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New Jersey Office of the Attorney General Division of Consumer Affairs

Office of Consumer Protection Charities Registration Section 124 Halsey Street, 7v" Floor, P.O. Box 45021 Newark, NJ 07101 (973) 504-6215



Form CRI-300R Long-Form Renewal Registration/Verification Statement

(Revised April 2008)

All questio ns must be answered.

Pursuant to the New Jersey Charitable Registration and Investigation Act (also known as "the C.R.I. Act" ( N.J.S.A . 45:17A-18 rtit and prior to operating or commencing solicitation activity in the State, a charitable organization unless exempted from registration requirements (or qualified to file a Short-Form Registration Statement, CRI-200) shall file a Long-Form Initial Registration Statement, CR1-150-I. Charities submitting their annual long-form renewal registration must use Form CRI-300R. Please see the checklist at the end of this form for a discussion of fees, financial statements, documents to be attached, and other requirements for registration. .).

1. This statement contains the facts and financial information for the fiscal year ending: 12

/ 31

1 2010

2. 3.

Federal ID Number (EIN)

2a. N.J. Charities Registration Number: CH- 33145

Full legal name of the registering organization Breast Cancer Survivors Foundation, Inc. :
In care of: (if necessary, otherwise leave this lint blank)


Mailing Address : 443 E Westfield Ave Ste 1


Roselle Park , NJ 07204



Change of Address

NOTE: If "in care of," a postal, private or 5.

rural delivery mail box number is used, the street address of 443 E Westfield Ave Ste 1

the charity must be given below. , NJ 07204


The principal street address of the registering organization

, Roselle Park


Same as Mailing Address

z rPCnde

Does the organization have any offices in New Jersey in addition to the one listed above?
If "Yes," attach a list giving the street address and telephone number of each office in New Jersey.

Yes X No

If the street address listed above is not where the organization's official records are kept, or if the organization does not maintain an office in New Jersey. indicate the name, full address. phone and fax numbcrof the person having custody of the of the organization's records, and to whom correspondence should be addressed.

Refer to attachment "Responsible for Custody of Financial Records"

Gntxt m on S,r c, bd " eu c Cby Rube ZIP G+Ie

Tetep1gw nw bn (,ndmk mea -kj

Faa -V . , t,ndn,k area eak)


Organization's contact information: 908-241-2288

ldrpim wnhr (tnd.& rca cadeI

fig tnrmh" (m. Ind: n,o -&)
L m ,1 aNra-


Type of organization (check one):

IN Nonprofit corporation Partnership Foundation Trust Individual Other (Specify) Association Society

Form CRI


Page 1 of 7

. cwi aS'6


Where and when was the organization legally established? Date: 611/2010 State: Delaware As required by the C.R.I. Act ( N.J.S.A . 45:1?A-24c(l)), attach to this registration a copy of the organization's bylaws and instrument of organization (that is. the organization's charter, articles of incorporation or organization, agreement of association. instrument of trust, or constitution) only if the document has been issued or amended during the fiscal year being reported. Does the organization solicit funds under any name or names other than as indicated on line 3 of this If "Yes." indicate all of the other names used: Does the organization intend to solicit contributions from the general public ? form? []Yes O No


11. 12.

0 Yes K1 Yes

C No 0 No

Is the organization authorized by any other state or jurisdiction to solicit contributions? If "Yes." please provide a list of those states or jurisdictions, below or on a separate sheet of paper.

Refer to attachment "List of States, Counties and Cities where Registered"


Does the organization have affiliates which share the contributions or other revenue it raised in New Jersey? O Yes If "Yes." provide a separate listing of those affiliates indicating the name, street address and telephone number for each one. What is the charitable purpose or purposes registration. for which the organization was formed? If necessary,

0 No


attach a separate statement to this

Refer to attachment "Statement of Charitable Purpose and Program Service Accomplishments"

14a. What are the specific programs and charitable purposes for which contributions arc used? For each program. state whether it already exists or is planned. Only major program categories need be listed. If necessary. attach a separate statement to this registration.

Refer to attachment "Statement of Charitable Purpose and Program Service Accomplishments"

15. Does the organization use an independent paid fund-raiser or fund-raising counsel'? KI Yes 0 No

if"Yes. " please attach to this registration a list of paid fund-raiser(s) or fund-raising counsel(s), including their full address, telephone number, fax number. registration number in New Jersey, and a contact person's name. 15a. Does the independent paid fund -raiser or fund-raising counsel have custody, control or access to the organization's funds?

O Yes If "Yes," please describe thesituation.


16. Has the organization permitted a charitable sales promotion to be conducted on its behalf by a commercial co-venturer during the fiscal year -end being reported? 0 Yes No If "Yes," please explain:

17. Has the Internal Revenue Service (I.R.S.) detennined that the organization is tax exempt under code 501(c)(3)? 1)51 Yes No 0 a. If"No," has an application been filed which is still pending? If so, please attach a copy of the
I.R.S. 1023 form filed. b. Has a tax exemption been granted under another I.R.S. code? If "Yes," advise which one: 3 c. Has an I.R.S. tax exemption been refused, changed or revoked? If an exemption has been refused, changed or revoked, attach to this registration a copy of the I.R.S. determination letter of notification and provide a detailed explanation of the circumstances on a separate sheet of paper. O Yes O Yes O Yes O No No No

Form CRI-


Page 2 of 7

ever , 18. Has the organization had its authority to conduct charitable activities denied, suspended or revoked in any jurisdiction or has the i Yes M No organization ever enterednto any voluntaryagreementof discontinuance with any governmentalentity?
If "Yes," attach to this registration a copy of the denial, document does not explain the reasons for the denial, separate sheet of paper. suspension , revocation or voluntary agreement of discontinuance. If the suspension or revocation, attach to this registration an explanation on a

19. Has the organization voluntarily entered into an assurance of voluntary compliance or similar order or agreement (including, but not limited to, a settlement of an administrative investigation or proceeding, with or without an admission of liability) with any jurisdiction, state federal agency or oficer? or f Yes IN No
If "Yes," please attach to this registration the relevant document.

or 20. Has the organization any of its present of ficers, directors, executive personnel or trustees ever been found to have engaged in unlawful practices in the solicitation of contributions or administration of charitable assets or been enjoined from soliciting , ? Yes KI No contributions or are such proceedings pending in this or any other jurisdiction If"Yes," attach to this registration photocopies of any and all written documentation as a court order (such , administrative order. judgment, fonnal notice written assurance or other document , ) which show the final disposition of the matter. or , 21. Has the organization any of its presentofficers, directors trustees or principal salaried executive staf f employees ever been convicted of any criminal offense committed in connection with the performance of activities regulated under this act or any criminal or civil of fense involving untruthfulness or dishonesty or any criminal fense relating adversely to the registrant's of fitness to perform activities regulatedby this Act? A plea of guilty, non vult, nolo contendere or any similar disposition . Yes K1 No of alleged criminalactivity shall be deemed a conviction
22. Has the organization or any of its officers , directors , trustees or principal salaried executive staf f employees been adjudged liable in any administrative or civil action involving theft , fraud, or deceptive business practices ? For purposes of this question a judgment of liability in an administrative or civil action shall include , but is not limited to, any finding or admission that the individual engaged in an unlawful practice in relation to the solicitation of contributions or the administration of charitable assets . Yes i No X If "Yes," identify the individual (s) below and attach to this registration a copy of any order, judgment or other documents indicating the final disposition of the matter.

23. Provide the following information for each of ficer, director, trustee and the five most-highly compensated executive staff employees:
Name Business address Telephone number (includearea code) Title Salary

N/A. Officers and Directors are not compensated.

Refer to attachment " List of Of ficers and Directors " for contact Information.

Form CRI

- 30OR

Page 3 of 7

CRI-300R Long -Form Registration Renewal Financial Statement

Note: If the financial value of a line hens = 0, place a zero in figures as GROSS, not NET the space provided.

Please report all Full legal name and street address of the organization

Full legal name: reast Cancer Survivors Foundation, Inc. B Fiscal year-end being reported: 12

/ 31 1 2010
dov cm

Federal [D Number (E1N, _

Mailing address: 443 E Westfield Ave Ste 1, Roselle Park, NJ 07204

Mali,, Ad ,u 'd P 0 tto' Nnmber er Sn Cq Scut 7IP coat

Street address of the registering organization: 443 E Westfield Ave Ste 1 , Roselle Park , NJ 07204
S M4 Addn s Gov sue ZIP Cods

New Jersey Charities Registration number: CH 33145


Telephone number: 908-241-2288

(lr,clydra'r C drl

Attach to this registration the most recent Internal Revenue Service Form 990 and ScheduleA (990). if the organization has filed those organization's annual financial repor t included an audited financial statement, or if the organization forms. Attach a copy if the received gross revenue in excess of $250,000. Note: l i t h e organization received gross revenue of less than $250.000. the financial reports must be certified by the organization's president or other authorized officer of the organization's board. ( i In lieu ofcompleting the CRI-300R Financial Statement pages. attached please find a copy of die LR.S. 990 filing for the fiscal year-end indicated above.

A. Receipts
Line A la. Direct Public Support received from the following sources:

(I) (2)
(3) (4) (5) (6) (7) (8) (9) (10) (I 1) Line A l b. Total Direct Publ

Direct mail ................................................. Telephone solicitation .....................................

Commercial co-venture ................................... Gross receipts from fund-raising events ............... Canisters, counter cards, door to door etc ............. Corporations and other businesses ...................... Foundations and tnists .................................... Donated land, buildings, property, equipment and materials .............. __ ........ ....... Legacies and bequests .................................... Membership dues solely resulting from solicitations .................................................. Other support (specify) ..... . ... . . . ........................

IRS 990 Is attached


ic Support (add lines Ala ( ]) through A l a(I 1) ......

Line A l e. Indirect Public Support received from the followingsources:

(1) (2) (3) Federated fund -raising organization .................... From an affiliated organization ... ....................... From another fund- raising organization ..... . .......... (add lines Alc(i) thru A I c(3))...........

Line A I d. Total Indirect Public Support

Line Ale Total Gross Contributions (add lines A i b and A Id) ..................

Form CRI-


Page 4 of 7

d . ......................................................................... Line Ale. Total Government Grants (add lines 2a thru2d) ............................ Line A3. Other Support

Line A2. Government grants including purchase of service contracts (specify agency) a . ......................................................................... b. ......................................................................... c.

a. b. c. d.

Bonafide membership .............................................. Program service revenue ............................................ Professional services rendered by volunteers .................. Miscellaneous income (specify) ..................................

Line.43e. Total Other Support (add the total lines A3a thru A3d) ................ of Line A4. Total Gross Revenue (add lines Ale, Ate and A3e) .....................

B. Expenses
Line BI. Line B2. Line B3. Line B4. Line B5. Program expenses .......................................................... Management and general expenses ...................................... Fund-raising expenses ..................................................... Payments to state/national affiliates (if applicable) .................... Total Expenses (add the totals of line B I thru B4) ......


C. Excess or Deficit
For the fiscal year-end (subtract line B5 from line A4) ........ .......................

D. Fund Balance
Line DI. Line D2. Line D3. of Net assets or fund balances at beginningyear ................... Otherchanges in net assets or fund balances explanation)..... (attach of yearCombine line DI and D2) ... ( C, Net assets or fund balances at end

Please Note: The amount of Gross Contributions ( line Ale on this form) determines the registration fee which must be paid and the form which should be used. July 2006 revisions to the Charities Registration Act now require all charities to pay a registration fee, including charities whose Gross Contributions are less than $10,000. Further information for charity registrants may be found on our Web site: Unp//www niconsumeraf fairs gov/ocp/charities htm

Form CRI-300R

Page 5 of 7

Long-Form Renewal Registration Statement Form CRI-300RC Confidential Information

Organization's Name: Breast Cancer Survivors Fo undation, Inc. N.J. Charities Registration Number: CH - 33145 Fiscal Year-End being reported: 12
m th


Federal ID Number (EIN,

/_ 31

i 2010


Are any of the organization's of ficers. directors, trustees or the five most-highly compensated employees related by blood, marriage or adoption to:
a. b. each other? Yes 9 No any officers, agents or employees of any fund-raising counsel or independent paid fund-raiser under contract to the organization? Yes IN No


d. 25.

any chief executive, employee, any other employee of the organization with a direct financial interest in the transaction, or any partner, proprietor, director, officer,trusteeor to any shareholder of the organization with more than two (2) , percent interest in any supplier or vendor providing goods or services to the organization? Ycs ig No If you answered "Yes." to questions 24a, b. or c, please provide a statement explaining these relationships.

