american college of lifestyle medicine, irs 990s 2008 + 2011-present

8/20/2019 American College of Lifestyle Medicine, IRS 990s 2008 + 2011-present

1/41

Short

Form

OMB No

1545-1150

Return

o f

Organization

Exempt

F ro m In co me

Ta x

99^^EZorm

Under

s e ct i o n 5 01

c ) ,

52 7

or

4947 a) 1) o f t h e

Internal

Revenue Code

8

except

b l ack

lun g

benefit

trust

or

pi r a t e

foundation)

Sponsoring or

g

anizations o f donor advised

funds a n d

c o n t r o l l i n g

or

g

anizations a s defined i n section

000 and t o t a l

12 bx13)

must

f i l e Form

990

A ll

other organizations

vnth

gross

receipts

less

than 1

_

Department

o f

t h e T r e a s u r y

assets

l e s s than

2 500,000 a t th e e nd

of

th e

year may

use t h i s

form.

a e

n t e r n a l

Revenue

S e r v i c e

The

organiz

ation

may

h a ve t o

use a

copy of

t h i s

retu

r n

to

s a t i s f y

state

r

ortng

requirements.,

A

Fo r

th e 2008

ca l e nd a r

y e a r

,

or

tax

y e a r

b e g i n n i n g

2008

,

and e nd i n g

,

20

B

Check

i f

a p p l i c a b l e

Please

C

Name

of org a n i z a ti on

D Employer identification

number

Address

change

u se I RS

l a b e l o r

- -

^ E

MEDICINE

^

I

1 =

SiE_

Q F _ _ - C

I E

x : . 3 2

p r 5

= > =

=

Name

c h a n g e

Ind

r e t u r

n

pdM

or

t

_

Number

and street

o r P.O

box if m a i l

is no t d e l i v e r ed to

street

address

Room/suite E

Telephone

number

T e „ n m a u o n

y p e

see

1475

Mt .

Hood Avenue

Amended

r a t a n

s p e c i f i c

I n s t r u c

C i t y

o r

t o w n ,

s ta te o r

c o u n t r y ,

and Z I P +

4

F

Group

Exemption

A p p r

o n p e n d n g

S o n s .

Woodburn OR

97071

Number

•

Section

501

c ) 3 )

or g a n i z a t i o n s and 4947 a ) 1 )

nonexempt

charitable

trusts must

attach

G Accountin g

method,

a sh

Accrual

a

completed

Schedule

A

F or m 9 9 0 or 99

- E Z ) .

Other

s p e c i f y )

1 0 -

I

Website

:

Ilfestylemedicme.org

H

r e C h e c k

D o - i f

q u i r e d

toattach

tSchedule

B f i

Form

no t

J

Or g a n i z a t i o n

type

check only one

01 c

6

t

i n s e r t

no .

)

4947 a

1 o r

527

990-EZ.

o r

990-PF)

K

Check

i f the organ ization

is

no t

a

section

509 aX3)

supporting organization and i t s

gross

receipts

are

normally not

more than

25,000 A

r e t u r n

is

no t

required, bu t

i f th e

organization

chooses

t o

f i l e a r e t u r n ,

be sure

t o

f i l e a c om pl e t e

r e t u r n .

L Add

l i n e s

5b„

6 b ,

a nd

7b, t o

l i n e 9

t o

determine

gross

r e c e i p t s ;

i f

1,000,000

o r

more,

f i l e

Form

9 9 0

i n s t e a d

o f

Form

990-EZ

33237

Revenue

,

Ex

pe

ns es

and

Chan

g e s

i n

N e t A ss et s

or

Fund

B a l a nc es

S e e

th e i n s t r u c t ions

f o r

P a r t

I .

I

Contributions grants

a nd

s i m i l a r

amounts

received

i f t s

1

10000

. .

.

.

.

2 Prog ra m

service revenue

including government

fees a nd

contracts

2

.

.

.

3 Me mb e r sh ip

d ues

a n d

assessments

3

23065

.

. .

.

.

.

.

.

.

.

4

Investment

income

.

.

. .

. .

.

.

.

.

.

4

172

.

a

Gross

amount

from

sale o f assets

other

than

inventory

5a

b Less:

cost

o r o th er

basis

a nd sales

expenses

5b

.

.

_

c Gain o r l o s s )

from

s a l e o f assets other

than

i n v e n t o r y S u b t r a c t

l i n e

5b from line

5 a )

a t t a c h schedule)

5C

6

S p e c i a l

e v e n t s

a n d a c t i v i t i e s

c o m p l e t e p p l i c b l e

p a r t s

o f

S c h e d u l e

G ) .

I f a n y a m o u n t i s

f r o m

g a m i n g c h e c k

h e r e

a

Gross

revenue

n o t including

o f

contributions

c c

reported on

l i n e 1 )

.

. .

.

.

.

.

.

.

.

6a

b Less: d i r e c t

expenses

other than fundraising expenses

.

.

6b

c Net

income

or

l o s s )

from

s p e c i a l

events

a nd

a c t i v i t i e s

Subtract l i n e 6b

from l i n e

6 a )

6c

7a

Gross sales

o f

inventory

l e s s

r e t u r n s a nd

allowances

7a

.

b Less:

cost

o f goods sold

7b

.

.

. .

.

c Gross

p r o f i t

or

l o s s )

from

sales

o f

inventory Subtract

l i n e

7b

from

l i n e

7 a )

7c

.

.

8

O ther revenue

describe

)

8

9

Total r e ve n u e

. Add l i n e s 1 , 2 , 3 , 4 , 5 c , 6 c ,

7 c ,

a nd

8.

.

9

33237

10 Grants

a n d

s i m i l a r am o u n t s paid a t t a c h schedule)

10

.

.

.

. .

.

11 Benefits paid

t o

or f o r members

11

.

.

.

.

.

.

.

.

.

.

.

12

Salanes,

other compensation

a nd

emp l o y e e

b e n e f i t s

12

10013

.

.

.

.

.

.

.

13 Professional

fees a other payments t o independent contractors

13

x 14

Occupancy

i l i t i e s

e n t p - s

14

W

15

P r i n t i n g

publicatlo

s e

16 Other

expenses ` r be

S

T )

16

5403

17

Total

expenses

. a d l i n h 16

1 1 0 -

17

15416

18

Excess

or

d e f i c i t

f b i

th e

y ea r S ub

e 1 m l i n e

9 )

18

17821

.

.

19

Net

assets

or

f u d

b t^e g i n

o f

r from l i n e

27, column

A ) must

a gree

with

a

end-of-year

f i g u

y

e t u )

19

-336

. . . .

.

.

. .

2

O ther

c h a n g es

i n

ne t

assets

or

a

a ch

explanation)

.

.

21

Net

assets

or

f un d b al a n ce s

a t

e nd o f

y e a r .

Combine

l i n e s

18 through 20 .

21

17485

Balance

Sheets .

I f Total

assets on

l i n e

2 5 , column B ) are

2,500,000

or

more,

f i l e

Form

9 90

instead o f

Form

990-EZ.

See

th e i ns tr u c t i o n s f o r P a rt

I I . )

A )

Beginn in g

o f

year

B)

End

o f

year

savings

a n d

investments

22

C ash

4664

22

20485

.

.

.

.

.

.

. .

23

Land

a nd buildings

23 1

.

.

.

.

.

.

.

.

.

t24

Other

assets

describe

)

24

25

Total

assets

4664

25

20485

.

. .

.

.

. .

.

. .

.

.

26

Total

l i a b i l i t i e s

describe

SEE STATEMENT

5000

26

3000

27

N e t

a s

se ts o r

f

un

d

b a l a nc es

l

i n e 27 o f c

o l u m

n

B )

must

a g ree

with l i n e

2 1 )

-336

27

17485

c

a

L

Fo r

Privacy

A ct

and

Paperwork

R educt i o n

A ct Notice

se e

the

Instruction

for

Form

9 9 0

.

Ca t

N o

1 0 6 4 2 1

Form 99U LZ

2 0 0 8 )


2/41

From 99n-EZ

120081

Page

O

tatement

o f

Prog

ram

Service

Accom

p

lishments

See

the

i n s tr u c t i o ns f or P a r t I I I .

Expenses

What

i s

th e

organization s primary

exempt

purpose?

Bus

Asso

of

Doctors

r

i

I l

R e q u i r e d

fo r

5 0 1 c x 3

and

4

o r g a n i z a t i o n s

d

4 9 4 7 a X l t r u s t s

e

manne

onc

exemp purposes. n

a

c ear an

escribe

what

was achieved

i n

c a r r y i n g

ou t

the

o r g a n i z a t i o n

;

n

describe

the ser vi ces pro vided, the

number o f

persons b e n e f i t e d , o r

o t h e r r e l e v a n t i n f o r m a t i o n f o r

each

program t i t l e .

o p t i o n a l

f or o t he r s .

