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

2012
Open to Public Inspection , D
Employer identification number

Department of the Treasury Internal Revenue Service

A B

For the 2012 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)

, 2012, and ending

4106 Austin St.

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

ILE
Room/suite

The Lazarus House: A Center for Wellness

76-0693417 (713) 526-5071

G

Telephone number

G I J K

Houston Accounting Method: X Cash Accrual Other (specify) Website: G www.thelazarushouse.org 501(c) ( ) Tax-exempt status (check only one) ' X 501(c)(3)

TX
G H(insert no.)

77004

F Group Exemption Number

4947(a)(1) or

H Check G if the organization is not required to attach Schedule B (Form 990, 990-EZ, or 990-PF). 527

Part I
1 2 3 4 5a b 6
R E V E N U E

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 Contributions, gifts, grants, and similar amounts received Program service revenue including government fees and contracts Membership dues and assessments Investment income Gross amount from sale of assets other than inventory 5a Less: cost or other basis and sales expenses 5b 1 2 3 4

TF
6b 6c 7a 7b
03/14/13

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. 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 $500,000 or more, file Form 990 instead of Form 990-EZ G$ 155,720.

X 60,201. 43,074.

NO
TEEA0812

c Gain or (loss) from sale of assets other than inventory (Subtract line 5b from line 5a) Gaming and fundraising events a Gross income from gaming (attach Schedule G if greater than $15,000) b 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

5c

6a of contributions

52,445. 7,381.
6d

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 11 12 13 14 15 16 17 18 19 Grants and similar amounts paid (list in Schedule O) Benefits paid to or for members Salaries, other compensation, and employee benefits Professional fees and other payments to independent contractors Occupancy, rent, utilities, and maintenance Printing, publications, postage, and shipping Other expenses (describe in Schedule O) Total expenses. Add lines 10 through 16 Excess or (deficit) for the year (Subtract line 17 from line 9)

45,064.

DO

E X P E N S E S

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

148,339.

14,985.

A NS ES TE T S

268. 144,806. 160,059. -11,720. 74,898. 63,178.

Form 990-EZ (2012)

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.

Form 990-EZ (2012)

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 See L-26 Stmt 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

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

60,639. 208,065. 0. 268,704. 205,526. 63,178.

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 See line 31 - Schedule O

(Grants 29

0.

) If this amount includes foreign grants, check here

ILE
G 28 a G 29 a G G 30 a 31 a G 32
(d) Health benefits, contributions to employee benefit plans, and deferred compensation

Part III

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

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

138,211.

(Grants 30

) If this amount includes foreign grants, check here

31 32

(Grants $ ) If this amount includes foreign grants, check here Other program services (describe in Schedule O) (Grants $ ) If this amount includes foreign grants, check here Total program service expenses (add lines 28a through 31a)

Part IV

138,211. 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
(a) Name and Title (b) Average hours per week devoted to position (c) Reportable compensation (Forms W-2/1099-MISC) (If not paid, enter -0-) (e) Estimated amount of other compensation

DO

Tino Ramirez President Marc Cohen V. Pres. Sandy Stacy Secretary Bonnie Purvis Treasurer Lynn Selzer Member David Gooding Member Patrick Woerner Member Carl Shearer Hon. Member Melissa Wilson Hon. Member Danielle Sampey Ex. Dir.

NO
3.00 3.00 3.00 3.00 1.00 1.00 1.00 0.00 0.00 40.00
TEEA0812 03/14/13

TF
0. 0. 0. 0. 0. 0. 0. 0. 0. 44,954.