Do any of the organization's officers, directors. trustees or the five most-highly compensated employees have a financial interest in any activities engaged in by a fund-raising counsel or independent paid fiindraiserunder contract to the organization, or any supplier or vendor providing goods or services to the organization? Yes 29 No
if "Yes." please detail these relationships below or on telephone num ber of all interested parties. a separate sheet of paper, and provide the name, business address and

We understand that this registration is being issued at the discretion of the Division of Consumer Affairs and agree that employees of the Division may inspect the records in the possession of this organization in order to ascertain compliance with the statute and all pertinent regulations. We also understand that we may be required to provide additional information if requested.

(s) and (s) . t We hereby certify that the above information and the attached financial schedule statement are true We are awarehat if any of the above statements are w l i lfully false we are sub to punishment leal , . e Yulius Poplyansky Title Pres Date Zhp Signature Signature .Qolr k2, ,'--` ame Marjorie Velasco Title Sec/of fic sare e 6-2/l

This form must be signed by two (2) authorised of

ficers of the

orguni:cuion . including rho: ciueffrnancial of cei:

Note : Form CRI-300RC

must be filed MJi1i Form CRI-3008.

Form CRI-300R

Page 6 of 7

Breast Cancer Survivors Foundation, Inc. Attachment referenced in question 6a


Responsible for Custody of Financial Records Yulius Poplyansky MD, President, Board Member 443 E Westfield Ave Ste 1 Roselle Park , NJ 07204 908-241-2288

Breast Cancer Survivors Foundation, Inc. Attachment referenced in question 12 List of States , Counties and Cities where Registered Alaska: Alaska Department Of Law, 1031 W. 4th Ave., Suite 200, Anchorage, AK 99501 Alabama: Consumer Affairs Section, 500 Dexter Avenue, Montgomery, AL 36130
Arkansas: Consumer Protection Division, 323 Center Street, 200 Tower Bldg, Little Rock, AR 72201 Arizona: Secretary of State-Charities Division, 1700 W. Washington St., 7th Floor, Phoenix, AZ 85007 California: Registry Of Charitable Trusts, 1300 1 Street, Suite 101, Sacramento, CA 95814 Colorado: Office Of The Secretary Of State, 1700 Broadway, Suite 300, Denver, CO 80290 Connecticut: Public Charities Unit, 165 Capitol Avenue, Hartford, CT 06106


Florida: Division Of Consumer Services, 2005 Apalachee Parkway. Tallahassee, FL 32399 GeorgiaOffice Of The Secretary Of State, 237 Coliseum Drive, , GA 31217 : Macon
Hawaii: Department of the Attorney General 425 Queen Street, Honolulu, HI 96813 , Illinois: Charitable Trust Bureau, 100 W. Randolph St., 11th Fl., Chicago, IL 60601 Kansas : Secretary Of State's Office, 120 S.W. 10th Ave., 1st Fl, Topeka, KS 66612 Kentucky: Consumer Protection Division, 1024 Capital Center Drive, Frankfort, KY 40601 Louisiana: Consumer Protection Section 1885 N. 3rd Street, Baton Rouge LA 70802 , , Massachusetts Public Charities Division 1 Ashburton Place Boston, MA 02108 : , , Maryland: Charitable Organization Division, 16 Francis Street, Annapolis, MD 21401 Maine: Office of Licensing and Regulation, 122 Northern Ave, Gardiner, ME 04345 Michigan: Charitable Trust Section , 690 Law Bldg , 525 W . Ottawa Street , Lansing , MI 48913 Minnesota: Office of the Attor General/Charities, 445 Minnesota Street, Suite 1200, St Paul, MN 55101 ney Mississippi Office Of The Secretary Of State, 700 North Street, Jackson, MS 39202-3024 : North Carolina: Secretary Of State, 2 South Salisbury Street, Raleigh, NC 27601 North Dakota: Secretary Of State, 600 East Boulevard , Bismarck, ND 58505 New Hampshire: Charitable Trusts Unit, 33 Capitol Street, Concord, NH 03301 New Jersey: Office of Consumer Protection, 124 Halsey Street, 7th Floor, Newark, NJ 07101 New Mexico: Office of the Attorney General, 111 Lomas Blvd., NW, Suite 300, Albuquerque, NM 87102 New York: Charities Bureau, 120 Broadway, New York, NY 10271 Ohio: Charitable Foundation Section, 150 E. Gay Steet, 23rd Floor, Columbus, OH 43215 Oklahoma: Oklahoma Secretary Of State, 2300 N. Lincoln Blvd., Room 101, Oklahoma City, OK 73105 Oregon: Department Of Justice, 1515 SW 5th Avenue, Suite 410, Portland, OR 97201 Pennsylvania: Bureau Of Charitable Organizations, 207 North Office Building, Harrisburg, PA 17120 Rhode Island: Charitable Organization Section 1511 Pontiac Ave, Bldg 69-1, Cranston, RI 02920 , South Carolina: Office Of The Attorney General, 1205 Pendleton Street, Ste 525, Columbia, SC 29201 Tennessee: Division Of Charitable Solicitations, 312 Rosa L. Parks Avenue, 8th Floor, Nashville, TN 37243 Utah: Division Of Consumer Protection, 160 East 300 South, Salt Lake City, UT 45804 Virginia: Office of Consumer Affairs, 102 Governor Street, Lower Level, Richmond, VA 23219 Washington: Charitable Solicitation Division, 801 Capitol Way South, Olympia, WA 98504 Wisconsin: Dept Of Regulation & Licensing, 1400 E. Washington Avenue, Madison, WI 53702 West Virginia: Office Of The Secretary Of State, 1900 Kanawha Blvd., East, Charleston, WV 25305

Breast Cancer Survivors Foundation, Inc. Attachment referenced in question List of Agreements Co-Venturers 15 & 16 , Professional Fundralsing


with Professional Fundraisers

Counsel , and/or Commerical

Outreach Calling 200 S. Virginia Street, 8th Floor,Reno, NV 89501 Term: 09-15-2010 to 09-14-2015

Breast Cancer Survivors Foundation, Inc. Attachment referenced in question 14 & 14a Statement of Charitable Purpose and Program Service Accomplishments


The purposes for which the Corporation is formed are to operate as a charitable and educational organization, to educate the public about breast cancer and the importance of early detection and self -examination to provide a ; forum for breast cancer survivors to convene and discuss issues related to breast cancer.

U} CY)

U ) N

0 O 0

0 0






310 W. 20TH STREET SUITE 300

KANSAS CITY, MISSOURI 64108 (816) 472-9000 FAX (8J6) 472-5000

July 15, 2011

Division of Consumer Affairs Charitable Registration & Investigation 124 Halsey Street, 7th Floor P.O. Box 45021 Newark, NJ 07101


Breast Cancer Survivors Foundation Inc. ,

Registration Number: CH3314500

Dear Sir/Madam: Enclosed please find the above organization's completed Long Form Renewal Registration Statement CRI-300R and $ 150 filing fee. Accompanying this registration is the organization's IRS 990 and audit for fiscal year ended December 31, 2010. Please be advised that Breast Cancer Survivors Foundation received an infusion of capital through donations and related fundraising in late 2010 soon af its formation and prior to implementation of its charitable ter , programs before the end of its initial fiscal year. Program service accomplishments commenced in 2011.

Thank you in advance for your assistance. Should you have any questions or comments concerning this matter, feel free to contact me.
Kind Regards,

Stephanie Wetschensky Legal Assistant For the Firm


D.C. OKcr: 1900 L STREET. SUITE 215. WASHINGTON. D.C. 20036 (202) 861-0740 FAX (202) 331-9841 E-MAIL co, Washington

26W1 Forrna


1 RetL -...of Organization Exempt From It? " - Tne Tax

Under soctton _1(c), 527, or 4947(a)(1) of the Internal Revenue Cow (except black lung benefit trust or private foundation) The organization may have to use a copy of this return to satisfy s tate reporting (equirements.
andendin D

N t 1 01

Department of the Treasury Internal Revenue Service A

a "1

totF' LBF3 C

For the 20'10 calendar year, or tax Year begInning

B ova a apdroehie.C Name of organization :_I Adeasaclings Nance f-hmalydummania i7 ` Tearwiat return Doing Buslaess As


Employer Identllcetlon number

Nunr and street forP.O. box It mail is not dekveied sheet address) iar to 443 EAST WES 'TFIELD AVENUE City or town, state countr , and ZIP 4 or y ROSELLE PARK

Telephone number

NJ 07204
H(a) Is Ussap H(b) Are all t

_.j an**Ad

GCsatr ns ocar
oup sax. far Mom? 01 ffifrates roil dad? Ll

Yes Yes No No

F Name and address of principal offuer: YULIUS POPLYANSKY, MD


I J K Tax-exem status pt webalte:) '
Fern d

NJ 07204
I _-t e9e7(a 1) w - ) 527

If -N >.' attach a list (see insinutioni)

501 c 3J .1 1 50lic)

) 4_f,nsen no.

loo A t CapaareI I _ I Trust i.... ( A7a0taUan l i I Vllld

{ H(c) Group exemption number

' S PURPOSE. ............... .......

srnr a gmaluon

" .v

a v

1 rn


c w w w ww.+a

1 Briefly describe the organization 's mission or most significant activities


.. .......



... .

2 Chock this box 1 J } if the organization discontinued its operations or disposed of more t
C7 3 _ Number of voting members of the governing body (Pan Vt, line is) ..... .. ., .. . .

han 25% of its net assets.

........ ......... .

4 Number of independent voting members of the governing body (Part VI, line 1b) 5 Total number of individuals employed in calendar year 2010 (Part V. line 2a) 6 Total number oflunteers (estimate If necessary vo ) 7a Total unrelated business revenue from Part VIII. columnline 12 (C),
b Net unrelated business taxable income from Fonn 990-T , line 34 ...

5 6 .. ... .... .... Prior Year 7a

2 2
0 0

Currant Year

m C

8 Contributions and grants V ill, line 1h) (Part ....... . . . 9 Program service revenue (Pan VIII, lute 2g) 10 Investment income (Part Vill. column (A). lines 3 . 4, and 7d) 11 Other revenue (Part Vill column (A). lines 5 . 6d. Se . 9c. lOc, and 1 le) . 12 Total revenue - add lines 8 through 11 must uaf Part Villcolumn A 13 Grants and similar amounts paid (Part IX. column (A), lines 1 - 3)
14 Benefits paid to or for members ( Part IX , column (A), line 4)

. . . . . .. , . , ,

53 1 ,041

fine 12 )



, employee benefits (Part IX, column(A), lines 5-10) 15 Salaries other compensation
, 16* Professional fundraising tees (Part IX, column (A), line 11e ) b Total fundralrring expenses (Part IX , column ( D), line 25) 47 8 , 918

47 8
cl og` ' ;T >e ` ... ^z


17 Other expenses (Part IX column (A). lines 1 la - ltd, 111-241) , 18 Total expensesAdd lines 13 17 (must equal Part IX, column. _ line 25) . . (A). , .. , , 19 Revenue less exenses. Subtract line 18fromline 12 p 20 Total assets (Part X line 16) , 21 Total liabilities (Part Xi tine 26 ) . .... .. 22 Net assets or fund balances ubtract line 21 from line 20 S
# ItV , Qt-4.- Rle.,.4 , I declare that I nave examined this roiurn Oeclaralion of preparer , inciudrtg aocompanying ichadules and statements . and to the Hest of my knowledge


.. . ... ...
inn in d CurrenYear t

'ss 41,E <<< 193 479,111 51 , 930 51,930 0

End of Year

. . . . . . .... . . . 0

51 , 930
and beli ef. if is

Underpenakies of perjury true, cor rect and complete

(other than of ficer ) is based on all lydormadorl of which prepaler has any knowledge.