8

Training,

educating

physician

i n

health

medicine

techniques

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

;

- - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - -

- - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - -

Grants

I f

t h i s amount includes f o r e i g

n g r a n t s

c heck here

2 8 a

15416

2 9

- - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - -

- - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - -

- - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - -

Grants

I f

t h i s

amount

includes f o r e i g n

g

r a n t s

c heck here

2 9a

30

- - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - -

- - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - -

- - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - -

Grants

I f

t h i s

amount includes f o r e i

g

n

g

r a n t s

c heck here

30 a

31

Other

program services a t t a c h

schedule)

. .

.

.

.

. . . . .

. . . . .

.

.

. .

.

Grants

I f

t h i s

amount includes

f o r e i

g

n

g r a n t s

c heck

here

31 a

Total program service expenses (add

l i n e s 2 8 a through 31 a .

32

15416

Z t

L i s t

of

Officers.

Directors, Trustees, and Key

Employees. L i s t

each one

even

i f

not compensated.

(See th e

I n s t r u c t i o n s

f o r

P ar t I V )

b

T i t l e

and average

c Compensation

d

C o n t r i b u t i o n s t o

e

Expense

a

Name

and

address

hours

per

week

Of

no t

paid, mployee

b e n e f i t

p l a n s 8

a c co u nt a nd

devoted

t o

position

enter

- 0 - .

d e t e r r e d

compensation othe r

allowances

See

L i s t

F o r m

99

EZ

2 o o e

0


3/41

Form

99 EZ (2008)

Page

statement

requirements

i n

th e

i n s t r u c t i o n s

f o r

P a r t

V I

33 `Did

th e

organization

engage i n

any

a c t i v i t y

no t

previously

reported

t o

th e

IRS?

f

Yes, attach

a

detailed

description o f e a c h

a c t i v i t y

33

34

Were

any

c h a n g e s

made

t o t he o rg an iz in g or

governing

documents

bu t

n o t r ep o rt ed

t o th e

IRS?

f

Yes,

attach a

conformed

c o p y o f

th e

c h a n g e s

34

35

f

t h e

o r g a n i z a t i o n ha d

income

from

b u s i n e s s a c t i v i t i e s ,

such

as t h o s e

r e p o r t e d on

l i n e s

2 ,

6 a ,

and 7a

(among

o t h e r s ) ,

b u t

no t

r e p o r t e d

on

Form

9 9 0 - T ,

a t t a c h

a statement

e x p l a i n i n g

y o u r r e a s on f o r

n o t

r e p o r t i n g t h e income on

Form 9 9 0 - T .

a

Did the or ganizati on

have

unrelated

b u s in e ss g r o ss

i n c o m e

o f

1,000

or

more

o r

section

6033(e)

n o t i c e , r e p o r t i n g ,

and

proxy

ta x

requirements ?

35 a

b

f

Yes,

has i t

f i l e d

a ta x

r e t u r n

o n Form

99

-T f o r

t h i s

year?

b

36

Was

there

a

l i q u i d a t i o n ,

d i s s o l u t i o n , termination, o r s u bs t a nt i a l contraction

during t he y ea r?

f Yes,

comp lete

applicable

parts

o f Schedu le

N

36

37 a

Enter amount

o f

p o l i t i c a l

expenditures, director

i n d i r e c t ,

as

described

i n

th e i n s t r u c t i o n s

37a

0 i

b

Did

the organization f i l e Form

1 1 2 0

POL f o r t h i s year?

37 b

38 a

Did

th e

organization

b o r r o w

fr om , o r make any loans

t o ,

any

o f f i c e r ,

d i r ec t or , t r u st e e ,

or

ke y

e m p l o ye e

or

were

an y such

loans

made in a p r i o r year

and s t i l l unpaid

a t

th e s t a r t

o f

th e

period

c ove red

b y t h i s

return?

b

f

Yes,

c o mp l e te S c he du l e

L ,

Part

and

e nt er t he

t o t a l

a m o u n t

involved

3 8 1 1 3

39

Section 5 0 1 ( c ) ( 7 )

organizations.

Enter

a

I n i t i a t i o n fees and c a p i t a l contributions included

o n

l i n e

9

b

Gross

r e c e i p t s ,

included o n l i n e 9 , f o r

public

use o f

club

f a c i l i t i e s

. .

40 a

Section

5 0 1 ( c ) ( 3 )

organization

Enter

amount

o f tax i m p o s ed

o n th e

organization during

th e

year

under:

section 4911 ;section

4912

section

4955

b Section

50 1

c 3

and

4

o r g a n i z a t i

s .

Di d t h e o r g an i z at i o n

engage

i n

any s e c t i o n

4958 excess

b e n e f i t

t r a n s a c t i o n

during

th e

year

o r

d i d i t become

awar o f

an excess b e n e f i t

t r a n s a c t i o n

from a

p r i o r

year?

f

Yes,

complete

Schedule

L ,

P a r t

T Obr

c

Enter a m o u n t o f

ta x

i m p o s e d

o n orga a t i o n

m a n a g e r s

or

d i s q u a l i f i e d

persons

during

th e

year

under

sections

4912, 4955,

an

4958

d

Enter amount o f

ta x o n l i n e 40 c

reimburs

b y

th e

organization

e

A l l organizations.

At any time during

th e

e a r ,

was

th e

organization

a

party

t o

a

p r o hi bited tax s h e l t e r

transaction?

I f

`Yes,

c o m p l e t e

Fo r m 8 8 8 6 -

40 e

41

L i s t

t h e

s t a t e s

w i t h

which

a c o p y o f t h i s

r e t u r n i s

f i l e d

California

42 a

T h e b o o k s

ar e

i n

care o f

Dr.-Braman

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Telep h one no .

- - - - - -

- - - - - - - - - - _ _ - - - - - _ _

Located a t

Addresspa9e

I

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

ZI P + 4

- - - - - - - - - - - - - - - - - - - - - - - - - - -

b At

any time

du ri ng t h e calendar y e a r ,

did

th e

organization

ha ve an i n t e r e s t

i n

or a s ig na tur e o r

other authonty

over

a

f i n a n c i a l

account

in

a

foreign

country

(such

as

a

bank

account,

s e c u r i t i e s

account,

o r

other

f i n a n c i a l

Yes

No

account)?

42 b

f Yes,

enter

th e

name

of

th e

f o r e i g n country:

Y

Se e

th e

i n s t r u c t i o n s

f o r

exceptions

and f i l i n g

requirements f o r

Form TD F 90

-

2 2 . 1 , R e p o r t of

Foreign

Bank

and

Financial

A c c o u n t s .

c

At an y time

during

th e

calendar y e a r ,

did th e organization maintain

an o f f i c e outside

o f

t he U .S. ?

42 c

f

r y e s ,

enter

th e

name of

th e

foreign country:

43

Section

4947(a)(1)

nonexempt

charitable t r u s t s

i l i n

Fo r m

990-EZ

i n

l i e u o f Form 1041

Check here

and enter th e

amount o f tax-exem pt

i n t e r e s t received

or

accrued

during

th e

tax

year

143

Yes No

44

Did

th e organization

maintain

any

donor

adv ised funds?

f Yes,

Fo r m

990 m us t

b e

c o m p l e t ed

instead

o f

Fo r m

990-EZ

44

45

I s

any r e l a t e d

organization

a

controlled

e n t i t y

of

the organization

w i t h i n th e

meaning

o f section

512(b)(13)?

f

y ' e s .

Form

990 m us t

b e c o mp l et ed

instead

o f

Fo r m

990-EZ

_

_ _ _ _ _

_

45

Form 99 EZ

( 2 0 0 8 )

V


4/41

Form

g90-EZ 2 0 0 8

S ec ti on 5 01

b 3

organizations

o n l y .

l l

section 501

and

complete

tk e

t a b l e s

f o r

l i n e s

50

an d

5 1 .

must

answer

q u e s t

Page

4

4 , 6 D id th e

organization

enga

i n

d i r e c t

or

i n d i r e c t p o l i t i c a l

campaign

a c t i v i t i e s on

behalf o f

or

i n

opposition

to

Yes

No

candidates

f o r

public

o f f i c e

f

Yes,

complete Schedule

C ,

Part

47

Did

th e

organization

engage

i obbying

a c t i v i t i e s ? I f Yes,

Complete

Schedule

C ,

Part

I I

47

48

I s th e

organization

operating

a

s ool as

described

i n

section

1 7 0 b 1 A ?

I f

Yes,

complete

Schedule

E

48

49 a

D id t he

organization

make

an y t r a

f e n s

t o

an exempt

non-charitable

r e l a t e d organization?

.

49 a

b

I f Yes,

was th e

r e l a t e d

organizatio

s

a

section

527

organization ?