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

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

BAA

Form 990-EZ (2012)

Form 990-EZ (2012)

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

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 34 Were any significant changes made to the organizing or governing documents? If Yes, attach a conformed copy of the amended documents if they reflect a change to the organizations name. Otherwise, explain the change on Schedule O (see instructions) 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 G 37 a 37 a Enter amount of political expenditures, direct or indirect, as described in the instructions 0. 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 Yes 33 34 35 a 35 b 35 c 36 37 b 38 a No

X X X X X X X

TF
G

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 G 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

ILE
TX
Telephone no. G ZIP + 4 G G 43

40 b

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

40 e

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

Danielle Sampey Austin

NO
TEEA0812

Houston

(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: G

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: G

42 c

DO

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

G Yes 44 a 44 b 44 c 44 d 45 a 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)
103/14/13

X X X X

45 b X Form 990-EZ (2012)

Form 990-EZ (2012) 46

The Lazarus House: A Center for Wellness

76-0693417
46

Page 4 Yes No

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 only All section 501(c)(3) organizations 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 47 48 49 a 49 b No

ILE
(d) Health benefits, contributions to employee benefit plans, and deferred compensation (b) Type of service

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. 47
(a) Name and title of each employee paid more than $100,000 (b) Average hours per week devoted to position (c) Reportable compensation (Forms W-2/1099-MISC)

X X X

(e) Estimated amount of other compensation

None

51

G f Total number of other employees paid over $100,000 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 (c) Compensation

NO
Preparers signature TEEA0812

None

TF
Date

52

d Total number of other independent contractors each receiving over $100,000 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

G G

Yes

No

DO
A A Danielle
Signature of officer

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.

08/31/13
Date

Sign Here

Sampey

Executive Director
PTIN Check if self-employed

Type or print name and title.

Print/Type preparers name

Al Zientek, CPA, CFP 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

P00171356

Firms EIN

TX

77077

Phone no.

G 76-0002535 (281) 496-6152 G Yes No Form 990-EZ (2012)

03/14/13

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.

2012
Open to Public Inspection
Employer identification number

Department of the Treasury Internal Revenue Service Name of the organization

G Attach to Form 990 or Form 990-EZ. G See separate instructions.

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.) An organization that normally receives: (1) more than 33-1/3% of its support from contributions, membership fees, and gross receipts from activities 9 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). 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 11 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. e f g a Type I b Type II c Type III ' Functionally integrated d Type III ' Non-functionally integrated 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). 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 Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons? Yes 11 g (i) 11 g (ii) 11 g (iii)
(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 monetary support

TF
(iv) Is the organization in column (i) listed in your governing document?

ILE
Yes No Yes No

No

(i) (ii) h

A family member of a person described in (i) above?

(iii) A 35% controlled entity of a person described in (i) or (ii) above? Provide the 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))

NO
TEEA0401

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?

Yes

No

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

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

DO

Schedule A (Form 990 or 990-EZ) 2012

08/09/12

Schedule A (Form 990 or 990-EZ) 2012

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) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (f) Total

63,163.

57,401.

56,234.

52,753.

60,201.

289,752.

63,163.

57,401.

56,234.

ILE
52,753. 60,201.
(d) 2011 (e) 2012

289,752.

77,266. 212,486.
(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.) (a) 2008

(b) 2009

63,163.

57,401.

TF
(c) 2010

56,234.

52,753.

60,201.

289,752.

10

11 12 13

Total support. Add lines 7 through 10 Gross receipts from related activities, etc (see instructions)

NO
TEEA0402

289,752.
12

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 2012 (line 6, column (f) divided by line 11, column (f)) Public support percentage from 2011 Schedule A, Part II, line 14 14 15 % %

Section C. Computation of Public Support Percentage

14 15

73.33 49.80

DO

16 a 33-1/3% support test ' 2012. 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 ' 2011. 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 ' 2012. 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 ' 2011. 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) 2012

08/09/12

Schedule A (Form 990 or 990-EZ) 2012

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) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (f) Total

Section B. Total Support

Section C. Computation of Public Support Percentage

15 16 Public support percentage for 2012 (line 8, column (f) divided by line 13, column (f)) Public support percentage from 2011 Schedule A, Part III, line 15 15 16

DO

(a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 Calendar year (or fiscal yr beginning in) G 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