Sign Here

Signature of officer


YULIUS POPLYANSKY, MD Type or print name and title

Print/Type preparers name Prepar Cs signature y

...._.`D ale 5/09/11
Check ( ., it KIN vnn,

Paid EDNOND BRADY Preparer rFirmsname 0 Use Only

seIl emp loyed

Fame address / May the IRS discuss this return with the preparer

shown above ? ( see instructions ) . .. , see the separate instructions

Firm's FIN

Pho no ne .
. - .. .


Yes j i No Form 990 (2010)

For Paperwork Reduction Act Notice DAA

2 0601 05MM92011 422 PU

Form 990 2010 BREAST CANCER S'L _,VIVORS FOUNDATION , .. Statement of Program Service Accomplishments Check if Schedule 0 contains a response to any question in this Part III 1 Briery desafbe the orgentzation 's mission:

page 2




Did the organization undertake any significant program services during the year

which were

not fisted on the

prior Form 990 or 990-EZ? 3 If "Yes,' describe these new services on Schedule 0. Did the organization cease conducting , or make significant changes in how it conducts , any program services? ..... . If 'Yes ," describe these changes on Schedule 0. Describe the exempt purpose achievements for each of the organization's three largest program services by expenses . Section 501(c )(3) and 501(c)(4 ) organizations and section 4947(a )(1) trusts are required to report the amount of grants and allocations to others , the total expenses , and revenue, i1 any, for each program service reported.

( . Yes [XI No

[ "' I Yes [Xf No


5 31

0 41

4b (Code:

) (Expenses $

, including grants of S

) (Revenue $

4c (Code: ,

) (Expenses $

including grants of S

(Revenue $

. . )

4d Other program services (Describe in Schedule 0.) (Expenses S including grants of S 4e Total program service expanses 111DM

)_(Revenue S

Form 990(2010)

21601 05109, 201 1 412 PM

Form 990 2010 BREAST CANCER S. _ VIVORS 4T ._ ( .(Q Chec klist of Required Schedules
1 2 3


Page 3
Yes No

is the organization described in section 501 (c)(3) or 4947 (a)(1) (other than a private foundation)? If'Yes, complete Schedule A .. ..... ...... ...................... Is the organization required to complete Schedule B. Schedule of Contributors ? (see instructions) ...... .................... Did the organization engage In direct or indirect political campaign activities on behalf of or in opposition to ..... ........................ , or have a section 501(h)



candidates for public office "Yes," complete Schedule C, Part ? If I .. 4 ' Section 501 (cX3) organizations. Did the organization engage in lobbying activities ,' election in effect during the tax year? If "Yes complete Schedule C, Part 11
5 is the organization a section 501 assessments Pert III 6 (cX4), 501 ( c)(5), or 501 , or similar amounts as defined in Revenue Procedure 90.19? If 'Yes

. . .. ...... ( c)(8) organization that receives membership dues. ," complete Schedule C,

? If'Yes;

Did the organization maintain any donor advised funds or any similar funds or accounts where donors have the right to provide advice on the distribution or investment of amounts In such funds or accounts complete Schedule D, Part I

7 8

.................................... .. easements to preserve open space. ............................... Did the organization receive or hold a conservation easement , including... the environment. historic [and areas , or historic structures ? ii'Yes; complete Schedule D. Pan II Did the organization maintain collections of worsts of art, historical treasures , or other similar assets ? If 'Yes,' complete Schedule O, Part ill
Did the organization report an amount in Part X complete Schedule D , Part IV







. fine 21 : serve as a custodian for .................................. amounts not listed in... ...... Part , credit repair, or debt negotiation services? If 'Yes,' , fold assets in term, permanent , or quasi.


X: or provide credit counseling , debt management 10 Did the organization

, directly or through a related organization

10 F.


endowments ? If -Yes,' complete Schedule D, Pan V 11 if the organization 's answer to any of the following questions ......................... ..................................... is'Yea; then complete Schedule D , Parts VI,

a b c d e f

ViU, VI1l. IX, or X as applicable. Did the organization report an amount for land, buildingsequipment in Part X. line 107 if 'Yes," , and complete Schedule 0, Part VI Did the organization report an amount for investments - other securities in Pan X , fine 12 that is 5% or more of its total assets reported Part X, line 16? It "Yes.' complete Schedule D. Part VII in Did the organization report an amount for Investments - program related in Part .X line 13 that is 5% or more of its total assets reported In Part X 16? If 'Yes.' complete Schedule Part VIII , line "D, Did the organization report an amount for other assetsin Pan X. fine 15 that is 5% or moreof its total assets reported in PaX , tine 18? If rt "Yes," complete Schedule D, Part IX Did the organization report an amount for other liabilities in Part X. fine 257 it'Yes,' complete Schedule D. Part X Did the organization's separate or consolidated financial statements for the lax year include a footnote that addresses .....
the organization 's liability for uncertain tax positions under FIN 48 Old the organization obtain separate , independent audited financ Schedule D, Parts X1 , XI1, and XIII .. _ . _ .. , , ( ASC 740 )? If -Yes." complete Schedule 0, Part X ial statements for the tax year? if ' Yes' complete



tic lid .......... lie


12a 12b 13
14a 14b


b 13 14a b 15 16 17 18 19

Was the organization included In consolidated . independent audited financial statements for the tax year? If 'Yes if .' and the organization answered "No " to line 12a , then completing Schedule D . Parts XI, XII, and X1ll is optional Is the organization a school described in section 170 (b)(1)(AXIi)7 tt 'Yes. complete Schedule E ' ........... .... ......... Did the organization maintain an office, employees , or agents outside of the United States? ,000 from grantmatcing, fundraising, Did the organization have aggregate revenues or expenses of more than $10 business , and program service activities outside the United States ? It 'Yes,' complete Schedule F. Parts I and IV ............... Did the organization report on Part IX, column (A), line 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 Did the organization report on Part IX. column (A), line 3 . more than $5,000 of aggregate grants of assistance to individuals located outside the United States ? If 'Yes,' complete Schedule . Parts III and IV F . ... .......... Did the organization report a total of more than $15of expenses for professional fundraising services on........ ,000 , Part IX column (A), lines 6 and Ile? if 'Yes ,' complete Schedule G. Part t (see instructions) Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII lines 1c and 8e if 'Yes,' complete Schedule GPart 11 , ? , . .......... .. on .... . line 9a? Did the organization report more than $15,000 of gross income from gaming activities.. .Pan V ill, ..............

15 16 17 18 19 20a





If 'Yes,' complete Schedule .G Part III 20a Did the organization operate one or more hospitals? II "Yes," complete Schedule H b If "Yes to line 20a did the organization attach its audited financial statements to this return Some " , ? Note. Form 990 Clers that operate one or more hospitals must attach audited financial statements (see ins tructionsZ .


Form 990 (zoio)

2t36Q 1 QS/Qgr2Q 1 f 4:22 PM

Form 990 2010 BREAST CANCER SL -.+IIVORS FOUNDATION aatn Checklist of Required Schedules (continued)
21 22 23 Did the organization reportmore than $5 ,000 of grants and other assistance to governments and organizations in the United States on Part IX , column (A), line 1? If "Yes." complete Schedule I, Parts I and II . the United States Did the organization report more than $5 of grants and other assistance to individuals in ........................ ,000 on Part IX, column(A), line 2? If' Yes,' complete Schedule 1, Parts I and III Did the organization answer'Yes Part VII, Section A, line,3 or 5 about compensation of the " to 4, organization 's current and former officers. directors, trustees , key employees . and highest compensated employees It 'Yes," complete Schedule .1 ? ............................................................ .................... Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100.000 as of the lass day of the year was issued after December 31, 2002 'Yes,' answer lines 24b , that ? If through 24d and complete Schedule If "No ; go to One 25 . K ... ....... . ................... ................... Did (he organization invest any proceeds of tax -exempt bonds beyond a temporary period exceptton2 .... .

Page 4


C Did the organization maintain an escrow account other than a refunding escrow at any time during the year to defease any tax -exempt bonds? d Did the organization act as an behalf or Issuer for bonds outstanding at any time during the year? i on ......... 25a Section 501(cX3) and 501 (c}(4) organizations . Did the organization engage in an excess benefit transaction b with a disqualified person during the year? I( complete Schedule L, Pan 1 ' Yes, ... .. ............................... Is the organization are that if engaged In an excess benefit transaction with a disqualified person in a prior year. and that the transaction has not been reported on any of the organization 's prior Forms 990 or 990-EZ? It "Yes; complete Schedule L, Part I ................ Was a loan to or by a current or former officer , director , ....................... trustee, key employee , highly compensated employee, or disqualified person outstanding as of the and of the organization 's tax year? It 'Yes." complete Schedule L . Pail if Did the organization provide a grant or other assistance to art officer , director, trustee , key employee, substantial contributor . or a grant selection committee member , or to a person related to such an Individual? If 'Yes,` complete Schedule L, Part III . .. . Was the organization a par ty to a business transaction with one of the following parflas (see Schedule L. Part IV instructions for applicable filing thresholds conditions, and exceptions). ,
a b A current or former officer , director, trustee , or key employee') It "Yes," complete Schedule L. Parl IV .. .. A family member of a current or former officer, direc tor, trustee, or key employee? If "Yes," complete

.. .......... . ......

26 27



Schedule L. Pan IV
C An entity of which a current or former officer , director , trustee , or key employee for a family member thereof) was an officer, director, trustee, or direct or indirect owner? If 'Yes,' complete Schedule L, Part IV

29 30

Did the organization receive more than $25 .000 in non-cash contributlons9 Ii'Yes; complete Schedule M Did the organization receive contributions of an , historical treasures , or other similar assets . or qualified conservation contributions
Did the organization liquidate Part I

....... ............

? If 'Yes," complete Schedule M

, terminate ............ , or dissolve and cease operations . ........

.. .......... .... ? If "Yes," complete Schedule N,

32 33

Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets') If'Yes " complete Schedule N, Part II Did the organization own 100% of an entity disregardedas separatefrom the organization under Regulations sections 301.7701-2 and 301.7701.3? If 'Yes,' complete Schedule R, Part I
Was the organization related to any tax-exempt or taxable entity IV, and V, line 1 .... . Is any related organization a controlled entity within the meaning of section 512 ......... ... .......... ......... ? If "Yes; complete Schedule R , Parts it. Ill. ( b)(13)? ... ... ............


Did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b
Pan V, fine 2

)(13)? If "Yes ,- complete Schedule R,

I Yes N. .


Section 501

( c)(3) organizations

. Did the organization make any transfers to an exempt non-charitable , Part V, line 2

related organization ? If 'Yes,' complete Schedule R



Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income lax purposes complete Schedule R, ? If'Yes' Part VI O for Pan VI, lines 11 and Did the organization complete Schedule D and provide explanations in Schedule 197 Note. All Form 990 filers are required to complete Schedule l? .

21801 0510912011 4:48 PM

Form990 2010 BREAST




Page 5 ..............

la b c 2a b 3a b 4a


Statements Regarding Other IRS Filings and Tax Compliance Check if Schedule 0 contains a response to any question in this Part V
. ,., I 1

Enter the number reported in Boxof Form 1098. Enter -0- if not applicable 3 Enter the number of Forms W -213 Included in line la. Enter -0- if not applicable

. Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling ) winnings to prize winners? Enter the number of employees reported on Form W -3, Transmittal of Wage and Tax Statements filed for the calendar year , ending with or within the year coveredby this return If at least one is reported on fine 2a, did the organization

L 1b .


file all required federal employment tax returns?

Note. If the sum of lines to and 2a is greater than you may be required to a-rite (see instructions) 250, . Did the organization have unrelated business gross income of $1,000 or more during the year? It Yes,' has it filed a Form 990 -T for this year? If 'No ,' provide an explanation In Schedule 0 ............... At any time during the calendar year , did the organization have an Interest in, or a signature or other authority ............. 3b

b 5a b c $a b 7 a

over, a financial account in a foreign country (such as a bank account , securities account, or other financial account)? ......... .. .... .... . ... ..... ................. .............. ........... .. . .... II"Yes: enter the name of the foreign country: ...... .......... ......... See instructions for filing requirements for Form TO F 90 . 22.1, Report of Foreign Bank and Financial Accounts. Was the organization a party to a prohibited tax shelter Iransectiany lime during the tax year? _ ,_ , on at , Did any taxable party notify the organization that it was or is a party to a prohibted tax shelter transaction? .. If -Yes to line 5a or 5bdid the organization file Form 8886-T? ' , Does the organization have annual grossreceipts that are normally greater than $100 .000, and did the organization solicit any contributions that were not tax deductible? .... If Yes,' did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible ? .. .. ......... . ............





