lifeline humanitarian organization of chicago - 2011 form 990
DESCRIPTION
hrh crown princess katherine of serbia's dubious charitable activitiesTRANSCRIPT
Form 999-PF Return of Private FoundationOMB No 1545 0052
or Section 4947(axl) Nonexempt Charitable Trust ^0.^ ,^• Treated as a Private Foundation
Department of the TieaswyInternal Revenue Service Note The foundation may be able to use a copy of this return to satisfy state reporting requirements
For calendar year 2011 , or tax year beginning , 2011 , and ending
LIFELINE HUMANITARIAN ORGANIZATION A Employer identification number
OF CHICAGO 36-3894439155 N. MICHIGAN AVE. SUITE 409 B Telephone number (see the nstructions)
CHICAGO IL 60601 (312) 781-9300,
C If exemption application is pending , check here
G Check all that apply Initial return Initial Return of a former public charity D 1 Foreign organizations , check here
I
Final return Amended return
X Address change Name change 2 Foreign organizations meeting the 85% test, check
H Check type of organization X Section 501 (c)(3) exempt private foundation
qhere and attach computation
Section 4947(a)(1) nonexempt charitable trust Other taxable private foundation E If private foundation status was terminatedI Fair market value of all assets at end of year J Accounting method X Cash Accrual
qunder section 507(b)( 1)(A), check here
(from Part 11, column (c), line 16)11 Other (specify) F If the foundation is in a 60- month termmatton
$ 124, 262. (Part 1, column (d) must be on cash basis) under section 507(b)( 1)(B), check herePart I Analysis of Revenue and
Ex penses he total of amounts rn(r (a ) Revenue and (b) Net investment (c) Adjusted net (d) Disbursements
columns (b), (c), and (d) may not neces -expenses per books income income for charitable
sarfly equal the amounts in column (a)purposes
(cash basis only)(see instructions)1 Contributions , gifts, grants etc , received ( att sch )
-
66 , 605. -1
if the foundn is not req to all Sch B2 Ck 1' 13 Interest on savings and temporary
cash investments 110. 110. 110.4 Dividends and interest from securities5a Gross rentsb Net rental income
or (loss) i
R 6a Net gain /( loss) from sale of assets not on tine 10
E b Gross sales price for allV asseE 7 Capi ^ gain n ^ aj (^e 2)
N 8 Net short-t'DI9Ni VU 9 Inc me -1110U_1Il(_dLlUilb__ (^E 10a retuI
dsIesQU
^
820^2
!/^
alto a
b Les Co of U)N goo s so
c Gro prof tomm
o l11 Ot er tn lc ile
-t S 186,712.12 Total . Add lines 1 through 11 253 427. 110. 110.
Q 13 Compensation of officers , directors trustees, etc , bUO.
14 Other employee salaries and wages
w 15 Pension plans, employee benefits
Z A 16a Legal fees (attach schedule)
Z M b Accounting fees (attach sch) SEE ST 2 3, 295.N c Other prof fees (attach sch) SEE ST 3 734 ., 17 Interest 180. 180. 180.
E TR
18 Taxes ( attach schedulexsee instrs ) SEE STM 4 2, 341. 23.A A 19 Depreciation (attachT T sch) and depletion 1, 013.N 20 Occupancy g 929.G E 21 Travel, conferences, and meetings 739.A EN
22 Printing and publications 2 , 546.D p 23 Other expenses (attach schedule)
EN SEE STATEMENT 5 26,230.S
E 24 Total operating and administrative
sexpenses . Add lines 13 through 23 76, 607. 180. 180. 329.
25 Contributions , gifts, grants paid STMT 6 226 143. 226 143.26 Total expenses and disbursements.
Add lines 24 and 25 302 750. 180. 180. 226,472.27 Subtract line 26 from line 12:
a Excess of revenue over expensesand disbursements -49,323. 1
b Net investment income ( if negative , enter 0 0 .
C Adjusted net income ( if negative , enter 0 ) 0.
BAA For Paperwork Reduction Act Notice , see instructions . TEEA0504L 12/05111 Form 990-PF (2011)
^C^„ IV
Form 990,-PF (2011) LIFELINE HUMANITARIAN ORGANIZATION
P rt IIAttached schedules and amounts in the description
Balance Sheets column should be for end of-year amounts only(See instructions )
1 Cash - non-interest-bearing
2 Savings and temporary cash investments
3 Accounts receivable ►-----------
Less allowance for doubtful accounts ►-----------
4 Pledges receivable ►-----------
Less allowance for doubtful accounts ►-----------
5 Grants receivable
6 Receivables due from officers, directors, trustees, and otherdisqualified persons (attach schedule) (see instructions)
7 Other notes and loans receivable (attach sch) ►S Less allowance for doubtful accounts ►
-----------S 8 Inventories for sale or use
ET 9 Prepaid expenses and deferred charges
S 10a Investments - U S and state governmentobligations (attach schedule)
b Investments - corporate stock (attach schedule)
c Investments - corporate bonds (attach schedule)
11 Investments - land, buildings, andequipment basis ►
-----------Less accumulated depreciation(attach schedule) ►
-----------12 Investments - mortgage loans
13 Investments - other (attach schedule)
14 Land, buildings, and equipment basis ► 1 1 ,42 7 ._ _ _ _ _
Less accumulated depreciation(attach schedule) SEE STMT 7 ► 11,427.
15------------
Other assets (describe ►----------------
16 Total assets (to be completed by all filers -see the instructions Also, see page 1, item I)
L 17 Accounts payable and accrued expenses
IA 18 Grants payable
B 19 Deferred revenue
IL 20 Loans from officers, directors, trustees, & other disqualified persons
1 21 Mortgages and other notes payable (attach schedule)
T 22 Other liabilities (describe ► )
ES 23 Total liabilities (add lines 17 through 22)
Foundations that follow SFAS 117 check here ► FX, _complete lines 24 through 26 and lines 30 and 31.
N F 24 UnrestrictedE UT N 25 Temporarily restricted
o 26 Permanently restricted
S B Foundations that do not follow SFAS 117. check here ►S A and complete lines 27 through 31.
E LT A 27 Capital stock, trust principal, or current funds
S N 28 Paid-in or capital surplus, or land, building, and equipment fund
O E 29 Retained earnings, accumulated income, endowment, or other funds
R S 30 Total net assets or fund balances (see instructions)31 Total liabilities and net assets/fund balances
6,651. 1,715.
171,306. 122,547.
564.1 _1
171,870. 122,547.
178,521. 124,262.Part III Analysis of Changes in Net Assets or Fund Balances
1 Total net assets or fund balances at beginning of year - Part II, column (a), line 30 (must agree withend-of-year figure reported on prior year's return) 1 171, 870.
2 Enter amount from Part I, line 27a 2 -49, 323.
3 Other increases not included in line 2 ( itemize) ►------------------------------
3
4 Add lines 1, 2, and 3 4 122, 547.5 Decreases not included in line 2 (itemize) ____________ 5_
6 Total net assets or fund balances at end of year (line 4 minus line 5) - Part II column (b), line 30 6 122,547.
BAA TEEA0302L 07/14111 Form 990-PF (2011)
36-3894439 Page 2Beginning of year End of year
(a) Book Value (b) Book Value (c) Fair Market Value
122,642. 69,836. 69,836.54,866. 54,426. 54,426.