.

.

. .

49 b

50 Complete

t h i s

table

f o r

th e

f i v e

high

compensated

employees

o t h e r

than

o f f i c e r s ,

d i r e c t o r s ,

trustees

and key employees)

who

each

received more

than

100,000

o f

pensation from

th e

organization.

I f there i s none, enter None.

a Name

and

address

o f

each

employee paid

more

than

100,000

b

T i t l e

and average

hours

pe r week

devoted

to

position

c Co m p ensatio n

d

C o n t r i b u t i o n s

to

e

mployee

b e n e f i t

p l a n s

d e f e r r e d

compensation

e

Expense

a c co u nt a n d

other allowances

--------------------------------------------------------------

--------------------------------------------------------------

--------------------------------------------------------------

--------------------------------------------------------------

---------------------------------------------------------------

T o t a l

number o f

other

employees

paid

over

100,000

51

Complete

t h i s table f o r th e f i v e highest compensated

independent

oo

ctors who each received more

than 100,000 o f

compensation

from

th e

organization

I f

there

i s

none

enter None.

a

Name an d

address

o f

each

independent

contractor

paid

more than

1 0 0 , 0 0 0

b Type

o f

service

c

Compensation

------------

- - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - -- - -

----

------------

- - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - -- - -

--------

------------

- - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - -- - --------

------------

- - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - -- - --------

- - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - -- - - - -

--------

Total

number o f other

independent

contractors each

r e c e i v i n g

over

100,000 . .

Under p e n a l t i e s

of pequry

I

d e c l a r e

t h a t

I

have examined

t h i s

r e t u r n i n c l u d i n g

accompanying

schedules

an d

s t a t e m e n t s ,

an d

t o th e b e s t

o f

my knowledge

and b e l i e f

it

i

true

correct

and

complete

Declaration

of

preparer

other than

o f f i c e r

i s

based on

a l l

information of

whi h preparer

h as

a n y k n ow l e dg e -

Sign

Here

signa t u

r e o f

o f f i c e r

W W

ype or pnnt

name

and t i t l e .

P a i d

Pmm

Use

Only

Preparer's

signature

nr m

s

name

or y o u r s

34629 Q=ina

T r ,

f

s e l f - employed).

address

and ZI P

+ 4

Ia

MLrada

C

a

6

May

th e I R

S

discuss

t h i s r e t u r n

with

th e

oreoarer

shown

above?


5/41

Page of

3

L C a r l

Corsi

From:

Kathy

Cater

[ k c a t e r @ f i f e s t y l e m e d i c i n e o r g ]

Sent

F r i d a y

February 2 7 2009

3:52

PM

To:

C a r l C o r s i

Subject

ACLM

requested

i n f o r m a t i o n

Dear Mr.

C o r s i

Here i s t h e

information y o u

r e q u e s t e d

f o r

our

t a x s t a t e m e n t

have n o t

heard

f r o m a l l

of

o ur

board

members. C an

we

use

an average

time

f o r them?

We h a d a n

e l e c t i o n

i n M a y t h a t was

f i n a l i z e d i n J u n e

At

t h a t

p o i n t

s o me

members were

a d d e d a n d i n

t h e

c a s e

o f J o h n

K e l l y

h i s

o f f i c i a l

s t a t u s

changed

from P r e s i d e n t

t o

Immediate P a s t

P r e s i d e n t

J ohn

Kelly

P r e s i d e n d l m m e d i a t e

Past

P r e s i d e n t

F o r

2008

J a n

8h

Feb

8h

Mar h

A pr

9h

May

10h

Ju n

9h

J u l

9h

Aug 12h.

Sep

20h

Oct

8h

No v

l0h

De c

9h

T o t a l

1 2 0 h

467 Misty

Lane

Boones

M i l l

24065

arc

Braman

S e c r e t a r y / P r e s i d e n t

Estimated

hours

pe r month:

5 0

1475

M t

ood A ve

Woodburn

OR

97071

Wayne

Dysinger

P r e s i d e n t

E l e c t

E s t i m a t e d

h o u r s per m o n t h : 8

24785

Stewart S t r e e t

EH

1 0 1


6/41

Page 2

o f

3

Gordon Betting

T r e a s u r e r

4 0 1

T a y l o r

Blvd

P l e a s a n t l l

94523

Hans

Diehl

D i r e c t o r

Estimated hours

per

month: 15

11538

Anderson

S t r e e t

Loma

Linda

92 3 5 4

J o e l

Fuhrman

D i r e c t o r

22

Buchanan

Way

Flemington

NJ 8822

Wes

Youngberg

D i r e c t o r

4 3 1 8 3

Corte

Cabrera

Temecula

92 5 92

John

Westerdahl

D i r e c t o r

Estimated

hours

per month: 3

Bragg

Health

Foundation

199

Winchester Canyon Rd

S a n t a

Barbara

9 3 1 1 7

Ron

S t o u t

D i r e c t o r

added i n

June

e l e c t i o n )

E s t i m a t e d

h o ur s p e r

m o n t h :

8

87

Mason

Montgomery

Rd

Mason

OH

4 5 4

Greg

S t e i n k e

Young

Director

added

i n

June

e l e c t i o n )

2 5 2 3 1

La

Mar

Rd

Apt

Loma

L i n d a ,

92354

Liana

Lianov

D i r e c t o r

a d d e d i n

June

e l e c t i o n )

Estimated

hours per

month:

2


7/41

rage

0 1

r

. C a r l Corsi

From

Kathy

Cater

[ k c a t e r @ l i f e s t y l e m e d i c i n e . o r g ]

Sent

Sunday

March

01

2009

4:03

PM

To:

C a r l

C o r s i

Subject

Fwd: CLM

t a x

statement i n f o r m a t i o n

needed

from

20 08

board

members

H i

Mr C o r s i

H e r e i s o n e more b o a r d member s

e s t i m a t e

o f h o u r s

s p e n t .

Kathy

B e g i n f o r w a r d e d

m e s s a g e :

From

Greg

Steinke

Date

March

1

20 09

11:10:15 M PST

T o: K at hy

Cater

< k c a t e r @ i f e s t y l e r n e d i c i n e _

org>

Subject Re: CLM t a x

statement

information needed

f ro m 20 0 8 board

members

I e s t i m a t e 2 hours p e r month

s o

f a r

G r e g .

On

Wed

Feb

25

2009

a t

2 : 27

PM

Kathy

C a t e r

w r o t e :

G r e e t i n g s

Mr.

C a r l

C o r s i

i s

p r e p a r i n g

our t a x

s t a t e m e n t

and

needs an

e s t i m a t e

of time

s p e n t

on

CLM

from each of our

2048

board

members

He

suggested

a monthly

e s t i m a t e

/

average

number of hours s p e n t .

I f

you

wou ld

send y our

b e s t

approximation

t o

t n e

I

w i l l

compile i t with

a l l

t h e

i n f o r m a t i o n Mr.

C o r s i

has

r e q u e s t e d .

Thank

you

Kathy

k c a t c r t c

l i f c s t y l c m e d i c i n c . o r g

American

Collc

L c

of

L i f e s t y l e

Medicine

c / o

Wellspring

Medical

Centci

1 47 5

Mt

Hood

Ave.

W o o d b u n i .

9707

9

71-9S

I 5 3 8 _ ;


8/41

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Lifestyle Medicine?

Abcu:

IM

Fi nd a

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Membership

Education

Events

LM News

Contact

Baard o f P . d

V11^L5

ors-2Lett4L5

About

LM

Th e

American

College o f

Ufestyle

Medicine

(ACLM)

I s

a new

n a t i o n a l

medical

s p e c i a l t y

s o c i e t y .

I t

h as

been formed I n

answer

to

th e

n e e d f o r

q u a l i t y

education

an d

c e r t i f i c a t i o n

of

th e

practice

I n

c l i n i c a l

l i f e s t y l e

medidne.

As

the f f n t

national

s p e c i a l t y society

f o r

c l i n i c i a n s

emp hasizing

th e

us e

of

l i f e s t y l e

interventions I n

th e

tr eatmen t

an d

management

o f disease

th e

ACLM I s

currently

working

t o

develop

formal

recognition

f o r

t h i s

important

f i e l d of

medical

p r a c t i c e

an d

r

s e ar ch . I n

th e

f u t u r e ,

I t

I s

th e

goal

of

th e

ACLM

t o e s t a b l i s h

an

o f f i c i a l

Board

o f

L i f e s t y l e

Medicine

that

w i I

grant

board

c e r t i f i c a t i o n I n

Ufestyle Medfdne.

Formed

in

2004 i n

C a l i f o r n i a , th e

ACLM

h as member s

a cr os s t he

U n it e d S t at e s

an d i n t e r n a t i o n a l

member s h i p I s

growing

r a p I d l y .