........ ....

. , . .....

Organizations that may receive deductible contributions under section 170(c). Did the organization receive a payment In excess of S75 made partly as a contribution and partly for goods 7a

and services provided to the payor? .......... . to If 'Yes,' did the organization notify 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 if was required to file Form 8282? .... ! d If 'Yes,' indicate the number of Forms 8282 filed during the year + 7d L a I g 8 ...... ......... , Did the-organization receive any funds , directly or Indirectly to pay premiums on a personal benefit contract? ... ................. Did the organization , during the year. pay premiums , directly or indirec , on a personal benerd contract? tly if the organization received a contribution of qualified intellectual property , did the organization file Form 8899 as required?


In if the organization received a contribution of cars . boats , airplanes , or other vehicles, did the organization file a Form 1098-C? (aM3i supporting Sponsoring organizations maintaining donor advised funds and section 509 organizations . Did the supporting organization , or a donor advised fund maintained by a sponsoring organization . have excess business holdings at anytime during the year?

9 a b 10 a b 11 a b 12a b 13 a b c 14a b Dar

Sponsoring organizations maintaining donor advised funds. Did the organization make any taxable distributions under section 4966? Did the organization make a distribution to a donor , donor advisoror related person , Section 501(cX7) organizations Enter. . Initiation fees and capital contributions included on Part VIII, line 12 Gross receipts included on Form 990, Part VIII. line 12. for public use of club facilities , , , Section 501 fc)(12) organizations Enter: . Gross income from members or shareholders ...... . ... Gross income from other sources Do not net amounts due or paid other sources ( to againstamounts due or received from them.) 11 b Section 4947 (a)(1) nonexempt charitable trusts . Is the organization filing Form 990 in lieu of Form 1041? If'Yes ; enter the amount of lax-exempt interest received or accrued during the year . . . . . , .. , . , , ( 12b Section 501(c}(29) qualifiod nonprofit health Insurance Issuers. Is the organization licensed to Issue qualified healthplansin more than one state?
Note . See the instructions for additional information the organization must report on Schedule O.




Enter the amount of reserves the organization is required to maintain by the in which states Enter the amountis licensed to issue qualified plans .. . the organization of reserves on hand health ,,_, Did the organization receive any payments for Indoor tanning services during the tax year? If 'Yes,' has it filed a Form 720 to report these payments ? if "No," provide an exp lanation in Schedule 0

13c 13b

;ci+': <?.- tz


114b I I Form 990 (2010)

2860105/0917011 4:22 PM

Form 990 2014 BREAST




Governance, Management and Disclosure For each "Yes" response to lines 2 through 7b below, and for a , "No" response to line 8a , 8b, or I Ob below , describe the circumstances, processes , or changes in Schedule 0. See instructions. iXL Check if Schedule0 contains a response to any question this Part VI in Section A. Governing Body and Managem ent
Ia Enter the number of voting members of the governing body al the end of the tax year

b 2 3 4 5 6 7a b 8 a b 9

Enter the number of voting members included in line la. atmve, who are independent Old any officerdirector trustee or keyemployee have a family relationship or a business relationship , , , with any other officerdirector trustee or key employee? , , , Did the organization delegate control over management duties customarily performed by or under the direct

1 tb 1 2 t :sr 2 ...... r, { s

supervision ofiof , directors or trustees or key employees to a management ompany or other person? fcers , c Did the organization make any significant changes to its gover ning documents since the prior Form 990 was filed? Did the organization become aware during the year of a significant diversion of the organizations assets? ...... ... ...... ...... Does the organization have members or stockholders? ... .......... .. ..... Does the organization have members , stockholders , or other persons who may elect one or more members of the governing body? Are any decisions of the governing body subject to approval by members , stockholders , or other persons Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following; The governing body? Each committee with authority to act on behalf of the governing body? ..... Is there anyofficer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization mailing address If 'Yes,' provide the names and addresses in Schedule 0 's ?

Section B. Policies
10a b 11e
b 12a

(This Section B requests information about policies not required by the Internal Revenue Code


Does the organization have local chapters , branches , or affiliates? If 'Yes,' does the organization have written policies and procedures governing the activities of such chapters , affiliates, and branches to ensure their operations are consistent with those of the organization Has the organization provided a copy of this Form 990 to all members of its gover
form? Descnbe in Schedule 0 the

?. . ...._

. ......

ning body before filing the

. process , If any, used by the organization to review this Farm 990. . Does the organization have a written conflict of interest policy? It *No,' go to line 13

b c 13 14 15 a b
16a b

Are oficers, directors or trustees f , and key employees required to disclose annually Interests that could give rise to conflicts? ? 11 'Yes,' Does the organization regularly and consistently monitor and enforce compliance with the policy describe in Schedule 0 how this is done .. ........... ...................... Does the organization have a written whistleblower policy? Does the organization have a written document retention and destruction policy? Did (he process for determining compensation of the following persons include a review and approval by Independent persons , comparability data, and contemporaneous substantiation of the deliberation and decision? The organization CEO, Executive Directoror lop management official 's , Other officers or key employees of the organization
Did the organization invest in, contribute assets to with a taxable entity during the year? If 'Yes ,' has the organization adopted a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law oroauization's exempt status with respect to such arrangements? , and taken steps to safeguard the






If'Yes' to line 15a or 15b, describe the process in Schedule O. (See instructions.)
, or participate in a joint venture or similar arrangement

Section C. Disclosure
17 18 list tho states with which a copy of this Form 090 is required to be filed AK, AL , AR, AZ , CA, CO , CT, DE , DC, FL , GA, HI , IA (or 1024 it applicable ). 990- and 990 . 7 (501 (c )(3)s only ) available Section 6104 requires an organization to make its Forms 1023 for public inspection. Indicate how you make these available . Check all that apply. I j Own websrte J Another's website U Upon request
19 Describe in Schedule 0 whether (and if so , how), the organization makes its governing documents , conflict of Interest policy. and financial statements available to the public.


State the name , physical address , and telephone number of the person who possesses the books and records of the organization : i' PRESIDENT 443 EAST WESTFIELD





816-472-9000 Form 990 (2010)

28601 O509r1011 4'22 PM

Form 990 2010 BREAST V : 4t




Pape 7

Section A.

Compensation of Of ficers, Directors , Trustees , Key Employees , Highest Compensated Employees, and Independent Contractors Check if Schedule 0 contains a response to any question in this Part VII .. . . Officers Directors Trustees Kep F , . .mptoyees and Highest Compensated Em oyeas


1a Complete this table for all persona required to be listed . Report compensation for the calendar yearending with or within the organization tax year. . 's List all of the organlrallon's current officers , directors, trustees (whether individuals or organizations), regardless of amount of compensationEnter-0- in columns (0), (E), and if no compensation was paid. . (F)
List all of the organization 's current key employees , it any. See instrvcirons 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 (Box5 of Form W-2 and /or Box 7 of Form 1099-MISC) of more than $100,000 from the organization and any related organizations. List all 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. Lis[ all of the 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 In the following order : Individual trustees or directors : institutional trustees ; officers : key employees ; highest compensated employees : and former such persons.
o k.neCK lrlrs pox II neruler me Or

(A) Name and Tide

zason nor an (81 Averags

hours per week

releleo or

aruzallorls rpm

nsateo an

current unlc

er, wrecior

or ellalee.

Position (check at that apply )
o 2

(D) Reponaote

RepoftJble cornpensa don tram related

Erumated amount o f other compencahon Isom the

o= c 8' g

Itts orpanrzalion

(dccaibe a hours for Rrelated g x txganlzadomr

in Schedule

rgan zahona o (W2)1099 -MISC)


arganizahpn and rel ated organ itons z a



X 0 0 0



ElO iin MEM BE>7 tor)





112) (13)



Form 990 (2010)

28601 05J09i20114:22 PM

Form 990 a1o





-t_.,ployees (continued)
compensation fr om re la te d orgsrwzailons 2J1o99 . k11

Page 8 (E) (F)

Section A. Officers , Directors , T.,

Name and Titb

.ees , Key Employees , and Highest Compensated

Position(fr edk at that apply) i R'
o 3 o 'n


Average hours per o week e h r t deecnbo hours for related

_ q G

R 3 R

(0 ) Rbponabte compensation tram


Estimated amount of

(W211099 -MISC)



from the
organization and related organi ation. z

at Schedule

O) (17) (16} (18) (24) (21)

(23) 1 T

124) (26) (26)



Sub-total ................


, Section A . . . --

Total from continuation sheets to Part VII

d 2

Total add lines ib and 1c) .. Total number of individuals (including but not limited to thoselisted above ) who received more than $100,000 in reportab compensationfrom the organization 0 fe Did the organization list any former officer , director or trustee , key employee , or highest compensated employee on line 1o1 If'Yes ,' completeSchedule J tar such individual .. . For any individual listed online 1a , is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150 ,0007 it 'Yes.' complete Schedule J for such i ndrvrdual
.. ...................... ................................................................ Did any person listed on line is receive or accrue..... compensation from any unrelated organization or individual

3 4

for services rendered to the organization) If 'Yes' complete Schedule J for such person Section B. independent Contractors 1 Complete this table for yourfive highest compensated independent contractors that received mo ms than $100,000 of compensation from the organization. Name w4 buat) ileas - 41111 0 serr+ce: MAIL RESPONSE SERVICES LAKE HIAWATHA


( )saaan

144 N 07034



Total number of independent contractors

received more than

(i ncluding but not limited to those listed above

g anization

) who

in $100.000 com pen sation from the or

1 , 1,1 7 7 }% y gyp-: .= -

Form, 990 (2010)

2960105I09!2011 4:22 PM

Form 990(2010
b F yy eft

C4,hsmonf of Clnvan
r da sL z i ir a` E y k

1 r` r f i a rY

a s 'x ; s a s ,


OIL ) OI edo + exempt Junuwn revenue J 5 r s 33 S r `
F_r t 7

Page 9
(C) Unre1ted bunass revenue

u fl f
a ~ `


k r ` rr s: s f } ';


tt ; <rat Pa i s .. .,



rY' tr}x !? c , ` t r x3i r

eve (D) R f tCkrtled 6om tax urtdarseclbns 517- 513. or 514


1e Federated cam Pai


. t


b Membership dues ..... ,. c Fundralstng events d Related o r nizations a g

pj oft COrArwala , of , tyeot5 t

lb 1a id Is
531 ,04 1

< ,


( i> G

rf ?



r 3 4?

R fl s Y

, x sr s

t *

i M

rs tr yY kf
, {


m 3

GovemmaM wants (owirttnbns )

} f r ; (,

4t }i

c r > , pt 3 tr


z gx,r
_.p} f
{ lr



aid svnlsr srnaanN nd mWdfd abov e tf 9 lia mh eaWmube inducted in tinesto-it. s

y s a 53 1, 041 ,y ;,- .


r ;. &



k' ; ,
`' >. ,

h Total Add Iles 1x -11 2a b

Busn . Code

r :, :. C

i 3 G.^.!'4iyt'^i"4 .,a<'l, S i


3 4 5

......... . .


+ e .b't'+e.;n,>,s :i; "s "L.s ;)` "'z; ' Y-"jk^' S u d. "'J"%J9.;c3 3 t fE'.

IF All other program service revenue...... . ..

