Part III Statement of Program Service Accomplishments

Transcription

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2 Form 990 (0) DEATH WITH DIGNITY NATIONAL CENTER Prt III Sttement of Progrm Servie Aomplishments Chek if Shedule O ontins response or note to ny line in this Prt III Briefly desrie the orgniztion's mission: THE MISSION OF THE DEATH WITH DIGNITY NATIONAL CENTER IS TO PROMOTE DEATH WITH DIGNITY LAWS BASED ON OUR MODEL LEGISLATION, THE OREGON DEATH WITH DIGNITY ACT, BOTH TO PROVIDE AN OPTION FOR DYING INDIVIDUALS AND TO STIMULATE NATIONWIDE IMPROVEMENTS IN END-OF-LIFE Did the orgniztion undertke ny signifint progrm servies during the yer whih were not listed on the prior Form 990 or 990-EZ? If "," desrie these new servies on Shedule O. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion ese onduting, or mke signifint hnges in how it onduts, ny progrm servies? ~~~~~~ If "," desrie these hnges on Shedule O. Desrie the orgniztion's progrm servie omplishments for eh of its three lrgest progrm servies, s mesured y expenses. Setion 0()() nd 0()() orgniztions re required to report the mount of grnts nd llotions to others, the totl expenses, nd Pge revenue, if ny, for eh progrm servie reported. ( Code: ) ( Expenses $ 87,7. inluding grnts of $ ) ( Revenue $ ) OREGON PLUS ONE: DURING THE YEAR ENDED MARCH, 0, THROUGH OUR CORE SERVICE, THE OREGON PLUS ONE PROGRAM, DEATH WITH DIGNITY NATIONAL CENTER LENT ITS EPERTISE IN PUBLIC POLICY ANALYSIS TO CITIZENS, PUBLIC OFFICIALS, AND END-OF-LIFE EPERTS INTERESTED IN THE OREGON AND WASHINGTON DEATH WITH DIGNITY EPERIENCE. WE PROVIDED INFORMATION ABOUT THE LATEST STATISTICS AND RESEARCH, AND WE PROVIDED DATA CONCERNING IMPLEMENTATION OF THE LAW. WE PROVIDED RESOURCES REGARDING THE LAW'S IMPACT ON THE MEDICAL PROFESSION, AND WE ASSISTED WITH RESEARCH AND ANALYSIS OF PUBLIC POLICY DATA. CONSISTENT WITH THE GOAL OF THE PROGRAM, WE PROVIDED ASSISTANCE AND DISSEMINATED INFORMATION TO INDIVIDUALS IN OTHER STATES WHICH ARE LOOKING TO ENHANCE END-OF-LIFE CARE FOR THE TERMINALLY ILL. ( Code: ) ( Expenses $ 0,87. inluding grnts of $ ) ( Revenue $ ) PUBLIC EDUCATION: THROUGH THIS PROGRAM, WE PROVIDED INFORMATION AND EDUCATIONAL MATERIALS ABOUT THE OREGON, WASHINGTON, AND VERMONT DEATH WITH DIGNITY LAWS TO INDIVIDUALS NATIONWIDE. IN ADDITION, WE RESPONDED TO REQUESTS FOR INFORMATION AND PROVIDED REFERRALS TO TERMINALLY ILL INDIVIDUALS AND THEIR FAMILY MEMBERS ABOUT A WIDE RANGE OF END-OF-LIFE ISSUES. WE PROVIDED EDUCATIONAL MATERIALS THROUGH OUR WEBSITE, ACTING AS A TRUSTED RESOURCE FOR LEGAL, MEDICAL, AND OTHER SCHOLARLY RESEARCH. OUR DIGNITY REPORT PROVIDED MORE THAN,000 INDIVIDUALS WITH SUBSTANTIVE ARTICLES, UPDATES, AND INTERVIEWS DURING THE YEAR. 9,888. COMMUNICATIONS: THIS PROGRAM PROMOTES DEATH WITH DIGNITY LAWS BASED ON OUR MODEL LEGISLATION, THE OREGON DEATH WITH DIGNITY ACT, AND OTHER END-OF-LIFE CARE ISSUES TO A NATIONAL AUDIENCE ONLINE AND THROUGH THE MEDIA. IMPORTANT TARGET AUDIENCES INCLUDED PUBLIC OFFICIALS AND POLICY DECISION-MAKERS, INDIVIDUALS WHO ARE TERMINALLY ILL AND THEIR FAMILY MEMBERS AND PHYSICIANS. ( Code: ) ( Expenses $ inluding grnts of $ ) ( Revenue $ ) d e Other progrm servies (Desrie in Shedule O.) ( Expenses $ inluding grnts of $ ) ( Revenue $ ) Totl progrm servie expenses 98,. Form 990 (0) DEATH WITH DIGNITY NATION 706

3 Form 990 (0) DEATH WITH DIGNITY NATIONAL CENTER Prt IV Cheklist of Required Shedules d e f Is the orgniztion desried in setion 0()() or 97()() (other thn privte foundtion)? If "," omplete Shedule A ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Is the orgniztion required to omplete Shedule B, Shedule of Contriutors? ~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion engge in diret or indiret politil mpign tivities on ehlf of or in opposition to ndidtes for puli offie? If "," omplete Shedule C, Prt I Setion 0()() orgniztions. Did the orgniztion engge in loying tivities, or hve setion 0(h) eletion in effet during the tx yer? If "," omplete Shedule C, Prt II ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "," omplete Shedule D, Prt I the environment, histori lnd res, or histori strutures? If "," omplete Shedule D, Prt II~~~~~~~~~~~~~~ If "," omplete Shedule D, Prt III ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "," omplete Shedule D, Prt IV Did the orgniztion report n mount for lnd, uildings, nd equipment in Prt, line 0? If "," omplete Shedule D, Prt VI ssets reported in Prt, line 6? If "," omplete Shedule D, Prt VII Prt, line 6? If "," omplete Shedule D, Prt I ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion report n mount for other liilities in Prt, line? If "," omplete Shedule D, Prt ~~~~~~ If "," omplete Shedule D, Prt Did the orgniztion otin seprte, independent udited finnil sttements for the tx yer? If "," omplete Shedule D, Prts I nd II ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ or more? If "," omplete Shedule F, Prts I nd IV ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ foreign orgniztion? If "," omplete Shedule F, Prts II nd IV olumn (A), lines 6 nd e? If "," omplete Shedule G, Prt I ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ nd 8? If "," omplete Shedule G, Prt II ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ omplete Shedule G, Prt III ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Is the orgniztion setion 0()(), 0()(), or 0()(6) orgniztion tht reeives memership dues, ssessments, or similr mounts s defined in Revenue Proedure 98-9? If "," omplete Shedule C, Prt III ~~~~~~~~~~~~~~ Did the orgniztion mintin ny donor dvised funds or ny similr funds or ounts for whih donors hve the right to provide dvie on the distriution or investment of mounts in suh funds or ounts? Did the orgniztion reeive or hold onservtion esement, inluding esements to preserve open spe, Did the orgniztion mintin olletions of works of rt, historil tresures, or other similr ssets? Did the orgniztion report n mount in Prt, line, for esrow or ustodil ount liility; serve s ustodin for mounts not listed in Prt ; or provide redit ounseling, det mngement, redit repir, or det negotition servies? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion, diretly or through relted orgniztion, hold ssets in temporrily restrited endowments, permnent endowments, or qusi-endowments? If "," omplete Shedule D, Prt V ~~~~~~~~~~~~~~~~~~~~~~~~ If the orgniztion's nswer to ny of the following questions is "," then omplete Shedule D, Prts VI, VII, VIII, I, or s pplile. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion report n mount for investments - other seurities in Prt, line tht is % or more of its totl Did the orgniztion operte one or more hospitl filities? If "," omplete Shedule H ~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion report n mount for investments - progrm relted in Prt, line tht is % or more of its totl ssets reported in Prt, line 6? If "," omplete Shedule D, Prt VIII ~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion report n mount for other ssets in Prt, line tht is % or more of its totl ssets reported in Did the orgniztion's seprte or onsolidted finnil sttements for the tx yer inlude footnote tht ddresses the orgniztion's liility for unertin tx positions under FIN 8 (ASC 70)? If "," ~~~~ Ws the orgniztion inluded in onsolidted, independent udited finnil sttements for the tx yer? If "," nd if the orgniztion nswered "" to line, then ompleting Shedule D, Prts I nd II is optionl ~~~~~ Is the orgniztion shool desried in setion 70()()(A)(ii)? If "," omplete Shedule E ~~~~~~~~~~~~~~ Did the orgniztion mintin n offie, employees, or gents outside of the United Sttes? ~~~~~~~~~~~~~~~~ Did the orgniztion hve ggregte revenues or expenses of more thn $0,000 from grntmking, fundrising, usiness, investment, nd progrm servie tivities outside the United Sttes, or ggregte foreign investments vlued t $00,000 Did the orgniztion report on Prt I, olumn (A), line, more thn $,000 of grnts or other ssistne to or for ny ~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion report on Prt I, olumn (A), line, more thn $,000 of ggregte grnts or other ssistne to or for foreign individuls? If "," omplete Shedule F, Prts III nd IV ~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion report totl of more thn $,000 of expenses for professionl fundrising servies on Prt I, Did the orgniztion report more thn $,000 totl of fundrising event gross inome nd ontriutions on Prt VIII, lines Did the orgniztion report more thn $,000 of gross inome from gming tivities on Prt VIII, line 9? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "" to line 0, did the orgniztion tth opy of its udited finnil sttements to this return? ~~~~~~~~~~~~~~~~ d e f Pge 0 Form 990 (0) DEATH WITH DIGNITY NATION 706

4 Form 990 (0) DEATH WITH DIGNITY NATIONAL CENTER Prt IV Cheklist of Required Shedules (ontinued) d Setion 0()() nd 0()() orgniztions. Did the orgniztion engge in n exess enefit trnstion with disqulified person during the yer? If "," omplete Shedule L, Prt I ~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion report more thn $,000 of grnts or other ssistne to ny domesti orgniztion or government on Prt I, olumn (A), line? If "," omplete Shedule I, Prts I nd II ~~~~~~~~~~~~~~~~~~ Did the orgniztion report more thn $,000 of grnts or other ssistne to individuls in the United Sttes on Prt I, olumn (A), line? If "," omplete Shedule I, Prts I nd III ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion nswer "" to Prt VII, Setion A, line,, or out ompenstion of the orgniztion's urrent nd former offiers, diretors, trustees, key employees, nd highest ompensted employees? If "," omplete Shedule J ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion hve tx-exempt ond issue with n outstnding prinipl mount of more thn $00,000 s of the lst dy of the yer, tht ws issued fter Deemer, 00? If "," nswer lines through d nd omplete Shedule K. If "", go to line Shedule L, Prt I If "," omplete of ny of these persons? If "," omplete Shedule L, Prt III ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ diretor, trustee, or diret or indiret owner? If "," omplete Shedule L, Prt IV ~~~~~~~~~~~~~~~~~~~~~ ontriutions? If "," omplete Shedule M ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "," omplete Shedule N, Prt I Shedule N, Prt II Prt V, line ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion invest ny proeeds of tx-exempt onds eyond temporry period exeption? Did the orgniztion mintin n esrow ount other thn refunding esrow t ny time during the yer to defese ny tx-exempt onds? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion t s n "on ehlf of" issuer for onds outstnding t ny time during the yer? If "," omplete ~~~~~~~~~~~ ~~~~~~~~~~~ Is the orgniztion wre tht it engged in n exess enefit trnstion with disqulified person in prior yer, nd tht the trnstion hs not een reported on ny of the orgniztion's prior Forms 990 or 990-EZ? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion report ny mount on Prt, line, 6, or for reeivles from or pyles to ny urrent or former offiers, diretors, trustees, key employees, highest ompensted employees, or disqulified persons? If so, omplete Shedule L, Prt II ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion provide grnt or other ssistne to n offier, diretor, trustee, key employee, sustntil ontriutor or employee thereof, grnt seletion ommittee memer, or to % ontrolled entity or fmily memer Ws the orgniztion prty to usiness trnstion with one of the following prties (see Shedule L, Prt IV instrutions for pplile filing thresholds, onditions, nd exeptions): A urrent or former offier, diretor, trustee, or key employee? If "," omplete Shedule L, Prt IV ~~~~~~~~~~~ A fmily memer of urrent or former offier, diretor, trustee, or key employee? If "," omplete Shedule L, Prt IV ~~ An entity of whih urrent or former offier, diretor, trustee, or key employee (or fmily memer thereof) ws n offier, Did the orgniztion reeive more thn $,000 in non-sh ontriutions? If "," omplete Shedule M ~~~~~~~~~ Did the orgniztion reeive ontriutions of rt, historil tresures, or other similr ssets, or qulified onservtion Did the orgniztion liquidte, terminte, or dissolve nd ese opertions? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion sell, exhnge, dispose of, or trnsfer more thn % of its net ssets? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion own 00% of n entity disregrded s seprte from the orgniztion under Regultions setions nd ? If "," omplete Shedule R, Prt I ~~~~~~~~~~~~~~~~~~~~~~~~ Ws the orgniztion relted to ny tx-exempt or txle entity? If "," omplete Shedule R, Prt II, III, or IV, nd ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion hve ontrolled entity within the mening of setion ()()? ~~~~~~~~~~~~~~~~~~ If "" to line, did the orgniztion reeive ny pyment from or engge in ny trnstion with ontrolled entity within the mening of setion ()()? If "," omplete Shedule R, Prt V, line ~~~~~~~~~~~~~~~~~~~ Setion 0()() orgniztions. Did the orgniztion mke ny trnsfers to n exempt non-hritle relted orgniztion? If "," omplete Shedule R, Prt V, line ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion ondut more thn % of its tivities through n entity tht is not relted orgniztion nd tht is treted s prtnership for federl inome tx purposes? If "," omplete Shedule R, Prt VI ~~~~~~~~ Did the orgniztion omplete Shedule O nd provide explntions in Shedule O for Prt VI, lines nd 9? te. All Form 990 filers re required to omplete Shedule O d Pge 8 Form 990 (0) DEATH WITH DIGNITY NATION 706