1,013.
178,521. 124,262. 124,262.6,651. 1,715.
Form 990-PF 2011) LIFELINE HUMANITARIAN ORGANIZATION 36-3894439 Page 3Part IV , Ca p ital Gains and Losses for Tax on Investment Income
• (a) List and describe the kind(s) of property sold (e g , real estate,2-story brick warehouse, or common stock, 200 shares MLC Company)
( How acquiredP - PurchaseD - Donation
(C) Date acquired(month day, year)
(d) Date sold(month, day, year)
l a N/Ab
Cd
e(e) Gross sales price (f) Depreciation allowed
(or allowable)(g) Cost or other basisplus expense of sale
(h) Gain or (loss)(e) plus (f) minus (g)
a
b
Cd
eComplete onl y for assets showing gain in column (h) and owned by the foundation on 12/31/69 (I) Gains (Column (h)
(i) Fair Market Valueas of 12/31/69
(j) Adjusted basisas of 12/31 /69
(k) Excess of column (l)over column (j), if any
gain minus column (k), but not lessthan -0-) or Losses (from column (h))
a
b
Cd
e
2 Capital gain net income or (net capital loss) {lf gain, also enter in Part I, line 7If (loss), enter -0- in Part I, line 7 2
3 Net short-term capital gain or (loss) as defined in sections 1222(5) and (6)
If gain, also enter in Part I, line 8, column (c) (see instructions) If (loss), enter -0-in Part I, line 8 3
Part V Qualification Under Section 4940(e) for Reduced Tax on Net Investment Income(For optional use by domestic private foundations subject to the section 4940(a) tax on net investment income )
If section 4940(d)(2) applies, leave this part blank
Was the foundation liable for the section 4942 tax on the distributable amount of any year in the base perlod7 Yes X No
If 'Yes,' the foundation does not qualify under section 4940 (e) Do not complete this part
1 Enter the appropriate amount to each column for each year , see the instructions before making any entries
(a)Base period years
Calendar year (or tax yearbeginning in)
(b)Adjusted qualifying distributions
(c)Net value of
noncharitable-use assets
(d)Distribution ratio
(column (b) divided by column (c))
2010 52,973. 40,028. 1.3233992009 35,414. 88,236. 0.4013552008 346,323. 116,501. 2.9727042007 196,336. 137,222. 1.4307912006 149,236. 233,480. 0.639181
2 Total of line 1, column (d) 2 6. 767430
3 Average distribution ratio for the 5-year base period - divide the total on linenumber of years the foundation has been in existence if less than 5 years
2 by 5, or by the3 1.353486
4 Enter the net value of noncharitable-use assets for 2011 from Part X, line 5 4 72,607.
5 Multiply line 4 by line 3 5 98,273.
6 Enter 1 % of net investment income (1 %a of Part I, line 27b) 6
7 Add lines 5 and 6 7 98,273.
8 Enter qualifying distributions from Part XII, line 4 8 226,472.
If line 8 is equal to or greater than line 7, check the box in Part VI, line 1 b, and complete that part using a 1 % tax rate See thePart VI instructions
BAA Form 990-PF (2011)
TEEA0303L 07/14/11
Form 99Q-PF (2011) LIFELINE HUMANITARIAN ORGANIZATION 3 6-3894439 Page 4Part VI• Excise Tax Based on Investment Income (section 4940(a), 4940(b), 4940(e ), or 4948 - see instructions)
1 a Exempt operating foundations described in section 4940(d)(2), check here and enter 'N/A' on line 1
Date of ruling or determination letter - _ _ - - - (attach copy of letter if necessary - see instrs)
b Domestic foundations that meet the section 4940(e) requirements in Part V, 1 0.
check here and enter 1 % of Part I, line 27b11-1
c All other domestic foundations enter 2% of line 27b Exempt foreign organizations enter 4% of Part I, line 12, column (b)
2 Tax under section 511 (domestic section 4947(a)(1) trusts and taxablefoundations only Others enter -0-) 2 .
3 Add lines 1 and 2 3 0.
4 Subtitle A (income) tax (domestic section 4947(a)(1) trusts and taxable foundations only Others enter -0-) 4 0.
5 Tax based on investment income . Subtract line 4 from line 3 If zero or less, enter -0- 5 0.
6 Credits/Payments
a 2011 estimated tax pmts and 2010 overpayment credited to 2011 6a
b Exempt foreign organizations - tax withheld at source 6b
c Tax paid with application for extension of time to file (Form 8868) 6c
d Backup withholding erroneously withheld 6d
7 Total credits and payments Add lines 6a through 6d 7 0.
8 Enter any penalty for underpayment of estimated tax Check here n if Form 2220 is attached 8
9 Tax due If the total of lines 5 and 8 is more than line 7, enter amount owed ► 9 0.
10 Overpayment If line 7 is more than the total of lines 5 and 8, enter the amount overpaid 10
11 Enter the amount of line 10 to ne Credited to 2012 estimated tax ► Refunded 11
Part VII -A Statements Regardin g Activities
ear1 a Durin the tax did the foundation attem t to influence an national or local le islation or did itstate Yes No,g y p y , , gparticipate or intervene in any political campaign? la X
b Did it spend more than $100 during the year (either directly or indirectly) for political purposes(see the instructions for definition) 1 b X
If the answer is 'Yes' to la or 1b, attach a detailed description of the activities and copies of any materials publishedor distributed by the foundation in connection with the activities
c Did the foundation file Form 1120-POL for this year?
d Enter the amount (if any) of tax on political expenditures (section 4955) imposed during the year(1) On the foundation I. $ 0. (2) On foundation managers B. $
e Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed onfoundation managers 0. $ 0.
2 Has the foundation engaged in any activities that have not previously been reported to the IRS)
If 'Yes,' attach a detailed description of the activities
3 Has the foundation made any changes, not previously reported to the IRS, in its governing instrument, articlesof incorporation, or bylaws, or other similar instruments? If 'Yes,' attach a conformed copy of the changes
4a Did the foundation have unrelated business gross income of $1,000 or more during the year?
b If 'Yes,' has it filed a tax return on Form 990-T for this year?