TF
TEEA0403 08/09/12

ILE
(f) Total

NO

% % % %

Section D. Computation of Investment Income Percentage

17 Investment income percentage for 2012 (line 10c, column (f) divided by line 13, column (f)) 17 18 Investment income percentage from 2011 Schedule A, Part III, line 17 18 19 a 33-1/3% support tests ' 2012. 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 ' 2011. 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

Schedule A (Form 990 or 990-EZ) 2012

Schedule A (Form 990 or 990-EZ) 2012

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

DO
Schedule A (Form 990 or 990-EZ) 2012
TEEA0404 08/10/12

NO

TF

ILE

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

2012
Employer identification number

The Lazarus House: A Center for Wellness

Organization type (check one): Filers of: Form 990 or 990-EZ Section: X 501(c)(

76-0693417

4947(a)(1) nonexempt charitable trust not treated as a private foundation 527 political organization Form 990-PF 501(c)(3) exempt private foundation

4947(a)(1) nonexempt charitable trust treated as a private foundation 501(c)(3) taxable private foundation

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.

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) (2012)

DO
TEEA0701 11/30/12

NO

TF

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.)

ILE

) (enter number) organization

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

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 Person

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

76712

(a) Number

ILE
$ 5,000.
Noncash (c) Total contributions Person Payroll

Payroll

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

Bunnies on the Bayou P O Box 66832 Houston TX 77266

7,500.

Noncash

(a) Number

(b) Name, address, and ZIP + 4

TF
$ TX 77027 $ TX 77079 $ IL 60523 $
11/30/12

(Complete Part II if there is a noncash contribution.) (d) Type of contribution Person Payroll

(c) Total contributions

AIDS Foundation Houston 3202 Weslayan Houston

15,928.

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

NO
TEEA0702

(a) Number

(b) Name, address, and ZIP + 4

(c) Total contributions

Christian Brothers Automotive

159951 N. Barkers Landing #145 Houston

(a) Number

20,000.

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

(b) Name, address, and ZIP + 4

(c) Total contributions

(d) Type of contribution Person Payroll

Nordstrom 701 Harger Road Oak Brook

DO

5,000.

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

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

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.

2012
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 Part I

76-0693417

c d

Phone solicitations In-person solicitations

Special fundraising events

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? 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 or entity (fundraiser) (ii) Activity (iii) Did fundraiser have custody or control of contributions? Yes 1 2 3 4 5 6 7 8 9 10 No (iv) Gross receipts from activity (v) Amount paid to (or retained by) fundraiser listed in column (i)

ILE

Fundraising Activities. Complete if the organization answered Yes to Form 990, Part IV, line 17. Form 990-EZ filers are not required to complete this part. 1 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 Internet and email solicitations Solicitation of government grants b f

Yes

No

(vi) Amount paid to (or retained by) organization

G 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 01/07/13

DO
Schedule G (Form 990 or 990-EZ) 2012

NO

TF

Schedule G (Form 990 or 990-EZ) 2012

Page 2 The Lazarus House: A Center for Wellness 76-0693417 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 2012
R E V E N U E (event type)

Aids Walk 2012

(event type)

OTHER
(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.

11,989.

38,459.

10,395.

16,075.

ILE
11,989. 7,381.
G G (c) Other gaming

38,459.

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

6 7 8 9 10 11

7,381. 31,078. 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

TF
(b) Pull tabs/Instant bingo/progressive bingo

7,381.

(a) Bingo

(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

D I R E C T

E X P E N S E S

3 4 5 6 7 8

NO
Yes No

Yes No

Yes No

Direct expense summary. Add lines 2 through 5 in column (d)

G G

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:

DO

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

01/07/13

Schedule G (Form 990 or 990-EZ) 2012

Schedule G (Form 990 or 990-EZ) 2012 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? G $ b If Yes, enter the amount of gaming revenue received by the organization 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 Description of services provided Director/officer 17 Mandatory distributions G G Employee

ILE

Yes

No

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 G $ organizations own exempt activities during the tax year

NO
TEEA3703

TF
Independent contractor Yes No
01/07/13

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

DO

Schedule G (Form 990 or 990-EZ) 2012

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.