Th e

value of Ufestyle

Medicine

i s

becoming

recognized

by

a l l

aspects

o f

medical

p r a c t i c e .

an d

ACIM

members

repres ent

the

broad d i v e r s i t y

of th e

medical

p r o f e s s i o n .

Members

Include

primary care

physicians,

s p e c i a l i s t s ,

researchers,

professors,

students,

p u b l i c

spokespersons, h o s p i t a l

administrators,

n u t r i t i o n i s t s ,

p u J t i c health

p r o f e s s i o n a l s ,

an d

many

o t h e r s .

; r l ,

AC.

American

College of

L i f e s t y l e

Medicine

I , • . v e i e d by

s/ I

d

Apnr; t

-

Membe,sh

c

nan^oe r .^nt

datah.I c

Online

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mteqra.ed

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t o f o ^,noc

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r h r . l i r i r s

and o t h e r

non-p

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h t t p

: / /

www.lifestylemedicine

org/aboutA

LM

2/25/2009


9/41

Amrican

00

lege

of

T i

festy

a

MBdicine: 501 ( c )

( 6 )

entity.

32

0204851

•

SIYXIDM

OIHER

MS

1 f e e s , serums:

1080

r i a a . i r g ,

gr

hics

1048

n site

2400

Various

f e e s , aaypal

lark

et c 312

Office

sulli e s ,

voi ce n ail 56 3

t o t a l

c a s t s

5 4 0 3

S D i I E

t E N

OF

PLUOCNIS PA ME

LM:

3 0 0 0 .

Involves a loan frmn

an

officer of

this e n t i t y ,

which

is being said

laic

by

AQM at

1 M

p er

month.

I t

i s

an n t

free

l e a n , nada wIm

the entity

was

in

effect

starting

up

in

a

a r e a ,

and men

r

smL-

f l a n s .


10/41IS A

Form

990-EZ

(2011o r P ap erw ork R ed uctio n A ct N otice , see th e se pa ra te in structio ns.

ec

I

e orgamza Ion use c e ue o respon o any ques Ion

In

IS

1

Contributions, gifts, grants, and Similaramounts received 1

2

Program service revenue including government fees and contracts 2

93 271

3

Membership dues and assessments ,

3

46 278

4 Investment income

l s l

4

5a

Gross amount from sale of assets other than inventory

. ~ ;

b

Less: cost or other basis and sales expenses ,

I 5b I

~

\ ~.:

c

Gain or (loss) from sale of assets other than inventory (Subtract line 5b from line 5a)

5c

0

S

Gaming and fundraising events

4 , : - - t t ,

a

Gross Income from gaming (attach Schedule G if greater than

>

I Sa

Y }

II

15,000) ,

.

: : : I

)

e

Gross income from fundrarsmq events (not including

of contributions

hk(:

I

b

>

II

from fundraising events reported on line 1) (attach Schedule G if the

ISb

um of such gross income and contributions exceeds 15,000) ,

1,~~1~

c

Less: direct expenses from gaming and fundraislng events

I Sc I

. 1

d

Net income or (loss) from gaming and fundraising events (add lines 6a and 6b and subtract

;\t

-line 6c)

Sd

0

7a

Gross sales of inventory, less returns and allowances

7a

,

b

Less' cost of goods sold

I 7b I

I';

c

Gross profit or (loss) from sales of inventory (Subtract line 7b from line 7a) , ,

7c

0

, -

8

2 297

Other revenue (descnbe

In

Schedule 0) , , , , , 'E 0 ' ,',

9

Total revenue. Add lines 1,2,3,4, 5c, 6d, 7c,

ia a ocr.F\V, '

. . . .

9

141 846

10 Grants and Similaramounts paid (list in Schedu

e

O~:- --:-, ,

w

10

11

Benefits paid to or for members , , , , , - g , , , 1 S 2 0 W , '

11

III

12

Salaries, other compensation, and employee be t {fj~ ~

12 38 128

II

III

13

Professional fees and other payments to indepe ~ t contrastgrs ,- U 1 , - 1

13

9 317

II

14

Occupancy, rent, utilities, and maintenance \ O G O E \ \ \ . -

14

6 728

.

)(

497

15 Printing, publications, postage, and shippm q ._ 15

1S

Other expenses (describe In Schedule 0)

1S

82 871

17

Total expenses. Add lines 10through 16

. . . .

17

137 541

.I l

18

Excess or (deflcit) for the year (Subtract line 17from line 9)

18

4 305

II

19

Net assets or fund balances at beginning of year (from line 27, column (A» (must agree with

III

~,~

III

end-of-year figure reported on prior year's return)

19

9 040

. . .

20 Other changes in net assets or fund balances (explain

In

Schedule

0) ,

20

II

z

21 Net assets or fund balances at end of year, Combine lines 18through 20

21

13 345

K

Check 0 If the crqaruzatron IS n o t a s ec tio n 5 09 (a )( 3) s up po rtin g o rg an iz a tio n o r a s ec tio n 5 27 o rg an iz atio n a nd its g ro ss r ec eip ts a re n or ma lly

n ot m ore th an $ 50 ,0 00 , A F orm 990 -E Z o r F orm 990 re tu rn IS n o t re qu ire d th oug h F orm 990 -N (e-p ostca rd) m ay b e re quire d (se e in stru ctio ns) B ut If

th e o rg an iz atio n c ho os es to file a re tu rn , b e s ure to file a c om ple te re tu rn ,

L

A dd lin es 5 b, 6 c, a nd 7 b, to lin e

9

to d ete rm in e g ro ss r ec eip ts If g ro ss r ec eip ts a re $ 20 0,0 00 o r m o re , o r If t o ta l a ss ets ( Pa rt

II,

l in e 2 5 , c o lu m n (8) below) are $500,000 or more, file Form 990 Instead of Form 990-EZ ... $

141 846

Id

Revenue, Expenses, and Changes in Net Assets or Fund Balances (see the instructions for Part

I.)

Ch k lf th izat d S h d lOt d t tion i thi P rt I I X

B

Check

d

applicable, C Nam eof

orqamzatcn

o

Employer I den t if ica ti on number

o Add resschan ge

Amer i c an Col l ege of L i f es t yl e Medi c i ne

32- 0208451

o Nam echan ge

N um b er a nd s tr ee t ( or P O bo x, If

ma u

is not del iveredto s t reetaddress)

I

Room/SUite

E T e le p ho n e n u m be r

D Imtlalreturn

612 Gl at t

Ci r c l e

971- 983- 5383

o

Termmated

o Amendedeturn

C i ty o r t own, s ta t eor coun try , and Z IP + 4

F G ro up E xe mp tio n

o Applicat ionending

Woodbur n

Or e gon 97071

Number

G

A c co u nt in g M e th o d,

I X

Cash

o Accrual

O th er ( sp ec ify ) ...

H

C heck ... 00 if the organiz ation IS not

I

W ebsite: ...

l i f es t y l er nedi c i ne. or g

re qu ire d to a tta ch S ch ed ule B

Tax-exem pt status (check only one) - 0 501 (c)(3) 00501 (c)(

6 . . . .

In se rt n o ) 0 4 94 7( a) (1 ) o r

0527

(F orm 9 90 , 9 90 -E Z, o r 9 90 -P F),

2

2 11

a nd e nd in gF or th e

2 11

calendar year, or

tax

y ea r b e gi nn in g

Departmentof theTreasury

InternalRevenueService

Open to Public

Inspection

O M B N o 1 54 5- 11 50

~ Q 1 1

Short Form

Return of Organization Exempt From Income Tax

U n de r s e ct io n 5 0 1( c) , 5 2 7, o r 4 9 47 (a )( 1) o f t he I nt er na l R e ve n ue C o d e

( ex ce p t b la c k l un g b e ne fi t t ru s t o r p riv a te fo u nd a ti on )

. ..S ponsor ingorganizat ionsof donoradv isedfunds,organizat ionsthat operateone or more hospi ta l fac ll ll les ,

and certa incont rol lingorganizat ionsas def ined Insection512(b)(13)must f i le Form990 (see ins truc tions)

Al l otherorqsmzanonawi th grossreceipts less than $200,000and total assets less than $500,000

a t t h e e n d o f t he y e ar m a y u s e t hi s f or m

he0

zsuon

ma have to use

co

of thisreturntossns state re ortm re uuements

Fonn 99 EZ


11/41


12/41Form 990-EZ (2011

and enter the amount of tax-exempt interest received or accrued during the tax year

.... 143

I

Yes

No

44a

Did the organization maintain any donor advised funds dunnq the year? If Yes,

Form 990 must be

_

completed instead of Form 990-EZ

44a

X

b

Old the organization operate one or more hospital facilities during the year? If Yes, Form 990 must be

_

completed instead of Form 990-EZ

44b

X

c

Old the organization receive any payments for indoor tanning servicesduring the year?