5 Was there a liquidation, termination, dissolution, or substantial contraction during the year?
If 'Yes,' attach the statement required by General Instruction T
6 Are the requirements of section 508(e) (relating to sections 4941 through 4945) satisfied either
• By language in the governing instrument, or
lc -- -X
2 X
3 X4a X
4b N /A5 X
• By state legislation that effectively amends the governing instrument so that no mandatory directions that conflict - - -with the state law remain in the governing instrument? 6 X
7 Did the foundation have at least $5,000 in assets at any time during the year? If ' Yes,' complete Part Il, column (c), and PartXV 7 X
8a Enter the states to which the foundation reports or with which it is registered (see instructions)
IL
b If the answer is 'Yes' to line 7, has the foundation furnished a copy of Form 990-PF to the Attorney General(or designate ) of each state as required by General Instruction G2 If 'No,' attach explanation 8b X
9 Is the foundation claiming status as a private operating foundation within the meaning of section 4942(1)(3) or 4942(j)(5)for calendar year 2011 or the taxable year beginning in 2011 (see instructions for Part XIV)7 If ' Yes,' complete Part XIV 9
10 Did any persons become substantial contributors during the tax year? If 'Yes,' attach a schedule listing their names
BAA
X
Form 990-PF (2011)
TEEA0304L 07/14111
orm 99Q-PF (2011) LIFELINE HUMANITARIAN ORGANIZATION 36-3894439 Page 5'art VH-A Statements Regardin g Activities continued
11 At any time during the year, did the foundation, directly or indirectly, own a controlled entitywithin the meaning of section 512(b)(13)' If 'Yes', attach schedule (see instructions) 11 X
12 Did the foundation make a distribution to a donor advised fund over which the foundation or a disqualified person hadadvisory privileges? If 'Yes,' attach statement (see instructions) 12 X
13 Did the foundation comply with the public inspection requirements for its annual returns and exemption application? 13 X
Website address ► WWW.LIFELINEAID.INFO---------------------------- -
14---
The books are in care of ► VICKI ZAMMICHIEL Telephone no ► (312)---------781-9300---------------------------- -----
Located at ► 155 N. MICHIGAN AVE. SUITE 409 CHICAGO IL ZIP+4 ► 60601--------
15 Section 4947(a)(1) nonexempt charitable trusts filing Form 990-PF in lieu of Form 1041 - Check here N/A ► ETand enter the amount of tax-exempt interest received or accrued during the year ► 15 N/A
16 At any time during calendar year 2011, did the foundation have an interest in or a signature or other authority over a Yes No
bank, securities, or other financial account in a foreign country? 16 X
See the instructions for exceptions and filing requirements for Form TD F 90-22 1 If 'Yes,' enter the name of theforeign country
Part VII-B Statements Reg arding Activities for Which Form 4720 May Be RequiredFile Form 4720 if any item is checked in the ' Yes' column, unless an exception applies. Yes No
1 a During the year did the foundation (either directly or indirectly)
(1) Engage in the sale or exchange, or leasing of property with a disqualified person? Yes No
(2) Borrow money from, lend money to or otherwise extend credit to (or accept it from) adisqualifieo person) Yes X No
(3) Furnish goods, services, or facilities to (or accept them from) a disqualified person? Yes M No
(4) Pay compensation to, or pay or reimburse the expenses of, a disqualified person? Yes N No
(5) Transfer any income or assets to a disqualified person (or make any of either availablefor the benefit or use of a dis ualified erson )? []Yes Noq p
(6) Agree to pay money or property to a government official? (Exception . Check 'No' if thefoundation agreed to make a grant to or to employ the official for a period after termination
f nt se f t inat n th 90 da s ) El Y Ngovernme rvice, i erm i g wi in yo es o
b If any answer is 'Yes' to 1 a( 1)-(6), did any of the acts fail to qualify under the exceptions described inRegulations section 53 4941 (d)- 3 or in a current notice regarding disaster assistance (see instructions)? lb N AOrganizations relying on a current notice regarding disaster assistance check here ► El
c Did the foundation engage in a prior year in any of the acts described in la, other than excepted acts, -that were not corrected before the first day of the tax year beginning in 2011' 1 c X
2 Taxes on failure to distribute income (section 4942) (does not apply for years the foundation was aprivate operating foundation defined in section 49420)(3) or 4942(1)(5)) -
a At the end of tax year 2011 , did the foundation have any undistributed income ( lines 6dand 6e , Part XIII ) for tax year (s) beginning before 2011 El Yes No
-If 'Yes,' list the years ► 20_ 20 - , 20 - , 20
b Are there any years listed in 2a for which the foundation is not applying the provisions of section 4942(a)(2)(relating to incorrect valuation of assets ) to the year's undistributed income? ( If applying section 4942 (a)(2) to -- -- --- -all years listed, answer 'No ' and attach statement - see instructions) 2b NVA
c If the provisions of section 4942(a)(2) are being applied to any of the years listed in 2a, list the years here
10, 20 , 20 , 20 , 20
3a Did the foundation hold more than a 2% direct or indirect interest in any businesst t d th Nt ? 11 Yeime uringen erprise a any e year s o
b If 'Yes ,' did it have excess business holdings in 2011 as a result of (1) any purchase by the foundationor disqualified persons after May 26, 1969, (2) the lapse of the 5-year period (or longer period approved
Rthe Commissioner under section 4943(c)(7)) to dispose of holdings acquired by gift or bequest, orthe lapse of the 10-, 15- , or 20-year first phase holding period? (Use Schedule C, Form 4720, to
determine If the foundation had excess business holdings in 2011) 3b N A
4a Did the foundation invest during the year any amount in a manner that would jeopardize itscharitable purposes? 4a X
b Did the foundation make any investment in a prior year (but after December 31, 1969) that couldjeopardize its charitable purpose that had not been removed from jeopardy before the first day of ---- - - -the tax year beginning in 20117 4b X
BAA Form 990-PF (2011)
TEEA0305L 07114111
Form 990,PF (2011) LIFELINE HUMANITARIAN ORGANIZATION 36-3894439 Page 6Part VI!-B Statements Regardin g Activities for Which Form 4720 May Be Req uired continued5a During the year did the foundation pay or incur any amount to
(1) Carry on propaganda, or otherwise attempt to influence legislation (section 4945(e))? Yes No
(2) Influence the outcome of any specific public election (see section 4955), or to carryon, directly or indirectly, any voter registration drive? Yes No
(3) Provide a grant to an individual for travel, study, or other similar purposes? H Yes X No
(4) Provide a grant to an organization other than a charitable, etc, organization describedin section 509(a)(1), (2), or (3), or section 4940(d)(2)'' (see instructions) Yes No
(5) Provide for any purpose other than religious, charitable, scientific, literary, orcational red f th f ltt h ldt l ?puu poses, or or e preven ion o crue y i ren or animao c s Yes No
b If any answer is 'Yes' to 5a(1)-(5), did any of the transactions fail to qualify under the exceptionsdescribed in Regulations section 53 4945 or in a current notice regarding disaster assistance - -- - - -- -(see instructions)? 5b N AOrganizations relying on a current notice regarding disaster assistance check here
c If the answer is 'Yes' to question 5a(4), does the foundation claim exemption from thetax because it maintained expenditure responsibility for the grant? N/A 11 Yes NoIf 'Yes,' attach the statement required by Regulations section 534945-5(d)
6a Did the foundation, during the year, receive any funds, directly or indirectly, to pay premiumson a personal benefit contract? []Yes No
b Did the foundation, during the year, pay premiums, directly or indirectly, on a personal benefit contract? 6b XIf 'Yes' to 6b, file Form 8870
7a At any time during the tax year, was the foundation a party to a prohibited tax shelter transaction? Yes XNo
b If 'Yes,' did the foundation receive any proceeds or have any net income attributable to the transact ion? N/A 7b
Part VIII Information About Officers , Directors , Trustees , Foundation Managers , Highly Paid Employees,and Contractors
1 List all officers . directors . trustees . foundation managers and their comoensatinn (see instructinnci
(a) Name and address
(b) Title, and averagehours per week
devoted to position
(c) Compensation(If not paid , enter -0-)
(d) Contributions toemployee benefitplans and deferred
compensation
(e) Expense account,other allowances
SEE STATEMENT-8 _-------____
30,600. 0. 0.