OMB No. 1545-0047

2012
Open to Public Inspection

Department of the Treasury Internal Revenue Service Name of the organization

G Attach to Form 990 or 990-EZ.

Employer identification number

The Lazarus House: A Center for Wellness Pt VI, Line 11a Pt VI, Line 15 Pt III, Line 31 Report is e-mailed to members. The United Way Compensation Survey is used. Wellness Program:

76-0693417

The Lazarus House: a center for wellness provided a

low cost program of wellness for individuals suffering from disease related muscle loss, or cachexia. The

Larzarus House provided an exercise program that utilized progressive resistance training to address and attenuate disease related muscle loss, cardiopulmonary training to increase endurance and address dysmorphic issues associated with some medications, and nutritional counseling to encourage optimal muscle growth.

attended three times weekly for an hour per session. Certified personal trainers provided researched and disease specific exercise training sessions. Progress

was documented through a series of measurements taken before initiation, at 6 weeks, and upon completion. Measurements demonstrated that clients, on average,

DO
2012. of cachexia.

gained muscle and reflected a decrease in muscular wasting. The Lazarus House: Worked with an average of 47

clients, adolescent and adults, three times weekly in Clients presented with vary etiologies and degrees Disease related muscle loss addressed at

Lazarus House involved clients who suffered from HIV/AIDS, cancer, and spinal trauma.

NO

Clients of Lazarus House:

TF
TEEA4901 12/8/12

a center for wellness

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

ILE
Schedule O (Form 990 or 990-EZ) 2012

Schedule O (Form 990 or 990-EZ) 2012

Name of the organization Employer identification number

Page 2

The Lazarus House: A Center for Wellness The Lazarus House:

76-0693417 Provided lectures for community

organizations, free of charge, offering information about exercise and disease related wasting. The Lazarus House purchase the facility/property for which we operate in Fall 2012.

started a capital campaign for an expansion and improvement to the existing property.

BAA
TEEA4902 12/8/12

DO
Schedule O (Form 990 or 990-EZ) 2012

NO

TF

ILE
Lazarus House also

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.

2012
Attachment Sequence No. Identifying number

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

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
1 2 3 4 5 6

Part II
14

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

NO
(business/investment use only ' see instructions)

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 2012 18 If you are electing to group any assets placed in service during the tax year into one or more general asset accounts, check here (a)

TF
Recovery period Convention

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 2011 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 2013. 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.

ILE
1 2 3 4 5 (c) Elected cost 8 9 10 11 12 17

Note: If you have any listed property, complete Part V before you complete Part I. 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)

1,754.

Section B ' Assets Placed in Service During 2012 Tax Year Using the General Depreciation System (c) Basis for depreciation (b) Month and (d) (e) (f)
year placed in service Method

(g) Depreciation
deduction

Classification of property

property i Nonresidential real 11/12 49,573. property Section C ' Assets Placed in Service During 2012 Tax Year Using the Alternative Depreciation System 20 a Class life S/L b 12-year 12 yrs S/L c 40-year 40 yrs MM S/L

DO

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

25 yrs 27.5 yrs 27.5 yrs 39 yrs

MM MM MM MM

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

159.

Summary (See instructions.) 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 23 the portion of the basis attributable to section 263A costs BAA For Paperwork Reduction Act Notice, see separate instructions. FDIZ0812 08/19/12
21 22

Part IV

21 22

1,913.
Form 4562 (2012)

Form 4562 (2012)

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. Section A ' Depreciation and Other Information (Caution: See the instructions for limits for passenger automobiles.)