Total . Add lines 2a -2f

Investment income (including dividends, interest,

and other similar amounts)

Income from investment of tax-exempt bond proceeds Royalties .... ........ ..... ................
() Real (ii) Personal t;
3 0 ,

$a Gross Rents
b Lef fengtf t

c Rental me of l ( 7a Gram amount ktrn sarosdasses M* Thaninviinloq b Less eoslordM :

base uim v.M.

lZ ` 'l' 1f(1, 9ps t4-.. ..A\.

i41 % ^ S<. .. i .s
AY. _

' ' e'



d Net rental Inco e or loss m

(i) Securities


(il) Other
({ af' ;i

tfii t
N) t

6; s . r 7b

t'N Y

L 7K a,:
sS ' ,.}
(( R 55 + rk

p , S
t T; >

m c suit sh `C^3 t ' K c ja


`^ `i'

_ 's

it b Yn, .. "54 ^ a r L; Yk .tot f dfS

a3t kji
( `f F a

r -S. s e ir'r ?F s

{x x'

?1 ,
Y 1` iLl


{ N

' ^A ` `



f .S'b'r 3't y ' y

r i ,,L

c Gain or (loss) d Net gain or (tos) ........... s .. Be Groan frsoorrte from fundraising events
(notincluding $ of co trfbulsrns reported on 1C). We

,4 ?k [ s s t

C`$ (

p- , 3.



-i a t ' r (f'

t3Ea r'

tkF. tic ! . .o f


ss l t

= y


See Pan IV, tine 18

........ b Less : direct expenses ... c Net income or (loss ) from fundraisi

b events ..... , .


_ >..

;S r> 1


i& - g i 3'< z _. s'

't 'c -'ate i s t

Zl"j` s F' yP k s

9a Gross intorrte born gaming activities . See Part IV . has 19 a ....... b b Less direct expenses : c Net income or (loss ) from gaming ac tivities
10a Gross sales of inventory , less r eturns an d a llowances a . ..


n t;3 S

r )
" < ;.

N y afi .4Z f ,

A s i x<s:

d a tx$

r, 1

a p y t

43 3 e

r d' '

v Yt

Y ,,


c.iYW -.Y.
t k >

L x a.

F, t s


t t<

p . ,.o : ?
3r f

c, qq r

Xy ,


e xr

e .

t a.

t 5 x zy is


a '

b Less cost of goods sold ;

c Net income or floss ) from sales of invento Miscellaneous Revenue Busn. Code

11a b

d AN olnerrevenue 0 Total. Add Imes 11 a -lid 12



.. 531,041 a: `'

K F2 ? 0

>`? '

w> , F' a 0

r z ", s^

5:> 0

Form 990 (2010)

28601 06/09/201 1 4 22 PM

Form 99 (2010) 0




)(4) organizations must complete all columns. (A) but are not required to complete columns ( m proara serv ice expenses


Page 10

Statement of Functional Expenses

Section 501 (c)(3) and 501(e All other organizations must complete column ( B). (C), and (D). fundra ci ig fA) total e xpenses

Do not include amounts reported on fines fib, 7b $b 9b , and 10b of Part Vill. 1 2 3

Management and

ge nera( expenses 3 M zf ' f a',S } , , ' 'a (J,--

expenses r 1 :. " , r q i". r rr 1 rr

Grants and other assistance to governments and organizations in the See Part N, line 21 .S. U Grants and other assistance to Individuals in the U.S See Part N. fine 22 . Grants and other assistance to governments , organizationsand individuals outside , the U.S. See Part IV , tines 15 and 16 Benefits paid to or for members Compensation of current officers, directors. trustees and key employees , Compensation not induded to disqualified , above

4 5 6

persons defined under section 4958 1)) (as (f)( and

parsons described in section 4958 (cx3j(B) 7 8 9 10 11 Other salaries and wages Pension plan contributions section 401(k) ( nctrde and section 403(b ) employer contributions) Other employee benefits PayroN taxes ......... ............. Fees for ser vices (non-employees).. . .............. . ....


a Management

. . . . ..... .

b Legal
c Accounting

d Lobbying a Professional fundraising services 1V, line 17 . See Part

f g Investment management fees Other ....... .. ..... ....

4 7 8 918 , ' <:o` ii? bi'::d' ', tt z3 .+ z3 <. a , ? v


478 , 918

12 13

Advertising and promotion Office expenses

Information technology



15 1s 17 18 19 20 21 22 23 24

Royalties Occupancy .... .. Travel Payments of travel or entertainment expenses for any federaldate, or local public officials , Conlerences conventions , , and meetings Interest.......... . . ..... ........... Payments to affiliates Depreciation depletionand amortization . , Insurance i" ` Other expenses . ltemrze expenses not covered above (List miscellaneous expenses inIf . fine 241 ; line 241amount exceeds 10% 0l column line 25 , ^ (A) amount fine 24f expenses on Schedule , list 0.) 5:
i H ;N ; =t'$ ,

a t f

# !
a ,z c 3k; : ` *t {

} r `
's: .,

k> a x ,r r. ;

'` }

b c d I 25 26


cNARG ...... .......... Es

....... .. .



AN other expenses Total functional ex penses Add lines I throw . n 24f Joint costsChad here ' + i it following . SOP 96-2 (ASC 958-720).'Complete this line
only if the organization reported in column (B) joint costs from a combined educational cam al n and fundrais' solicitation . .

479, 111


4 7 8 , 918

Form990 (2010)

284101 05109/2011 4:72 PM

Form 990 (2010) BREAST ENU'l Balance sheet



(A) Beginning of year

Page 11 lf3) End of year 1 2 3

1 2 3

Cash-- non-interest bearing Savings and temporary cash investments Pledges and grants receivable, net ... .. . ...... . . .. ...
Y gx r s i# : ) l

4 5 ,854


Accounts receivable , nat

Receivables from current and former officers, directors, trustees, key

e r ) ?r ;s. - s

6 , 076
u ,

employees and highest compensated employees , . Complete Part 11f o Schedule L ..... .. . .... ... . . .. Receivables from other disqualified personsdefined under. section (as 4958(1)(1)), persons described in section 4958 (cx3)(B), and contributing employers and sponsorin organizations of section 501(c volunta g )(9) ry employees' beneficiary organizations Instructions) (see Notes and loans receivable, net
Inventories for sale or use



, `

+, ; }



7 g

9 Prepaid expenses and deferred charges '108 Land, buildings, and equipment: cost or other basisComplete Part Vi of Schedule D . b Less accumulated depreciation .
11 investments - publicy traded securities

.. 102 10b
... ....... .........

. .

... .. .. .. ... 11

12 13

lnvestments other securitiesSee Part IV, fine f f .

intangible assets


....... investments prograrr related See Part IV, line 11 >.

....................... ...

. ......



. . . ..

12 13

15 16 17 18
19 20

Other assetsSee Part IV, line 11 . Total assets . Add lines 1 through 15 (must e qual line 34 ............. Accounts payable and accrued expenses Grants payable ..... ..... ...... .... ... ......... Deferred revenue
Tax -exempt bond liabilities .. . .. ............

15 .... ... 0 16 17 18
19 20 Si tw

51 , 930

... ....


21 22

Escrow or custodial account lability . Complete Part 1V of Schedule D Payables to current and former officers . directors trustees key , . employees highest compensated employees disqualified persons , , and . Complete Part 11 of Schedule L Secured mortgages and notes payable to unrelated third parties Unsecured notes and loans payable to unrelated third parties Other liabilities Complete Part X of Schedule D Total liabilities Add lines 17 .
Organizations that follow SFAS 117

ro 23 24 25 26

21 1xb , 9 22 23 24 25 26



ugh 25
, check here iXj and complete c a; r f Y a


: t 3 }?rb y" 1 ;

CO 27 M


lines 27 through 29, and lines 33 and 34. Unrestricted net assets Temporarily restricted net assets
Permanently restricled,net assets

27 28

51 , 930


Organizations that do not follow SFAS 111, check here j

complete lines 30 through 34.

and s

s5 `

X s` l nk fa d 30
31 32

} i

3 F

. or xr 30 Capital stock or trust principal current funds

U% 31 32 Retained earnings

...... .... Paid-in or capital surplus , or land , building, or equipment fund ...............
, endowment , accumulated Income , or other funds

33 34

Total net assets or fund balances Total liabilities and net essets/fund balances ....



. ...

0 0

33 34

51 , 93 0

51 9 3 0
farm 990 [2010)

28601 05i 9120114 22 PM

Form 990 2010 BREAST





Page 12

Reconciliation of Net Assets

Check if Schedule 0 contains a response to any question in this Part X1. .

I 2 3 4 5 6 Total revenue(must equal Part III, column (A), line 12) V Total expenses (must equal Part )X column (A), line 25) , Revenue less expenses . Subtract line 2 from Mne 1 Net assets or fund balances at beginning of year (must equal Part X, line 33 , column (A)) ...... .... Other changes in net assets or fund balances (explain in Schedule 0) Net assets or fund balances at end year. Combine lines 3 4, and 5 (must equal of , Part X, line 33, column 8

1 2 4 6

531, 041 479,111 51,930


51, 930 Financial Statements and Reporting Check if Schedu le 0 conta ins a response to any question in this Part XII

Accounting method used to prepare the Form 990 '


iX1 Accrual

I . ; Other

If the organization changed its method of accounting from a prior year or checked 'Other ,' explain in Schedule O. 2s Were the organization's financial statements compiled or reviewed by an independent accountant? b Were the organization 's financial statements audited by an independent accountant?
c if `Yes' to line 2a or 2b , does the organization have a committee that assumes responsibility for oversight process , explain in of the audit Schedule O. d It 'Yes " to tine 2a of 2b issued on a separate basis , check a box below to indicate whether the financial statements for the year were , consolidated basis , o r both: , review , or compilatlon of Its financial statements and selection of an independent accountant? during the tax year

If the organization changed either Its oversight process or selection

lI separate basis Consolidated basis Both consolidated and separate basis 3a As a result of a federal award , was the organization required to undergoan audit or audits as setforth to the Single Audit Act and OMB Circular A-133?
b It'Yes' did the organization undergo the required audit or audits , exp lain etry in Schedule ? If the organization did not undergo the undergo such audits. required .auditor audits 0 a nd desc r be any steps taken to i

2B601(15 10912011 4:22 PM

SCHEDULE A (Form 990 or 990-F2)

Departrnenlol"treasury Intema, Revenue Servioe

Public' Charity Status and Public Support

Complete If the organization Is a section 501(c organization or a section }(3) 4947(2)(1) nonexempt charitable trust. Attach to Form 990 or Form 990-E2. See separateinstructions.

usme of th orgenizattoe BREAST e




F.....1..,.--',4-"ltcadon number

INC. Reason for Public Charity Status (All organizations must complete this part,) See instructions.
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)

1 " 2

A church, convention o(churches , or association of churches described in section 170(b)(1NA)(i). A school described In section 170(b )(1)(A)(Ii). (Attach Schedule E.)
A hospital or a cooperative hospital service organization described In section 'T0 (b)(1j(A}(iil).

4 lf

A medical research organization operated In conjunction with a hospital described In section 170(b )(1)(A)(ili). Enter the hospital's name, city,and state. An organization operated for the benefit of a college or university ownedor operated by a governmental unit described in section 170(b)(1)(A)(iv, (Complete Part 11.) )
A federal. state. or local government or governmental unit described in section 170 ( b)(i)(A)(v).


7 8

X An organization that normallyreceivesa substantial pail of its support from a governmental unit or from the general public described In sects n 170(b)(IXA)(vl). (Complete Part It.) tt t A community trust described in section 170 (b)(1)(A)fvI). (Complete Pan ii.)
14 , An organization that normally receives : ( 1) more than 33 113% of its support from contributions , membership fees, and gross ) from businesses receipts from achvilles related to its exempt functions-subject to certain exceptions support from gross investment income and unrelated business taxable income acquired by the organization after June 30 , 1975 . See section 509(s , and (2 ) no more than 33 113% of its ( less section 511 tax )(2). (Complete Part It.)

