Short Form OMB No For organizations with gross receipts less than $100,000 and total assets less

(1)

Short Form

OMB No . 1545-1150

Form

990-EZ

Return of Organization Exempt From Income Tax

Under section 501(c), 527, or 4947(axl) of the Internal Revenue Code ₂₀₀₃

(except black lung benefit trust or private foundation)

For organizations with gross receipts less than $100,000 and total assets less . ... . ... .. . . ---

Department of me Treasury than $250,000 at the end of the year. ~OR~ne

Internal Revenue Service ~ The organization may have to use a copy of this return to satisfy state reporting requirements. I 'a 04

A For the 2003 calendar ear, or tax ear beginning 9 / 01 , 2003, and ending 8 / 31 , 2004

B Check if applicable: C D Employer identification number

X Address change _UflaIRS

OREGON MEDICAL CASE MANAGEMENT GROUP

93-1076 734

Name change label or

(OMCMG)

_{E Telephone number}

~

riot or

Initial return

Pe. 833 SW 22ND #507

503-224-9460

Final return _{specific PORTLAND, OR 97205}

Amended return Insfruc- _,. _{F Group Exemption}

Application pending Number. . . .

X 3347

0 Section 501(c,Y3) organizations and 4947(a,Yl) nonexempt charitable trusts G Accounting method: E] Cash N Accrual

must atfach a completed Schedule A (Form 990 or 990-E~. Other (speci )

H Check 1, X if the organization is not

I Web site: - WWW . OMCMG . ORG required to attach Schedule B (Form 990,

990-EZ, or 990-PF). J Organization type (check only one) - X 501(c) ( 6 ) ~ (insert no.) 4941(a)(1) or 527

K Check 1, if the organization's gross receipts are normally not more than $25,000 . The organization need not file a return with the IRS ; but if the organization received a Form 990 Package in the mail, it should file a return without financial data. Some states require a complete return .

L Add lines 5b, 6b, and 7b, to line 9 to determine gross receipts ; if $100,000 or more, file Form 990

instead of Form 990-EZ . . . . . . . . . . . . . . . . . . . . . . . ~ $ 39,181 .

left I

Revenue, Expenses, and Changes in Net Assets or Fund Balances see

Instructions

1 Contributions, gifts, grants, and similar amounts received . . 1

2 Program service revenue including government fees and contracts . . . . . . . . . . . . . 2 37,050 .

3 Membership dues and assessments . . . 3 2,131 .

4 Investment income . . . . . . .. . . _--4 w

5a Gross amount from sale of assets other than inventory . . . . . . . . . . . . . 5a

b Less: cost or other basis and sales expenses . . . . . 5b

c Gain or (loss) from sale of assets other than inventory (line 5a less line 5b) (attach schedule) . . . 5c w 6 Special events and activities (attach schedule) . If any amount is from gaming, check here . . . . ~ _E

a Gross revenue (not including $ of contributions

reported on line 1). . . . . 6a

''1Q b less: direct expenses other than fundraising expenses. . . . . . . 6b

c Net income or (loss) from special events and activities _Cline 6a less line 6b) . . . . . . . . 6c '- 7a Gross sales of inventory, less returns and allowances . . . . . . . . . . . . . . . . 7a

b Less: cost of goods sold . . 7b

c; c Gross profit or (loss) from sales of inventory (line 7a less line 7b) . . . . . . . . . . . . .. . 7c

8 Other revenue (describe ~ ) . . 8

9 Total revenue add lines 1, 2, 3, 4, 5c, 6c, 7c, and 8 . . . . . . .

.

. . . . . . . . ~ 9 39,181 .

10 Grants and similar amounts paid (attach schedule). . . . . . . . . . . . . . . . . . . 10

E 11 Benefits paid to or for members . . . . . . . . . . . 11

Q P 12 Salaries, other compensation, and employee benefits, . 12

N 13 Professional fees and other payments to independent contractors . . . 13 4,015 .

5 14 Occupan q2owlaFf

ig . . . . . . . . . . . . . . . . . . . . 14

@PQ W-

E 15 Printing, ublica, ship . .

. . . .

. . . . 15 1,299 .

16 Other expe es escn e

SEE STATEMENT 1) . . . 16

27, 282 .

