community Health Center
Attn: Bernadete Lujan 110 E Routt Ave
Pueblo Community Health Center
1385 S Colorado Blvd, Ste A‐302 Sense of Security
11115 W Highway 24, Unit 2C Teller County Public Health
Colorado Springs
Colorado Springs
Pueblo
Pueblo
Pueblo
Pueblo
Pueblo
Denver
Divide
CO
CO
CO
CO
CO
CO
CO
CO
CO
80903
80903
81004
81004
81004
81004
81004
80222
80814
84‐0617567
84‐0617567
84‐0902211
84‐0902211
84‐0902211
84‐0921521
84‐0921521
84‐1539558
84‐6000809
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
CO102 ‐ The Denver Metropolitan Affiliate of Susan G. Komen Breast Cancer Foundation
1835 Franklin St St. Joseph Hospital Foundation
1835 Franklin St St. Joseph Hospital Foundation
2315 E Harmony Rd Ste 200
Poudre Valley Health System Foundation
1805 E 18th St Ste 9 McKee Medical Center Foundation
P.O. Box 9047 4715 Arapahoe Ave.
Boulder Community Hospital
7155 E 38th Ave Planned Parenthood
4300 Cherry Creek Drive South Colo Dept of Public Health & Environment
424 Pine Street, Suite 201 Women's Resource Center
3081 Bergen Peak Drive Mount Evans Hospice, Inc.
4231 W. 16th Ave St. Anthony Health Foundation
600 Grant Street, Suite 800 Colorado Community Health Network
2111 Champa St. Colorado Coalition for the Homeless
655 Broadway MC 1925 Denver Health Foundation
P.O. Box 1600 525 Hathaway
Rocky Mountain Rural Health
and The Environment 9457 S. University Blvd., #513
Colorado Foundation for Public Health
P.O. Box 95 Grand County Rural Health Network, Inc.
P.O. Box 9039 The Raymond Wentz Foundation
1000 W. 8th Avenue Yuma District Hospital
Denver
Denver
Ft. Collins
Loveland
Boulder
Denver
Denver
Fort Collins
Evergreen
Denver
Denver
Denver
Denver
Denver
Denver
Fairplay
Highlands Ranch
Hot Sulpher Springs
Denver
Yuma
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
80218
80218
80528
80538
80303
80207
80246
80524‐2421
80439
80204
80203
80205
80203
80203
80203
80440
80126
80451
80209
80759
53‐0196617
53‐0196617
74‐1894581
74‐2182919
84‐0175870
84‐0404253
84‐0644739
84‐0732631
84‐0831843
84‐0902211
84‐0910590
84‐0951575
84‐1085196
84‐1085196
84‐1085196
84‐1106335
84‐1267213
84‐1587575
27‐0029283
84‐1149702
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
CT100 ‐ Connecticut Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
20 York Street, MCS Yale‐New Haven Hospital
80 Seymour Street, P. O. Box 5037 Hartford Hospital
1598 East Main Street Charlotte Hungerford Hospital
1598 East Main Street Charlotte Hungerford Hospital
540 Saybrook Road, Suite 280 Middlesex Hospital
540 Saybrook Road, Suite 280 Middlesex Hospital
Development Office 100 Grand Street
Hospital of Central Connecticut
Development Office 100 Grand Street
Hospital of Central Connecticut
95 Woodland Street Saint Francis Hospital & Medical Center
30 Shelburne Road P.O. Box 9317
Stamford Hospital
130 Division Street Griffin Hospital
1450 Chapel Street Hospital of St. Raphael
1450 Chapel Street Hospital of St. Raphael
Attn: Katherine Sullivan 21 Elm Street
New Milford Hospital
400 Columbus Ave Cornell Hill Scott
400 Columbus Ave Cornell Hill Scott
374 Grand Avenue Fair Haven Community Health Center
374 Grand Avenue Fair Haven Community Health Center
New Haven
Hartford
Torrington
Torrington
Middletown
Middletown
New Britain
New Britain
Hartford
Stamford
Derby
New Haven
New Haven
New Milford
New Haven
New Haven
New Haven
New Haven
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
06504‐0000
06102‐5037
06790‐0000
06790‐0000
06457‐0000
06457‐0000
06050
06050
06105
06904
06418‐0000
06511‐0000
06511‐0000
06776‐3029
06519
06519
06513‐0000
06513‐0000
06‐0646652
06‐0646668
06‐0646678
06‐0646678
06‐0646718
06‐0646718
06‐0646768
06‐0646768
06‐0646813
06‐0646917
06‐0647014
06‐0653171
06‐0653171
06‐0669121
06‐0870990
06‐0870990
06‐0883545
06‐0883545
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
Hospice By The Bay
Ravenswood Family Health Center
Ravenswood Family Health Center
5741 Telegraph Avenue 5741 Telegraph Avenue 17E Sir Frances Drake Blvd
South County Community Health Center 1798A Bay Road
South County Community Health Center 1798A Bay Road
Page 5 of 34
25,957 Education
59,500 Treatment
15,125 Education
31,315 Screening
13,980 Treatment
23,925 Education
35,887 Screening
34,000 Treatment
274,715
473,805 Screening
378,000 Treatment
104,393 Treatment
75,000 Treatment
20,566 Treatment
115,290 Screening
586,781 Screening
57,611 Education
32,000 Treatment
84,125 Treatment
252,994 Screening
41,842 Screening
8,150 Education
33,304 Screening
166,464 Treatment
17,901 Screening
55,728 Education
77,593 Treatment
32,372 Treatment
2,623,417
50,000 Education
50,000 Screening
25,000 Education
25,000 Screening
25,000 Education
25,000 Screening
25,000 Education
25,000 Screening
50,000 Education
50,000 Screening
50,000 Education
25,000 Education
25,000 Screening
50,000 Screening
25,000 Education
25,000 Screening
25,000 Education
25,000 Screening
ATTACHMENT 5
EIN # 75‐2462834
2012 Form 990
Schedule I, Part II
F
Recipient Name
Hispanic Health Council Center of Grtr D
Norwalk Smilow
Nat'l Assoc. for the Advncmnt of Colored
Cancer Care of Connecticut
University of Connecticut Health Center
University of Connecticut Health Center
Community Health Center
St Vincent Medical Center
Street Address
175 Main Street 34 Maple Street 262 Main Street 535 Connecticut Avenue, Suite 104 Attn: David Larkin 263 Farmington Avenue
Attn: David Larkin 263 Farmington Avenue
2823 N Austrailian Avenue Attn: Tazi Lutgring 0405 Castle Creek Rd. #6
Attn: Tazi Lutgring 0405 Castle Creek Rd. #6
2131 W. Third St City
State
Zip
EIN #
IRS
Total Amount of
Purpose of Grant
Hartford
Norwalk
Norwich
Norwalk
Farmington
Farmington
West Palm Beach
Aspen
Aspen
Los Angeles
CT
CT
CT
CT
CT
CT
FL
CO
CO
CA
06106
06856
06360
06854
06030‐5335
06030‐5335
33407
81611
81611
90057
06‐1056978
06‐6068853
06‐6099300
13‐1825919
23‐7187838
23‐7187838
26‐3611337
84‐0609057
84‐0609057
91‐2154438
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
FL100 ‐ Southwest Florida Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
PO Box 1115 Lymphedema Resources, Inc.
PO Box 1115 Lymphedema Resources, Inc.
12478 Green Stone Ct L.I.G.H.T.
990 First Avenue South, Suite 200 Cancer Alliance of Naples
990 First Avenue South, Suite 200 Cancer Alliance of Naples
8931 Colonial Center Drive, Suite 200 REGIONAL CANCER CENTER
8931 Colonial Center Drive, Suite 200 REGIONAL CANCER CENTER
2350 Scenic Drive Senior Friendship Centers
Po Box 1357 (2232 Grand Ave ) Family Health Centers of SW Florida
1454 West Madison Ave Collier Health Services, Inc.
350 7th Street NCH Healthcare System
120 Goodlette Rd N Neighborhood Health Clinic
120 Goodlette Rd N Neighborhood Health Clinic
9470 HealthPark Circle Partners For Breast Care
9470 HealthPark Circle Partners For Breast Care
21297 Olean Blvd Unit B Virginia B Andes
21297 Olean Blvd Unit B Virginia B Andes
Estero
Estero
Ft Myers
Naples
Naples
Fort Myers
Fort Myers
Venice
Fort Myers
Fort Myers
Fort Myers
Immokalee
Immokalee
Immokalee
Naples
Naples
Naples
Naples
Naples
Fort Myers
Fort Myers
Port Charlotte
Port Charlotte
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
33928
33928
33913‐6737
34102
34102
33905‐7809
33905‐7809
33952
33902
33902
33902
34142‐1454
34142‐1454
34142‐1454
34102
34102
34102
34102
34102
33908
33908
33952
33952
20‐2246162
20‐2246162
20‐8860104
22‐3879709
22‐3879709
25‐1385075
25‐1385075
59‐1522614
59‐1741273
59‐1741273
59‐1741273
59‐1741277
59‐1741277
59‐1741277
59‐2314655
59‐2314655
59‐2314655
59‐3546884
59‐3546884
65‐0290568
65‐0290568
65‐0958642
65‐0958642
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
8,762 Education
31,064 Treatment
10,728 Treatment
10,271 Education
30,813 Treatment
35,750 Screening
107,250 Treatment
18,042 Education
71,108 Screening
16,981 Treatment
5,352 Education
43,408 Screening
10,703 Treatment
5,488 Education
21,954 Screening
27,442 Treatment
26,389 Screening
33,585 Treatment
111,642 Screening
26,188 Treatment
30,263 Education
101,314 Screening
797,358
FL101 ‐ Central Florida Affiliate of the of the Susan G. Komen Breast Cancer Foundation, Inc.
1718 S Orange Ave Libby's Legacy Breast Cancer Foundation
PO Box 952283 Ribbon Riders, Inc.
Attn: Warren Hougland 700 Generation Point
Osceola Council on Aging, Inc.
Attn: Catherine McQuade 303 N. Clyde Morris Blvd.
Halifax Medical Center
2300 Kurt St Florida Hospital ‐ Waterman Community
232 N. Orange Blossom Trail Health Care Center for the Homeless
1900 Don Wickham Drive South Lake Hospital
2575 N. Courtenay Pkwy Brevard County Health Department
400 West Airport Blvd Seminole County Health Department
Orlando
Orlando
Orlando
Lake Mary
Kissimmee
Daytona Beach
Eustis
Orlando
Clermont
Merritt Island
Merritt Island
Merritt Island
Sanford
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
32806
32806
32806
32795
34744
32114
32726
32805
34711
32953
32953
32953
32773
11‐3812766
11‐3812766
11‐3812766
26‐2717017
59‐1595398
59‐2893051
59‐3140669
59‐3185020
59‐3322533
59‐3502843
59‐3502843
59‐3502843
59‐3502843
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
12,949 Screening
37,500 Screening
50,000 Treatment
50,000 Screening
50,000 Screening
19,000 Screening
50,000 Screening
20,000 Education
20,000 Screening
10,000 Treatment
410,639
FL102 ‐ North Florida Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
5644 Colcord Avenue Women's Center of Jacksonville
41 E Duval Street Volunteers in Medicine
480 W Lowder St. Baker County Health Department
Hill Breast Center 1235 San Marco Boulevard #419
Baptist Medical Center
479 Houston Street Way Free Clinic
c/o St. Vincents Medical Center Attn: Elaine Murtha
ST VINCENT HEALTH CENTER
Jacksonville
Jacksonville
MacClenny
Jacksonville
Green Cove Springs
Jacksonville
FL
FL
FL
FL
FL
FL
32211
32202‐3201
32063‐2664
32207
32043‐2411
32204
23‐7437216
57‐0959206
59‐3502843
59‐3614273
72‐0828154
26‐0479484
501c3
501c3
501c3
501c3
501c3
501c3
20,000 Education
20,000 Screening
29,900 Screening
20,000 Screening
20,000 Screening
129,900
FL103 ‐ Miami Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
7800 SW 57th Avenue Suite 300
Lymphedema Foundation
P.O. Box 382035 The Beautiful Gate Inc.
P.O. Box 565371 Sandy B. Muller Breast Cancer Foundation
7241 SW 63 AVE Suite 102 Well Come Center
7200 SW 108 Terrace Save Our Sisters DBT
8484 SW 42 Ct. Arrow, Inc.
6200 SW 72 Avenue, Suite 302 Baptist Health
6200 SW 72 Avenue #302 Baptist Outpatient Services, Inc.
Miami
Miami
Miami
South Miami
Pinecrest
Davie
South Miami
South Miami
FL
FL
FL
FL
FL
FL
FL
FL
33143
33150‐3064
33256‐5371
33143
33156
33328
33143
33143
11‐3828375
20‐4260216
26‐2346144
26‐5461984
37‐1571296
56‐2290370
56‐2290370
56‐2290370
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
Page 6 of 34
50,000 Education
50,000 Screening
50,000 Education
50,000 Education
25,000 Education
25,000 Screening
50,000 Education
25,000 Education
25,000 Screening
50,000 Screening
1,000,000
35,000 Treatment
10,000 Education
10,000 Treatment
12,000 Treatment
7,000 Treatment
9,965 Education
26,250 Screening
ATTACHMENT 5
EIN # 75‐2462834
2012 Form 990
Schedule I, Part II
F
Recipient Name
Women's Breast Health Initiative, Florid
Broward County Health Department
YWCA of Greater Miami‐Dade
YWCA of Greater Miami‐Dade
University of Miami
University of Miami
Holy Cross Hospital
La Liga Contra el Cancer
Public Health Trust of Miami‐Dade County
Memorial Foundation For Cancer Institute
Memorial Foundation For Cancer Institute
Broward Public Library Foundation
North Broward Hospital District
Miami‐Dade Area Health Educ Ctr AHEC
Florida Keys Area Health Education Ctr.
Florida Keys Area Health Education Ctr.
FANM Ayisyen Nan Miyami, Inc.
Saint John Bosco Clinic
Gilda's Club ‐ South Florida
Human Services Coalition
Cancer Support Community Greater Miami
Cancer Support Community Greater Miami
Womankind, Inc.
Project Access Foundation, Inc.
Community Life Support
Community Life Support
Open Door Health Center
Open Door Health Center
Street Address
2000 Ponce de Leon Blvd., suite 1300 780 SW 24th Street 351 NW 5th Street 351 NW 5th Street 1400 NW 10th Avenue, Room 1007 1400 NW 10th Avenue, Room 1007 4725 North Federal Hwy 2180 SW 12th Avenue 1500 NW 12 Ave (Genetics) 3711 Garfield St (Genetics) 3711 Garfield St 100 S. Andrews Avenue 303 SE 17th Street #309 1200 N.W. 78 Avenue, Suite 209 5800 Overseas Hwy #38 5800 Overseas Hwy #38 181 NE 82 Street 3661 S. Miami Ave #103 119 Rose Drive 1900 Biscayne Blvd. 8609 S. Dixie Highway 8609 S. Dixie Highway 1511 Truman Avenue 11865 SW 26th Street Unit G‐10
490 Fisherman Street 490 Fisherman Street 1350 SW 4th Street 1350 SW 4th Street City
State
Zip
EIN #
IRS
Total Amount of
Purpose of Grant
Coral Gables
Ft. Lauderdale
Miami
Miami
Miami
Miami
Fort Lauderdale
Miami
Miami
Hollywood
Hollywood
Ft. Lauderdale
Ft. Lauderdale
Miami
Marathon
Marathon
Miami
Miami
Fort Lauderdale
Miami
Miami
Miami
Key West
Miami
Opa Locka
Opa Locka
Homestead
Homestead
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
33134
33315
33128
33128
33136
33136
33308
33129
33136
33021
33021
33301
33316
33126
33050
33050
33138
33133
33316
33132
33143
33143
33040
33175
33054
33054
33030
33030
56‐2540735
59‐0502843
59‐0624450
59‐0624450
59‐0624458
59‐0624458
59‐0791028
59‐1629554
59‐1713947
59‐2082218
59‐2082218
59‐2224746
59‐6012065
65‐0009277
65‐0183810
65‐0183810
65‐0334201
65‐0435764
65‐0528626
65‐0690368
65‐0930551
65‐0930551
65‐1003208
65‐1073105
65‐1128302
65‐1128302
83‐0375996
83‐0375996
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
16,650 Education
28,350 Screening
45,000 Screening
37,500 Treatment
45,000 Treatment
77,125 Screening
26,250 Screening
150,000 Screening
10,000 Education
80,000 Screening
43,645 Education
11,670 Education
7,780 Screening
10,000 Education
24,918 Education
16,000 Education
15,795 Education
30,662 Treatment
31,000 Education, Screening, Treatment
12,000 Education
18,000 Screening
20,000 Education
20,000 Screening
1,102,508
FL104 ‐ Florida Suncoast Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
Project Reach ‐ St Joseph's Women's 3030 W Dr MLK, Jr., Blvd #3201
St Joseph's Women's Hospital
Mammography Voucher Program 205 Dr. Martin Luther King Jr. Street N.
Morton Plant Mease Health Care
37240 Lock Street Farmworkers Self‐Help, Inc.
12902 Magnolia Drive H Lee Moffitt Cancer Center
2201 Cantu Court, Suite 220 Gulfcoast South Area Health Educ. Cntr.
10841 Little Road Pasco County Health Dept
6950 Outreach Way Sarasota County Health Dept.
5110 S. Florida Ave. #111 We Care of Polk County
300 Riverside Drive East, Ste 2000 We Care of Manatee
1700 S. Tamiami Trail Sarasota Memorial Health Care System
Tampa
St. Petersburg
Dade City
Tampa
Sarasota
New Port Richey
North Port
Lakeland
Bradenton
Sarasota
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
33607
33701
33523
33612
34232
34654
34287
33813
34208
34939
16‐0743163
59‐2374556
59‐2382744
59‐3238636
59‐3342312
59‐3502843
65‐0945355
59‐3529279
59‐3606103
59‐6012500
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
154,937 Screening
195,373 Screening
51,000 Education
160,057 Screening
31,164 Education
160,000 Screening
25,027 Screening
199,110 Screening
200,000 Screening
263,152 Screening
1,439,820
FL105 ‐ The South Florida Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
112 SE 23rd Avenue Marie Louis Cancer Foundation
PO Box 209 Pink Tie Friends
Attn: Jacqueline Clark P.O. Box 1696, 15161 SW 169th
Indiantown Community Outreach
Attn: Jacqueline Clark P.O. Box 1696, 15161 SW 169th
Indiantown Community Outreach
39200 Hooker Hwy Lakeside Medical Center
417 SE Balboa Avenue Volunteers in Medicine
2396 S.E. Ocean Blvd Martin Memorial Cancer Center
P.O. Box 9010 Martin Memorial Cancer Center
690 Meadows Way Boca Raton Community Hospital
Attn: Maria Kulp 2300 N. Florida Mango Road
Planned Parenthood of South Florida
1240 S Old Dixie Hwy Jupiter Medical Center
4450 S. Tiffany Drive Florida Community Health Centers (RIA)
4450 S. Tiffany Drive Florida Community Health Centers (RIA)
1411 North Flagler Drive, Ste 8900‐B Palm Beach Cancer Intstitute Foundation
10301 Hagen Ranch Road, Suite 920A Bethesda Women's Health Center
PO Box 29 West Palm Beach Co. Health Dept.
8645 W Boynton Beach Blvd. Caridad Center, Inc.
Attn: Maryanne Bohartritz, Executive Dir. 621 Clearwater Park Road
H.O.P.E. Project
P.O. Box 12397, 777 North 7th Street In The Image of Christ, Inc.
430 SE Osceola Street Molly's House, Inc.
Boynton Beach
Stuart
Indiantown
Indiantown
Belle Glades
Stuart
Stuart
Stuart
Stuart
Stuart
Boca Raton
Boca Raton
Boca Raton
West Palm Beach
Jupiter
West Palm Beach
West Palm Beach
West Palm Beach
Boynton Beach
Boynton Beach
Boynton Beach
West Palm Beach
Boynton Beach
West Palm Beach
Fort Pierce
Stuart
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
FL
33435
34995
34956
34956
33430
34994
34996
34996
34996
34995
33486
33486
33486
33409
33458
33407
33407
33401
33437
33437
33437
33402‐0029
33472
33401
34979‐2397
34007
20‐5248662
27‐0122917
30‐0033778
30‐0033778
35‐2226306
57‐0959206
59‐0637874
59‐0637874
59‐0637874
59‐0637874
59‐1006663
59‐1006663
59‐1006663
59‐1391115
59‐1460239
59‐1671640
59‐1671640
59‐2541781
59‐2771779
59‐2771779
59‐2771779
59‐3502843
65‐0149423
65‐0859412
65‐1104332
65‐0407242
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
Page 7 of 34
13,550 Education
102,566 Treatment
44,764 Education
17,042 Screening
25,200 Screening
15,375 Education
53,628 Screening
96,004 Treatment
40,810 Education
59,008 Education
119,537 Screening
43,306 Treatment
20,000 Education
5,563 Education
60,519 Screening
66,710 Education
261,226 Screening
46,647 Treatment
38,799 Education
32,330 Screening
24,562 Education
5,400 Education
ATTACHMENT 5
EIN # 75‐2462834
2012 Form 990
Schedule I, Part II
F
Recipient Name
Cancer Alliance of Help & Hope
Cancer Alliance of Help & Hope
Street Address
15 Shady Lane 15 Shady Lane City
State
Zip
EIN #
IRS
Total Amount of
Purpose of Grant
Tequesta
Tequesta
FL
FL
33469
33469
90‐0101236
90‐0101236
501c3
501c3
7,625 Education
24,705 Education
1,339,990
GA100 ‐ The Greater Atlanta Affiliate of the Susan G. Komen Brea 2675 N. Decatur Rd, Suite 312 DeKalb Medical Foundation
6066 Leesburg Pike, Ste. 100 Boat People, SOS
11180 State Bridge Rd, Ste 503 TurningPoint Women's Healthcare
Piedmont Hospital Attn: Robert DiVito
Piedmont Hospital
151 Spring Street, NW Atlanta Legal Aid Society,Inc.
957 N. Highland Ave NE YWCA of Greater Atlanta
P.O. Box 897 East Metro Health District
1117 Battle Creek Road Clayton County Board of Health
868 York Ave SW West End Medical Centers, Inc.
3510 Shallowford Rd NE Center for Pan Asian Community Service
Cobb Public Health 1650 County Services Pkwy
Cobb and Douglas County Boards of Health
2000 South Park Place, Suite 202 WellStar Foundation
Northside Hospital ‐ Dale Israel 1000 Johnson Ferry Road NE
Northside Hospital Foundation
424 Decatur St, SE Saint Joseph's Mercy Care Services, Inc.
7823 Spivey Station Blvd, Ste 250 Southern Regional Medical Center
191 Peachtree Street,Suite 820 Henry W. Grady Foundation
634 McDonough Blvd SE Family Health Enterprise
477 Windsor St, SW, Suite 309 Center for Black Womens Wellness, Inc.
Attn: Erin Parker 1015 Donald Lee Hollowell Parkway, NW
Good Samaritan Health Center
137 Mitchell Street Fulton County Dept. of Health & Wellness
Decatur
Falls Church
Alpharetta
Atlanta
Atlanta
Atlanta
Lawrenceville
Jonesboro
Atlanta
Atlanta
Marietta
Atlanta
Atlanta
Atlanta
Jonesboro
Atlanta
Atlanta
Atlanta
Atlanta
Atlanta
GA
GA
GA
GA
GA
GA
GA
GA
GA
GA
GA
GA
GA
GA
GA
GA
GA
GA
GA
GA
30033
22041
30022
30309
30303
30306
30046
30236‐2407
30310
30341
30008
30339
30342‐1611
30312‐1848
30236
30303
30315
30312
30318
30313
53‐1924605
54‐1563619
56‐2318721
58‐0566213
58‐0568691
58‐0593442
58‐0964522
58‐1108112
58‐1233448
58‐1437980
58‐1517015
58‐1627413
58‐1653541
58‐1752700
58‐1983516
58‐2130437
58‐2155835
58‐2212203
58‐2373395
58‐6001729
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
150,000 Screening
50,000 Education
50,000 Treatment
216,007 Screening
50,000 Education
50,000 Education
150,000 Screening
127,211 Screening
150,000 Screening
74,648 Screening
75,000 Screening
27,000 Screening
189,627 Screening
94,135 Screening
148,135 Screening
150,000 Screening
150,000 Screening
75,547 Screening
149,138 Screening
74,398 Screening
2,200,846
GA101 ‐ Central Georgia Affiliate of the Susan G. Komen Breast Cancer Foundation
c/o Beth Jones 233 North Houston Road Ste 140‐D
Houston Healthcare
c/o Beth Jones 233 North Houston Road Ste 140‐D
Houston Healthcare
Katherine McLeod P.O. Box 4363
First Choice Primary
1014 Forsyth St., MSC #166 Central Georgia Breast Care Center w/Med
Cancer Well‐Fit 3797 Northside Dr.
The Medical Ctr of Central GA‐Cancer Wel
c/o Cile Lind 376 Rogers Ave.
Macon Volunteer Clinic1
Warner Robins
Warner Robins
Macon
Macon
Macon
Macon
GA
GA
GA
GA
GA
GA
31093
31093
31208
31201
31210
31204
07‐6991628
07‐6991628
20‐4391090
23‐7363555
58‐2149128
74‐3055376
501c3
501c3
501c3
501c3
501c3
501c3
9,500 Education
25,500 Screening
40,000 Education. Screening
137,500
GA102 ‐ Southeast Georgia Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
4700 Waters Ave. Memorial Health Univ. Medical Ctr Inc.
4700 Waters Ave. Memorial Health Univ. Medical Ctr Inc.
5353 Reynolds Street St. Joseph's / Candler Hospital
310 Eisenhower Drive Bldg 5 Community Health Mission
310 Eisenhower Drive Bldg 5 Community Health Mission
2500 Starling Street, Suite 202 Southeast Georgia Health System‐Brunswic
P O Box 231 Liberty County Health Department
P O Box 231 Liberty County Health Department
106 E. Broad Street Curtis V. Cooper Primary Health Care
127 North College Street Hearts and Hands Clinic
Savannah
Savannah
Savannah
Savannah
Savannah
Brunswick
Hinesville
Hinesville
Savannah
Statesboro
GA
GA
GA
GA
GA
GA
GA
GA
GA
GA
31404
31404
31405
31406
31406
31520
31313
31313
31402
30458
31‐1126469
31‐1126469
58‐1553254
58‐2611264
58‐2611264
58‐6000498
58‐6001384
58‐6001384
58‐1136296
26‐4597700
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
19,900 Education
59,920 Screening
45,000 Screening
31,669 Education
10,556 Screening
7,688 Education
23,063 Screening
30,000 Screening
289,795
HI100 ‐ Hawaii Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
95 Mahalani St, Ste 8 Pacific Cancer Center Foundation
P.O. Box 395 56‐565 Kam Hwy
Koolauloa Comm Health & Wellness Center
P.O. Box 395 56‐565 Kam Hwy
Koolauloa Comm Health & Wellness Center
1301 Punchbowl Street Queen's Medical Center, Cancer Center
45‐549 Plumeria Hamakua Health Center
45‐549 Plumeria Hamakua Health Center
2239 North School Street Kokua Kalihi Valley Comprehensive Family
277 Ohua Ave. Waikiki Health Center
277 Ohua Ave. Waikiki Health Center
915 North King Street Kalihi‐Palama Health Ctr Breast Screenin
224 Haili Street, Bldg. B Bay Clinic, Inc.
PO Box 408280 Home Olu Place Molokai General Hosp., Rural Health Clin
41‐1347 Kalanianaole Hwy Waimanalo Health Center
41‐1347 Kalanianaole Hwy Waimanalo Health Center
894 Queen Street Papa Ola Lokahi
69A Railroad Avenue Hui Malama Ola Na Oiwi
69A Railroad Avenue Hui Malama Ola Na Oiwi
Wailuku
Kahuku
Kahuku
Honolulu
Honolulu
Honolulu
Honokaa
Honokaa
Honolulu
Honolulu
Honolulu
Honolulu
Hilo
Kaunakakai
Waimanalo
Waimanalo
Honolulu
Hilo
Hilo
HI
HI
HI
HI
HI
HI
HI
HI
HI
HI
HI
HI
HI
HI
HI
HI
HI
HI
HI
96793
96731
96731
96813
96813
96813
96727
96727
96819
96815
96815
96817
96771
96748
96795
96795
96813
96720
96720
51‐0548338
73‐1681833
73‐1681833
99‐0073524
99‐0073524
99‐0073524
99‐0115515
99‐0115515
99‐0149797
99‐0159253
99‐0159253
99‐0161221
99‐0222784
99‐0251372
99‐0273205
99‐0273205
99‐0273735
99‐0286468
99‐0286468
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
10,274 Education
9,110 Screening
44,100 Education
12,475 Screening
41,100 Treatment
5,500 Education
19,500 Screening
25,000 Education
7,500 Education
17,500 Screening
13,500 Education
11,500 Screening
24,750 Education
10,000 Treatment
351,809
IA100 ‐ Quad Cities Affiliate of the Susan G. Komen Breast Cancer 1227 East Rusholme St Attn: Stef Dreher
Genesis Medical Center
Davenport
IA
52803
42‐1418847
501c3
222,000 Screening
Page 8 of 34
ATTACHMENT 5
EIN # 75‐2462834
2012 Form 990
Schedule I, Part II
F
Recipient Name
Louisa County Public Health
Louisa County Public Health
Street Address
805 J.L. Hodges Ave N. 805 J.L. Hodges Ave N. City
State
Zip
EIN #
IRS
Total Amount of
Purpose of Grant
Wapello
Wapello
IA
IA
52653
52653
42‐6005313
42‐6005313
501c3
501c3
IA101 ‐ Southeast Iowa Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
Lucas State Office Building 321 E 12 Street
Iowa Department of Public Health
6580 165th Street Monroe County Hospital
1229 C. Ave E. Mahaska Health Partnership
1200 North 7th Street Lucas County Health Center
Des Moines
Albia
Oskaloosa
Chariton
IA
IA
IA
IA
50319‐0075
52531
52577
50049
42‐6004523
42‐6037692
42‐6038099
42‐6039708
501c3
501c3
501c3
501c3
74,874
IA102 ‐ Siouxland Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
230 Nebraska Street June E Nylen Cancer Center
321 E. 12th Street Iowa Department of Public Health
338 1st Avenue NW Greater Sioux Community Health Center
Sioux City
Des Moines
Sioux Center
Sioux Center
Sioux Center
IA
IA
IA
IA
IA
51101
50319
51250
51250
51250
42‐1411233
42‐6004523
20‐5896415
20‐5896415
20‐5896415
501c3
501c3
501c3
501c3
501c3
30,635 Screening
30,000 Education
12,500 Screening
7,500 Treatment
159,903
IA103 ‐ The Des Moines Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
Jennie Edmundson Cancer Center Attn: Steve Baumert
Jennie Edmundson Hospital
Jennie Edmundson Cancer Center Attn: Steve Baumert
Jennie Edmundson Hospital
905 Franklin Street Peoples Community Health Clinic, Inc.
Attn: Scott Slater/ Terrii Henkels 1907 Carpenter Ave.
