Short Form OMB No For organizations with gross receipts less than $100,000 and total assets less

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1 Form 990-EZ Short Form OMB No Return of Organization Exempt From Income Tax Under section 501(c), 527, or 4947(axl) of the Internal Revenue Code (except black lung benefit trust or private foundation) 2003 For organizations with gross receipts less than $100,000 and total assets less --- Department of me Treasury than $250,000 at the end of the year ~OR~ne Internal Revenue Service ~ The organization may have to use a copy of this return to satisfy state reporting requirements I 'a 04 A For the 2003 calendar ear, or tax ear be g innin g 9 / 01, 2003, and endin g 8 / 31, 2004 B Check if applicable: C D Employer identification number X Address change UflaIRS OREGON MEDICAL CASE MANAGEMENT GROUP Name change label or riot or (OMCMG) E Telephone number Initial return ~ Pe 833 SW 22ND # Final return specific PORTLAND, OR Amended return Insfruc-, F Group Exemption Application pending Number X Section 501(c,Y3) organizations and 4947(a,Yl) nonexempt charitable trusts G Accounting method : E] Cash N Accrual must atfach a completed Schedule A (Form 990 or 990-E~ Other (speci ) H Check 1, X if the organization is not I Web site : - WWW OMCMG ORG re q uired to attach Schedule B (Form 990, J Organization type (check only one) - X 501(c) ( 6 ) ~ (insert no ) 4941(a)(1) or EZ, or 990-PF) K Check 1, if the organization's gross receipts are normally not more than $25,000 The organization need not file a return with the IRS ; but if the organization received a Form 990 Package in the mail, it should file a return without financial data Some states require a complete return L Add lines 5b, 6b, and 7b, to line 9 to determine gross receipts ; if $100,000 or more, file Form 990 instead of Form 990-EZ ~ $ 39,181 left I Revenue, Expenses, and Changes in Net Assets or Fund Balances see Instructions 1 Contributions, gifts, grants, and similar amounts received 1 2 Program service revenue including government fees and contracts 2 37,050 3 Membership dues and assessments 3 2,131 4 Investment income 5a Gross amount from sale of assets other than inventory 5a 4 -- w b Less : cost or other basis and sales expenses 5b c Gain or (loss) from sale of assets other than inventory (line 5a less line 5b) (attach schedule) 5c w E 6 Special events and activities (attach schedule) If any amount is from gaming, check here ~ a Gross revenue (not including $ of contributions reported on line 1) 6a ''1Q b less : direct expenses other than fundraising expenses 6b c Net income or ( loss ) from special events and activities C line 6a less line 6b ) 6c '- 7a Gross sales of inventory, less returns and allowances 7a b Less : cost of goods sold 7b c; c Gross profit or (loss) from sales of inventory (line 7a less line 7b) 7c 8 Other revenue (describe ~ ) 8 9 Total revenue add lines 1, 2, 3, 4, 5c, 6c, 7c, and 8 ~ 9 39, Grants and similar amounts paid (attach schedule) 10 E 11 Benefits paid to or for members 11 Q P 12 Salaries, other compensation, and employee benefits, 12 N 13 Professional fees and other payments to independent contractors 13 4, W- q2owlaff 14 E 15 Printing, ublica, ship ig 15 1, Other expe es escn e SEE STATEMENT 1) 16 27, Total ex s ~id_lines 10 through f ~ 17 32, Excess o ~A1 I tici_r t 9 ~ line 17) 18 6,585 N s 19 Net asse s or~fdnc~bakmce CIL nag f year (from line 27, column (A)) (must agree with end-of-year E E fi g ure re orted qili, 19 7, 627 T 5 20 Other ch n e ~~~ ) ~ es (attach explanation) Net assets or fund balances at end of ear combine lines 18 throug h ,212 Balance Sheets - If Total assets on line 25, column B are $250,000 or more, file Form 990 instead of Form 990-EZ (See Instructions) A Be g innin g of ear B End of ear 22 Cash, savings, and investments 7,627 2Z 14, Land and buildings Other assets (describe ~ ) Total assets 7, , Total liabilities (describe 0, ) Net assets or fund balances line 27 of column B must ag ree with line 21 7, ,212 BAA For Paperwork Reduction Act Notice, see the separate instructions TEEA0803L Form 990-EZ (2003)