17 Total ex s ~id_lines 10 through f . . . . . . . . . . . . . . . . . . ~ 17 32, 596 .

18 Excess o ~A1 tici_r t _I 9 ~ line 17) . . . . .. . . . . . 18 6,585 .

N s 19 Net asse s CIL

qili,

or~fdnC~bakmce nag f year (from line 27, column (A)) (must agree with end-of-year

E E figure re orted . . . 19 7, 627 .

T 5 20 Other ch n e ~~~ ) ~ es (attach explanation). . . . . . . . . . . . 20

21 Net assets or fund balances at end of ear combine lines 18 through 24 . . . . . . . 11 21 14,212 .

Balance Sheets

- If Total assets on line 25, column B are $250,000 or more, file Form 990 instead of Form 990-EZ.

(See Instructions) A Beginning of ear B End of ear

22 Cash, savings, and investments . 7,627 . 2Z 14,212 .

23 Land and buildings . . 23

24 Other assets (describe ~ ) . . . . . . . . . . 24

25 Total assets . . . . . . .

. . . . . . . . . . .

7,627 . 25

14,212 .

26 Total liabilities (describe 0, ). . . 0 . 26 0 .

27 Net assets or fund balances line 27 of column B must agree with line 21 . . . . . . 7,627 .

1

27

1

14,212 .

(2)

Other Inf01't11at1011 Note the attachment requirement in the instructions SEE STATEMENT 3 Yes No 33 Did the organization engage in any activity not previously reported to the IRS? If 'Yes,' attach a detailed description

of each activity . . . . . . . . . . . . . . . . . . .

34 Were any changes made to the organizing or governing documents but not reported to the IRS? If 'Yes,' attach a conformed copy of the changes . . . . . . . . X 35 If the organization had income from business activities, such as those reported on lines 2, 6, and 7 (among others), but not reported on Form 990-T, attach a

statement explaining your reason for not reporting the income on Form 990-T.

a Did the organization have unrelated business grass income of $1,000 or mare or 6033(e) notice, reporting, and proxy tax requirements?. . . X b If 'Yes,' has it filed a tax return on Form 990-T for this year?. . . . . . . . . . N ,'A 36 Was there a liquidation, dissolution, termination, or substantial contraction during the year? (If 'Yes,' attach a statement.) . . . . . . . . . . . X 37a Enter amount of political expenditures, direct or indirect, as described in the instructions . . . "37a 0 . ' ^

b Did the organization file Form 1120-POL for this year? . . . . ,

38a 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 unpaid at the start of the period covered by this return? . . . . . . . . . . . . . . . X b If 'Yes,' attach the schedule specified m the line 38 Instructions and enter the amount involved . . . . . . . . . 38b N/A

39 50t(c)(7) organizations Enter: a Initiation fees and capital contributions included on line 9. . . . . 39a N/A . I b Gross receipts, included on line 9, for public use of club facilities . . . . . . . . . . . 39h N/Ai I 40a 501(c)(3) organizations, Enter: Amount of tax imposed on the organization during the year under:

section 491 1 0, N/A ;section 4912 ~ N/A ; Section 4955 ~

b 501(c)(3) and (4) organizations. Did the organization engage in any section 4958 excess benefit transaction during the year or did it become aware of an excess

benefit transaction from a prior year? If 'Yes,' attach an explanation . . . . .. . . . . , , . , . , , . . . , . . . . . I ~] II ~'1 L~-c Amount of tax imposed on organization managers or disqualified persons during the year under 4912, 4955, and 4958 . . . ~ 0 . d Enter. Amount of tax on line 40c, above, reimbursed by the organization . . . . , . . . . . . ~ 0 . 41 List the states with which a copy of this return is filed - NONE

42 The books are in care of " JEANNE COVEY Telephone no. ~ 503-224-9460 Located at - 833 SW 22ND, STE 507, PORTLAND OR ZIP+4 ~ 97205

43 Section 4947(a)(1) nonexempt charitable trusts fling Form 990-EZ m lieu of Form 1047 - Check here. . . . . . . 11. LJ N/A

and enter the amount of tax-exem pt interest received or accrued durin g the tax ear . . . . . . -43 N/A Und penalties of penury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is

~1 'lease true . rrect, and complete Declaration of reparer (other than officer) is based on all information of which pre~arer has any knowledge. _. _r _n

Sign

Here

Paid Preparer's

Pre

' signature

pacer's

Firm's name

(or MARCY D . LANTZ, A

yours if self-

Use

employed),

~ 12800 SW MORNINGSTA

Only IZP+4

"and

_{TIGARD, OR 97223-17}

BAA

Form 99o-EZ (2003) OREGON MEDICAL CASE MANAGEMENT GROUP 93-1 076734 Page 2

Peat 11111 ' { Statement of Program Service Accomplishments (See Instructions) Expenses

What is the organization's primary exempt purpose? (Required for 501(c)(3)

Describe what was achieved in carrying out e orgarnza ion s exemp purposes. n a clear an concise manner, and (4) organizations and describe the services provided, the number of persons benefited, or other relevant information for each 4947(a)(1) trusts; optional

program title. for others .