Page 2

24 a Do you have evidence to support the business/investment use claimed? (a)

Type of property (list vehicles first)

Yes (e)

No 24b If Yes, is the evidence written? (f)

Recovery period

Yes (h) (i)

No

(b)
Date placed in service

(c)
Business/ investment use percentage

(d)
Cost or other basis

(g)
Method/ Convention

Basis for depreciation (business/investment use only)

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:

27

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

28 29

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 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? (a) Vehicle 1 (b) Vehicle 2 (c) Vehicle 3 (d) Vehicle 4 (e) Vehicle 5 (f) Vehicle 6

31 32 33

Yes 34 35 36

No

TF
Yes No Yes No Yes (c)
Amortizable amount

Add amounts in column (h), lines 25 through 27. Enter here and on line 21, page 1 Add amounts in column (i), line 26. Enter here and on line 7, page 1 Section B ' Information on Use of Vehicles

ILE
25 28 No Yes No (d)
Code section

29

Yes

No

Section C ' Questions for Employers Who Provide Vehicles for Use by Their Employees 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 38 39 40 41 Do you maintain a written policy statement that prohibits all personal use of vehicles, including commuting, by your employees? 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 Yes No

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.

Part VI

DO
Amortization
(a)

Do you treat all use of vehicles by employees as personal use? 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?

NO
(b)
Date amortization begins

(e)
Amortization period or percentage

(f)
Amortization for this year

Description of costs

42

Amortization of costs that begins during your 2012 tax year (see instructions):

43 44

Amortization of costs that began before your 2012 tax year Total. Add amounts in column (f). See the instructions for where to report
FDIZ0812 08/19/12

43 44 Form 4562 (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

2012

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

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)

Part IV ' Tax Year and Filing Information X

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

NO
Due Date Date Paid

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

Part V ' 2012 Estimated Taxes Paid

Check this box if the organization is a private foundation

TF
Ending date Form 990-T Amount Paid

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.

DO
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

Amount of 2011 overpayment credited to 2012 estimated tax Form 990-PF Date Paid Amount Paid

04/17/12 06/15/12 09/17/12 12/17/12

ILE
220(e) Trust 408A Trust 529(a) Corporation 529(a) Trust 530(a) Trust 527 Organization 501(c) Association Form 990-T

Form 990-PF

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 08/21/2013

Electronic Filing of Extensions: 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

NO
Checking

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

DO
Extended Due Date Letter Salutation

TF
Savings Form 990-EZ or Form 990

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

ILE
Form 990-PF Form 990-T

QuickZoom to Form 990-T, Page 1 QuickZoom to Form 990-N, e-PostCard QuickZoom to Client Status
teew0101.SCR 11/30/12

DO

NO

TF

ILE

Form 4562
The Lazarus House: A Center for Wellness Form 990 - / Form 990EZ
Asset Description DEPRECIATION Building - 4106 Austin St. SUBTOTAL CURRENT YEAR 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 in Code Date Service

Depreciation and Amortization Report

Tax Year 2012 G Keep for your records
Land

IL
0 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 0 0
FDIV3601 08/27/12

2012
76-0693417
Method/ Convention Prior Depreciation Current Depreciation

Cost (net of land)

Special Business Section 179 Depreciation Use Allowance %

Depreciable Basis

Life

11/08/12

49,573 49,573

TF
153,866 100.00 153,866

49,573 39.00 49,573 7,900 2,000 1,592 318 476 4,530 4,020 1,860 1,000 150 350 2,650 26,846 76,419 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00

SL/MM 0 200DB/HY 200DB/HY 200DB/HY 200DB/HY 200DB/HY 200DB/HY 200DB/HY 200DB/HY 200DB/HY 200DB/HY 200DB/HY 200DB/HY 7,900 1,913 1,368 247 370 3,519 3,123 1,445 563 84 197 1,491 22,220 22,220

159 159 0 87 149 28 42 404 359 166 125 19 44 331 1,754 1,913

NO
76,419

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

0 0

153,866

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

DO

Page 1 of 1

Form 4562

Alternative Minimum Tax Depreciation Report

Tax Year 2012 G Keep for your records
Special Business Section 179 Depreciation Use Allowance %