Polk County Health Department
22 N. Georgia Ave Suite 300 Cerro Gordo County Dept of Public Health
22 N. Georgia Ave Suite 300 Cerro Gordo County Dept of Public Health
211 Highland Ave. Loring Hospital
211 Highland Ave. Loring Hospital
1801 Hickman Road Broadlawns Medical Center
1525 West Fifth St. Box 309 Buena Vista Regional Medical Center
350 North Grandview Avenue Iowa Mind Body Institute
822 S. Main Street Visiting Nurse Association
Council Bluffs
Council Bluffs
Waterloo
Des Moines
Mason City
Mason City
Sac City
Sac City
Des Moines
Des Moines
Des Moines
Storm Lake
Dubuque
Council Bluffs
IA
IA
IA
IA
IA
IA
IA
IA
IA
IA
IA
IA
IA
IA
51503
51503
50703‐4407
50314‐1310
50401‐3435
50401‐3435
50583
50583
50314
50319‐0075
50319‐0075
50588
52001
51503
42‐0680355
42‐0680355
42‐1058629
42‐1063074
42‐1351175
42‐1351175
42‐1418132
42‐1418132
42‐1527407
42‐6004523
42‐6004523
42‐6037827
45‐5361915
74‐6087587
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
31,500 Education
58,500 Screening
199,951 Screening
11,157 Education
63,223 Screening
8,425 Education
8,425 Screening
7,500 Education
19,685 Education
177,165 Screening
8,100 Screening
10,000 Education
24,803 Treatment
722,101
ID100 ‐ Boise, Idaho Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc. 267 North Canyon Drive North Canyon Medical Center
3080 Gentry Way, Suite 150 St. Luke's MSTI ‐ Boise
100 East Idaho Street St. Luke's MSTI ‐ Breast Care Services
2676 S. Vista Ave. American Cancer Society
3525 E. Louise Drive, Suite 320 St. Luke's MSTI‐MOBILE/BCD
1055 North Curtis St. Alphonsus Breast Care Center
1055 N. Curtis Road St. Alphonsus Cancer Care Center
1512 12th Ave. Road St. Alphonsus
1177 W. State Street Treasure Valley Family YMCA
1224 8th Street Minidoka Memorial Hospital
PO Box 9 211 16th Avenue N
Terry Reilly Health Services
P.O. Box AK, 775 Pole St. Luke's Magic Valley Health
PO Box 266 486 W. First Avenue
Glenns Ferry Health Clinic
1000 State Street St. Luke's McCall Foundation
2001 E Madison Street Planned Parenthood of Idaho
8500 N. Atlas
Panhandle Health District #1
1501 Hiland Ave. Cassia Regional Medical Center
Gooding
Meridian
Boise
Boise
Meridian
Boise
Boise
Nampa
Boise
Rupert
Nampa
Twin Falls
Glenns Ferry
McCall
Seattle
Hayden
Burley
ID
ID
ID
ID
ID
ID
ID
ID
ID
ID
ID
ID
ID
ID
WA
ID
ID
83330
83642
83712
83705
83642
83706
83706
83686
83702
83350
83653‐0009
83301
83623
83638
98122
83835
83318
26‐1938641
56‐2570681
82‐0295026
58‐0659875
56‐2570681
82‐0200895
82‐0200895
82‐0200896
82‐0200908
82‐0291854
82‐0300537
82‐0342863
82‐0372009
82‐0384205
82‐0597551
82‐0537262
94‐2854057
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
5,090 Treatment
4,499 Screening
8,497 Treatment
20,000 Screening
39,915 Screening
10,000 Treatment
10,000 Treatment
11,150 Screening
29,970 Screening
9,990 Screening
10,000 Screening
10,000 Screening
59,702 Screening
271,119
IL101 ‐ The Chicagoland Area Chapter of the Susan G. Komen Brea 1645 W. Jackson, Suite 450 Metropolitan Chicago Breast Cancer
4336 S. Greenwood Avenue Sisters Working It Out
180 W. Washington, Suite 1000 Asian Health Coalition
355 Ridge Ave St Francis Hospital
2233 W Division Street Presence Saints Mary and Elizabeth Medic
Attn: Sophia Worobec 1700 W Van Buren St, Suite 250
Rush University Medical Center
5145 N. California Ave Swedish Covenant Hospital
645 S. Central Loretto Hospital
2240 W. Ogden Avenue ‐ 2nd floor Hektoen Institute of Medicine
4300 N California Ave Korean American Community Services
2000 Ogden Ave Rush‐Copley Foundation
Attn: Maria Milcahy, L.A.C., MSOM 2525 S. Michigan Ave.
Mercy Hospital & Medical Center
2240 W. Ogden Ave., 2nd Floor Michael Reese Education & Research Found
5417 W. Division St. Westside Health Authority
Attn: Babara Jia 1163 E Ogden Ave, Suite 301
Xilin Association
228 East Lake Street Hamdard Center
Chicago
Chicago
Chicago
Evanston
Chicago
Chicago
Chicago
Chicago
Chicago
Chicago
Aurora
Chicago
Chicago
Chicago
Naperville
Addison
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
60612
60653
60602
60202
60602
60612
60625
60544
60612
60618
60504
60616
60612
60651
60563
60101
26‐2264895
26‐2862273
31‐1607193
36‐2167800
36‐2171079
36‐2174823
36‐2179813
36‐2200248
36‐2244897
36‐2746468
36‐3093877
36‐3227350
36‐3731674
36‐3789879
36‐3890616
36‐3917885
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
Page 9 of 34
5,540 Education
6,341 Screening
233,881
75,000 Education
10,000 Education
75,000 Screening
75,000 Screening
75,000 Screening
75,000 Education
75,000 Screening
10,000 Education
75,000 Screening
75,000 Education
75,000 Education
75,000 Treatment
75,000 Screening
75,000 Screening
10,000 Education
8,220 Education
ATTACHMENT 5
EIN # 75‐2462834
2012 Form 990
Schedule I, Part II
F
Recipient Name
Family Health Partnership Clinic
Visiting Nurses Assoc of Fox Valley
Access Community Health Center
A Silver Lining Foundation
Cancer Legal Resource Foundation
Healthcare Alternative Systems, Inc.
Street Address
13707 W Jackson 400 North Highland Avenue 600 W. Fulton St. Attn: Sandra Goldberg, PhD 134 N LaSalle Street, Suite 1218
C/O McDermott Will & Emery 227 W. Monroe St., 44th FL
2755 W. Armitage Avenue City
State
Zip
EIN #
IRS
Total Amount of
Purpose of Grant
Woodstock
Aurora
Chicago
Chicago
Chicago
Chicago
IL
IL
IL
IL
IL
IL
60098
60506
60661
60602
60606‐5096
60647
36‐4277029
36‐6086742
39‐1391134
90‐0097495
95‐2960607
23‐7432930
501c3
501c3
501c3
501c3
501c3
501c3
IL102 ‐ The Peoria Memorial Affiliate of the Susan G. Komen Brea 1250 E US Hwy 36 Douglas County Health Department
1000 Health Center Drive Sarah Bush Lincoln Health Center
400 North Highland Ave. VNA of Fox Valley
9119 S. Exchange Ave. Chicago Family Health Center
Attn: Anne Bowman 5215 N. Knoxville, Suite 209
Hult Health Education Center
407 E. Vernon Avenue Community Cancer Center
407 E. Vernon Avenue Community Cancer Center
401 Division St. Winnebago County Health Department
2390 W. Station Street Kankakee County Health Department
Well Women of Northwest Illinois 10 W. Linden Street
Stephenson County Health Department
200 S. Cedar Shelby Memorial Hospital
800 E. Carpenter Street Friends of St. John’s Hospital
806 E. Kansas Boys & Girls Clubs of Greater Peoria
515 1/2 East Vine Southern Seven Health Department
6501 N. Sheridan Road, Suite 209 Institute of Physical Medicine & Rehab
P.O. Box 357, 671 Wabash Ave. Hancock County Health Department
P.O. Box 357, 671 Wabash Ave. Hancock County Health Department
530 NE Glen Oak Ave. OSF‐St Francis Medical Center
1701 W. Garden Street Heartland Community Health Clinic
1701 W. Garden Street Heartland Community Health Clinic
5215 N. Knoxville Cancer Center for Healthy Living
700 East Oak Street Fulton County Health Department
700 East Oak Street Fulton County Health Department
1361 W. Fremont St., Suite 209 Knox County Health Department
1361 W. Fremont St., Suite 209 Knox County Health Department
P.O. Box 650, 310 E. Torrance Livingston County Health Department
P.O. Box 650, 310 E. Torrance Livingston County Health Department
109 Third Street PO Box 508
Logan County Health Department
109 Third Street PO Box 508
Logan County Health Department
505 E Jackson Street McDonough County Health Department
505 E Jackson Street McDonough County Health Department
200 W. Front St., Room 304 Mclean County Health Department
11191 IL Rte 185 Montgomery County Health Department
2833 South Grand Avenue East Sangamon County Dept of Public Health
21306 Illinois Rt 9 Tazewell County Health Department
21306 Illinois Rt 9 Tazewell County Health Department
Attn: Cathy Propst 201 W. Kenyon Road
Champaign‐Urbana Public Health Dept
Board of Trustees 327 W. Calhoun
Southern Illinois University
120 NE Glen Oak, Ste 209 Methodist Medical Center Foundation
3402 Stephanie Road Central Illinois Chapter, The Links Inc.
415 E. Washington Street, Suite 112 Lake County Health Department
919 Albany Street Cancer Legal Resource Foundation
Tuscola
Mattoon
Aurora
Chicago
Peoria
Normal
Normal
Rockford
Kankakee
Freeport
Shelbyville
Springfield
Peoria
Vienna
Peoria
Carthage
Carthage
Peoria
Peoria
Peoria
Peoria
Peoria
Peoria
Canton
Canton
Galesburg
Galesburg
Pontiac
Pontiac
Lincoln
Lincoln
Macomb
Macomb
Bloomington
Hillsboro
Springfield
Tremont
Tremont
Champaign
Springfield
Peoria
Peoria
Peoria
Bloomington
Waukegan
Los Angeles
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
IL
CA
61953‐8020
61938
60506
60617
61614
61761
61761
61104‐2096
60901
61032
62565‐1838
62769‐0002
61603
62995‐1615
61614
62321
62321
61637
61637
61637
61605
61605
61614
61520
61520
61401‐2436
61401‐2436
61764
61764
62656
62656
61455
61455
61701
62049
62703
61568‐9252
61568‐9252
61820
62794‐9616
61603
61603
61603
61704
60085
90015
03‐7600728
23‐7098532
36‐2182095
36‐2893854
36‐3510390
36‐4425147
36‐4425147
36‐4529968
36‐6006595
36‐6006654
37‐0512290
37‐0661238
37‐0800010
37‐1069423
37‐1089050
37‐1096249
37‐1096249
37‐1259284
37‐1259284
37‐1259284
37‐1270794
37‐1270794
37‐1363257
37‐6000896
37‐6000896
37‐6001167
37‐6001167
37‐6001248
37‐6001248
37‐6001284
37‐6001284
37‐6001537
37‐6001537
37‐6001569
37‐6001661
37‐6002039
37‐6002170
37‐6002170
37‐6005435
37‐6005961
51‐0186460
51‐0186460
51‐0186460
52‐1170830
59‐3502843
95‐2960607
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
7,100 Screening
7,100 Screening
16,210 Education
24,300 Education
8,100 Screening
11,000 Screening
7,000 Screening
8,100 Screening
8,100 Education
6,600 Screening
9,233 Education
9,233 Education
16,989 Education
18,031 Screening
15,299 Treatment
63,796 Education
27,994 Screening
39,557 Education
12,636 Education
10,527 Screening
16,202 Education
5,992 Screening
8,262 Education
10,938 Screening
9,680 Education
8,225 Screening
8,019 Education
5,931 Screening
24,300 Education
12,990 Screening
10,692 Education
45,408 Screening
40,850 Screening
24,149 Education
53,751 Screening
9,474 Treatment
13,021 Education
5,427 Education
714,105
IN100 ‐ Greater Evansville Affiliate of the Susan G. Komen Breast 2401 E. Chandler Touch, Inc.
421 Chestnut Attn: Michelle Kuenzli
Deaconess Foundation
421 Chestnut Attn: Michelle Kuenzli
Deaconess Foundation
3700 Washington Avenue St. Mary's Foundation
800 West 9th Street Memorial Hospital & Health Care Center
Attn: Susan Reichard P.O. Box 729
Dubois‐Pike‐Warrick Economic Opportunity
One Hospital Road Attn: Jennifer Scherzinger
Perry Memorial Hospital
P.O. Box 1990 Good Samaritan Hospital
303 NW 11th Street Attn: Michael Brown
Fairfield Memorial Hospital
800 East Locust Street Richland Memorial Hospital
800 Hospital Drive Trover Health System
Dottie Davidson 521 Stevenson Hall
University of Louisville
Evansville
Evansville
Evansville
Evansville
Jasper
Jasper
Tell City
Kearney
Fairfield
Olney
Madisonville
Louisville
IN
IN
IN
IN
IN
IN
IN
NE
IL
IL
KY
KY
47714
47713
47713
47750
47546
47547
47586
68848‐1990
62837
62450
42431
40292
26‐3989768
35‐0593390
35‐0593390
35‐0869065
35‐0985964
35‐1121163
35‐1121699
35‐6001532
37‐1185754
37‐1363001
61‐0654587
61‐1029626
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
15,000 Treatment
14,373 Education
33,538 Screening
99,999 Screening
95,908 Treatment
14,239 Education
Page 10 of 34
75,000 Screening
75,000 Screening
75,000 Education
75,000 Screening
50,000 Education
20,000 Education
1,308,220
ATTACHMENT 5
EIN # 75‐2462834
2012 Form 990
Schedule I, Part II
F
Recipient Name
Foundation for Health
Indiana Women in Need Fdtn
Methodist Hospital
Street Address
City
State
Zip
EIN #
IRS
Total Amount of
Purpose of Grant
Owensboro
Indianapolis
Arcadia
KY
IN
CA
42304‐2505 61‐1251763
46220
91‐2057735
92834
95‐1643336
501c3
501c3
501c3
IN101 ‐ Indianapolis Affiliate of the Susan G. Komen Breast Cance 1300 N Main St PO Box 608
Rush Memorial Hospital
605 North 6th Street YWCA Greater Lafayette
2001 W 86 St. St. Vincent Hospital & Health Care Ctr.
1801 N Meridian Street Little Red Door Cancer Agency
2311 W. Jackson St. Cancer Services of East Central IN
2311 W. Jackson St. Cancer Services of East Central IN
305 S Norton Avenue Cancer Services of Grant County
615 SR 38West PO Box 449
Interlocal Community Action Program
615 SR 38West PO Box 449
Interlocal Community Action Program
720 N Lincoln St Decatur County Memorial Hosp
801 North State Street Hancock Regionall Hospital‐Andi
615 N Alabama Str. Ground Flr., Ste B Gennesart Free Clinics Inc
404 W Camp St Boone County Community Clinic
1001 W 10th St , OPE 303 Wishard Health Services
Deana Tuell 2326 18th Street, Suite 110
Columbus Regional Hospital
1515 N. Madison Ave. Community Hospital Anderson
1515 N. Madison Ave. Community Hospital Anderson
Rushville
Lafayette
Lafayette
Lafayette
Indianapolis
Indianapolis
Indianapolis
Indianapolis
Muncie
Muncie
Marion
New Castle
New Castle
Greensburg
Greenfield
Greenfield
Greenfield
Indianapolis
Indianapolis
Indianapolis
Lebanon
Indianapolis
Columbus
Anderson
Anderson
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
46173
47901
47901
47901
46260
46202
46202
46202
47303
47303
46952
47362
47362
47240
46140
46140
46140
46204
46204
46204
46052
46202‐2859
47201
46011
46011
20‐3199892
35‐0868224
35‐0868224
35‐0868224
35‐0869066
35‐0914096
35‐0914096
35‐0914096
35‐0988703
35‐0988703
35‐1058216
35‐1116629
35‐1116629
35‐1141109
35‐1543491
35‐1543491
35‐1543491
35‐1776518
35‐1776518
35‐1776518
35‐2127378
35‐6005697
35‐6023714
35‐1069822
35‐1069822
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
15,100 Education
223,485 Screening
63,421 Treatment
9,910 Education
336,931 Screening
49,549 Treatment
16,311 Education
27,774 Screening
16,083 Education
24,124 Screening
12,920 Education
19,709 Screening
11,168 Treatment
16,060 Education
16,060 Screening
16,546 Treatment
36,468 Screening
36,468 Treatment
1,310,974
IN102 ‐ Northern Indiana Affiliate of the Susan G.Komen Breast C PO Box 250 La Porte Hospital Foundation
2200 Randallia Dr Parkview Hospital Comp Cancer Center
2200 Randallia Dr Parkview Hospital Comp Cancer Center
615 North Michigan Beacon Health System, Inc.
919 East Jefferson Blvd, Suite 401 River Bend Cancer Services
919 East Jefferson Blvd, Suite 401 River Bend Cancer Services
6316 Mutual Drive Cancer Services of Northeast Indiana
213 Middlebury Street Maple City Health Care Center, Inc.
23971 US Highway 33 United Cancer Services of Elkhart County
600 East Boulevard Elkhart General Hospital Fountation, Inc
6910 North Main Street, Suite 300 Foundation of SJRMC
6507 Carrolton Av ‐ Ste B Indiana Women in Need Fdtn
6910 North Main St Bldg 9 Unit 10
United Health Systems
La Porte
Ft Wayne
Ft Wayne
South Bend
South Bend
South Bend
Ft Wayne
Goshen
Elkhart
Elkhart
Mishawaka
Indianapolis
Granger
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
46350
46805
46805
46601
46617
46617
46825
46528
46517
46514
46545
46220
46530
31‐0952775
35‐0868085
35‐0868085
35‐0868132
35‐0872359
35‐0872359
35‐0965609
35‐1749398
35‐2960607
35‐6061200
53‐0196617
91‐2057735
35‐1118647
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
7,050 Screening
7,950 Treatment
8,265 Education
7,500 Education
7,500 Treatment
15,000 Treatment
15,000 Treatment
15,000 Treatment
13,640 Education
171,905
IN103 ‐ Wabash Valley Affiliate of the Susan G. Komen Breast Can 1000 Health Center Drive Sarah Bush Lincoln Health Center
1711 N. 6 1/2 Street Suite 300 Clara Fairbanks Center, Inc.
1711 N. 6 1/2 Street Suite 300 Clara Fairbanks Center, Inc.
Mattoon
Terre Haute
Terre Haute
IL
IN
IN
61938
47804
47804
23‐7098532
35‐6042734
35‐6042734
501c3
501c3
501c3
5,553 Screening
22,211 Treatment
47,500
Wichita
Wichita
Garden City
Garden City
Topeka
Topeka
Topeka
Topeka
Wichita
Pittsburg
Pittsburg
Pittsburg
Hays
Junction City
Junction City
Topeka
KS
KS
KS
KS
KS
KS
KS
KS
KS
KS
KS
KS
KS
KS
KS
KS
67214‐3031
67214
67846
67846
66612
66612
66612‐1274
66612‐1274
67214
66762
66762
66762
67601
66441‐3344
66441‐3344
66604‐4056
27‐3955402
37‐1540007
47‐1049519
47‐1049519
48‐0299250
48‐0299250
48‐0299250
48‐0299250
48‐0805658
48‐0961283
48‐0961283
48‐1103608
48‐1179684
48‐6075585
48‐6075585
74‐1185665
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
41,759 Education
23,050 Education
21,700 Education
9,300 Screening
13,742 Education
84,414 Screening
7,130 Education
111,706 Screening
32,501 Education
12,558 Education
12,558 Screening
37,570 Education
19,800 Education
13,200 Screening
20,500 Treatment
KS100 ‐ Mid‐Kansas Chapter of the Susan G. Komen Foundation
Witness Project
E. C. Tyree Clinic
United Methodist Mexican‐American Minist
United Methodist Mexican‐American Minist
Kansas Dept of Health & Environment
UKSM‐W Medical Practice Association
Via‐Christi‐ Pittsburg
Via‐Christi‐ Pittsburg
Crawford County Health Dept.
Hays Cancer Center
Junction City‐Geary County Health Dept.
Junction City‐Geary County Health Dept.
American Cancer Society
P.O. Box 22505 6507 Carrolton Av ‐ Ste B 300 West Huntington Drive Witness Project of Kansas 1135 N Cleveland
1525 N Lorraine Jacquelyn Smith 712A St. John
Jacquelyn Smith 712A St. John
1000 SW Jackson St., Ste 230 1000 SW Jackson St., Ste 230 1000 SW Jackson, Ste 230 1000 SW Jackson, Ste 230 c/o Lorene R Valentine 1010 N. Kansas
1 Mount Carmel Way 1 Mount Carmel Way 410 E. Atkinson Anne O'Dea, MD 2220 Canterbury Drive
Gayle Stallcup 1212 W Ash, PO Box 282
Gayle Stallcup 1212 W Ash, PO Box 282
1315 SW Arrowhead Raod Page 11 of 34
15,000 Treatment
492,374
ATTACHMENT 5
EIN # 75‐2462834
2012 Form 990
Schedule I, Part II
F
Recipient Name
Street Address
City
State
Zip
EIN #
IRS
Total Amount of
Purpose of Grant
475,988
KY100 ‐ Lexington Affiliate of the Susan G. Komen Breast Cancer F Ensuring Access P.O.Box 1208
Madison County Health Department
KY Pink Connection Patient Navigation P.O.Box 25088
Pink Connection
Pink Connection
Pink Connection
60 Mercy Court Marcum & Wallace Memorial Hospital Found
Digital Mobile Mammmography Unit 1 Medical Village Dr.
St. Elizabeth's Medical Center
2201 Lexington Ave. King's Daughters Medical Center
222 Medical Circle St. Claire Regional Medical Center
650 Newtown Pike Lexington Fayette County Health Dept.
650 Newtown Pike Lexington Fayette County Health Dept.
One Saint Joseph Drive Saint Joseph Breast Center
"Yes, Mamm!" 11203 Main Street P.O.Box 910
Saint Joseph‐Martin
1000 St. Christopher Drive Our Lady of Bellefonte Hospital
Breast Cancer Access to Health Care 1504 College Way
Richmond
Lexington
Lexington
Lexington
Irvine
Edgewood
Ashland
Ashland
Morehead
Lexington
Lexington
Lexington
Martin
Ashland
Lexington
KY
KY
KY
KY
KY
KY
KY
KY
KY
KY
KY
KY
KY
KY
KY
40476
40524
40524
40524
40336
41017
41101
41101
40351
40508
40508
40504
41649
41101
40502
24‐0000119
26‐2704188
26‐2704188
26‐2704188
32‐0026557
61‐0445850
61‐0503715
61‐0503715
61‐0605336
61‐0920825
61‐0920825
61‐1334601
61‐1012503
61‐1381952
74‐1185665
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
10,000 Screening
15,000 Education
25,000 Screening
60,000 Treatment
28,500 Screening
16,225 Education
36,115 Screening
6,250 Education
18,750 Screening
12,660 Screening
278,526
KY101 ‐ Louisville, Kentucky Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
PO Box 1123 Casting for Recovery, Inc.