28 PROVIDED MONTHLY EDUCATIONAL FORUMS FOR ALL GROUP MEMBERS

--- --- Grants $ 28a 29 --- --- Grants $ 29a 3Q --- --- (Grants $ ) 30a

31 Other program services attach schedule . Grants $ ) 31 a

32 Total ro ram service expenses (add lines 28a through 31a) . . . ll~32

~!>: List of Officers, Directors, Trustees, and Key Et1'1 l0 ee5 (List each one even if not compensated . See Instructions,) (B) Title and average hours (C) Compensation If (D) Contributions to (E) Expense account (A) Name and address per week devoted not paid, enter-0- employee benefit plans and and other allowances

to position deferred compensation

--- ---

SRF qTATRMRNT 7 O .I O . O .

---

Type or prmt~namd and title -

~-Date ~ Check if Preparei s SSN or PTIN (See ~_ Pmlnl-d r F X-11 Instruction W)

EIN

- N/A

Phone no.

- (503) 590-4890

TEEA0812L 12/23/03 Form 990-EZ (2003)

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2003

FEDERAL STATEMENTS

PAGE 1

OREGON MEDICAL CASE MANAGEMENT GROUP

(OMCMG)

93-1076734

STATEMENTI

FORM 990-EZ, PART I, LINE 16

OTHER EXPENSES

BANK CHARGES & FEES. . . . . . . .

. . . . . . . . $

163 .

BOARD DEVELOPMENT EXP. . . . . . . . . . . .

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

9,133 .

BUSINESS LICENSE/CORP LICENSE . . .

425 .

CONFERENCE LUNCHEON. . . . . . . . . . . . . . . . .

. . . . . . . . .

500 .

CONFERENCE SPEAKER FEES .

. . .

. .

3,500 .

CONFERENCE SUPPLIES. . . . . . . . . . . . . . .

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

910 .

CONFERENCE TRAVEL EXP. . . . . . . . . . . .

. . . . . . .

413 .

CONFERENCE VENDOR REFUNDS . . . . . . . .

. . . . . .

100 .

CONTINUING EDUCATION . . . . . . . . . . . . . . . . . . . . . .

2,604 .

FLOWERS/PROMOTIONAL . . . . .

. . . . . . . . . .

20 .

MEMBERSHIP/CHAPTER FEE .

. . . . .

75 .

MONTHLY LUNCHEON EXP .. . .

5,883 .

OFFICE SUPPLIES. . . . . . . .

1,969 .

PHONE ANSWERING SERVICE. . . .

257 .

106 .

SPEAKER FEES. . . . . . . . .

WEB SITE DEVELOPMENT/MAINT . .

. . . . . .

1,224 .

TOTAL

27,282 .

STATEMENT 2

FORM 990-EZ, PART IV

LIST OF OFFICERS, DIRECTORS, TRUSTEES, AND KEY EMPLOYEES

TITLE AND

CONTRI-

EXPENSE

AVERAGE HOURS

COMPEN-

BUTION TO ACCOUNT/

NAME AND ADDRESS

PER WEEK DEVOTED

SATION

EBP & DC

OTHER

JENNIFER WRIGHT

PRESIDENT

$

0 . $

0 .

5530 NE 122ND AVE, #329

2 PORTLAND, OR 97230

CRISTIE WIGGS

VICE PRESIDENT

0 .

5530 NE 122ND AVE, #329

2 PORTLAND, OR 97230

CAM CAMBURN SECRETARY 0 . 0 . 0 . 20540 NW YONCALLA CT 2

PORTLAND, OR 97229

MICHELE NIELSEN

TREASURER

0 .

19363 WILLAMETTE DR ., #134

2 WEST LINN, OR 97068

JEANNE COVEY

TREA5 - CURRENT

0 .

