Charitable Activities Section Oregon Department of Justice

Transcription

1 Form CT-12 For Oregon Charities Section I. General Information 1. THE KYRON HORMAN FOUNDATION 1338 SW VIOLET CT BEAVERTON, OR RECEDED Charitable Activities Section Oregon Department of Justice 1515 SW 5th Avenue, Suite 41 Portland, OR Web site: VOICE (971) TTY (8) FAX (971) For Accounting Periods Beginning in: 21 Cross Through Incorrect Items and Correct Here: (See instructions for change of name or accounting period.) Registration #^ Organization Name: JPkH 3 * Address: City, State, Zip: Phone: Fax: Amended Report? Period Beginning: 8/ 23 /21 Period Ending: 12/ 31 /21 Did a certified public accountant audit your financial records? - If yes, attach a copy of the auditor's report, financial statements, accompanying notes, schedules, or other documents supplementing the report or financial statements. Is the organization a party to a contract involving person-to-person, advertising, vending machine or telephone fund-raising in Oregon? If yes, write the name of the fund-raising firm(s) who conducts the campaign(s): Has the organization or any of its officers, directors, trustees, or key employees ever signed a voluntary agreement with any government agency, such as a state attorney general, or secretary of state, or local district attorney, or been a party to legal action in any court regarding charitable solicitation, administration, management, or fiduciary practices? If yes, attach explanation of each such agreement or action. See instructions. During this reporting period, did the organization amend its articles of incorporation, bylaws, or trust documents, OR did the organization receive a determination letter from the Internal Revenue Service indicating a new or amended tax-exempt status? If yes, attach a copy of the amended document or letter. Is the organization ceasing operations and is this the final report? (If yes, see instructions on how to close your registration.) Provide contact information for the person responsible for retaining the organization's records. O Name Position Phone Mailing Address & Address KRISTI B HORMAN SECRETARY NE 183RD STREET SHORELINE, WA KRISTI.NILESWORD@COMCAST.NET List of Officers, Directors, Trustees and Key Employees - List each person who held one of these positions at any time during the year even if they did not receive compensation. Attach additional sheets if necessary. If an attached IRS form includes substantially the same compensation information, the phrase "See IRS Form" may be entered in lieu of completing that section. (Oregon law requires a minimum of three directors.) Name: Address: Phone: KRISTI B HORMAN (A) Name, mailing address, daytime phone number and address 1224 NE 183RD STREET SHORELINE, WA (_26_) (B) Title & average weekly hours devoted to position SECRETARY (C) Compensation (enter $ if position unpaid) Name: Address: Phone: KAINE HORMAN NW SHELTERED NOOK ROAD PORTLAND, OR (_ J PRESIDENT Name: Address: Phone: BRUCE HOLIDAY 1338 SW VIOLET CT BEAVERTON, OR 978 (_ J TREASURER Form Continued on Reverse Side

2 Section II. Fee Calculation Total Revenue (From Line 12 (current year) on Form 99; Line 9 on Form 99-EZ; Part I, Line 12a on Form 99-PF; Line 9 on Form 141 or Form 141-A; or see page 3 of the instructions if no federal tax retum was prepared. Attach explanation if Total Revenue is $.) 27, Revenue Fee (See chart below. Minimum fee is $1, even if total revenue is a negative amount.) Amount on Line 9 Revenue Fee $ $24,999 $1 $25, $49,999 $25 $5, $99,999 $45 $1, $249,999 $75 $25, $499,999 $1 $5, $749,999 $135 $75, $999,999 $17 $1,, more $ Net Assets or Fund Balances at End of the Reporting Period... (From Line 22 (end of year) on Form 99, Line 21 on Form 99-EZ, or Part III, Line 6 on Form 99-PF; or see page 4 to calculate.) , Net Fixed Assets Used to Conduct Charitable Activities (Generally, from Part X, Line 1c on Fonn 99, Line 23B on Form 99-EZ or Part II, Line 14b on Form 99-PF; or see page 4 to calculate. See instructions if organization owns income-producing assets.) Amount Subject to Net Assets or Fund Balances Fee. (Line 11 minus Line 12. tf Line 11 minus Line 12 is less than $5,, write $.) Net Assets or Fund Balances Fee (Line 13 multiplied by.1. If the fee is less than $5, enter $. t to exceed $1,. Round cents to the nearest whole dollar.) Are you filing this report late?.. (If yes, the late fee is a minimum of $2. You may owe more depending on how late the report is. See Instruction 15 for additional information or contact the Charitable Activities Section at (971) to obtain late fee amount.) Total Amount Due (Add Lines 1,14, and 15. Make check payable to the Oregon Department of Justice.) Attach a copy of the organization's federal tax return and all supporting schedules and attachments that were filed with the IRS with the exception that 17. Form 99 & 99EZ filers do not need to attach a copy of their Schedule B. Also, if the organization did not file with the IRS, but had Total Revenue of $25, or more, or Net Assets or Fund Balances of $5, or more, see the instructions as the organization is required to complete certain IRS Forms for Oregon purposes only. If the attached return was not filed with the IRS, then mark any such return as "For Oregon Purposes Only." If your organization files IRS Form 99-N (e-postcard) please attach a copy or confirmation of its filing Please Sign Here Paid Preparer's Use Only Under penalties of perjury, I declare that I have examined this return, including all accompanying forms, schedules, and attachments, and to the best of my knowledge and belief, it is true, correct, and complete. Date Date Title Phone FOX & COMPANY CPAs, LLC ^reijajjr^sjiame^ 1818 NE COXLEY DRIVE, SUITE E VANCOUVER. WA Address 2

