Form

990-EZ
G

Short Form Return of Organization Exempt From Income Tax

Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung benefit trust or private foundation)
Sponsoring organizations of donor advised funds, organizations that operate one or more hospital facilities, and certain controlling organizations as defined in section 512(b)(13) must file Form 990 (see instructions). All other organizations with gross receipts less than $200,000 and total assets less than $500,000 at the end of the year may use this form. G The organization may have to use a copy of this return to satisfy state reporting requirements.

OMB No. 1545-1150

2011
Open to Public Inspection ,

Department of the Treasury Internal Revenue Service

A B

For the 2011 calendar year, or tax year beginning Check if applicable: C Name of organization
Address change Name change Initial return Terminated Amended return Application pending Number and street (or P.O. box, if mail is not delivered to street address)

, 2011, and ending D

Room/suite

Employer identification number

The Lazarus House: A Center for Wellness

E

76-0693417
Telephone number

4106 Austin St.

City or town, state or country, and ZIP + 4

(713) 526-5071 TX 77004

F Group Exemption Number

G H Check G if the organization is not required to attach Schedule B (Form I 990, 990-EZ, or 990-PF). J 4947(a)(1) or 527 K Check G if the organization is not a section 509(a)(3) supporting organization or a section 527 organization and its gross receipts are normally not more than $50,000. A Form 990-EZ or Form 990 return is not required though Form 990-N (e-postcard) may be required (see instructions). But if the organization chooses to file a return, be sure to file a complete return. L Add lines 5b, 6c, and 7b, to line 9 to determine gross receipts. If gross receipts are $200,000 or more, or if total assets (Part II, line 25, column (B) below) are $500,000 or more, file Form 990 instead of Form 990-EZ

Houston Accounting Method: X Cash Accrual Other (specify) G Website: G www.thelazarushouse.org X 501(c)(3) Tax-exempt status (ck only one) ' 501(c) ( ) H(insert no.)

Part I
1 2 3 4 5a b c 6 a b

$ 133,565. Revenue, Expenses, and Changes in Net Assets or Fund Balances (see the instructions for Part I.) Check if the organization used Schedule O to respond to any question in this Part I X Contributions, gifts, grants, and similar amounts received 1 52,753. Program service revenue including government fees and contracts 2 39,816.
3 4 5a 5b 5c 6a of contributions 6b 6c

R E V E N U E

Membership dues and assessments Investment income Gross amount from sale of assets other than inventory Less: cost or other basis and sales expenses Gain or (loss) from sale of assets other than inventory (Subtract line 5b from line 5a) Gaming and fundraising events Gross income from gaming (attach Schedule G if greater than $15,000) Gross income from fundraising events (not including $ from fundraising events reported on line 1) (attach Schedule G if the sum of such gross income and contributions exceeds $15,000) c Less: direct expenses from gaming and fundraising events

40,996. 5,021.
6d

E X P E N S E S

d Net income or (loss) from gaming and fundraising events (add lines 6a and 6b and subtract line 6c) 7 a Gross sales of inventory, less returns and allowances b Less: cost of goods sold c Gross profit or (loss) from sales of inventory (Subtract line 7b from line 7a) 8 Other revenue (describe in Schedule O) 9 Total revenue. Add lines 1, 2, 3, 4, 5c, 6d, 7c, and 8 10 Grants and similar amounts paid (list in Schedule O) 11 Benefits paid to or for members 12 Salaries, other compensation, and employee benefits 13 Professional fees and other payments to independent contractors 14 Occupancy, rent, utilities, and maintenance 15 Printing, publications, postage, and shipping 16 Other expenses (describe in Schedule O) 17 Total expenses. Add lines 10 through 16 18 Excess or (deficit) for the year (Subtract line 17 from line 9) 19

35,975.

7a 7b 7c 8 9 10 11 12 13 14 15 See Form 990-EZ, Part I, Line 16 Other Expenses 16 17 18 19 20 21

128,544.

112,789. 27,859. 711. 28,736. 170,095. -41,551. 116,449. 74,898.

Form 990-EZ (2011)

A N S E S TE T S

Net assets or fund balances at beginning of year (from line 27, column (A)) (must agree with end-of-year figure reported on prior years return) 20 Other changes in net assets or fund balances (explain in Schedule O) 21 Net assets or fund balances at end of year. Combine lines 18 through 20 BAA For Paperwork Reduction Act Notice, see the separate instructions.

TEEA0812

02/14/12

Form 990-EZ (2011)

The Lazarus House: A Center for Wellness Part II Balance Sheets. (see the instructions for Part II.)
Check if the organization used Schedule O to respond to any question in this Part II 22 23 24 25 26 27 Cash, savings, and investments Land and buildings Other assets (describe in Schedule O) Total assets Total liabilities (describe in Schedule O) Net assets or fund balances (line 27 of column (B) must agree with line 21)

76-0693417
(A) Beginning of year

Page 2

(B) End of year 22 23 24 25 26 27

109,209. 7,240. 0. 116,449. 0. 116,449.

70,272. 4,626. 0. 74,898. 0. 74,898.

Part III

Statement of Program Service Accomplishments (see the instrs for Part III.)

Check if the organization used Schedule O to respond to any question in this Part III What is the organizations primary exempt purpose? Charitable nonprofit wellness. Describe the organizations program service accomplishments for each of its three largest program services, as measured by expenses. In a clear and concise manner, describe the services provided, the number of persons benefited, and other relevant information for each program title. 28 Clients attended three times weekly for an hour per

Expenses (Required for section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts; optional for others.)

29

session for specific exercise training. There was an average of 43 clients (both adolescent & adults). (Grants $ 0. ) If this amount includes foreign grants, check here Provided lectures for communiuty organizations offering information about exercise and disease related wasting.
(Grants $ ) If this amount includes foreign grants, check here

28 a

121,622.

29 a

30

30 a Other program services (describe in Schedule O) (Grants $ ) If this amount includes foreign grants, check here 31 a 32 Total program service expenses (add lines 28a through 31a) 32 121,622. Part IV List of Officers, Directors, Trustees, and Key Employees. List each one even if not compensated. (see the instructions for Part IV.) Check if the organization used Schedule O to respond to any question in this Part IV (b) Title and average (c) Reportable compensation (d) Health benefits, (e) Estimated amount of hours per week (Form W-2/1099-MISC) other compensation (a) Name and address contributions to employee devoted to position (If not paid, enter -0-) benefit plans, and deferred compensation 31

Formed a collaboration with Houston Buyers Club to provide space & opportunity for a Registered Dietician provided by HBC to work with our clients concerning nutritional counseling. (Grants $ ) If this amount includes foreign grants, check here

Tino Ramirez 4106 Austin St. Houston TX 77004 Marc Cohen 4106 Austin St. Houston TX 77004 Sandy Stacy 4106 Austin St. Houston TX 77004 Elizabeth Smith 4106 Austin St. Houston TX 77004 Boyd Edwards, RN 4106 Austin St. Houston TX 77004 Betsie Weatherford 4106 Austin St. Houston TX 77004 Carlos Cordova, Jr. 4106 Austin St. Houston TX 77004 Robert Westfall 4106 Austin St. Houston TX 77004 Melissa Wilson 4106 Austin St. Houston TX 77004

President 3.00 V. Pres. 3.00 Secretary 3.00 Treasurer 3.00 Member 1.00 Member 1.00 Member 1.00 Hon. Member 0.00 Hon. Member 0.00

0.

0.

0.

0.

0.

0.

0.

0.

0.

0.

0.

0.

0.

0.

0.

0.

0.

0.

0.

0.

0.

0.

0.

0.

0.

0.

0.