633 Baxter Ave Gilda's Club
1206 Spring Street Clark Memorial Hospital Foundation
1206 Spring Street Clark Memorial Hospital Foundation
1451 N Gardner St Scott Memorial Hospital
1319 Duncan Avenue Family Health Center of Clark County
1319 Duncan Avenue Family Health Center of Clark County
6066 Leesburg Pike, Suite 100 Boat People, SOS
4305 New Shepherdsville Road Flaget Memorial Hospital Foundation, Inc
4000 Kresge Way Baptist Hospital East
4001 Dutchmans Lane Suburban Plaza II
Norton Cancer Institute
Suburban Medical Plaza II 3991 Dutchmans Lane, Ste 405
982 Eastern Parkway Suite 7 Junior League of Louisville
982 Eastern Parkway Suite 7 Junior League of Louisville
Interdisciplinary Program for Palliative Care & Chronic Care
Univ of Louisville Research Foundation Med Center One Suite 315
Univ of Louisville Research Foundation Med Center One Suite 315
163 Ridgewood Dr. Friend For Life
Louisville Metro Department of Public Health & Wellness 400 East Gray Street
Louisville Metro Government
Manchester
Louisville
Jeffersonville
Jeffersonville
Scottsburg
Jeffersonville
Jeffersonville
Falls Church
Bardstown
Bardstown
Bardstown
Louisville
Louisville
Louisville
Louisville
Louisville
Louisville
Louisville
Louisville
Louisville
Louisville
Louisville
Louisville
Pewee Valley
Louisville
VT
KY
IN
IN
IN
IN
IN
VA
KY
KY
KY
KY
KY
KY
KY
KY
KY
KY
KY
KY
KY
KY
KY
KY
KY
05254
40204
47130
47130
47170
47130
47130
22041
40004
40004
40004
40207
40207
40207
40207
40207
40217
40217
40292
40292
40292
40202
40202
40056
40202
03‐0354382
06‐1662883
35‐0944638
35‐0944638
35‐1089437
35‐1842342
35‐1842342
54‐1563619
56‐2351341
56‐2351341
56‐2351341
61‐0444707
61‐1028725
61‐1028725
61‐1028725
61‐1028725
61‐6000295
61‐6000295
61‐1029626
61‐1029626
61‐1029626
61‐1029626
61‐1029626
61‐1139410
27‐3175977
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
12,600 Education
35,000 Education
24,000 Education
6,000 Screening
30,186 Education
17,728 Screening
13,212 Education
32,014 Screening
5,590 Treatment
11,080 Education
19,200 Treatment
12,000 Education
48,000 Screening
27,199 Education
9,066 Screening
17,500 Education
17,500 Treatment
14,263 Education
86,601 Education
56,175 Treatment
25,000 Education
75,000 Screening
643,283
LA100‐Acadiana Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
935 Camelia Blv d. Suite 100 Breast Center of Acadiana Foundation
935 Camelia Blv d. Suite 100 Breast Center of Acadiana Foundation
8762 Hwy 182 SW LA Primary Health Care Ctr, Inc.
806 Jefferson Terrace Blvd. Iberia Comprehensive Health Center, Inc.
806 Jefferson Terrace Blvd. Iberia Comprehensive Health Center, Inc.
917 General Mouton Ave. Sallie Astor Burdine Foundation
1204 Johnston St Acadiana Medical Research Foundation
1317 Jefferson St Lafayette Community Health Care Clinic
Lafayette
Lafayette
Opelousas
New Iberia
New Iberia
Lafayette
Lafayette
Lafayette
Lafayette
Lafayette
LA
LA
LA
LA
LA
LA
LA
LA
LA
LA
70508
70508
70570
70560
70560
70501
70506
70501
70501
70501
37‐1584294
37‐1584294
58‐2003179
58‐2164455
58‐2164455
59‐7800251
72‐0876773
72‐1221982
72‐1221982
72‐1221982
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
8,000 Education
42,000 Screening
7,500 Education
42,500 Screening
35,000 Treatment
25,000 Screening
16,866 Education
23,425 Screening
6,559 Treatment
241,850
LA101‐Baton Rouge Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
Attn: Jesse Rodrigue 4950 Essen Lane
Mary Bird Perkins Cancer Center
Attn: Tammy Riviere 350 Hospital Road
Pointe Coupee Homebound Health Services
Attn: Tammy Riviere 350 Hospital Road
Pointe Coupee Homebound Health Services
Attn: Ramona Boatner 4950 Essen Lane, Suite 611
YWCA of Greater Baton Rouge
100 Woman's Way Women's Hospital
Attn: Karen Banks P.O. Box 335
River Region Cancer Screening Center
Baton Rouge
New Roads
New Roads
Baton Rouge
Baton Rouge
Sorrento
LA
LA
LA
LA
LA
LA
70809
70760
70760
70809
70817‐1300
70809
23‐7010520
41‐2157300
41‐2157300
72‐0650993
72‐0652905
72‐6087770
501c3
501c3
501c3
501c3
501c3
501c3
75,000 Screening
7,310 Education
54,000 Education
77,225 Screening
54,508 Screening
303,733
LA102‐New Orleans Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
1020 St. Andrew St. St. Thomas Community Health Center
1203 S. Tyler St. Mary Bird Perkins Cancer Center
New Orleans
Covington
LA
LA
70130
70433
14‐1958494
23‐7010520
501c3
501c3
126,153 Screening
Page 12 of 34
ATTACHMENT 5
EIN # 75‐2462834
2012 Form 990
Schedule I, Part II
F
Recipient Name
Cancer Assoc of Greater New Orleans
West Jefferson Medical Center
West Jefferson Medical Center
LSUHSC School of Public Health
St. Charles Community Health Center
Thomas/McMahan Cancer Foundation
Street Address
824 Elmwood Pkwy. Blvd. Suite 240
Outpatient Rehab Dept. 4519 Westbank Expressway
Women's Imaging & Breast Care Ctr 1111 Medcial Center Blvd SUite 201
2025 Gravier St., 3rd floor 843 Milling Ave. 1120 Robert Road City
State
Zip
EIN #
IRS
Total Amount of
Purpose of Grant
New Orleans
Marrero
Marrero
New Orleans
Luling
Slidell
LA
LA
LA
LA
LA
LA
70123
70072
70072‐3191
70112
70070
70458
72‐0517802
72‐6014898
72‐6014898
72‐6087770
47‐0852944
72‐1423840 501c3
501c3
501c3
501c3
501c3
501c3
29,400 Treatment
35,025 Screening
165,322 Screening
7,500 Treatment
417,500
LA103‐Shreveport Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
20 Jefferson Street DeSoto Regional Health System
1501 Kings Hwy Feist Weiller Cancer Center
1635 Marvel St. Christus Cabrini Fdtn. FBO Christus Cous
1635 Marvel St. Christus Cabrini Fdtn. FBO Christus Cous
Attn: Janet Menteseane 827 Margaret Pl., Suite 201
Martin Luther King Health Center
Attn: Janet Menteseane 827 Margaret Pl., Suite 201
Martin Luther King Health Center
Mansfield
Shreveport
Coushatta
Coushatta
Shreveport
Shreveport
LA
LA
LA
LA
LA
LA
71052
71130
71019
71019
71101
71101
72‐0500565
72‐0702002
72‐0998302
72‐0998302
72‐1079721
72‐1079721
501c3
501c3
501c3
501c3
501c3
501c3
5,679 Education
27,724 Screening
72,884 Education
8,098 Screening
240,098
LA104‐Bayou Region Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
Attn: Jesse Rodrigue 4950 Essen Lane
Mary Bird Perkins Cancer Center
602 North Acadia Road Thibodaux Regional Medical Center
602 North Acadia Road Thibodaux Regional Medical Center
1978 Industrial Blvd. Leonard J. Chabert Medical Center
Mammogram Assist & Breast Cancer Edu Attn: Tracy George, CFO
St. James Parish Hospital
P. O. Box 2054 Nicholls State University
200 W. 134th Place Lady of the Sea General Hospital
Baton Rouge
Thibodaux
Thibodaux
Houma
Lutcher
Thibodaux
Cut Off
LA
LA
LA
LA
LA
LA
LA
70809
70302
70302
70343
70071
70310
70345
23‐7010520
72‐0763512
72‐0763512
72‐0824119
72‐6010747
72‐6011797
72‐6012041
501c3
501c3
501c3
501c3
501c3
501c3
501c3
7,000 Screening
7,500 Screening
12,500 Treatment
15,000 Treatment
8,000 Education
8,000 Screening
65,000
LA105‐The Northeast Louisiana Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
3330 Masonic Drive St. Francis Cabrini Hospital
3330 Masonic Drive St. Francis Cabrini Hospital
P.O. Box 1300 Franklin Medical Center
407 Cincinnati Street Delhi Hospital
254 Hwy 3048 P.O. box 388
Richardson Medical Center
411 Calypso Street Louisiana Cancer Foundation
323 W Walnut Street Morehouse General Hospital
1101 Fourth Street, Suite 101A Cenla Medication Access Program
1101 Fourth Street, Suite 101A Cenla Medication Access Program
165 Beech Springs Road Jackson Parish Hospital
Alexandria
Alexandria
Winnsboro
Delhi
Rayville
Monroe
Monroe
Monroe
Bastrop
Alexandria
Alexandria
Jonesboro
LA
LA
LA
LA
LA
LA
LA
LA
LA
LA
LA
LA
71301
71301
71295
71232
71269
71201
71201
71201
71221
71301
71301
71251
72‐0408984
72‐0408984
72‐0685044
72‐1179027
72‐1179028
72‐1461890
72‐1461890
72‐1461890
72‐6011528
02‐0751416 02‐0751416 72‐1164536 501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
10,028 Education
48,960 Screening
41,639 Screening
7,500 Education
7,500 Screening
75,000 Treatment
52,500 Screening
6,919 Education
20,756 Screening
344,707
MA100‐Massachusetts Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
140 Clarendon Street, Suite 403 YWCA Boston
14 Prospect Street Milford Regional Medical Center Inc.
VNA Care Network & Hospice 5 Federal Street
VNA HEALTH CENTER, INC.
VNA Care Network & Hospice 5 Federal Street
VNA HEALTH CENTER, INC.
54 Washington Street YWCA Malden
26 Queen Street Family Health Center of Worcester
435 Warren Street Roxbury Comprehensive Comm. Health Ctr.
522 North Main Street Steppingstone Incorporated
522 North Main Street Steppingstone Incorporated
269 Union Street Lynn Community Health Center
322 Tremont Street Mass. Alliance of Portuguese Speakers
1125 Tremont Street Whittier Street Health Center
1125 Tremont Street Whittier Street Health Center
147 Norman Street Gandara Center
Attn: Sanja Percac‐Lima Chelsea Healthcare Center
Massachusetts General Hospital
38 Lawrence Street YWCA Greater Lawrence
777 North Street Women's Imaging
585 Lebannon Street Hallmark Health System, Inc.
Western MA Office 425 Union Street, Executive Office Bldg.
Russian Community Association of MA
888 Washington Street Suite 102
Massachusetts Asian & Pacific Islanders
Boston
Milford
Danvers
Danvers
Malden
Worcester
Roxbury
Fall River
Fall River
Lynn
Boston
Roxbury
Roxbury
West Springfield
Boston
Boston
Chelsea
Lawrence
Lawrence
Lawrence
Pittsfield
Pittsfield
Pittsfield
Melrose
W. Springfield
W. Springfield
W. Springfield
Boston
Boston
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
02116‐0000
01757
01923
01923
02148‐0000
01610‐0000
02119
02720‐0000
02720‐0000
01901‐0000
02116
02120‐0000
02120‐0000
01089‐0000
02114
02114
02150‐0000
01840‐0000
01840‐0000
01840‐0000
01201‐0000
01201‐0000
01201‐0000
02176‐0000
01089‐0000
01089‐0000
01089‐0000
02111‐1446
02111‐1446
04‐2103548
04‐2103602
04‐2103825
04‐2103825
04‐2125009
04‐2485308
04‐2501921
04‐2505146
04‐2505146
04‐2525066
04‐2596270
04‐2619517
04‐2619517
04‐2622756
04‐2697983
04‐2697983
04‐2697983
04‐2130847
04‐2130847
04‐2130847
04‐2733429
04‐2733429
04‐2733429
04‐2767880
04‐3102943
04‐3102943
04‐3102943
04‐3294008
04‐3294008
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
Page 13 of 34
13,438 Education
26,550 Treatment
22,821 Education
13,751 Screening
27,892 Education
11,964 Screening
8,000 Education
19,940 Screening
19,940 Education
15,200 Education
14,400 Screening
10,400 Treatment
11,347 Education
15,667 Screening
17,987 Treatment
8,000 Education
8,000 Screening
16,000 Treatment
19,544 Education
8,964 Screening
ATTACHMENT 5
EIN # 75‐2462834
2012 Form 990
Schedule I, Part II
F
Recipient Name
Boston Medical Center
Dorchester Nazarene
North Adams Regional Hospital
Massachusetts Community Health Services
Latino American Health Institute
Community Servings, Inc.
Community Servings, Inc.
Joseph M. Smith Community Health Center
Joseph M. Smith Community Health Center
LaEsperanza /The Hope of the Pioneer Vly
La Esperanza, Inc.
La Esperanza, Inc.
La Esperanza, Inc.
A Little Easier Recovery
A Little Easier Recovery
Alliance Foundation For Community Health
Holyoke Health Center
The Ellie Fund
YWCA Southeastern Massachusets
YWCA Southeastern Massachusets
Street Address
660 Harrison Avenue 2nd Floor
130 River Street REACH Community Health 71 Hospital Avenue
REACH Community Health 71 Hospital Avenue
REACH Community Health 71 Hospital Avenue
1106 Main Street ‐ Suite 109 95 Berkeley Street, Suite 600 18 Marbury Terrace 18 Marbury Terrace 1380 Soldiers Field Rd 1380 Soldiers Field Rd 237 South Street The Hope of the Pioneer Valley, Inc. 237 South Street
The Hope of the Pioneer Valley, Inc. 237 South Street
The Hope of the Pioneer Valley, Inc. 237 South Street
43 High Street, Suite 120 43 High Street, Suite 120 Cambridge Health Alliance 230 Highland Ave. Son 509
Cambridge Health Alliance 230 Highland Ave. Son 509
Cambridge Health Alliance 230 Highland Ave. Son 509
240 Maple Street‐PO Box 6260 475 Hillside Avenue 20 South Sixth Street 20 South Sixth Street MD100‐Maryland Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
11110 Medical Campus Road, Suite 229 Meritus Healthcare Foundation
11110 Medical Campus Road, Suite 229 Meritus Healthcare Foundation
8268 Academy Road Cancer Support Foundation
22 South Greene Street University of Maryland‐Baltimore"
100 E. Carroll Street Peninsula Regional Medical Center
227 St Paul Place Weinberg 6th floor
Mercy Medical Center
227 St Paul Place Weinberg 6th floor
Prevention and Research Center 227 St. Paul Place
827 Linden Ave Maryland General Hospital
827 Linden Ave Maryland General Hospital
1650 Orleans Street, CRB 1‐189 Johns Hopkins University, School of Medi
1650 Orleans Street, CRB 1‐189 Johns Hopkins University, School of Medi
9103 Franklin Square Drive Suite 2200
Franklin Square Hospital
9103 Franklin Square Drive Suite 2200
Franklin Square Hospital
130 Hospital Road, Suite 102 Calvert Memorial Hospital
130 Hospital Road, Suite 102 Calvert Memorial Hospital
25500 Point Lookout Road PO Box 527
St Mary's Hospital
25500 Point Lookout Road PO Box 527
St Mary's Hospital
909 Progress Circle Suite 100
MAC, Incorporated
1211 Cathedral St. Center for a Healthy Maryland, Inc.
3001 South Hanover Street LRC 105
Harbor Hospital Foundation
3001 South Hanover Street LRC 105
Harbor Hospital Foundation
3501 Sinclair Lane Baltimore Medical Systems
3501 Sinclair Lane Baltimore Medical Systems
5401 Old Court Road Northwest Hospital Center
5401 Old Court Road Northwest Hospital Center
1001 Cathedral Street Chase Brexton Health Services
1001 Cathedral Street Chase Brexton Health Services
PO Box 2298 Moveable Feast, Inc.
110 West Road, Suite 202 Pro Bono Counseling Projects
110 West Road, Suite 202 Pro Bono Counseling Projects
7180 Columbia Gateway Drive Howard County Health Department
7180 Columbia Gateway Drive Howard County Health Department
108 E. Main Street Wicomico County Health Department
108 E. Main Street Wicomico County Health Department
401 Bow Street Cecil County Health Department
12501 Willowbrook Road SE Allegany Cnty Health Dept.
12501 Willowbrook Road SE Allegany Cnty Health Dept.
Medical System Foundation 110 S. Paca St. 9th Fl.
University of Maryland'
City
State
Zip
EIN #
IRS
Boston
Boston
Mattapan
North Adams
North Adams
North Adams
Brockton
Boston
Jamaica Plain
Jamaica Plain
Boston
Boston
North Hampton
Northampton
Northampton
Northampton
North Andover
North Andover
Cambridge
Cambridge
Cambridge
Holyoke
Needham
New Bedford
New Bedford
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
MA
02111‐1446
02118
02126‐0000
01247‐0000
01247‐0000
01247‐0000
02301‐0000
02116‐0000
02130
02130
02135
02135
01060
01060‐4111
01060‐4111
01060‐4111
00000
00000
02143
02143
02143
01040‐0000
02494
02740
02740
04‐3294008
04‐3314093
04‐3335808
04‐3470287
04‐3470287
04‐3470287
04‐3492530
22‐2979908
22‐3154028
22‐3154028
23‐7221597
23‐7221597
27‐2760538
31‐1606956
31‐1606956
31‐1606956
90‐1403400 90‐1403400 01‐0676306
01‐0676306
01‐0676306
22‐2520073
04‐3280390
04‐2104747
04‐2104747
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
Hagerstown
Hagerstown
Ellicott City
Baltimore
Salisbury
Baltimore
Baltimore
Baltimore
Baltimore
Baltimore
Baltimore
Baltimore
Baltimore
Baltimore
Prince Frederick
Prince Frederick
Leonardtown
Leonardtown
Salisbury
Baltimore
Baltimore
Baltimore
Baltimore
Baltimore
Randallstown
Randallstown
Baltimore
Baltimore
Baltimore
Baltimore
Baltimore
Columbia
Columbia
Salisbury
Salisbury
Elkton
Elkton
Elkton
Cumberland
Cumberland
Baltimore
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
21742
21742
21042
21209
21801
21202
21202
21202
21201
21201
21287‐0013
21287‐0013
21237
21237
20678
20678
20650
20650
21804
21201
21225
21225
21213
21213
21133
21133
21201
21201
21203
21204
21204
21046
21046
21801
21801
21921
21921
21921
21501
21501
21201
01‐0639265
01‐0639265
20‐3112832
31‐1678679
52‐0591628
52‐0591658
52‐0591658
52‐0591658
52‐0591667
52‐0591667
52‐0595110
52‐0595110
52‐0608007
52‐0608007
52‐0619000
52‐0619000
52‐0619006
52‐0619006
52‐0992005
52‐1110642
52‐1284532
52‐1284532
52‐1358241
52‐1358241
52‐1372665
52‐1372665
52‐1638592
52‐1638592
52‐1663825
52‐1784604
52‐1784604
52‐1892929
52‐1892929
52‐2046019
52‐2046019
52‐2046029
52‐2046029
52‐2046029
52‐2046033
52‐2046033
52‐2238893
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
Page 14 of 34
Total Amount of
Purpose of Grant
10,325 Treatment
10,000 Screening
8,000 Education
13,600 Education
13,600 Screening
12,800 Treatment
7,677 Education
23,960 Education
15,960 Treatment
9,600 Education
22,400 Screening
18,400 Education
11,400 Screening
12,200 Treatment
7,998 Education
23,994 Treatment
20,240 Education
12,240 Screening
7,520 Treatment
33,651 Education
8,155 Screening
967,393
47,798 Education
71,697 Screening
10,000 Treatment
75,000 Treatment
85,000 Treatment
30,000 Education
45,000 Treatment
75,000 Treatment
33,974 Education
50,961 Screening
45,000 Education
30,000 Treatment
29,918 Education
44,877 Treatment
13,374 Education
20,061 Treatment
13,383 Education
20,075 Screening
85,000 Treatment
56,589 Education
69,911 Education
79,911 Screening
74,993 Education
74,993 Screening
42,302 Education
42,302 Screening
32,304 Education
48,456 Screening
85,000 Treatment
16,074 Education
64,294 Treatment
34,000 Education
51,000 Screening
30,000 Education
45,000 Screening
34,000 Education
42,500 Screening
8,500 Treatment
15,163 Education
22,745 Screening
74,977 Education
ATTACHMENT 5
EIN # 75‐2462834
2012 Form 990
Schedule I, Part II
F
Recipient Name
University of Maryland'
Baltimore County
Baltimore County
Carroll County Health Department
Nueva Vida, Inc.
Nueva Vida, Inc.
Red Devils
Queen Anne's County Health Department
The Red Devils
Street Address
Medical System Foundation 110 S. Paca St. 9th Fl.
Drumcastle Government Center 6401 York Road, 3rd Floor
Drumcastle Government Center 6401 York Road, 3rd Floor
Ms. Judy Trickett PO Box 845
2000 P Street NW, Suite 300 2000 P Street NW, Suite 300 PO Box 36291 206 North Commerce Street Attn: Janice Wilson P.O. Box 36291
City
State
Zip
EIN #
IRS
Total Amount of
Purpose of Grant
Baltimore
Baltimore
Baltimore
Westminster
Washington
Washington
Towson
Centreville
Towson
MD
MD
MD
MD
DC
DC
MD
MD
MD
21201
21212
21212
21158‐0845
20036
20036
21286
21617
21286
52‐2238893
52‐6000889
52‐6000889
52‐6002033
54‐1943145
54‐1943145
74‐3070929
52‐1839026
74‐3070929
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
ME100‐Maine Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
PO Box 200 Western Maine Community Action, Inc
240 Bates Street Community Concepts, Inc.
Norman Fournier, Exec Dir P.O. Box 309
Fish‐River Rural Health
499 Broadway, PMB362 Maine Breast Cancer Coalition
499 Broadway, PMB362 Maine Breast Cancer Coalition
Rob Reeves, Exec Dir 17 Second Street
Bangor Y
Bangor Y
Bangor Y
149 North Street Maine General Medical Center
149 North Street Maine General Medical Center
700 Mount Hope Ave Suite 420
Mabel Wadsworth Women's Health Center
700 Mount Hope Ave Suite 420
Mabel Wadsworth Women's Health Center
PO Box 299 Washington Hancock Community Agency
262 Harlow St Penquis CAP
262 Harlow St Penquis CAP
East Wilton
Lewiston
Eagle Lake
Bangor
Bangor
Bangor
Bangor
Bangor
Waterville
Waterville
Bangor
Bangor
Ellsworth
Bangor
Bangor
ME
ME
ME
ME
ME
ME
ME
ME
ME
ME
ME
ME
ME
ME
ME
04234
04240
04739‐0309
04401
04401
04401‐6133
04401‐6133
04401‐6133
04901‐4974
04901‐4974
04401
04401
04605
04401
04401
01‐0275156
01‐0424969
01‐0452749
01‐0483084
01‐0483084
01‐2111485
01‐2111485
01‐2111485
04‐3369649
04‐3369649
22‐2667466
22‐2667466
23‐7226828
16‐023748
16‐023748
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
7,500 Screening
42,500 Treatment
34,182 Education
12,156 Screening
7,786 Treatment
8,784 Education
40,016 Screening
14,212 Education
14,212 Screening
57,361 Treatment
14,755 Screening
22,132 Treatment
346,454
MI100‐Greater Lansing Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
2010 Hogback Road, Suite 3 Cancer Support Comm. of Greater Ann Arbo
9970 Winegar Road The Oldham Project
119 N. Washington Square YMCA of Metro Lansing
119 N. Washington Square YMCA of Metro Lansing
3305 Spring Arbor Road, Suite 400 Allegiance Women's Health Center
P.O. Box 995 Saint Joseph Mercy Health System
P.O. Box 995 Saint Joseph Mercy Health System
1619 E. Kalamazoo St. Allen Neighborhood Center
1200 E. Michigan Ave. Ste 655 MSU Department of Surgery
2800 Plymouth Road Building 100, Room 104
University of Michigan
P.O. Box 10842 Grass Lake Sanctuary
P.O. Box 10842 Grass Lake Sanctuary
328 Marshall Eastern Michigan University
328 Marshall Eastern Michigan University
Ann Arbor
Laingsburg
Lansing
Lansing
Jackson
Ann Arbor
Ann Arbor
Lansing
Lansing
Lansing
Lansing
Ann Arbor
Ann Arbor
Ann Arbor
Ypsilanti
Ypsilanti
MI
MI
MI
MI
MI
MI
MI
MI
MI
MI
MI
MI
MI
MI
MI
MI
48105
48848
48933
48933
49203‐3796
48106‐0995
48106‐0995
48912‐2701
48912
48912
48912
48109‐2800
48113
48113
48197
48197
05‐0597871
26‐3862784
38‐1359576
38‐1359576
38‐2027689
38‐2113393
38‐2113393
38‐3502484
38‐6005984
38‐6005984
38‐6005984
38‐6006309
42‐1714363
42‐1714363
38‐6005986
38‐6005986
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
16,800 Education
25,200 Treatment
20,844 Education
48,637 Screening
22,443 Education
9,088 Education
27,263 Screening
9,088 Treatment
7,000 Education
37,565 Education
37,565 Treatment
30,136 Education
30,136 Screening
384,446
MI101‐Grand Rapids Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
1806 Bridge Street NW Gilda's Club
1211 Lafayette Ave. NE Catherine's Care Center
Breast Health for the Uninsured 100 S Pine St Ste 140
City on a Hill Clinic
250 Cherry Street SE Saint Mary's Health Care.
145 Michigan Street NE MC202
Spectrum Health Services
145 Michigan Street NE MC202
Spectrum Health Services
25 Michigan St. NE MC 004 Spectrum Health Services
2700 Baker Street 3rd Floor Hackley Community Care Center
2700 Baker Street 3rd Floor Hackley Community Care Center
5900 Byron Center Avenue SW Metro Health Hospital Foundation
2201 S. Getty St Muskegon Family Care
Grand Rapids
Grand Rapids
Zeeland
Grand Rapids
Grand Rapids
Grand Rapids
Grand Rapids
Muskegon Heights
Muskegon Heights
Wyoming
Muskegon Heights
MI
MI
MI
MI
MI
MI
MI
MI
MI
MI
MI
49504
49505
49464
49503
49503
49503
49503
49444
49444
49519
49444
06‐1662883
20‐3572418
20‐3901260
38‐2113393
38‐2752328
38‐2752328
38‐2752328
38‐3014011
38‐3014011
38‐3033329
38‐3324611
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
10,000 Education
10,000 Education
48,940 Screening
9,309 Education
17,289 Screening
49,800 Screening
19,184 Education
17,709 Screening
34,092 Screening
294,256
MI102‐The Southwest Michigan Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
1234 Napier Ave. Lakeland HealthCare
200 North Park Street West Michigan Cancer Center
3299 Gull Road, PO Box 42 Kalamazoo Health and Community Services
3299 Gull Road, PO Box 42 Kalamazoo Health and Community Services
1000 Oakland Drive P. O. Box 51365
Access Breast Cancer Screening
1000 Oakland Drive P. O. Box 51365
Access Breast Cancer Screening
St. Joseph
Kalamazoo
Nazareth
Nazareth
Kalamazoo
Kalamazoo
MI
MI
MI
MI
MI
MI
49085
49007
49074‐0042
49074‐0042
49005
49005
38‐2539929
38‐3061574
38‐6004880
38‐6004880
80‐0633085
80‐0633085
501c3
501c3
501c3
501c3
501c3
501c3
40,000 Screening
150,000 Screening
64,125 Screening
21,375 Treatment
11,979 Treatment
304,458
MN101‐Minnesota Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
366 Jackson Street, Suite 400 Cancer Legal Line
Saint Paul
MN
55101
02‐0736402
501c3
100,000 Education
Page 15 of 34
74,977 Screening
30,000 Education
55,000 Screening
10,000 Treatment
75,000 Education
75,000 Screening
85,000 Treatment
10,000 Screening
10,000 Treatment
2,296,107
ATTACHMENT 5
EIN # 75‐2462834
2012 Form 990
Schedule I, Part II
F
Recipient Name
NorthPoint Health & Wellness Center Inc.
Southside Community Health Services, Inc
Southside Community Health Services, Inc
West Side Community Health Service
St. Joseph's Foundation
American Indian Cancer Foundation
Allina Associated Foundation
Mercy & Unity Hospitals Foundation
YWCA of Duluth
YWCA of Duluth
YWCA of Duluth
Comunidades Latinas Unidas En Servicio
Comunidades Latinas Unidas En Servicio
Open Arms of Minnesota
Riverwood Foundation
North Memorial Health Care Foundation
Angel Foundation
Care Partners, Inc.