3 Form 99-EZ Department of the Treasury Internal Revenue Service A B For the 21 calendar year, or tax year beginning Check if applicable: Address change Name change Initial return Terminated Amended return Application pending Short Form Return of Organization Exempt From Income Tax Under section 51(c), 527, or 4947(aX1) of the Internal Revenue Code (except black lung benefit trust or private foundation) Sponsoring organizations of donor advised funds, organizations that operate one or more hospital facilities, and certain controlling organizations as defined in section 512(b)(13) must file Form 99 (see instructions). All other organizations with gross receipts less than $2, and total assets less than $5, at the end of the year may use this form. The organization may have to use a copy of this return to satisfy state reporting requirements. THE KYRON HORMAN FOUNDATION 1338 SW VIOLET CT BEAVERTON, OR G Accounting Method: [Xj Cash Accrual Other (specify) I J K Website: - BRINGKYRONHOME. ORG Tax-exempt status (ck only one), 21, and ending X 51(c)(3) 51(c) ( ) * (insert no.) 4947(a)(1) or 527 D E F OMB Open to Public inspection Employer identification number Telephone number Group Exemption Number Check * [x] if the organization is not required to attach Schedule B (Form 99, 99-EZ, or 99-PF). Check * X if the organization is not a section 59(a)(3) supporting organization and its gross receipts are normally not more than $5,. A Form 99-EZ or Form 99 return is not required though Form 99-N (e-postcard) may be required (see instructions). But if the organization chooses to file a return, be sure to file a complete return. Add lines 5b, 6c, and 7b, to line 9 to determine gross receipts. If gross receipts are $2, or more, or if total assets (Part II, line 25, column (B) below) are $5, or more, file Form 99 instead of Form 99-EZ *- $ 27,246. Part I 1 Revenue, Expenses, and Changes in Net Assets or Fund Balances (See the instructions for Part I.) Check if the organization used Schedule O to respond to any question in this Part I 1 Contributions, gifts, grants, and similar amounts received 1 27,246. A N S E S T E T S 2 Program service revenue including government fees and contracts. 3 Membership dues and assessments 4 Investment income 5a Gross amount from sale of assets other than inventory b Less: cost or other basis and sales expenses c Gain or (loss) from sale of assets other than inventory (Subtract line 5b from line 5a) 6 Gaming and fundraising events 7a a Gross income from gaming (attach Schedule G if greater than $15,). b Gross income from fundraising events (not including $ from fundraising events reported on line 1) (attach Schedule G if the sum of such gross income and contributions exceeds $15,) c Less: direct expenses from gaming and fundraising events Net income or (loss) from gaming and fundraising events (add lines 6a and 6b and subtract line 6c) b Less: cost of goods sold c Gross sales of inventory, less returns and allowances Gross profit or (loss) from sales of inventory (Subtract line 7b from line 7a) Other revenue (describe in Schedule O) Total revenue. Add lines 1, 2, 3, 4, 5c, 6d, 7c, and 8 Grants and similar amounts paid (list in Schedule O) Benefits paid to or for members Salaries, other compensation, and employee benefits Professional fees and other payments to independent contractors Occupancy, rent, utilities, and maintenance Printing, publications, postage, and shipping 5a 5b 6a of contributions Other expenses (describe in Schedule O) See..Schedule... Total expenses. Add lines 1 through 16 6b 6c 7a 7b 5c 6d 7c ,246. 1, , Excess or (deficit) for the year (Subtract line 17 from line 9) , Net assets or fund balances at beginning of year (from line 27, column (A)) (must agree with end-of-year figure reported on prior year's return) Other changes in net assets or fund balances (explain in Schedule O) Net assets or fund balances at end of year. Combine lines 18 through 2. *~ ,62. BAA For Paperwork Reduction Act tice, see the separate instructions. Form 99-EZ (21) TEEA83L 2/1/11