See List of Officers, Directors, Trustees, & Key Employees Stmt

BAA

TEEA0812

02/14/12

Form 990-EZ (2011)

Form 990-EZ (2011)

The Lazarus House: A Center for Wellness Part V Other Information (Note the Schedule A and personal benefit contract statement requirements in
33 34

76-0693417

Page 3

the instructions for Part V.) Check if the organization used Schedule O to respond to any question in this Part V Did the organization engage in any activity not previously reported to the IRS? If Yes, provide a detailed description of each activity in Schedule O Were any significant changes made to the organizing or governing documents? If Yes, attach a conformed copy of the amended documents if they reflect a change to the organizations name. Otherwise, explain the change on Schedule O (see instructions) Yes 33 34 35 a 35 b 35 c 36 No

X X X

35 a Did the organization have unrelated business gross income of $1,000 or more during the year from business activities (such as those reported on lines 2, 6a, and 7a, among others)? b If Yes, to line 35a, has the organization filed a Form 990-T for the year? If No, provide an explanation in Schedule O c Was the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization subject to section 6033(e) notice, reporting, and proxy tax requirements during the year? If Yes, complete Schedule C, Part III 36 Did the organization undergo a liquidation, dissolution, termination, or significant disposition of net assets during the year? If Yes, complete applicable parts of Schedule N 37 a Enter amount of political expenditures, direct or indirect, as described in the instructions 37 a b Did the organization file Form 1120-POL for this year? 38 a Did the organization borrow from, or make any loans to, any officer, director, trustee, or key employee or were any such loans made in a prior year and still outstanding at the end of the tax year covered by this return? b If Yes, complete Schedule L, Part II and enter the total amount involved 38 b 39 Section 501(c)(7) organizations. Enter: a Initiation fees and capital contributions included on line 9 39 a b Gross receipts, included on line 9, for public use of club facilities 39 b 40 a Section 501(c)(3) organizations. Enter amount of tax imposed on the organization during the year under: section 4911 G ; section 4912 G ; section 4955 G b Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in any section 4958 excess benefit transaction during the year or did it engage in an excess benefit transaction in a prior year that has not been reported on any of its prior Forms 990 or 990-EZ? If Yes, complete Schedule L, Part I c Section 501(c)(3) and 501(c)(4) organizations. Enter amount of tax imposed on organization managers or disqualified persons during the year under sections 4912, 4955, and 4958 d Section 501(c)(3) and 501(c)(4) organizations. Enter amount of tax on line 40c reimbursed by the organization e All organizations. At any time during the tax year, was the organization a party to a prohibited tax shelter transaction? If Yes, complete Form 8886-T 41 List the states with which a copy of this return is filed G

X X X

0.
37 b 38 a

40 b

40 e

42 a The organizations books are in care of G Located at G 4106

Danielle Sampey Austin

Houston

TX

Telephone no. G ZIP + 4 G

(713) 526-5071 77004

Yes 42 b No

b At any time during the calendar year, did the organization have an interest in or a signature or other authority over a financial account in a foreign country (such as a bank account, securities account, or other financial account)? If Yes, enter the name of the foreign country:

See the instructions for exceptions and filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts. c At any time during the calendar year, did the organization maintain an office outside of the U.S.? If Yes, enter the name of the foreign country:

42 c

43

Section 4947(a)(1) nonexempt charitable trusts filing Form 990-EZ in lieu of Form 1041 ' Check here and enter the amount of tax-exempt interest received or accrued during the tax year

43 Yes No

44 a Did the organization maintain any donor advised funds during the year? If Yes, Form 990 must be completed instead of Form 990-EZ b Did the organization operate one or more hospital facilities during the year? If Yes, Form 990 must be completed instead of Form 990-EZ c Did the organization receive any payments for indoor tanning services during the year? d If Yes to line 44c, has the organization filed a Form 720 to report these payments? If No, provide an explanation in Schedule O 45 a Did the organization have a controlled entity of the organization within the meaning of section 512(b)(13)? b Did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If Yes, Form 990 and Schedule R may need to be completed instead of Form 990-EZ (see instructions)
TEEA0812 02/14/12

44 a 44 b 44 c 44 d 45 a

X X X X

45 b X Form 990-EZ (2011)

Form 990-EZ (2011) 46

The Lazarus House: A Center for Wellness

76-0693417

Page 4 Yes No 46

Did the organization engage, directly or indirectly, in political campaign activities on behalf of or in opposition to candidates for public office? If Yes, complete Schedule C, Part I

Part VI

Section 501(c)(3) organizations and section 4947(a)(1) nonexempt charitable trusts only. All section 501(c)(3) organizations and section 4947(a)(1) nonexempt charitable trusts must answer questions 47-49b and 52, and complete the tables for lines 50 and 51.
Check if the organization used Schedule O to respond to any question in this Part VI Yes No

47

Did the organization engage in lobbying activities or have a section 501(h) election in effect during the tax year? If Yes, complete Schedule C, Part II 48 Is the organization a school as described in section 170(b)(1)(A)(ii)? If Yes, complete Schedule E 49 a Did the organization make any transfers to an exempt non-charitable related organization? b If Yes, was the related organization a section 527 organization? 50 Complete this table for the organizations five highest compensated employees (other than officers, directors, trustees and key employees) who each received more than $100,000 of compensation from the organization. If there is none, enter None.
(a) Name and address of each employee paid more than $100,000 (b) Title and average hours per week devoted to position (c) Reportable compensation (Forms W-2/1099-MISC) (d) Health benefits, contributions to employee benefit plans, and deferred compensation

47 48 49 a 49 b

X X X

(e) Estimated amount of other compensation

None

None

e Total number of other employees paid over $100,000 51 Complete this table for the organizations five highest compensated independent contractors who each received more than $100,000 of compensation from the organization. If there is none, enter None.
(a) Name and address of each independent contractor paid more than $100,000 (b) Type of service (c) Compensation

None

e Total number of other independent contractors each receiving over $100,000 52 Did the organization complete Schedule A? Note: All section 501(c)(3) organizations and 4947(a)(1) nonexempt charitable trusts must attach a completed Schedule A

Yes

No

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.

Sign Here

A A Danielle

06/15/12
Date

Signature of officer

Sampey
Preparers signature Date

Executive Director
Check if PTIN

Type or print name and title.

Print/Type preparers name

Kathy Ploch, CPA Paid Preparer Firms name G ZIENTEK & CO., P.C. Use Only Firms address G 2465 SOUTH KIRKWOOD HOUSTON
May the IRS discuss this return with the preparer shown above? See instructions

self-employed

P00158545

Firms EIN

TX

77077

Phone no.

G 76-0002535 (281) 496-6152 Yes No Form 990-EZ (2011)

TEEA0812

02/14/12

OMB No. 1545-0047

SCHEDULE A
(Form 990 or 990-EZ)

Public Charity Status and Public Support

Complete if the organization is a section 501(c)(3) organization or a section 4947(a)(1) nonexempt charitable trust. G Attach to Form 990 or Form 990-EZ. G See separate instructions.

2011
Open to Public Inspection
Employer identification number

Department of the Treasury Internal Revenue Service Name of the organization

The Lazarus House: A Center for Wellness 76-0693417 Part I 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 A church, convention of churches or association of churches described in section 170(b)(1)(A)(i). 2 A school described in section 170(b)(1)(A)(ii). (Attach Schedule E.) 3 A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii). 4 A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the hospitals name, city, and state: 5 An organization operated for the benefit of a college or university owned or operated by a governmental unit described in section 170(b)(1)(A)(iv). (Complete Part II.) 6 A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v). 7 X An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 170(b)(1)(A)(vi). (Complete Part II.) 8 A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.) 9 An organization that normally receives: (1) more than 33-1/3% of its support from contributions, membership fees, and gross receipts from activities related to its exempt functions ' subject to certain exceptions, and (2) no more than 33-1/3% of its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.) 10 An organization organized and operated exclusively to test for public safety. See section 509(a)(4). 11 An organization organized and operated exclusively for the benefit of, to perform the functions of, or 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 11e through 11h. a Type I b Type II c Type III ' Functionally integrated d Type III ' Other e 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 more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). f If the organization received a written determination from the IRS that is a Type I, Type II or Type III supporting organization, check this box g Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons? Yes No (i) A person who directly or indirectly controls, either alone or together with persons described in (ii) and (iii) below, the governing body of the supported organization? 11 g (i) (ii) A family member of a person described in (i) above? 11 g (ii) (iii) A 35% controlled entity of a person described in (i) or (ii) above? 11 g (iii) h Provide the following information about the supported organization(s).
(i) Name of supported organization (ii) EIN (iii) Type of organization (described on lines 1-9 above or IRC section (see instructions)) (iv) Is the organization in column (i) listed in your governing document? (v) Did you notify the organization in column (i) of your support? (vi) Is the organization in column (i) organized in the U.S.? (vii) Amount of support

Yes (A) (B) (C) (D) (E)

No

Yes

No

Yes

No

Total BAA For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Schedule A (Form 990 or 990-EZ) 2011

TEEA0401

09/28/11

Schedule A (Form 990 or 990-EZ) 2011

The Lazarus House: A Center for Wellness 76-0693417 Part II Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)

Page 2

Section A. Public Support

Calendar year (or fiscal year beginning in) G 1 Gifts, grants, contributions, and membership fees received. (Do not include any unusual grants.) 2 Tax revenues levied for the organizations benefit and either paid to or expended on its behalf 3 The value of services or facilities furnished by a governmental unit to the organization without charge 4 Total. Add lines 1 through 3 5 The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f) 6 Public support. Subtract line 5 from line 4 (a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (f) Total

133,630.