5 Form 990 (0) DEATH WITH DIGNITY NATIONAL CENTER Pge Prt V Sttements Regrding Other IRS Filings nd Tx Compline Chek if Shedule O ontins response or note to ny line in this Prt V Enter the numer reported in Box of Form 096. Enter -0- if not pplile ~~~~~~~~~~~ d e f g h Enter the numer of Forms W-G inluded in line. Enter -0- if not pplile ~~~~~~~~~~ Did the orgniztion omply with kup withholding rules for reportle pyments to vendors nd reportle gming If t lest one is reported on line, did the orgniztion file ll required federl employment tx returns? ~~~~~~~~~~ te. If the sum of lines nd is greter thn 0, you my e required to e-file (see instrutions) ~~~~~~~~~~~ Orgniztions tht my reeive dedutile ontriutions under setion 70(). Sponsoring orgniztions mintining donor dvised funds nd setion 09()() supporting orgniztions. Sponsoring orgniztions mintining donor dvised funds. Setion 0()(7) orgniztions. Enter: Setion 0()() orgniztions. Enter: Setion 97()() non-exempt hritle trusts. Is the orgniztion filing Form 990 in lieu of Form 0? (gmling) winnings to prize winners? Enter the numer of employees reported on Form W-, Trnsmittl of Wge nd Tx Sttements, filed for the lendr yer ending with or within the yer overed y this return ~~~~~~~~~~ Did the orgniztion hve unrelted usiness gross inome of $,000 or more during the yer? ~~~~~~~~~~~~~~ If "," hs it filed Form 990-T for this yer? If "," to line, provide n explntion in Shedule O ~~~~~~~~~~ At ny time during the lendr yer, did the orgniztion hve n interest in, or signture or other uthority over, finnil ount in foreign ountry (suh s nk ount, seurities ount, or other finnil ount)? ~~~~~~~ If "," enter the nme of the foreign ountry: J See instrutions for filing requirements for Form TD F 90-., Report of Foreign Bnk nd Finnil Aounts. Ws the orgniztion prty to prohiited tx shelter trnstion t ny time during the tx yer? Did the orgniztion reeive pyment in exess of $7 mde prtly s ontriution nd prtly for goods nd servies provided to the pyor? Setion 0()(9) qulified nonprofit helth insurne issuers. te. See the instrutions for dditionl informtion the orgniztion must report on Shedule O. ~~~~~~~~~~~~ Did ny txle prty notify the orgniztion tht it ws or is prty to prohiited tx shelter trnstion? ~~~~~~~~~ If "," to line or, did the orgniztion file Form 8886-T? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 6 Does the orgniztion hve nnul gross reeipts tht re normlly greter thn $00,000, nd did the orgniztion soliit ny ontriutions tht were not tx dedutile s hritle ontriutions? If "," did the orgniztion inlude with every soliittion n express sttement tht suh ontriutions or gifts were not tx dedutile? ~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "," did the orgniztion notify the donor of the vlue of the goods or servies provided? Did the orgniztion sell, exhnge, or otherwise dispose of tngile personl property for whih it ws required to file Form 88? ~~~~~~~~~~~~~~~ If "," indite the numer of Forms 88 filed during the yer ~~~~~~~~~~~~~~~~ Did the orgniztion reeive ny funds, diretly or indiretly, to py premiums on personl enefit ontrt? Did the orgniztion, during the yer, py premiums, diretly or indiretly, on personl enefit ontrt? 7d Did the supporting orgniztion, or donor dvised fund mintined y sponsoring orgniztion, hve exess usiness holdings t ny time during the yer? 0 0 ~~~~~~~ ~~~~~~~~~ If the orgniztion reeived ontriution of qulified intelletul property, did the orgniztion file Form 8899 s required? ~ If the orgniztion reeived ontriution of rs, ots, irplnes, or other vehiles, did the orgniztion file Form 098-C? Did the orgniztion mke ny txle distriutions under setion 966? ~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion mke distriution to donor, donor dvisor, or relted person? Initition fees nd pitl ontriutions inluded on Prt VIII, line Gross reeipts, inluded on Form 990, Prt VIII, line, for puli use of lu filities Gross inome from memers or shreholders ~~~~~~~~~~~~~~~ Gross inome from other soures (Do not net mounts due or pid to other soures ginst mounts due or reeived from them.) ~~~~~~~~~~~~~~~~~~~ ~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "," enter the mount of tx-exempt interest reeived or rued during the yer Is the orgniztion liensed to issue qulified helth plns in more thn one stte? ~~~~~~~~~~~~~~~~~~~~~ Enter the mount of reserves the orgniztion is required to mintin y the sttes in whih the orgniztion is liensed to issue qulified helth plns ~~~~~~~~~~~~~~~~~~~~~~ Enter the mount of reserves on hnd ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion reeive ny pyments for indoor tnning servies during the tx yer? ~~~~~~~~~~~~~~~~ If "," hs it filed Form 70 to report these pyments? If "," provide n explntion in Shedule O e 7f 7g 7h Form 990 (0) DEATH WITH DIGNITY NATION 706

6 Form 990 (0) DEATH WITH DIGNITY NATIONAL CENTER Pge 6 Prt VI Governne, Mngement, nd Dislosure For eh "" response to lines through 7 elow, nd for "" response to line 8, 8, or 0 elow, desrie the irumstnes, proesses, or hnges in Shedule O. See instrutions. Chek if Shedule O ontins response or note to ny line in this Prt VI Setion A. Governing Body nd Mngement Enter the numer of voting memers of the governing ody t the end of the tx yer 8 9 Is there ny offier, diretor, trustee, or key employee listed in Prt VII, Setion A, who nnot e rehed t the orgniztion's miling ddress? If "," provide the nmes nd ddresses in Shedule O Setion B. Poliies (This Setion B requests informtion out poliies not required y the Internl Revenue Code.) 6 9 If there re mteril differenes in voting rights mong memers of the governing ody, or if the governing ody delegted rod uthority to n exeutive ommittee or similr ommittee, explin in Shedule O. Enter the numer of voting memers inluded in line, ove, who re independent Did the orgniztion ontemporneously doument the meetings held or written tions undertken during the yer y the following: Were offiers, diretors, or trustees, nd key employees required to dislose nnully interests tht ould give rise to onflits? in Shedule O how this ws done ~~~~~~ ~~~~~~ Did ny offier, diretor, trustee, or key employee hve fmily reltionship or usiness reltionship with ny other offier, diretor, trustee, or key employee? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion delegte ontrol over mngement duties ustomrily performed y or under the diret supervision of offiers, diretors, or trustees, or key employees to mngement ompny or other person? ~~~~~~~~~~~~~~ Did the orgniztion mke ny signifint hnges to its governing douments sine the prior Form 990 ws filed? ~~~~~ Did the orgniztion eome wre during the yer of signifint diversion of the orgniztion's ssets? ~~~~~~~~~ 6 Did the orgniztion hve memers or stokholders? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 7 Did the orgniztion hve memers, stokholders, or other persons who hd the power to elet or ppoint one or more memers of the governing ody? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Are ny governne deisions of the orgniztion reserved to (or sujet to pprovl y) memers, stokholders, or persons other thn the governing ody? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ The governing ody? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Eh ommittee with uthority to t on ehlf of the governing ody? ~~~~~~~~~~~~~~~~~~~~~~~~~~ 0 Did the orgniztion hve lol hpters, rnhes, or ffilites? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "," did the orgniztion hve written poliies nd proedures governing the tivities of suh hpters, ffilites, nd rnhes to ensure their opertions re onsistent with the orgniztion's exempt purposes? ~~~~~~~~~~~~~ Hs the orgniztion provided omplete opy of this Form 990 to ll memers of its governing ody efore filing the form? Desrie in Shedule O the proess, if ny, used y the orgniztion to review this Form 99 Did the orgniztion hve written onflit of interest poliy? If "," go to line ~~~~~~~~~~~~~~~~~~~~ Did the orgniztion regulrly nd onsistently monitor nd enfore ompline with the poliy? Did the orgniztion hve written whistlelower poliy? If "," desrie for puli inspetion. Indite how you mde these ville. Chek ll tht pply. Own wesite Another's wesite Upon request Other (explin in Shedule O) ~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion hve written doument retention nd destrution poliy? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~ Did the proess for determining ompenstion of the following persons inlude review nd pprovl y independent persons, omprility dt, nd ontemporneous sustntition of the deliertion nd deision? The orgniztion's CEO, Exeutive Diretor, or top mngement offiil Other offiers or key employees of the orgniztion If "" to line or, desrie the proess in Shedule O (see instrutions). ~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion invest in, ontriute ssets to, or prtiipte in joint venture or similr rrngement with txle entity during the yer? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "," did the orgniztion follow written poliy or proedure requiring the orgniztion to evlute its prtiiption in joint venture rrngements under pplile federl tx lw, nd tke steps to sfegurd the orgniztion's exempt sttus with respet to suh rrngements? 6 Setion C. Dislosure 7 List the sttes with whih opy of this Form 990 is required to e filed JAK,AL,AR,AZ,CA,CO,CT,FL,GA,IL,KS,KY 8 Setion 60 requires n orgniztion to mke its Forms 0 (or 0 if pplile), 990, nd 990-T (Setion 0()()s only) ville Desrie in Shedule O whether (nd if so, how), the orgniztion mde its governing douments, onflit of interest poliy, nd finnil sttements ville to the puli during the tx yer. 0 Stte the nme, physil ddress, nd telephone numer of the person who possesses the ooks nd reords of the orgniztion: PEG SANDEEN SW 6TH AVENUE, SUITE 0, PORTLAND, OR SEE SCHEDULE O FOR FULL LIST OF STATES Form 990 (0) DEATH WITH DIGNITY NATION