IL
0 0 0 0 0 0
FDIV3701 08/27/12

The Lazarus House: A Center for Wellness Form 990 - / Form 990EZ
Asset Description DEPRECIATION Building - 4106 Austin St. SUBTOTAL CURRENT YEAR 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

2012
76-0693417
Method/ Convention Prior Depreciation Current Depreciation Adjustment/ Preference

Depreciable Basis

Life

11/08/12

49,573 49,573 7,900 2,000 1,592 318 476 4,530 4,020 1,860 1,000 150 350 2,650 26,846 76,419

153,866 100.00 153,866 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00

TF

49,573 39.00 49,573 7,900 2,000 1,592 318 476 4,530 4,020 1,860 1,000 150 350 2,650 26,846 76,419 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00

SL/MM 0 150DB/HY 150DB/HY 150DB/HY 150DB/HY 150DB/HY 150DB/HY 150DB/HY 150DB/HY 150DB/HY 150DB/HY 150DB/HY 150DB/HY 7,900 1,895 1,297 221 330 3,143 2,789 1,291 448 67 157 1,189 20,727 20,727

159 159 0 105 197 39 58 555 492 228 123 18 43 325 2,183 2,342

0. 0. 0. -18. -48. -11. -16. -151. -133. -62. 2. 1. 1. 6. -429. -429.

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

DO

NO
0 153,866

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

Page 1 of 1

Form

8879-EO

IRS e-file Signature Authorization for an Exempt Organization

For calendar year 2012, or fiscal year beginning , 2012, 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.

2012
Employer identification number

The Lazarus House: A Center for Wellness

Name and title of officer

76-0693417

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 G Form 990-EZ check here Form 1120-POL check here Form 990-PF check here Form 8868 check here G 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) G b Tax based on investment income (Form 990-PF, Part VI, line 5) G b Balance Due (Form 8868, Part I, line 3c or Part II, line 8c) G 1b 2b 3b 4b 5b

ILE
93417
Enter five numbers, but do not enter all zeros

Danielle Sampey Executive Director Part I Type of Return and Return Information (Whole Dollars Only)

148,339.

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 2012 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.,

TF
to enter my PIN
Date G Date G TEEA7401 11/09/12

on the organizations tax year 2012 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 2012 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

NO
ERO firm name

P.C.

as my signature

08/31/2013

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 2012 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

DO
G

ERO Must Retain This Form ' See Instructions Do Not Submit This Form To the IRS Unless Requested To Do So Form 8879-EO

BAA For Paperwork Reduction Act Notice, see instructions.

IRS e-file Authentication Statement

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

2012
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)

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EFIN

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 2012 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.

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

NO
TEEW2701

Electronic Funds Withdrawal Consent (if applicable):

TF
07/13/12

766545

Self-Select PIN

77077

93417 08/21/2013

DO

Electronic Filing Information Worksheet

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

2012
Identifying number

The Lazarus House: A Center for Wellness

76-0693417

Firm Name

Preparer PTIN

ZIENTEK & CO., P.C.

ERO Name

P00171356

Employer Identification Number

AL ZIENTEK, CPA, CFP

ERO Address

76-0002535
Phone Number State ZIP Code

2465 SOUTH KIRKWOOD

City

(281) 496-6152 TX 77077 766545

Electronic Filers Identification Number (EFIN) Preparer E-mail Address

HOUSTON
Country

Firm Name

ZIENTEK & CO., P.C.

Preparer Name

Al Zientek, CPA, CFP

Address

TF
Preparer PTIN

P00171356

Employer Identification Number

76-0002535
Phone Number

2465 SOUTH KIRKWOOD

City State

(281) 496-6152

ZIP Code

HOUSTON
Country

TX

77077

Preparer E-mail Address

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 * Select the NY State or City Amended return to file electronically.

Part IV ' Name Control

Name Control, enter here to override default

cpcv1701.SCR 10/06/10

NO

DO

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Fax Number

The ERO Information below will automatically calculate based on the preparer code entered on the return.