63,163.

57,401.

56,234.

52,753.

363,181.

133,630.

63,163.

57,401.

56,234.

52,753.

363,181.

182,328. 180,853.
(a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (f) Total

Section B. Total Support

Calendar year (or fiscal year beginning in) G 7 8 Amounts from line 4 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 sale of capital assets (Explain in Part IV.) Total support. Add lines 7 through 10 Gross receipts from related activities, etc (see instructions) First five years. If the Form 990 is for the organizations first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization, check this box and stop here Public support percentage for 2011 (line 6, column (f) divided by line 11, column (f)) Public support percentage from 2010 Schedule A, Part II, line 14 14 15

133,630.

63,163.

57,401.

56,234.

52,753.

363,181.

10

11 12 13

363,181.
12

Section C. Computation of Public Support Percentage

14 15

49.80 45.60

% %

16 a 33-1/3% support test ' 2011. If the organization did not check the box on line 13, and the line 14 is 33-1/3% or more, check this box and stop here. The organization qualifies as a publicly supported organization b 33-1/3% support test ' 2010. If the organization did not check a box on line 13 or 16a, and line 15 is 33-1/3% or more, check this box and stop here. The organization qualifies as a publicly supported organization 17 a 10%-facts-and-circumstances test ' 2011. If the organization did not check a box on line 13, 16a, or 16b, and line 14 is 10% or more, and if the organization meets the facts-and-circumstances test, check this box and stop here. Explain in Part IV how the organization meets the facts-and-circumstances test. The organization qualifies as a publicly supported organization

b 10%-facts-and-circumstances test ' 2010. If the organization did not check a box on line 13, 16a, 16b, or 17a, and line 15 is 10% or more, and if the organization meets the facts-and-circumstances test, check this box and stop here. Explain in Part IV how the organization meets the facts-and-circumstances test. The organization qualifies as a publicly supported organization 18 Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see instructions BAA Schedule A (Form 990 or 990-EZ) 2011

TEEA0402

05/25/11

Schedule A (Form 990 or 990-EZ) 2011

Part III

The Lazarus House: A Center for Wellness Support Schedule for Organizations Described in Section 509(a)(2)

76-0693417

Page 3

(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)

Section A. Public Support

Calendar year (or fiscal yr beginning in)G 1 Gifts, grants, contributions and membership fees received. (Do not include any unusual grants.) 2 Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organizations tax-exempt purpose 3 Gross receipts from activities that are not an unrelated trade or business under section 513 4 Tax revenues levied for the organizations benefit and either paid to or expended on its behalf 5 The value of services or facilities furnished by a governmental unit to the organization without charge 6 Total. Add lines 1 through 5 7 a Amounts included on lines 1, 2, and 3 received from disqualified persons b Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year c Add lines 7a and 7b 8 Public support (Subtract line 7c from line 6.) (a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (f) Total

Section B. Total Support

Calendar year (or fiscal yr beginning in)G (a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 9 Amounts from line 6 10 a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975 c Add lines 10a and 10b 11 Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on 12 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.) 13 Total support. (Add lns 9, 10c, 11, and 12.) 14 First five years. If the Form 990 is for the organizations first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization, check this box and stop here (f) Total

Section C. Computation of Public Support Percentage

15 16 Public support percentage for 2011 (line 8, column (f) divided by line 13, column (f)) Public support percentage from 2010 Schedule A, Part III, line 15 15 16

% % % %

Section D. Computation of Investment Income Percentage

17 Investment income percentage for 2011 (line 10c, column (f) divided by line 13, column (f)) 17 18 Investment income percentage from 2010 Schedule A, Part III, line 17 18 19 a 33-1/3% support tests ' 2011. If the organization did not check the box on line 14, and line 15 is more than 33-1/3%, and line 17 is not more than 33-1/3%, check this box and stop here. The organization qualifies as a publicly supported organization b 33-1/3% support tests ' 2010. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33-1/3%, and line 18 is not more than 33-1/3%, check this box and stop here. The organization qualifies as a publicly supported organization 20 Private foundation. If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions BAA
TEEA0403 05/25/11

Schedule A (Form 990 or 990-EZ) 2011

Schedule A (Form 990 or 990-EZ) 2011

Part IV

The Lazarus House: A Center for Wellness 76-0693417 Supplemental Information. Complete this part to provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and Part III, line 12. Also complete this part for any additional information. (See instructions).

Page 4

BAA
TEEA0404 05/25/11

Schedule A (Form 990 or 990-EZ) 2011

OMB No. 1545-0047

SCHEDULE G
(Form 990 or 990-EZ)

Supplemental Information Regarding Fundraising or Gaming Activities

Complete if the organization answered Yes to Form 990, Part IV, lines 17, 18, or 19, or if the organization entered more than $15,000 on Form 990-EZ, line 6a. G Attach to Form 990 or Form 990-EZ. G See separate instructions.

2011
Open to Public Inspection
Employer identification number

Department of the Treasury Internal Revenue Service Name of the organization

The Lazarus House: A Center for Wellness the organization answered Yes to Form 990, Part IV, line 17. Part I Fundraising Activities. Complete ifto complete this part. Form 990-EZ filers are not required
1

76-0693417

Indicate whether the organization raised funds through any of the following activities. Check all that apply. a Mail solicitations e Solicitation of non-government grants b Internet and email solicitations f Solicitation of government grants c Phone solicitations g Special fundraising events d In-person solicitations 2 a 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?

Yes

No

b If Yes, list the ten highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is to be compensated at least $5,000 by the organization. (i) Name and address of individual (ii) Activity (iii) Did fundraiser (iv) Gross receipts (v) Amount paid to (vi) Amount paid to or entity (fundraiser) have custody or control from activity (or retained by) (or retained by) of contributions? fundraiser listed in organization column (i) Yes 1 2 3 4 5 6 7 8 9 10 No

Total 3 List all states in which the organization is registered or licensed to solicit contributions or has been notified it is exempt from registration or licensing.

BAA For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
TEEA3701 01/24/12

Schedule G (Form 990 or 990-EZ) 2011

Schedule G (Form 990 or 990-EZ) 2011

The Lazarus House: A Center for Wellness 76-0693417 Page 2 Part II 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 #1 (b) Event #2 (c) Other events

Fiesta 2011
R E V E N U E (event type)

Aids Walk 2011

(event type)

NONE
(total number)

(d) Total events (add column (a) through column (c))

1 2 3 4 5

Gross receipts Less: Charitable contributions Gross income (line 1 minus line 2) Cash prizes Noncash prizes Rent/facility costs Food and beverages Entertainment Other direct expenses

10,395.

16,075.

26,470.

10,395.

16,075.

26,470.

D I R E C T E X P E N S E S

6 7 8 9 10 11

26,470. Part III Gaming. Complete if the organization answered Yes to Form 990, Part IV, line 19, or reported more than $15,000 on Form 990-EZ, line 6a.
R E V E N U E

Direct expense summary. Add lines 4 through 9 in column (d) Net income summary. Combine line 3, column (d), and line 10

(a) Bingo

(b) Pull tabs/Instant bingo/progressive bingo

(c) Other gaming

(d) Total gaming (add column (a) through column (c))

1 2

Gross revenue Cash prizes Non-cash prizes Rent/facility costs Other direct expenses Volunteer labor Yes No

D I R E C T

E X P E N S E S

3 4 5 6 7 8

Yes No

Yes No

Direct expense summary. Add lines 2 through 5 in column (d) Net gaming income summary. Combine lines 1, column (d) and line 7

Enter the state(s) in which the organization operates gaming activities: a Is the organization licensed to operate gaming activities in each of these states? b If No, explain:

Yes

No

10 a Were any of the organizations gaming licenses revoked, suspended or terminated during the tax year? b If Yes, explain:

Yes

No

BAA

TEEA3702

01/24/12

Schedule G (Form 990 or 990-EZ) 2011

Schedule G (Form 990 or 990-EZ) 2011 The Lazarus House: 11 Does the organization operate gaming activities with nonmembers? 12

A Center for Wellness

76-0693417
Yes Yes

Page 3 No No

Is the organization a grantor, beneficiary or trustee of a trust or a member of a partnership or other entity formed to administer charitable gaming?