------------------------
------------------------
-------------------------
2 Compensation of five hiahest-paid emolovees (other than those included on line 1- see inctructinns)- If none- entpr'NONF'
(a) Name and address of each employeepaid more than $50,000
(b) Title, and averagehours per week
devoted to position
(c) Compensation (d) Contributions toemployee benefitplans and deferred
compensation
(e) Expense account,other allowances
NONE --------------------
------------------------
------------------------
------------------------
------------------------
Total number of other employees paid over $50,000 ► 0t5AA TEEA0306L 12/05/11 Form 990-PF (2011)
Form 990•PF (2011) LIFELINE HUMANITARIAN ORGANIZATION 36-3894439 Page 7Part VPII Information About Officers , Directors, Trustees, Foundation Managers, Highly Paid Employees,
and Contractors (continued)
3 Five highest- paid independent contractors for p rofessional services (see instructions). If none , enter ' NONE.'
(a) Name and address of each person paid more than $50,000 (b) Type of service (c) Compensation
NONE--------------------------------------
--------------------------------------
--------------------------------------
--------------------------------------
--------------------------------------
Total number of others receiving over $50,000 for professional services 0
Part IX-A Summary of Direct Charitable Activities
List the foundation's four largest direct charitable activities during the tax year Include relevant statistical information such as the number of Expensesorganizations and other beneficiaries served, conferences convened, research papers produced, etc
1 CONTRIBUTIONS-TO PRINCESS-KATHERINE FOUNDATION-SERBIA- - HOSPITAL--------------------------------------------------EQUIPMENT-AND-MEDICAL-SUPPLIES-- DISTRIBUTED TO VARIOUS HOSPITALS-IN-------------------------------------------------SERBIA 33,512.
2 CONTRIBUTION TO PRINCESS KATHERINE FOUNDATION - SERBIA ------------------------------------------------------
------------------------------------------------------170, 909.
3------------------------------------------------------
------------------------------------------------------
4
------------------------------------------------------
Part IX-B Summary of Program - Related Investments (see instructions)
Describe the two largest program-related investments made by the foundation during the tax year on lines 1 and 2 Amount
1------------------------------------------------------N/A------------------------------------------------------
2------------------------------------------------------
------------------------------------------------------
All other program-related investments See instructions
3------------------------------------------------------------------------------------------------------------
Total . Add lines 1 through 3 0- 1 0.
BAA Form 990-PF (2011)
TEEA0307L 09/01/11
Form 990.PF (2011) LIFELINE HUMANITARIAN ORGANIZATION 36- 3894439 Page 8Part X • Minimum Investment Return (All domestic foundations must complete this part. Foreign foundations,
see instructions.)
1 Fair market value of assets not used (or held for use) directly in carrying out charitable, etc, purposesa Average monthly fair market value of securities
-1 a
b Average of monthly cash balances 1 b 73,713.
c Fair market value of all other assets (see instructions) 1 c
d Total (add lines 1 a, b, and c) l d 73,713.
e Reduction claimed for blockage or other factors reported on lines 1a and lc
(attach detailed explanation) 1 e 0.
2 Acquisition indebtedness applicable to line 1 assets 2 0.
3 Subtract line 2 from line ld 3 73,713.
4 Cash deemed held for charitable activities Enter 1-1/2% of line 3(for greater amount, see instructions) 4 1, 106.
5 Net value of noncharitable -use assets . Subtract line 4 from line 3 Enter here and on Part V, line 4 5 72,607.
6 Minimum investment return . Enter 5% of line 5 6 3,630.Part XI Distributable Amount (see instructions) (Section 4942(j)(3) and (j)(5) private operating foundations
and certain forei g n organizations check here ► and do not comp lete this art.1 Minimum investment return from Part X, line 6
2a Tax on investment income for 2011 from Part VI, line 5
b Income tax for 2011 (This does not include the tax from Part VI )
c Add lines 2a and 2b
3 Distributable amount before adjustments Subtract line 2c from line 1
4 Recoveries of amounts treated as qualifying distributions
5 Add lines 3 and 4
6 Deduction from distributable amount (see instructions)
3,630.2a2b
2c
3 3,630.4
5 3,630.6
7 Distributable amount as adjusted Subtract line 6 from line 5 Enter here and on Part XIII, line 1 7 3,630.
Part XII Qualifying Distributions (see instructions)
1 Amounts paid (including administrative expenses) to accomplish charitable, etc, purposesa Expenses, contributions, gifts, etc - total from Part I, column (d), line 26 1 a 226,472.
b Program-related investments - total from Part IX-B 1 b
2 Amounts paid to acquire assets used (or held for use) directly in carrying out charitable, etc, purposes 2
3 Amounts set aside for specific charitable projects that satisfy thea Suitability test (prior IRS approval required) 3a
b Cash distribution test (attach the required schedule) 3b
4 Qualifying distributions . Add lines la through 3b Enter here and on Part V, line 8, and Part XIII, line 4 - 4 226,472.
5 Foundations that qualify under section 4940(e) for the reduced rate of tax on net investment incomeEnter 1 % of Part I, line 27b (see instructions) 5
6 Adjusted qualifying distributions . Subtract line 5 from line 4 6 226,472.
Note . The amount on line 6 will be used in Part V, column (b), in subsequent years when calculating whether the foundationqualifies for the section 4940(e) reduction of tax in those years
BAA Form 990-PF (2011)
TEEA0308L 12/05/11
Form 990-PF (2011) LIFELINE HUMANITARIAN ORGANIZATION 36-3894439 Page 9
Part XIII Undistributed Income (see instructions)
(a ) brio 01 ^dCorpus Years p r to 2010 2 0 1 120
1 Distributable amount for 2011 from Part XI,line 7 3,630.
2 Undistributed income, if any, as of the end of 2011
a Enter amount for 2010 only 0.
b Total for prior years 20 20 20 0.
3 Excess distributions carryover, if any, to 2011
aFrom2006 137,596.bFrom2007 189,475.
c From 2008 340,498. -d From 2009 31,002.
e From 2010 50,972. -- - - - -If Total of lines 3a through e 749, 543.
4 Qualifying distributions for 2011 from Part
XII, line 4 ► $ 226,472.a Applied to 2010, but not more than line 2a 0.
b Applied to undistributed income of prior years(Election required - see instructions) 0.
c Treated as distributions out of corpus(Election required - see instructions) 0.
d Applied to 2011 distributable amount 3,630.e Remaining amount distributed out of corpus 222, 842.
5 Excess distributions carryover applied to 2011 0. 0.(If an amount appears in column (d), thesame amount must be shown in column (a) )
6 Enter the net total of each column asindicated below:
a Corpus Add lines 3f, 4c, and 4e Subtract line 5 972,385.
b Prior years' undistributed income Subtractline 4b from line 2b 0.
c Enter the amount of prior years' undistribut-ed income for which a notice of deficiencyhas been issued, or on which the section4942(a) tax has been previously assessed 0.
d Subtract line 6c from line 6b Taxableamount - see instructions 0.
e Undistributed income for 2010 Subtract line 4a fromline 2a Taxable amount - see instructions 0.
f Undistributed income for 2011 Subtract lines4d and 5 from line 1 This amount must bedistributed in 2012 0.