2 Form 99o-EZ (2003) OREGON MEDICAL CASE MANAGEMENT GROUP Page 2 Peat ' { Statement of Program Service Accomplishments (See Instructions) Expenses What is the organization's primary exempt purpose? (Required for 501(c)(3) Describe what was achieved in carrying out e orgarnza ion s exemp purposes n a clear an concise manner, and (4) organizations and describe the services provided, the number of persons benefited, or other relevant information for each 4947(a)(1) trusts ; optional p ro gram title for others 28 PROVIDED MONTHLY EDUCATIONAL FORUMS FOR ALL GROUP MEMBERS 29 3Q Other Inf01't11at1011 Note the attachment re quirement in the instructions SEE STATEMENT 3 Yes No 33 Did the organization engage in any activity not previously reported to the IRS? If 'Yes,' attach a detailed description of each activity 34 Were any changes made to the organizing or governing documents but not reported to the IRS? If 'Yes,' attach a conformed copy of the changes X 35 If the organization had income from business activities, such as those reported on lines 2, 6, and 7 (among others), but not reported on Form 990-T, attach a statement explaining your reason for not reporting the income on Form 990-T a Did the organization have unrelated business grass income of $1,000 or mare or 6033(e) notice, reporting, and proxy tax requirements? X b If 'Yes,' has it filed a tax return on Form 990-T for this year? N,'A 36 Was there a liquidation, dissolution, termination, or substantial contraction during the year? (If 'Yes,' attach a statement ) X 37a Enter amount of political expenditures, direct or indirect, as described in the instructions "37a 0 ' ^ b Did the organization file Form 1120-POL for this year?, 38a Did the organization borrow from, or make any loans to, any officer, director, trustee, or key employee or were any such loans made in a prior year and still unpaid at the start of the period covered by this return? X b If 'Yes,' attach the schedule specified m the line 38 Instructions and enter the amount involved 38b N/A 39 50t(c)(7) organizations Enter : a Initiation fees and capital contributions included on line 9 39a N/A I b Gross receipts, included on line 9, for public use of club facilities 39h N/Ai I 40a 501(c)(3) organizations, Enter : Amount of tax imposed on the organization during the year under : section , N/A ;section 4912 ~ N/A ; Section 4955 ~ b 501(c)(3) and (4) organizations Did the organization engage in any section 4958 excess benefit transaction during the year or did it become aware of an excess benefit transaction from a prior year? If 'Yes,' attach an explanation,,,,,, I L~c Amount of tax imposed on organization managers or disqualified persons during the year under 4912, 4955, and 4958 ~ 0 ~] II ~'1 d Enter Amount of tax on line 40c, above, reimbursed by the organization, ~ 0 41 List the states with which a copy of this return is filed - NONE 42 The books are in care of " JEANNE COVEY Telephone no ~ Located at SW 22ND, STE 507, PORTLAND OR ZIP+4 ~ Section 4947(a)(1) nonexempt charitable trusts fling Form 990-EZ m lieu of Form Check here 11 LJ N/A 'lease Sign Here Paid - Grants $ Grants $ (Grants $ ) 30a 31 Other p rogram services attach schedule Grants $ ) 31 a 32 Total ro ram service expenses (add lines 28a throug h 31a) ll~32 ~!> : List of Officers, Directors, Trustees, and Key Et1'1 l0 ee5 (List each one even if not compensated See Instructions,) (B) Title and average hours (C) Compensation If (D) Contributions to (E) Expense account (A) Name and address per week devoted not paid, enter-0- employee benefit plans and and other allowances to p osition deferred compensation SRF qtatrmrnt 7 O I O O and enter the amount of tax-exem pt interest received or accrued durin g the tax ear -43 N/A Und penalties of penury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true rrect, and complete Declaration of reparer (other than officer) is based on all information of which pre~arer has any knowledge ~1 Preparer's signature Pre ' pacer's Firm's name (or MARCY D LANTZ, A yours if self- Use employed), ~ SW MORNINGSTA Only IZP+4 " and BAA r n TIGARD, OR a 29a Type or prmt~namd and title - ~-Date ~ Check if Preparei s SSN or PTIN (See ~_ Pmlnl-d r F X-11 Instruction W) EIN - N/A Phone no - (503) TEEA0812L 12/23/03 Form 990-EZ (2003)