(281) 496-7920

Fax Number

(281) 496-7920

LAZA

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)

Total

Schedule O (Form 990 or 990-EZ), Supplemental Information to Form 990 or 990-EZ Form 990-EZ, Page 1, Part II, Line 26

Line 26 - Total Liabilities:

N/P - Central Bank Property Taxes for 2012 paid 2013 - Closing Credit
Total

TF

DO

NO

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144,806.
Beginning of Year End of Year

Depreciation Program Expenses Payroll taxes Supplies Fees Newsletter Miscellaneous - Prior period adjustment Payroll fees

1,913. 138,211. 1,971. 534. 1,069. 85. 174. 849.

200,000. 5,526. 205,526.

The Lazarus House: A Center for Wellness

76-0693417

Supporting Statement of:

Form 990-EZ/Line 6c Description ADVERTISEMENT FUNDRAISER FUNDRAISER MATERIALS GRANT ACCESS SERVICE
Total

Amount 183. 1,950. 5,069. 179. 7,381.

Supporting Statement of:

Form 990-EZ/Line 23, Column (B) Description BUILDING LAND OTHER

Total

TF

Supporting Statement of:

Sch. G, page 2/Other Gross Receipts Description Amount 6,497. 5,492. 11,989.

Golf Tournament NIBL

Total

DO

NO

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Amount 49,573. 153,866. 4,626. 208,065.

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

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

Sch. B, page 2 (Copy 1): Contributors

Description for this copy of Schedule B, Part I

NO

General Information Smart Worksheet Copy 1

DO

TF
Explanation

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1,913.

O O

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

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 Pt III, Line 31

DO

Report is e-mailed to members. The United Way Compensation Survey is used. Wellness Program: The Lazarus House: a center for wellness provided a low cost program of wellness for individuals suffering from disease related muscle loss, or cachexia. The Larzarus House provided an exercise program that utilized progressive resistance training to address and attenuate disease related muscle loss, cardiopulmonary training to increase endurance and address dysmorphic issues associated with some medications, and nutritional counseling to encourage optimal muscle growth. Clients of Lazarus House: a center for wellness attended three times weekly for an hour per session.

See Supplemental Information Smart Worksheet 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

NO

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 11g QuickZoom to Line 11g Stmt Form 990, Page 10, Part IX, Line 24e QuickZoom to Line 24e 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, 11b, 12c, 15a, or 15b 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 9, Part VIII Form 990, Page 11, Part X Form 990, Page 12, Part XI Form 990, Page 12, Part XII, Line 1, 2c or 3b

TF

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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 VI, Line 50 or Line 51 (HCE and Independent Contractors)

The Lazarus House: A Center for Wellness

76-0693417

Sch O, page 2 (Copy No. 1): Supplemental Information to Form 990 Supplemental Information Smart Worksheet
Description of this copy of Schedule O, page 2 Copy No. 1 QuickZoom here to another copy of Schedule O, page 2

DO

NO

TF

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The Lazarus House: A Center for Wellness Schedule 0, Page 1 Supplemental Information Smart Worksheet Line Number

76-0693417

Explanation

DO

NO

TF

Certified personal trainers provided researched and disease specific exercise training sessions. Progress was documented through a series of measurements taken before initiation, at 6 weeks, and upon completion. Measurements demonstrated that clients, on average, gained muscle and reflected a decrease in muscular wasting. The Lazarus House: Worked with an average of 47 clients, adolescent and adults, three times weekly in 2012. Clients presented with vary etiologies and degrees of cachexia. Disease related muscle loss addressed at Lazarus House involved clients who suffered from HIV/AIDS, cancer, and spinal trauma. The Lazarus House: Provided lectures for community organizations, free of charge, offering information about exercise and disease related wasting. The Lazarus House purchase the facility/property for which we operate in Fall 2012. Lazarus House also started a capital campaign for an expansion and improvement to the existing property.

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