7 Amounts treated as distributions out ofcorpus to satisfy requirements imposedby section 170(b)(1)(F) or 4942(g)(3)(see instructions) 0.
8 Excess distributions carryover from 2006 notapplied on line 5 or line 7 (see instructions) 137, 596.
9 Excess distributions carryover to 2012.Subtract lines 7 and 8 from line 6a 834, 789.
10 Analysis of line 9
a Excess from 2007 189,475.
b Excess from 2008 340, 498.
c Excess from 2009 31,002.
d Excess from 2010 50,972.
e Excess from 2011 222, 842.
BAA Form 990-PF (2011)
TEEA0309L 07/14/11
Form 99Q-PF (2011) LIFELINE HUMANITARIAN ORGANIZATION 36-3894439 Page 10Part XIV Private Operating Foundations (see instructions and Part VII-A, q uestion 9 N/A
1 a If the foundation has received a ruling or determination letter that it is a private operating foundation, and the rulingis effective for 2011, enter the date of the ruling
b Check box to indicate whether the foundation is a private o erating foundation described in section 4942(1)(3) or 7 4942(1)(5)
2a Enter the lesser of the adjusted net Tax year Prior 3 yearsincome from Part I or the minimum
(a) 2011investment return from Part X for ) (b) 2010 (c) 2009 (d 2008 (e) Total
each year listed
b 85% of line 2a
c Qualifying distributions from Part XII,line 4 for each year listed
d Amounts included in line 2c not used directlyfor active conduct of exempt activities
e Qualifying distributions made directlyfor active conduct of exempt activitiesSubtract line 2d from line 2c
3 Complete 3a, b, or c for thealternative test relied upon
a 'Assets' alternative test - enter
(1) Value of all assets
(2) Value of assets qualifying undersection 49420)(3)(B)(i)
b 'Endowment' alternative test - enter 2/3 ofminimum investment return shown in Part X,line 6 for each year listed
c 'Support' alternative test - enter
(1) Total support other than grossinvestment income (interest,dividends, rents, paymentson securities loans (section512(a)(5)), or royalties)
(2) Support from general public and 5 ormore exempt organizations as providedin section 4942(I)(3)(B)(ni)
(3) Largest amount of support froman exempt organization
(4) Gross investment income
Part XV Supplementary Information (Complete this part only if the organization had $5 ,000 or more inassets at any time during the year - see instructions.)
1 Information Regarding Foundation Managers:a List any managers of the foundation who have contributed more than 2% of the total contributions received by the foundation before theclose of any tax year (but only if they have contributed more than $5,000) (See section 507(d)(2)
NONE
b List any managers of the foundation who own 10% or more of the stock of a corporation (or an equally large portion of the ownea partnership or other entity) of which the foundation has a 10% or greater interest
NONE
2 Information Regarding Contribution , Grant , Gift, Loan , Scholarship , etc, Programs:
Check here " 1-1 if the foundation only makes contributions to preselected charitable organizations and does not accept unsolicitedrequests for funds If the foundation makes gifts, grants, etc, (see instructions) to individuals or organizations under other conditions,complete items 2a, b, c, and d
a The name, address, and telephone number of the person to whom applications should be addressed
SEE STATEMENT 9
b The form in which applications should be submitted and information and materials they should include
SEE STATEMENT FOR LINE 2A
c Any submission deadlines
SEE STATEMENT FOR LINE 2A
d Any restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other factors
SEE STATEMENT FOR LINE 2A
BAA TEEA0310L 07/14/11 Form 990-PF (2011)
Form 990-PF (2011) LIFELINE HUMANITARIAN ORGANIZATION 36-3894439 Page 11Part XV Supplementary Information (continued)3 Grants and Contributions Paid During the Year or Approved for Future Payment
RecipientIf recipient is an individual,show any relationship to
any foundation manager or
Foundationstatus of Purpose of grant or
t b t AmountName and address (home or business) substantial contributor recipient con ri ionu
a Paid during the year
Total 3a
b Approved for future payment
Total lb' 3bi
BAA TEEA0501L 07/14/11 Form 990-PF (2011)
Form 990-PF (2011) LIFELINE HUMANITARIAN ORGANIZATION 36-3894439 Page 12
Part XV'I-A Analysis of Income-Producing Activities
Erite
1
c
2
3
4
5
6
7
8
9
10
11
12
13 Total . Add line 12, columns (b), (d), and (e) 13 173, 677.
(See worksheet in line 13 instructions to verify calculations )
Part XVI-B Relationship of Activities to the Accomplishment of Exempt Purposes
gross amounts unless otherwise indicated Unrelated business income Excluded by section 512, 513 , or 514 (e)
rogram service revenue
(a)Businesscode
(b)Amount
(c)Exclu-sioncode
(d)Amount
Related or exemptfunction income
(See instructions)
Fees and contracts from government agencies
Membership dues and assessments
Interest on savings and temporary cash investments 14 110.
Dividends and interest from securities
Net rental income or (loss ) from real estate
Debt-financed property
Not debt-financed property
Net rental income or (loss ) from personal property
Other investment income
Gain or ( loss) from sales of assets other than inventory
Net income or ( loss) from special events 1 173, 567.Gross profit or (loss) from sales of inventory
Other revenue
Subtotal Add columns ( b), (d), and (e) 173, 677 .
BAA TEEA0502L 07/14/11 Form 990-PF (2011)
Form 990-PF (2011) LIFELINE HUMANITARIAN ORGANIZATION 36-3894439 Page 13Part X-VII Information Regarding Transfers To and Transactions and Relationships With Noncharitable
Exempt Organizations
Yes No1 Did the organization directly or indirectly engage in any of the following with any other organization
described in section 501(c) of the Code (other than section 501(c)(3) organizations) or in section 527,relating to political organizations?