833 SW 22ND, STE 507

2 PORTLAND, OR 97205

(4)

(5)

c from line 8a. Include your payment with this form, or, if required, deposit with =DQn-m,vif neaarired, b using EFTPS (Electronic Federal Tax Payment System). See instructions . . .

VuLC~e~ . v

_{...._._.J}

_{Signature and Verification}

Under penalties of penury, I declare that I have examined this form . including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete, and (fiat I am authorized to pr9pare this form .

Date '-

I

-" ° TiNe 10' ( F iV

By

Director Date

Alternate Mailing Address - Enter the address if you want the copy of this application for an additional 3-month

1,MOVED

address different than the one entered above.

Name

Marc D . Lantz, CPA

APR

2 9 205

Type or Number and street pnclude suite, room, or apartment number) or a P .O, box number

print _{12800 SW Mornin star Dr} ,FIELD DIRECTOR,

_N

City or town . province or stale, and country (including postal or ZIP code)

Ti ard, OR 97223-1784

BAA FIFZ0502L 01105104 Form 8868 (Rev 12-2000)

Form 8868 12-2000 Pa e 2

0 If you are filing for an Additional (not automatic) 3-Month Extension, complete only Part II and check this box. . . . . . . . . ~ X Note: Only complete Part // if you have already been granted an automatic 3-month extension on a previously filed

Form 8868.

a If you are filing far an Automatic 3-Month Extension, com plete only Part I on a e 1) .

Additional not automatic 3-Month Extension of Time - Must File Ori

g

inal and One Go

Name of Exempt Organization Employer Identification number

Type or Oregon Medical Case Management Group

print

(OMCMG)

J

I 93-1076734

Number, street . and room or suite number. If a P .O . box, see instructions . I For IRS Use Only File by the

extended due date for

~

f

ling the

PO Box

11 5 1

return . See _{City, town}

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

i . ~

Mulino, OR 97042-1151

Check type of return to be filed (file a separate application for each return) :

Forr^ o9Q nFo!-m 940-EZ nFOrm 990-T (Section 4Jl ;z; or 4QQ(a; trust) Form 1041-A ~crm 5227 UForn. 8870

o H Form 990-BL ~ Form 990-PF ~ Form 990-T (trust other than above) _HForm 4720 ~ Form 6069

Stop: Do not complete Part II if you were not already ranted an automatic 3-month extension on a previousl y filed Form 8868. 0 If the organization does not have an office or place of business in ?he United States, check this box. . .

0 If this is for a Group Return, enter the organizations four digit Group Exemption Number (GEN). . . . If this is for the Q whole group, check this box. . . ~ ~ _{. If it is pan of the group, check this box . . 0' F land attach a list with the names and EINs of all}

members the extension is for.

UJI 4 I request an additional 3-month extension of time until ` 7/15 20 05 .

~+ p 5 For calendar year _--_ , or other tax year beginning _ 9/01~ , 20 0~l-and ending - 8/31 , 20 04 . 6 If this tax year is for less than 12 months, check reason: ~Initial return _LJ _{L. J} return _-D~--~ Change in accounting period Change

> ~ 7 state in detail why you need the extension Organization recLuests-additional time-to gather u y

_a

documents necessary to_prepare a complete

-and accurate return .

- - - -,Sa..li this application-i!5 for.fofw1990-BL, 990-PF, 990-T, 4720, or 6069, enter the tentative tax, less any

. norn rqLoU See irhstructions. . . . . . . . . . . . . . . . . . . . $ b f this application is for F _990-PF, 990-T, 4720, or 6069, enter any refundable credits and estimated tax

ayrP~t~s~~Je de dry prior year overpayment allowed as a credit and any amount paid previously with

~P ~4 2

$

_- I / / Notic~~o Applicant - To be Completed by the IRS We have approved this appli~~ion . Please*ach this form to the organization's return.

-j We have not approved this application . However, we have granted a 10-day grace period from the later of the date shown below or the due date of the organization's return (including any prior extensions) . This grace period is considered to be a valid extension of time for elections otherwise required to be made on a timely filed return. Please attach this form to the organization's return .

We have not approved this application . After considering the reasons stated in item 7, we cannot grant your request for an extension of time to file. We are not granting a 10-day grace period .

e We cannot consider this application because it was filed after the due date of the return for which an extension was requested ---Other: