Return 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)
D epartmentofthe Treasury
InternalRev enueS erv Ice
~ Th e organization may h ave to use a copy of th is return to satisfy state reporting req uirements.
OMBNo 1545· 0047
Open to P ublic
A For the 2005 calendar year or tax year beginning
P leaseC N ame of organization
DEmployer identification number
applocab leus e IRS
N umber and street (or P .O. box If rnaihs not dehvered to street address)
IB oom/s uiteETelephone number
S pecIfic100DOUBLE BEACH ROAD
Ins truc-C ity or tow n, state or country, and ZIP + 4
OA mend ed
• Section 501(c)(3) organizations and 4947(a)(1) nonexempt charitable trusts
Hand Iarenot applIcable to section 5 2 7orgamzatlons
must attach a completed Schedule A (Form 990 or 990-EZ).
H (a) Is this a group return for afflhates?
[XJ N O
GW ebsite:~W W W .
H(b) If "Yes,' enter number of affihates~
JOrganization type(ch eck onlyone)~
).... Onsertno)0 4947(a)( 1) or0 527H(c) Areall atnhates Included?
KCheck here ~ D
If the ornamzanon's gross receipts are normally not more than $25,000. The
(If 'N o,' attach a hst)
H (d) Is this a separate return filed by an or-D
organization need not file a return W ith the IRS ; but If the orpamzanon chooses to file a return, be
ganlzallon covered by a group ruhng?
sure to file a complete return. Some states require a complete return.
IG rouo Exernnuon N umber ~
MCheck ~0 Ifthe organization ISnot requued to attach
LGross receipts: Add hnes 6b, 8b, 9b, and 10b to hne 12 ~
30 031 823.
Sch. B (Form 990, 990-EZ, or 990-PF).
IPart IRevenue, Expenses, and C hanges in N et Assets or Fund Balances
C ontnbutrons, giftS, grants, and Similar amounts received:
a Direct pubhc support
bIndirect pubhc support
cGovernment contnounons (grants)
dTotal (add hnes 1a through 1c) (cash $
P rogram service revenue including government fees and contracts (from P art V II, line 93)
Membership dues and assessments
Interest on savings and temporary cash Investments
DIVidends and Interest from securmes
6 aGross rents
bLess: rental expenses
cNet rental Income or (loss) (subtract hne 6b from hne 6a)
Other Investment Income (descnbe ~
8 aG ross amount from sales of assets other
( A I S ecurities
(8 lOth er
bLess: cost or other baSIS and sales expenses
cGain or (loss) (attach schedule)
dN et gain or (loss) (combine line 8c, columns (A ) and (B ))
Special events and activities (attach schedule).If any amount IS from g~~ing, ~h~ck here ~ D
a Gross revenue (not Including $
reported on hne 1a)
bLess: direct expenses other than fund raising expenses
cNet Income or (loss) from special events (subtract hne 9b from hne 9a)
10 a G ross sales of Inventory, less returns and allowances
bLess: cost of goods sold.
c G ross profit or (loss) from sales of Inventory (attach schedule) (subtract hne 10b from hne 10a) .
Other revenue (from P art V II, hne 103)
Total revenue (add hnes 1d 2 3 4 5 6c 7 8d 9c 10c and 11l
w e44, ~olumn (B))
e 44, column (C))
om hne 44, col
1 70) ota
dd hnes 16J riit.A .column (All
act hne 17 from hne 12)
, re~ Ia
of year (from hne73, column (A))
'IIv~In ne~ sets
or fund balances (attach explanation)
N et assets or fund balances at end of year (combine hnes 18, 19, and 20)
l J ...J
~~~f - 1 BLHA
For Privacy Act and Paperw ork Reduction Act N otice, see the separate instructions.
Form 990 (2005)
13020810 755449 8481
2005.09001 THE CONNECTICUT
HOSPICE, IN 8481