Minnesota Department of Health
Abbott Northwestern Hospital
Abbott Northwestern Hospital
Essentia Health St. Joseph's Medical Cen
Essentia Health St. Joseph's Medical Cen
Street Address
1315 Penn Avenue North 4243 4th Avenue South 4243 4th Avenue South 153 Cesar Chavez St. 153 Cesar Chavez St. 153 Cesar Chavez St. 523 North Third Street 80 S 8th St., Ste 800 80 S 8th St., Ste 800 80 S 8th St., Ste 800 701 South Dellwood Street 7590 Lyric Lane NE 32 East 1st Street, Suite 202 32 East 1st Street, Suite 202 32 East 1st Street, Suite 202 720 East Lake Street 720 East Lake Street 2500 Bloomington Avenue South 200 Bunker Hill Drive 200 Bunker Hill Drive 200 Bunker Hill Drive 3300 Oakdale Avenue N. 700 South Third Street, Suite 106W P.O. Box 217 85 E 7th Place MR 16509, 800 East 28th Street MR 16509, 800 East 28th Street 523 North 3rd Street 523 North 3rd Street City
State
Zip
EIN #
IRS
Total Amount of
Purpose of Grant
Minneapolis
Minneapolis
Minneapolis
St. Paul
St. Paul
St. Paul
Brainerd
Minneapolis
Minneapolis
Minneapolis
Cambridge
Fridley
Duluth
Duluth
Duluth
Minneapolis
Minneapolis
Minneapolis
Aitkin
Aitkin
Aitkin
Robbinsdale
Minneapolis
Eveleth
St. Paul
Minneapolis
Minneapolis
Brainerd
Brainerd
MN
MN
MN
MN
MN
MN
MN
MN
MN
MN
MN
MN
MN
MN
MN
MN
MN
MN
MN
MN
MN
MN
MN
MN
MN
MN
MN
MN
MN
55411‐3047
55409‐2113
55409‐2113
55107
55107
55107
56401
55402
55402
55402
55008
55432‐3251
55802
55802
55802
55407‐1547
55407‐1547
55414
56431‐1865
56431‐1865
56431‐1865
55422‐2926
55415‐1116
55734‐0217
55164‐0882
55407‐3799
55407‐3799
56401
56401
20‐0898277
23‐7113799
23‐7113799
23‐7156236
23‐7156236
23‐7156236
26‐3359418
27‐0300026
27‐0300026
27‐0300026
27‐4116873
30‐0086426
41‐0696493
41‐0696493
41‐0696493
41‐1386986
41‐1386986
41‐1681317
41‐1738787
41‐1738787
41‐1738787
41‐1777966
41‐1990883
41‐2011488
41‐6007162
04‐3643816 04‐3643816 26‐3359418
26‐3359418
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
MO100‐Mid‐Missouri Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
3220 Bluff Creek Dr, Suite 100 Vincent P. Gurucharri MD Foundation
P.O. Box 807012 University of Missouri
PO Box 570 Department of Health and Senior Services
900 Leslie Blvd, South Campus Bldg Lincoln Univ. Coop Ext. Paula J.Carter C
423 E Logan St Randolph County Caring Community Partner
423 E Logan St Randolph County Caring Community Partner
Columbia
Kansas City
Kansas City
Kansas City
Kansas City
Jefferson
Jefferson City
Moberly
Moberly
MO
MO
MO
MO
MO
MO
MO
MO
MO
65201
64180‐7012
64180‐7013
64180‐7013
64180‐7013
65102‐0570
65101
65270
65270
22‐3960959
43‐6003859
43‐6003859
43‐6003859
43‐6003859
44‐6000987
44‐6001089
52‐2199775
52‐2199775
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
15,000 Treatment
37,309 Education
23,626 Education
50,960 Screening
45,106 Treatment
40,000 Screening
29,448 Education
37,500 Education
12,500 Treatment
291,449
MO101‐Greater Kansas City Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
PO Box 14414 Northland Health Care Access
825 Euclid Samuel U.Rodgers Health Center
825 Euclid Samuel U.Rodgers Health Center
3801 Blue Parkway Swope Health Services
3801 Blue Parkway Swope Health Services
2310 Holmes, Suite 735 Truman Medical Center Charitable Found
2310 Holmes, Suite 735 Truman Medical Center Charitable Found
66675 Holmes, Suite 650 Black Health Care Coalition
4225 Baltimore Ave. Saint Luke's Hospital Foundation
2121 Summit Street Cabot Westside Health Center
1000 SW Jackson St., Ste 230 Kansas Dept of Health & Environment
1000 SW Jackson St., Ste 230 Kansas Dept of Health & Environment
800 Raven Hill Drive Atchison Hospital Association
10520 Barkley, Suite 100 Cancer Action Inc.
10520 Barkley, Suite 100 Cancer Action Inc.
619 Ann Avenue, Rm112 Unified Government KC,KS Public Health
1333 South 27th St., Suite 10 Coalition of Hispanic Women Against Canc
904 S. 10th St., Suite A Social Welfare Board St. Joseph
904 S. 10th St., Suite A Social Welfare Board St. Joseph
Parkville
Parkville
Parkville
Kansas Ctiy
Kansas Ctiy
Kansas City
Kansas City
Kansas City
Kansas City
Kansas City
Kansas City
Kansas City
Topeka
Topeka
Atchison
Overland Park
Overland Park
Kansas City
Kansas City
St. Joseph
St. Joseph
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
KS
KS
KS
KS
KS
KS
KS
MO
MO
64154
64154
64154
64124
64124
64130
64130
64108
64108
64132
64111
64108
66612
66612
66002
66212‐1811
66212‐1811
66101
66106‐2124
64503
64503
43‐0545808
43‐0545808
43‐0545808
43‐0899356
43‐0899356
43‐0957840
43‐0957840
43‐1194064
43‐1194064
43‐1515059
43‐1933950
44‐0546280
48‐0299250
48‐0299250
48‐0561974
48‐0650257
48‐0650257
48‐1194075
48‐1230884
80‐0308973
80‐0308973
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
19,147 Education
11,488 Screening
7,659 Treatment
11,273 Education
59,184 Screening
31,973 Education
59,379 Screening
39,020 Education
21,011 Treatment
233,575 Screening
7,679 Education
54,923 Screening
25,654 Education
5,200 Education
98,800 Treatment
71,594 Screening
47,791 Education
88,754 Screening
912,851
MO102‐St. Louis Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
Cynthia Frank 845 N. New Ballas Ct., Ste. 380
Gateway to Hope
Cynthia Frank 845 N. New Ballas Ct., Ste. 380
Gateway to Hope
Laverne Lewis 401 Holly Hills Ave.
Family Care Health Centers
St. Louis
St. Louis
St. Louis
MO
MO
MO
63141
63141
63111
20‐2737792
20‐2737792
23‐7076112
501c3
501c3
501c3
12,000 Education
68,000 Treatment
Page 16 of 34
100,000 Education
68,368 Education
29,301 Screening
35,264 Education
26,448 Screening
26,448 Treatment
30,000 Treatment
75,000 Education
10,000 Screening
15,000 Treatment
16,500 Treatment
12,000 Education
12,000 Screening
6,000 Treatment
50,000 Education
50,000 Screening
86,245 Treatment
12,000 Education
24,000 Screening
44,000 Treatment
100,000 Treatment
100,000 Education
75,000 Treatment
855,989 Screening
5,231 Education
20,926 Treatment
74,029 Education
18,507 Treatment
2,167,256
ATTACHMENT 5
EIN # 75‐2462834
2012 Form 990
Schedule I, Part II
F
Recipient Name
Madison County Health Department
Alton Memorial Hospital
Southern Illinois Healthcare Foundation
St. Clair County Health Department
Washington University at St. Louis, Scho
Saint Louis University
Grace Hill Neighborhood Health Center
East Missouri Action Agency
East Missouri Action Agency
People's Health Centers
People's Health Centers
Food Outreach, Inc.
Cancer Support Comm. of Grtr St. Louis
CHIPS
SSM St. Joseph Foundation
Barnes‐Jewish Hospital
Missouri Baptist Medical Center
Missouri Baptist Medical Center
The Breakfast Club, Inc.
Christian Hospital NE‐NW
Mercy Health Foundation St. Louis
Mercy Health Foundation St. Louis
Jefferson Regional Medical Center
Mercy Hospital
Mercy Hospital
Street Address
Amy J. Yeager, MPH 101 E. Edwardsville Road
One Memorial Drive One Memorial Drive One Memorial Drive Paul Kaiser 2041 Goose Lake Rd.
Paul Kaiser 2041 Goose Lake Rd.
Paul Kaiser 2041 Goose Lake Rd.
Jan Nevois 19 Public Square, Suite 150
Nicole Nichols/Sarah Gehlert 660 S. Euclid Ave., Campus Box 8056
Suzanne M. Mahon Ofc of Rsrch Development & Serv.
Glynis Rodgers 2524 Hadley Street
P.O. Box 308 403 Parkway Drive
P.O. Box 308 403 Parkway Drive
Tyrrell Rogers 5701 Delmar Blvd
Tyrrell Rogers 5701 Delmar Blvd
Greg Lukeman 3117 Olive Street
1058 Old Des Peres Road Margie Diekemper, RN, MSN 2431 N. Grand Blvd.
477 North Lindbergh 1001 Highlands Plaza West Suite 140 1001 Highlands Plaza West Suite 140 1001 Highlands Plaza West Suite 140 510 South Kingshighway Blvd, Box 8131 510 South Kingshighway Blvd, Box 8131 1001Highlands Plaza Drive, West Suite 140 Mailstop: 84‐84‐105
1001Highlands Plaza Drive, West Suite 140 Mailstop: 84‐84‐105
3935 Galaxie Drive Michele Hoeft 11133 Dunn Rd, Suite 300N
615 S. New Ballas Road, Suite 1440 615 S. New Ballas Road, Suite 1440 1400 US Highway 61 S 1400 US Highway 61 S 1400 US Highway 61 S 901 E. Fifth Street 901 E. Fifth Street City
State
Zip
EIN #
IRS
Total Amount of
Purpose of Grant
Wood River
Alton
Alton
Alton
Sauget
Sauget
Sauget
Belleville
St. Louis
St. Louis
St. Louis
St. Louis
St. Louis
Park Hills
Park Hills
St. Louis
St. Louis
St. Louis
St. Louis
St. Louis
St. Louis
St. Louis
St. Louis
St. Louis
St. Louis
St. Louis
St. Louis
St. Louis
Florissant
St. Louis
St. Louis
St. Louis
Festus
Festus
Festus
Washington
Washington
IL
IL
IL
IL
IL
IL
IL
IL
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
62095
62002
62002
62002
62206
62206
62206
62220
63110
63108‐3306
63108‐3306
63108‐3306
63106‐4019
63601
63601
63112‐0937
63112‐0937
63103
63110
63106
63141‐7813
63110
63110
63110
63110
63110
63110‐1339
63110‐1339
63034
63136
63141
63141
63028
63028
63028
63090
63090
24‐0000119
37‐0661172
37‐0661172
37‐0661172
37‐1158318
37‐1158318
37‐1158318
37‐6001924
43‐0653611
43‐0654872
43‐0654872
43‐0654872
43‐0817642
43‐0838255
43‐0838255
43‐1036785
43‐1036785
43‐1492878
43‐1587517
43‐1589851
43‐1591556
43‐1617558
43‐1617558
43‐1617558
43‐1617558
43‐1617558
43‐1617558
43‐1617558
43‐1892689
43‐6057893
52‐2440020
52‐2440020
71‐0329353
71‐0329353
71‐0329353
24‐0795456 24‐0795456 501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
32,372 Screening
7,050 Education
29,375 Screening
10,575 Treatment
57,473 Education
57,473 Screening
172,420 Treatment
70,501 Screening
72,391 Education
69,960 Screening
289,027 Treatment
40,000 Education
40,637 Education
33,249 Screening
23,480 Education
93,921 Screening
95,945 Treatment
31,500 Treatment
50,000 Education
425,000 Screening
25,000 Treatment
97,802 Education
24,451 Treatment
74,017 Education
172,705 Screening
34,061 Education
193,012 Screening
30,524 Education
43,604 Screening
13,081 Treatment
18,281 Education
30,469 Treatment
3,104,242
MS100‐Central Mississippi Steel Magnolias Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
300 Third Avenue Southeast HealthTrust Found., Magee Gen Hosp
300 Third Avenue Southeast HealthTrust Found., Magee Gen Hosp
427 Hwy 51 North King's Daughter Medical Center
1417 College Street Delta State University CCED
1417 College Street Delta State University CCED
Magee
Magee
Brookhaven
Cleveland
Cleveland
MS
MS
MS
MS
MS
39111
39111
39601
38733
38733
27‐0031018
27‐0031018
62‐1373067
64‐6026565
64‐6026565
501c3
501c3
501c3
501c3
501c3
45,000 Screening
9,000 Treatment
34,400 Education
5,600 Screening
114,000
MS101‐North Mississippi Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
3249 Craigmont Circle Sisters Network
P. O. Box 1821 420 Magazine Street
Antone Tannehill Good Samaritan Free Cli
P.O. Box 179 63450 Hwy. 25 North,
Access Family Health Services
P.O. Box 179 63450 Hwy. 25 North,
Access Family Health Services
611 Alcorn Drive Magnolia Regional Health Center
830 South Gloster St. North Mississippi Med. Ctr. Breast Care
830 South Gloster St. North Mississippi Med. Ctr. Breast Care
820 Ridgecrest Drive North Mississippi Medical Center‐Spirit
350 N. Humphreys Blvd. Baptist Memorial Hospital‐Booneville
835 Medical Center North Mississippi Medical Center‐West Po
1777 Curtis Drive Tishomingo Health Services
520 College Street, P. O. Box 661 The Good Samaritan Medical Clinic
Tupelo
Tupelo
Smithville
Smithville
Corinth
Tupelo
Tupelo
Tupelo
Memphis
West Point
Iuka
Columbus
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
MS
38801
38802‐1821
38870‐4670
38870‐4670
38834
38801‐6516
38801‐6516
38801
38120
39773
38852‐0860
39703‐0661
32‐0071835
58‐1986683
64‐0612902
64‐0612902
64‐0640292
64‐0662976
64‐0662976
64‐0662976
64‐0663760
64‐0668465
64‐0741047
64‐0926626
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
17,000 Screening
5,250 Education
9,750 Screening
7,000 Education
10,580 Education
12,420 Screening
8,000 Education
11,000 Screening
167,000
MT100‐Montana Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
500 W. Broadway Montana Cancer Institute Foundation
335 Makawasha Avenue Messengers for Health
P.O. Box 1231 Northern Montana Health Care Foundation
1105 North 30th St Vincent Healthcare Foundation
6 13th Ave East St. Joseph Medical Center
6 13th Ave East St. Joseph Medical Center
17 North Miles Big Horn County Hospital
PO Box 31031 Billings Clinic Foundation
Missoula
Crow Agency
Havre
Billings
Polson
Polson
Hardin
Billings
MT
MT
MT
MT
MT
MT
MT
MT
59802
59022
59501
59101
59860
59860
59034
59107‐1031
02‐0768250
27‐0566321
36‐3464641
53‐0196617
53‐0196617
53‐0196617
81‐0384618
81‐0407289
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
30,000 Education
15,000 Education
14,977 Screening
12,907 Education
12,907 Screening
15,000 Screening
29,988 Screening
Page 17 of 34
ATTACHMENT 5
EIN # 75‐2462834
2012 Form 990
Schedule I, Part II
F
Barrett Hospital
Street Address
Recipient Name
600 MT Highway 91 South City
State
Zip
EIN #
IRS
Dillon
MT
59725‐3597 86‐3597000
501c3
NC100‐Charlotte Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
920 Church Street North Carolinas Medical Center ‐ NorthEast
920 Church Street North Carolinas Medical Center ‐ NorthEast
2211 West A Street Kannapolis Church of God
514 Corporate Circle Rowan Regional Medical Center
514 Corporate Circle Rowan Regional Medical Center
301 Yadkin Street PO Box 1489 Stanly Regional Medical Center
PO Box 1489 Stanly Regional Medical Center
PO Box 1489 Stanly Regional Medical Center
7007 Idlewild Road Girl Scouts Hornets Nest Council
306 S Columbia Street Cancer Services of Gaston County, Inc.
PO Box 668093 CW Williams
10620 Park Road, Suite 200 Carolina's Rehab
1100 Blythe Blvd Carolina's Rehab
1307 S. Cannon Blvd. Cabarrus Health Alliance
1307 S. Cannon Blvd. Cabarrus Health Alliance
6900 Farmingdale Drive Charlotte Community Health Clinic
6900 Farmingdale Drive Charlotte Community Health Clinic
151 Sigmon Rd Lincoln County Health Department
600 E Fourth St, 11th Floor, Mecklenburg County Health Department
600 E Fourth St, 11th Floor, Mecklenburg County Health Department
1224 W. Roosevelt Blvd Union County Health Dept
1224 W. Roosevelt Blvd Union County Health Dept
1000 N. First St., Suite 3 Stanly County Health Department
Matthews Breast Center PO Box 33549, 200 Hawthorne Lane
Presbyterian Cancer Center
P. O. Box 33549, 200 Hawthorne Lane Presbyterian Cancer Center
Rehab 125 Baldwin Ave., Suite 100
Presbyterian Cancer Center
c/o 105 Stone House Drive Chestnut Grove Community Center
2525 Court Drive Caromont Cancer Center @ GMH
2525 Court Drive Caromont Cancer Center @ GMH
Service 2893 Sturgis Road
Catawba Service Unit ‐ Indian Health
991 West Hudson Boulevard Gaston County Health Department
991 West Hudson Boulevard Gaston County Health Department
14230 Hunters Road
Lake Norman Free Clinic
Concord
Concord
Kannapolis
Salisbury
Salisbury
Albemarle
Albemarle
Albemarle
Charlotte
Gastonia
Charlotte
Charlotte
Charlotte
Kannapolis
Kannapolis
Charlotte
Charlotte
Lincolnton
Lincolnton
Lincolnton
Charlotte
Charlotte
Monroe
Monroe
Albemarle
Charlotte
Charlotte
Charlotte
Statesville
Gastonia
Gastonia
Rock Hill
Gastonia Gastonia Huntersville
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
SC
NC
NC
NC
28025
20‐8776473
28025
20‐8776473
28081
56‐0543258
28147
56‐0547479
28147
56‐0547479
28802
56‐0556760
28002
56‐0556760
28002
56‐0556760
28212
56‐0563842
28054
56‐1164253
28266
56‐1262478
28210
56‐1398930
28203
56‐1398930
28083
56‐2016594
28083
56‐2016594
28212
56‐2274174
28212
56‐2274174
28092
56‐6000315
28092
56‐6000315
28092
56‐6000315
28202
56‐6000319
28202
56‐6000319
28110
56‐6000345
28110
56‐6000345
28001
56‐6001537
28233
58‐1413074
28233‐3549 58‐1413074
28233
58‐1413074
28625
58‐1481755
28054
58‐1636959
28054
58‐1636959
29730
34‐2061903 28052
56‐6000300 28052
56‐6000300 28078 43‐723062
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
NC101‐NC Triangle Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
211 Trimble Plant Road Moore Free Care Clinic, Inc.
310 Nantucket Drive Caring Community Foundation, Inc.
PO Box 1364 Caring Community Foundation, Inc.
546 West Ridgeway Street Warren County Free Clinic, Inc.
546 West Ridgeway Street Warren County Free Clinic, Inc.
2460 Curtis Ellis Drive Nash Health Care
2460 Curtis Ellis Drive Nash Health Care
Duke ORA, Box 104008 Erwin Square, Suite 820
Duke University Medical Center.
299 Lloyd Street Piedmont Health Services, Inc.
299 Lloyd Street Piedmont Health Services, Inc.
1301 Fayetteville Street Lincoln Community Health Center
1301 Fayetteville Street Lincoln Community Health Center
4 N. Blount Street,Suite 200 El Pueblo, Inc.
PO Box 3000 First Health of the Carolinas Inc.
PO Box 3000 First Health of the Carolinas Inc.
111 Hospital Drive Vidant Edgecombe Hospital
600 E Main St El Centro Hispano
407 Crutchfield Street Community Health Coalition
407 Crutchfield Street Community Health Coalition
106 Hillcrest Street Lee County Health Dept.
Attn: Karen Ramsey 214 S. Barnes Street
Nash County Health Department
Attn: Karen Ramsey 214 S. Barnes Street
Nash County Health Department
Wake County Finance Department, AR PO Box 550
Wake County Human Services
Div of Heme/Oncology Cecile Skrzynia
Univ of North Carolina at Chapel Hill.
Get Real and Heel Impacting Survivorship OSR 104 Airport Drive, Suite 2200
Univ of North Carolina at Chapel Hill.
2500 Blue Ridge Road #325 REX Healthcare Foundation
Southern Pines
Cary
Cary
Warrenton
Warrenton
Rocky Mount
Rocky Mount
Durham
Durham
Durham
Carrboro
Carrboro
Durham
Durham
Raleigh
Pinehurst
Pinehurst
Tarboro
Durham
Durham
Durham
Sanford
Nashville
Nashville
Raleigh
Chapel Hill
Chapel Hill
Raleigh
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
28387
27513
27605
27589
27589
27804
27804
27710
27710
27710
27510
27510
27707
27707
27601
28374
28374
27886
27701
27704
27704
27331
27856
27856
27602‐0550
27599‐7264
27599‐1350
27607
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
Page 18 of 34
01‐0781234
20‐0036976
20‐0036976
20‐4307481
20‐4307481
31‐1802814
31‐1802814
56‐0532129
56‐0532129
56‐0532129
56‐0952737
56‐0952737
56‐1031244
56‐1031244
56‐1934310
56‐1936354
56‐1936354
56‐2003393
56‐2011661
56‐2269385
56‐2269385
56‐6000313
56‐6000323
56‐6000323
56‐6000347
56‐6001393
56‐6001393
56‐6052117
Total Amount of
Purpose of Grant
6,785 Screening
167,563
142,500 Screening
7,500 Treatment
34,346 Screening
6,032 Education
54,289 Screening
13,088 Education
117,788 Screening
13,100 Education
38,340 Screening
5,470 Treatment
35,915 Treatment
11,027 Education
15,868 Screening
20,318 Education
38,830 Screening
5,818 Education
38,399 Screening
13,963 Treatment
66,300 Screening
63,700 Treatment
5,147 Education
97,784 Screening
25,036 Education
100,144 Screening
7,200 Screening
7,131 Education
7,048 Screening
1,339,566
9,956 Education
10,000 Education
21,631 Treatment
21,921 Education
49,982 Screening
50,126 Education
16,709 Screening
14,773 Education
28,847 Screening
28,847 Treatment
30,000 Education
70,000 Screening
24,068 Education
52,174 Screening
95,739 Education
34,095 Education
34,095 Screening
40,350 Education
21,140 Education
49,328 Screening
15,000 Education
30,000 Screening
64,529 Screening
68,818 Education
15,500 Education
ATTACHMENT 5
EIN # 75‐2462834
2012 Form 990
Schedule I, Part II
F
Recipient Name
REX Healthcare Foundation
REX Healthcare Foundation
Scotland Memorial Foundation
Edgecombe County Health Dept.
Gregory B. Davis Foundation
Health Connections Network
Street Address
2500 Blue Ridge Road #325 2500 Blue Ridge Road #325 500 Lauchwood Drive 2909 Main Street 11404 December Way Suite 103
P.O. Box 10013 City
State
Zip
EIN #
IRS
Total Amount of
Purpose of Grant
Raleigh
Raleigh
Laurinburg
Tarboro
Silver Spring
Wilmington
NC
NC
NC
NC
MD
NC
27607
27607
28352
27886
20904
28404
56‐6052117
56‐6052117
58‐1828201
56‐6000298
52‐2257352
80‐0722080
501c3
501c3
501c3
501c3
501c3
501c3
30,000 Screening
55,000 Treatment
75,000 Screening
10,500 Education
7,700 Education
1,250,278
NC102‐North Carolina Foothills Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
420 North Center St. Frye Regional Medical Center
305 West Union Street Good Samaritan Clinic
810 Harper Avenue NW Helping Hands Clinic
737 12th St SW Catawba County Hispanic Ministry
3070 11th Ave Dr SE Catawba County Health Department
3070 11th Ave Dr SE Catawba County Health Department
2345 Morganton Blvd., SW, Suite B Caldwell County Health Dept.
2201 S. Sterling St. Blue Ridge Healthcare Foundation
2201 S. Sterling St. Blue Ridge Healthcare Foundation
Hickory
Morganton
Lenoir
Hickory
Hickory
Hickory
Lenoir
Morganton
Morganton
NC
NC
NC
NC
NC
NC
NC
NC
NC
28601
28655
28645
28602
28602
28602
28645
28655
28655
56‐1497360
56‐1939030
56‐2076541
56‐2170931
56‐6001814
56‐6001814
56‐6001967
58‐2063920
58‐2063920
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
10,000 Screening
22,500 Treatment
13,000 Education
18,000 Screening
152,000
NC103‐North Carolina Triad Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
364 White Oak Street Randolph Hospital
Post Office Box HP‐5 High Point Regional Health System
Med Ctr Treas, WFBMC, Medical Ctr Blvd. North Carolina Baptist Hospital
117 East Kings Highway Morehead Memorial Hospital
3175 Maplewood Avenue Cancer Services, Inc.
2135 New Walkertown Road Community Care Center of Forsyth Co.
2135 New Walkertown Road Community Care Center of Forsyth Co.
3333 Silas Creek Parkway Forsyth Medical Center Foundation
P.O. Box 439 Davidson County Health Dept.
Post Office Box 848 Davie County Health Department
Post Office Box 187 Stokes Family Health Center
306 College Street Wilkes County Health Department
P.O. Box 457 Yadkin County Health Department
830 Rockford Street Northern Hospital of Surry County
1200 N. Elm St, Fund Development Moses Cone Health System Reg. Cancer Ctr
1240 Huffman Mill Road Norville Breast Care Center/ARMC
Asheboro
High Point
Winston‐Salem
Eden
Winston‐Salem
Winston‐Salem
Winston‐Salem
Winston‐Salem
Winston‐Salem
Winston‐Salem
Lexington
Mocksville
Danbury
Wilkesboro
Yadkinville
Mt. Airy
Greensboro
Burlington
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
27203
27265
27157
27288
27103
27101
27101
27103
27103
27103
27293
27028
27016
28697
27055
27030‐5322
27401
27216
56‐0530234
56‐0532309
56‐0552787
56‐0591294
56‐0656375
56‐1403699
56‐1403699
56‐2120959
56‐2120959
56‐2120959
56‐6000294
56‐6000295
56‐6000340
56‐6000350
56‐6000352
56‐6015416
58‐1588823
58‐1681363
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
45,000 Screening
40,000 Screening
24,750 Screening
20,250 Treatment
17,500 Education
34,200 Screening
10,800 Treatment
25,000 Screening
50,000 Treatment
50,000 Screening
556,500
ND100‐North Dakota Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc
210 2nd Avenue NW Custer Health
1000 Highway 12 West River Health Services
Mandan
Hettinger
ND
ND
58554
45‐6004343
58650‐7530 45‐0340688
501c3
501c3
6,223 Screening
14,773
NE100‐Nebraska Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
7637 Grover St. A Time to Heal
7637 Grover St. A Time to Heal
202 High Street Johnson County Hospital Foundation
202 High Street Johnson County Hospital Foundation
984030 NE Medical Ctr, 5555 no place Board of Regents
626 N Street, P.O. Box 509 Central Nebraska Community Services
4920 South 30th Street, Ste. 103 One World Community Health Center, Inc
217 E. Stolley Park Road, Ste. E PO Box 2539
Central Health Center
217 E. Stolley Park Road, Ste. E PO Box 2539
Central Health Center
12809 West Dodge Road Alegent Health Image Recovery Center
P.O. Box 212 CATCH, Inc
P.O. Box 212 CATCH, Inc
12565 West Center Road, Ste. 100 Visiting Nurse Association
233 S 13th Street Suite 1200
Nebraska Cancer Coalition
233 S 13th Street Suite 1200
Nebraska Cancer Coalition
PO Box 648 West Central District Health Department
PO Box 648 West Central District Health Department
Omaha
Omaha
Tecumseh
Tecumseh
Omaha
Loup City
Omaha
Omaha
Omaha
Grand Island
Grand Island
Omaha
York
York
Omaha
Lincoln
Lincoln
North Platte
North Platte
NE
NE
NE
NE
NE
NE
NE
NE
NE
NE
NE
NE
NE
NE
NE
NE
NE
NE
NE
68124
68124
68450
68450
68198‐0000
68853
68107
68107
68107
68801
68801
68154
68467
68467
68144
68508
68508
69103
69103
27‐0297726
27‐0297726
27‐0317629
27‐0317629
47‐0049123
47‐0495122
47‐0548990
47‐0548990
47‐0548990
47‐0562234
47‐0562234
47‐0757164
47‐0812317
47‐0812317
74‐6087587
27‐3176291 27‐3176291 47‐0879835 47‐0879835 501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
5,270 Education
16,200 Treatment
5,624 Education
31,867 Screening
65,000 Education
36,127 Education
13,249 Education
95,499 Screening
5,250 Treatment
28,520 Education
63,480 Screening
26,960 Treatment
33,750 Education
11,250 Screening
148,297 Treatment
13,486 Education
40,458 Screening
55,166 Education
36,777 Screening
732,230
NJ100‐Central and South Jersey Affiliate of Susan G. Komen Breast Cancer Foundation, Inc.