4 Form 99-EZ (21) THE KYRON HORMAN FOUNDATION Page 2 Paflllljl Balance Sheets, (see the instructions for Part II.) Cash, savings, and investments Land and buildings Other assets (describe in Schedule O) Total assets Total liabilities (describe in Schedule O) Net assets or fund balances (line 27 of column (B) must agree with line 21). ) Part III Statement of Program Service Accomplishments (see the instrs for Part Check if the organization used Schedule O to respond to any question in this Part III. (A) Beginning of year 1 What is the organization's primary exempt purpose? See Schedule O Describe what was achieved in carrying out the organization's exempt purposes. In a clear and concise manner, describe the services provided, the number of persons benefited, and other relevant information for each program title. 28 J I (B) End of year 22 25, , ,62. Expenses (Required for section 51 (c)(3) and 51 (c)(4) organizations and section 4947(a)(1) trusts; optional for others.) 29 (Grants $ ) If this amount includes foreign grants, check here. 28 a 3 (Grants $ ) If this amount includes foreign grants, check here. 29 a 31 (Grants $ ) If this amount includes foreign grants, check here. 3 a Other program services (describe in Schedule O) (Grants $ ) If this amount includes foreign grants, check here. u 31a 32 Total program service expenses (add lines 28a through 31a) H 32 Part IV List of Officers, Directors, Trustees, and Key Employees. List each one even if not compensated, (see the instructions for Part IV. Check if the organization used Schedule O to respond to any question in this Part IV (a) Name and address _KRIS_TI _B_ HORMAN JL2 2 4_ NE _18 3RD_ STREET_ SHORELINE, WA _KAIN_E_ HORMAN J572_5_NW_ SpjLTERED_NOOK _RAD PORTLAND, OR _BRUCE_ HOLIDAY _1338 SW VIOLET _COURT_ BEAVERTON, OR 978 (b) Title and average hours per week devoted to position Secretary Presidentl Treasurer! (c) Compensation (If not paid, enter --.). (d) Contributions to employee benefit plans and deferred compensation. fa (e) Expense account and other allowances... BAA TEEA812L 2/18/11 Form 99-EZ (21)