3 2003 FEDERAL STATEMENTS PAGE 1 OREGON MEDICAL CASE MANAGEMENT GROUP (OMCMG) STATEMENTI FORM 990-EZ, PART I, LINE 16 OTHER EXPENSES BANK CHARGES & FEES $ 163 BOARD DEVELOPMENT EXP 9,133 BUSINESS LICENSE/CORP LICENSE 425 CONFERENCE LUNCHEON 500 CONFERENCE SPEAKER FEES 3,500 CONFERENCE SUPPLIES 910 CONFERENCE TRAVEL EXP 413 CONFERENCE VENDOR REFUNDS 100 CONTINUING EDUCATION FLOWERS/PROMOTIONAL 2, MEMBERSHIP/CHAPTER FEE 75 MONTHLY LUNCHEON EXP 5,883 OFFICE SUPPLIES 1,969 PHONE ANSWERING SERVICE 257 SPEAKER FEES 106 WEB SITE DEVELOPMENT/MAINT 1,224 TOTAL 27,282 STATEMENT 2 FORM 990-EZ, PART IV LIST OF OFFICERS, DIRECTORS, TRUSTEES, AND KEY EMPLOYEES TITLE AND CONTRI- EXPENSE AVERAGE HOURS COMPEN- BUTION TO ACCOUNT/ NAME AND ADDRESS PER WEEK DEVOTED SATION EBP & DC OTHER JENNIFER WRIGHT PRESIDENT $ 0 $ 0 $ NE 122ND AVE, #329 2 PORTLAND, OR CRISTIE WIGGS VICE PRESIDENT NE 122ND AVE, #329 2 PORTLAND, OR CAM CAMBURN SECRETARY NW YONCALLA CT 2 PORTLAND, OR MICHELE NIELSEN TREASURER WILLAMETTE DR, #134 2 WEST LINN, OR JEANNE COVEY TREA5 - CURRENT SW 22ND, STE PORTLAND, OR TOTAL 0 $ 0 0

4

5 ~ Form Pa e 2 0 If you are filing for an Additional (not automatic) 3-Month Extension, complete only Part II and check this box ~ X Note : Only complete Part // if you have already been granted an automatic 3-month extension on a previously filed Form 8868 a If you are filing far an Automatic 3-Month Extension, com plete only Part I on a e 1 ) Additional not automatic 3-Month Extension of Time - Must File Original and One Go Name of Exempt Organization Employer Identification number Type or Oregon Medical Case Management Group print (OMCMG) J I Number, street and room or suite number If a P O box, see instructions I For IRS Use Only File by the extended due date for ling the PO Box f return See nswctions City, town or post office, state, and ZIP code For a foreign address see instructions i ~ Mulino, OR Check type of return to be filed (file a separate application for each return) : Forr^ o9q nfo!-m 940-EZ nform 990-T (Section 4Jl ;z; or 4QQ(a; trust) Form 1041-A ~crm 5227 UForn 8870 o H Form 990-BL ~ Form 990-PF ~ Form 990-T (trust other than above) H Form 4720 ~ Form 6069 Stop: Do not complete Part II if you were not already ranted an automatic 3-month extension on a previousl y filed Form If the organization does not have an office or place of business in?he United States, check this box 0 If this is for a Group Return, enter the organizations four digit Group Exemption Number (GEN) If this is for the Q whole group, check this box ~ ~ If it is pan of the group, check this box 0' F land attach a list with the names and EINs of all members the extension is for UJI 4 I request an additional 3-month extension of time until ` 7/ ~+ p 5 For calendar year _--_, or other tax year beginning _ 9/01~, 20 0~l-and ending - 8/31, If this tax year is for less than 12 months, check reason : ~Initial LJ return L J return -D ~--~ Change in accounting period > ~ 7 state in detail why you need the extension Organization recluests-additional time-to gather u y documents necessary to_prepare a complete -and accurate return a ,Sali this application-i!5 forfofw1990-bl, 990-PF, 990-T, 4720, or 6069, enter the tentative tax, less any nor See irhstructions $ n rqlou b f this application is for F _990-PF, 990-T, 4720, or 6069, enter any refundable credits and estimated tax ayrp~t~s~~je de dry prior year overpayment allowed as a credit and any amount paid previously with ~P ~4 2 $ c from line 8a Include your payment with this form, or, if required, deposit with =DQn-m,vif neaarired, b using EFTPS (Electronic Federal Tax Payment System) See instructions VuLC~e~ v J Signature and Verification Under penalties of penury, I declare that I have examined this form including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete, and (fiat I am authorized to pr9pare this form TiNe 10' ( F iv _- I / / Notic~~o Applicant - To be Completed by the IRS We have approved this appli~~ion Please*ach this form to the organization's return Date '- I-" -j We have not approved this application However, we have granted a 10-day grace period from the later of the date shown below or the due date of the organization's return (including any prior extensions) This grace period is considered to be a valid extension of time for elections otherwise required to be made on a timely filed return Please attach this form to the organization's return We have not approved this application After considering the reasons stated in item 7, we cannot grant your request for an extension of time to file We are not granting a 10-day grace period e We cannot consider this application because it was filed after the due date of the return for which an extension was requested Other : By Director Date Alternate Mailing Address - Enter the address if you want the copy of this application for an additional 3-month 1,MOVED address different than the one entered above Type or print Name Marc D Lantz, CPA APR Number and street pnclude suite, room, or apartment number) or a P O, box number SW Mornin star Dr City or town province or stale, and country (including postal or ZIP code),field DIRECTOR, N Ti ard, OR BAA FIFZ0502L Form 8868 (Rev )

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