7 Form 990 (0) DEATH WITH DIGNITY NATIONAL CENTER Prt VII Compenstion of Offiers, Diretors, Trustees, Key Employees, Highest Compensted Employees, nd Independent Contrtors Setion A. Chek if Shedule O ontins response or note to ny line in this Prt VII Offiers, Diretors, Trustees, Key Employees, nd Highest Compensted Employees Complete this tle for ll persons required to e listed. Report ompenstion for the lendr yer ending with or within the orgniztion's tx yer. List ll of the orgniztion's urrent offiers, diretors, trustees (whether individuls or orgniztions), regrdless of mount of ompenstion. Enter -0- in olumns (D), (E), nd (F) if no ompenstion ws pid. List ll of the orgniztion's urrent key employees, if ny. See instrutions for definition of "key employee." List the orgniztion's five urrent highest ompensted employees (other thn n offier, diretor, trustee, or key employee) who reeived reportle ompenstion (Box of Form W- nd/or Box 7 of Form 099-MISC) of more thn $00,000 from the orgniztion nd ny relted orgniztions. List ll of the orgniztion's former offiers, key employees, nd highest ompensted employees who reeived more thn $00,000 of reportle ompenstion from the orgniztion nd ny relted orgniztions. List ll of the orgniztion's former diretors or trustees tht reeived, in the pity s former diretor or trustee of the orgniztion, more thn $0,000 of reportle ompenstion from the orgniztion nd ny relted orgniztions. List persons in the following order: individul trustees or diretors; institutionl trustees; offiers; key employees; highest ompensted employees; nd former suh persons. (A) (B) (C) (D) (E) (F) Position (do not hek more thn one ox, unless person is oth n offier nd diretor/trustee) Individul trustee or diretor Institutionl trustee Offier Key employee Highest ompensted employee Former Chek this ox if neither the orgniztion nor ny relted orgniztion ompensted ny urrent offier, diretor, or trustee. Nme nd Title () STEVE TELFER PRESIDENT () CAROL PRATT, PHD, JD TREASURER () ELI STUTSMAN, JD SECRETARY () GEORGE EIGHMEY BOARD MEMBER () PEG SANDEEN EECUTIVE DIRECTOR Averge hours per week (list ny hours for relted orgniztions elow line) Reportle ompenstion from the orgniztion (W-/099-MISC) 8,98. Reportle ompenstion from relted orgniztions (W-/099-MISC) Pge 7 Estimted mount of other ompenstion from the orgniztion nd relted orgniztions 8, Form 990 (0) DEATH WITH DIGNITY NATION 706

8 Form 990 (0) DEATH WITH DIGNITY NATIONAL CENTER Pge 8 Prt VII Setion A. Offiers, Diretors, Trustees, Key Employees, nd Highest Compensted Employees (ontinued) (A) (B) (C) (D) (E) (F) Nme nd title Averge Position Reportle Reportle Estimted (do not hek more thn one hours per ox, unless person is oth n ompenstion ompenstion mount of week offier nd diretor/trustee) from from relted other (list ny the orgniztions ompenstion hours for orgniztion (W-/099-MISC) from the relted (W-/099-MISC) orgniztion orgniztions nd relted elow orgniztions line) Individul trustee or diretor Institutionl trustee Offier Key employee Highest ompensted employee Former Su-totl~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 8,98. 8,866. Totl from ontinution sheets to Prt VII, Setion A ~~~~~~~~~~ d Totl (dd lines nd ) 8,98. 8,866. Totl numer of individuls (inluding ut not limited to those listed ove) who reeived more thn $00,000 of reportle ompenstion from the orgniztion 0 Did the orgniztion list ny former offier, diretor, or trustee, key employee, or highest ompensted employee on line? If "," omplete Shedule J for suh individul ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ For ny individul listed on line, is the sum of reportle ompenstion nd other ompenstion from the orgniztion nd relted orgniztions greter thn $0,000? If "," omplete Shedule J for suh individul ~~~~~~~~~~~~~ Did ny person listed on line reeive or rue ompenstion from ny unrelted orgniztion or individul for servies rendered to the orgniztion? If "," omplete Shedule J for suh person Setion B. Independent Contrtors Complete this tle for your five highest ompensted independent ontrtors tht reeived more thn $00,000 of ompenstion from the orgniztion. Report ompenstion for the lendr yer ending with or within the orgniztion's tx yer. (A) (B) (C) Nme nd usiness ddress NONE Desription of servies Compenstion Totl numer of independent ontrtors (inluding ut not limited to those listed ove) who reeived more thn $00,000 of ompenstion from the orgniztion 0 Form 990 (0) DEATH WITH DIGNITY NATION 706

9 Form 990 (0) DEATH WITH DIGNITY NATIONAL CENTER Prt VIII Sttement of Revenue Contriutions, Gifts, Grnts nd Other Similr Amounts Progrm Servie Revenue Other Revenue d e f g nsh ontriutions inluded in lines -f: $ h d e f g 6 d d d e f Totl. Add lines -f Business Code Totl. Add lines -f Misellneous Revenue Business Code OTHER INCOME All other ontriutions, gifts, grnts, nd similr mounts not inluded ove ~~ Pge 9 Chek if Shedule O ontins response or note to ny line in this Prt VIII (A) (B) (C) (D) Totl revenue Relted or Unrelted Revenue exluded exempt funtion usiness from tx under setions revenue revenue - Federted mpigns Memership dues Fundrising events Relted orgniztions ~~~~~~ ~~~~~~~~ ~~~~~~~~ ~~~~~~ Government grnts (ontriutions) All other progrm servie revenue ~~~~~ Investment inome (inluding dividends, interest, nd other similr mounts) ~~~~~~~~~~~~~~~~~ Inome from investment of tx-exempt ond proeeds Roylties Gross rents ~~~~~~~ Less: rentl expenses ~~~ Rentl inome or (loss) Net rentl inome or (loss) ~~ 7 Gross mount from sles of ssets other thn inventory Less: ost or other sis nd sles expenses ~~~ Gin or (loss) ~~~~~~~ (i) Rel (ii) Personl (i) Seurities 07,7 (ii) Other,78. Net gin or (loss) Gross inome from fundrising events (not inluding $ of ontriutions reported on line ). See Prt IV, line 8 ~~~~~~~~~~~~~ Less: diret expenses ~~~~~~~~~~ Net inome or (loss) from fundrising events Gross inome from gming tivities. See Prt IV, line 9 ~~~~~~~~~~~~~ Less: diret expenses ~~~~~~~~~ Net inome or (loss) from gming tivities Gross sles of inventory, less returns nd llownes ~~~~~~~~~~~~~ Less: ost of goods sold,8. -,98. ~~~~~~~~ Net inome or (loss) from sles of inventory,78. 9,8,78.,78. 7,. 7,. -,98. -,98. d All other revenue ~~~~~~~~~~~~~ e Totl. Add lines -d ~~~~~~~~~~~~~~~ 7. Totl revenue. See instrutions. 9,., Form 990 (0) DEATH WITH DIGNITY NATION 706

10 Form 990 (0) DEATH WITH DIGNITY NATIONAL CENTER Prt I Sttement of Funtionl Expenses Setion 0()() nd 0()() orgniztions must omplete ll olumns. All other orgniztions must omplete olumn (A). Chek if Shedule O ontins response or note to ny line in this Prt I Do not inlude mounts reported on lines 6, (A) (B) (C) (D) Totl expenses Progrm servie Mngement nd Fundrising 7, 8, 9, nd 0 of Prt VIII. expenses generl expenses expenses d e f g d e Grnts nd other ssistne to governments nd orgniztions in the United Sttes. See Prt IV, line Grnts nd other ssistne to individuls in the United Sttes. See Prt IV, line ~~~ Grnts nd other ssistne to governments, orgniztions, nd individuls outside the United Sttes. See Prt IV, lines nd 6 ~ Benefits pid to or for memers ~~~~~~~ Compenstion of urrent offiers, diretors, trustees, nd key employees ~~~~~~~~ Compenstion not inluded ove, to disqulified persons (s defined under setion 98(f)()) nd persons desried in setion 98()()(B) Pension pln ruls nd ontriutions (inlude ~~~ Other slries nd wges ~~~~~~~~~~ setion 0(k) nd 0() employer ontriutions) Other employee enefits ~~~~~~~~~~ Pyroll txes ~~~~~~~~~~~~~~~~ Fees for servies (non-employees): Mngement ~~~~~~~~~~~~~~~~ Legl ~~~~~~~~~~~~~~~~~~~~ Aounting ~~~~~~~~~~~~~~~~~ Loying ~~~~~~~~~~~~~~~~~~ Professionl fundrising servies. See Prt IV, line 7 Investment mngement fees ~~~~~~~~ Other. (If line g mount exeeds 0% of line, olumn (A) mount, list line g expenses on Sh O.) Advertising nd promotion ~~~~~~~~~ Offie expenses~~~~~~~~~~~~~~~ Informtion tehnology ~~~~~~~~~~~ Roylties ~~~~~~~~~~~~~~~~~~ Oupny ~~~~~~~~~~~~~~~~~ Trvel ~~~~~~~~~~~~~~~~~~~ Pyments of trvel or entertinment expenses for ny federl, stte, or lol puli offiils Conferenes, onventions, nd meetings ~~ Interest ~~~~~~~~~~~~~~~~~~ Pyments to ffilites ~~~~~~~~~~~~ Depreition, depletion, nd mortiztion Insurne All other expenses Totl funtionl expenses. Add lines through e Joint osts. Complete this line only if the orgniztion reported in olumn (B) joint osts from omined edutionl mpign nd fundrising soliittion. ~~ ~~~~~~~~~~~~~~~~~ Other expenses. Itemize expenses not overed ove. (List misellneous expenses in line e. If line e mount exeeds 0% of line, olumn (A) mount, list line e expenses on Shedule O.) ~~ MISCELLANEOUS MEDIA & PUBLIC EDUCATIO Chek here if following SOP 98- (ASC 98-70) 0,89. 66,9.,.,86.,66.,0. 0,00,66, 9,0. 9,. 9,.,.,9,8. 7,7. Pge 0 70,6.,88. 7,8.,. 9,6.,., ,. 707.,. 6,6,9. 6,9.,99.,907. 8,7. 0, ,6.,06. 9,78. 6,86.,99. 8,9.,069.,.,. 6,06.,8.,., ,.,. 8, 6,7.,8. 98,. 0,66., Form 990 (0) DEATH WITH DIGNITY NATION 706

11 Form 990 (0) DEATH WITH DIGNITY NATIONAL CENTER Pge Prt Blne Sheet Chek if Shedule O ontins response or note to ny line in this Prt Net Assets or Fund Blnes Liilities Assets (A) (B) Beginning of yer End of yer Csh - non-interest-ering ~~~~~~~~~~~~~~~~~~~~~~~~~, ,78. Svings nd temporry sh investments ~~~~~~~~~~~~~~~~~~,.,. Pledges nd grnts reeivle, net ~~~~~~~~~~~~~~~~~~~~~ Aounts reeivle, net ~~~~~~~~~~~~~~~~~~~~~~~~~~ Lons nd other reeivles from urrent nd former offiers, diretors, trustees, key employees, nd highest ompensted employees. Complete Prt II of Shedule L ~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 6 Lons nd other reeivles from other disqulified persons (s defined under setion 98(f)()), persons desried in setion 98()()(B), nd ontriuting employers nd sponsoring orgniztions of setion 0()(9) voluntry 7 8 employees' enefiiry orgniztions (see instr). Complete Prt II of Sh L ~~ tes nd lons reeivle, net ~~~~~~~~~~~~~~~~~~~~~~~ Inventories for sle or use ~~~~~~~~~~~~~~~~~~~~~~~~~~ Prepid expenses nd deferred hrges ~~~~~~~~~~~~~~~~~~,06. 9,76. 0 Lnd, uildings, nd equipment: ost or other sis. Complete Prt VI of Shedule D ~~~ 0,798. Less: umulted depreition ~~~~~~ 0 6,6. 6, ,. Investments - pulily trded seurities ~~~~~~~~~~~~~~~~~~~ 9, 9,8. Investments - other seurities. See Prt IV, line ~~~~~~~~~~~~~~ Investments - progrm-relted. See Prt IV, line ~~~~~~~~~~~~~ Intngile ssets ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Other ssets. See Prt IV, line ~~~~~~~~~~~~~~~~~~~~~~ 0,9.,7. 6 Totl ssets. Add lines through (must equl line ) 79,6. 6,08. 7 Aounts pyle nd rued expenses ~~~~~~~~~~~~~~~~~~ 8,9. 7 9, Grnts pyle ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Deferred revenue ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Tx-exempt ond liilities ~~~~~~~~~~~~~~~~~~~~~~~~~ 0 Esrow or ustodil ount liility. Complete Prt IV of Shedule D ~~~~ Lons nd other pyles to urrent nd former offiers, diretors, trustees, key employees, highest ompensted employees, nd disqulified persons. Complete Prt II of Shedule L ~~~~~~~~~~~~~~~~~~~~~~~ Seured mortgges nd notes pyle to unrelted third prties ~~~~~~ Unseured notes nd lons pyle to unrelted third prties ~~~~~~~~ Other liilities (inluding federl inome tx, pyles to relted third prties, nd other liilities not inluded on lines 7-). Complete Prt of Shedule D ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 6 Totl liilities. Add lines 7 through 8,9. 6 9,7. Orgniztions tht follow SFAS 7 (ASC 98), hek here nd omplete lines 7 through 9, nd lines nd. 7 Unrestrited net ssets ~~~~~~~~~~~~~~~~~~~~~~~~~~~,. 7 6, Temporrily restrited net ssets Permnently restrited net ssets ~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~ 8 9 Orgniztions tht do not follow SFAS 7 (ASC 98), hek here nd omplete lines 0 through. 0 Cpitl stok or trust prinipl, or urrent funds ~~~~~~~~~~~~~~~ 0 Pid-in or pitl surplus, or lnd, uilding, or equipment fund ~~~~~~~~ Retined ernings, endowment, umulted inome, or other funds ~~~~ Totl net ssets or fund lnes ~~~~~~~~~~~~~~~~~~~~~~,. 6,06. Totl liilities nd net ssets/fund lnes 79,6.,08. Form 990 (0) DEATH WITH DIGNITY NATION 706

12 Form 990 (0) DEATH WITH DIGNITY NATIONAL CENTER Prt I Reonilition of Net Assets Chek if Shedule O ontins response or note to ny line in this Prt I Totl revenue (must equl Prt VIII, olumn (A), line ) Totl expenses (must equl Prt I, olumn (A), line ) Revenue less expenses. Sutrt line from line ~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Net ssets or fund lnes t eginning of yer (must equl Prt, line, olumn (A)) Net unrelized gins (losses) on investments Donted servies nd use of filities Investment expenses Prior period djustments ~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Other hnges in net ssets or fund lnes (explin in Shedule O) ~~~~~~~~~~~~~~~~~~~ Pge 0 Net ssets or fund lnes t end of yer. Comine lines through 9 (must equl Prt, line, olumn (B)) 0 6,06. Prt II Finnil Sttements nd Reporting Chek if Shedule O ontins response or note to ny line in this Prt II Aounting method used to prepre the Form 990: Csh Arul Other If the orgniztion hnged its method of ounting from prior yer or heked "Other," explin in Shedule O. Were the orgniztion's finnil sttements ompiled or reviewed y n independent ountnt? ~~~~~~~~~~~~ If "," hek ox elow to indite whether the finnil sttements for the yer were ompiled or reviewed on seprte sis, onsolidted sis, or oth: Seprte sis Consolidted sis Both onsolidted nd seprte sis Were the orgniztion's finnil sttements udited y n independent ountnt? ~~~~~~~~~~~~~~~~~~~ If "," hek ox elow to indite whether the finnil sttements for the yer were udited on seprte sis, onsolidted sis, or oth: Seprte sis Consolidted sis Both onsolidted nd seprte sis If "" to line or, does the orgniztion hve ommittee tht ssumes responsiility for oversight of the udit, review, or ompiltion of its finnil sttements nd seletion of n independent ountnt? ~~~~~~~~~~~~~~~ If the orgniztion hnged either its oversight proess or seletion proess during the tx yer, explin in Shedule O. As result of federl wrd, ws the orgniztion required to undergo n udit or udits s set forth in the Single Audit At nd OMB Cirulr A-? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "," did the orgniztion undergo the required udit or udits? If the orgniztion did not undergo the required udit or udits, explin why in Shedule O nd desrie ny steps tken to undergo suh udits 9,. 7,7. 77,78.,. 7, Form 990 (0) DEATH WITH DIGNITY NATION 706

13 SCHEDULE A OMB (Form 990 or 990-EZ) Complete if the orgniztion is setion 0()() orgniztion or setion 97()() nonexempt hritle trust. Deprtment of the Tresury Atth to Form 990 or Form 990-EZ. Open to Puli Internl Revenue Servie Informtion out Shedule A (Form 990 or 990-EZ) nd its instrutions is t Inspetion Nme of the orgniztion Employer identifition numer Prt I The orgniztion is not privte foundtion euse it is: (For lines through, hek only one ox.) e f g h A hurh, onvention of hurhes, or ssoition of hurhes desried in A shool desried in setion 70()()(A)(ii). (Atth Shedule E.) setion 70()()(A)(i). A hospitl or oopertive hospitl servie orgniztion desried in setion 70()()(A)(iii). A medil reserh orgniztion operted in onjuntion with hospitl desried in setion 70()()(A)(iii). Enter the hospitl's nme, ity, nd stte: An orgniztion operted for the enefit of ollege or university owned or operted y governmentl unit desried in setion 70()()(A)(iv). (Complete Prt II.) A federl, stte, or lol government or governmentl unit desried in setion 70()()(A)(v). An orgniztion tht normlly reeives sustntil prt of its support from governmentl unit or from the generl puli desried in setion 70()()(A)(vi). (Complete Prt II.) A ommunity trust desried in setion 70()()(A)(vi). (Complete Prt II.) An orgniztion tht normlly reeives: () more thn /% of its support from ontriutions, memership fees, nd gross reeipts from tivities relted to its exempt funtions - sujet to ertin exeptions, nd () no more thn /% of its support from gross investment inome nd unrelted usiness txle inome (less setion tx) from usinesses quired y the orgniztion fter June 0, 97. See setion 09()(). (Complete Prt III.) An orgniztion orgnized nd operted exlusively to test for puli sfety. See setion 09()(). An orgniztion orgnized nd operted exlusively for the enefit of, to perform the funtions of, or to rry out the purposes of one or more pulily supported orgniztions desried in setion 09()() or setion 09()(). See setion 09()(). Chek the ox tht desries the type of supporting orgniztion nd omplete lines e through h. Type I Type II Type III - Funtionlly integrted d Type III - n-funtionlly integrted By heking this ox, I ertify tht the orgniztion is not ontrolled diretly or indiretly y one or more disqulified persons other thn foundtion mngers nd other thn one or more pulily supported orgniztions desried in setion 09()() or setion 09()(). If the orgniztion reeived written determintion from the IRS tht it is Type I, Type II, or Type III supporting orgniztion, hek this ox (i) (ii) (iii) Puli Chrity Sttus nd Puli Support DEATH WITH DIGNITY NATIONAL CENTER Reson for Puli Chrity Sttus (All orgniztions must omplete this prt.) See instrutions. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Sine August 7, 006, hs the orgniztion epted ny gift or ontriution from ny of the following persons? A person who diretly or indiretly ontrols, either lone or together with persons desried in (ii) nd (iii) elow, the governing ody of the supported orgniztion? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ A fmily memer of person desried in (i) ove? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ A % ontrolled entity of person desried in (i) or (ii) ove? ~~~~~~~~~~~~~~~~~~~~~~~~ Provide the following informtion out the supported orgniztion(s) g(i) g(ii) g(iii) (i) Nme of supported (ii) EIN (iii) Type of orgniztion (iv) Is the orgniztion (v) Did you notify the (vi) Is the (vii) (desried on lines -9 in ol. (i) listed in your orgniztion in ol. orgniztion in ol. orgniztion (i) orgnized in the ove or IRC setion governing doument? (i) of your support? U.S.? (see instrutions) ) Amount of monetry support Totl LHA For Pperwork Redution At tie, see the Instrutions for Form 990 or 990-EZ. Shedule A (Form 990 or 990-EZ) DEATH WITH DIGNITY NATION 706

14 Shedule A (Form 990 or 990-EZ) 0 DEATH WITH DIGNITY NATIONAL CENTER Prt II Support Shedule for Orgniztions Desried in Setions 70()()(A)(iv) nd 70()()(A)(vi) Clendr yer (or fisl yer eginning in) Totl. Add lines through ~~~ 6 Puli support. Sutrt line from line. Clendr yer (or fisl yer eginning in) Totl support. Add lines 7 through 0 () 009 () 00 () 0 (d) 0 (e) 0 (f) Totl Pge () 009 () 00 () 0 (d) 0 (e) 0 (f) Totl,9. 9,966. 7,99. 6,, First five yers. If the Form 990 is for the orgniztion's first, seond, third, fourth, or fifth tx yer s setion 0()() orgniztion, hek this ox nd stop here Setion C. Computtion of Puli Support Perentge Puli support perentge for 0 (line 6, olumn (f) divided y line, olumn (f)) ~~~~~~~~~~~~ 8.8 Puli support perentge from 0 Shedule A, Prt II, line ~~~~~~~~~~~~~~~~~~~~~ (Complete only if you heked the ox on line, 7, or 8 of Prt I or if the orgniztion filed to qulify under Prt III. If the orgniztion fils to qulify under the tests listed elow, plese omplete Prt III.) Setion A. Puli Support Gifts, grnts, ontriutions, nd memership fees reeived. (Do not inlude ny "unusul grnts.") ~~ Tx revenues levied for the orgniztion's enefit nd either pid to or expended on its ehlf ~~~~ The vlue of servies or filities furnished y governmentl unit to the orgniztion without hrge ~ The portion of totl ontriutions y eh person (other thn governmentl unit or pulily supported orgniztion) inluded on line tht exeeds % of the mount shown on line, olumn (f) ~~~~~~~~~~~~ Setion B. Totl Support Amounts from line ~~~~~~~ Gross inome from interest, dividends, pyments reeived on seurities lons, rents, roylties nd inome from similr soures ~ Net inome from unrelted usiness tivities, whether or not the usiness is regulrly rried on ~ Other inome. Do not inlude gin or loss from the sle of pitl ssets (Explin in Prt IV.) ~~~~,9.,9. 9,966. 9,966. Gross reeipts from relted tivities, et. (see instrutions) ~~~~~~~~~~~~~~~~~~~~~~~ 7,99. 6,, ,99. 6,, /% support test - 0. If the orgniztion did not hek ox on line or 6, nd line is /% or more, hek this ox nd stop here. The orgniztion qulifies s pulily supported orgniztion ~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 7 0% -fts-nd-irumstnes test - 0. If the orgniztion did not hek ox on line, 6, or 6, nd line is 0% or more, nd if the orgniztion meets the "fts-nd-irumstnes" test, hek this ox nd stop here. Explin in Prt IV how the orgniztion meets the "fts-nd-irumstnes" test. The orgniztion qulifies s pulily supported orgniztion ~~~~~~~~~~~~~~~ 0% -fts-nd-irumstnes test - 0. If the orgniztion did not hek ox on line, 6, 6, or 7, nd line is 0% or more, nd if the orgniztion meets the "fts-nd-irumstnes" test, hek this ox nd stop here. Explin in Prt IV how the orgniztion meets the "fts-nd-irumstnes" test. The orgniztion qulifies s pulily supported orgniztion ~~~~~~~~ Privte foundtion. If the orgniztion did not hek ox on line, 6, 6, 7, or 7, hek this ox nd see instrutions 9, ,7,9.,80. 8,. 7,. 99, /% support test - 0. If the orgniztion did not hek the ox on line, nd line is /% or more, hek this ox nd stop here. The orgniztion qulifies s pulily supported orgniztion ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Shedule A (Form 990 or 990-EZ) 0 % % DEATH WITH DIGNITY NATION 706