10 11

An organization organized and operated exclusively to test for public safety See section 609(x)(4). An organization organized and operatedexclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509 (a)(1) or section 509(a )(2). See section 509(a)(3). Check the box that describes the type of supporting organization and complete lines t 1e through 11 h. a [ ] Type l j Type hi Other b E_ J. Type Il c J._! Type Ill-Functionally integrated d By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or publicly more supported organizations described in section 509(a)(1) or section 509 (x)(2).
If the organization received a written determination from the IRS that it is a Type I. Type II, or Type ill supporting organization , check this box I i

.... Since August 17. 20M . has the organization accepted any gift or contribution from any of the

following persons?
(I) A person who directly or indirectly controls , either alone or together with persons described In (it) and _ 11 it of 11 ii .. .. ... (ull) Amount of support Yes No (iii) below , the governing body of the supported organization? (ii) A family member of a person described In (I) above (iii) A 35% controlled entity of a person described in (i) or (ii) above?


Provide the fill -

information about the su orled ill) Elk

anization s .

(i) Nam of supported organization

(R!) Type of orpenizalbn (described on lines 1-9 above at rRC section

(sae Instructions))

(WI) is die (iv) Is lie orgadzae ur (v) Did you notit / IM in In rd. 0) feted in your orgarora6on egs uizsen n ork mu lii your () agasged n the govemng doamte ? a d No Yes No Yes No Yes


(D) (E)
! a. .3 ` ,L , tic f,.rs} !3a



.. .."`

ear. ;?

)) . *J:z, 1 l yr E


w l..K-'a ,i" 'ki r


. .

i, r? .

`Y L sY

) < .. ?rry,,.n,

For Paperwork Reduction Act Notice Form 990 or 990-EZ.

, see the Instructions for

Schedule A (Form 990 or 990

-F2) 2010

28601 0&OD'2(it) 4.22 PM

Schedule A (Form 990 or990-EZ 2010 BRED.- 2 CANCER SURVIVORS FOUNDAZ _JN 'W 0 0" , # Support Schedule for Organizations Described in Sections 170(b )(1)(A)(iv) and 170(b)(1)(A)(vf)

Page 2

(Complete only If you checked the box on line 5, 7, or 8 of Part I or if the organization fared to qualify under Part III, If the organization fails to qualify under the tests listed below. please complete Part II1.) Section A. Public Su rt
Calendar yearor fiscal year beglnning,ln) ( 1 Gifts grants contributions, and , , membership fees received. (Do not Include any *unusual grants." ) Tax revenues levied the for organization benefit and either paid 's to or expended omits behalf The value ofservices or facilities , furnished by a governmental unit to the organization without charge
Tote I . Add lines l through 3 , , , . .... 531 0 41 531,041

a 2006

(b) 2007

(c) 2008

(d) 2009


(f) Total



. ection B Total Suppor t

7 Amounts from tine 4

The portion of total contributions by each person(other thena governmental unit or publicly supported organization ) Included on line 1 that exceeds 2% of the amount sho wn on Fne 11, column Public sir oft Subtract ilia 5 from line 4 .

`, L Z ``l t '. y t

3rd r

' s r

s ey k `;r r k'f 4,. ,

S r s

n I '

x ty

a : , z< x ,, ;

531,041 (t) Total


Calendayear(or fiscal r yearbeginning In)

8 Gross Income from interest , dividends, payments received on securities loans, rents, royalties and income from similar sources .. Net income from unrelated business activities whether or not the business , is regularly carried on ... ... . . . Other income Do not include gain or .
loss from the sate of capital assets (Explain in Part I V.) ............

(a) 2006

(b) 2007

(c) 2008

(d) 2009

le) 2010
531 , 041 1


11 12 13

Total support

Add lines 7 through 10 (see instructions)


Gross receipts from related activities, etc.


First five years . If the Form 990 is for the organization 's first, second , third, fourth. or fifth tax year as a section 501 (c)(3) organizationcheck this box and stop hero ,
Public support percentage for 2010 Public Su pport Percenta 33 1f3 % support test 2010 (line 6 , coiumm( t) divided by line 11, column A, Part it. line 14 did not check the box on line 13 , and line 14 is 33113 % or more , check this (1)) 14 15 100.00% d

Section C . Computation of Public Support Percentage

14 15 16a ge from 2009 Schedule . If the organization

box and stop here . The organization qualifies as a publicly supported organization b 17a 33 113%support test - 2009. If the organization did not check a box on line 13 or 16a , and line 15 is 33 113%or more. check this box and stop here . The organization qualifies aspublicly supportedorganization a 10% -facts-and-circumstances test--2010 . If the organization did not check a box on line 13, 18a . or 16b, and line 14 is 10% or more , and if the organization meets the -facts -and-arcumstances ' test, check this box and stop here . Explain in Part IV how the organization meets the "lads -and.circumstances ' test. The organization qualifies as a publicly supported b organization 10%-facts-and-clreumstences test-2009. If the organization not checka box on line 13. 16atab. or 17a, and line did ,
15 is 10% or more . and if the organization meets the'iacts organization meets the "facts check a -and-circumstances -and-circumstances box on line ' test, check " teal. The this box and stop here. as a publicly Explain in Part IV how the supported organization organization qualifies


L 13, 16a , 16b. 17a , or 17b. check this box and see


Private foundation , If the organiz ation did not


r Schedule A (Form 990 or 990 -E2) 2010


28601 05)09M 11 4:22 PM

Schedule A Forth 990or 990 2010 BRt3k . X CANCER -E2 SURVIVORS FOUNDAI _JN _ ,atffij Support Schedule for Organizations Descr ibed in Section 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization failed to quality under Part II. If the organization fails to qualify under the tests listed below, please complete Part 11.)

Page 3

Section A . Public Su pp ort

Calendar year fiscal year beginning In) (or 1 2 (a) 2006 b 2007 (c) 2008 d) 2009 (e 2010 (f) Total Gifs, grants r s t . cont n u b i o t , and membership fees received not include any 'unusual . (Do grants .' . ... .. . .. .. . .... . ... .. . Gross receipts admissions from , merdtandise sold tservices performed , or facilities furnished in any activity that is related to the organization 's tax-exempt purpose ...... .. Gross receipts from aclnities that are not an unr elated Veda or business under section 513
Tax revenues levied for the


organization benefit and either paid 's

to or expended on its behalf

The value of services or facilities

furnished by a governmental unit to the

organization without charge.

8 Total. Add lines 1 t hrough 5


Amounts included on lines2, and 3 , 1 received from disqualified persons

to Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1 % 01 the amount on line 13 for the year c Add lines 7a and 7b 8 Public support(Subtract tine 7c from t x a3 line B .

$ c


Section B . Total Support

Calendar year(or fiscal year beginning In) 9 T Amounts from fine 8 10a Gross income from interest , dividends, payments received on securities , rents, loans royalties and moms (mm similar _ . . sources b Unrelated business taxable income (less section 511 taxesfrom businesses ) acquired after June 30, 1975 .... ..... Net incomerom unrelated business f
activities not includedhe 10b , whether in t or not the business is regularly canted on 12 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)

Lx t # 'x i sr 'r4= la . iF m f+iN k ? , j '')f , gt' #,t .b Z," i e: g ;^ .F

f Y ,

r r} ` r

l f

# :'fie S b ")^a 'D" '.c & arT

) t mac j F<yyL


b 2007

(c) 2008

(dl 2009

(a) 2010


c 11

Add lines 10a and 1Db

13 14

Total Support (Add lines 9, loc. 11, . and 12.) First five years . If the Form 990 is for the organization 's first, second , (hird, fourth, or fifth tax year as a section 50l fc)(3) organization, check this box and stop here

Section C
15 16
17 18

. Com p utation of Public Su

pp ort Percenta


0, i 1
17 18 %

Public support percentage for 2010 (fine 8. column (f) divided by line 13, column (I)) Public supportpercentagefrom 2009 Schedule A, Part ill, line 15

Section D. Com

p utation of Investment Income Percenta

percentage fom 2009 Schedule A r . Part 111, line 17


investment income percentage Investment income 33 113 % support tests-2010 33 113 .6 support tests Private foundation

for 2010 lithe lDc. column ff) divided by line 13. Column (1)) . If the organization did not check the box on it" id, and line 15 is more than 33 113 %. and tine

19a b 20

17 is not more than 33 113%, check this box and stop here . The organization qualifies as a publicly supported organization
-- 2009 . If the organization did not check a box on line 14 or kne 199 , and line 18 is more than 33 1 /3%. and ion tine 18 Is not more than 33 113% . check this box and stop here . The organization qualities as a publicly supported organizat

_ Li

, it the organization did not check a box on line 14, 19a, or 19b. check this box and see instructions

E' 1

Schedule A (Form 990or 990-EZ) 2010

2860) 05109l2O114.22 PM

Schedule A Forth 990 or990 2010 BR&_ i CANCER SURVIVORS EZ FOUNDAI _JN Supplemental Information . Complete this part to provide the explanations required by Part it, line 10;

Page 4

Part It, line 17a or 17b; and Part III, line 12. Also complete this part for any additional information. (See instructions).


Schaduie A (Forth 990 or 990.EZ) 2010

2806105 +091201 i 1.22 PM SCHE RULE D (Form 990) Depwlmanr of the Treasury Internet Revenue Service
Nam" of th e organizadon

Lpplementai Financial Staterii, I-hits

Complete N the organization answered " Yes," to Form 990, Part IV , line 6, 7 , 8.9,10 , 11. or 12.

OM9 No. 1545.0047

i! Attach to Form 990. i See separate Instructions.

2010 : 3,tIbIid
Employerldentflcation number







Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV , fine 6.
(a) Donor advised funds (b) Funds and other accounts

I 2 3 4 5

Total number of and of year .......... Aggregatecontributions to (during year)......... .... Aggregate grants from (duringyear)

.. ......... . ................

Aggregate value at of year end ........ . Did the organization inform at donors and donor advisors writing that theassetsheld in donor advised in funds arethe organization property, subject to the organization 's 's exclusive legal control?
Did the organization inform all grantees , donors , and donor advisors at writing that grant funds can be used only for charitable purposes and not for the benefit of the donor or donor advisor , or for any other purpose I i Yes 1 I No

conferring impermissible private benefit?


Conservation Easements Complete if the organization answered "Yes" to Form 990, Part IV, line 7
important land area

I 1 Yea O r


Purpose( s) of conservation easements hetd by the organization (check all that apply). rl Preservation of land for public use (e.g., recreation or education ) Preservation of an hlsrorically Protection of natural habitat Preservation of open space Preservation o( a certi

fied historic structure

Complete lines 2a t hrough 2d if the organization held a qualified conservation contribution In the form of a conservation easement on the last day of the tax year. Held at the End of the Tax Year

a Total number of conservationeasements

b Total acreage restricted by conservation easements included in (c) acquired after 8117106, . , transferred , released , extinguished .....

24 2b

c Number of conservation easements on a certified historic structure included in (a)

d Number of conservation easements hislwlc structure listed 3 tax year 4 Number of states where property subject to conservation easement is located Number of conservation'easements modified and not on a in the National Register

, or terminated by the organization during the

1 2d


Does the organization have a written policy regarding the periodic monitoring
violations , and enforcement of the conservation easements if holds? Staff and volunteer hours devoted to monitoring, inspecting

, inspection , handling of
ii . you l : No

, and enforcing conservation easements during the year

7 8 9

Amount of expenses incurred in monitoring 5

, inspecting , and enforcing conservation-easements during the year

Does each conservation easement reported on line 2(d) above satisfy the requirements section 1701h)(4)(B) of (i) and section 170(h)(4)(B)( u)? In Part XIV, describe how the organization reports conservation easements in its revenue and expense statement, and balance sheet . and include, it applicable, the feat of the footnote to the organization's financial statements that describesdhe organization accounting for conservation easements. 's

_i Yes

err 4 1 >

organizations Maintaining Collections of Art, Historical Complete if the organization answered 'Yes" to Form 990
, as permitted under SFAS 116 (ASC 958 . or other similar assets held for public exhibition

Treasures , or Other Similar , Part IV , line 8

in furtherance of


1a It the organization elected

). not to report In its revenue statement and balance sheet , education , or research that describes these Items.

works of art, historical treasures b if the organization elected

public servi e, provide , in Part XIV, the , as permitted

text of the footnote to its financial statements under SFAS 1 16 (ASC 958), to report assets held for public

in its revenue statement and balance sheet in furtherance of

works of art, historical treasures (i)

, or other similar

exhibition , education, or research

public service , provide the following amounts relating to these Items: Revenues included in Form 990, Pan Vill. line 1 (11) Assets included in Form 990, Part X

s 2 If the organization received or held works,of art historical treasures other similar assets for financial gain, provide the , or
following amounts required to be reported SFAS 1 18 (ASC9S8) relating to these items: under a Revenuesncluded in Form 990Part Vill line t i ,
D Assets rnauoeo In corm 990 , Part X Reduction Act Notiea , See the Instructions for Form 990. For Paperwork OAA

Schedule D (Form 990) 2010

28801 03109/20114 22 PM

,. Schedu le D Fam 990 2010 I.;g3 ar . 3 BREAST C

. .::ER


Organizations Maintaining Collections of Art, Historical Treasures , or Other Similar Assets (continued)
. and other records , check any of the following that are a significant use of its

Using the organization 's acquisition , accession collection Items (check aft that apply):

a I I Pub9c exhibition b t` Scholarly research c 4 5

d e

Loan or exchange programs Other

Preservation for future generations Provide a description of the organization 's collections and explain how they further the organizations exempt purpose in Part

XIV, During the year, did the organization solicit or receive donations of art. historical treasures, or other similar
assets to be sold to raise funds rather then to be maintained as part o( the organization 's collection ? Yes No

Escrow and Custodial Arrangements . Complete if the organization answered ' Yes' to Form 990, Part IV, line 9, or reported an amount on Form 990 , Part X, line 21.
la Is the organization an agent, trustee , custodian or other intermediary for contributions or other assets not included on Form 990 , Part X? ............ ......... ....... b lf'Yes .' explain the arrangement in Part XIV and complete the following table: 1c td 1e

Yes EI No

c Beginning balance d Additions during the year e Distributions during the year , . . . .... f Ending balance .. . .....