5 Form 99-EZ (21) THE KYRON HORMAN FOUNDATION Page 3 Part V Other Information (te the statement requirements in the instructions for Part V.) See Schedule Check if the organization used Schedule O to respond to any question in this Part V JEL Did the organization engage in any activity not previously reported to the IRS? If ', 1 provide a detailed description of each activity in Schedule Q Were any significant changes made to the organizing or governing documents? If ',' attach a conformed copy of the amended documents if they reflect a change to the organization's name. Otherwise, explain the change on Schedule (see instructions) If the organization had income from business activities, such as those reported on lines 2, 6a, and 7a (among others), but not reported on Form 99-T, explain in Schedule why the organization did not report the income on Form 99-T. a Did the organization have unrelated business gross income of $1, or more or was it a section 51(c)(4), 51(c)(5), or 51(c)(6) organization subject to section 633(e) notice, reporting, and proxy tax requirements? b If ',' has it filed a tax return on Form 99-T for this year (see instructions)? 36 Did the organization undergo a liquidation, dissolution, termination, or significant disposition of net assets during the year? If ',' complete applicable parts of Schedule N 37a Enter amount of political expenditures, direct or indirect, as described in the instructions. H 37a[ b Did the organization file Form 112-POL for this year? 38a Did the organization borrow from, or make any loans to, any officer, director, trustee, or key employee or were any such loans made in a prior year and still outstanding at the end of the tax year covered by this return? b If ',' complete Schedule L, Part II and enter the total amount involved 39 Section 51(c)(7) organizations. Enter: a Initiation fees and capital contributions included on line 9 b Gross receipts, included on line 9, for public use of club facilities 4 a Section 51(c)(3) organizations. Enter amount of tax imposed on the organization during the year under: section ; section 4912 *. ; section 4955 b Section 51 (c)(3) and 51 (c)(4) organizations. Did the organization engage in any section 4958 excess benefit transaction during the year or did it engage in an excess benefit transaction in a prior year that has not been reported on any of its prior Forms 99 or 99-EZ? If ',' complete Schedule L, Part I c Section 51(c)(3) and 51(c)(4) organizations. Enter amount of tax imposed on organization managers or disqualified persons during the year under sections 4912, 4955, and b 39 a 39 b _. N/A N/A N/A a 35 b b 38 a 4 b d Section 51(c)(3) and 51 (c)(4) organizations. Enter amount of tax on line 4c reimbursed by the organization e All organizations. At any time during the tax year, was the organization a party to a prohibited tax shelter transaction? If ',' complete Form 8886-T. 41 List the states with which a copy of this return is filed - OR 4 e 42 a The organization's books are in care of * Located at KRIS_T I _B_ HORMAN NE 183RD STREET SHORELINE WA Telephone no. * _(26)_ _19 ZIP b 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)? If ',' enter the name of the foreign country:.. 42 b See the instructions for exceptions and filing requirements for Form TD F , Report of a Foreign Bank and Financial Accounts. c At any time during the calendar year, did the organization maintain an office outside of the U.S.? If ',' enter the name of the foreign country:.. * 42 c 43 Section 4947(a)(1) nonexempt charitable trusts filing Form 99-EZ in lieu of Form Check here [_J N/A and enter the amount of tax-exempt interest received or accrued during the tax year. H 43 44a Did the organization maintain any donor advised funds during the year? If ',' Form 99 must be completed instead of Form 99-EZ bdid the organization operate one or more hospital facilities during the year? If ',' Form 99 must be completed instead of Form 99-EZ c Did the organization receive any payments for indoor tanning services during the year? d If '' to line 44c, has the organization filed a Form 72 to report these payments? If ',' provide an explanation in Schedule O. 44d BAA TEEA812L 2/18/11 Form 99-EZ (21) 44a 44b 44c N/A X X X

6 Form 99-EZ (21) THE KYRON HORMAN FOUNDATION Page 4 45 Is any related organization a controlled entity of the organization within the meaning of section 512(b)(13)7 a 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 ',' Form 99 and Schedule R may need to be completed instead of Form 99-EZ (see inst.). 46 Did the organization engage, directly or indirectly, in political campaign activities on behalf of or in opposition to candidates for public office? If ',' complete Schedule C, Part I Part VI 45 X 45 a X 46 X 1 section 51(c)(3) organizations and section 4947(a)(1) nonexempt charitable trusts must answer questions 47-49b and 52, and complete the tables for lines 5 and 51. Check if the organization used Schedule Q to respond to any question in this Part VI ~~ 47 Did the organization engage in lobbying activities? If ',' complete Schedule C, Part II 48 Is the organization a school as described in section 17(b)(l)(A)(ii)? If ',' complete Schedule E 49a Did the organization make any transfers to an exempt non-charitable related organization? b If ',' was the related organization a section 527 organization? 5 Complete this table for the organization's five highest compensated employees (other than officers, directors, trustees and key X 48 X 49 a X 49 b (a) Name and address of each employee paid more than $1, (b) Title and average hours per week devoted to position (c) Compensation (d) Contributions to employee benefit plans and deferred compensation (e) Expense account and other allowances ne f Total number of other employees paid over $1, *~ 51 Complete this table for the organization's five highest compensated independent contractors who each received more than $1, of ne (a) Name and address of each independent contractor paid more than $1, (b) Type of service (c) Compensation d Total number of other independent contractors each receiving over $1, 52 Did the organization complete Schedule A? te: All section 51(c)(3) organizations and 4947(a)(1) nonexempt,.,, charitable trusts must attach a completed Schedule A ** IX: 1 Under penalties of perjury, I declare that I have examined thi/ return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete, Declaration of piepatey (gthjft tjfen officer) is based on all information of which preparer has any knowledge. ' ' Sign Here Signature of officer Type or print name and title. Print/Type preparer's name >. 4h#/tofA( f VflPZrWti 7 / ) / A NJ Preparer's sifgne'ture /\ fre e/>* Date / / GEORGE FOX, CPA self-employed P75443 Paid Preparer F.rm'sname- FOX & CO. CPAS, LLC' Use Only Firm's address 1818 NE COXLEY DR STE E Firm's EIN VANCOUVER, WA Phoneno. (36) May the IRS discuss this return with the preparer shown above? See instructions. 1 t I I HX BAA Form 99-EZ (21) Date Check if PTIN TEEA812L 2/18/11

7 SCHEDULE A (Form 99 or 99-EZ) Department of the Treasury Internal Revenue Service Name of the organization Public Charity Status and Public Support Complete if the organization is a section 51 (cx3) organization or a section 4947(aX1) nonexempt charitable trust. * Attach to Form 99 or Form 99-EZ. * See separate instructions. Employer identification number THE KYRON HORMAN FOUNDATION Part I! Reason for Public Charity Status (All organizations must complete this part.) See instructions. The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.) 1 11 A church, convention of churches or association of churches described in section 17(bX1XAX- A school described in section 17(bX1XAX'i)- (Attach Schedule E.) A hospital or a cooperative hospital service organization described in section 17(bX1XAXiii)- OMB Open to Public Inspection A medical research organization operated in conjunction with a hospital described in section 17(bX1X A Xiii)- Enter the hospital's name, city, and state: An organization operated for the benefit of a college or university owned or operated by a governmental unit described in section 17(bX1XAX'v). (Complete Part II.) A federal, state, or local government or governmental unit described in section 17(bX1XAXv)- An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 17(bX1XAXvi). (Complete Part II.) I I A community trust described in section 17(bX1X A X v - (Complete Part II.) [X~ 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 3, See section 59(aX2). (Complete Part III.) An organization organized and operated exclusively to test for public safety. See section 59(aX4). An organization organized and operated exclusively for, the benefit of, to perform the functions of, or carry out the purposes of one or more publicly supported organizations described in section 59(a)(1) or section 59(a)(2). See section 59(aX3). Check the box that describes the type of supporting organization and complete lines lie through 11h. a [_]Type I b [_]Type II c [_] Type III Functionally integrated d [_] Type III - Other 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 59(a)(1) or section 59(a)(2). If the organization received a written determination from the IRS that is a Type I, Type II or Type III supporting organization, check this box Since August 17, 26, has the organization accepted any gift or contribution from any of the following persons? (i) (ii) (iii) A person who directly or indirectly controls, either alone or together with persons described in (ii) and (iii) below, the governing body of the supported organization? A family member of a person described in (i) above? A 35% controlled entity of a person described in (i) or (ii) above?. Provide the following information about the supported organization(s). (i) Name of supported organization (ii) EIN (iii) Type of organization (described on iines 1-9 above or IRC section (see instructions)) (iv) Is the organization in column (i) listed in your governing document? (v) Did you notify the organization in column (t) of your support? (vi) Is the organization in column (i) organized in the U.S.? iig(j) ng(jj) 119 (iii) (vii) Amount of support I I L I (B) (C) (D) (E) Total BAA For Paperwork Reduction Act tice, see the Instructions for Form 99 or 99-EZ. Schedule A (Form 99 or 99-EZ) 21

