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        <City>Arlington Hts</City>
        <State>IL</State>
        <ZIPCode>60005</ZIPCode>
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        <BusinessNameLine1>Arlington Hts Historical Society</BusinessNameLine1>
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        <AddressLine1>110 Fremont Street</AddressLine1>
        <City>Arlington Hts</City>
        <State>IL</State>
        <ZIPCode>60005</ZIPCode>
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      <Name>Wm S Kmiecik Jr</Name>
      <Title>Treasurer</Title>
      <DateSigned>2013-04-30</DateSigned>
      <AuthorizeThirdParty>false</AuthorizeThirdParty>
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    <Preparer>
      <Name>William S Kmiecik Jr</Name>
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        <PersonName>Betsy Kmiecik</PersonName>
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          <State>IL</State>
          <ZIPCode>60005</ZIPCode>
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        <Title>Secretary</Title>
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        <PersonName>Dawn Walter</PersonName>
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        <PersonName>Adam Pateracki</PersonName>
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          <AddressLine1>114 S Dwyer Ave</AddressLine1>
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      <TrnsfrsExemptNonCharRelatedOrg>false</TrnsfrsExemptNonCharRelatedOrg>
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      <Post1975UBTI>
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        <DirectExpenseSummaryEvents>12218</DirectExpenseSummaryEvents>
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        <VolunteerLaborOtherGaming>true</VolunteerLaborOtherGaming>
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        <DirectExpenseSummaryGaming>3500</DirectExpenseSummaryGaming>
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      <MemberOfOtherEntity>false</MemberOfOtherEntity>
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        <City>Arlington Hts</City>
        <State>IL</State>
        <ZIPCode>60004</ZIPCode>
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