15 Shedule A (Form 990 or 990-EZ) 0 Prt III Support Shedule for Orgniztions Desried in Setion 09()() Clendr yer (or fisl yer eginning in) 6 The vlue of servies or filities furnished y governmentl unit to the orgniztion without hrge ~ Totl. Add lines through ~~~ 7 Amounts inluded on lines,, nd reeived from disqulified persons Amounts inluded on lines nd reeived from other thn disqulified persons tht exeed the greter of $,000 or % of the mount on line for the yer ~~~~~~ Add lines 7 nd 7 ~~~~~~~ 8 Puli support (Sutrt line 7 from line 6.) Clendr yer (or fisl yer eginning in) 9 Amounts from line 6 ~~~~~~~ 0 Gross inome from interest, dividends, pyments reeived on seurities lons, rents, roylties nd inome from similr soures ~ () 009 () 00 () 0 (d) 0 (e) 0 (f) Totl () 009 () 00 () 0 (d) 0 (e) 0 (f) Totl hek this ox nd stop here Setion C. Computtion of Puli Support Perentge 6 Puli support perentge from 0 Shedule A, Prt III, line Setion D. Computtion of Investment Inome Perentge (Complete only if you heked the ox on line 9 of Prt I or if the orgniztion filed to qulify under Prt II. If the orgniztion fils to qulify under the tests listed elow, plese omplete Prt II.) Setion A. Puli Support Gifts, grnts, ontriutions, nd memership fees reeived. (Do not inlude ny "unusul grnts.") ~~ Gross reeipts from dmissions, merhndise sold or servies performed, or filities furnished in ny tivity tht is relted to the orgniztion's tx-exempt purpose Gross reeipts from tivities tht re not n unrelted trde or usiness under setion ~~~~~ Tx revenues levied for the orgniztion's enefit nd either pid to or expended on its ehlf ~~~~ Setion B. Totl Support Unrelted usiness txle inome (less setion txes) from usinesses quired fter June 0, 97 ~~~~ Add lines 0 nd 0 ~~~~~~ Net inome from unrelted usiness tivities not inluded in line 0, whether or not the usiness is regulrly rried on ~~~~~~~ Other inome. Do not inlude gin or loss from the sle of pitl ssets (Explin in Prt IV.) ~~~~ Totl support. (Add lines 9, 0,, nd.) First five yers. If the Form 990 is for the orgniztion's first, seond, third, fourth, or fifth tx yer s setion 0()() orgniztion, Pge Puli support perentge for 0 (line 8, olumn (f) divided y line, olumn (f)) ~~~~~~~~~~~~ % Investment inome perentge for 0 (line 0, olumn (f) divided y line, olumn (f)) Investment inome perentge from 0 Shedule A, Prt III, line 7 ~~~~~~~~~~~~~~~~~~ 6 ~~~~~~~~ 7 % 9 /% support tests - 0. If the orgniztion did not hek the ox on line, nd line is more thn /%, nd line 7 is not more thn /%, hek this ox nd stop here. The orgniztion qulifies s pulily supported orgniztion ~~~~~~~~~~ /% support tests - 0. If the orgniztion did not hek ox on line or line 9, nd line 6 is more thn /%, nd line 8 is not more thn /%, hek this ox nd stop here. The orgniztion qulifies s pulily supported orgniztion ~~~~ Privte foundtion. If the orgniztion did not hek ox on line, 9, or 9, hek this ox nd see instrutions Shedule A (Form 990 or 990-EZ) DEATH WITH DIGNITY NATION % %

16 Shedule A (Form 990 or 990-EZ) 0 DEATH WITH DIGNITY NATIONAL CENTER Pge Prt IV Supplementl Informtion. Provide the explntions required y Prt II, line 0; Prt II, line 7 or 7; nd Prt III, line. Also omplete this prt for ny dditionl informtion. (See instrutions) Shedule A (Form 990 or 990-EZ) DEATH WITH DIGNITY NATION 706

17 Shedule B (Form 990, 990-EZ, or 990-PF) Deprtment of the Tresury Internl Revenue Servie Nme of the orgniztion ** PUBLIC DISCLOSURE COPY ** Shedule of Contriutors Atth to Form 990, Form 990-EZ, or Form 990-PF. Informtion out Shedule B (Form 990, 990-EZ, or 990-PF) nd its instrutions is t OMB Employer identifition numer Orgniztion type (hek one): DEATH WITH DIGNITY NATIONAL CENTER Filers of: Setion: Form 990 or 990-EZ 0()( ) (enter numer) orgniztion 97()() nonexempt hritle trust not treted s privte foundtion 7 politil orgniztion Form 990-PF 0()() exempt privte foundtion 97()() nonexempt hritle trust treted s privte foundtion 0()() txle privte foundtion Chek if your orgniztion is overed y the Generl Rule or Speil Rule. te. Only setion 0()(7), (8), or (0) orgniztion n hek oxes for oth the Generl Rule nd Speil Rule. See instrutions. Generl Rule For n orgniztion filing Form 990, 990-EZ, or 990-PF tht reeived, during the yer, $,000 or more (in money or property) from ny one ontriutor. Complete Prts I nd II. Speil Rules For setion 0()() orgniztion filing Form 990 or 990-EZ tht met the /% support test of the regultions under setions 09()() nd 70()()(A)(vi) nd reeived from ny one ontriutor, during the yer, ontriution of the greter of () $,000 or () % of the mount on (i) Form 990, Prt VIII, line h, or (ii) Form 990-EZ, line. Complete Prts I nd II. For setion 0()(7), (8), or (0) orgniztion filing Form 990 or 990-EZ tht reeived from ny one ontriutor, during the yer, totl ontriutions of more thn $,000 for use exlusively for religious, hritle, sientifi, literry, or edutionl purposes, or the prevention of ruelty to hildren or nimls. Complete Prts I, II, nd III. For setion 0()(7), (8), or (0) orgniztion filing Form 990 or 990-EZ tht reeived from ny one ontriutor, during the yer, ontriutions for use exlusively for religious, hritle, et., purposes, ut these ontriutions did not totl to more thn $,00 If this ox is heked, enter here the totl ontriutions tht were reeived during the yer for n exlusively religious, hritle, et., purpose. Do not omplete ny of the prts unless the Generl Rule pplies to this orgniztion euse it reeived nonexlusively religious, hritle, et., ontriutions of $,000 or more during the yer ~~~~~~~~~~~~~~~~~ $ Cution. An orgniztion tht is not overed y the Generl Rule nd/or the Speil Rules does not file Shedule B (Form 990, 990-EZ, or 990-PF), ut it must nswer "" on Prt IV, line, of its Form 990; or hek the ox on line H of its Form 990-EZ or on its Form 990-PF, Prt I, line, to ertify tht it does not meet the filing requirements of Shedule B (Form 990, 990-EZ, or 990-PF). LHA For Pperwork Redution At tie, see the Instrutions for Form 990, 990-EZ, or 990-PF. Shedule B (Form 990, 990-EZ, or 990-PF) (0) 0--

18 Shedule B (Form 990, 990-EZ, or 990-PF) (0) Nme of orgniztion Employer identifition numer Pge DEATH WITH DIGNITY NATIONAL CENTER Prt I Contriutors (see instrutions). Use duplite opies of Prt I if dditionl spe is needed. (). () Nme, ddress, nd ZIP + () Totl ontriutions (d) Type of ontriution Person Pyroll $,97. nsh (Complete Prt II for nonsh ontriutions.) (). () Nme, ddress, nd ZIP + () Totl ontriutions (d) Type of ontriution Person Pyroll $ 9,607. nsh (Complete Prt II for nonsh ontriutions.) (). () Nme, ddress, nd ZIP + () Totl ontriutions (d) Type of ontriution Person Pyroll $,6 nsh (Complete Prt II for nonsh ontriutions.) (). () Nme, ddress, nd ZIP + () Totl ontriutions (d) Type of ontriution $ Person Pyroll nsh (Complete Prt II for nonsh ontriutions.) (). () Nme, ddress, nd ZIP + () Totl ontriutions (d) Type of ontriution $ Person Pyroll nsh (Complete Prt II for nonsh ontriutions.) (). () Nme, ddress, nd ZIP + () Totl ontriutions (d) Type of ontriution Person Pyroll nsh 0-- Shedule B (Form 990, 990-EZ, or 990-PF) (0) DEATH WITH DIGNITY NATION 706 $ (Complete Prt II for nonsh ontriutions.)

19 Shedule B (Form 990, 990-EZ, or 990-PF) (0) Nme of orgniztion Pge Employer identifition numer DEATH WITH DIGNITY NATIONAL CENTER Prt II nsh Property (see instrutions). Use duplite opies of Prt II if dditionl spe is needed. (). from Prt I STOCK () Desription of nonsh property given () FMV (or estimte) (see instrutions) (d) Dte reeived $,77. 0// (). from Prt I () Desription of nonsh property given () FMV (or estimte) (see instrutions) (d) Dte reeived $ (). from Prt I () Desription of nonsh property given () FMV (or estimte) (see instrutions) (d) Dte reeived $ (). from Prt I () Desription of nonsh property given () FMV (or estimte) (see instrutions) (d) Dte reeived $ (). from Prt I () Desription of nonsh property given () FMV (or estimte) (see instrutions) (d) Dte reeived $ (). from Prt I () Desription of nonsh property given () FMV (or estimte) (see instrutions) (d) Dte reeived 0-- Shedule B (Form 990, 990-EZ, or 990-PF) (0) DEATH WITH DIGNITY NATION 706 $

20 Shedule B (Form 990, 990-EZ, or 990-PF) (0) Nme of orgniztion Pge Employer identifition numer DEATH WITH DIGNITY NATIONAL CENTER Prt III (). from Prt I Exlusively religious, hritle, et., individul ontriutions to setion 0()(7), (8), or (0) orgniztions tht totl more thn $,000 for the yer. Complete olumns () through (e) nd the following line entry. For orgniztions ompleting Prt III, enter the totl of exlusively religious, hritle, et., ontriutions of $,000 or less for the yer. (Enter this informtion one.) $ Use duplite opies of Prt III if dditionl spe is needed. () Purpose of gift () Use of gift (d) Desription of how gift is held (e) Trnsfer of gift Trnsferee's nme, ddress, nd ZIP + Reltionship of trnsferor to trnsferee (). from Prt I () Purpose of gift () Use of gift (d) Desription of how gift is held (e) Trnsfer of gift Trnsferee's nme, ddress, nd ZIP + Reltionship of trnsferor to trnsferee (). from Prt I () Purpose of gift () Use of gift (d) Desription of how gift is held (e) Trnsfer of gift Trnsferee's nme, ddress, nd ZIP + Reltionship of trnsferor to trnsferee (). from Prt I () Purpose of gift () Use of gift (d) Desription of how gift is held (e) Trnsfer of gift Trnsferee's nme, ddress, nd ZIP + Reltionship of trnsferor to trnsferee 0-- Shedule B (Form 990, 990-EZ, or 990-PF) (0) DEATH WITH DIGNITY NATION 706

21 SCHEDULE C (Form 990 or 990-EZ) Deprtment of the Tresury Internl Revenue Servie For Orgniztions Exempt From Inome Tx Under setion 0() nd setion 7 J Complete if the orgniztion is desried elow. J Atth to Form 990 or Form 990-EZ. See seprte instrutions. Informtion out Shedule C (Form 990 or 990-EZ) nd its instrutions is t If the orgniztion nswered "," to Form 990, Prt IV, line, or Form 990-EZ, Prt V, line 6 (Politil Cmpign Ativities), then Setion 0()() orgniztions: Complete Prts I-A nd B. Do not omplete Prt I-C. Setion 0() (other thn setion 0()()) orgniztions: Complete Prts I-A nd C elow. Do not omplete Prt I-B. Setion 7 orgniztions: Complete Prt I-A only. Politil Cmpign nd Loying Ativities If the orgniztion nswered "," to Form 990, Prt IV, line, or Form 990-EZ, Prt VI, line 7 (Loying Ativities), then Setion 0()() orgniztions tht hve filed Form 768 (eletion under setion 0(h)): Complete Prt II-A. Do not omplete Prt II-B. If the orgniztion nswered "," to Form 990, Prt IV, line (Proxy Tx) or Form 990-EZ, Prt V, line (Proxy Tx), then OMB Open to Puli Inspetion Setion 0()() orgniztions tht hve NOT filed Form 768 (eletion under setion 0(h)): Complete Prt II-B. Do not omplete Prt II-A. Setion 0()(), (), or (6) orgniztions: Complete Prt III. Nme of orgniztion Employer identifition numer DEATH WITH DIGNITY NATIONAL CENTER Prt I-A Complete if the orgniztion is exempt under setion 0() or is setion 7 orgniztion. Provide desription of the orgniztion's diret nd indiret politil mpign tivities in Prt IV. Politil expenditures ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ J $ Volunteer hours ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Prt I-B Complete if the orgniztion is exempt under setion 0()(). Enter the mount of ny exise tx inurred y the orgniztion under setion 9 ~~~~~~~~~~~~~ J $ Enter the mount of ny exise tx inurred y orgniztion mngers under setion 9 ~~~~~~~~~~ J $ If the orgniztion inurred setion 9 tx, did it file Form 70 for this yer? ~~~~~~~~~~~~~~~~~~~ Ws orretion mde? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "," desrie in Prt IV. Prt I-C Complete if the orgniztion is exempt under setion 0(), exept setion 0()(). Enter the mount diretly expended y the filing orgniztion for setion 7 exempt funtion tivities ~~~~ J $ Enter the mount of the filing orgniztion's funds ontriuted to other orgniztions for setion 7 exempt funtion tivities ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ J $ Totl exempt funtion expenditures. Add lines nd. Enter here nd on Form 0-POL, line 7 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ J $ Did the filing orgniztion file Form 0-POL for this yer? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Enter the nmes, ddresses nd employer identifition numer (EIN) of ll setion 7 politil orgniztions to whih the filing orgniztion mde pyments. For eh orgniztion listed, enter the mount pid from the filing orgniztion's funds. Also enter the mount of politil ontriutions reeived tht were promptly nd diretly delivered to seprte politil orgniztion, suh s seprte segregted fund or politil tion ommittee (PAC). If dditionl spe is needed, provide informtion in Prt IV. () Nme () Address () EIN (d) Amount pid from (e) Amount of politil filing orgniztion's ontriutions reeived nd funds. If none, enter -0-. promptly nd diretly delivered to seprte politil orgniztion. If none, enter -0-. For Pperwork Redution At tie, see the Instrutions for Form 990 or 990-EZ. Shedule C (Form 990 or 990-EZ) 0 LHA DEATH WITH DIGNITY NATION 706