8 Schedule A (Form 99 or 99-EZ) 21 THE KYRON HORMAN FOUNDATION Page 2 Part II Support Schedule for Organizations Described in Sections 17(bX1XA)(iv) and 17(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.) Calendar year (or fiscal year beginning in) 1 Gifts, grants, contributions, and membership fees received. (Do not include 'unusual grants.')... 2 Tax revenues levied for the organization's benefit and either paid to it or expended on its behalf 3 The value of services or facilities furnished by a governmental unit to the organization without charge... 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)... 6 Public support. Subtract line 5 from line 4 Section B. Total SUDDOII Calendar year (or fiscal year beginning in) * (a) 26 (b) 27 (c) 28 (d) 29 (e) 21 (f) Total. \ \ : iiiibjiil, - r =it! (a) 26 (b) 27 (c) 28 (d) 29 (e) 21 ( Total 7 Amounts from line 4 8 Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources 9 Net income from unrelated business activities, whether or not the business is regularly carried on 1 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.) 11 Total support. Add lines 7 through 1 12 Gross receipts from related activities, etc (see instructions) First five years. If the Form 99 is for the organization's first, second, third, fourth, or fifth tax year as a section 51(c)(3),. organization, check this box and stop here " I 1 Section C. Computation of Public Support Percentage 14 Public support percentage for 21 (line 6, column (f) divided, by line 11, column (f)). 15 Public support percentage from 29 Schedule A, Part II, line 14 16a 33-1/3% supporttest If the organization did not check the box on line 13, and the line 14 is 33-1/3% or more, check this box._, and stop here. The organization qualifies as a publicly supported organization I ] b 33-1/3% support test 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 a 1%-facts-and-circumstances test If the organization did not check a box on line 13, 16a, or 16b, and line 14 is 1% 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 LJ b 1%-facts-and-circumstances test If the organization did not check a box on line 13, 16a, 16b, or 17a, and line 15 is 1% 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... BAA Schedule A (Form 99 or 99-EZ) 21 1 TEEA42L 12/23/1

9 Schedule A (Form 99 or 99-EZ) 21 THE KYRON HORMAN FOUNDATION Page 3 Part ill Support Schedule for Organizations Described in Section 59(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 Calendar year (or fiscal yr beginning in)»- (a) 26 (b) 27 (c)28 (d) 29 (e) 21 ( Total 1 Gifts, grants, contributions and membership fees received. (Do not include any 'unusual grants.') 27, , 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 Gross receipts from activities that are not an unrelated trade or business under section Tax revenues levied for the organization's benefit and either paid to or expended on its behalf. 5 The value of services or facilities furnished by a governmental unit to the organization without charge Total. Add lines 1 through , ,246. 7a 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, or 1% of the amount on line 13 for the year c Add lines 7a and 7b Public support (Subtract line 7c from line 6.) Section B. Total Support *. 27,246. Calendar year (or fiscal yr beginning in) * (a) 26 (b)27 (c) 28 (d) 29 (e) 21 (f) Total 9 Amounts from line , ,246. 1a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources. b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 3, c Add lines 1a and 1b Net income from unrelated business activities not included in line 1b, whether or not the business is regularly carried on. 12 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.). 13 Total Support. (Add Ins 9,1c, 11, and 12.) , , First five years. If the Form 99 is for the organization's first, second, third, fourth, or fifth tax year as a section 51(c)(3) organization, check this box and stop here Section C. Computation of Public Support Percentage 15 Public support percentage for 21 (line 8, column (f) divided by line 13, column (f)) 16 Public support percentage from 29 Schedule A, Part III, line 15 Section D. Computation of Investment Income Percentage 17 Investment income percentage for 21 (line 1c, column (f) divided by line 13, column (). 18 Investment income percentage from 29 Schedule A, Part III, line 17 19a 33-1/3% support tests 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 [XJ b 33-1/3% support tests If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33-1/3%, and line 18 is not more than 33-1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ** 2 Private foundation. If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions *" BAA TEEA431 12/29/1 Schedule A (Form 99 or 99-EZ) n

10 Schedule A (Form 99 or 99-EZ) 21 THE KYRON HORMAN FOUNDATION Page 4 PartlV Supplemental Information. Complete this part to provide the explanations required by Part II, line 1; ~ ""Part II, line 17a or 17b; and Part III, line 12. Also complete this part for any additional information. (See instructions). BAA Schedule A (Form 99 or 99-EZ) 21 TEEAC44L 9/8/1