2a Did the organization include an amountForm 990, Part X, line 217 . on b If 'Yes,' explain the arrangement Part XIV. in

r 1__1 Yes

{.i No

=;t?aittt ,

Endowment Funds . Complete if organization answered

{ar uur. nr year

"Yes" to Form 990 , Part IV, line 10

(C) Two years back

(b) Prioi year

d) Three years bac : K.

(e) Four years back

i a Beginning of year balance b Contributions

c Net Investment earnings , gains, and losses


d Grants or scholarships a Other expenditures for facilities and programs _f Administrative expenses g End of year balance _ 2 a b c

.. _ ....... .

Provide the estimated percentage of the year end balance held as: Board'designated or quasi-endowment _ % Permanent endowment % Term endowment %
funds not in the possession of the organization that are held and administered for the

3a Are there endowment

organization by: (i) unrelated organizations t(q related organizations b II 'Yes to 3a(0), are the related organizations listed as required on Schedule R?
4 Describe in Par XIV the intended uses of the organization's endowment funds

Yes 3a 11 '' 31)


tP>ar`/JV e

land Buildin s and E

Description of investment

ui ment See Form 990 Part X tine10

(a) Cost or other bas is (Inveatmenl) (b) Cost or other basis (other) (c) Accumulated deorearalion (d) Book value

1a Land b Buildings c Leasehold improvements d Equipment e Other . ... . . ........ Total. Add lines la through le. (Column must equal Form 990, Part X, column tine 10(c).) (d) (B). I

Schedule D(Form 990) 2010


28901 0510912011 -22 PM 4

Schedule 0F ( orm 990 2010 BREAST G. ;.'E12 SURVIVORS FOUNDATION Investments=Other SecuritiesSee Form 990, Part X line 12. .
(a) Desatption of set taity a category (indudmg Marne of security ) (b) Bookvelue (c) Meth o f valuation'. od Cost or tnd-olyear market value -

Page 3

(1) Financial derivatives (2) Closely -held equity interests (3) Other

(C) .....








..... _ . .... ..............

. ............... .. ....... ........ .......
(b) Book value

(F) ............................ IF) ............... ......

(H) .............. ........

...... ........... .. .................. ......................

Total. Column b must equal Form M . Part X , col. 8 line 12.

. tx


., s, s


Investments - Pro ram Related . See Form 99 0 Part X , line 13.

(a) Desalpbon of vestment type In
I N Method of velualron. Cost or endyear market val r o ue

(1 2

3 5 6) 7 8 e 10 Total Column (b) must e qual Form 990. Part X. cof. 8 titre 13.


.iX3 'spf


Other As sets . See F or m 990 , Part X, line 15.

(a) Description lb) Book value

(2 3 5 (6) (7 ) (8 9 (10 Total. Column b must equal Form 990, Pan X, cot (B) line 15.

. , ..
(b) Amours <, -

2 (3

arf= ' Jf,:

Other Liabrlrties . See F orm 990 . Part X, line 25.

(a) Description of IlabitIty

Federal Income taxes


P 3

10 (11 Total . (Column must e qual Form 990 , Part X , cal B) Ilne 25 .) (ASC 740)

h `

E s

x ,<



2- FIN 48 (ASC 740 ) Footnote . In Pall XIV, provide the text organization 's liability for uncertain tax positions under FIN 48

or The footnote to the organization

.i R. x" t a '-` 's financial statements that reports the


Schedule D(Form 990) 2010

26801 0519912011 '4 PM 22

Schedule D (Form 990 ) 2010 .

I 2 3 4 5 8 7 B 9






Page 4 531 , 041 479 , 111

51 , 930

Reconciliation of Chan g e in Net Assets from Form 990 to Audited Financial Statements
Total revenue (Form 990, Part V)II, column(A), line 12) Total expenses (Form 990, Part IX, column (A), line 25) .... Excess or(deficit for the year Subtract line 2 from line t ) . Net unrealized gains (losses) on investments ... Donated services and use of facilities Investment expenses Prior period adjustments Other(Describe in Pori XIV.) Total adjustmentsnet). Add lines 4 through B ( ......... . ... ................
.. ....... .... ... ....

2 3
4 5

a ...... .... .... ... ...

. .. ........ 9

10 Excess or deficit for theyear pet audited financial statements . Combine lines 3 and 9. i? .a .1 t *;' Reconciliation of Revenue p er Audited Financial Statements With Revenue I 2 Amounts included on line I but not on Form Part Vtll. line 12: 990, a Net unrealized gains on investments b Donated services and use of facilities c Recoveries of prior year grants d Other (Describe In Part XIV.) .... Total revenue gains and other support per audited financial statements , , .. .... ............ 2a 2b 2c 2d .........

10 p er Retum .





.. .. ....


e Add lines 2a through 2d ... 3 Subtract line 2e from line 1 4 Amounts included on Form 990. Part Vill, line 12, but not on line 1 a Investment expenses not included on Form .990 Vlll, fine Tb Part
b Other (Describe in Part XIV.)



2e 3


-4 1


c Add lines 4a and 4b 5 Total revenue Add lines 3 and 4c(This must e . . qual Form 990 Part I tine12.)

4c 5


Reconciliation of Expenses per Audited Financial Statements With Expenses per

1 2


Total expenses and losses per audited financial statements Amounts included on line1 but not on Form 990. Part IX, fine 25:
Prior year adjustments


a Donated services and use of facilities c Other losses d Other (Describe In Part XIV ) ................ a Add lines 2a through 2d
3 Subtract line 2e from line 1

2a 2b 2c 2d 2e 3 4a 4b 4c



Amounts included on Form 990 , Part IX, line 25, but not on line 1:

a Investment expenses not included on Form 990, Part VIII, line 7b b Other(Describe in Part XIV) c Add lines 4e and 4b 5 Total expenses. Add lines 3 and 4c . (This must equal Form 990 , Part [ line 18


t' Supplemental Information

Complete this part to provide the descriptions required for Part it, lines 3, 5, and 9; Part Ill, lines Is and 4; Part IV, lines lb and 2b; Part V, one 4; Part X line 2; Part XI, line 8; Part XIIlines 2d and 4b and Part XIII, tines 2d and 4b , , ; . Also,complete this part to provide any additional information.

Schedule D (Form 990) 2010


2 8801 0 5009 1 4:22 PM /101

Schedule D Form 990 2010 Su






1 ,j M Page 5

tementai Information


Schedule 13 (Form 990) 2010

28601 05A)9120114 PM '22

(Form 990 or 990 -EZ){ I
uepartrnenr or the Treasury lntefnal Revenue Service Name of the organzation

supplemental Information Regar ii._.g l Fundraising or Gaming Activities

Complete if the oroanl x atlon enewarad ' ran" to Fnrm eafl Part N Imes 17 1R nr 14 nr If the

OMB ND . 16s50o47

.. , Inn .. .'fiber

organization entered more than $16,001 on Form 990-EZ , line Ga. F Anash to Form 990 or Form 090-2- Sae se 1 In trvcdons.
Erhptover 61enNn


BREAST CANCER SURVIVORS FOUNDATION, INC. Fundraising Activities . Complete if the organization answered Form 990-EZ filers are not required to complete this part.

"Yes" to Form 990, Part IV, line 17.

1 a b
c l i

Indicate whether the organization raised funds through any of the following activities . Check all that apply, Marl solicitations e Solicitation of non-govemment grants Internet and email solicitations
Phone solicitations

t g

Solicitation of government grants Special fundraising events

In-person solicitations

2a Did the organization have a written or oral agreement with any individual (including officers , directors. trustees or key employees listed in Form 990 . Part VII ) or entity in connection with professional fundraising services? b If'Yes ," lief the (en highest paid individuals or entities (fundraisers ) pursuant to agreements under which the fundraiser Is to be compensated at least$5 000 by the or anization.
(1) NW* and addressof iMiv;duai or entity (lundrarsa) (ii) Activi ty (Ili) Did rW rd'SQ "" Custody or mryrd or ( tv) Gross receipts from activel y

1 1 Yes


(r) Amount paid to

(or retained by) rundralser listed in cot. (I)

(vI)Amount paid to
(or retaned by) organization


Yes No PUNDRAIS2 X 53.1, 041 476 , 918 52,123

10 Total ......





. ..
1s registered

or licensed to solicit contributions or has

been notified it

is exempt from


List alt states

in which the organization

registralion or licensing, All states

Paperwork Reduction Act Notice, OAA

see the Instructions for Form 990 or 990-EZ.

Schedule G (Form 990 or 990-EZ) 2010

28601 05/09201 1 4 22 PM

Schedule G (Form 990 or 990 2D10 -EZ)

Sf. .&ST CANCER SURVIVORS FOUNL, ION Page 2 Fundraising Events . Complete if the organization answered "Yes' to Form 990, Part IV, line 18 , or reported more than $15,000 of fundraising event contributions and gross income on Form 990-EZ , lines 1 and 6b. List . events with gross receipts greater than $5, 000
(a) Event at

(b) event 112

Ic) Other events

(d) Tour events (add cot(a) through .


(event type)

(total number)

col. (c))

I Gross receipts ,,. 2 Less: Charitable


3 Gross income time 1 minus fine 2

4 Cash prizes

5 Noncash prizes 6 Renufacility costs 7 Food and beverages 8 Entertainment 9 Other direct expenses 10 Direct expense summary . Add lines 4 through gin column (d) .. 11 Net income summary . Combine line 3, column(d) and line 10 ...... .. Vj ,f ft Gaming. Complete if the organization answered "Yes" ....... . . 110. p.

w m 0

to Form 990, Part IV,line 19, or reported more

(d) Total gaming (add cW (a) throughW. (c))

than $15 ,000 on Form 990-EZ , line 6a.

(a) tango o:
(b) Pull labsjnstant bngo/progfeseive bingo

1 Gross revenue
2 Cash prizes

w 0
4 Rent/ tacility costs 5 Other dir expenses ect Yes 6 Volunteer labor No
Yes No a Yes No %


3 Noncash prizes

7 Direct expense summaryAdd lines2 through 5 in column (d) , 8 Net gaming income summary . Combine line 1, column d, and line 7 9 Enter the state (s) in which the organization operates gaming activities.
activities in each of these states?

b. k

a Is the organization licensed to operate gaming b It 'No,' explain,-




10a Were any of the organization 's gaming licenses revoked , suspended or terminated during the tax year ? b tl'Yes .* explain.