44c

X

d

If Yes to line 44c, has the organization filed a Form 720 to report these payments?

If No provide an

_

explanation in Schedule

44d

45a Did the organization have a controlled entity within the meaning of section 512(b)(13)?

45a

X

45b

Did the organization receive any payment from or engage in any transaction with a controlled entity within the

__

eaning of section 512(b)(13)? If Yes, Form 990 and Schedule R may need to be completed instead of

Form 990-EZ (see instructions) . 45b

X

- - - - - - -

Yes No

42b

X

42c

X

41 List the states with which a copy of this return ISfiled. ....

42a The organization's books are in care of ....

: : 1 - ? : E _ < ? : ._ ? _ ~ § ~ ~ _ l _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Telephone no. ....

9 7 1 - 9 8 3 - 5 3 8 3

Located at ....

_?J~ ~J~ _tf _ ~ E _ < ? : . ~ . § _ L _ _

~ s ? _ s ~ _ I } _ ~ _ l _ _

Q ~ . § _ g ~ _ I ) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

ZIP + 4.... 2 ~ 7 ~ Q - 7 T : : - 9 6 - 7 - 5 - -

b At any time dunng the calendaryear, did the organizationhavean interestin or a signatureor other authorityover

a financialaccountin a foreigncountry (suchas a bankaccount,secunnesaccount,orother financialaccount)?

If Yes, enter the name of the foreign country: ....

See the instructions for exceptions and filing requirementsfor Form TO F 90-22.1, Report of Foreign Bank

and Financial Accounts.

c At any time dunng the calendar year, did the organization maintain an office outside the U.S.? .

If Yes, enter the name of the foreign country· ....

43 Section 4947(a)(1) nonexempt charitable trusts filing Form990-EZ in lieu of Form 1041-Check here .... ....

40e

40b

X

b

39

38a

37a

36 Did the organization undergo a liquidation, dissolution, termination, or significant disposition of net assets

during the year? If Yes, complete applicable parts of Schedule N 36 X

Enteramountof politicalexpenditures,director Indirect,as describedInthe instructions. .... 1'-'3:....:7....:a:...JI

l

Did the organization file Form 1120-POL for this year? 37b

X

Did the organization borrow from, or makeany loans to, any officer, director, trustee, or key employee or were

any such loans made in a prior year and stili outstandingatthe end of the tax year covered by this return? 38a X

If Yes, complete Schedule L, Part II and enter the total amount involved 38b

;

Section 501(c)(7) organizations. Enter: __

a Initiation fees and capital contributions included on line 9 1-'3:....:9:.=a+-

I

b Gross receipts, included on line 9, for public use of club facihties '-'3:....:9;.;;:b:...J....

I

40a Section 501(c)(3) organizations. Enter amount of tax Imposedon the organization during the year under:

section 4911 .... , section 4912.... , section 4955 ....

b Section 501(c)(3) and 501(c)(4) organizations Did the organization engage in any section 4958 excess benefit

transaction dunng the year, or did It engage Inan excess benefit transaction in a pnor year that has not been

reported on any of Its prior Forms 990 or 990-EZ? If Yes, completeSchedule L, Part I

c Section 501(c)(3) and 501(c)(4) organizations. Enter amount of tax imposed on

organization managers or disqualified persons during the year under sections 4912,

4955, and 4958 . ....

d Section 501(c)(3) and 501(c)(4) organizations. Enter amount of tax on line 40c

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? lf 'Yes. complete Form 8886-T.

33

Yes No

33 Old the organization engage in any significant activity not previously reported to the IRS? If Yes, provide a

detailed description of each activity in Schedule

34 Were any significant changes made to the organizing or governing documents? If Yes, attach a conformed

copy of the amended documents If they reflect a change to the organization's name. Otherwise, explain the

change on Schedule

0

(see Instructions) 34

X

35a Did the organization have unrelated businessgross incomeof 1,000 or more during the year from business

activities (such as those reported on lines 2, 6a, and 7a, among others)? 35a X

b If Yes, to line35a,hastheorganizationileda Form

990-T

fortheyear?IfUNo,provideanexplanationnSchedule

1-'3;_;5;.;;:b+-_-

C Was the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization subject to section 6033(e) notice,

reporting, and proxy tax requirements during the year? If Yes, complete Schedule C, Part III 35c X

Form 990-EZ (2011) Page

C Other Information Note th e S che du le A a nd pe rs ona l b ene fit co ntra ct statem ent requ ire ments in th e

in stru ctio ns fo r P art V . C he ck if th e o rg an iz atio n u se d S ch ed ule 0 to re sp on d to a ny q ue stio n in th is P art V X


13/41

M ay th e IR S d is cu ss th is re tu rn W ith th e p re pa re r s ho wn a bo ve ? S ee in stru ctio ns

F orm 99 0-E Z (2 01 1

Paid Pnnvrypepreparer'sname PTIN

Prepare r~T~h~e~o~d~o~r~e~R~._A~h~r~e-= __ ~~~~~~ __ ~~~~~~~~~~~~~P~ ~ ~ ~6~4~ ~8~2~

UseOnly~F~lr~m~'s~n=am~e~~~_T~h~e~o~d~o_r~e~~~_~r_e_,~~_~ ~= ~~~ __ ~~~~~~~~~~~ __

Flrm'saddress

~576

G latt rc le, Woodburn , OR

97 7

S /~ I:;2

Date

Executive D irector

Sign

Here

~ Signatureof of f icer

~ Marc Braman,

Typeorpnntnameandt i t le

Un derpena ltiesof perjury, I declarethatI haveexam inedhiSretum,includingaccom panyingchedulesands tatemen ts,nd to the bestof my know ledgeand belief,ItIS

true,correct,and com pleteDeclaration of preparer otherthanofficer)ISbasedon allinform ationof whichpreparerhasa nykn owledg e

d Total number o f other independent contractors each receiving over 100,000 . . ... _

52 O ld th e o rg an iz atio n c om ple te S ch ed ule A ? N ote ' A ll s ec tio n 5 01 ( c)(3 ) o rg an iz atio ns a nd 4 94 7(a )(1 )

nonexempt charitable trusts must a ttach a completed Schedule A . . . . . ... DYes D No

(b)Typeofservice

e Compensat ion

a)NameandaddressofeachIndependentontractorpaidmorethan 100,000

f Total number o f other employees paid o ver 100,000 . . . . ... _

51 C om plete th is ta ble for the orga nization 's five hig hest com pensated indep ende nt co ntra ctors w ho each receive d m ore tha n

1 00,000 of com pensation fro m the org aniza tion If th ere IS n one, en ter N one .

(d)Healthbenefits,

(c)Reportable contnbunons to employee (e)Est imatedamountof

compensat ion

(FormsW 2 1099-MISC)bene f itp lans ,andde fe r red o thercompensa tion

compensat ion

(b)Tit leandaverage

hoursperweek

devotedo posinon

(a)Nameandaddressof eachemployee

paidmorethan 100,000

5

C om ple te th is ta ble fo r th e o rg an iz atio n's fiv e h ig he st c om pe ns ate d e mp lo ye es (o th er th an o ffic ers , d ire cto rs , tru ste es a nd k ey

e mp loyee s) w ho e ach received m ore th an 100 ,0 00 of com pen sation from the organ ization . If there IS n one, enter N on e.

ec

I e orqaruza Ion u se c e ue

o respon o any ques Ion n IS

a

Yes No

47 D id the organization engage in lobbym q activ ities or have a section 501 ( h) election in effect during the tax

y ea r? If Y es , c om ple te S ch ed ule C , P art II

47

48

Is th e o rg an iz atio n a s ch oo l a s d es cn be d in s ec tio n 1 70 (b )(1 )(A )(ii)? If Y e s, c om p le te S ch ed ule E

48

49a

D id th e o rg an iz atio n m ak e a ny tra ns fe rs to a n e xe mp t n on -c ha rita ble re la te d o rg an iz atio n?

49a

b

If Y es , w a s th e re la te d o rg an iz atio n a s ec tio n 5 27 o rg an iz atio n?

49 b

l Iffiia JI Section 501(c)(3) o rganiza tions and section 4947(a)(1) nonexempt charitable trusts on ly. All section

501 (c)(3 ) o rganizations and section 4947(a)(1 ) nonexempt charitab le trusts m ust answer questions 47-49b

and 52, and complete the tables for lines 50 and 51.

Ch k f h . tl d S h d lO t d t tion l thi P rt VI D

4 6 O ld the organ ization e ngag e, d irectly or ind irectly, in politica l cam paign a ctiv itie s on beha lf of or in o ppo sition ~

to candidates fo r public office? If Yes, comp lete Schedule C , Part I . . . . . . Ts X

Form990-EZ(2911) Page 4

Yes No


14/41ISA

Schedule 0 Form 990 or 990-EZ 2011

or Paperwork Reduction Act Notice, see the Instruct ions for Form 990 or 990-EZ.