a Transfers from the reporting foundation to a noncharltable exempt organization of
(1) Cash a 1 X
(2) Other assets 1 a (2) X
b Other transactions
(1) Sales of assets to a noncharitable exempt organization 1 b (1) X
(2) Purchases of assets from a noncharitable exempt organization 1 b (2) X
(3) Rental of facilities, equipment, or other assets 1 b (3) X
(4) Reimbursement arrangements 1 b (4) X
(5) Loans or loan guarantees 1 b (5) X
(6) Performance of services or membership or fundraising solicitations 1 b (6) X
c Sharing of facilities, equipment, mailing lists, other assets, or paid employees 1 c X
d If the answer to any of the above is 'Yes,' complete the following schedule Column (b) should always show the fair mthe goods, other assets, or services given by the reportin foundation If the foundation received less than fair markeany transaction or sharing arrangement, show in column d) the value of the goods, other assets, or services receive
arket valt value ind
ue of
(a) Line no (b) Amount involved (c) Name of noncharltable exempt organization (d) Description of transfers, transactions, and sharing arrangements
N/A
2a Is the foundation directly or indirectly affiliated with, or related to, one or more tax - exempt organizationsdescribed in section 501 (c) of the Code (other than section 501(c)(3)) or in section 527 E Yes No
h If 'Ypc ' cmmnlete the fnllowinn schedule
(a ) Name of organization (b) Type of organization c Description of relationshi p
N/A
Under penalties of perjury, I declare that I has amined this return, including accocorrect, and complete D laration of preparer of than taxpayer) is based on all i
SignHere
signature of offic r trustee 3 D e
PrinV7ype preparer's name parer's signature
Paid RUSSELL P. CANNIZZO,CPA RUSSELL P. C
Preparer Firm's name ► RUSSELL P. CANNIZZO & COMPANY
Use Only Firm's address ► 415 E. GOLF ROAD SUITE 119
ARLINGTON HEIGHTS, IL 60005
BAA
Schedule B OMB No 1545.0047
(Form 990 , 990-EZ ,or•990-PF) Schedule of Contributors
201 1Department of the Treasury ► Attach to Form 990, Form 990-EZ, or Form 990-PFInternal Revenue Service
Name of the organization LIFELINE HUMANITARIAN ORGANIZATION Employer identification number
OF CHICAGO 136-3894439Organization type (check one)
Filers of: Section:
Form 990 or 990-EZ 501(c)( ) (enter number) organization
4947(a)(1) nonexempt charitable trust not treated as a private foundation
527 political organization
Form 990-PF X 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 RuleNote . 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 onecontributor (Complete Parts I and II )
Special Rules
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 sections509(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 1 h or ( it) 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, orthe 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 $1000If 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 W $
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, or990-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 itsForm 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990, 990-EZ, or 990-PF)
BAA For Pa perwork Reduction Act Notice , see the Instructions for Form 990 , Schedule B (Form 990, 990-EZ, or 990-PF) (2011)990EZ , or 990-PF.
TEEA0701L 01116112
Schedule. B (Form 990, 990-EZ, or 990-PF) (2011) Page 1 of 1 of Part 1Name of organization Employer identification number
LIFELINE HUMANITARIAN ORGANIZATION 36-3894439
Part 1 Contributors (see instructions) Use duplicate copies of Part I if additional space is needed
(a) (b) (c) (d)Number Name , address , and ZIP + 4 Total Type of contribution
contributions
1 RICHARD AND KATHY FANSLOW _ _ _ _------------------------------- Person XPayroll
2314 LINCOLN PARK- WEST - - - - - - - - - - - - - - - - - - - - - $- - - - - - 6,195. Noncash
( Part 1 if thereo p lCHICAGO,-IL 60614_________________________ a oncashcon tribuion)
is
(a) (b) (c) (d)Number Name , address , and ZIP + 4 Total Type of contribution
contributions
2 FRED KREHBIEL------------------------------------- Person X
Payroll505 S_COUNTYLINE RD_______________________ $----- 35, 000. Noncash H
o lHINSDALE, IL 60521_________________ isa no ncashcon tributi on)
(a) (b) (c) (d)Number Name , address, and ZIP + 4 Total Type of contribution
contributions
3 SCUPE FOUNDATION------------------------------------- Person X
Payroll5722 DEMPSTER ___________________________ $36,000. Noncash
Part 1 if thereo p lMORTON -GROVE ,- IL 60053 is a no ncash con tribut on
(a) (b) (c) (d)Number Name , address , and ZIP + 4 Total Type of contribution
contributions
4 LESTER_CROWN ____________________________ Person XPayroll
1155 MOHAWK RD $ 7,500. Noncash
lete Part 1 if thereo lWILMETTE, IL 60091 is a non cash con tribut on
(a) (b) (c) (d)
Number Name , address , and ZIP + 4 Total Type of contributioncontributions
5 DRIEHAUS CHARITABLE TRUST Person XPayrol l
25 E ERIE $ 10, 000. Noncash
(Complete Part II if thereCHICAGO,- IL 60611_________________________ is anoncashcontribution )
(a) (b) (c) (d)
Number Name , address, and ZIP + 4 Total Type of contributioncontributions
6 DAVID-STEVENS------------------------------------ Person X
Payroll
2255 BORDEAUX WALK $ 7, 372. Noncash
(Complete Part II if thereHIGHLAND , _IN 46322 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ is a noncash contribution )
BAA TEEA0702L 08/30/11 Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Schedule.B (Form 990, 990-EZ, or 990-PF) (2011) Page 1 to 1 of Part IIName of organization Employer identification number
LIFELINE HUMANITARIAN ORGANIZATION 36-3894439
Part II Noncash Property (see instructions) Use duplicate copies of Part II if additional space is needed
(a)No. fromPart I
(b)Description of noncash property given
(c)FMV (or estimate)(see instructions)
(d)Date received
N/A
(a)No. fromPart I
(b)Description of noncash property given
(c)FMV (or estimate)(see instructions)
(d)Date received
(a)No. fromPart I
(b)Description of noncash property given
(C)FMV (or estimate)(see instructions)
(d)Date received
(a)No. fromPart I
(b)Description of noncash property given
(C)FMV (or estimate )(see instructions)
(d)Date received
(a)No. fromPart I
(b)Description of noncash property given
(c)FMV (or estimate )(see instructions)
(d)Date received
(a)No. fromPart I
(b)Description of noncash property given
(c)FMV (or estimate)(see instructions)
(d)Date received
BAA Sche dule B (Form 990. 990-EZ. or 990-PF) (2011)
TEEA0703L 08/30/11
Schedule B (Form 990, 990-EZ, or 990-PF) (2011) Pa g e 1 to 1 of Part IIIName of organization Employer identification numberLIFELINE HUMANITARIAN ORGANIZATION 36-3894439Part III I 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 cols (a) through (e) and the following line entryFor organizations completing Part III, enter total of exclusively religious, charitable, etc,contributions of $1,000 or less for the year (Enter this information once See instructions) $ N/AUse duplicate copies of Part III if additional space is needed
(a)
No. fromPart I
(b)
Purpose of gift
(c)
Use of gift
(d)
Description of how gift is held
N/A
(e)Transfer of gift
Transferee's name , address , and ZIP + 4 Relationship of transferor to transferee
(a)
No. fromPart l
(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 Relationship of transferor to transferee
(a)
No. fromPart 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 Relationship of transferor to transferee
(a)
No. fromPart 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 Relationship of transferor to transferee
BAA Schedule B (Form 990, 990-EZ, or 990-PF) (2011)TEEA0704L 0813011
2011 FEDERAL STATEMENTS PAGE 1LIFELINE HUMANITARIAN ORGANIZATION
CLIENT 1601 OF CHICAGO 36-3894439
7/24/12 05 23PM
STATEMENT1FORM 990-PF , PART I , LINE 11OTHER INCOME
(A) (B) NET (C)REVENUE INVESTMENT ADJUSTED
PER BOOKS INCOME NET INCOME
INCOME FROM SPECIAL EVENTS $ 186,712.TOTAL $ 186,712.$ 0.$ 0.
STATEMENT 2FORM 990-PF , PART I , LINE 16BACCOUNTING FEES
(A) (B) NET (C) (D)EXPENSES INVESTMENT ADJUSTED CHARITABLEPER BOOKS INCOME NET INCOME PURPOSES
ACCOUNTING FEE $ 3 , 295.TOTAL 3,295. 0. 0. $ 0.