13

Indicate the percentage of gaming activity operated in: a The organizations facility 13 a b An outside facility 13 b 14 Enter the name and address of the person who prepares the organizations gaming/special events books and records: Name G Address G 15 a Does the organization have a contact with a third party from whom the organization receives gaming revenue? b If Yes, enter the amount of gaming revenue received by the organization G $ and the amount of gaming revenue retained by the third party G $ . c If Yes, enter name and address of the third party: Name G Address G 16 Gaming manager information: Name G Gaming manager compensation G Description of services provided G Director/officer 17 Mandatory distributions a Is the organization required under state law to make charitable distributions from the gaming proceeds to retain the state gaming license? b Enter the amount of distributions required under state law to be distributed to other exempt organizations or spent in the organizations own exempt activities during the tax year G $ Yes Employee Independent contractor Yes

% %

No

No

Part IV

Supplemental Information. Complete this part to provide the explanations required by Part I, line 2b, columns (iii) and (v), and Part III, lines 9, 9b, 10b, 15b, 15c, 16, and 17b, as applicable. Also complete this part to provide any additional information (see instructions).

BAA

TEEA3703

05/20/11

Schedule G (Form 990 or 990-EZ) 2011

SCHEDULE O
(Form 990 or 990-EZ)

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. G Attach to Form 990 or 990-EZ.

OMB No. 1545-0047

2011
Open to Public Inspection

Department of the Treasury Internal Revenue Service Name of the organization

Employer identification number

The Lazarus House: A Center for Wellness Pt VI, Line 11a Pt VI, Line 15 Report is e-mailed to members. The United Way Compensation Survey is used.

76-0693417

BAA For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

TEEA4901

07/14/11

Schedule O (Form 990 or 990-EZ) 2011

Schedule B
(Form 990, 990-EZ, or 990-PF)
Department of the Treasury Internal Revenue Service Name of the organization

OMB No. 1545-0047

Schedule of Contributors
G Attach to Form 990, Form 990-EZ, or Form 990-PF

2011
Employer identification number

The Lazarus House: A Center for Wellness

Organization type (check one): Filers of: Form 990 or 990-EZ

76-0693417

Section: X 501(c)( 3 ) (enter number) organization 4947(a)(1) nonexempt charitable trust not treated as a private foundation 527 political organization 501(c)(3) exempt private foundation 4947(a)(1) nonexempt charitable trust treated as a private foundation 501(c)(3) taxable private foundation

Form 990-PF

Check if your organization is covered by the General Rule or a Special Rule. Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions. General Rule For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, $5,000 or more (in money or property) from any one contributor. (Complete Parts I and II.)

Special Rules

For a section 501(c)(3) organization filing Form 990 or 990-EZ that met the 33-1/3% support test of the regulations under sections 509(a)(1) and 170(b)(1)(A)(vi), and received from any one contributor, during the year, a contribution of the greater of (1) $5,000 or (2) 2% of the amount on (i) Form 990, Part VIII, line 1h or (ii) Form 990-EZ, line 1. Complete Parts I and II. For a section 501(c)(7), (8), or (10) organization filing Form 990 or 990-EZ that received from any one contributor, during the year, total contributions of more than $1,000 for use exclusively for religious, charitable, scientific, literary, or educational purposes, or the prevention of cruelty to children or animals. Complete Parts I, II, and III. For a section 501(c)(7), (8), or (10) organization filing Form 990 or 990-EZ that received from any one contributor, during the year, contributions for use exclusively for religious, charitable, etc, purposes, but these contributions did not total to more than $1,000. If this box is checked, enter here the total contributions that were received during the year for an exclusively religious, charitable, etc, purpose. Do not complete any of the parts unless the General Rule applies to this organization because it received nonexclusively religious, charitable, etc, contributions of $5,000 or more during the year $

Caution: An organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990, 990-EZ, or 990-PF) but it must answer No on Part IV, line 2, of its Form 990; or check the box on line H of its Form 990-EZ or on Part I, line 2, of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990, 990-EZ, or 990-PF). BAA For Paperwork Reduction Act Notice, see the Instructions for Form 990, 990EZ, or 990-PF. Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

TEEA0701

01/16/12

Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Name of organization

Page

of

of Part 1

Employer identification number

The Lazarus House: A Center for Wellness Part I

(a) Number

76-0693417

Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(b) Name, address, and ZIP + 4 (c) Total contributions (d) Type of contribution

Gary and Diane Heavin Community Fund 100 Ritchie Road Woodway TX
(b) Name, address, and ZIP + 4

$ 76712

7,000.

Person Payroll Noncash

(Complete Part II if there is a noncash contribution.) (c) Total contributions (d) Type of contribution

(a) Number

Bunnies on the Bayou P O Box 66832 Houston TX

(b) Name, address, and ZIP + 4

$ 77266

10,000.

Person Payroll Noncash

(Complete Part II if there is a noncash contribution.) (c) Total contributions (d) Type of contribution

(a) Number

AIDS Foundation Houston 3202 Weslayan Houston TX

(b) Name, address, and ZIP + 4

$ 77027

16,075.

Person Payroll Noncash

(Complete Part II if there is a noncash contribution.) (c) Total contributions (d) Type of contribution

(a) Number

NRG 1301 McKinney Houston TX

(b) Name, address, and ZIP + 4

$ 77011

5,000.

Person Payroll Noncash

(Complete Part II if there is a noncash contribution.) (c) Total contributions (d) Type of contribution

(a) Number

Person Payroll Noncash (Complete Part II if there is a noncash contribution.)

(a) Number

(b) Name, address, and ZIP + 4

(c) Total contributions

(d) Type of contribution

Person Payroll Noncash (Complete Part II if there is a noncash contribution.)

BAA

TEEA0702

08/30/11

Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

OMB No. 1545-0172

Form

4562
(99)

Depreciation and Amortization

(Including Information on Listed Property)
G See separate instructions. G Attach to your tax return.

Department of the Treasury Internal Revenue Service Name(s) shown on return

2011
Attachment Sequence No. Identifying number

179

The Lazarus House: A Center for Wellness

Business or activity to which this form relates

76-0693417

Form 990 / Form 990EZ Part I Election To Expense Certain Property Under Section 179
Note: If you have any listed property, complete Part V before you complete Part I. 1 2 3 4 5 6 Maximum amount (see instructions) Total cost of section 179 property placed in service (see instructions) Threshold cost of section 179 property before reduction in limitation (see instructions) Reduction in limitation. Subtract line 3 from line 2. If zero or less, enter -0Dollar limitation for tax year. Subtract line 4 from line 1. If zero or less, enter -0-. If married filing separately, see instructions (a) Description of property (b) Cost (business use only) 1 2 3 4 5 (c) Elected cost

7 Listed property. Enter the amount from line 29 7 8 Total elected cost of section 179 property. Add amounts in column (c), lines 6 and 7 9 Tentative deduction. Enter the smaller of line 5 or line 8 10 Carryover of disallowed deduction from line 13 of your 2010 Form 4562 11 Business income limitation. Enter the smaller of business income (not less than zero) or line 5 (see instrs) 12 Section 179 expense deduction. Add lines 9 and 10, but do not enter more than line 11 13 Carryover of disallowed deduction to 2012. Add lines 9 and 10, less line 12 13 Note: Do not use Part II or Part III below for listed property. Instead, use Part V.

8 9 10 11 12

Part II
14

Special Depreciation Allowance and Other Depreciation (Do not include listed property.) (See instructions.)
14 15 16

Special depreciation allowance for qualified property (other than listed property) placed in service during the tax year (see instructions) 15 Property subject to section 168(f)(1) election 16 Other depreciation (including ACRS) Part III MACRS Depreciation (Do not include listed property.) (See instructions.) Section A 17 MACRS deductions for assets placed in service in tax years beginning before 2011 18

17

2,614.