1771 Madison Avenue Lakewood Resource and Referral Center
1771 Madison Avenue Lakewood Resource and Referral Center
660 N. Princeton Avenue Clark Family Breast Cancer Fdn.
660 N. Princeton Avenue Clark Family Breast Cancer Fdn.
Lakewood
Lakewood
Cherry Hill
Cherry Hill
NJ
NJ
NJ
NJ
08701
08701
08002
08002
20‐1324142
20‐1324142
20‐3735151
20‐3735151
501c3
501c3
501c3
501c3
20,400 Education
30,600 Screening
23,784 Education
10,193 Screening
Page 19 of 34
ATTACHMENT 5
EIN # 75‐2462834
2012 Form 990
Schedule I, Part II
F
Recipient Name
Cooper Cancer Institute
Cooper Cancer Institute
AtlantiCare Regional Medical Center
AtlantiCare Regional Medical Center
Princeton HealthCare System
Princeton HealthCare System
Breast Cancer Resource Center
Breast Cancer Resource Center
Cape Regional Medical Center
Cape Regional Medical Center
Gateway Community Action Partner
Gateway Community Action Partner
Puerto Rican Action Committee
Puerto Rican Action Committee
South Jersey Family Medical Center
South Jersey Family Medical Center
Saint Peter's University Hospital
Jersey Shore University Medical Center
Jersey Shore University Medical Center
Ocean Medical Center Foundation
Southern Ocean Medical Center
Southern Ocean Medical Center
Robert Wood Johnson University Hospital
Robert Wood Johnson University Hospital
Monmouth Medical Center Foundation
Monmouth Medical Center Foundation
Hunterdon Regional Cancer Ctr
Hunterdon Regional Cancer Ctr
Community Medical Center Foundation
Community Medical Center Foundation
Somerset Medical Center
Somerset Medical Center
St. Francis Medical Center
Virtua Health
Virtua Health
JFK Medical Center, Edison
JFK Medical Center, Edison
Sisters Network, Inc.
Sisters Network, Inc.
Street Address
Cooper Univ Hospital 3 Cooper Plaza, Suite 310
Cooper Univ Hospital 3 Cooper Plaza, Suite 310
2500 English Creek Ave. 2500 English Creek Ave. 300B Princeton Hightstown Rd Suite 102 300B Princeton Hightstown Rd Suite 102 YWCA Princeton 59 Paul Robeson Place
YWCA Princeton 59 Paul Robeson Place
2 Stone Harbor Boulevard 2 Stone Harbor Boulevard 110 Cohansey Street 110 Cohansey Street 114 East Main Street 114 East Main Street 607 North Jerome Avenue 607 North Jerome Avenue 1 North White Horse Pike 1 North White Horse Pike 254 Easton Avenue 1345 Campus Parkway, Suite A2 1345 Campus Parkway, Suite A2 1345 Campus Parkway, Suite A2 425 Jack Martin Blvd. 425 Jack Martin Blvd. RWJ University Hospital Foundation 10 Plum Street, Suite 910
RWJ University Hospital Foundation 10 Plum Street, Suite 910
300 Second Avenue 300 Second Avenue 2100 Wescott Drive 2100 Wescott Drive 99 Highway 37 West 99 Highway 37 West 110 Rehill Avenue 110 Rehill Avenue 601 Hamilton Ave. 2225 Evesham Road, Suite 104 2225 Evesham Road, Suite 104 80 James Street 80 James Street 2600 US Highway 1 1210 Hamilton Street 1210 Hamilton Street NJ101‐The North Jersey Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
PO Box 527 Breast Cancer Emergency Aid Foundation
141 Dayton Street Cancer Care of New Jersey
141 Dayton Street Cancer Care of New Jersey
935 Garfield Avenue Metropolitan Family Health Network, Inc
400 Hospital Plaza St Joseph's Regional Medical Center
Rainbows of Hope CEED Program 703 Main Street
St Joseph's Regional Medical Center
One Clara Maass Drive Clara Maass Medical Center
One Clara Maass Drive Clara Maass Medical Center
124 Grand Street Hoboken Family Planning Inc
124 Grand Street Hoboken Family Planning Inc
Trinitas Health Foundation PO Box 259
Trinitas Hospital
Trinitas Hospital
Trinitas Hospital
Access to Digital Breast Screening Srvcs. 200 South Orange Avenue
Saint Barnabas Medical Center
Lymphedema Grmnts & Lymph Educ. 200 South Orange Avenue
Saint Barnabas Medical Center
Project Self Sufficiency of SussexCounty 127 Mill Street
Project Self Sufficiency
Project Self Sufficiency of SussexCounty 127 Mill Street
Project Self Sufficiency
17 South Street Zufall Health Center
17 South Street Zufall Health Center
242 10th Street Hudson Perinatal Consortium
242 10th Street Hudson Perinatal Consortium
P.O. Box 1956,475 South Street Foundation for Morristown Medical Center
City
State
Zip
EIN #
IRS
Total Amount of
Purpose of Grant
Camden
Camden
Egg Harbor Twp.
Egg Harbor Twp.
East Windsor
East Windsor
Princeton
Princeton
Cape May Court House
Cape May Court House
Bridgeton
Bridgeton
Penns Grove
Penns Grove
Margate City
Margate City
Hammonton
Hammonton
New Brunwick
Neptune
Neptune
Neptune
Brick
Brick
New Brunswick
New Brunswick
Longbranch
Longbranch
Flemington
Flemington
Toms River
Toms River
Somerville
Somerville
Trenton
Voorhees
Voorhees
Edison
Edison
North Brunswick
Somerset
Somerset
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
08103
08103
08234
08234
08520
08520
08540
08540
08210
08210
08032
08032
08069
08069
08402
08402
08037
08037
08901
07753
07753
07753
08724
08724
08901
08901
07740
07740
08822
08822
08755
08755
08876
08876
08629
08043
08043
08820
08820
08902
08873
08873
21‐0634462
21‐0634462
21‐0634549
21‐0634549
21‐0635009
21‐0635009
21‐0635056
21‐0635056
21‐0662542
21‐0662542
22‐1942357
22‐1942357
22‐1970239
22‐1970239
22‐2119902
22‐2119902
22‐2159336
22‐2159336
22‐2329197
22‐2342452
22‐2342452
22‐2361311
22‐2666099
22‐2666099
22‐2378007
22‐2378007
22‐2456079
22‐2456079
22‐2516895
22‐2516895
22‐2597592
22‐2597592
22‐3294408
22‐3294408
22‐3431049
22‐3524939
22‐3524939
22‐6019101
22‐6019101
58‐0659875
76‐0480069
76‐0480069
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
35,020 Education
65,036 Screening
21,627 Education
64,881 Screening
6,325 Education
25,298 Screening
20,316 Education
8,707 Screening
27,415 Education
22,431 Screening
75,316 Education
32,278 Screening
35,083 Education
23,389 Screening
22,323 Education
41,456 Screening
89,985 Education
48,454 Screening
37,000 Education
11,736 Education
35,209 Screening
17,742 Education
7,604 Screening
19,265 Education
44,951 Screening
56,625 Education
169,875 Screening
13,007 Education
7,004 Screening
16,086 Education
37,534 Screening
11,765 Education
6,335 Screening
5,917 Education
23,667 Screening
23,598 Education
28,842 Screening
18,577 Education
7,962 Screening
1,426,745
Morristown
Ridgewood
Ridgewood
Jersey City
Paterson
Paterson
Paterson
Paterson
Belleville
Belleville
Hoboken
Hoboken
Elizabeth
Elizabeth
Elizabeth
Livingston
Livingston
Newton
Newton
Dover
Dover
Jersey City
Jersey City
Morristown
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
07963‐0527
07450
07450
07304‐2731
07503
07503‐2621
07503‐2621
07503‐2621
07109
07109
07030‐2510
07030‐2510
07207‐0259
07207‐0259
07207‐0259
07039‐5817
07039‐0000
07860‐1456
07860‐1456
07801‐4506
07801‐4506
07306
07306
07960
03‐0600624
13‐1825919
13‐1825919
20‐4904872
22‐1487602
22‐1487602
22‐1487602
22‐1487602
22‐1500556
22‐1500556
22‐2051458
22‐2051458
22‐2353773
22‐2353773
22‐2353773
22‐2378422
22‐2378422
22‐2727412
22‐2727412
22‐3125397
22‐3125397
22‐3205376
22‐3205376
22‐3392808
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
75,000 Treatment
11,700 Education
42,500 Treatment
75,000 Treatment
15,484 Education
40,393 Screening
11,445 Treatment
12,581 Education
29,355 Treatment
9,093 Education
51,529 Treatment
21,537 Education
39,998 Screening
27,000 Treatment
22,580 Education
53,896 Treatment
44,845 Education
44,845 Screening
9,523 Education
38,094 Screening
15,054 Education
22,581 Treatment
61,450 Education
Page 20 of 34
ATTACHMENT 5
EIN # 75‐2462834
2012 Form 990
Schedule I, Part II
F
Recipient Name
Foundation for Morristown Medical Center
Newark Beth Israel Medical Center
Newark Beth Israel Medical Center
UMDNJ Robert Wood Johnson MC
Overlook Foundation
Overlook Foundation
Overlook Foundation
Planned Parenthood
Sister's Network
Street Address
P.O. Box 1956,475 South Street 201 Lyons Ave 201 Lyons Ave Foundation of UMDNJ 120 Albany Street Tower Two, Suite 850
Foundation of UMDNJ 120 Albany Street Tower Two, Suite 850
Foundation of UMDNJ 120 Albany Street Tower Two, Suite 850
36 Upper Overlook Road 36 Upper Overlook Road 36 Upper Overlook Road Planned Parenthood of Grtr NJ 196 Speedwell Ave.
PO Box 66 City
State
Zip
EIN #
IRS
Total Amount of
Purpose of Grant
Morristown
Newark
Newark
New Brunswick
New Brunswick
New Brunswick
Summit
Summit
Summit
Morristown
Paterson
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
NJ
07960
07112‐2027
07112‐2027
08901
08901
08901
07902
07902
07902
07960‐2934
07544
22‐3392808
22‐3452311
22‐3452311
23‐7313160
23‐7313160
23‐7313160
51‐0194054
51‐0194054
51‐0194054
74‐1005756
76‐0480063
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
8,380 Screening
41,987 Education
21,750 Treatment
31,406 Education
94,219 Screening
31,406 Treatment
16,650 Education
36,629 Screening
13,320 Treatment
20,004 Education
1,122,200
NM100‐Central New Mexico Affiliate of the Susan G. Komen Brea Attn: Corinne Collins P.O. Box 5038
Cancer Institute Foundation
Attn: Corinne Collins P.O. Box 5038
Cancer Institute Foundation
10501 Montgomery Blvd. NE, Ste 300 American Cancer Society
YWCA Middle Rio Grande 210 Truman NE
YWCA
7155 E 38th Ave Planned Parenthood of New Mexcio
5301 Central NE #800 Anita Salas Memorial fund
3411 Candelaria Rd. NE Suite M People Living Through Cancer
Breast and Cervical Cancer 5301 Central Ave. Suite 800
New Mexico Department of Health
Santa Fe
Santa Fe
Albuquerque
Albuquerque
Denver
Albuquerque
Albuquerque
Albuquerque
NM
NM
NM
NM
CO
NM
NM
NM
87502
87502
87111
87108
80207
87108
87107
87108
41‐2079799
41‐2079799
74‐1185665
85‐0107101
85‐0197745
85‐0311210
85‐0324330
85‐6000565
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
6,000 Education
14,000 Treatment
19,500 Treatment
20,000 Treatment
30,000 Education
48,200 Screening
200,000
NV100‐The Las Vegas Chapter of the Susan G. Komen Breast Canc 823 South 6th Street R.E.A.C.H.
823 South 6th Street R.E.A.C.H.
O'Callaghan Integrated Oncology Network 2021 Park Way North
ORION
O'Callaghan Integrated Oncology Network 2021 Park Way North
ORION
4770 Harrison Road Suite 200
Volunteers In Medicine of Southern Nevad
4770 Harrison Road Suite 200
Volunteers In Medicine of Southern Nevad
4131 Swenson Street Center for Compassionate Care
R.E.D. Rose Program‐Holly Lyman 3001 St. Rose Parkway
St Rose Dominican Health Foundation
R.E.D. Rose Program‐Holly Lyman 3001 St. Rose Parkway
St Rose Dominican Health Foundation
WomensCare Breast Cancer Support 3001 St. Rose Parkway
St. Rose Dominican Health Foundation
3223 Research Way Nevada Health Centers
250 N. Highway 160 Suite 4
Nye County Health and Human Services
1930 Village Center Circle Suite #3‐531
Smiles for Survivors
Las Vegas
Las Vegas
Las Vegas
Las Vegas
Las Vegas
Las Vegas
Las Vegas
Henderson
Henderson
Henderson
Carson City
Carson City
Carson City
Pahrump
Las Vegas
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
89101
89101
89106
89106
89121
89121
89119
89015
89015
89052
89706
89706
89706
89060
89134
26‐4575003
26‐4575003
27‐1732991
27‐1732991
39‐2072453
39‐2072453
45‐0473026
88‐0349432
88‐0349432
88‐0349432
94‐3199117
94‐3199117
94‐3199117
88‐6000111
26‐4749691
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
21,736 Education
21,736 Treatment
24,308 Screening
137,746 Treatment
12,541 Education
71,064 Screening
57,255 Treatment
150,000 Screening
150,000 Treatment
39,390 Treatment
44,634 Education
89,267 Screening
14,878 Treatment
7,500 Treatment
848,055
NV101‐Northern Nevada Affiliate of the Susan G. Komen Breast C 1450 Ridgeview Drive, Suite 200 HAWC Community Health Center
1450 Ridgeview Drive, Suite 200 HAWC Community Health Center
1155 Mill Street Reno Cancer Foundation
P. O. Box 2508 Tahoe Forest Health System Foundation
Reno
Reno
Reno
Truckee
Carson City
NV
NV
NV
CA
NV
89519
89519
89502‐1576
96160
89706
88‐0293149
88‐0293149
88‐6002500
94‐3047869
94‐3199117
501c3
501c3
501c3
501c3
501c3
18,856 Education
33,522 Screening
35,091 Treatment
41,344 Screening
138,001
NY100‐The Western New York Affiliate of the Susan G. Komen Bre 35 State Street Research foundation of state univ. of NY
864 Delaware Ave International Institute of Buffalo
207 Foote Avenue WCA Hospital ‐ Jamestown
Elm & Carlton Sts National Witness Project
Elm & Carlton Sts National Witness Project
Elm & Carlton Sts, RSC 234 Roswell Park Alliance Foundation.
2495 Main St., Suite 446 Deaf Adult Services Inc.
2495 Main St., Suite 446 Deaf Adult Services Inc.
16 Bank Street Genesee Cancer Assistance
16 Bank Street Genesee Cancer Assistance
95 Franklin Street, Room 979 Erie County Dept of Health
95 Franklin Street, Room 979 Erie County Dept of Health
County Office Bldg., 7 Court Street Allegany Cnty Health Dept.
Albany
Buffalo
Buffalo
Buffalo
Jamestown
Jamestown
Jamestown
Buffalo
Buffalo
Buffalo
Buffalo
Buffalo
Buffalo
Buffalo
Batavia
Batavia
Buffalo
Buffalo
Belmont
Belmont
Belmont
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
12207‐2826
14209
14209
14209
14701
14701
14701
14263
14263
14263
14263
14263
14214
14214
14020
14020
14202
14202
14813
14813
14813
14‐1368361
16‐0743052
16‐0743052
16‐0743052
16‐0743226
16‐0743226
16‐0743226
16‐1391608
16‐1391608
16‐1391608
16‐1391608
16‐1391608
16‐1433932
16‐1433932
16‐1510816
16‐1510816
16‐6002558
16‐6002558
52‐2046033
52‐2046033
52‐2046033
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
Page 21 of 34
16,327 Education
6,531 Screening
9,796 Treatment
25,087 Education
15,052 Screening
10,035 Treatment
39,278 Education
39,278 Screening
48,647 Education
22,452 Screening
5,742 Treatment, Education
14,000 Education
6,000 Treatment
18,850 Treatment
47,717 Treatment
10,612 Education
11,117 Screening
28,803 Treatment
ATTACHMENT 5
EIN # 75‐2462834
2012 Form 990
Schedule I, Part II
F
Recipient Name
Greater Emmanuel Temple Church
Niagara Falls Memorial Medical Center
Street Address
151‐161 Richmond Avenue 621 Tenth St. City
State
Zip
EIN #
IRS
Total Amount of
Purpose of Grant
Buffalo
Niagara Falls
NY
NY
14222
14302
16‐6083033
16‐0743094
501c3
501c3
6,233 Education
428,090
NY101‐Central New York Affiliate of the Susan G. Komen Breast C 1001 West Street Carthage Area Hospital
8 Dill Street Cayuga Cty Dept: Health & Human Services
7785 North State St. Lewis County Health Department
185 Genesee Street, 5th Floor Oneida County Department of Health
185 Genesee Street, 5th Floor Oneida County Department of Health
421 Montgomery St., 9th Floor,Civic Ctr. Onondaga County Health Department
421 Montgomery St., 9th Floor,Civic Ctr. Onondaga County Health Department
Attn. Kindra Cousineau 80 State Highway 310, Suite 2
St Lawrence County Public Health Dept
Attn. Stacy Portella 500 Red Creek Dr., Suite 130
Highland Hospital & Partners
Cancer Service Prgrm of Monroe County 46 Prince Street
University of Rochester
50 Leroy Street Canton‐Potsdam Hospital
700 Oswego St Spanish Action League
635 James Street ARISE
635 James Street ARISE
736 Irving Avenue Crouse Hospital
736 Irving Avenue Crouse Hospital
24 Conkey Avenue Chenango Health Network
973 James St., Suite 250 St Joseph's Hosp. Health Cntr Foundation
Carthage
Auburn
Lowville
Lowville
Lowville
Utica
Utica
Syracuse
Syracuse
Canton
Rochester
Rochester
Potsdam
Syracuse
Syracuse
Syracuse
Syracuse
Syracuse
Norwich
Norwich
Norwich
Syracuse
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
13619
13021
13367
13367
13367
13501
13501
13202
13202
13617‐1476
14623
14607
13676
13204
13203‐2226
13203‐2226
13210
13210
13815
13815
13815
13203
15‐0622079
15‐6000450
15‐6000458
15‐6000458
15‐6000458
15‐6000460
15‐6000460
15‐6000458
15‐6000458
15‐6000465
16‐0743037
16‐0743209
16‐1012691
16‐1023352
16‐1186293
16‐1186293
16‐1576637
16‐1576637
52‐1987010
52‐1987010
52‐1987010
55‐0810542
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
20,773 Education
10,000 Education
8,000 Screening
22,000 Treatment
15,600 Education
57,850 Education
7,150 Screening
25,000 Education
29,066 Education
7,267 Treatment
27,495 Education
14,805 Screening
8,800 Education
19,360 Screening
7,040 Treatment
421,015
NY102‐Elmira Affiliate of the Susan G. Komen Breast Cancer Foun 80 Hawley Street YWCA of Binghamton/Broome
Falck Cancer Center 600 Roe Avenue
Arnot Ogden Medical Center
211 Lake Street YWCA of Elmira
15 Public Square, Suite 600 Maternal & Family Health Services
960 Penn Avenue, Suite 600 Adagio Health Inc
PO Box 97 S'AY Rural Health Network
Binghamton
Elmira
Elmira
Wilkes‐Barre
Pittsburgh
Pittsburgh
Conring
Conring
Conring
NY
NY
NY
PA
PA
PA
NY
NY
NY
13901
14905
14901
18701
15222‐3812
15222‐3812
14830
14830
14830
15‐0564074
16‐0743905
16‐0767225
23‐1856766
23‐7104168
23‐7104168
55‐0810542
55‐0810542
55‐0810542
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
15,000 Education
20,000 Treatment
5,708 Education
13,318 Screening
7,280 Education
6,240 Screening
7,280 Treatment
107,250
NY103‐Northeastern New York Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
100 Park Street Glens Falls Hospital
100 Park Street Glens Falls Hospital
Women's Health Center 2212 Burdett Ave.
NE Health/Samaritan Hospital
Women's Health Center 2212 Burdett Ave.
NE Health/Samaritan Hospital
44 Washington Ave. YWCA of Schenectady
450 Salmon River Road Community Link Mobile Health
450 Salmon River Road Community Link Mobile Health
Image Enhancement & Other Support 410 Kenwood Ave
To Life!
19 Cambridge Road Camp Bravehearts, Inc.
3740 Rynex Corners Rd Peaceful Acres Horses, Inc.
2 Lyon Place American Cancer Society
125 Wolf Road Suite 124
Cap. Reg. Action Against Breast Cancer
PO Box 167 Creative Healing Connections
160 Stone Street Planned Parenthood of the North Country
Glens Falls
Glens Falls
Rensselaer
Rensselaer
Schenectady
Platttsburgh
Platttsburgh
Delmar
Albany
Pattersonville
White Plains
White Plains
White Plains
Albany
Keene,
Watertown
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
12801
12801
12180
12180
12305
12901
12901
12054
12203
12137
10601
10601
10601
12205
12942
13601
14‐1338413
14‐1338413
14‐1338544
14‐1338544
14‐1340139
14‐1603303
14‐1603303
14‐1808431
23‐3066704
26‐2219064
58‐0659875
58‐0659875
58‐0659875
16‐0919175
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
24,200 Education
5,800 Treatment
18,900 Education
11,100 Screening
30,000 Education
12,500 Education
12,500 Screening
30,000 Education
30,000 Education
30,000 Treatment
12,000 Education
9,000 Screening
9,000 Treatment
12,224 Education
16,139 Education
298,286
NY104‐Greater New York City Affiliate of the Susan G. Komen Bre 1 South Avenue P.O. Box 701
Adelphi NY Statewide Hotline & Support
585 Schnectady Avenue Kingsbrook Jewish Medical Center
4500 Parsons Blvd. Flushing Hospital Medical Center
Central Suffolk Hospital 1300 Roanoke Avenue
Peconic Bay Medical Center
540 Fulton Avenue Planned Parenthood of Nassau Cty, Inc
One Helen Keller Way, 5th Fl Nassau/Suffolk Law Svcs Committee, Inc
121 Dekalb Avenue Brooklyn Hospital Center
Jack D. Weiler Hospital 1825 Eastchester Road
Montefiore Medical Center
160 North Midland Avenue Nyack Hospital
4422 Third Avenue St Barnabas Hospital
4422 Third Avenue St Barnabas Hospital
Garden City
Brooklyn
Flushing
Riverhead
Hempstead
Hempstead
Brooklyn
Bronx
Nyack
Bronx
Bronx
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
11530‐0701
11203
11355
11901
11550
11550
11201
10461
10960‐1998
10457
10457
11‐1630741
11‐1631759
11‐1631781
11‐1661359
11‐1776035
11‐2125411
11‐2936410
13‐1740114
13‐1740119
13‐1740122
13‐1740122
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
96,870 Treatment
72,675 Education
99,908 Education
99,999 Screening
100,000 Education
94,300 Treatment
97,800 Treatment
99,205 Treatment
99,866 Screening
85,580 Education
29,867 Screening
Page 22 of 34
14-1807124
26-1788222
ATTACHMENT 5
EIN # 75‐2462834
2012 Form 990
Schedule I, Part II
F
Recipient Name
St. John's Riverside Health System
YWCA White Plains & Central Westchester
Cancer Care Inc.
Memorial Sloan Kettering Cancer Center
Memorial Sloan Kettering Cancer Center
Project Renewal
Lincoln Medical & Mental Health Center
Woodhull Medical & Mental Health Center
Open Door Family Medical Centers
Ryan ‐ NENA Community Health Center
St. Luke's ‐ Roosevelt Hospital
God's Love We Deliver
New York Legal Assistance Group
The Family Center
Independence Care System
Gilda's Club New York City Inc.
Columbia University
United Cerebral Palsy of NYC, Inc
City Bar Justice Center
Korean Community Services
Chemo Comfort, Inc.
Richmond University Medical Center
Chai Lifeline, Inc.
Charles B Wang Community Health Ctr Inc
Michael Callen‐Audre Lorde
North Shore LI Jewish Health System
The Ralph Lauren Center for Cancer Care
Street Address
967 N. Broadway 515 North Street 275 Seventh Ave 633 Third Avenue, 28th Floor 633 Third Avenue, 28th Floor 200 Varick Street, 9th Fl 234 East 149th Street Room 9A‐5I
760 Broadway 165 Main Street 110 West 97th Street 1090 Amsterdam Ave. Suite 10A 166 Avenue of the Americas Legalhealth 7 Hanover Square, 18th Floor
315 West 36th Street 4th Floor
275 Park Avenue South 2nd Floor
195 West Houston Street Office of Grants & Contracts 722 West 168rh St, RM 734
80 Maiden Lane 42 West 44th Street 2 West 32nd St. #604 81 Bedford St., Suite 1A 355 Bard Avenue Room 625
151 West 30th Streeet, 3rd Floor 268 Canal St Community Health Center 356 West 18th Street
270‐05 76th Avenue Cancer Care and Preventtion 1919 Madison Avenue
City
State
Zip
Yonkers
White Plains
New York
New York
New York
New York
Bronx
Brooklyn
Ossining
New York
New York
New York
New York
New York
New York
New York
New York
New York
New York
New York
New York
Staten Island
New York
New York
New York
New Hyde Park
New York
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
NY
10701
10605
10001
10017
10017
10014
10451
11206
10562
10025
10025
10013
10004
10018
10010‐7304
10014‐4803
10032
10038
10036
10001
10014
10310
10001
10013
10011
11040
10035
OH100‐Greater Cincinnati Affiliate of the Susan G. Komen Breast 234 Goodman Street, ML#0772 Barrett Cancer Ctr., University Hospital
7500 State Road Mercy Hospital Anderson
7500 State Road Mercy Hospital Anderson
898 Walnut Street YWCA of Greater Cincinnati
898 Walnut Street YWCA of Greater Cincinnati
580 Lincoln Park Blvd., Suite 200 Kettering Health Network
1275 North High St. Highland District Hospital
Attn: Lisa Western 2421 Auburn Avenue
Cancer Family Care, Inc.
Attn: Lisa Western 2421 Auburn Avenue
Cancer Family Care, Inc.