STATEMENT 3FORM 990-PF , PART I , LINE 16COTHER PROFESSIONAL FEES
(A) (B) NET (C) (D)EXPENSES INVESTMENT ADJUSTED CHARITABLEPER BOOKS INCOME NET INCOME PURPOSES
PROFESSIONAL FEES $ 734.TOTAL $ 734. $ 0. $ 0. $ 0.
STATEMENT 4FORM 990-PF , PART I , LINE 18TAXES
(A) (B) NET (C) (D)EXPENSES INVESTMENT ADJUSTED CHARITABLEPER BOOKS INCOME NET INCOME PURPOSES
PAYROLL TAXES $ 2,341. $ 23.TOTAL $ 2,341. $ 0. $ 0. $ 23.
2011
CLIENT 1 601
7/24/12
STATEMENT 5FORM 990-PF, PART I, LINE 23OTHER EXPENSES
FEDERAL STATEMENTSLIFELINE HUMANITARIAN ORGANIZATION
OF CHICAGO
ADVERTISINGBOOKS & SUBSCRIPTIONSCREDIT CARD FEEEQUIPMENT RENTAL AND REPAIRINSURANCEMISCELLANEOUSOUTSIDE SERVICESPAYROLL SERVICESPOSTAGE & SHIPPINGSPECIAL EVENT EXPENSESSTATE REGISTRATION FEESSUPPLIESTELEPHONE
PAGE 21
36-38944391
05 23PM
(A) (B) NET (C) (D)EXPENSES INVESTMENT ADJUSTED CHARITABLEPER BOOKS INCOME NET INCOME PURPOSES
$ 365.273.
1,176.3,005.
970.599.
1,177.291.803.
13,145.604.
1,094.2,728.
TOTAL $ 26,230. $ 0. $ 0. $ 0.
STATEMENT 6FORM 990-PF, PART I, LINE 25CONTRIBUTIONS, GIFTS, AND GRANTS
CASH GRANTS AND ALLOCATIONS
CLASS OF ACTIVITY: MEDICAL ASSISTANCEDONEE'S NAME: FOUNDATION OF HRH CROWN PRICESS KATHERINDONEE'S ADDRESS: THE ROYAL PALACE
BELGRADE, BELGRADE 11040 RBRELATIONSHIP OF DONEE: NONEORGANIZATIONAL STATUS OF DONEE: GRANTAMOUNT GIVEN: $ 170,909.
NONCASH GRANTS AND ALLOCATIONS
CLASS OF ACTIVITY:DONEE ' S NAME:DONEE ' S ADDRESS:
RELATIONSHIP OF DONEE:ORGANIZATIONAL STATUS OF DONEE:FMV OF PROPERTY:DESCRIPTION OF PROPERTY:DATE OF GIFT:BOOK VALUE:METHOD USED TO DETERMINE BV:METHOD USED TO DETERMINE FMV:
MEDICAL ASSISTANCEHRH CROWN PRINCESS KATHERINE FOUNDATIONTHE ROYAL PALACEBELGRADE, BELGRADE 11040 RBNONEGRANT
MEDICAL EQUIP & SUPPLIES
55,234.PURCHASEDRESALE VALUE
55,234.
TOTAL $ 226,143.
2011 FEDERAL STATEMENTS PAGE 3LIFELINE HUMANITARIAN ORGANIZATION
CLIENT 1601 OF CHICAGO 36-3894439
7/24/12 05 23PM
STATEMENT 7FORM 990-PF , PART II , LINE 14LAND, BUILDINGS , AND EQUIPMENT
ACCUM. BOOK FAIR MARKETCATEGORY BASIS DEPREC. VALUE VALUE
FURNITURE AND FIXTURES $ 7,848. $ 7,848. $ 0. $ 0.MACHINERY AND EQUIPMENT 3,579. 3,579. 0. 0.
TOTAL $ 11,427. $ 11,427. $ 0. $ 0.
STATEMENT 8FORM 990-PF, PART VIII, LINE 1LIST OF OFFICERS, DIRECTORS, TRUSTEES, AND KEY EMPLOYEES
TITLE AND CONTRI- EXPENSEAVERAGE HOURS COMPEN- BUTION TO ACCOUNT/
NAME AND ADDRESS PER WEEK DEVOTED SATION EBP & DC OTHER
KATHY FANSLOW PRESIDENT $ 0. $ 0. $ 0.155 N MICHIGAN AVE, SUITE 409 20.00CHICAGO, IL 60601
MELANIE SEVER TREASURER 0. 0. 0.155 N MICHIGAN AVE, SUITE 409 5.00CHICAGO, IL 60601
VICKI ZAMMICHIELI SECRETARY 30,600. 0. 0.155 N MICHIGAN AVE, SUITE 409 30.00CHICAGO, IL 60601
ANDRIANA IVANOVIC DIRECTOR 0. 0. 0.155 N MICHIGAN AVE, SUITE 409 0CHICAGO, IL 60601
MARINA MIHAILOVIC CATO DIRECTOR 0. 0. 0.155 N MICHIGAN AVE SUITE 409 0CHICAGO, IL 60601
DRAGANA CUPIC DIRECTOR 0. 0. 0.155 N MICHIGAN AVE, SUITE409 0CHICAGO, IL 60601
THOMAS KARACIC DIRECTOR 0. 0. 0.155 N MICHIGAN AVE, SUITE 409 0CHICAGO, IL 60601
SUZANNE LEMIGNOT DIRECTOR 0. 0. 0.155 N MICHIGAN AVE, SUITE 409 0CHICAGO, IL 60601
NADA MLINAREVIC DIRECTOR 0. 0. 0.155 N MICHIGAN AVE, SUITE 409 0CHICAGO, IL 60601
2011 FEDERAL STATEMENTS PAGE 4LIFELINE HUMANITARIAN ORGANIZATION
CLIENT 1601 OF CHICAGO 36-3894439
7/24/12 05 23PM
STATEMENT 8 (CONTINUED)FORM 990-PF , PART VIII, LINE 1LIST OF OFFICERS , DIRECTORS , TRUSTEES , AND KEY EMPLOYEES
TITLE AND CONTRI- EXPENSEAVERAGE HOURS COMPEN- BUTION TO ACCOUNT/
NAME AND ADDRESS PER WEEK DEVOTED SAT ION EBP & DC OTHER
SANDY RADOJA DIRECTOR $ 0. $ 0. $ 0.155 N MICHIGAN AVE, SUITE 409 0CHICAGO, IL 60601
ZIKA PAVLOVIC DIRECTOR 0. 0. 0.155 N MICHIGAN AVE, SUITE 409 0CHICAGO, IL 60601
NADEZDA D. RAKIC DIRECTOR 0. 0. 0.155 N MICHIGAN AVE, SUITE 409 0CHICAGO, IL 60601
JELENA STOJAKOVIC DIRECTOR 0. 0. 0.155 N MICHIGAN AVE, SUITE 409 0CHICAGO, IL 60601
VESNA ZAFIROVSKI VICE PRESIDENT 0. 0. 0.155 N MICHIGAN AVE, SUITE4 09 0CHICAGO, IL 60601
LYNN SVILAR DIRECTOR 0. 0. 0.155 N MICHIGAN AVE, SUITE 409 0CHICAGO, IL 60601
DEJAN VUCIC DIRECTOR 0. 0. 0.155 N MICHIGAN AVE, SUITE 409 0CHICAGO, IL 60601
LJUBA STOJILJKOVIC DIRECTOR 0. 0. 0.155 N MICHIGAN AVE, SUITE 409 0CHICAGO, IL 60601
VERA BJELOPETROVICH DIRECTOR 0. 0. 0.155 N. MICHIGAN AVE. SUITE 409 0LINCOLNWOOD, IL 6071 2
TOTAL $ 30, 600. $ 0. $ 0.