11 SCHEDULE (Form 99 or 99-EZ) Department of the Treasury Internal Revenue Service Name of the organization THE KYRON HORMAN FOUNDATION Supplemental Information to Form 99 or 99-EZ Complete to provide information for responses to specific questions on Form 99 or 99-EZ or to provide any additional information.» Attach to Form 99 or 99-EZ. Employer identification number OMB Open to Public Inspection PJENPLNG_APPLICMIPN OF TAX EXEMPT_STAIUS_ THE FOUNDATION FILED JETS APPLICATION FOR TAX EXEMPT _STATUS_N_ OCTOBER 1,_ 21JL AFTER. AJDI ALOG_ WITH _THE JERS _(_SEE NOTI CE _DATED_ DECEMBE_R_ 9,_ 2 1_AND_ JANUARY 27, _ 211 _ ANp_THE_RESPONSES_ THERETO) _ON APRIL_14 x _2_11,_ E_ f OUNDATJON WITHDREW, ITS_ INITIAL. APPLICATIONFOR_TAX_EXEMPT_STATUS.._ JDN_AUGUST. 23,_ 2_THE _FOUNDATIN_AMENDE_D_ITS ARTICLES OF.INCORPORATION.TO CONFORM TO_THE_ADVICE_RECEIVED_FROM THE JRS,_ ADDJNG NEW SECTION_12_T_ THE_ ARTICLES^ _A_ REVISED, APPLICATION. FOR. TAX_ EXEDMPT. STATUS WAS FILED WITH THE JRS ON J3CTOBER_9, _211 ^ ON OCTOBER 21 L _211, _THE_IRS_SENT _A NOTICE TO_THE _ FOyNDATION_SJATING_ BE J'ROCESSED. OR THE JOTNDATJON..WOULD. BE _ CONTACTED WITHIN 9 DAYS. THE FOUNDATION. FILED AND RJECEJVED_ AN EXTE_NSION_OF_ TIME_TO_ FILE_ITS_2J JTAX JUSTUML THE FOUNDATIONS _EXTEN_SIO.N_ EXPIRED. ON AUGUST _1_5 X _2_11AND_ AN.ADDJTIONAL.EXTENSION WAS NOT APPROVED. THIS RETURN_I_S_FILED FOR THE YEAR. ENDING J2/3J/1_ REFLECTJNG THE FOUNDATIONS STATUS _A_S_ A TAX EXEMPT _ENTITY X _EVEN THOUGH _AN_ I NJ TI AL_ DEJERMI NATION OF _TAX _EJffiMPT_ STATUS, _HAS_NOTJ3EEN RECEIVED. _P_F_FICERS AND DNECTORS _ T JE _QFFICERS_ AND _D IRE_CTORS_OF_ THE_ FOUNDATION AS..SHOWN. ON THIS. RETURN WERE_ THE_ J 3!!*.???. i^nd DIRECTORS_qF_ THE_ FOUNDATION AS _OF_DECEMBER2\ ± _2_1. TJffi_ OFFICERS_AND DIRECTORS, OF THE ORGANIZATION. HAVE_BEEN J3HANGED_SINCE_ DECEMBER_31_, _2_1AND THE _CURRENT JDFFICERS AND DIRECTOR_S_ARE2 Todd Janber,_.Chaijman,_7149 AiYirpool. Seville, _CA_ 957_47 D J^bie_Watson, DVice J3hairman,_ 161_SW_Go_shawk_S_tjeet_,_Beaverton._,_OR_ 97_7 Carla Kellogg, DSectretary 1344 Lawnridge Ave, Springfield, ORD97477 BAA For Paperwork Reduction Act tice, see the Instructions for Form 99 or 99-EZ. TEEA491L IO/26/IO Schedule O (Form 99 or 99-EZ) 21

12 Schedule (Form 99 or 99-EZ) 21 Page 2 Name of the organization Employer identification number THE KYRON HORMAN FOUNDATION Matt Russell,_ Treasurer L _17425_Snohomish Ave,_ Snqhpmish,_ WA_9_8296.Jeff _ s waine,_ Boajrd_Member_ 622_2_DeJ_Oro_Rqad,_ granite Jay_,_ CA _9574_6 Form?9J)iEZi.Part IH -_Organ\ttiionyj > j\]^ PROVIDE FUNDS AND SERVICES TO HELP LOCATE MISSING CHILDREN AND TO BUILD AWARENESS CAMPAIGNS TO HELP BRING MISSING CHILDREN HOME Form 99-EZ, Part_V_-_Regarding Transfers Associated with Pejsonal_Benefit Contracts (a) Did the organization, during the year, receive any funds, directly or indirectly, to pay premiums on a personal benefit^ contract? N _ _ (b) Did the organization, during the year, payjpremiums, directly or indirectly, on a personal benefit contract?.. _ BAA TEEA492L 1/26/1 Schedule O (Form 99 or 99-EZ) 21

13 21 Schedule - Supplemental Information Pagel Client 557 THE KYRON HORMAN FOUNDATION /13/12 2:48PM Form 99-EZ, Part I, Line 16 Other Expenses BANK/PAY PAL FEES $ 383. ROUNDING ADJUSTMENT Total $