If you are electing to group any assets placed in service during the tax year into one or more general asset accounts, check here Section B ' Assets Placed in Service During 2011 Tax Year Using the General Depreciation System (c) Basis for depreciation (a) (b) Month and (d) (e) (f)
Classification of property year placed in service (business/investment use only ' see instructions) Recovery period Convention Method

(g) Depreciation
deduction

19 a 3-year property b 5-year property c 7-year property d 10-year property e 15-year property f 20-year property g 25-year property h Residential rental property i Nonresidential real property 20 a Class life b 12-year c 40-year

25 yrs 27.5 yrs 27.5 yrs 39 yrs

MM MM MM MM

S/L S/L S/L S/L S/L S/L S/L S/L

21 22

Section C ' Assets Placed in Service During 2011 Tax Year Using the Alternative Depreciation System

12 yrs 40 yrs

MM

Part IV
21 22

Summary (See instructions.) 2,614.

Form 4562 (2011)

Listed property. Enter amount from line 28 Total. Add amounts from line 12, lines 14 through 17, lines 19 and 20 in column (g), and line 21. Enter here and on the appropriate lines of your return. Partnerships and S corporations ' see instructions 23 For assets shown above and placed in service during the current year, enter the portion of the basis attributable to section 263A costs 23 BAA For Paperwork Reduction Act Notice, see separate instructions. FDIZ0812 05/20/11

Form 4562 (2011)

Part V

The Lazarus House: A Center for Wellness 76-0693417 Listed Property (Include automobiles, certain other vehicles, certain computers, and property used for entertainment,
recreation, or amusement.) Note: For any vehicle for which you are using the standard mileage rate or deducting lease expense, complete only 24a, 24b, columns (a) through (c) of Section A, all of Section B, and Section C if applicable.

Page 2

Section A ' Depreciation and Other Information (Caution: See the instructions for limits for passenger automobiles.) 24 a Do you have evidence to support the business/investment use claimed? Yes No 24b If Yes, is the evidence written? Yes No (a) (b) (c) (d) (e) (f) (g) (h) (i)
Type of property (list vehicles first) Date placed in service Business/ investment use percentage Cost or other basis Basis for depreciation (business/investment use only) Recovery period Method/ Convention Depreciation deduction Elected section 179 cost

25 26

Special depreciation allowance for qualified listed property placed in service during the tax year and used more than 50% in a qualified business use (see instructions) Property used more than 50% in a qualified business use:

25

27 Property used 50% or less in a qualified business use:

28 Add amounts in column (h), lines 25 through 27. Enter here and on line 21, page 1 28 29 Add amounts in column (i), line 26. Enter here and on line 7, page 1 29 Section B ' Information on Use of Vehicles Complete this section for vehicles used by a sole proprietor, partner, or other more than 5% owner, or related person. If you provided vehicles to your employees, first answer the questions in Section C to see if you meet an exception to completing this section for those vehicles. 30 Total business/investment miles driven during the year (do not include commuting miles) Total commuting miles driven during the year Total other personal (noncommuting) miles driven Total miles driven during the year. Add lines 30 through 32 Yes 34 35 36 Was the vehicle available for personal use during off-duty hours? Was the vehicle used primarily by a more than 5% owner or related person? Is another vehicle available for personal use? Section C ' Questions for Employers Who Provide Vehicles for Use by Their Employees No Yes No Yes No Yes No Yes No Yes No (a) Vehicle 1 (b) Vehicle 2 (c) Vehicle 3 (d) Vehicle 4 (e) Vehicle 5 (f) Vehicle 6

31 32 33

Answer these questions to determine if you meet an exception to completing Section B for vehicles used by employees who are not more than 5% owners or related persons (see instructions). 37 Do you maintain a written policy statement that prohibits all personal use of vehicles, including commuting, by your employees? 38 Do you maintain a written policy statement that prohibits personal use of vehicles, except commuting, by your employees? See the instructions for vehicles used by corporate officers, directors, or 1% or more owners 39 Do you treat all use of vehicles by employees as personal use? 40 Do you provide more than five vehicles to your employees, obtain information from your employees about the use of the vehicles, and retain the information received? 41 Do you meet the requirements concerning qualified automobile demonstration use? (See instructions.) Note: If your answer to 37, 38, 39, 40, or 41 is Yes, do not complete Section B for the covered vehicles. Yes No

Part VI

Amortization
(a)
Description of costs

(b)
Date amortization begins

(c)
Amortizable amount

(d)
Code section

(e)
Amortization period or percentage

(f)
Amortization for this year

42

Amortization of costs that begins during your 2011 tax year (see instructions):

43 44

Amortization of costs that began before your 2011 tax year Total. Add amounts in column (f). See the instructions for where to report
FDIZ0812 05/20/11

43 44 Form 4562 (2011)

Form

8868

(Rev January 2012) Department of the Treasury Internal Revenue Service

Application for Extension of Time To File an Exempt Organization Return

G File a separate application for each return.

OMB No. 1545-1709

If you are filing for an Automatic 3-Month Extension, complete only Part I and check this box If you are filing for an Additional (Not Automatic) 3-Month Extension, complete only Part II (on page 2 of this form). Do not complete Part II unless you have already been granted an automatic 3-month extension on a previously filed Form 8868. Electronic filing (e-file). You can electronically file Form 8868 if you need a 3-month automatic extension of time to file (6 months for a corporation required to file Form 990-T), or an additional (not automatic) 3-month extension of time. You can electronically file Form 8868 to request an extension of time to file any of the forms listed in Part I or Part II with the exception of Form 8870, Information Return for Transfers Associated With Certain Personal Benefit Contracts, which must be sent to the IRS in paper format (see instructions). For more details on the electronic filing of this form, visit www.irs.gov/efile and click on e-file for Charities & Nonprofits.

? ?

Part I

Automatic 3-Month Extension of Time. Only submit original (no copies needed).

A corporation required to file Form 990-T and requesting an automatic 6-month extension ' check this box and complete Part I only All other corporations (including 1120-C filers), partnerships, REMICS, and trusts must use Form 7004 to request an extension of time to file income tax returns. Enter filers identifying number, see instructions
Name of exempt organization or other filer, see instructions. Employer identification number (EIN) or

Type or print
File by the due date for filing your return. See instructions.

The Lazarus House: A Center for Wellness

Number, street, and room or suite number. If a P.O. box, see instructions.

X 76-0693417
Social security number (SSN)

4106 Austin St.

City, town or post office, state, and ZIP code. For a foreign address, see instructions.

Houston
Enter the Return code for the return that this application is for (file a separate application for each return) Application Is For Form 990 Form 990-BL Form 990-EZ Form 990-PF Form 990-T (section 401(a) or 408(a) trust) Form 990-T (trust other than above) Return Code 01 02 01 04 05 06 Application Is For Form 990-T (corporation) Form 1041-A Form 4720 Form 5227 Form 6069 Form 8870

TX

77004 01
Return Code 07 08 09 10 11 12

? ? ?

The books are in the care of

Danielle Sampey

Telephone No. (713) 526-5071 FAX No. If the organization does not have an office or place of business in the United States, check this box If this is for a Group Return, enter the organizations four digit Group Exemption Number (GEN) . If this is for the whole group, check this box . If it is for part of the group, check this box and attach a list with the names and EINs of all members the extension is for. 1 I request an automatic 3-month (6 months for a corporation required to file Form 990-T) extension of time until Aug 15 , 20 12 , to file the exempt organization return for the organization named above. The extension is for the organizations return for:

G G
2

calendar year 20 11 tax year beginning

or , 20 , and ending , 20 Initial return . Final return

If the tax year entered in line 1 is for less than 12 months, check reason: Change in accounting period

3 a If this application is for Form 990-BL, 990-PF, 990-T, 4720, or 6069, enter the tentative tax, less any nonrefundable credits. See instructions b If this application is for Form 990-PF, 990-T, 4720, or 6069, enter any refundable credits and estimated tax payments made. Include any prior year overpayment allowed as a credit c Balance due. Subtract line 3b from line 3a. Include your payment with this form, if required, by using EFTPS (Electronic Federal Tax Payment System). See instructions

3a

0. 0. 0.