STATEMENT 9FORM 990-PF , PART XV, LINE 2A-DAPPLICATION SUBMISSION INFORMATION
NAME OF GRANT PROGRAM: GRANT REQUESTSNAME: VICKI ZAMMICHIELICARE OF:STREET ADDRESS: 155 NORTH MICHIGAN AVE SUITE 409CITY, STATE, ZIP CODE: CHICAGO, IL 60601-5908TELEPHONE: (312) 781-9300FORM AND CONTENT: WRITTEN DESCRIPTION OF NEED, AMOUNT NEEDED, AND PROCEDURE
TO ENSURE PROPER AUTHORIZATION OF FUNDSSUBMISSION DEADLINES: NONE
2011 FEDERAL STATEMENTS PAGE 5LIFELINE HUMANITARIAN ORGANIZATION
CLIENT 1601 OF CHICAGO 36-3894439
7/24/12 05 23PM
STATEMENT 9 (CONTINUED)FORM 990-PF, PART XV, LINE 2A-DAPPLICATION SUBMISSION INFORMATION
RESTRICTIONS ON AWARDS: AWARDS ARE MADE BASED UPON NEED AND IN THE SPIRIT OF THEORGANIZATION'S CHARITABLE PURPOSE.
12/31/11 2011 FEDERAL BOOK DEPRECIATION SCHEDULE PAGE 1LIFELINE HUMANITARIAN ORGANIZATION
CLIENT 1601 OF CHICAGO 36-3894439
7/24/12 05 23PM
PRIORCUR SPECIAL 179/ PRIOR SALVAG
DATE DATE COST/ BUS 179 DEPR BONUS/ DEC BAL /BASIS DEPR PRIOR CURRENTDFSCRIPTION A(COIIIRFD 501 D RASIS Pf.T BONUS Al I OW SP DFPR DFPR RFOIICT BASIS DFPR MFTHOD RATF DFP
FORM 990/990-PF
FURNITURE AND FIXTURES
1 FURNITURE
TOTAL FURNITURE AND FIXTURE
MACHINERY AND EQUIPMENT
2 COPY MACHINE
3 TELEPHONE
4 COMPUTER
TOTAL MACHINERY AND EQUIPME
TOTAL DEPRECIATION
GRAND TOTAL DEPRECIATION
1/01/03 7,848 7,848 6,936 200DB HY 7 912
7,848 0 0 0 0 0 7,848 6,936 912
1/01/03 370 370 360 200DB HY 5 10
1/01/03 212 212 204 200DB HY 5 8
1/01/03 2,997 2,997 2,914 200DB HY 5 83
3,579 0 0 0 0 0 3,579 3,478 101
11,427 0 0 0 0 0 11,427 10,414 1,013
11,427 0 0 0 0 0 11,427 10,414 1,013
Form 8868 I Application for Extension of Time To File an(Rev January 2012) Exempt Organization Return OMB No 1545-1709
Department of the TreasuryInternal Revenue Service ► File a separate application for each return.
• If you are filing for an Automatic 3-Month Extension , complete only Part I and check this box ► X
• If you are filing for an Additional (Not Automatic) 3-Month Extension , complete only Part 11 (on page 2 of this form)Do not complete Part // unless you have already been granted an automatic 3-month extension on a previously filed Form 8868
Electronic filing (e-fi/e). You can electronically file Form 8868 if you need a 3-month automatic extension of time to file (6 months for acorporation required to file Form 990-T), or an additional (not automatic) 3-month extension of time You can electronically file Form 8868 torequest an extension of time to file any of the forms listed in Part I or Part II with the exception of Form 8870, Information Return for TransfersAssociated With Certain Personal Benefit Contracts, which must be sent to the IRS in paper format (see instructions). For more details on theelectronic filing of this form, visit www us go viefrle and click on a-file for Charities & Nonprofits
Part I Automatic 3-Month Extension of Time . Onl y submit ori g inal (no cop ies needed) .A corporation required to file Form 990-T and requesting an automatic 6-month extension - check this box and complete Part I only ►All other corporations (including 1120-C filers), partnerships, REMICS, and trusts must use Form 7004 to request an extension of time to fileincome tax returns
Enter filer's identifying number, see instructionsName of exempt organ i zat i on or other filer , see instructions Employer identif i cation number (EIN) or
Type orLIFELINE HUMANITARIAN ORGANIZATIONprintOF CHICAGO X136-38 94439
File by the Number , street , and room or suite number If a P 0 box, see instructions Social security number (SSN)due date for
treturnrn See 155 N. MICHIGAN AVE. SUITE 409re your Finstructions City, town or post office, state , and ZIP code For a foreign address , see instructions
CHICAGO, IL 60601
Enter the Return code for the return that this application is for (file a separate application for each return) 04
ApplicationIs For
ReturnCode
ApplicationIs For
ReturnCode
Form 990 01 Form 990-T (corporation) 07
Form 990-BL 02 Form 1041-A 08
Form 990-EZ 01 Form 4720 09
Form 990-PF 04 Form 5227 10
Form 990-T (section 401(0 or 408(a) trust) 05 Form 6069 11
Form 990-T (trust other than above) 06 Form 8870 12
• The books are in the care of ► VICKI- ZAMMICHIEL-----------------------------------
TelephoneNo 9300 -____ FAX No ►----------------
• If the organization does not have an office or place of business in the United States, check this box ► 9• If this is for a Group Return, enter the organization ' s four digit Group Exemption Number (GEN) If this is for the whole group,
check this box ► 9 If it is for part of the group , check this box ► 9 and attach a list with the names and EINs of all members
the extension is for.
1 I request an automatic 3 - month (6 months for a corporation required to file Form 990 - T) extension of time
until 8/15 , 20 12 _ , to file the exempt organization return for the organization named above
The extension is for the organization ' s return for
► XX calendar year 20 11 or
► tax year beginnin g , 20 , and endin g , 20
2 If the tax year entered in line 1 is for less than 12 months , check reason 9Initial return 9 Final return
9 Change in accounting period
3a If this application is for Form 990-BL, 990-PF, 990-T, 4720, or 6069, enter the tentative tax, less anynonrefundable credits See instructions 3a $ 0.
b If this application is for Form 990-PF, 990-T, 4720, or 6069, enter any refundable credits and estimated taxpayments made Include any p rior year overpayment allowed as a credit 3b l $ 0.
c Balance due . Subtract line 3b from line 3a Include your payment with this form, if required, by usingEFTPS (Electronic Federal Tax Payment System) See instructions 3c 1 $ 0.
Caution . If you are going to make an electronic fund withdrawal with this Form 8868, see Form 8453-EO and Form 8879-EO forpayment instructions
BAA For Paperwork Reduction Act Notice , see Instructions . Form 8868 (Rev 1-2012)FIFZ0501L 01/04/12