22 Shedule C (Form 990 or 990-EZ) 0 DEATH WITH DIGNITY NATIONAL CENTER Prt II-A Complete if the orgniztion is exempt under setion 0()() nd filed Form 768 (eletion under setion 0(h)). A B Chek Chek J J if the filing orgniztion elongs to n ffilited group (nd list in Prt IV eh ffilited group memer's nme, ddress, EIN, expenses, nd shre of exess loying expenditures). if the filing orgniztion heked ox A nd "limited ontrol" provisions pply. Limits on Loying Expenditures (The term "expenditures" mens mounts pid or inurred.) () Filing orgniztion's totls () Pge Affilited group totls d e f Totl loying expenditures to influene puli opinion (grss roots loying) ~~~~~~~~~~ Totl loying expenditures to influene legisltive ody (diret loying) ~~~~~~~~~~~ Totl loying expenditures (dd lines nd ) ~~~~~~~~~~~~~~~~~~~~~~~~ Other exempt purpose expenditures ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Totl exempt purpose expenditures (dd lines nd d) ~~~~~~~~~~~~~~~~~~~~ Loying nontxle mount. Enter the mount from the following tle in oth olumns. If the mount on line e, olumn () or () is: The loying nontxle mount is: t over $00,000 0% of the mount on line e. Over $00,000 ut not over $,000,000 $00,000 plus % of the exess over $00,00 Over $,000,000 ut not over $,00,000 $7,000 plus 0% of the exess over $,000,00 Over $,00,000 ut not over $7,000,000 $,000 plus % of the exess over $,00,00 Over $7,000,000 $,000,00 0,00 0,00 8,88. 8,88. 67,776. g h i j Grssroots nontxle mount (enter % of line f) Sutrt line g from line. If zero or less, enter -0- ~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~ Sutrt line f from line. If zero or less, enter -0- ~~~~~~~~~~~~~~~~~~~~~~~ If there is n mount other thn zero on either line h or line i, did the orgniztion file Form 70 reporting setion 9 tx for this yer? 6,9. -Yer Averging Period Under Setion 0(h) (Some orgniztions tht mde setion 0(h) eletion do not hve to omplete ll of the five olumns elow. See the instrutions for lines through f on pge.) Loying Expenditures During -Yer Averging Period Clendr yer (or fisl yer eginning in) () 00 () 0 () 0 (d) 0 (e) Totl Loying nontxle mount Loying eiling mount (0% of line, olumn(e)) 00,8.,06. 96,97. 67, ,7. 8,8. Totl loying expenditures 80,00 0,00 00,00 d e Grssroots nontxle mount Grssroots eiling mount (0% of line d, olumn (e)),08.,0.,9. 6,9. 97,07.,96. f Grssroots loying expenditures Shedule C (Form 990 or 990-EZ) DEATH WITH DIGNITY NATION 706

23 Shedule C (Form 990 or 990-EZ) 0 DEATH WITH DIGNITY NATIONAL CENTER Prt II-B Complete if the orgniztion is exempt under setion 0()() nd hs NOT filed Form 768 (eletion under setion 0(h)). Pge For eh "," response to lines through i elow, provide in Prt IV detiled desription of the loying tivity. () () Amount d e f g h i j d If the filing orgniztion inurred setion 9 tx, did it file Form 70 for this yer? Prt III-A Complete if the orgniztion is exempt under setion 0()(), setion 0()(), or setion 0()(6). Did the orgniztion gree to rry over loying nd politil expenditures from the prior yer? Prt III-B Complete if the orgniztion is exempt under setion 0()(), setion 0()(), or setion 0()(6) nd if either () BOTH Prt III-A, lines nd, re nswered "," OR () Prt III-A, line, is nswered "." During the yer, did the filing orgniztion ttempt to influene foreign, ntionl, stte or lol legisltion, inluding ny ttempt to influene puli opinion on legisltive mtter or referendum, through the use of: Volunteers? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Pid stff or mngement (inlude ompenstion in expenses reported on lines through i)? Medi dvertisements? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Milings to memers, legisltors, or the puli? Pulitions, or pulished or rodst sttements? Grnts to other orgniztions for loying purposes? expenses for whih the setion 7(f) tx ws pid). ~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~ Diret ontt with legisltors, their stffs, government offiils, or legisltive ody? Rllies, demonstrtions, seminrs, onventions, speehes, letures, or ny similr mens? ~~~~ Other tivities? (do not inlude mounts of politil expenditure next yer? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Txle mount of loying nd politil expenditures (see instrutions) Prt IV Supplementl Informtion ~ ~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Totl. Add lines through i ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the tivities in line use the orgniztion to e not desried in setion 0()()? If "," enter the mount of ny tx inurred under setion 9 If "," enter the mount of ny tx inurred y orgniztion mngers under setion 9 Were sustntilly ll (90% or more) dues reeived nondedutile y memers? Did the orgniztion mke only in-house loying expenditures of $,000 or less? Dues, ssessments nd similr mounts from memers Setion 6(e) nondedutile loying nd politil expenditures Current yer Crryover from lst yer ~~~~ ~~~~~~~~~~~~~~~~ ~~~ ~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Totl ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Aggregte mount reported in setion 60(e)()(A) noties of nondedutile setion 6(e) dues If noties were sent nd the mount on line exeeds the mount on line, wht portion of the exess does the orgniztion gree to rryover to the resonle estimte of nondedutile loying nd politil ~~~~~~~~ Provide the desriptions required for Prt I-A, line ; Prt I-B, line ; Prt I-C, line ; Prt II-A (ffilited group list); Prt II-A, line ; nd Prt II-B, line. Also, omplete this prt for ny dditionl informtion Shedule C (Form 990 or 990-EZ) DEATH WITH DIGNITY NATION 706

24 SCHEDULE D (Form 990) Complete if the orgniztion nswered "," to Form 990, Prt IV, line 6, 7, 8, 9, 0,,,, d, e, f,, or. Deprtment of the Tresury Atth to Form 99 Internl Revenue Servie Informtion out Shedule D (Form 990) nd its instrutions is t OMB Open to Puli Inspetion Nme of the orgniztion Employer identifition numer DEATH WITH DIGNITY NATIONAL CENTER Prt I Orgniztions Mintining Donor Advised Funds or Other Similr Funds or Aounts. Complete if the d (i) (ii) orgniztion nswered "" to Form 990, Prt IV, line 6. Totl numer t end of yer ~~~~~~~~~~~~~~~ Aggregte ontriutions to (during yer) Aggregte grnts from (during yer) Aggregte vlue t end of yer ~~~~~~~~ ~~~~~~~~~~ ~~~~~~~~~~~~~ () Donor dvised funds Did the orgniztion inform ll donors nd donor dvisors in writing tht the ssets held in donor dvised funds re the orgniztion's property, sujet to the orgniztion's exlusive legl ontrol? ~~~~~~~~~~~~~~~~~~ Did the orgniztion inform ll grntees, donors, nd donor dvisors in writing tht grnt funds n e used only for hritle purposes nd not for the enefit of the donor or donor dvisor, or for ny other purpose onferring impermissile privte enefit? Prt II Conservtion Esements. Complete if the orgniztion nswered "" to Form 990, Prt IV, line 7. Purpose(s) of onservtion esements held y the orgniztion (hek ll tht pply). Preservtion of lnd for puli use (e.g., reretion or edution) Protetion of nturl hitt Preservtion of open spe () Funds nd other ounts d Preservtion of n historilly importnt lnd re Preservtion of ertified histori struture Complete lines through d if the orgniztion held qulified onservtion ontriution in the form of onservtion esement on the lst dy of the tx yer. Totl numer of onservtion esements Totl rege restrited y onservtion esements ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~ Numer of onservtion esements on ertified histori struture inluded in () ~~~~~~~~~~~~ Numer of onservtion esements inluded in () quired fter 8/7/06, nd not on histori struture listed in the Ntionl Register ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Numer of onservtion esements modified, trnsferred, relesed, extinguished, or terminted y the orgniztion during the tx yer Numer of sttes where property sujet to onservtion esement is loted Does the orgniztion hve written poliy regrding the periodi monitoring, inspetion, hndling of violtions, nd enforement of the onservtion esements it holds? ~~~~~~~~~~~~~~~~~~~~~~~~~ Stff nd volunteer hours devoted to monitoring, inspeting, nd enforing onservtion esements during the yer Amount of expenses inurred in monitoring, inspeting, nd enforing onservtion esements during the yer $ Does eh onservtion esement reported on line (d) ove stisfy the requirements of setion 70(h)()(B)(i) nd setion 70(h)()(B)(ii)? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Held t the End of the Tx Yer In Prt III, desrie how the orgniztion reports onservtion esements in its revenue nd expense sttement, nd lne sheet, nd inlude, if pplile, the text of the footnote to the orgniztion's finnil sttements tht desries the orgniztion's ounting for onservtion esements. Prt III Orgniztions Mintining Colletions of Art, Historil Tresures, or Other Similr Assets. Complete if the orgniztion nswered "" to Form 990, Prt IV, line 8. If the orgniztion eleted, s permitted under SFAS 6 (ASC 98), not to report in its revenue sttement nd lne sheet works of rt, historil tresures, or other similr ssets held for puli exhiition, edution, or reserh in furtherne of puli servie, provide, in Prt III, the text of the footnote to its finnil sttements tht desries these items. If the orgniztion eleted, s permitted under SFAS 6 (ASC 98), to report in its revenue sttement nd lne sheet works of rt, historil tresures, or other similr ssets held for puli exhiition, edution, or reserh in furtherne of puli servie, provide the following mounts relting to these items: Revenues inluded in Form 990, Prt VIII, line Assets inluded in Form 990, Prt ~~~~~~~~~~~~~~~~~~~~~~~~~~~~ $ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If the orgniztion reeived or held works of rt, historil tresures, or other similr ssets for finnil gin, provide the following mounts required to e reported under SFAS 6 (ASC 98) relting to these items: Revenues inluded in Form 990, Prt VIII, line Assets inluded in Form 990, Prt Supplementl Finnil Sttements ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ $ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ $ $ 0 LHA For Pperwork Redution At tie, see the Instrutions for Form 99 Shedule D (Form 990) DEATH WITH DIGNITY NATION 706

25 Shedule D (Form 990) 0 DEATH WITH DIGNITY NATIONAL CENTER Pge Prt III Orgniztions Mintining Colletions of Art, Historil Tresures, or Other Similr Assets (ontinued) d e f d e If "," explin the rrngement in Prt III. Chek here if the explntion hs een provided in Prt III Prt V Endowment Funds. Complete if the orgniztion nswered "" to Form 990, Prt IV, line d e f g (i) (ii) Desrie in Prt III the intended uses of the orgniztion's endowment funds. Prt VI Lnd, Buildings, nd Equipment. Using the orgniztion's quisition, ession, nd other reords, hek ny of the following tht re signifint use of its olletion items (hek ll tht pply): Puli exhiition Sholrly reserh Preservtion for future genertions Lon or exhnge progrms Provide desription of the orgniztion's olletions nd explin how they further the orgniztion's exempt purpose in Prt III. During the yer, did the orgniztion soliit or reeive dontions of rt, historil tresures, or other similr ssets to e sold to rise funds rther thn to e mintined s prt of the orgniztion's olletion? Prt IV Esrow nd Custodil Arrngements. Complete if the orgniztion nswered "" to Form 990, Prt IV, line 9, or reported n mount on Form 990, Prt, line. Is the orgniztion n gent, trustee, ustodin or other intermediry for ontriutions or other ssets not inluded on Form 990, Prt? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Other If "," explin the rrngement in Prt III nd omplete the following tle: Beginning lne Additions during the yer ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Distriutions during the yer ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Ending lne ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion inlude n mount on Form 990, Prt, line? Beginning of yer lne Contriutions ~~~~~~~~~~~~~~ Net investment ernings, gins, nd losses Grnts or sholrships Other expenditures for filities nd progrms Administrtive expenses End of yer lne ~~~~~~~ ~~~~~~~~~ ~~~~~~~~~~~~~ ~~~~~~~~ ~~~~~~~~~~ () Current yer () Prior yer () Two yers k (d) Three yers k (e) Four yers k,788. 8,0. 8,6.,89.,6. Provide the estimted perentge of the urrent yer end lne (line g, olumn ()) held s: Bord designted or qusi-endowment 000 % Permnent endowment % Temporrily restrited endowment % The perentges in lines,, nd should equl 00%. d e ~~~~~~~~~~~~~~~~~~~~~~~~~ Are there endowment funds not in the possession of the orgniztion tht re held nd dministered for the orgniztion y: unrelted orgniztions ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ relted orgniztions ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "" to (ii), re the relted orgniztions listed s required on Shedule R? ~~~~~~~~~~~~~~~~~~~~~~ Complete if the orgniztion nswered "" to Form 990, Prt IV, line. See Form 990, Prt, line Desription of property Lnd ~~~~~~~~~~~~~~~~~~~~,79.. 6,76., ,788. f Amount (i) (ii) () Cost or other () Cost or other () Aumulted (d) Book vlue sis (investment) sis (other) depreition Buildings ~~~~~~~~~~~~~~~~~~ Lesehold improvements ~~~~~~~~~~,6.,89. d Equipment ~~~~~~~~~~~~~~~~~,. 7,877. e Other 9,00,7 Totl. Add lines through e. (Column (d) must equl Form 990, Prt, olumn (B), line 0().). 8,0., ,6. 0,69.,89.,77.,7., 8,. Shedule D (Form 990) DEATH WITH DIGNITY NATION 706

26 Shedule D (Form 990) 0 DEATH WITH DIGNITY NATIONAL CENTER Pge Prt VII Investments - Other Seurities. Complete if the orgniztion nswered "" to Form 990, Prt IV, line. See Form 990, Prt, line. () Desription of seurity or tegory (inluding nme of seurity) () Book vlue () Method of vlution: Cost or end-of-yer mrket vlue () Finnil derivtives ~~~~~~~~~~~~~~~ () Closely-held equity interests ~~~~~~~~~~~ () Other (A) (B) (C) (D) (E) (F) (G) (H) Totl. (Col. () must equl Form 990, Prt, ol. (B) line.) Prt VIII Investments - Progrm Relted. Complete if the orgniztion nswered "" to Form 990, Prt IV, line. See Form 990, Prt, line. () Desription of investment () Book vlue () Method of vlution: Cost or end-of-yer mrket vlue () () () () () (6) (7) (8) (9) Totl. (Col. () must equl Form 990, Prt, ol. (B) line.) Prt I Other Assets. Complete if the orgniztion nswered "" to Form 990, Prt IV, line d. See Form 990, Prt, line. () Desription () Book vlue () INTERORGANIZATIONAL RECEIVABLE,7. () () () () (6) (7) (8) (9) Totl. (Column () must equl Form 990, Prt, ol. (B) line.),7. Prt Other Liilities. Complete if the orgniztion nswered "" to Form 990, Prt IV, line e or f. See Form 990, Prt, line.. () Desription of liility () Book vlue () Federl inome txes () () () () (6) (7) (8) (9) Totl. (Column () must equl Form 990, Prt, ol. (B) line.). Liility for unertin tx positions. In Prt III, provide the text of the footnote to the orgniztion's finnil sttements tht reports the orgniztion's liility for unertin tx positions under FIN 8 (ASC 70). Chek here if the text of the footnote hs een provided in Prt III Shedule D (Form 990) DEATH WITH DIGNITY NATION 706

27 Shedule D (Form 990) 0 DEATH WITH DIGNITY NATIONAL CENTER Pge Prt I Reonilition of Revenue per Audited Finnil Sttements With Revenue per Return. Complete if the orgniztion nswered "" to Form 990, Prt IV, line. Totl revenue, gins, nd other support per udited finnil sttements Amounts inluded on line ut not on Form 990, Prt VIII, line : ~~~~~~~~~~~~~~~~~~~ Net unrelized gins on investments Donted servies nd use of filities ~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~ Reoveries of prior yer grnts ~~~~~~~~~~~~~~~~~~~~~~~~~ d Other (Desrie in Prt III.) ~~~~~~~~~~~~~~~~~~~~~~~~~~ d e Add lines through d ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ e Sutrt line e from line ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Amounts inluded on Form 990, Prt VIII, line, ut not on line : Investment expenses not inluded on Form 990, Prt VIII, line 7 ~~~~~~~~ Other (Desrie in Prt III.) ~~~~~~~~~~~~~~~~~~~~~~~~~~ Add lines nd ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Totl revenue. Add lines nd. (This must equl Form 990, Prt I, line.) Prt II Reonilition of Expenses per Audited Finnil Sttements With Expenses per Return. Complete if the orgniztion nswered "" to Form 990, Prt IV, line. Totl expenses nd losses per udited finnil sttements ~~~~~~~~~~~~~~~~~~~~~~~~~~ Amounts inluded on line ut not on Form 990, Prt I, line : Donted servies nd use of filities ~~~~~~~~~~~~~~~~~~~~~~ Prior yer djustments ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Other losses ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ d Other (Desrie in Prt III.) ~~~~~~~~~~~~~~~~~~~~~~~~~~ d e Add lines through d ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ e Sutrt line e from line ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Amounts inluded on Form 990, Prt I, line, ut not on line : Investment expenses not inluded on Form 990, Prt VIII, line 7 ~~~~~~~~ Other (Desrie in Prt III.) ~~~~~~~~~~~~~~~~~~~~~~~~~~ Add lines nd ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Totl expenses. Add lines nd. (This must equl Form 990, Prt I, line 8.) Prt III Supplementl Informtion. Provide the desriptions required for Prt II, lines,, nd 9; Prt III, lines nd ; Prt IV, lines nd ; Prt V, line ; Prt, line ; Prt I, lines d nd ; nd Prt II, lines d nd. Also omplete this prt to provide ny dditionl informtion. PART V, LINE : EPLANATION: TO CREATE A FUND FOR FUTURE UNEPECTED LEGAL CHALLENGES Shedule D (Form 990) DEATH WITH DIGNITY NATION 706

28 SCHEDULE M (Form 990) OMB J Complete if the orgniztions nswered "" on Form 990, Prt IV, lines 9 or Deprtment of the Tresury Internl Revenue Servie J Atth to Form 99 J Informtion out Shedule M (Form 990) nd its instrutions is t Open to Puli Inspetion Nme of the orgniztion Employer identifition numer DEATH WITH DIGNITY NATIONAL CENTER Prt I Types of Property () () () (d) Chek if Method of determining pplile nonsh ontriution mounts Art - Works of rt Art - Historil tresures ~~~~~~~~~~~~~ ~~~~~~~~~ Art - Frtionl interests ~~~~~~~~~~ Books nd pulitions ~~~~~~~~~~ Clothing nd household goods ~~~~~~ Crs nd other vehiles ~~~~~~~~~~ Bots nd plnes ~~~~~~~~~~~~~ Intelletul property Seurities - Pulily trded ~~~~~~~~~~~ ~~~~~~~~ Seurities - Closely held stok ~~~~~~~ Seurities - Prtnership, LLC, or trust interests Seurities - Misellneous ~~~~~~~~~~~~~~ Qulified onservtion ontriution - Histori strutures ~~~~~~~~ ~~~~~~~~~~~~ Qulified onservtion ontriution - Other~ Rel estte - Residentil Rel estte - Commeril Rel estte - Other ~~~~~~~~~ ~~~~~~~~~ ~~~~~~~~~~~~ Colletiles ~~~~~~~~~~~~~~~~ Food inventory Drugs nd medil supplies ~~~~~~~~ Txidermy Historil rtifts Sientifi speimens ~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~ ~~~~~~~~~~~ Numer of ontriutions or items ontriuted Arheologil rtifts ~~~~~~~~~~ Other J ( ) Other J ( ) Other J ( ) Other J ( ) Numer of Forms 88 reeived y the orgniztion during the tx yer for ontriutions nsh ontriution mounts reported on Form 990, Prt VIII, line g for whih the orgniztion ompleted Form 88, Prt IV, Donee Aknowledgement ~~~~ 0 During the yer, did the orgniztion reeive y ontriution ny property reported in Prt I, lines - 8, tht it must hold for t lest three yers from the dte of the initil ontriution, nd whih is not required to e used for exempt purposes for the entire holding period? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "," desrie the rrngement in Prt II. Does the orgniztion hve gift eptne poliy tht requires the review of ny non-stndrd ontriutions? ~~~~~~ Does the orgniztion hire or use third prties or relted orgniztions to soliit, proess, or sell nonsh LHA ontriutions? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "," desrie in Prt II. If the orgniztion did not report n mount in olumn () for type of property for whih olumn () is heked, desrie in Prt II. nsh Contriutions 0 9,8 ACTUAL SALES PRICE For Pperwork Redution At tie, see the Instrutions for Form 99 Shedule M (Form 990) (0) DEATH WITH DIGNITY NATION 706

29 Shedule M (Form 990) (0) DEATH WITH DIGNITY NATIONAL CENTER Pge Prt II Supplementl Informtion. Provide the informtion required y Prt I, lines 0,, nd, nd whether the orgniztion is reporting in Prt I, olumn (), the numer of ontriutions, the numer of items reeived, or omintion of oth. Also omplete this prt for ny dditionl informtion Shedule M (Form 990) (0) DEATH WITH DIGNITY NATION 706

30 SCHEDULE O (Form 990 or 990-EZ) Deprtment of the Tresury Internl Revenue Servie Nme of the orgniztion Supplementl Informtion to Form 990 or 990-EZ OMB Complete to provide informtion for responses to speifi questions on Form 990 or 990-EZ or to provide ny dditionl informtion. Atth to Form 990 or 990-EZ. Open to Puli Informtion out Shedule O (Form 990 or 990-EZ) nd its instrutions is t Inspetion Employer identifition numer DEATH WITH DIGNITY NATIONAL CENTER FORM 990, PART III, LINE, DESCRIPTION OF ORGANIZATION MISSION: CARE. FORM 990, PART VI, SECTION B, LINE : EPLANATION: THE ORGANIZATION'S EECUTIVE AND BOARD PRESIDENT ARE RESPONSIBLE FOR REVIEWING THE FORM 990 BEFORE FILING. ANY SUBSTANTIVE DEPARTURES FROM PRIOR YEAR ARE DISCUSSED WITH THE FINANCE, ADMINISTRATIVE, AND AUDIT COMMITTEE. THE EECUTIVE DIRECTOR SIGNS AND SUBMITS THE 990 INFORMATION RETURN. FORM 990, PART VI, SECTION B, LINE C: EPLANATION: ANNUALLY, BOARD MEMBERS ARE ASKED TO SUBMIT A COMPLETED CONFLICT OF INTEREST FORM FOR REVIEW BY THE EECUTIVE DIRECTOR. IF THERE ARE ANY CONFLICTS IDENTIFIED, THE EECUTIVE DIRECTOR NOTIFIES THE BOARD PRESIDENT. THE BOARD PRESIDENT REVIEWS THE EECUTIVE DIRECTOR'S CONFLICTS. FORM 990, PART VI, SECTION B, LINE : EPLANATION: THE BOARD DETERMINES EECUTIVE DIRECTOR SALARY, BASED ON A PERFORMANCE REVIEW, EDUCATION AND EPERIENCE, AND COMPARISONS TO NONPROFIT SALARIES USING VARIOUS DATA SOURCES. GUIDESTAR'S NONPROFIT SALARY SURVEY PUBLICATION WILL BE USED FOR COMPARISON PURPOSES. FORM 990, PART VI, LINE 7, LIST OF STATES RECEIVING COPY OF FORM 990: AK,AL,AR,AZ,CA,CO,CT,FL,GA,IL,KS,KY,MA,MD,ME,MI,MN,MS,NC,ND,NH,NJ,NM,NY,OH OK,OR,PA,RI,SC,TN,UT,VA,WA,WI,WV,DC,IN,MO LHA For Pperwork Redution At tie, see the Instrutions for Form 990 or 990-EZ. Shedule O (Form 990 or 990-EZ) (0) DEATH WITH DIGNITY NATION 706

31 Shedule O (Form 990 or 990-EZ) (0) Pge Nme of the orgniztion Employer identifition numer DEATH WITH DIGNITY NATIONAL CENTER FORM 990, PART VI, SECTION C, LINE 9: EPLANATION: UPON REQUEST FORM 990, PART II, LINE C: EPLANATION: THE AUDIT OVERSIGHT AND INDEPENDENT ACCOUNTANT SELECTION PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR Shedule O (Form 990 or 990-EZ) (0) DEATH WITH DIGNITY NATION 706

32 SCHEDULE R (Form 990) Complete if the orgniztion nswered "" on Form 990, Prt IV, line,,, 6, or 7. Atth to Form 99 See seprte instrutions. Deprtment of the Tresury Internl Revenue Servie Informtion out Shedule R (Form 990) nd its instrutions is t Nme of the orgniztion Relted Orgniztions nd Unrelted Prtnerships DEATH WITH DIGNITY NATIONAL CENTER OMB Open to Puli Inspetion Employer identifition numer Prt I Identifition of Disregrded Entities Complete if the orgniztion nswered "" on Form 990, Prt IV, line. () () () (d) (e) (f) Nme, ddress, nd EIN (if pplile) of disregrded entity Primry tivity Legl domiile (stte or foreign ountry) Totl inome End-of-yer ssets Diret ontrolling entity Prt II Identifition of Relted Tx-Exempt Orgniztions orgniztions during the tx yer. Complete if the orgniztion nswered "" on Form 990, Prt IV, line euse it hd one or more relted tx-exempt () () () (d) (e) (f) (g) Nme, ddress, nd EIN of relted orgniztion OREGON DEATH WITH DIGNITY POLITICAL ACTION FUND , 0 SW 6TH AVENUE, SUITE 0, PORTLAND, OR 970 Primry tivity Legl domiile (stte or foreign ountry) Exempt Code setion Puli hrity sttus (if setion 0()()) EDUCATION, RESEARCH OREGON 0(C)() N/A Diret ontrolling entity Setion ()() ontrolled entity? For Pperwork Redution At tie, see the Instrutions for Form 99 Shedule R (Form 990) LHA

33 Shedule R (Form 990) 0 Prt III Identifition of Relted Orgniztions Txle s Prtnership Complete if the orgniztion nswered "" on Form 990, Prt IV, line euse it hd one or more relted orgniztions treted s prtnership during the tx yer. () () () (d) (e) (f) (g) (h) (i) (j) (k) Legl Primry tivity Diret ontrolling Predominnt inome Shre of totl Shre of Disproportionte Code V-UBI Generl or domiile mnging (stte or entity (relted, unrelted, inome end-of-yer llotions? mount in ox prtner? foreign exluded from tx under ssets 0 of Shedule ountry) setions -) K- (Form 06) Nme, ddress, nd EIN of relted orgniztion DEATH WITH DIGNITY NATIONAL CENTER Pge Perentge ownership Prt IV Identifition of Relted Orgniztions Txle s Corportion or Trust Complete if the orgniztion nswered "" on Form 990, Prt IV, line euse it hd one or more relted orgniztions treted s orportion or trust during the tx yer. () () () (d) (e) (f) (g) (h) (i) Nme, ddress, nd EIN of relted orgniztion Primry tivity Legl domiile (stte or foreign ountry) Diret ontrolling entity Type of entity (C orp, S orp, or trust) Shre of totl inome Shre of end-of-yer ssets Perentge ownership Setion ()() ontrolled entity? Shedule R (Form 990) 0

34 Shedule R (Form 990) 0 DEATH WITH DIGNITY NATIONAL CENTER Pge Prt V Trnstions With Relted Orgniztions Complete if the orgniztion nswered "" on Form 990, Prt IV, line,, or 6. te. Complete line if ny entity is listed in Prts II, III, or IV of this shedule. d e During the tx yer, did the orgniztion engge in ny of the following trnstions with one or more relted orgniztions listed in Prts II-IV? Reeipt of (i) interest (ii) nnuities (iii) roylties or (iv) rent from ontrolled entity ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Gift, grnt, or pitl ontriution to relted orgniztion(s) Gift, grnt, or pitl ontriution from relted orgniztion(s) Lons or lon gurntees to or for relted orgniztion(s) Lons or lon gurntees y relted orgniztion(s) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ d e f g h i j Dividends from relted orgniztion(s) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Sle of ssets to relted orgniztion(s) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Purhse of ssets from relted orgniztion(s) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Exhnge of ssets with relted orgniztion(s) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Lese of filities, equipment, or other ssets to relted orgniztion(s) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ f g h i j k Lese of filities, equipment, or other ssets from relted orgniztion(s) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ l Performne of servies or memership or fundrising soliittions for relted orgniztion(s) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ m Performne of servies or memership or fundrising soliittions y relted orgniztion(s) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ n Shring of filities, equipment, miling lists, or other ssets with relted orgniztion(s) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ o Shring of pid employees with relted orgniztion(s) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ k l m n o p q Reimursement pid to relted orgniztion(s) for expenses ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Reimursement pid y relted orgniztion(s) for expenses ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ p q r s Other trnsfer of sh or property to relted orgniztion(s) Other trnsfer of sh or property from relted orgniztion(s) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If the nswer to ny of the ove is "," see the instrutions for informtion on who must omplete this line, inluding overed reltionships nd trnstion thresholds. () () () (d) Nme of relted orgniztion Trnstion Amount involved Method of determining mount involved type (-s) r s () () () () () (6) Shedule R (Form 990) 0

35 Shedule R (Form 990) 0 DEATH WITH DIGNITY NATIONAL CENTER Pge Prt VI Unrelted Orgniztions Txle s Prtnership Complete if the orgniztion nswered "" on Form 990, Prt IV, line 7. Provide the following informtion for eh entity txed s prtnership through whih the orgniztion onduted more thn five perent of its tivities (mesured y totl ssets or gross revenue) tht ws not relted orgniztion. See instrutions regrding exlusion for ertin investment prtnerships. () () () (d) (e) (f) (g) (h) (i) (j) (k) Are ll Primry tivity prtners se. Shre of Shre of Disproportionte mount in ox 0 mnging Code V-UBI Generl or 0()() orgs.? totl end-of-yer llotions? prtner? Nme, ddress, nd EIN of entity Legl domiile (stte or foreign ountry) Predominnt inome (relted, unrelted, exluded from tx under setion -) of Shedule K- inome ssets (Form 06) Perentge ownership Shedule R (Form 990)

36 Shedule R (Form 990) 0 DEATH WITH DIGNITY NATIONAL CENTER Prt VII Supplementl Informtion Provide dditionl informtion for responses to questions on Shedule R (see instrutions). Pge Shedule R (Form 990) DEATH WITH DIGNITY NATION 706

37 Form Deprtment of the Tresury Internl Revenue Servie A For lendr yer 0 or other tx yer eginning, nd ending. OMB Informtion out Form 990-T nd its instrutions is ville t Open to Puli Inspetion for Do not enter SSN numers on this form s it my e mde puli if your orgniztion is 0()(). 0()() Orgniztions Only Employer identifition numer Nme of orgniztion ( Chek ox if nme hnged nd see instrutions.) D (Employees' trust, see instrutions.) B Exempt under setion Print DEATH WITH DIGNITY NATIONAL CENTER 0( )( ) or Numer, street, nd room or suite no. If P.O. ox, see instrutions. Type 08(e) 0(e) 0 SW 6TH AVENUE, NO. 0 E Unrelted usiness tivity odes (See instrutions.) 08A 0() City or town, stte or provine, ountry, nd ZIP or foreign postl ode 9() PORTLAND, OR 970 Book vlue of ll ssets C t end of yer F Group exemption numer (See instrutions.) 9,. G Chek orgniztion type 0() orportion 0() trust 0() trust Other trust H Desrie the orgniztion's primry unrelted usiness tivity. I During the tx yer, ws the orportion susidiry in n ffilited group or prent-susidiry ontrolled group? ~~~~~~ If "," enter the nme nd identifying numer of the prent orportion. J The ooks re in re of PEG SANDEEN Telephone numer 0-8- Prt I Unrelted Trde or Business Inome (A) Inome (B) Expenses (C) Net Less returns nd llownes Blne ~~~ Other inome (See instrutions; tth shedule.) ~~~~~~~~~~~~ Totl. Comine lines through Prt II Dedutions t Tken Elsewhere (See instrutions for limittions on dedutions.) (Exept for ontriutions, dedutions must e diretly onneted with the unrelted usiness inome.) T Chek ox if ddress hnged Gross reeipts or sles Cost of goods sold (Shedule A, line 7) ~~~~~~~~~~~~~~~~~ Gross profit. Sutrt line from line ~~~~~~~~~~~~~~~~ Cpitl gin net inome (tth Form 899 nd Shedule D) ~~~~~~~~ Net gin (loss) (Form 797, Prt II, line 7) (tth Form 797) ~~~~~~ Cpitl loss dedution for trusts ~~~~~~~~~~~~~~~~~~~~ Inome (loss) from prtnerships nd S orportions (tth sttement) ~~~ Rent inome (Shedule C) ~~~~~~~~~~~~~~~~~~~~~~ Unrelted det-finned inome (Shedule E) ~~~~~~~~~~~~~~ Interest, nnuities, roylties, nd rents from ontrolled orgniztions (Sh. F)~ Investment inome of setion 0()(7), (9), or (7) orgniztion (Shedule G) Exploited exempt tivity inome (Shedule I) ~~~~~~~~~~~~~~ Advertising inome (Shedule J) ~~~~~~~~~~~~~~~~~~~~ Compenstion of offiers, diretors, nd trustees (Shedule K) Slries nd wges Repirs nd mintenne Bd dets Interest (tth shedule) Totl dedutions. Add lines through 8 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Txes nd lienses ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Chritle ontriutions (See instrutions for limittion rules.) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Depreition (tth Form 6) Less depreition limed on Shedule A nd elsewhere on return Depletion Contriutions to deferred ompenstion plns ~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Employee enefit progrms ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Exess exempt expenses (Shedule I) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Exess redership osts (Shedule J) Other dedutions (tth shedule) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Unrelted usiness txle inome efore net operting loss dedution. Sutrt line 9 from line ~~~~~~~~~~~~ Net operting loss dedution (limited to the mount on line 0) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Unrelted usiness txle inome efore speifi dedution. Sutrt line from line 0 Speifi dedution (Generlly $,000, ut see instrutions for exeptions.) REQUEST FOR R CREDIT ONLY Exempt Orgniztion Business Inome Tx Return (nd proxy tx under setion 60(e)) APR, 0 MAR, 0 ~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~ ,00 Unrelted usiness txle inome. Sutrt line from line. If line is greter thn line, enter the smller of zero or line LHA For Pperwork Redution At tie, see instrutions. Form 990-T (0) DEATH WITH DIGNITY NATION 706

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