3333 Burnet Avenue, ML 7030 Cincinnati Children's Hospital Medical
3333 Burnet Avenue, ML 7030 Cincinnati Children's Hospital Medical
23 Jasper St. Premier Health Network
4918 Cooper Road Cancer Support Community Ohio
425 Home Street Brown County Health and Wellness Foundat
600 Wilson Creek Road Dearborn County Hospital
8385 State Route 821 Center for Appalachian Research in Cance
One Medical Village Drive St. Elizabeth Healthcare
One Medical Village Drive St. Elizabeth Healthcare
230 Medical Center Dr. Adams County Medical Foundation, Inc.
Cincinnati
Cincinnnati
Cincinnnati
Cincinnati
Cincinnati
Kettering
Hillsboro
Cincinnati
Cincinnati
Cincinnati
Cincinnati
Dayton
Cincinnati
Georgetown
Lawrence
Lawrence
Lawrence
Whipple
Whipple
Edgewood
Edgewood
Seaman
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
IN
IN
IN
OH
OH
KY
KY
OH
OH101‐The Northeast Ohio Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
224 W. Exchange Street Akron General Medical Center
224 W. Exchange Street Akron General Medical Center
3631 Perkins Ave., Suite 2A‐W Asian Services in Action
2725 Lincoln Street East Canton Community Clinic, Inc.
2725 Lincoln Street East Canton Community Clinic, Inc.
P.O. Box 309 SR 45 Columbiana County Health Dept
P.O. Box 309 SR 45 Columbiana County Health Dept
5550 Venture Drive Cuyahoga County Board of Health
5550 Venture Drive Cuyahoga County Board of Health
21139 Lorain Rd., Ste. 1 Journey of Hope
1320 Mercy Drive NW Mercy Medical Center
Akron
Akron
Cleveland
Canton
Canton
Whipple
Whipple
Lisbon
Lisbon
Parma
Parma
Cleveland
Canton
Canton
Canton
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
Page 23 of 34
EIN #
13‐1740128
13‐1740519
13‐1825919
13‐1924236
13‐1924236
13‐2602882
13‐2655001
IRS
Total Amount of
Purpose of Grant
11‐3418133
20‐597827
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
77,000 Screening
44,276 Education
100,000 Treatment
91,220 Education
50,000 Treatment
100,000 Screening
100,000 Treatment
79,730 Screening
100,000 Screening
75,000 Screening
88,121 Treatment
100,000 Treatment
100,000 Treatment
95,000 Treatment
80,000 Screening
76,350 Treatment
100,000 Treatment
84,033 Education
60,000 Treatment
83,000 Screening
16,485 Treatment
100,000 Treatment
76,876 Treatment
68,000 Education
72,500 Screening
90,039 Screening
84,649 Screening
3,168,349
45219
45255
45255
45202
45202
45429
45133
45219
45219
45229
45229
45409
45242
45167
47025
47025
47025
45788
45788
41017
41017
45693
26‐1594868
31‐0537085
31‐0537085
31‐0537518
31‐0537518
31‐0621866
31‐0653685
31‐0805286
31‐0805286
31‐0833936
31‐0833936
31‐1122883
31‐1287785
31‐6001668
35‐6006595
35‐6006595
35‐6006595
45‐0678814
45‐0678814
61‐0445850
61‐0445850
76‐0801729
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
49,364 Education
19,753 Education
28,011 Screening
10,467 Education
50,144 Screening
20,000 Education
24,000 Education
44,440 Education
436,440 Treatment
12,025 Education
21,725 Screening
20,000 Education
36,280 Education
15,000 Education
14,352 Education
46,775 Screening
28,704 Treatment
9,334 Education
21,778 Screening
8,873 Education
272,753 Screening
20,000 Education
1,210,217
44307
44307
44114
44707
44707
45788‐5169
45788‐5169
44432
44432
44130
44130
44126
44708‐2614
44708‐2614
44708‐2614
34‐0714478
34‐0714478
34‐1798850
34‐1709801
34‐1709801
45‐0678814
45‐0678814
34‐6000745
34‐6000745
34‐6000817
34‐6000817
34‐1936925
52‐0591658
52‐0591658
52‐0591658
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
13-2655001
13‐2813113
13‐2884976
13‐2997301
13‐3366846
13‐3505428
13‐3910716
13‐3964284
13‐4046652
13‐5598093
13‐5654532
13‐6003018
23‐7348989
65‐1169320
74‐3177454
11-2940331
11‐2940331
13-3409680
17,052 Education
60,458 Screening
18,000 Education
18,000 Screening
40,908 Education
61,363 Screening
28,252 Education
15,213 Screening
18,600 Education
105,400 Screening
32,180 Treatment
30,000 Education
30,000 Screening
30,000 Treatment
ATTACHMENT 5
EIN # 75‐2462834
2012 Form 990
Schedule I, Part II
F
Recipient Name
Mercy Regional Medical Center
Mercy Regional Medical Center
MetroHealth Foundation
Northeast Ohio Neighborhood Services
South Pointe Hospital
South Pointe Hospital
Summa Health System Hospitals
Summa Health System Hospitals
Trinity Medical Health System
Trinity Medical Health System
University Hospital
University Hospital
University Hospital
University Hospital
University Hospitals Geneva Medical
University Hospitals Geneva Medical
Wheeling Hospital Inc.
Street Address
3700 Kolbe Rd. 3700 Kolbe Rd. 2500 Metro Health Drive 2500 Metro Health Drive 2500 Metro Health Drive 4800 Payne Avenue 4800 Payne Avenue 4800 Payne Avenue 20000 Harvard Road 20000 Harvard Road 75 Arch Street, Suite 105 75 Arch Street, Suite 105 380 Summit Avenue 380 Summit Avenue Seidman Cancer Center Attn: Hermione Malone
Seidman Cancer Center Attn: Hermione Malone
c/o Komen Northeast Ohio 26210 Emery Road, Suite 307
c/o Komen Northeast Ohio 26210 Emery Road, Suite 307
870 West Main Street 870 West Main Street Breast Center Wheeling Hospital One Medical Park
OH102‐Columbus Affiliate of the Susan G. Komen Breast Cancer F 272 Hospital Road Adena Health System
272 Hospital Road Adena Health System
272 Hospital Road Adena Health System
5555 Frantz Road American Cancer Society
454 E. Clearview Ave. Asian‐American Community Service Council
454 E. Clearview Ave. Asian‐American Community Service Council
1280 North Court Street Berger Hosptial
401 North Ewing Fairfield Medical Center Foundation
401 North Ewing Fairfield Medical Center Foundation
1430 Columbus Avenue Fayette County Memorial Hospital
1135 Maple Ave Genesis Healthcare System
Southeastern Ohio Reg. Med. Ctr. 1341 Clark Street
Guernsey Health Systems
100 Jackson Pike Holzer Medical Center
660 Ackerman Road James Cancer Hospital
660 Ackerman Road James Cancer Hospital
1330 Coshocton Avenue Knox Community Hospital
675 Price Road Licking County Health Department
1699 W. Mound Street Lifecare Alliance
210 North Main Street PO Box 651
Madison County Health Partners
210 North Main Street PO Box 651
Madison County Health Partners
210 N Main Street Madison County Hospital
PO Box 97 Marietta Memorial Health Foundation
117 East Memorial Dr. Ste. 5, PO Box 85 Meigs County Cancer Initiative
117 East Memorial Dr. Ste. 5, PO Box 85 Meigs County Cancer Initiative
500 London Avenue Memorial Hospital of Union County
6150 East Broad Street Mount Carmel Health System Foundation
Research & Sponsored Programs 105 Research & Technology
Ohio University
Research & Sponsored Programs 105 Research & Technology
Ohio University
180 East Broad Street, 31st Floor OhioHealth Foundation
180 East Broad Street, 31st Floor OhioHealth Foundation
City
State
Zip
EIN #
IRS
Lorain
Lorain
Cleveland
Cleveland
Cleveland
Cleveland
Cleveland
Cleveland
Warrensville Heights
Warrensville Heights
Akron
Akron
Steubenville
Steubenville
Cleveland
Cleveland
Cleveland
Cleveland
Geneva
Geneva
Wheeling
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
WV
44053‐1697
44053‐1697
44109
44109
44109
44103
44103
44103
44122
44122
44304
44304
43952
43952
44106‐5065
44106‐5065
44128
44128
44041
44041
26003‐6379
34‐0714704
34‐0714704
34‐6607695
34‐6607695
34‐6607695
34‐1014291
34‐1014291
34‐1014291
34‐0714585
34‐0714585
34‐6002767
34‐6002767
34‐0875691
34‐0875691
34‐0714775
34‐0714775
34‐0714775
34‐0714775
34‐0714461
34‐0714461
55‐0357057
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
Chillicothe
Chillicothe
Chillicothe
Dublin
Worthington
Worthington
Circleville
Whipple
Whipple
Lancaster
Lancaster
Washington Court House
Zanesville
Cambridge
Gallipolis
Gallipolis
Gallipolis
Columbus
Columbus
Ashland
Mount Vernon
Mount Vernon
Mount Vernon
Newark
Columbus
Columbus
Columbus
London
London
London
London
London
Marietta
Pomeroy
Pomeroy
Marysville
Marysville
Marysville
Columbus
Columbus
Columbus
Athens
Athens
Columbus
Columbus
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
KY
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
45601
45601
45601
43017
43085
43085
43113
45788
45788
43130
43130
43160
43701
43725
45631
45631
45631
43218
43218
41101
43050
43050
43050
43055
43223
43223
43223
43140
43140
43140‐1115
43140‐1115
43140‐1115
45750
45769
45769
43040
43040
43040
43213
43213
43213
45701
45701
43215
43215
31‐4379443
31‐4379443
31‐4379443
74‐1185665
31‐1422583
31‐1422583
33‐1031454
45‐0678814
45‐0678814
20‐8952945
20‐8952945
31‐1526002
31‐1480941
31‐1148352
31‐0927482
31‐0927482
31‐0927482
31‐1301428
31‐1301428
61‐0503715
31‐0929576
31‐0929576
31‐0929576
30‐0332439
31‐4379494
31‐4379494
31‐4379494
20‐2375865
20‐2375865
23‐7423524
23‐7423524
23‐7423524
31‐1011321
31‐1712900
31‐1712900
31‐6402480
31‐6402480
31‐6402480
31‐1113966
31‐1113966
31‐1113966
31‐6402113
31‐6402113
23‐7446919
23‐7446919
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
Page 24 of 34
Total Amount of
Purpose of Grant
13,800 Education
9,200 Screening
72,569 Education
46,180 Screening
13,194 Treatment
44,000 Education
16,000 Screening
20,000 Treatment
57,332 Education
29,535 Screening
35,000 Education
17,175 Education
51,525 Screening
54,874 Education
23,517 Screening
9,093 Education
51,529 Screening
48,667 Education
20,857 Screening
8,600 Screening
1,187,800
15,944 Education
44,933 Screening
11,596 Treatment
75,000 Screening
40,203 Education
30,328 Screening
19,622 Education
29,432 Screening
6,245 Education
15,453 Education
37,086 Screening
9,272 Treatment
8,079 Education
32,314 Screening
19,075 Screening
6,715 Education
58,756 Screening
18,466 Treatment
9,406 Education
58,840 Screening
16,811 Treatment
8,319 Education
33,277 Screening
14,717 Education
19,812 Screening
22,076 Treatment
20,910 Education
21,763 Screening
7,105 Education
33,493 Screening
10,149 Treatment
36,836 Education
28,871 Screening
33,849 Treatment
9,970 Education
56,496 Screening
31,037 Education
152,780 Screening
ATTACHMENT 5
EIN # 75‐2462834
2012 Form 990
Schedule I, Part II
F
Recipient Name
OhioHealth Foundation
Ohiohealth Research Institute
Perry County Health Department
Ross County Health District
Ross County Health District
Sisters Network Columbus OH
Southern Ohio Medical Center
Southern Ohio Medical Center
The Community Mercy Foundation
The Ohio State University College
Vinton County Health dept
YMCA
YMCA
Young Survival Coalition
Street Address
180 East Broad Street, 31st Floor 3545 Olentangy River Road Suite 414
212 South Main Street,P.O. Box 230 212 South Main Street,P.O. Box 230 212 South Main Street,P.O. Box 230 475 Western Avenue Suite A
475 Western Avenue Suite A
P.O. Box 137 1121 Kinneys Lane 1121 Kinneys Lane 1 South Limestone Street Suite 700
Office of Sponsored Programs 1960 Kenny Rd.
31927 State Route 93 31927 State Route 93 31927 State Route 93 100 Mill Street 100 Mill Street 6990 Hillsdale Ct 6990 Hillsdale Ct City
State
Zip
EIN #
IRS
Total Amount of
Purpose of Grant
Columbus
Columbus
New Lexington
New Lexington
New Lexington
Chillicothe
Chillicothe
Brice
Portsmouth
Portsmouth
Springfield
Columbus
McArthur
McArthur
McArthur
Chillicothe
Chillicothe
Indianapolis
Indianapolis
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
IN
IN
43215
43214
43764
43764
43764
45601
45601
43109
45662
45662
45502
43210‐1016
45651
45651
45651
45601
45601
46250
46250
23‐7446919
31‐6059784
31‐6400082
31‐6400082
31‐6400082
31‐6400085
31‐6400085
26‐2114262
31‐0678022
31‐0678022
31‐1443778
38‐1746722
31‐6400088
31‐6400088
31‐6400088
24‐0795516
24‐0795516
13‐4057685
13‐4057685
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
OH103‐Northwest Ohio Affiliate of the Susan G. Komen Breast Ca 2200 Randallia Drive Parkview Foundation, Inc.
Attn: Deborah Miller 417 Quarry Lakes Drive
North Coast Cancer Foundation
269 Portland Way South Bucyrus Community Hospital LLC
3231 Central Park West Drive, Suite 200 Hospital Council of Northwest Ohio, Inc.
1900 South Main Street Blanchard Valley Health System
5532 W. Central Ave., Suite B The Victory Center
511 Perry Street Raven's Care, Inc.
2213 Cherry Str., ACC Bldg, Ste 307 Mercy Health Partners
2213 Cherry Str., ACC Bldg, Ste 307 Mercy Health Partners
730 W. Market St. Rita's Medical Center
Attn: Bonnie Gratop, LSW, OSW‐C 5200 Harroun Rd.
Flower Hospital
Attn: Bonnie Gratop, LSW, OSW‐C 5200 Harroun Rd.
Flower Hospital
219 E Market Street Allen County Health Department
256 Williamstown Rd. P.O. Box 330
Putnam County Health Department
71 S. Washington St. Suite 1102
Seneca County General Health District
Grants Accounting MS‐455 2801 West Bancroft
The University of Toledo
1840 E. Gypsy Lane Road Wood County Health Department
127‐A South Sandusky Avenue Wyandot County General Health District
Attn: Gail Gedelian 718 N. Macomb St.
Mercy Memorial Hospital
3231 Central Park West, Suite 200 Toledo‐Lucas County CareNet
4727 Sylvania Avenue NIghtingale's Harvest
Student Recreation Center 1411 Ridge Street
Bowling Green State University
1111 Hayes Avenue Firelands Regional Medical Center
1001 Bellfontaine Avenue Lima Memorial Health System
Fort Wayne
Sandusky
Galion
Toledo
Toledo
Toledo
Findlay
Toledo
Definance
Toledo
Toledo
Lima
Sylvania
Sylvania
Lima
Ottawa
Tiffin
Toledo
Bowling Green
Upper Sandusky
Monroe
Toledo
Toledo
Toledo
Whipple
Toledo
Bowling Green
Sandusky
Lima
IN
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
OH
MI
OH
OH
OH
OH
OH
OH
OH
OH
46805
44870
44833‐2312
43617
43617
43617
45840
43615
43512
43608
43608
45801
43560
43560
45801
45875‐0330
44883
43606
43402
43351
48162
43617
43617
43617
45788
43623
43403
44870
45804
23‐7220589
26‐0270967
27‐4283931
34‐1116795
34‐1116795
34‐1116795
34‐1370522
34‐1767997
34‐1809898
34‐4428250
34‐4428250
34‐4428265
34‐4428794
34‐4428794
34‐6400019
34‐6401116
34‐6401331
34‐6401483
34‐6401607
34‐6401620
38‐1984289
43‐1986672
43‐1986672
43‐1986672
45‐0678814
61‐1647237
34‐6402018
34‐1401660 34‐1883284 501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
40,000 Education
6,200 Education
91,760 Screening
26,040 Treatment
17,000 Education
8,000 Education
7,500 Education
42,500 Screening
8,000 Treatment
34,850 Screening
50,150 Treatment
10,100 Screening
6,000 Education
6,626 Education
53,008 Screening
6,626 Treatment
8,000 Education
10,000 Education
675,033
OK100‐Central Oklahoma Chapter of the Komen Foundation, Inc.
Community Health Centers, Inc
Community Health Centers, Inc
Oklahoma City Indian Clinic
Oklahoma City Indian Clinic
Latino Community Development Agency
OU Health Sciences Cntr‐OU Breast Instit
OU Health Sciences Cntr‐OU Breast Instit
Mercy Health Center
OU Womens Outreach Center
Midwest City
Midwest City
Oklahoma City
Oklahoma City
Oklahoma City
Oklahoma City
Oklahoma City
Oklahoma City
Norman
OK
OK
OK
OK
OK
OK
OK
OK
OK
73140‐3589
73140‐3589
73127
73127
73109
73104
73104
73120
73069
73‐0930123
73‐0930123
73‐0955756
73‐0955756
73‐1424239
73‐1477155
73‐1477155
73‐1593024
73‐6017987
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
11,846 Education
106,618 Screening
40,791 Education
61,187 Screening
44,250 Education
47,455 Education
142,366 Screening
124,786 Screening
29,402 Education
608,701
Tulsa
Tulsa
Tulsa
Tulsa
Tulsa
OK
OK
OK
OK
OK
74120‐3820
74120‐3820
74106
74106
74159
73‐1042545
73‐1042545
73‐1177858
73‐1177858
73‐1616817
501c3
501c3
501c3
501c3
501c3
26,990 Education
152,944 Screening
90,000 Education
90,000 Screening
45,000 Education
P.O. Box 30589 P.O. Box 30589 4913 W. Reno Ave. 4913 W. Reno Ave. 420 SW 10th 825 N.E. 10th Street OUPB 3500
825 N.E. 10th Street OUPB 3500
4300 W. Memorial Rd, Tower Suite 301 900 Asp Avenue Room 247 OK101‐Tulsa Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
550 South Peoria Indian Health Care Resource Ctr of Tulsa
550 South Peoria Indian Health Care Resource Ctr of Tulsa
1334 N. Lansing Avenue Morton Comprehensive Health Services
1334 N. Lansing Avenue Morton Comprehensive Health Services
P. O. Box 14026 Tulsa Project Women Inc.
Page 25 of 34
67,118 Treatment
16,319 Education
19,755 Screening
6,871 Treatment
10,130 Education
91,168 Screening
8,341 Education
55,824 Screening
21,000 Screening
23,634 Education
15,953 Screening
19,498 Treatment
19,120 Education
8,194 Treatment
19,157 Education
6,386 Treatment
1,898,838
ATTACHMENT 5
EIN # 75‐2462834
2012 Form 990
Schedule I, Part II
F
Recipient Name
Tulsa Project Women Inc.
Street Address
P. O. Box 14026 City
State
Zip
EIN #
IRS
Total Amount of
Purpose of Grant
Tulsa
OK
74159
73‐1616817
501c3
135,000 Screening
539,934
OR100‐The Oregon and Southwest Washington Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc
351 SW 9th St. Saint Alphonsus Medical center ‐ Ontario
712 Jay St. PO Box 307
Asher Community Health
0330 SW Curry St. American Cancer Society
1040 S. Henderson St. Sea‐Mar Community Health Centers
ATTN: Summer Goff PO Box 47855
State of Washington DOH
1700 East 19th Street Mid‐Columbia Health Foundation
2710 NE 14th Avenue Familias en Accion
Department of Human Services 800 NE Oregon St., Ste 370
OBCCP
444 NW Elks Drive Attn: Judy Corwin
Corvallis Clinic Foundation
PO Box 4484 Emanuel Medical Center Foundation
2740 SE Powell Blvd., #5 Attn: Director of Social Services
Catholic Charities
138 NE 3rd St. Suite 140 Catholic Charities El Programa Hispano
2880 NW Stewart Parkway, Suite 100 Community Cancer Foundation
4033 SE Woodstock Blvd. Ecumenical Ministries of Oregon
557 W. Washington Harney District Hospital
230 Rowe St., P.O. Box 176 Rinehart Clinic
123 International Way Sacred Heart Medical
815 NW 9th St., Suite 136 Samaritan Health Services INC
Ontario
Fossil
Portland
Seattle
Olympia
The Dalles
Portland
Portland
Corvallis
Portland
Portland
Gresham
Roseburg
Portland
Burns
Wheeler
Springfield
Corvallis
OR
OR
OR
WA
WA
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
97914
97830
97239
98108
98504‐7855
97058
97212
97232
97330
97208‐4484
97202
97030
97471
97202
97720
97147
97447
97330
27‐1789847
38‐3692646
84‐1316555
91‐1020139
91‐1444603
93‐0854433
93‐1284335
93‐6001752
93‐6021898
93‐6095667
93‐0386801
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
35,000 Education
32,000 Education
110,000 Treatment
35,000 Education
65,000 Screening
32,760 Education
34,914 Education
547,917 Screening
31,071 Education
35,000 Education
44,000 Treatment
35,000 Education
95,000 Education
35,000 Education
25,615 Education
35,000 Education
35,000 Education
60,000 Education
1,323,277
PA100‐Philadelphia Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc
100 Medical Campus Dr. 2nd Flr. Founder's Building
Abington Health ‐ Lansdale Hospital
Attn: Monica Simon 1200 Old York Road
Abington Memorial Hosp
Development Ofc, Einstein Medical Ctr 5401 Old York Road
Albert Einstein Medical Center
245 North 6th Street Allentown Health Bureau
1501 Germantown Avenue Arab‐American Development
640 South State Street Bayhealth Medical Center
1217 Spring Garden Street, 1st Floor BEBASHI, Inc.
Attn Judith Ramirez, EdD 424 Savannah Road
Beebe Medical Center Tunnell Cancer Ctr
5412 North 5th Street Cambodian Assn of Greater Phila
Delaware Technology Park 1 Innovation Way, Suite 400
Cancer Care Connection
3400 Bath Pike Cancer Support Community of the Greater
4701 Ogletown‐Stanton Road Christiana Care Health Services
4701 Ogletown‐Stanton Road Christiana Care Health Services
3801 Market Street Consortium, Inc.
3 Executive Campus, Route 70, Suite 310 Cooper Health System
One Medical Center Blvd Crozer‐Chester Foundation
One Medical Center Blvd Crozer‐Chester Foundation
Delaware County Regional Cancer Ctr 501 N. Lansdowne Avenue
Delaware County Regional Cancer Center
Delaware County Regional Cancer Ctr 501 N. Lansdowne Avenue
Delaware County Regional Cancer Center
1412 Fairmount Avenue Delaware Valley Community Health, Inc.
3201 Arch Street Drexel University College Of Medicine
1108 S. 5th Street, Suite 20 Greater Phila Overseas Chinese Assn
260 S. Broad Street 18th Floor
Health Promo Council of SE PA
925 Chestnut Street, Suite 320A Jefferson Kimmel Cancer Center
731 West Cypress Street La Comunidad Hispana
216 N. Race Street La Esperanza, Inc.
Lancaster Gen Wellness Ctr. & Gen Health 2100 Harrisburg Pike, P.O. Box 3200
Lancaster General Hospital
1445 City Avenue, Suite 6B Living Through Cancer
21 S. 12th Street, 12th Floor Mazzoni Center
325 South Belmont Street Memorial Health
2323 Ranstead Street Metropolitan Area Neighborhood Nutrition
260 S. Broad Street National Nursing Centers Consortium
1600 Haddon Avenue Our Lady of Lourdes Health Foundation
420 Old York Road Penn Asian Senior Services
642 North Broad Street Philadelphia Corporation for Aging
Ambulatory Health ‐Suite 360 500 South Broad Street
Philadelphia Dept. of Public Health
6705 Old York Road Philip Jaisohn Foundation
2470 Sunset Lake Road Practice without Pressure
818 Broadway Puerto Rican Unity For Progress
1711 S. Broad Street Southeast Asian Mutual Assistance Assoc.
Saint Mary Medical Center 1201 Langhorne‐Newtown Road
St. Mary Medical Center Foundation
Lansdale
Abington
Philadelphia
Allentown
Philadelphia
Dover
Philadelphia
Lewes
Philadelphia
Newark
Bethlehem
Newark
Newark
Philadelphia
Cherry Hill
Cherry Hill
Cherry Hill
Upland
Upland
Drexel Hill
Drexel Hill
Philadelphia
Philadelphia
Philadelphia
Philadelphia
Philadelphia
Kennett Square
Georgetown
Lancaster
Lancaster
Lancaster
Wynnewood
Philadelphia
York
Philadelphia
Philadelphia
Camden
Jenkintown
Philadelphia
Philadelphia
Philadelphia
Newark
Camden
Philadelphia
Langhorne
PA
PA
PA
PA
PA
DE
PA
DE
PA
DE
PA
DE
DE
PA
NJ
NJ
NJ
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
DE
PA
PA
PA
PA
PA
PA
PA
PA
NJ
PA
PA
PA
PA
DE
NJ
PA
PA
19446
19001
19141
18102
19122
19901‐3530
19123
19958
19120
19711
18017
19713
19713
19104
08002
08002
08002
19013
19013
19026
19026
19130
19104
19147‐5203
19102
19107
19348
19947
17602‐3200
17602‐3200
17602‐3200
19096
19107
17403
19103
19102
08103‐3101
19046
19130‐3409
19146
19126‐2841
19702
08103
19148
19047
26‐3359979
23‐1352152
23‐2290323
23‐6003116
31‐1620684
22‐2559843
23‐2484046
51‐0067938
23‐2169935
51‐0398061
73‐1653737
51‐0103684
51‐0103684
23‐1744721
21‐0634462
21‐0634462
21‐0634462
23‐1637191
23‐1637191
22‐2980746
22‐2980746
23‐2077750
23‐2979433
23‐2222723
23‐2182113
23‐1352651
23‐2041915
31‐1606956
Page 26 of 34
93-0386801
93-0748388
93-0625359
93-6002332
93-1191793
94-3076293
93-0951989
23-1352651
23-1352651
23-1352651
23‐1365353
23‐2176338
23‐1265004
23‐2586142
23-2176338
22‐2351960
20‐2643138
23‐1905649
23-1905649
23‐6003047
04‐3627646
22‐2158431
23‐2567468
23‐2567468
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
22,500 Education
100,000 Screening
30,000 Education
7,210 Education
30,000 Education
30,000 Education
29,708 Education
30,000 Education
35,000 Education
65,000 Screening
27,726 Education
64,378 Education
60,000 Screening
20,000 Treatment
65,000 Screening
35,000 Treatment
65,000 Screening
35,000 Treatment
30,000 Education
99,628 Screening
26,975 Education
30,000 Education
30,000 Education
20,344 Education
25,000 Education
50,000 Screening
25,000 Treatment
17,850 Education
30,000 Education
13,188 Education
30,000 Education
30,000 Education
41,081 Education
29,970 Education
22,435 Education
100,000 Screening
30,000 Education
29,986 Education
30,000 Education
30,000 Education
29,880 Education
ATTACHMENT 5
EIN # 75‐2462834
2012 Form 990
Schedule I, Part II
F
Recipient Name
The Breathing Room Foundation
The Wellness Community‐Delaware
Unemployment Information Center
Virtua Health
Street Address
120 S. York Road ‐ Suite 7 18947 John J. Williams Hwy, #312 112 North Braod Street, 11th Floor 2225 Evesham Rd., Suite 104 P.O. Box 386 City