~ ~~~ ~~ I ~~ ~~~~ ~~ ~ ~~ ~ . :? _

~ _ ~ ~ _ ~ ~ _ ~ _ ~ ~ _ I ~ 9 _ ~ ~

~ ~ g

_ l ? _ ~ ~ _ ~ ~ _ ~ ~ _ ~ ~ _ ~ ~ ~

9 _ £ _ ~ _ ~ ~

~ _ ~ E ~ _ ~ ~ _ ~

~ ~ § ~

? _

~ _ ~ ~ _ ~ _ ~ ~ _ : ~ _ ~ ~

~ _ ~ _ § _ 4 _ 9 _

~ _ ~ £ _ ~ ~ ~ _ ~ ~ _ 9 ~ _ ~ _ § _ ~ _ ~ _

54

i censes

267

nsurance

~ _ ~ ~ X ~ £ _ ~ ~ _ ~ ~~ _ _ _ ~ l _ 9 ~ _ I 2 ~ _ ~ ~ _~ } ;?_ ? _

6 291

ubl i cat i ons

Y _ ~ £ _ ~ ~ b _ _ ~ p ? § _ ~ _ ~ ? _ ? _

9 _ :0 _ ~ _ ~~ ~ P ~ l _ ? ~ _ ~ _ _

Employer Identification number

32 0208451

Nam e o f th e o rq a ru za no n

Amer i can Col l e e of Li f est l e Medi ci ne

pento Public

nspection

OMB No 1545-0047

Supplemental Information to Form 99 or 99 EZ

~ Q 1 1

SCHEDULED

FonY : I9 9 0 o r 9 9 0-EZ

Complete to provide information for responses to specific questions on

Form 990 or 990-EZ or to provide any additional information.

~ Attach to Form 990 or 990-EZ.

D e pa rt m en t o f t he T re a su ry

I nt er na l R e ve n ue S e rv ic e


15/41

Forme O (2

or PaperworkReductionAct Notice, seethe separate Instructions.

D A A

DYes DNo

ay the IRS diSCUSShiS return Withthe preparer shown above? (see Instructions)

503- 982- 520

honeno

576 Gl at t Ci r cl e

Firm'saddress ~ Woodbur n OR 97071- 9675

Theodor eR Ahr e CPA Theodor eR Ahr e CPA

P00064082

Firm'sname ~

Theodor e R. Ahr e CPA

secretar y- t r easur er

eorge Gut hr i e

TypeorpnntnameandbUe

medthis retum,includingaccompanyingschedulesandstatements,andto the bestof myknowledgeandbelief,It IS

arer otherthanofficer)ISbasedon all Informationof whichpreparerhasany knowledge.

~ r . . ~ _ ~_

~ n ~~~ ~ ~~~

gn ~

ere ~

~ ~~ ~ ~ ~ ~ ~ r ~ r = =

PnnVTypereparer'same Preparer'signature PTIN

Use Only

P rt J 5

or

e ca en ar vear or tax~_ar

esinruns

an

en ma

B Checkfapplicable

C4 Nameof

orqaruzauon

Employerdentificationumber

D Addresshan~e

Amer i can Col l ege of

Li f estyl e

Med

D Namehange

OolngBusiness

s

32-0208451

D Imbalretum

NumberndstreetorPObox Ifmaillsnotdeliveredostreetaddress)

I Room/sUite

E

Telephoneumber

612

Gl at t Ci r cl e 971- 983- 5383

D Terrmnated

City,ownorpostoffice,state,andZIPcode

D Amendedeturn

Woodbur n

OR

97071

G Grosseceipts

206 1

D Applicabonending

F Nameandaddressf

pnncipal

officer

DYes

~

(a)

IsthiSagroupeturnoraffil iates?

H(b)

Areallaffi liatesncluded?

Dyes

D

If No, attachal ist (seemstrucuons)

Tax-exempt

status I I 501(c)(3) IX I 501(c) ( 6 I l I I (Insertno) I I 4947(a)(1)r

I I

527

J Website:~

l i f est yl emedi ci ne. or g H(c)

Groupexemptionumber

K Formfo r q a m z a u o n

IX I

Corporation rustJ

I

A s s o c r a u o n

I I

Other~

IL

Yearofformaaon

I M

StateofleQalomicile

a

ummary

1 Bnefly descnbe the organization's mission or most significant activities

GI

To of f er qual i t y educat i on and cer t i f i cat i on

of

the pract i ce

i n cl i ni cal

u

l i f es tyl e medi ci ne.

a

GI

Check this box ~

if the organization discontinued its operations or disposed of more than 25 of Its net assets.2

C )

3 Number of voting members of the governing body (Part VI, line 1a) 3

0

1/1

4

Number of Independent voting members of the governing body (Part VI, line 1b) 4

0

I

:;:;

Total number of Individuals employed Incalendar year 2012 (Part V, line 2a)

0

s

5 5

:;:;

0

6 Total number of volunteers (estimate If necessary)

6

<

7a Total unrelated business revenue from Part VIII, column (C), line 12 7a

b Net unrelated business taxable income from Form 990-T, line 34 7b

PriorYear CurrentYear

GI

8 Contnbutions and grants (Part VIII, l ine 1h)

:::I

9

Proqram service revenue (Part VIII. II,e 29) _- ~

197 06

GI

Investment income (Part VIII, column ~ lines 3 6~~

10

I

a ::

Other revenue (Part VIII, column (A) lin ~ , Oc, and 1

9 11

1

Total revenue - add lmes•

I h r o u Q ~ ; r . k . t

ecual Part

V l I I . . ; ~ ~

ti,e 12)

2

206 18

13

G and

mol

amountspaid(P~\~: 3\W~

14 Benefits paid to or for members (Part I, umn (A), lin

\ fr

1/1

15 Salanes, other compensation, empIOye~~~ rrn lines 5-10)

46 38

GI

1/1

16aProfessionai fundraising fees (Part IX, co umn ~11e)

GI

b Total fundraising expenses (Part IX, column (0), line 25) ~

0

C

w

17 Other expenses (Part IX, column (A), lines 11a-11d, 11f-24e)

163 64

18

Total expenses Add lines 13-17 (must equal Part IX, column (A), l ine 25)

210 02

19

Revenue less expenses, Subtract line 18from line 12

- 3 84

~'

BeginningofCurrentYear EndofYear

g

20

Total assets (Part X, line 16) 13 345 9 49

,,,,

i i

21

Total liabilities (Part X, line 26)

0

22

Net assets or fund balances. Subtract line 21 from line 20 13 345

9 49

b d d

F th 2012 d

Opento Publi

Inspectlc)n

OMBNo154~047

2 2

eturn of Organization Exempt From Income Tax

Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung

benefit trust or private foundation)

~ The organization may have to use a copy of this return to satisfy state reporting requirements

DepartmentftheTreasury

tntemalRevenueervice

AM

o~


16/41

Form 99 (2

4e Total program service expenses ~ 210 026

) (Revenue

4d Other program services. (Descnbe in Schedule

0.

(Expenses including grants of

) (Revenue

ncluding grants of

(Expenses

c (Code:

) (Revenue ncluding grants of

(Expenses

b (Code.

) (Revenue

10 026 Including grants of a (Code: ) (Expenses

Pr ovi de wor kshops

DYes [ ] N

DYes [ ] N

2 Did the organization undertake any significant program services dunng the year which were not listed on the

pnor Form 990 or 990-EZ?

If Yes, descnbe these new services on Schedule O.

3 Did the organization cease conducting, or make significant changes in how Itconducts, any program

services?

If Yes, descnbe these changes on Schedule 0

4 Descnbe the organization s program service accomplishments for each of ItSthree largest program services, as measured by

expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others,

the total expenses, and revenue, If any, for each program service reported.

1 Briefly describe.the organization s mission:

To of f er qual i t y educat i on and cer t i f i cat i on of t he pr act i ce i n cl i ni cal

l i f est yl e medi ci ne.