Ye s



Schedule G(Form 990 or 990-E2) 2010

2860105109/2011 a 22 PM

Schedule G (Form 990 or 990-EZ) 2010 11

13 a





...... .

...Page. 3.

Does the organizationoperate gaming activities nonmembers? with

.. .. entity iary of partnership or other .... . . ......... Is the organization a grantor, benefic or trustee of a trust or a member .. a..........
formed to administer charitable gaming Indicate the percentage The organizations facility ? .. ..... . of gaming activity operated in

13a 113b



1..1 Yos

b An outside tacirrty
14 Enter the name and records: Name Address Y 16a b c

.... ... .... ........ .. .............. ....... 's gaming/special events books and ............. .... ............ address of the person who prepares the organization




Does the organization have a contract with a third party from whom the revenue? If 'Yes.' enter the amount of gaming revenue received by amount of gaming revenue retainedt e third party by h If -Yes; enter name and address of third party the Name Address

organization receives gaming Yes 0 No S. and the

the organizat on $


Gaming manager Name


Gaming manager compensation $ Description of services provided Director /officer Employee Independeni contractor

17 a b

Mandatory distributions: is the organization required under state law to make charitable distributions from the gaming proceeds to retain the state gaming license ? Enter the amount of distributions required under slate Jaw to be distributed to other exempt sent in the or anlzatlon own exem activities duri the taxyear $ 's pt ng organizations or Yes No

Eai `, w Supplemental Information. Complete this part to provide the explanations required by Part 1, tine 2b, columns (iii) and (v), and Part III, tines 9 9b, 10b, 15b, 15c, 16, and 17b, as applicable. Also complete this , part to provide any additional information (see inst ructions

Schedule G (Form 990 or 990-EZ) 2010


28801 051Ogr2e1I A-53 PIA

SCHEDULE O (Form 990 or 990-EZ)

Depadment of the Treasury tnleni& Revenue Ser, cs

Supplemental Information to Form 990 or 990-EZ

Complete to provide Information for responses to specific questions on Form 990 or 990-EZ or to provide any additional information. Attach to Forrn 990 or 99O-EL

MB No 1545-0047 .


i t f 1Fpyye Rr f3et13t3 '6 t'


Name orihaorpani BREAST ,aoen INC.




Form 990

- Additional Information


..Form 990 THE BOARD

, Part VI, Line lib - Organizations MEMBERS


to Review

Form 990



Form 990, Part VI, Line 17 - Other States J


Copy of Return is Filed .. .. ........

Idaho,..I13.inois, Indiana,. Kansas, xentucky, Massachusetts, Maryland. .Maine,..Michigan, Minnesota, Missouri, Mississippi, Montana,

North Carolina, North Dakota, Nebraska, New Hampshire, New Jersey, New: Mexico, Nevada.,._New York, Ohio, Oklahoma, Oregon, Pennsy3vania,

Rhode Island, South Carolina, South Dakota,

Tennessee , Texas, Utah,

Virginia, Vermont, Washington, Wisconsin, West Virginia,..Wyoming

Form..9901 .



J9 ,




Explanation N


For Paperwork Reduction Act Notice o m

, see the Instructions for Form 990 or 990


Schedule 0 (Form 990 or 990-EZI (2010)

Breast Cancer Survivors Foundation, Inc.

Financial Statements and Independent Auditors' Report December 31, 2010

McEnerney, Brady & Company, LLC

Certified Public Accountants

Breast Cancer Survivors Foundation, inc. Table of Contents December 31, 2010


Independent uditors' Report A Statement of Financial Position Statement f Activities o Statement of Functional Expenses
Statement of Cash Flows


5 6-8

Notes to Financial Statements





To the Executive Board Breast Cancer Survivors Foundation, Inc. Roselle Park, NJ 07204 We have audited the accompanying statements of financial position of Breast Cancer Survivors Foundation, Inc. {the "Foundation) as of December 31, 2010 and the related statements of activities, functional expenses, and cash flows for the period June 1, 2010 (date of inception) through December 31, 2010. These financial statements are the responsibility of the Foundation's management. Our responsibility is to express an opinion on these financial statements based on our audit. We conducted our audit in accordance with auditing standards generally accepted in the United States of America. Those standards require that we plan and perform the audit to obtain reasonable assurance about whether the financial statements are free of material misstatement. An audit includes examining, 'on a test basis, evidence supporting the amounts and disclosures in the financial statements An audit also includes . assessing the accounting principles used and significant estimates made by management, as well as evaluating the overall financial statement presentation. We believe that our audit provides a reasonable basis for our opinion. In our opinion the financial statements referred to above present fairly, in all material respects, the financial position of Breast Cancer Survivors Foundation, Inc. as of December 31, 2010 and the changes in its net assets and its cash flows for the period then ended in conformity with generally accepted accounting principles in the United States of America.

Livingston, New Jersey May 27, 2011

293 Eisenhower Parkway, Livingston , NJ 07039 (973) 535. 2880

832 McLean Avenue. Yonkers. NY 10704 (914) 237.3676

Breat Cancer Survivors Foundation, Inc. Statements of Financial Position December 31, 2010

Assets Current Assets Cash Contributions receivable $ 45,854 6,076 $ 51,930 Net Assets UnrestrictedNet assets $ 51,930

The Notes to Financial Statements are an integral part of these statements

Breast Cancer Survivors Foundation, Inc. Statementsof Activities and Changesin Net Assets December 31, 2010

Revenues and Support: Professional Fundraising


Expenses: Management and general Fundraising Total expenses Increase In Net Assets Unrestricted Net Assets Beginningof the Period , Unrestricted Net AssetsEnd of the Period , $

193 478,918 479,111 51,930


The Notes to Financial Statements are an integral part of these statements 3

Breast Cancer Survivors Foundation, Inc. Statements of Functional Expenses December 31, 2010

2010 Program Services Professional Fundraising $ Management and General $ $ Fundraising 478,918 $ 478,918 $ Total 478,918


110 193

110 479,111

Total costs

The Notes to Financial Statements are an integral part of these statements


Breast Cancer Survivors Foundation, Inc. Statements of Cash Flows December 31, 2010

Cash Flows from Operating ctivities: A Changein net assets

Adjustments to reconcile change in net assets operating activities: Changes in operating assets: Contributions receivable to net cash provided by

$ 51,930

(6,076 45,854 45,854

Net cash provided by operating activities Net increase in cash Cash, beginning of the period Cash, end of the period
Supplemental Disclosures: Interest paid

$ 45,854

Taxes paid

The Notes to Financial Statements are an integral part of these statements 5

BreastCancer Survivors Foundation, Inc. Notes to Financial Statements December31, 2010

1. Organization and Purpose Nature of Activities Founded in 2010, the Breast Cancer Survivors Foundation, Inc. (the "Foundation`), incorporated under the laws of the State of Delaware, was founded by Yutius Poptyansky, MD to provide informational and educational materials to the public at large regarding breast cancer, self-examination, and physician examinations and other breast cancer related Information. The Foundation also holds meetings and conferences for the public where physicians, oncologists, breast cancer survivors, and other individuals can exchange vital information about breast cancer and breast cancer related issues. 2. Summary of Significant Accounting Policies Basis of Accounting and Presentation
The accompanying financial statements have been prepared on the accrual basis of accounting in accordance with accounting principles generally accepted in the United States of America. The financial statement presentation follows the guidance of the accounting standards relating to financial statementsof not-for-profit organizations. Under these standards, the Foundation is required to report information regarding its financial position and activities according to three classes of net assets: unrestricted net assets, temporarily restricted net assets, and permanently restricted net assets.

Use of Estimates
The preparation of financial statements in conformity with U.S. generally accepted accounting principles requires management to make estimates and assumptions that affect the reported amounts of assets and liabilities and disclosures of contingent assets and liabilities at the date of the financial statements. Estimates also affect the reported amounts of revenue and expenses during the reporting period. The estimated useful life of fixed assets, depreciation, and accounts payable and accrued expenses, among other accounts, require the significant use of estimates. Actual results could differ from those estimates.

Support and Revenue

Contributions The Foundation reports gifts of cash, other assets and long-lived assets as restricted support if they are received with donor stipulations that limit the use of the donated assets. When a donor restriction expires, that is, when a stipulated time restriction ends or purpose restriction is accomplished, temporarily restricted net assets are reclassified as unrestricted net assets and reported in the statements of activities as net assets released from restrictions. In the absence of donor specification that income and gains on donated funds are restricted, such income and gains are reported as revenues of unrestricted net assets. Earnings on permanently and temporarily restricted net assets are recorded as unrestricted or temporarily restricted revenues and follow the restrictions set forth by the donor.

Breast Cancer Survivors Foundation, Inc. Notes to Financial Statements

December 31, 2010

Classification of Net Assets Unrestricted - includes resources that have not been restricted by an outside donor, and are therefore, available, for use in carrying out the general operations of the Foundation. Temporarily Restricted - includes resources that have been limited by donor-imposed stipulations that either expire with the passage of time or can be fulfilled and removed by the actions of the Foundation pursuant to those stipulations. Permanently Restricted - Includes resources whereby donors have stipulated that the corpus of the gift be invested and maintained in perpetuity. Income earned from such gifts is generally available for expenditures according to donor-imposed restriction, if any. Financial Instruments
The carrying values of the Foundation's financial instruments as of December 31,2010 include cash and accounts receivable, and approximate their fair value due to the relatively short maturity of these instruments.

Fair Value Disclosures The Foundation has provided fair value disclosure information for relevant assets and liabilities in these financial statements.
For applicable assets and-liabilities subject to the provisions of the accounting standard relating to fair value measurements, the Foundation will value, such assets and liabilities using quoted market process in active markets for identical assets and liabilities to the extent possible. To the extent that such market prices are not available, management will next attempt to value such assets and liabilities using observable measurement criteria, including quoted market prices of similar assets and liabilities in active and inactive markets and other corroborated factors. In the event that quoted market prices in active markets for identical assets orliabilities (Level 1) and other observable measurement criteria (Level 2) or unobservable inputs that are not available (Level 3), the Foundation will develop measurement criteria based on the best information available, including information from banking institutions and advisors. All of the Foundation's financial instruments are Level 1.

Concentrations of Credit Risk

Financial instruments which potentially subject the Foundation to concentrations of credit risk consist principally of cash. The Foundation places its cash with high credit quality financial institutions. At times, such amounts exceed the current insured amount under the Federal Deposit Insurance Corporation of $250,000.

Breast Cancer Survivors Foundation, Inc. Notes to Financial Statements December 31, 2010 Income Taxes The Foundation qualifies as not-for-profit organizations as described In Section 501 (c)(3) of the Inter al Revenue Code (the "Code") and Is exempt from federal income taxes on related n income pursuant to Section 101(a) of the Code and Is also exempt from state and local Income taxes. The Foundation has adopted the recognition and disclosure provisions of the accounting standard related accounting for uncertainty in incofne taxes. Under this standard, tax to positions are evaluatedfor recognition using a more-likely-than-not threshold, and those tax positions requiring recognitionare measured at the largest amount of tax benefit that is greater than 50% likely of being realized upon ultimate settlementwith a taxing authority that has full knowledge of all relevant information. The Foundation has evaluated the likelihood of its tax positions being challenged as remote and, accordingly has not included any income tax a provisions, including interest nd penalties the financial statements related to potential , in violations. Upon adoption of this accounting pronouncement, the Foundation had no unrecognized tax benefits. The Foundation files tax retur ns in the U.S. federal jurisdiction and various states. The Foundation has no open years prior to 2010 as this is the year of inception. Functional Allocation of Expenses The costs of providing the various programs and other activities have been summarized on a functional basis in the statement of functional expenses. Accordingly, certain costs have been allocated among the programs and supporting services benefited based upon management estimates. 3. Commitments Professional Fund Raiser
The Foundation entered into an agreement with a professional fund raising organization in September 2010, which expires in September 2015. Terms of the agreement provide the Foundation with a percentage of gross contributions received by the fund raiser.


Subsequent Events
The Foundation has evaluated subsequent events occurring after December 31,2010 through the date of May 27, 2011. which is the date the financial statements were available to be issued. Based on this evaluation, the Foundation has determined that no subsequent events have occurred which require disclosure in the financial statements.