State
Zip
EIN #
IRS
Total Amount of
Purpose of Grant
Hatboro
Rehoboth Beach
Philadelphia
Voorhees
Spring House
PA
DE
PA
NJ
PA
19040
19971
19102
08043
19477
23‐2916337
51‐0351863
23‐2000486
22‐3524939
13‐4057685
501c3
501c3
501c3
501c3
501c3
30,000 Treatment
30,000 Education
25,159 Education
49,302 Education
21,106 Education
2,038,569
PA101‐Pittsburgh Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
100 Mayfair Drive Satchels of Caring Foundations
Financial Dept at Indiana Regional Ctr. 835 Hospital Road
INDIANA REGIONAL MEDICAL CENTER
300 Halket Street MAGEE WOMENS HOSPITAL (HALKET ST)
300 Halket Street MAGEE WOMENS HOSPITAL (HALKET ST)
1500 Fifth Ave. UPMC McKeesport
305 Wood Street YWCA GREATER PITTSBURGH
Dept. of Physical Therapy‐Ofc. of Rsrch 123 University Place
University of Pittsburgh
Dept. of Physical Therapy‐Ofc. of Rsrch 123 University Place
University of Pittsburgh
320 E NORTH AVE ALLEGHENY SINGER RESEARCH INSTITUTE
320 EAST NORTH AVE West Penn ‐ Allegheny General Hospital
7 Glassworks Road Cornerstone Care, Inc.
300 Halket Street MAGEE WOMENS HOSPITAL (WARD ST)
241 W. Grant St., PO Box 189 Allied Coordinated Transportation Serv
Heritage valley Health System 100 Dutch Ridge Road
Valley Medical Facilities, Inc. / Herita
102 Cleveland Avenue Hair Peace Charities
187 Hospital Drive Tyrone Hospital
Pittsburgh
Pittsburgh
Pittsburgh
Pittsburgh
Indiana
Pittsburgh
Pittsburgh
McKeesport
Pittsburgh
Pittsburgh
Pittsburgh
Pittsburgh
Pittsburgh
Pittsburgh
Pittsburgh
Greensboro
Pittsburgh
New Castle
Beaver
Pittsburgh
Tyrone
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
15228‐1145
15222‐3812
15222‐3812
15222‐3812
15701
15213
15213
15132
15222
15213‐2303
15213‐2303
15212‐4756
15212‐4756
15212‐4756
15212‐4756
15338
15213
16103‐0189
15009‐9727
15202‐2302
16686
20‐1677474
23‐7104168
23‐7104168
23‐7104168
25‐0965404
25‐0965420
25‐0965420
25‐0965423
25‐0965639
25‐0966691
25‐0966691
25‐1320493
25‐1322626
25‐1322626
25‐1322626
25‐1346194
25‐1462312
25‐1530677
25‐1801532
56‐2524841
23‐1440116
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
10,020 Treatment
10,158 Education
899,610 Screening
7,493 Treatment
99,570 Education
24,861 Treatment
30,613 Education
19,140 Education
23,625 Treatment
52,964 Education
28,390 Screening
5,700 Treatment
25,000 Education
43,728 Treatment
25,391 Education
19,050 Treatment
7,500 Education
1,459,972
PA102‐The Northeastern Pennsylvania Chapter of the Susan G. Komen Breast Cancer Foundation
700 E Broad St. Northeastern Pennsylvania Health Corp.
100 Abington Executive Park Allied Services Foundation
Attn: Laura Toole 334 Jefferson Avenue
Northeast Regional Cancer Institute
190 Welles Street, Suite 120 Candy's Place
19 Cambridge Road Camp Bravehearts, Inc.
1020 Thompson Street Jersey Shore Hospital
One Hospital Drive Evangelical Community Hospital
231 East Brown Street Pocono Medical Center
Box 200 Physical Activity Intervention Surviving
3400 Bath Pike Cancer Support Community of the Greater
Wilkes‐Barre
Wilkes‐Barre
Wilkes‐Barre
Hazleton
Clarks Summit
Scranton
Forty Fort
Albany
Jersey Shore
Lewisburg
East Stroudsburg
Waverly
Bethlehem
PA
PA
PA
PA
PA
PA
PA
NY
PA
PA
PA
PA
PA
18701
18701
18701
18201
18411
18510
18704
12203
17740‐1794
17837
18301
18471
18017
23‐1856766
23‐1856766
23‐1856766
23‐2421970
23‐2523682
23‐2662214
23‐2973385
23‐3066704
24‐0792115
24‐0795411
24‐0795623
27‐2135231
73‐1653737
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
18,000 Education
101,250 Screening
30,750 Treatment
261,763
SC100‐Lowcountry Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
3226 Maybank Hwy. , Suite 1‐A Barrier Islands Free Medical Clinic, Inc
3226 Maybank Hwy. , Suite 1‐A Barrier Islands Free Medical Clinic, Inc
PO Box 200 United Way of BCH
PO Box 200 United Way of BCH
3400 Harden St. Ext. Alala Cancer Society
P.O.Box 100551, 555 E. Cheves St McLeod Health
PO Box 357, 721 Okatie, Hwy 170 Beaufort Jasper Hampton Comp Health
PO Box 357, 721 Okatie, Hwy 170 Beaufort Jasper Hampton Comp Health
Teresa Pischner 316 Calhoun Street
Roper St. Francis Healthcare
300 Singleton Ridge Road Conway Hospital Foundation, Inc.
Jean Accardi 20 Northridge Drive
Volunteers in Medicine
86 Jonathan Lucas St., MSC 955 PO Box 250955
MUSC Hollings Cancer Center
PO Box 218 Allendale County Hospital
PO Box 218 Allendale County Hospital
3000 St. Matthews Road Regional Med Center of Orangeburg
1800 St. Julian Place Best Chance Network
Johns Island
Johns Island
Walterboro
Walterboro
Columbia
Florence
Ridgeland
Ridgeland
Charleston
Charleston
Charleston
Conway
Hilton Head Island
Charleston
Fairfax
Fairfax
Orangeburg
Orangeburg
Orangeburg
Columbia
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
26455
26455
29488
29488
29203
29502‐0551
29936
29936
29401
29401
29401
29526
29926
29425
29827
29827
29118‐1498
29118‐1498
29118‐1498
29204
20‐5628911
20‐5628911
23‐7158388
23‐7158388
26‐1783126
51‐0473500
57‐0523586
57‐0523586
57‐0831165
57‐0831165
57‐0831165
57‐0870199
57‐0959206
57‐6000722
57‐6001334
57‐6001334
57‐6008010
57‐6008010
57‐6008010
75‐2844655
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
11,880 Education
22,063 Screening
19,248 Education
10,827 Screening
38,000 Treatment
32,760 Education
45,240 Screening
44,460 Education
27,300 Screening
6,240 Treatment
10,000 Screening
10,665 Education
48,585 Screening
8,262 Education
40,210 Screening
6,610 Treatment
80,000 Screening
678,484
SC101‐Upstate South Carolina Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
131 Commonwealth Dr Suite 220 Bon Secours St. Francis Health
Greenville
SC
29615
26‐0012031
501c3
Page 27 of 34
ATTACHMENT 5
EIN # 75‐2462834
2012 Form 990
Schedule I, Part II
F
Recipient Name
Cancer Association of Anderson
Cancer Society of Greenville County
Spartanburg Regional Healthcare System
Greenville Hospital System Cancer Center
Street Address
215 East Calhoun Street 113 Mills Avenue 113 Mills Avenue 113 Mills Avenue 101 E. Wood Street Cancer Center Attn: Lynette Bouldin
City
State
Zip
EIN #
IRS
Total Amount of
Purpose of Grant
Anderson
Greenville
Greenville
Greenville
Spartanburg
Greenville
SC
SC
SC
SC
SC
SC
29621
29605
29605
29605
29303
29605
54‐2098883
57‐0471686
57‐0471686
57‐0471686
57‐6000934
57‐6007863
501c3
501c3
501c3
501c3
501c3
501c3
41,950 Treatment
8,183 Education
5,208 Screening
61,302 Treatment
74,999 Screening
301,641
SD100‐South Dakota Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
c/o April Sorensen 1300 Oak St, PO Box 100
FAMC Breast Health Education & Screening
1000 E 23rd St. Avera Breast Center
1000 E 23rd St. Avera Breast Center
c/o Patty Kussman 353 Fairmont Blvd
John T Vucurevich Regional Cancer Care
1309 W 17th Street, Suite G01 Sanford Breast Health Institute
615 E 4th Str. All Women Count
Faulkton
Faulkton
Faulkton
Mandan
Mandan
Sioux Falls
Sioux Falls
Rapid City
Sioux Falls
Pierre
SD
SD
SD
ND
ND
SD
SD
SD
SD
SD
57438
57438
57438
58554
58554
57105‐2108
57105‐2108
57701
57104
57501
36‐3317416
36‐3317416
36‐3317416
45‐6004343
45‐6004343
46‐0224743
46‐0224743
46‐0319070
46‐0447693
46‐6000364
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
10,200 Education
10,200 Screening
5,100 Treatment
7,945 Screening
7,945 Treatment
6,309 Education
14,722 Treatment
24,000 Education
50,000 Screening
158,196
TN100‐Chattanooga Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
P.O. Box 182 1105 Memorial Drive
Northwest Georgia Healthcare Partnership
6120 Alabama Highway North Georgia Healthcare Center
2525 DeSales Avenue Memorial Health Care System Foundation
426 5th Ave. North, 6th Floor Cordell Hull Bldg.
TN Dept. of Health Breast/Cervical Scree
Dalton
Ringgold
Chattanooga
Nashville
GA
GA
TN
TN
30720‐8742
30736
37404
37243
58‐2043430
58‐2573259
62‐1839548
62‐6001445
501c3
501c3
501c3
501c3
42,558 Screening
137,991
TN101‐Upper Cumberland Affiliate of the Susan G. Komen Breast Cancer Foundation
1010 9th St YMCA
1010 9th St YMCA
421 South Main Street Cumberland Medical Center
P.O. Box 728 Warren County Educational Foundation
425 5th Ave. North, 4th Floor Cordell Hull Building
Tennessee Department of Health
1 Medical Center Boulevard Cookeville Regional Medical Center
Wichita Falls
Wichita Falls
Crossville
McMinnville
Nashville
Cookeville
TX
TX
TN
TN
TN
TN
76301
76301
38555
37111
37243‐3400
38501
24‐0795516
24‐0795516
62‐0790132
62‐1655194
62‐6001445
20‐1550666
501c3
501c3
501c3
501c3
501c3
501c3
6,750 Screening
15,750 Treatment
101,882
TN102‐Tri‐Cities Affiliate of the Susan G. Komen Breast Cancer Foundation
9000 Executive Park Dr, Suite 240 University of Tennessee
PO Box 2347 Cumberland Plateau Health District
134 Roberts AvenueSW Lenowisco Health District
201 Francis Marion Lane Virginia Department of Health Center
103 West Stone Drive Suite 101
Wellmont Health System
1420 Tusculum Blvd Laughlin Health Care Foundation
Breast & Cervical Screening Program 426 5th Ave. North, 4th Flr Cordell
TN Department of Health
Breast & Cervical Screening Program 426 5th Ave. North, 4th Flr Cordell
126 Poplar Grove Connector Appalachian District Health Dept.
4485 W. Stone Dr. Suite 200
Wellmont Holston Valley Medical Center
Knoxville
Lebanon
Wise
Marion
Kingsport
Greenville
Nashville
Nashville
Boone
Kingsport
TN
VA
VA
VA
TN
TN
TN
TN
NC
TN
37923
24266
24293
24354
37660‐3220
37745
37203
37203
28607
37660
31‐1626179
54‐6000175
54‐6001775
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
11,587 Screening
25,410 Screening
7,750 Education
69,750 Screening
345,000
TN103‐Knoxville Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
PO Box 577 Rural Medical Services, Inc.
PO Box 577 Rural Medical Services, Inc.
1915 White Ave., Second Flr., COS Thompson Cancer Survival Center
907 E. Lamar Alexander Pkwy Blount Memorial Cancer Center
9724 Kingston Pike, Suite 1000 Cathy L. Hodges Memorial Cancer Fdn
P.O. Box 540, 107 S. Main St. Dayspring Family Health Center
824 Tucker Place Way Celebrate Life Cancer Support Group
426 5th Ave. North TN Breast and Cervical Screening
1934 Alcoa Hwy, Suite 478 UT Cancer Institute
1934 Alcoa Hwy, Suite 478 UT Cancer Institute
Newport
Newport
Knoxville
Knoxville
Knoxville
Maryville
Knoxville
Jellico
Dandridge
Nashville
Knoxville
Knoxville
TN
TN
TN
TN
TN
TN
TN
TN
TN
TN
TN
TN
37822
37822
37916
37916
37916
37804
37922
37762
37725
37243
37920
37920
62‐1102683
62‐1102683
62‐1250943
62‐1250943
62‐1250943
62‐1412287
62‐1620282
62‐1781732
62‐1854671
62-6001445
31-1626179
31-1626179
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
39,217 Education
39,217 Screening
40,618 Education
75,000 Screening
47,682 Treatment
28,000 Treatment
100,000 Screening
10,000 Education
90,000 Screening
530,581
TN104‐Memphis‐Midsouth Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
P O Box 42048 Methodist Healthcare Foundation
1471 Semmes St Urban Health Education & Support Service
1216 Peabody Avenue Church Health Center
877 Jefferson Avenue The Regional Medical Center at Memphis
Memphis
Memphis
Memphis
Memphis
Memphis
Memphis
Memphis
Memphis
TN
TN
TN
TN
TN
TN
TN
TN
38174‐2048
38174‐2048
38174‐2048
38114
38104
38104
38104
38103
23‐7320638
23‐7320638
23‐7320638
30‐0145801
58‐1716113
58‐1716113
58‐1716113
58‐1737037
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
Page 28 of 34
54-6001775
58‐1594191
58‐2105492
62‐6001445
62‐6001445
26‐1346239
58-1594191
37,913 Education
40,303 Screening
30,418 Treatment
15,000 Education
33,263 Education
31,557 Screening
20,470 Treatment
18,439 Education
ATTACHMENT 5
EIN # 75‐2462834
2012 Form 990
Schedule I, Part II
F
Recipient Name
The Regional Medical Center at Memphis
The Regional Medical Center at Memphis
Memphis Cancer Foundation
West Tennessee Area Health Education
Christ Community Health Services
Julie B Baier Foundation
Baptist Memorial Hospital For Women
Baptist Memorial Hospital‐DeSoto
Street Address
877 Jefferson Avenue 877 Jefferson Avenue 7945 Wolf River Blvd., Suite 300 PO Box 572, 316 Midland Street 2595 Central Ave 6005 Park Ave, Suite 700 ATTN: Annis Smith 350 N. Humphreys Blvd
Attn: Mary Jane Dewey 425 5th Ave North, 4th Floor
350 N. Humphreys Blvd. City
State
Zip
EIN #
IRS
Total Amount of
Purpose of Grant
Memphis
Memphis
Germantown
Somerville
Memphis
Memphis
Memphis
Nashville
Memphis
TN
TN
TN
TN
TN
TN
TN
TN
MS
38103
38103
38138
38068
38112
38119
38120
37243
38120
58‐1737037
58‐1737037
62‐1329519
62‐1332822
62‐1583270
62‐1753576
62‐1854358
62‐6001445
64‐0682111
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
67,609 Screening
16,390 Treatment
71,000 Screening
130,000 Treatment
177,032 Screening
32,950 Screening
29,967 Screening
800,001
TN105‐The Greater Nashville Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
1000 Church Street YMCA
4220 Harding Road Saint Thomas Health Services
African American Breast Health Outreach Attn: Retha Thomas
Saint Thomas Health Services
African American Breast Health Outreach Attn: Retha Thomas
Saint Thomas Health Services
820 Gale Lane Siloam Family Health Center
820 Gale Lane Siloam Family Health Center
VUMC, Station 17, Res 7 Vanderbilt Center for Health Svsc
1818 Albion Street Friends in General, Inc.
426 5th Ave. No., 4th Flr. Cordell Hull Bldg. Tennessee Department of Health
Attn: Jocelyn Phillips 2000 Charlotte Avenue
Attn: Jocelyn Phillips 2000 Charlotte Avenue
Nashville
Nashville
Nashville
Nashville
Nashville
Nashville
Nashville
Nashville
Nashville
Nashville
Nashville
Nashville
Nashville
Nashville
Nashville
Nashville
Nashville
TN
TN
TN
TN
TN
TN
TN
TN
TN
TN
TN
TN
TN
TN
TN
TN
TN
37203
37205
37205
37205
37209
37209
37204
37204
37232
37208‐2918
37208‐2918
37208‐2918
37243
37243
37243
37203
37203
24‐0795516
58‐1663055
58‐1663055
58‐1663055
58‐1663055
58‐1663055
58‐1867940
58‐1867940
62‐0476822
62‐1383977
62‐1383977
62‐1383977
62‐6001445
62‐6001445
62‐6001445
74‐1185665
74‐1185665
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
46,744 Education
34,850 Education
33,825 Screening
33,825 Treatment
32,707 Education
41,628 Screening
20,671 Education
20,671 Screening
60,000 Education
25,500 Education
24,750 Screening
24,750 Treatment
25,500 Education
24,750 Screening
17,500 Education
17,500 Treatment
511,921
TX100‐Greater Amarillo Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
Attn: Leticia Goodrich PO Box 1400
Amarillo Area Breast Health Coalition
224 E. 2nd St. Moore County Hospital District
224 E. 2nd St. Moore County Hospital District
1600 Wallace Blvd. Harrington Cancer Center
1600 Wallace Blvd. Harrington Cancer Center
Amarillo
Dumas
Dumas
Amarillo
Amarillo
TX
TX
TX
TX
TX
79105
79029
79029
79106
79106
32‐0170235
75‐1302152
75‐1302152
75‐1578415
75‐1578415
501c3
501c3
501c3
501c3
501c3
15,000 Education
7,800 Education
52,200 Screening
81,000 Screening
19,000 Treatment
175,000
TX101 Austin Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
Attn: Ken Lambrecht 201 East Ben White Blvd, Bldg B
Planned Parenthood
Attn: Ken Lambrecht 201 East Ben White Blvd, Bldg B
Planned Parenthood
Attn Lydia Perez PO Box 748
Community Action Partnership
1770 FM 967 National Center of Farmworker Health Inc
1640 E. 2nd St. #B Ste 200 Helping The Aging, Needy and Dis
Attn:Erika Pratt PO Box 133
Samaritan Hlth Ministries
Attn:Erika Pratt PO Box 133
Samaritan Hlth Ministries
PO Box 300040 Breast Cancer Resource Center of Austin
PO Box 300040 Breast Cancer Resource Center of Austin
Attn: Terri Jones 7500 Highway 90 West #2‐240
Wings
1700 Red River The University of Texas at Austin
1700 Red River The University of Texas at Austin
1710 Red River University of Texas Family Wellness Cent
1710 Red River University of Texas Family Wellness Cent
3066 E. Commerce Communicare Health Centers
3066 E. Commerce Communicare Health Centers
P.O. Box 300117 Alliance for African American Health in Central Texas
Austin
Austin
San Marcos
San Marcos
San Marcos
Buda
Austin
Cedar Park
Cedar Park
Austin
Austin
San Antonio
Austin
Austin
Austin
Austin
San Antonio
San Antonio
Austin
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
78704
78704
78667
78667
78667
78610
78702
78630‐0133
78630‐0133
78703
78703
78227
78701
78701
78701
78701
78220
78220
78703
74‐1005756
74‐1005756
74‐1541726
74‐1541726
74‐1541726
74‐1826899
74‐1888198
74‐2570190
74‐2570190
74‐2743333
74‐2743333
74‐2920912
74‐6000203
74‐6000203
74‐6000203
74‐6000203
94‐2188574
94‐2188574
20‐3820579
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
11,124 Education
33,373 Screening
26,609 Education
41,743 Screening
177,779 Treatment
49,926 Education
28,900 Treatment
6,402 Education
25,607 Screening
11,416 Education
34,249 Treatment
231,840 Treatment
6,928 Screening
42,555 Treatment
19,532 Education
93,978 Screening
29,876 Education
41,258 Screening
964,217
TX102‐Dallas County Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
7424 Greenville Avenue, Suite 206 Planned Parenthood of Greater Texas
2304 Midwestern Parkway American Cancer Society
5323 Harry Hines Boulevard, MC8585 UT Southwestern Medical Center'
5323 Harry Hines Boulevard, MC8585 UT Southwestern Medical Center'
5323 Harry Hines Blvd. UT Southwestern Medical Center"
4144 N. Central Expressway, Suite 580 YWCA of Metropolitan Dallas
1441 N. Beckley Avenue Methodist Health System Foundation
1441 N. Beckley Avenue Methodist Health System Foundation
1901 N. MacArthur Blvd. Irving Healthcare Foundation
Dallas
Wichita Falls
Dallas
Dallas
Dallas
Dallas
Dallas
Dallas
Dallas
Irving
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
75231
76308
75390‐9105
75390‐9105
75390‐9105
75204
75204
75203
75203
75061
52‐1243221
74‐1185665
74‐6000203
74‐6000203
74‐6000203
75‐0800699
75‐0800699
75‐1548343
75‐1548343
75‐1570933
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
91,676 Screening
85,125 Treatment
8,750 Education
166,250 Screening
50,000 Screening
35,097 Education
315,873 Screening
98,060 Education
228,808 Screening
Page 29 of 34
ATTACHMENT 5
EIN # 75‐2462834
2012 Form 990
Schedule I, Part II
F
Recipient Name
Methodist Richardson Medical Center/CFWH
Methodist Richardson Medical Center/CFWH
Texas Health Presbyterian Foundation
Parkland Foundation
Parkland Foundation
Bridge Breast Network
Bridge Breast Network
Muslim Community Center for Human Servic
Street Address
403 West Campbell, Suite 205 403 West Campbell, Suite 205 8200 Walnut Hill Lane 2777 N. Stemmons Freeway, Ste 1700 2777 N. Stemmons Freeway, Ste 1700 3600 Gaston Avenue, Suite 401 3600 Gaston Avenue, Suite 401 7600 Glenview Drive City
State
Zip
EIN #
IRS
Total Amount of
Purpose of Grant
Richardson
Richardson
Dallas
Dallas
Dallas
Dallas
Dallas
Richland Hills
TX
TX
TX
TX
TX
TX
TX
TX
75080
75080
75231
75390
75390
75246
75246
76118
75‐1788520
75‐1788520
75‐2022128
75‐2089180
75‐2089180
75‐2436606
75‐2436606
75‐2580038
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
37,296 Education
87,024 Screening
30,000 Screening
45,000 Education
105,000 Screening
79,759 Screening
319,035 Treatment
20,000 Education
1,912,753
TX103‐El Paso Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
1359 Lomaland, Ste. 400 Lulac Project Amistad
1400 Hardaway, Suite 220 UMC Foundation
110 Mesa Park Cancer and Chronic Disease Consortium
3601 4th Street Texas Tech Univ Breast Care Center
3601 4th St.,MS 6274 TTUHSC Department of Family Comm. Med.
3601 4th St.,MS 6274 TTUHSC Department of Family Comm. Med.
El Paso
El Paso
El Paso
El Paso
El Paso
Lubbock
Lubbock
Lubbock
TX
TX
TX
TX
TX
TX
TX
TX
79935
79903
79912
79912
79912
79430‐6274
79430‐6274
79430‐6274
74‐1861796
74‐2540513
74‐2686131
74‐2686131
74‐2686131
75‐6043842
75‐6043842
75‐6043842
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
35,000 Treatment
30,000 Treatment
36,646 Education
41,926 Screening
41,926 Treatment
15,552 Education
32,002 Education
59,173 Screening
292,225
TX104‐Tarrant County Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
P.O. Box 15610 Catholic Charities,Diocese of Fort Worth
623 S. Henderson Cancer Care Services
1400 8th Avenue All Saints Health Foundation
3600 Gaston Avenue, Suite 401 Bridge Breast Network
7600 Glenview Drive Muslim Community Center for Human Servic
1350 S Main Street Suite‐4000 JPS HEALTH NETWORK
2500 Circle Drive JPS HEALTH NETWORK
800 W. Magnolia Avenue Cancer Assistance Fund of North Texas
100 E. Weatherford TARRANT COUNTY PUBLIC HEALTH DEPT
1701 River Run, Suite 500 Moncrief Cancer Institue / UTSW
P.O. Box 6337 huguley Memorial Medical Center
6100 Western Place, Suite 1001 Texas Health Harris Methodist Foundation
612 E. Lamar, Suite 300 Texas Health Harris Methodist Foundation
Fort Worth
Fort Worth
Fort Worth
Dallas
North Richland Hills
Fort Worth
Fort Worth
Fort Worth
Fort Worth
Ft. Worth
Fort Worth
Fort Worth
Arlington
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
76119
76014
76104
75246
76118
76104
76119
76104
76196
76107‐6548
76115
76107
76011
75‐0808769
75‐1025511
75‐1947007
75‐2436606
75‐2580038
75‐2717782
75‐2717782
75‐2871087
75‐6001170
75‐6002868
23‐7219332
75‐6000439
75‐6000439
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
27,500 Education
60,500 Treatment
15,000 Education
12,000 Education
22,500 Education
65,000 Treatment
101,163 Screening
245,000 Screening
10,000 Screening
15,000 Treatment
174,138 Screening
903,300
TX105‐Houston Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc. PO BOX 398 Bayside Healthcare Foundation
PO BOX 398 Bayside Healthcare Foundation
3440 South MacGregor Reconstruction of a Survivor
3440 South MacGregor Reconstruction of a Survivor
605 S. Conroe Medical Dr. Lone Star Community Health Center, Inc.
605 S. Conroe Medical Dr. Lone Star Community Health Center, Inc.
7001 Corporate, Suite 120 Asian American Health Coalition
1707 Sunset Blvd. Methodist Hospital Foundation
11360 Bellaire Blvd. Suite 910 Boat People, SOS
307 N. William Barnett Ave Health Center of Southeast Texas
307 N. William Barnett Ave Health Center of Southeast Texas
18951 Memorial North MH Northeast Hospital Foundation
6301 Richmond Avenue American Cancer Society
One Baylor Plaza, BCM 600 Baylor College Medicine.
190 Heights Blvd. Good Neighbor Healthcare Center
190 Heights Blvd. Good Neighbor Healthcare Center
301 University Boulevard University of Texas Medical Branch
MD Anderson Cancer Center 1515 Holcombe Boulevard, Unit 1354
UTMD Anderson Cancer Ctr.
MD Anderson Cancer Center 1515 Holcombe Boulevard, Unit 1354
UTMD Anderson Cancer Ctr.
12700 N. Featherwood, Suite 260 The Rose, Inc.
1705 Jackson Street Oak Bend Medical Center
Anahuac
Anahuac
Houston
Houston
Conroe
Conroe
Houston
Houston
Houston
Houston
Houston
Houston
Houston
Houston
Houston
Cleveland
Cleveland
Humble
Humble
Humble
Houston
Houston
Houston
Houston
Houston
Houston
Galveston
Houston
Houston
Houston
Houston
Houston
Richmond
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
77514
77514
77021
77021
77304
77304
77036
77036
77036
77005
77005
77005
77072
77072
77072
77327‐4061
77327‐4061
77388
77388
77388
77057
77030
77030
77030
77007
77007
77555‐0587
77030‐4009
77030‐4009
77034
77034
77034
77469
20‐5853573
20‐5853573
26‐0455144
26‐0455144
30‐0038860
30‐0038860
31‐1756818
31‐1756818
31‐1756818
47‐0639839
47‐0639839
47‐0639839
54‐1563619
54‐1563619
54‐1563619
56‐2508501
56‐2508501
74‐1152597
74‐1152597
74‐1152597
74‐1185665
74‐1613878
74‐1613878
74‐1613878
74‐1746576
74‐1746576
74‐6000949
74‐6001118
74‐6001118
76‐0193812
76‐0193812
76‐0193812
76‐0339462
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
43,341 Education
14,447 Screening
10,000 Education
10,000 Treatment
11,419 Education
76,421 Screening
22,617 Education
150,779 Screening
15,078 Treatment
9,975 Education
69,300 Screening
25,725 Treatment
40,050 Education
32,400 Screening
17,550 Treatment
10,008 Education
61,992 Screening
32,000 Education
131,999 Screening
36,000 Treatment
224,965 Treatment
16,205 Education
24,000 Screening
44,000 Treatment
88,148 Education
88,148 Screening
49,818 Education
50,151 Treatment
7,791 Education
427,941 Screening
22,050 Treatment
111,780 Screening
Page 30 of 34
ATTACHMENT 5
EIN # 75‐2462834
2012 Form 990
Schedule I, Part II
F
Recipient Name
Harris County Hospital District
D'Feet Breast Cancer
Shalom Mobile Health Ministry
Shalom Mobile Health Ministry
Light & Salt Association
Light & Salt Association
Street Address
2525 HOLLY HALL SUITE 292 27 Colony Park Circle 8121 Broadway, Suite 103 8121 Broadway, Suite 103 9800 Town Park Drive, Suite 258B 9800 Town Park Drive, Suite 258B City
State
Zip
EIN #
IRS
Total Amount of
Purpose of Grant
Houston
Galveston
Houston
Houston
Houston
Houston
TX
TX
TX
TX
TX
TX
77054
77551
77061
77061
77036
77036
76‐0408224
76‐0521474
76‐0570086
76‐0570086
76‐0604950
76‐0604950
501c3
501c3
501c3
501c3
501c3
501c3
TX106‐Lubbock Area Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
3513 10th Street American Cancer Society
6500 Amarillo Blvd. West Texas AgriLife Extension Service 1
3101 35th St. YWCA of Lubbock
3601 4th Street, STOP 6271 Texas Tech Univ. Health Sciences Ctr.