Part III Statementof ProgramServiceAccomplishments

Check if Schedule 0 contains a response to any question in this Part III

Pag

orm 990(2012) Amer i can Col l ege of Li f est yl e Med 32 0208451

AM


17/41

11a

X

11b

X

11c

X

11d

X

11e

X

11f

X

12a

X

12b

X

13

X

14a

X

14b

X

15

X

16

X

17

X

18

X

19

X

20a

X

20b

Form

99

(2

1 Is the organizaijon described In section 501(c)(3) or 4947(a)(1) (other than a pnvate foundation)? If Yes,

complete Schedule A

2 Isthe organization required to complete Schedule B, Schedule of Contnbutors (see instructions)?

3 Old the organization engage in direct or Indirect pohtical campaign activit ies on behalf of or In opposmon to

candidates for public office? If Yes, complete Schedule C, Part I

4 Section 501(c)(3) organizations. Oldthe organization engage In lobbYing activit ies, or have a section 501(h)

election in effect during the tax year? If Yes, complete Schedule C, Part II

5 Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues,

assessments, or similar amounts as defined In Revenue Procedure 98-19? If Yes, complete Schedule C,

Part III

6 Old the organization maintain any donor advised funds or any similar funds or accounts for which donors

have the nght to provide advice on the distribution or investment of amounts In such funds or accounts? If

Yes, complete Schedule 0, Part I

7 Did the organization receive or hold a conservation easement, including easements to preserve open space,

the environment, hrstonc land areas, or hrstonc structures? If Yes, complete Schedule 0, Part II

8 Old the organization maintain collections of works of art, rustoncal treasures, or other Similar assets? If Yes,

complete Schedule 0, Part III

9 Oldthe organization report an amount In Part X, l ine 21, for escrow or custodial account l iabil ity, serve as a

custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or

debt negotiation services? If Yes, complete Schedule 0, Part IV

10 Old the organization, directly or through a related organization, hold assets in temporarily restricted

endowments, permanent endowments, or quasi-endowments? If Yes, complete Schedule 0, Part V

11 If the organization's answer to any of the followmq questions IS Yes, then complete Schedule 0, Parts VI,

VII, VIII, IX, or X as applicable

a Oldthe organization report an amount for land, buildings, and equipment In Part X, l ine 10? If Yes,

complete Schedule 0, Part VI

b Did the organization report an amount for investments--other secunties in Part X, l ine 12 that is 5% or more

of ItStotal assets reported In Part X, line 16? If Yes, complete Schedule 0, Part VII

c Oldthe organization report an amount for Investments--program related In Part X, line 13that IS5% or more

of ItStotal assets reported in Part X, line 16? If Yes, complete Schedule 0, Part VIII

d Oldthe organization report an amount for other assets in Part X, line 15that IS5% or more of its total assets

reported InPart X, line 16? If Yes, complete Schedule 0, Part IX

e Oldthe organization report an amount for other l iabi lit ies in Part X, l ine 25? If Yes, complete Schedule D, Part X

f

Old the organization's separate or consolidated financial statements for the tax year Include a footnote that addresses

the organization's liability for uncertain tax positions under FIN 48 (ASC 740)? If Yes, complete Schedule 0, Part X

12a Old the organization obtain separate, Independent audited financial statements for the tax year? If Yes, complete

Schedule 0, Parts XI and XII

b Was the organization included In consolidated, Independent audited financial statements for the tax year? If Yes, and If

the organization answered No to line 12a, then completing Schedule 0, Parts XI and XII ISoptional

13 Is the organization a school descnbed In section 170(b)(1)(A)(II)? If Yes, complete Schedule E

14a Did the organization maintain an office, employees, or agents outside of the United States?

b Old the organization have aggregate revenues or expenses of more than 10,000 from grantmaklng,

fundraising, business. Investment, and program service activities outside the United States, or aggregate

foreign investments valued at 100,000 or more? If Yes, complete Schedule F, Parts I and IV

15 Old the organization report on Part IX, column (A), l ine 3, more than 5,000 of grants or assistance to any

organization or entity located outside the United States? If Yes, complete Schedule F, Parts II and IV

16 Did the organization report on Part IX, column (A), l ine 3, more than 5,000 of aggregate grants or assistance

to lndivrduals located outside the United States? If Yes, complete Schedule F, Parts III and IV

17 Oldthe organization report a total of more than 15,000 of expenses for professional fundraising services on

Part IX, column (A), lines 6 and 11e? If Yes, complete Schedule G, Part I (see instrucbons)

18 Did the organization report more than 15,000 total of fundratsmq event gross Income and contnbutlons on

Part VIII, lines 1cand 8a? If Yes, complete Schedule G, Part II

19 Did the organization report more than 15,000 of gross income from gaming activit ies on Part VIII, l ine 9a?

If Yes, complete Schedule G, Part III

20a Did the organization operate one or more hospital facilities? If Yes, complete Schedule H

b If Yes to line 20a did the orqanlzatlon attach a

py

of its audited financial statements to this return?

Pag

Yes

N

1

X

2

X

3

X

4

5

X

6

X

7

X

8

X

9

X

10

X

Part V hecklist of ReQUiredSchedules

32 2 8451

orm 990 (2012)

merican ollege of Lifestyle Med

AM


18/41

Form

99

(2

Part IV

Checklist of Required Schedules (continued)

Yes

N

21

Did the orqaruzanon report more than 5,000 of grants and other assistance to any govemment or organization

in the tini ted States on Part IX, column (A), line ? If Yes, complete Schedule I, Parts I and II

21

X

22

Did the organization report more than 5,000 of grants and other assistance to individuals the United States

on Part IX, column (A), l ine 2? If Yes, complete Schedule I, Parts I and III

22

X

23

Did the organization answer Yes to Part VII, Section A, line 3, 4, or 5 about compensation of the

organization's current and former officers, directors, trustees, key employees, and highest compensated

employees? If Yes, complete Schedule J

23

X

24a

Did the organization have a tax-exempt bond Issue Withan outstanding principal amount of more than

100,000 as of the last day of the year, that was issued after December 31, 2002? If Yes, answer l ines 24b

through 24d and complete Schedule K. If No, go to line 25 24a

X

b Did the organization Invest any proceeds of tax-exempt bonds beyond a temporary period exception?

24b

c Did the organization maintain an escrow account other than a refunding escrow at any time dunng the year

to defease any tax-exempt bonds? 24c

d Did the organization act as an on behalf of issuer for bonds outstanding at any time during the year? 24d

25a Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage an excess benefit transaction

Witha disqualified person dunng the year? If Yes, complete Schedule L, Part I

25a

Is the organization aware that it engaged In an excess benefit transaction Witha disqualified person a pnor

year, and that the transaction has not been reported on any of the organization's pnor Forms 990 or 990-EZ?

If Yes, complete Schedule L, Part I 25b

26

Was a loan to or by a current or former officer, director, trustee, key employee, highest compensated employee, or

disqualified person outstanding as of the end of the organization's tax year? If Yes, complete Schedule L, Part II

26 X

27

Did the organization provide a grant or other assistance to an officer, director, trustee, key employee,

substantial contnbutor or employee thereof, a grant selection committee member, or to a 35% controlled

entity or family member of any of these persons? If Yes, complete Schedule L, Part III 27

X

28

Was the organization a party to a business transaction Withone of the follOWingparties (see Schedule L,

Part IV Instructions for applicable filing thresholds, conditions, and exceptions)

a A current or former officer, director, trustee, or key employee? If Yes, complete Schedule L, Part IV

28a

X

b A family member of a current or former off icer, director, trustee, or key employee? If Yes, complete

Schedule L, Part IV 28b

X

c An entity of which a current or former off icer, director, trustee, or key employee (or a family member thereof)

was an officer, director, trustee, or direct or indirect owner? If Yes, complete Schedule L, Part IV 28c

X

29

Did the organization receive more than 25,000 in non-cash contributions? If Yes. complete Schedule M 29

X

30 Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified

conservation contnbunons? If 'Yes, complete Schedule M 30

X

31 Did the organization hquidate, terminate, or dissolve and cease operations? If Yes, complete Schedule N,

Part I

31

X

32

Did the organization sell, exchange, dispose of, or transfer more than 25% of ItSnet assets? If Yes,

complete Schedule N, Part II

32

X

33

Did the organization own 100% of an entity disregarded as separate from the organization under Regulations

sections 301.7701-2 and 301.7701-3? If ·Yes, complete Schedule R, Part I

33

X

Was the organization related to any tax-exempt or taxable entity? If Yes, complete Schedule R, Parts II, III,

or IV, and Part V, line 1

X

35a

Did the organization have a controlled entity within the meaning of section 512(b)(13)?

35a

X

b

If Yes to line 35a, did the organization receive any payment from or engage Inany transaction with a

controlled entity Withinthe meaning of section 512(b)(13)? If Yes, complete Schedule R, Part V, line 2

35b

36

Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable

related organization? If Yes, complete Schedule R, Part V, line 2 36

37

Did the organization conduct more than 5% of ItSactivities through an entity that ISnot a related organization

and that is treated as a partnership for federal Income tax purposes? If Yes. complete Schedule R,

Part VI 37

X

38

Did the organization complete Schedule and provide explanations Schedule for Part VI, l ines 11b and

19? Note. All Form 990 filers are reauired to complete Schedule

38

X

Paq

2 2 8451orm 990 (2012)

merican College of Li festyle Med

212 139 7

AM


19/41

Form 99 (20

14b

x

4a

13a

14a Old the organization receive any payments for Indoor tanning services during the tax year?

b If Yes, has itf iled a Form 720 to report these pavments? If No, provide an explanation In Schedule

13c

13 Section 501(c)(29) qualified nonprofit health insurance issuers.

a Isthe organization l icensed to issue qualif ied health plans in more than one state?