3b $ 3c

Caution. If you are going to make an electronic fund withdrawal with this Form 8868, see Form 8453-EO and Form 8879-EO for payment instructions. BAA For Paperwork Reduction Act Notice, see Instructions.
FIFZ0501 01/04/12

Form 8868 (Rev 1-2012)

990-EZ, 990, 990-T and 990-PF Information Worksheet

Part I ' Identifying Information
Employer Identification Number Name Doing Business As Address City Foreign Country Telephone Number Fax

2011

76-0693417 The Lazarus House: A Center for Wellness 4106 Austin St. Houston (713) 526-5071
State Extension E-Mail Address Room/Suite TX ZIP Code

77004

Eligible for hurricane tax relief legislation benefits, check here

Part II ' Type of Return X

Form 990-EZ only Form 990 only Form 990-PF only Form 990-T only Form 990-EZ with Form 990-T Form 990 with Form 990-T Form 990-PF with Form 990-T Form 990-N (gross receipts $50,000 or less) for Electronic Filing only

QuickBooks Import Users & 990 to 990-EZ Data Transfer Option: Check if youre filing the EZ & want 990 imported data copied to the EZ OR for those not importing from QuickBooks who transferred from prior year 990 and now qualify to file the EZ this year, check this box to transfer 990 data to the EZ. IMPORTANT Before transferring data from Form 990 to Form 990-EZ , refer to "How to transfer data from filing Form 990 to 990-EZ" listed above in the Most Common Support Questions or Tax Help for this line.

Part III ' Type of Organization X

501(c) Corporation/Association 501(c) Trust 4947(a)(1) Trust 408(e) Trust 401(a) Trust Other (describe)

3 (subsection number)
(subsection number)

220(e) Trust 408A Trust 529(a) Corporation 529(a) Trust 530(a) Trust 527 Organization 501(c) Association

Part IV ' Tax Year and Filing Information X

Calendar year Fiscal year ' Short year ' Ending month Beginning date

Ending date

Check this box if the organization is enrolled in the Electronic Federal Tax Payment System (EFTPS)

Part V ' 2011 Estimated Taxes Paid

Check this box if the organization is a private foundation Form 990-T Amount of 2010 overpayment credited to 2011 estimated tax Form 990-T Due Date Date Paid Amount Paid Date Paid Form 990-PF Amount Paid Form 990-PF

Payment Quarters 1st Quarter Payment 2nd Quarter Payment 3rd Quarter Payment 4th Quarter Payment Additional Payment 1 Additional Payment 2 Additional Payment 3 Additional Payment 4

04/18/11 06/15/11 09/15/11 12/15/11

The Lazarus House: A Center for Wellness Part VI ' Electronic Filing Information

76-0693417

Page 2

IMPORTANT: Do not use the Miscellaneous Statement or Additional Information if filing Form 990 or Form 990-EZ. These statements will not be transmitted with the return. Use Schedule O or the applicable Supplemental Information for the appropriate Schedule. Electronic Filing: X File the federal return electronically Practitioner PIN program: X Sign this return electronically using the Practitioner PIN X ERO entered PIN Officers PIN (enter any 5 numbers) 93417 Date PIN entered 05/24/2012 Electronic Filing of Extensions: X Check this box to file Form 8868 (application for extension of time to file return) electronically Information required for Electronic Filing: Officers Name Danielle Sampey Electronic Filing of Amended Return: Check this box to file amended return electronically

Part VII ' Electronic Funds Withdrawal Information (Form 990PF filers only)
Yes No Use electronic funds withdrawal of federal balance due (EF only)? Use electronic funds withdrawal of Form 8868 balance due (EF only)? Use electronic funds withdrawal of amended return balance due (EF only)? If any options selected above, enter information below, (Review transferred information for accuracy) Bank Information Name of Financial Institution (optional) Check the appropriate box Routing number Account number

Checking

Savings

Payment Information Enter the payment date to withdraw tax payment Balance due amount from this return Enter an amount to withdraw tax payment If partial payment is made, the remaining balance due Payment date for amended returns Balance due amount for amended returns

Part VIII ' Information for Client Letter

Form 990-EZ or Form 990 Extended Due Date Letter Salutation Form 990-PF Form 990-T

Danielle

Part IX ' Return Preparer

Enter preparer code from Firm/Preparer Info (See Help) QuickZoom to Firm/Preparer Info QuickZoom to Form 990-EZ, Pages 1 through 4 QuickZoom to Form 990, Page 1 QuickZoom to Form 990-PF, Page 1

QuickZoom to Form 990-T, Page 1 QuickZoom to Form 990-N, e-PostCard QuickZoom to Client Status
teew0101.SCR 12/09/11

Form 4562
The Lazarus House: A Center for Wellness Form 990 - / Form 990EZ
Asset Description DEPRECIATION Prior assets Equipment Bioelectric impedance analysis AT&T telephone system Mats, Bosu, Flex-Test FreeMotion Cable Landice Rehab Treadmill Handicap access Cybex Cable Multistation Cybex Olympic Flat Bench Cybex Squat Rack Handicap access improvement SUBTOTAL PRIOR YEAR TOTALS Code Date in Service

Depreciation and Amortization Report

Tax Year 2011 G Keep for your records
Land Business Special Use Section 179 Depreciation % Allowance Depreciable Basis Life Method/ Convention

2011
76-0693417
Prior Depreciation Current Depreciation

Cost (net of land)

01/01/04 05/01/05 05/01/06 03/07/07 04/10/07 07/25/07 09/07/07 10/04/07 04/11/09 04/11/09 04/11/09 05/01/09

7,900 2,000 1,592 318 476 4,530 4,020 1,860 1,000 150 350 2,650 26,846 26,846

100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 0 0 0 0 0 0

7,900 2,000 1,592 318 476 4,530 4,020 1,860 1,000 150 350 2,650 26,846 26,846

7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00

200DB/HY 200DB/HY 200DB/HY 200DB/HY 200DB/HY 200DB/HY 200DB/HY 200DB/HY 200DB/HY 200DB/HY 200DB/HY 200DB/HY

7,335 1,738 1,219 219 327 3,115 2,764 1,279 388 58 136 1,028 19,606 19,606

565 175 149 28 43 404 359 166 175 26 61 463 2,614 2,614

Code: S = Sold, A = Auto, L = Listed, C = COGS

FDIV3601

09/22/11

Page 1 of 1

Form 4562

Alternative Minimum Tax Depreciation Report

Tax Year 2011 G Keep for your records
Business Special Use Section 179 Depreciation % Allowance Depreciable Basis Life Method/ Convention Prior Depreciation

The Lazarus House: A Center for Wellness Form 990 - / Form 990EZ
Asset Description DEPRECIATION Prior assets Equipment Bioelectric impedance analysis AT&T telephone system Mats, Bosu, Flex-Test FreeMotion Cable Landice Rehab Treadmill Handicap access Cybex Cable Multistation Cybex Olympic Flat Bench Cybex Squat Rack Handicap access improvement SUBTOTAL PRIOR YEAR TOTALS Code Date in Service Cost (net of land) Land

2011
76-0693417
Current Depreciation Adjustment/ Preference

01/01/04 05/01/05 05/01/06 03/07/07 04/10/07 07/25/07 09/07/07 10/04/07 04/11/09 04/11/09 04/11/09 05/01/09

7,900 2,000 1,592 318 476 4,530 4,020 1,860 1,000 150 350 2,650 26,846 26,846

100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 0 0 0 0 0 0

7,900 2,000 1,592 318 476 4,530 4,020 1,860 1,000 150 350 2,650 26,846 26,846

7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00

150DB/HY 150DB/HY 150DB/HY 150DB/HY 150DB/HY 150DB/HY 150DB/HY 150DB/HY 150DB/HY 150DB/HY 150DB/HY 150DB/HY

7,285 1,686 1,101 182 272 2,588 2,296 1,063 298 45 104 791 17,711 17,711

615 209 196 39 58 555 493 228 150 22 53 398 3,016 3,016

-50. -34. -47. -11. -15. -151. -134. -62. 25. 4. 8. 65. -402. -402.

Code: S = Sold, A = Auto, L = Listed, C = COGS, P = Passive

FDIV3701

09/09/11

Page 1 of 1

Form

8879-EO

IRS e-file Signature Authorization for an Exempt Organization

For calendar year 2011, or fiscal year beginning , 2011, and ending

OMB No. 1545-1878

Department of the Treasury Internal Revenue Service Name of exempt organization

G Do not send to the IRS. Keep for your records. G See instructions.

2011
Employer identification number

The Lazarus House: A Center for Wellness

Name and title of officer

76-0693417

Danielle Sampey Executive Director Part I Type of Return and Return Information (Whole Dollars Only)
Check the box for the return for which you are using this Form 8879-EO and enter the applicable amount, if any, from the return. If you check the box on line 1a, 2a, 3a, 4a, or 5a, below, and the amount on that line for the return being filed with this form was blank, then leave line 1b, 2b, 3b, 4b, or 5b, whichever is applicable, blank (do not enter -0-). But, if you entered -0- on the return, then enter -0- on the applicable line below. Do not complete more than 1 line in Part I. 1a 2a 3a 4a 5a Form 990 check here Form 990-EZ check here Form 1120-POL check here Form 990-PF check here Form 8868 check here b Total revenue, if any (Form 990, Part VIII, column (A), line 12) b Total revenue, if any (Form 990-EZ, line 9) b Total tax (Form 1120-POL, line 22) b Tax based on investment income (Form 990-PF, Part VI, line 5) b Balance Due (Form 8868, Part I, line 3c or Part II, line 8c) 1b 2b 3b 4b 5b

128,544.

Part II

Declaration and Signature Authorization of Officer

Under penalties of perjury, I declare that I am an officer of the above organization and that I have examined a copy of the organizations 2011 electronic return and accompanying schedules and statements and to the best of my knowledge and belief, they are true, correct, and complete. I further declare that the amount in Part I above is the amount shown on the copy of the organizations electronic return. I consent to allow my intermediate service provider, transmitter, or electronic return originator (ERO) to send the organizations return to the IRS and to receive from the IRS (a) an acknowledgement of receipt or reason for rejection of the transmission, (b) the reason for any delay in processing the return or refund, and (c) the date of any refund. If applicable, I authorize the U.S. Treasury and its designated Financial Agent to initiate an electronic funds withdrawal (direct debit) entry to the financial institution account indicated in the tax preparation software for payment of the organizations federal taxes owed on this return, and the financial institution to debit the entry to this account. To revoke a payment, I must contact the U.S. Treasury Financial Agent at 1-888-353-4537 no later than 2 business days prior to the payment (settlement) date. I also authorize the financial institutions involved in the processing of the electronic payment of taxes to receive confidential information necessary to answer inquiries and resolve issues related to the payment. I have selected a personal identification number (PIN) as my signature for the organizations electronic return and, if applicable, the organizations consent to electronic funds withdrawal. Officers PIN: check one box only X I authorize ZIENTEK & CO.,

P.C.
ERO firm name

to enter my PIN

93417
Enter five numbers, but do not enter all zeros

as my signature

on the organizations tax year 2011 electronically filed return. If I have indicated within this return that a copy of the return is being filed with a state agency(ies) regulating charities as part of the IRS Fed/State program, I also authorize the aforementioned ERO to enter my PIN on the returns disclosure consent screen. As an officer of the organization, I will enter my PIN as my signature on the organizations tax year 2011 electronically filed return. If I have indicated within this return that a copy of the return is being filed with a state agency(ies) regulating charities as part of the IRS Fed/State program, I will enter my PIN on the returns disclosure consent screen.
Officers signature

Date G

06/15/2012

Part III Certification and Authentication

EROs EFIN/PIN. Enter your six-digit electronic filing identification number (EFIN) followed by your five-digit self-selected PIN

76654577077
do not enter all zeros

I certify that the above numeric entry is my PIN, which is my signature on the 2011 electronically filed return for the organization indicated above. I confirm that I am submitting this return in accordance with the requirements of Pub 4163, Modernized e-File (MeF) Information for Authorized IRS e-file Providers for Business Returns.

EROs signature

Date G

ERO Must Retain This Form ' See Instructions Do Not Submit This Form To the IRS Unless Requested To Do So BAA For Paperwork Reduction Act Notice, see instructions. Form 8879-EO (2011)

TEEA7401

12/01/11

IRS e-file Authentication Statement

G Keep for your records
Name(s) Shown on Return Employer ID Number

.11
76-0693417

The Lazarus House: A Center for Wellness A ' Practitioner PIN Authorization
Please indicate how the taxpayer(s) PIN(s) are entered into the program. Officer(s) entered PIN(s) ERO entered Officers PIN

B ' Signature of Electronic Return Originator

ERO Declaration: I declare that the information contained in this electronic tax return is the information furnished to me by the Corporation. If the Exempt Organization furnished me a completed tax return, I declare that the information contained in this electronic tax return is identical to that contained in the return provided by the Exempt Organization. If the furnished return was signed by a paid preparer, I declare I have entered the paid preparers identifying information in the appropriate portion of this electronic return. If I am the paid preparer, under the penalties of perjury, I declare that I have examined this electronic return, and to the best of my knowledge and belief, it is true, correct, and complete. This declaration is based on all information of which I have any knowledge. I am signing this Tax Return by entering my PIN below. EROs PIN (EFIN followed by any 5 numbers) EFIN

766545

Self-Select PIN

77077

C ' Signature of Officer

Perjury Statement: Under penalties of perjury, I declare that I am an officer of the above Exempt Organization and that I have examined a copy of the Exempt Organizations 2011 electronic income tax return and accompanying schedules and statements and to the best of my knowledge and belief, it is true, correct, and complete. Consent to Disclosure: I consent to allow my electronic return originator (ERO), transmitter, or intermediate service provider to send the Exempt Organizations return to the IRS and to receive from the IRS (a) and acknowledgement of receipt or reason for rejection of the transmission, (b) an indication of any refund offset, (c) the reason for any delay in processing the return or refund, and (d) the date of any refund. Electronic Funds Withdrawal Consent (if applicable): I authorize the U.S. Treasury and its designated Financial Agent to initiate an electronic funds withdrawal (direct debit) entry to the financial institution account indicated in the tax preparation software for payment of the Exempt Organizations Federal taxes owed on this return, and the financial institution to debit the entry to this account. To revoke a payment, I must contact the U.S. Treasury Financial Agent at 1-888-353-4537 no later than 2 business days prior to the payment (settlement) date. I also authorize the financial institution involved in the processing of the electronic payment of taxes to receive confidential information necessary to answer inquiries and resolve issues related to the payment. I am signing this Tax Return and Electronic Funds Withdrawal Consent, if applicable, by entering my self-selected PIN below. Officers PIN Date

93417 05/24/2012

TEEW2701

09/20/11

Electronic Filing Information Worksheet

G Keep for your records
Name(s) shown on return

2011
Identifying number

The Lazarus House: A Center for Wellness Part I ' State Mandated Electronic Filing:
Check this box to file the state return(s) electronically Note: Federal Return is not being E-filed with the state return(s)

76-0693417

State(s)

* Select the state or states to file electronically. Multiple states can be entered.

Check this box to file the Massachusetts Fiduciary extension (Form M-8736) electronically

Part I ' Electronic Return Originator Information

The ERO Information below will automatically calculate based on the preparer code entered on the return. If the ERO is not the same as the preparer designated on the return, enter a Preparer Code from the Firm/Preparer Info to assign an ERO to this return. Check to use ERO name instead of firm name in electronic file and on Forms 8453, 8878A, & 8879
Firm Name Social Security Number or PTIN

ZIENTEK & CO., P.C.

Name

P00158545
Employer Identification Number

Kathy Ploch, CPA

Address

76-0002535
Phone Number Fax Number

2465 SOUTH KIRKWOOD

City State ZIP Code

(281) 496-6152 TX 77077 766545

E-mail Address

(281) 496-7920

Electronic Filers Identification Number (EFIN)

HOUSTON
Country

Enter a Preparer Code from the Firm/Preparer Info to assign a different ERO to this return. (See Help)

Part II ' Paid Preparer Information

Firm Name Social Security Number or PTIN

ZIENTEK & CO., P.C.

Name

P00158545
Employer Identification Number

Kathy Ploch, CPA

Address

76-0002535
Phone Number Fax Number

2465 SOUTH KIRKWOOD

City State ZIP Code

(281) 496-6152 TX 77077

E-mail Address

(281) 496-7920

HOUSTON
Country

If your firm is ONLY the ERO and the return being transmitted was not prepared by your firm, enter a preparer code from the Alternative EF Preparer Information to assign a paid preparer. (See Help)

Part IV ' Amended Returns

Enter the payment date to withdraw tax payment Amount you are paying with the amended return Check this box to file another amended return electronically

Part V ' Name Control

Name Control, enter here to override default
cpcv1701.SCR 10/06/10

LAZA

Form 8868 Electronic Filing Information Worksheet

Name

2011

Social Security Number

The Lazarus House: A Center for Wellness Prepare Form 8868 for Electronic Filing
Extension accepted

76-0693417

Signature of Officer
Officers Name Officers Title Signature Date

Electronic Funds Withdrawal - Amount paid with Form 8868

NOTE - A practitioner PIN or Form 8453 is required for Form 8868 efile if using electronic funds withdrawal Enter the payment date to withdraw tax payment

Practitioner PIN information for Form 8868

Sign Form 8868 electronically using the Practitioner PIN NOTE - A practitioner PIN or Form 8453 is required for Form 8868 efile if using electronic funds withdrawal Please indicate how the Officer PIN is entered into the program. Officer entered PIN ERO entered Officers PIN EROs Practitioner PIN (EFIN followed by any 5 numbers) EFIN Self-Select PIN

ERO Declaration: I certify that the above numeric entry is my PIN, which is my signature to authorize submission of the electronic application for extension and electronic funds withdrawal for the corporation indicated above. I confirm that I am submitting application for extension in accordance with the requirements of the Pracitioner PIN method and Publications 4163, Modernized e-File Information for Authorized IRS e-file Providers, and 3112, IRS e-file Application and Participation.

Perjury Statement: Under penalties of perjury, I declare that I have been authorized by the above taxpayer to make this authorization and that I have examined a copy of the taxpayers electronic extension (Form 7004) for the tax period indicated above and to the best of my knowledge and belief, it is true, correct, and complete. Consent to disclosure: I consent to allow my electronic return originator (ERO), transmitter, or intermediate service provider to send the exempt organizations return to the IRS and to receive from the IRS (a) an acknowledgement of receipt or reason for rejection of the transmission, (b) an indication of any refund offset, (c) the reason for any delay in processing the return or refund, and (d) the date of any refund.

Electronic Funds Withdrawal Consent (if applicable): I authorize the U.S. Treasury and its designated
Financial Agent to initiate an electronic funds withdrawal (direct debit) entry to the financial institution account indicated in the tax preparation software for payment of the corporations Federal taxes owed on Form 8868, and the financial institution to debit the entry to this account. To revoke a payment, I must contact the U.S. Treasury Financial Agent at 1-888-353-4537 no later than 2 business days prior to the payment (settlement) date. I also authorize the financial institution involved in the processing of the electronic payment of taxes to receive confidential information necessary to answer inquiries and resolve issues related to the payment. I certify that I have the authority to execute this consent on behalf of the organization. I am signing this Disclosure Consent by entering my self-selected PIN below. Date Officers PIN (enter any 5 numbers)

The Lazarus House: A Center for Wellness

76-0693417

Schedule O (Form 990 or 990-EZ), Supplemental Information to Form 990 or 990-EZ Form 990-EZ, Part I, Line 16 Other Expenses Other expenses (describe in Schedule O)

Payroll taxes Supplies Fees Miscellaneous Equipment maintenance Client appreciation Web page Payroll fee Insurance Continuing education Dues Depreciation
Total

8,970. 3,171. 1,318. 85. 1,750. 1,164. 152. 778. 4,142. 4,393. 199. 2,614. 28,736.

Form 990-EZ, Page 2, Part IV List of Officers, Directors, Trustees, & Key Employees Stmt average hours per week devoted to position compensation (Form W-2/1099-MISC) (if not paid, enter -0-) benefits, contributions to employee benefit plans, and deferred compensation amount of other compensation

Business

Person

X
Title

Melissa Wilson 4106 Austin St. Houston TX

Foreign City Foreign Country Business

Hon. Member 77004

Hours/Week

0.00
Person

0.

0.

0.

X
Title

Danielle Sampey 4106 Austin St. Houston TX

Foreign City Foreign Country

Ex. Dir. 77004

Hours/Week

40.00

47,723.

0.

0.

The Lazarus House: A Center for Wellness

76-0693417

Form 990-EZ: Short Form Return of Organization Exempt From Income Tax Other Expenses Smart Worksheet
To enter assets, QuickZoom to Asset Entry Worksheet To view a calculated report of all depreciation information, QuickZoom to Depreciation Reports QuickZoom to Form 4562 The following items carry to the expanding table on line 16 below: A Depreciation B Amortization

O O O
2,614.

Sch. A, page 4: Schedule A, Page 4 Part IV, Supplemental Information Supplemental Information Smart Worksheet
The descriptions will be automatically included in the lines below. Line Number Explanation

The Lazarus House: A Center for Wellness

76-0693417

Schedule O: Supplemental Information to Form 990 Supplemental Information Smart Worksheet

QuickZoom here to Schedule O, page 2

Specific Information for Form 990-EZ, Parts I, II, III and V Note: The following lines for 990-EZ have their own supplemental overflow statement. If information is required for these lines, enter the information on the appropriate supplemental overflow statement: Form 990-EZ, Part I, Line 8 QuickZoom to Part I, Line 8 Form 990-EZ, Part I, Line 10 QuickZoom to Part I, Line 10 Form 990-EZ, Part I, Line 16 QuickZoom to Part I, Line 16 Form 990-EZ, Part I, Line 20 QuickZoom to Part I, Line 20 Form 990-EZ, Part II, Line 24 QuickZoom to Part II, Line 24 Form 990-EZ, Part II, Line 26 QuickZoom to Part II, Line 26 Note: Enter information specific to any of the following lines below: Form 990-EZ, Part III, Line 31 (Description of other program services) Form 990-EZ, Part IV (Officer, Directors, Trustees, Key Employees additional information) Form 990-EZ, Part V, Personal Benefit Contract(s) Form 990-EZ, Part V, Line 33 (Response to Yes for Question 33) Form 990-EZ, Part V, Line 34 (Response to Yes for Question 34) Form 990-EZ, Part V, Line 35b (Why organization did not report unrelated business income) Form 990-EZ, Part V, Line 44d (Response to No for Question 44d) Form 990-EZ, Part IV, Line 50 or Line 51 (HCE and Independent Contractors) Specific Information for Form 990, Parts III, V, VI, VII, IX, XI and XII Note: The following lines for 990 have their own supplemental overflow statement. If information is required for these lines, enter the information on the appropriate supplemental overflow statement: Form 990, Page 2, Part III, Line 4d QuickZoom to Part III, Line 4d Form 990, Page 6, Part VI, Section A, Line 9 QuickZoom to Part VI, Line 9 Form 990, Page 6, Part VI, Section C, Line 17 QuickZoom to Part VI, Line 17 Form 990, Page 10, Part IX, Line 24f QuickZoom to Line 24f Stmt Note: Enter information specific to any of the following below: Form 990, Page 2, Part III, Line 2, or Line 3. Form 990, Page 5, Part V, Line 3b, 13a or 14b Form 990, Page 6, Part VI, Section A, Lines 1a, 2-7b, 8a, or 8b. Form 990, Page 6, Part VI, Section B, Lines 10b, 11a, 12c or 15 Form 990, Page 6, Part VI, Section C, Line 18, or 19 Form 990, Page 7, Part VII, Column (E) or Column (F) Form 990, Page 12, Part XI Form 990, Page 12, Part XII, Line 1, 2c or 3b Choose a specific line number from the Line Number picklist and enter an explanation. The line number references and explanations entered here are automatically included in the lines below the Smart Worksheet and Schedule O page 2 if needed. Line Number Explanation

Pt VI, Line 11a Pt VI, Line 15

Report is e-mailed to members. The United Way Compensation Survey is used.

Note: Enter the line number and explanation for lines not mentioned above here. The line number references and explanations entered here are automatically included in the lines below the Smart Worksheet and Schedule O, page 2 if needed. Line Number Explanation

The Lazarus House: A Center for Wellness Sch. B, page 2 (Copy 1): Contributors

76-0693417

General Information Smart Worksheet

A Description for this copy of Schedule B, Part I

Copy 1

8868 p1- 990: Application for Extension of Time to File (1st Ext) -990/990-EZ Filing Address Smart Worksheet
Send Form 8868 to:

Department of the Treasury Internal Revenue Service Center Ogden, UT 84201-0012