3623 22nd Place Covenant Health System
Attn: Charley Wasson 4101 22nd Place
Joe Arrington Cancer
Univ. Medical Ctr. & S.W. Cancer Treatmnt PO Box 5980
University Medical Center
Lubbock
Amarillo
Lubbock
Lubbock
Lubbock
Lubbock
Lubbock
TX
TX
TX
TX
TX
TX
TX
79415
79106
79424
79430
79410
79410
79408
74‐1185665
74‐2648747
75‐0939427
75‐2668014
75‐2765566
75‐2765566
86‐0572438
501c3
501c3
501c3
501c3
501c3
501c3
501c3
12,910 Education
129,205 Screening
10,000 Treatment
44,907 Screening
19,918 Treatment
265,856
TX107‐North Texas Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
205 N. Houston Ave Grayson County Health Department
205 N. Houston Ave Grayson County Health Department
1701 River Run, Suite 500 Moncrief Cancer Institue / UTSW
Dallas
Dallas
Dallas
Dallas
Denison
Denison
Ft. Worth
TX
TX
TX
TX
TX
TX
TX
75204
75246
75246
75246
75021
75021
76107‐6548
75‐0800699
75‐2436606
75‐2436606
75‐2436606
75‐6000969
75‐6000969
75‐6002868
501c3
501c3
501c3
501c3
501c3
501c3
501c3
16,442 Education
101,938 Screening
210,452 Treatment
44,951 Education
134,853 Screening
191,919 Screening
750,000
TX108‐The San Antonio Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
P. O. Box 29331 ThriveWell Cancer Foundation
P. O. Box 29331 ThriveWell Cancer Foundation
12521 Nacogdoches Road Suite 101 Slew, inc
12521 Nacogdoches Road Suite 101 Slew, inc
197 Summer Street American Cancer Society
3750 Commercial Avenue CentroMed
3750 Commercial Avenue CentroMed
Attn: Anna McAndrew 903 W Martin, MS 28‐2
University Health System
Attn: Terri Jones 7500 Highway 90 West #2‐240
Wings
1510 S Hackberry St Martinez Street Womens Center
3066 East Commerce Communicare Health Centers
San Antonio
San Antonio
San Antonio
San Antonio
Buffalo
San Antonio
San Antonio
San Antonio
San Antonio
San Antonio
San Antonio
San Antonio
San Antonio
TX
TX
TX
TX
NY
TX
TX
TX
TX
TX
TX
TX
TX
78229
78229
78217
78217
14222
78221
78221
78207
78227
78210
78220
78220
78220
26‐0371270
26‐0371270
42‐1580967
42‐1580967
74‐1185665
74‐1787031
74‐1787031
74‐2335396
74‐2920912
74‐2934053
94‐2188574
94‐2188574
94‐2188574
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
28,170 Education
28,170 Treatment
7,794 Education
80,146 Treatment
37,170 Treatment
21,051 Education
189,459 Screening
209,430 Screening
112,860 Treatment
17,204 Education
58,782 Screening
67,384 Treatment
910,000
TX109‐Texarkana Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
451 W. Locke Street Little River Memorial
451 W. Locke Street Little River Memorial
University of Arkansas Fdn dba UAMS 300 East 6th Street
University of Arkansas
University of Arkansas Fdn dba UAMS 300 East 6th Street
University of Arkansas
Attn: Edward Eichler 803 Spruce St.
Hospice of Texarkana
Attn: Pam Glover P. O. Box 1049,1007 S William St
Atlanta Memorial Hospital
2600 St. Michael Drive Christus St. Michael Health System
2600 St. Michael Drive Christus St. Michael Health System
Ashdown
Ashdown
Texarkana
Texarkana
Texarkana
Atlanta
Texarkana
Texarkana
AR
AR
AR
AR
TX
TX
TX
TX
71822‐3325
71822‐3325
71854
71854
75501
75551
75503
75503
71‐6046530
71‐6046530
71‐6056774
71‐6056774
75‐2025071
75‐2705456
75‐2796815
75‐2796815
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
9,560 Education
17,755 Screening
48,017 Education
72,025 Screening
8,000 Treatment
10,785 Education
168,966 Screening
354,716
TX110‐Tyler Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
1301 S. Broadway Ave. American Cancer Society
Health System Foundation 611 S. Fleishel
Trinity Mother Frances
315 N. Broadway, Suite 404 Northeast Texas Public Health District
PO Box 6400 ETMC Cancer Institute
Tyler
Tyler
Tyler
Tyler
TX
TX
TX
TX
75701
75701
75702
75711
74‐1185665
75‐2028241
75‐2254544
75‐2695524
501c3
501c3
501c3
501c3
25,000 Treatment
228,596 Screening
7,750 Education
271,750
TX111‐Central Texas Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
6600 Fish Pond Road, Suite 104 Providence Breast Health Center
P.O. Box 1459 Planned Parenthood of Central Texas
Attn: Robyn R. Young, MD 2401 South 31st Street
Scott & White Ctr for Cancer Prevention
P.O. Box 5002 Community Cancer Association
Waco
Waco
Temple
Waco
TX
TX
TX
TX
76710
76703‐1459
76508
76708
74‐1109636
74‐1143143
74‐1166904
74‐6061914
501c3
501c3
501c3
501c3
22,500 Screening
24,349 Screening
35,000 Treatment
113,849
TX112‐Wichita Falls Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
Attn: Kristi McCasland P.O. Box 720, 200 Martin Luther King
N Central TX Community Healthcare Center
Wichita Falls
Wichita Falls
Wichita Falls
TX
TX
TX
76307‐0720 75‐2429644
76307‐0720 75‐2429644
76307‐0720 75‐2429644
501c3
501c3
501c3
160,000 Screening
275,578 Screening
40,600 Education
99,400 Screening
19,370 Education
6,630 Treatment
3,027,677
9,095 Education
54,568 Screening
27,284 Treatment
90,947
UT100‐Salt Lake City Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
Page 31 of 34
ATTACHMENT 5
EIN # 75‐2462834
2012 Form 990
Schedule I, Part II
F
Recipient Name
Comunidades Unidas
Comunidades Unidas
Utah Partners for Health
Utah Partners for Health
Needs Beyond Medicine
Needs Beyond Medicine
Community Nursing Services
Active Re‐Entry
Utah Pride Center
Huntsman Cancer Institute
Cancer Wellness House
Cancer Wellness House
People's Health Clinic
Utah Cancer Control Program
Intermountain Healthcare
Intermountain Healthcare
Street Address
1750 Research Way, Suite 102 1750 Research Way, Suite 102 1111 E. Brickyard Road, Suite 109 1111 E. Brickyard Road, Suite 109 3665 S 8400 W, Suite 110 3665 S 8400 W, Suite 110 P.O. Box 521618 P.O. Box 521618 383 W Vine Street, Suite 300 10 S Fairgrounds Road 355 N. 300 W., 1st Floor 2000 Circle of Hope, Room 1142 59 South 1100 East 59 South 1100 East P.O. Box 681558 PO Box 142107 288 N. 1460 W.
PO Box 142107 288 N. 1460 W.
PO Box 142107 288 N. 1460 W.
Intermountain Healthcare SW Region 1380 East Medical Center Drive
Intermountain Healthcare SW Region 1380 East Medical Center Drive
VA100‐Greater Richmond, Virginia Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
4480 Cox Road, Suite 100 Ellen Shaw de Paredes
201 North Main Street P.O. Box 142
Heart of Virginia Free Clinic
P.O. Box 607 Community Memorial Healthcenter
P.O. Box 607 Community Memorial Healthcenter
800 Oak Street Centra‐Southside Community Hospital
P.O. Box 220 Central Virginia Health Services
1010 N. Thompson St., P.O. Box 6477 Fan Free Clinic, Inc.
1010 N. Thompson St., P.O. Box 6477 Fan Free Clinic, Inc.
14051 St. Francis Boulevard, Suite 1100 Bon Secours Richmond Health Care
8600 Quioccasin Road, Suite 102 CrossOver Ministry
342 Mule Academy Road P.O. Box 153
Augusta Regional Free Clinic
2000 P Street NW, Suite 300 Nueva Vida, Inc.
5225 Wisconsin Avenue N.W.,Suite 503 Nueva Vida, Inc.
5225 Wisconsin Avenue N.W.,Suite 503 Nueva Vida, Inc.
212 Weaver Avenue Family YMCA of Emporia/Greensville
P.O. Box 980037 401 College Street
Virginia Commonwealth University.
1138 Rose Hill Drive
Charlottesville/Albemarle Health Departm
1 Hayden Drive, P.O. Box 9082
Virginia State Univ. Student Health Ctr.
1 Hayden Drive, P.O. Box 9082
Virginia State Univ. Student Health Ctr.
City
State
Zip
EIN #
IRS
Total Amount of
Purpose of Grant
West Valley City
West Valley City
Salt Lake City
Salt Lake City
Magna
Magna
Salt Lake City
Salt Lake City
Murray
Price
Salt Lake City
Salt Lake City
Salt Lake City
Salt Lake City
Park City
Salt Lake City
Salt Lake City
Salt Lake City
St. George
St. George
UT
UT
UT
UT
UT
UT
UT
UT
UT
UT
UT
UT
UT
UT
UT
UT
UT
UT
UT
UT
84119
84119
84106
84106
84074
84074
84152
84152
84123
84501
84103
84112
84102
84102
84068
84114‐2107
84114‐2107
84114‐2107
84790‐2123
84790‐2123
13‐4257724
13‐4257724
22‐2119902
22‐2119902
27‐0021804
27‐0021804
27‐0436521
27‐0436521
87‐0212459
87‐0446885
87‐0504077
87‐0541293
87‐0568405
87‐0568405
87‐0638042
87‐6000545
87‐6000545
87‐6000545
94‐2854057
94‐2854057
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
40,950 Education
40,950 Screening
32,779 Education
32,779 Treatment
7,209 Education
28,835 Screening
16,425 Education
49,275 Treatment
45,000 Treatment
12,000 Treatment
20,672 Education
11,272 Education
45,088 Treatment
25,000 Education
6,111 Screening
55,001 Treatment
101,520 Screening
11,280 Treatment
633,032
Glen Allen
Farmville
South Hill
South Hill
Farmville
New Canton
Richmond
Richmond
Midlothian
Richmond
Fishersville
Fishersville
Fishersville
Washington
Washington
Washington
Washington
Washington
Emporia
Richmond
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
DC
DC
DC
DC
DC
VA
VA
23060
23901‐1300
23970‐0607
23970‐0607
23901
23123
23230
23230
23114
23229‐5514
22939
22939
22939
20036
20036
20036
20015
20015
23947
23298‐5017
20‐2671818
27‐2785970
54‐0551711
54‐0551711
54‐0555201
54‐0887287
54‐0927792
54‐0927792
54‐1201346
54‐1371067
54‐1651896
54‐1651896
54‐1651896
54‐1943145
54‐1943145
54‐1943145
54‐1943145
54‐1943145
54‐2005981
54‐6001758
Charlottesville
Petersburg
Petersburg
VA
VA
VA
22903
23806
23806
54-6001775
54-6001811
54-6001811
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
54,770 Screening
22,500 Education
27,500 Screening
24,991 Screening
50,000 Screening
22,584 Education
22,584 Screening
12,306 Education
24,612 Screening
12,306 Treatment
6,250 Education
6,250 Screening
12,500 Treatment
7,500 Education
17,500 Screening
31,858 Education
23,750 Education
26,250 Screening
536,722
VA101‐Greater Roanoke Valley Area Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
Martinsville/Henry County Coalition for health and wellness
Ladies First‐MHC Coalition for Health
Martinsville/Henry County Coalition for health and wellness
Ladies First‐MHC Coalition for Health
933 S. Jefferson Street
Carilion Clinic Breast Care Center
1701 Thomson Drive
Centra‐Alan B. Pearson Region Cancer Ctr
1701 Thomson Drive
Centra‐Alan B. Pearson Region Cancer Ctr
P.O. Box 1573 25 Northridge Lane
Rockbridge Area Free Clinic
200 H. G. McGhee Drive
Pittsylvania ‐ Danville Health District
201 Francis Marion Lane
Virginia Department of Health Center
2207 Peters Creek Road
Planned Parenthood Health Systems, Inc
2207 Peters Creek Road
Planned Parenthood Health Systems, Inc
Martinsville
Martinsville
Roanoke
Lynchburg
Lynchburg
Lexington
Chatham
Marion
Marion
Marion
Roanoke
Roanoke
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
24111
24111
24016
24501-1118
24501-1118
24450
24531
24354
24354
24354
24017
24017
20-2448149
20-2448149
54-0506332
54-0715569
54-0715569
54-1642220
54-6001775
54-6001775
54-6001775
54-6001775
56-1282557
56-1282557
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
9,309
21,722
39,895
6,846
50,204
12,747
48,819
7,950
51,675
19,875
10,434
10,434
Education
Screening
Screening
Education
Treatment
Education, Screening, Treatment
Education, Screening, Treatment
Education
Screening
Treatment
Education
Screening
289,910
VA102‐Tidewater Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
2019 Meade Pkwy
Western Tidewater Free Clinic
2019 Meade Pkwy
Western Tidewater Free Clinic
12100 Warwick Blvd., Suite 101
Riverside Health System
12100 Warwick Blvd., Suite 101
Riverside Health System
Attn: Valda Branch 1033-28th Street
Peninsula Institute for Community Health
3396 Holland Rd., Ste 102
Beach Health Clinic
c/o Breast Cancer 600 Gresham Drive
Sentara Norfolk General Hospital
Suffolk
Suffolk
Newport News
Newport News
Newport News
Virginia Beach
Norfolk
Page 32 of 34
VA
VA
VA
VA
VA
VA
VA
23434
23434
23601
23601
23607-4233
23452
23507
26-3302837
26-3302837
52-1245746
52-1245746
54-1083954
54-1366960
54-1547408
501c3
501c3
501c3
501c3
501c3
501c3
501c3
32,646 Education
69,093 Screening
6,010 Education
79,850 Screening
78,060 Screening
6,579 Screening
ATTACHMENT 5
EIN # 75‐2462834
2012 Form 990
Schedule I, Part II
F
Recipient Name
Sentara Obici Hospital
Mount Sinai Gospel Tabernacle
Mount Sinai Gospel Tabernacle
Norther Neck Free Health Clinic
Norther Neck Free Health Clinic
Chesapeake Regional Medical Center
Eastern Shore Health District
Eastern Shore Health District
Hampton Health Department
Three Rivers Health District
Street Address
City
State
Zip
EIN #
Total Amount of
Purpose of Grant
54‐1659568
54‐1659568
54‐1679279
54‐1679279
54‐1693739
54‐6001775
54‐6001775
54‐6001775
54‐6001775
8,432 Education
17,119 Treatment
9,076 Education
13,615 Screening
10,000 Screening
17,948 Education
53,843 Screening
9,926 Education
500,895
03755‐1404
03755‐1404
03756
05405
05403
05401
05201
05201
05301
05701
05201
05855
05641
05641
05641
03860
03054
02‐0222111
02‐0222111
02‐0222140
03‐0179440
03‐0289111
03‐0365270
03‐0369844
03‐0369844
22‐2519596
22‐2534389
22‐2563241
22‐2566964
22‐2610477
22‐2610477
22‐2610477
23‐1265004
23‐7331452
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
5,518 Education
31,266 Screening
45,000 Treatment
81,417 Education
22,354 Treatment
8,545 Education
15,190 Screening
25,000 Treatment
5,728 Education
40,668 Screening
10,238 Treatment
40,000 Treatment
458,753
WA
WA
98114
98122
98118
98121
98584‐1668
98584‐1668
98584
98584
98402‐3515
98402‐3515
98504‐7880
98201
98109‐1023
98103‐5358
98203
26‐0493856
81‐0983698
91‐0482890 91‐0823767
91‐0836763
91‐0836763
91‐1065249
91‐1065249
91‐1145592
91‐1145592
91‐1444603
91‐1717603
91‐6001537
91‐6182951
93‐0386860
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
98,729 Education
18,402 Treatment
65,367 Education
25,052 Education
7,434 Education
42,123 Treatment
52,940 Education
9,342 Screening
107,344 Education
18,943 Treatment
1,300,555 Screening
27,950 Treatment
266,186 Treatment
33,518 Education
2,101,001
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
99212
99301
98902
98902
99201
99040
99040
99201
99201
99362
99201
98501
99201
99201
99201
99201
99202
99202
99202
20‐1453390
31‐0007578
74‐1005756
74‐1005756
74‐1185665
91‐0606339
91‐0606339
91‐0613587
91‐0613587
91‐1144144
91‐1307555
91‐1444603
91‐1462366
91‐1641797
91‐1641797
91‐1764236
91‐6055019
91‐6055019
91‐6055019
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
12,500 Education
22,620 Screening
9,000 Education
21,000 Screening
26,928 Treatment
11,400 Education
18,600 Screening
16,425 Education
5,475 Screening
5,100 Treatment
14,364 Education
30,000 Screening
16,555 Education
13,365 Screening
10,900 Education
6,000 Screening
25,350 Treatment
310,717
Suffolk
VA
23439
54-1547408
P.O.Box 89 P.O.Box 89 P.O. Box 1694 P.O. Box 1694 Attn: Brenda Kuntz 736 Battlefield Blvd. North
Tracey Dedicatoria, Program Coor PO Box 177
Tracey Dedicatoria, Program Coor PO Box 177
Attn: Irene E. Ferrainolo, MPH 3130 Victoria Blvd
P.O. Box 415, 2780 General Puller Hwy Townsend
Townsend
Kilmarnock
Kilmarnock
Chesapeake
Accomac
Accomac
Hampton
Saluda
VA
VA
VA
VA
VA
VA
VA
VA
VA
23443‐0089
23443‐0089
22482
22482
23320‐9941
23301
23301
23661
23149
VT100‐Vermont‐New Hampshire Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
Office of Sponsored Projects 11 Rope Ferry Road, HB 6210
Trustees of Dartmouth College
Office of Sponsored Projects 11 Rope Ferry Road, HB 6210
Trustees of Dartmouth College
Attn: Laurel Ludy One Medical Center Drive
Mary Hitchcock Memorial Hospital
89 Beaumont Avenue, Given E‐213 UVM & State Agricultural College
Attn: Nicole Lukas 108 Cherry St., PO Box 70
Vermont Dept of Health
ACC East Pavilion, Level 2 111 Colchester Ave.
Cancer Patient Support Program
107 Adams St. Greater Bennington Interfaith Community
107 Adams St. Greater Bennington Interfaith Community
38 Park Place, 2C Forest Moon, Inc
Breast Care Program, 160 Allen Street Rutland Regional Medical Center
Ruth Metcalfe Breast Care Program 100 Hospital Dr.
Southwestern Vermont Health Care
North Country Breast Cancer Outreach Prog 189 Prouty Drive
North Country Health System
CVMC Breast Care Program PO Box 547
Central Vermont Medical Center
Women's Integrated Health Initiative White Mountain Highway
Memorial Health
7 Executive park Dr. Home Health and Hospice Care
Hanover
Hanover
Lebanon
Burlington
Burlington
Burlington
Bennington
Bennington
Brattleboro
Rutland
Bennington
Newport
Barre
Barre
Barre
North Conway
Merrimack
NH
NH
NH
VT
VT
VT
VT
VT
VT
VT
VT
VT
VT
VT
VT
NH
NH
WA100‐The Puget Sound Chapter of the Susan G. Komen Foundation, Inc.
PO Box 3007 International Community Health Services
1120 East Terrace Street Suite 200
Center for MultiCultural Health
2024 Third Avenue YWCA of Seattle‐King & Snohomish County
2208 2nd Avenue, Suite 100 Senior Services of Seattle
901 Mountain View Dr. Mason General Hospital
901 Mountain View Dr. Mason General Hospital
3104 SE Old Olympic Highway South Puget Intertribal Planning Agency
3104 SE Old Olympic Highway South Puget Intertribal Planning Agency
1149 Market Street MS‐10‐02 Franciscan Foundation
1149 Market Street MS‐10‐02 Franciscan Foundation
Mailstop #47880 111 Israel Rd. SE WA State Department of Health
2718 Rockefeller Avenue Citrine Health
825 Eastlake Avenue E University of Washington at Seattle
6522 Fremont Ave N Cancer Lifeline
6315 Fleming St. #B Lutheran Community Services Northwest
Seattle
Seattle
Seattle
Seattle
Shelton
Shelton
Shelton
Shelton
Tacoma
Tacoma
Tumwater
Everett
Seattle
Seattle
Everett
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA101‐Eastern Washington Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
5105 E. Third Avenue Cancer Care Northwest Foundation
520 N. 4th Ave. Lourdes Health Netwrk
1117 Tieton Ave Planned Parenthood
1117 Tieton Ave Planned Parenthood
920 N. Washington, Suite 200 American Cancer Society
PO Box 100 Spokane Tribe of Indians
PO Box 100 Spokane Tribe of Indians
Women’s Recovery Program (UGM) 2828 W. Mallon Ave.
Anna Ogden Hall
Women’s Recovery Program (UGM) 2828 W. Mallon Ave.
Anna Ogden Hall
Laurie Klicker 1067 E. Isaacs
Walla Walla Community Hospice
Inland Northwest Health Services 601 W 1st Ave
Community Health Education & Resources
111 Israel Rd. SE, Suite 200 Washington State Dept of Health
1803 W Maxwell NATIVE Project
203 N. Washington, Suite 300 Community Health Association of Spokane
203 N. Washington, Suite 300 Community Health Association of Spokane
1101 W College Ave, Suite 200 Spokane Regional Health District
104 S. Freya Ste. 212 Green Flag Bldg. Cancer Patient Care
Spokane Valley
Pasco
Yakima
Yakima
Spokane
Wellpinit
Wellpinit
Spokane
Spokane
Walla Walla
Spokane
Kent
Spokane
Spokane
Spokane
Spokane
Spokane
Spokane
Spokane
Page 33 of 34
IRS
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
2800 Goodwin Blvd.
ATTACHMENT 5
EIN # 75‐2462834
2012 Form 990
Schedule I, Part II
F
Recipient Name
WI100‐Central Wisconsin Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
1000 North Oak Av. Marshfield Clinic Research Foundation
425 Pine Ridge Blvd. Aspirus Health Foundation
425 Pine Ridge Blvd. Aspirus Health Foundation
420 Dewey Street Wood County Health Department
1000 Lake View Dr. Ste.100 Marathon County Health Department
Street Address
City
State
Zip
EIN #
IRS
Total Amount of
Purpose of Grant
Marshfield
Wausau
Wausau
Wisconsin Rapids
Wausau
WI
WI
WI
WI
WI
54449
54401
54401
54467
54403
39‐0452970
39‐1609532
39‐1609532
39‐1740383
39‐2000079
501c3
501c3
501c3
501c3
501c3
14,745 Education
65,214 Education
65,214 Screening
11,125 Education
19,775 Education
176,072
WI101‐Milwaukee Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
3237 S 16th Street Wheaton Franciscan Healthcare
All Saints Foundation Attn: Chris Krizek
Wheaton Franciscan Healthcare
All Saints Foundation Attn: Chris Krizek
St. Joseph Foundation Attn: Shelli Marquardt
Oconomowoc and Waukesha Memorial Hospital 725 American Avenue
ProHealth Care
Oconomowoc and Waukesha Memorial Hospital 725 American Avenue
ProHealth Care
2320 N Lake Drive Columbia St. Mary's Foundation
Attn:Yvonne Beamon 2555 N. Martin Luther King Jr. Drive
Milwaukee Health Services, Inc.
Attn:Yvonne Beamon 2555 N. Martin Luther King Jr. Drive
Milwaukee Health Services, Inc.
Dept of Nursing, Sandra Underwood PO Box 413
UW‐Milwaukee
2503 Todd Dr Wisconsin Women's Health Foundation
Milwaukee
Racine
Racine
Milwaukee
Waukesha
Waukesha
Milwaukee
Milwaukee
Milwaukee
Milwaukee
Madison
Madison
Madison
WI
WI
WI
WI
WI
WI
WI
WI
WI
WI
WI
WI
WI
53215
53406
53406
53210
53188
53188
53211
53212‐2707
53212‐2707
53201‐0413
53713
53713
53713
39‐0907740
39‐0907740
39‐0907740
39‐0907740
39‐1314542
39‐1314542
39‐1494981
39‐1664109
39‐1664109
39‐1805963
39‐1900678
39‐1900678
39‐1900678
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
30,198 Education
61,800 Education
36,296 Screening
31,726 Education
10,575 Screening
55,169 Education
24,390 Education
14,949 Screening
113,773 Education
131,363 Education
223,389 Screening
69,000 Treatment
836,963
WI102‐Madison Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
1000 Nichols Road Monona Public Library
PO Box 5003,1000 Mineral Point Ave. Mercy Health System
1862 Beld Street Catholic Multicultural Center
200 W. Milwaukee St. Community Action Inc of Rock and Walwort
200 W. Milwaukee St. Community Action Inc of Rock and Walwort
2901 W. Beltline Highway, Suite 120 Access Community Health Center
975 Bascom Mall Suite 4311
Center for Patient Partnerships, UW Law
UW Hospital & Clinics Authority 600 Highland Ave., CSC/H4/722
UW Hospital Clinic
UW Hospital Clinic
UW Hospital Clinic
Attn: Ms. Kari Sievert 210 Martin Luther Jr. Blvd. Rm 507
Wisconsin Well Women Program
Monona
Janesville
Janesville
Janesville
Madison
Janesville
Janesville
Madison
Madison
Madison
Madison
Madison
Madison
Madison
Madison
WI
WI
WI
WI
WI
WI
WI
WI
WI
WI
WI
WI
WI
WI
WI
53716
53547
53547
53547
53713
53548
53548
53713
53706
53792
53792
53792
53704
53704
53704
20-1963368
39-0816848
39-0816848
39-0816848
39-0824008
39-1052077
39-1052077
39‐6005507
39‐6005507
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
15,000 Education
15,396 Education
5,132 Screening
5,132 Treatment
84,300 Education
28,053 Education
28,053 Screening
37,432 Screening
11,541 Education
26,517 Education
26,517 Screening
79,550 Treatment
23,437 Education
71,087 Screening
165,870 Treatment
623,018
WV100‐West Virginia Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc.
1520 Washington St East West Virginia Health Right, Inc.
800 Garfield Avenue, P.O. Box 718 Camden‐Clark Foundation
Attn: Deborah Radosevich 1 Medical Park, Tower 3, Ste 201
Wheeling Hospital
Attn: Trinity Swain 122 Pinnell Street
Jackson General Hospital
400 North Jefferson Street Robert C. Byrd Clinic
400 North Jefferson Street Robert C. Byrd Clinic
Attn: Kathie Whitt P.O. Box 426
McDowell County FACES
Attn: Kathie Whitt P.O. Box 426
McDowell County FACES
Attn: Jame Abraham MD PO Box 9300
WVU Foundation
Increasing Early Detection of Brst Cancer PO Box 6887
WVU Foundation
Increasing Early Detection of Brst Cancer PO Box 6887
WVU Foundation
Reaching Out to Women of Color PO Box 6886
WVU Foundation
Reaching Out to Women of Color PO Box 6886
WVU Foundation
Charleston
Parkersburg
Wheeling
Ripley
Lewisburg
Lewisburg
Welch
Welch
Morgantown
Morgantown
Morgantown
Morgantown
Morgantown
WV
WV
WV
WV
WV
WV
WV
WV
WV
WV
WV
WV
WV
25311
26102
26003
25271
24901
24901
24801
24801
26506
26506
26506
26506
26506
31‐1066881
31‐1524546
55‐0357057
55‐0462730
55‐0559322
55‐0559322
55‐0757546
55‐0757546
55‐6017181
55‐6017181
55‐6017181
55‐6017181
55‐6017181
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
501c3
35,000 Education
12,950 Education
22,050 Screening
28,000 Education
7,000 Screening
35,000 Education
24,850 Education
10,150 Screening
24,850 Education
10,150 Screening
314,742
WY100‐Wyoming Chapter of the Susan G. Komen Breast Cancer Foundation, Inc.
6101 Yellowstone Road Suite 259A
Wyoming Department of Health
416 W. 24th Street Wyoming Health Council/Women's Wellness
PO Box 2266 The Caring Foundation
100 Central Avenue Cheyenne Laramie County Health Dept.
2301 S. 4‐J Road, P.O.Box 3420 Campbell County Public Health
Cheyenne
Cheyenne
Cheyenne
Cheyenne
Gillette
WY
WY
WY
WY
WY
82002
82001
82003
82007‐1330
82717
83‐0208667
83‐0292017
83‐0292601
83‐0332023
83‐6000103
501c3
501c3
501c3
501c3
501c3
50,000 Screening
50,000 Screening
181,162
39‐1391134
39‐1805963
39-1805963
39-1805963
39-1805963
39-6005507
Group total
Page 34 of 34
87,493,338
ATTACHMENT 5

Yes - Susan G. Komen Twin Cities Race for the Cure

Transcription

Similar documents

Yes - Susan G. Komen