Note. See the Instructions for additional information the organization must report on Schedule O.

b Enter the amount of reserves the organization is required to maintain by the states in which

the organization ISlicensed to issue qualified health plans

c Enter the amount of reserves on hand

12a

b

11a

10b

l10a I

9b

9a

8

7a

7f

7eDid the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?

f Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?

g Ifthe organization received a contribution of qualified Intellectual property, did the organization file Form 8899 as required?

7d

organization, have excess business holdings at any time during the year?

9 Sponsoring organizations maintaining donor advised funds.

a Did the organization make any taxable distributions under section 4966?

b Did the organization make a distnbution to a donor, donor advisor, or related person?

10 Section 501(c)(7) organizations. Enter:

a Initiation fees and capital contnbunons included on Part VIII, l ine 12

b Gross receipts, included on Form 990, Part VIII , l ine 12,for public use of club facmties

11 Section 501(c)(12) organizations. Enter:

a Gross income from members or shareholders

b Gross income from other sources (Do not net amounts due or paid to other sources

against amounts due or received from them.) L...:1..:.1=b...L..

Section 4947(a)(1) non-exempt charitable trusts. Is t he organization filing Form 990 In l ieu of Forml1041? 1-=-1=2a=-+-_-4_

If Yes: enter the amount of tax-exempt interest received or accrued dunng the year L...:1.=2=b-LI -{

h Ifthe organization received a contnbution of cars, boats, airplanes, or other vehicles, did the organization fi le a Form 1098-C? f-'7:.. :h.=.... f_

r

8 Sponsoring organizations maintaining donor advised funds and section 509(a)(3) support ing

organizations. Old the supporting organization, or a donor advrsed fund maintained by a sponsonng

x

7c

7b

7a

6b

6a

required to file Form 8282?

d If Yes: Indicate the number of Forms 8282 filed dunng the year

x

5c

5b

x

a

x

a

3b

3a

2bIf at least one is reported on line 2a, did the organization file all required federal employment tax returns?

Note. If the sum of l ines 1aand 2a is greater than 250, you may be required to e-fi le (see instructions)

3a Old the organization have unrelated business gross Income of 1,000 or more during the year?

b If Yes: has it filed a Form 990-T for this year? If No: provide an explanation In Schedule 0

4a At any time dunng the calendar year, did the organization have an interest in, or a signature or other authority

over, a financial account Ina foreign country (such as a bank account, securities account, or other financial

account)?

b If Yes: enter the name of the foreign country ....

See instructions for fil ing requirements for Form TO F 90-22 1, Report of Foreign Bank and Financial Accounts.

5a Was the organization a party to a prohibited tax shelter transaction at any time dunng the tax year?

b Old any taxable party notify the organization that Itwas or ISa party to a prohibited tax shelter transaction?

c If Yes to l ine 5a or 5b, did the organization fi le Form 8886-T?

6a Does the organization have annual gross receipts that are normally greater than 100,000, and did the

organization solicit any contributions that were not tax deductible as charitable contnbutions?

b If Yes: did the organization Include with every solicitation an express statement that such contributions or

gifts were not tax deductible?

7 Organizations that may receive deductible contributions under section 170(c).

a Did the organization receive a payment Inexcess of 75 made partly as a contnbunon and partly for goods

and services provided to the payor?

b If Yes, did the organization noti fy the donor of the value of the goods or services provided?

c Did the organization sell, exchange, or otherwise dispose of tangible personal property for which It was

x

x

c

1a Enter the number reported InBox 3 of Form 1096 Enter -0- If not applicable

b Enter the number of Forms W-2G Included in l ine 1a. Enter -0- Ifnot appl icable

c Did the organization comply with backup Withholding rules for reportable payments to vendors and

reportable gaming (gambling) Winnings to pnze Winners?

2a Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax

Statements, filed for the calendar year ending Withor Within the year covered by this return

1b

1a

Yes N

PiilrtV StatementsRegardingOtherIRS ilings and Tax ompliance

Check if Schedule 0 contains a response to any Question this Part V

Page

drm 990 (2012)

American College of Lifestyle Med 32 2 8451

212 139 7


20/41


21/41

Fonm

990

(2

AA

(A)

(8)

(C)

(0)

(E) (F)

Name and Tltle Average

Position Reportable Reportable

Esbmated

hours per

(do not check more than one compensation

compensabon from

amount of

week

box, unless person IS both an

from related other

(list any

officer and a director/trustee)

the

organizations

compensation

hours for

~

~

~

3~

T1

orqarnzatron

(W-211099-MISC)

fromtlhe

related

(W-211099-MISC)

organization

~

-e

0 ::r

organizations

o~ ~

and related

5

3

elow dotted

~

C

organizations

0

line)

<

0

::>

en

D

(1)Liana Lianov

4 00

Presi dent

0 00 X

0 0

(2) David

Katz

0 50

Presi dent

l ect

0 00 X

0 0

(3)Wayne Dysinger

3 00

Past Presi dent

0 00 X

0

0

(4) George Guthrie

4 00

Secr etary Treasur er

0 00

X 0 0

(5)

(6)

7

(8)

(9)

(10)

(11)

1a Complete

trus

table for all persons required to be listed. Report compensation for the calendar year ending with or within the

organization's tax year

• List all of the organization's current officers, directors, trustees (whether individuals or organizations), regardless of amount of

compensation. Enter -0- in columns (0), (E), and (F) If no compensation was paid

• List all of the organization's current key employees, If any. See Instructions for definition of key employee.

• List the organization's five current highest compensated employees (other than an officer, director, trustee, or key employee)

who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than 100,000 from the

organization and any related organizations.

• Listall of the organization's former officers, key employees, and highest compensated employees who received more than

100,000 of reportable compensation from the organization and any related organizations.

• List all ofthe organization's former directors or trustees that received, in the capacity as a former director or trustee of the

organization, more than 10,000 of reportable compensation from the organization and any related organizations.

List persons n the folloWing order: Individual trustees or directors; institutional trustees; officers; key employees, highest

compensated employees; and former such persons

~ Check this box If neither the organization nor any related organizations compensated any current officer, director, or trustee.

Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees

Form 990(2012) American College of Lifestyle Med

32 0208451

Pag

Part VII Compensation of Officers, Directors, Trustees, Key Employees, Highest Compensated Employees, and

Independent Contractors

Check if Schedule 0 contains a response to any question in this Part VII

M


22/41

Form990(2

cornoensanon from the organization. Report compensation for the calendar year ending WIthor within the organization's tax vear.

(A ) (8)

(e)

Namendbusinessddress

Descl1Qbonfservices

C o r n r e r i s a n o n

2

Total number of independent contractors (including but not limited to those listed above) who

received more than 100,000 of compensation from the organization ~

0

1 Complete this table for your f ive highest compensated independent contractors that received more than 100,000 of

Section B. Independent Contractors

reportable compensation

om the orcaruzanon

Yes N

3 Oldthe organization l ist any former off icer, director, or trustee, key employee, or highest compensated

employee on line 1a? If Yes, complete Schedule J for such individual

3

X

4

For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the

organization and related organizations greater than 150,OOO?If Yes, complete Schedule J for such

X

ndividual

4

5

Old any person listed on line 1areceive or accrue compensation from any unrelated organization or lndrvrdual

for services rendered to the orqaruzanon? If Yes, complete Schedule J for such person

5

X

2 Total number of tndividuals (including but not limited to those listed above) who received more than 100,000 In

fr ~

, ,

,

(A)

8)

C 0)

(E)

(F)

Nameandutle Average

Posmon

Reportable Reportable EstImated

hoursper (donotcheckmorehanone

compensation cornpensanon

from amountf

week box.unlesspersonSbothan from

related other

(lostny officerandadirector/trustee) the orqaruzauons compensahon

hoursor

orqaruzatron (W-211099-MtSC)

fromhe

::

a

; < ;

CD

T1

(W-211099-MtSC) orqaruzanonelated

CD

3c5

~

3l

<

0 :T

3

andrelated

rqaruzatrons

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o

3

belowdotted

'

orqaruzanons

::

lone)

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e

3

CD

0

CD

CD

~

::

)

CD

a;

c

(12)

(13)

(14)

(15)

(16)

(17)

(18)

(19)

1b Sub-total

~

c Total from continuation sheets to Part VII, Section A

~

d Total (add lin

american college of lifestyle medicine, irs 990s 2008 + 2011-present

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