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Form 990pf: Return of Private Foundation

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Return of Private Foundation
Part I Analysis of Revenue and Expenses (The total of amounts in columns (b), (c), and (d) may not necessarily equal the amounts in column (a) (see instructions).)Revenue and expenses per books Net investment income Adjusted net income Disbursements for charitable purposes (cash basis only)
Revenue1
2if the foundation is not required to attach Sch. B
3
4
5a
b
6a
b
7
8
9
10a
b
c
11
12
Operating
and
Administrative
Expenses
13
14
15
16a
b
c
17
18
19
20
21
22
23
24
25
26
27
a
b
c
Part II Balance Sheets Attached schedules and amounts in the description column should be for end-of-year amounts only. (See instructions.)Beginning of yearEnd of year
Book Value Book Value Fair Market Value
Assets1
2
3
4
5
6
7
8
9
10a
b
c
11
12
13
14
15)
16
Liabilities17
18
19
20
21
22)
23
Net Assets or Fund Balances
24
25
26
27
28
29
30
31
Part III Analysis of Changes in Net Assets or Fund Balances
11
22
33
44
55
66
Part IV Capital Gains and Losses for Tax on Investment Income
1a
b
c
d
e
a
b
c
d
a
Complete only for assets showing gain in column (h) and owned by the foundation on 12/31/69
a
b
c
d
e
22
33
Part V Qualification Under Section 4940(e) for Reduced Tax on Net Investment Income
(For optional use by domestic private foundations subject to the section 4940(a) tax on net investment income.)
If section 4940(d)(2) applies, leave this part blank.
Yes   No
If “Yes,” the foundation does not qualify under section 4940(e). Do not complete this part.
1Enter the appropriate amount in each column for each year; see the instructions before making any entries.

Base period years
Calendar year (or tax year beginning in)

Adjusted qualifying distributions

Net value of noncharitable-use assets

Distribution ratio
(col. (b) divided by col. (c))
2015
2014
2013
2012
2011
22
33
44
55
66
77
88
Part VI Excise Tax Based on Investment Income (Section 4940(a), 4940(b), 4940(e), or 4948—see instructions)
1 (attach copy of letter if necessary—see instructions)1
22
33
44
55
6
a6a
b6b
c6c
d6d
77
8 8
99
1010
11 11
Part VII-A Statements Regarding Activities
1a1a
b
If the answer is “Yes” to 1a or 1b, attach a detailed description of the activities and copies of any materials published or distributed by the foundation in connection with the activities.
1b
c1c
d $ $
eEnter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed on foundation managers. $
2
If “Yes,” attach a detailed description of the activities.
2
33
4a4a
4b4b
5If “Yes,” attach the statement required by General Instruction T.5
66
77
8a
8b8b
99
1010
1111
1212
13
13
14
15
15
16
16
Part VII-B Statements Regarding Activities for Which Form 4720 May Be Required
File Form 4720 if any item is checked in the “Yes” column, unless an exception applies.
1aDuring the year did the foundation (either directly or indirectly):
(1) Yes   No
(2) Yes   No
(3) Yes   No
(4) Yes   No
(5) Yes   No
(6) Yes   No
b
1b
c1c
2Taxes on failure to distribute income (section 4942) (does not apply for years the foundation was a private operating foundation defined in section 4942(j)(3) or 4942(j)(5)):2
a Yes   No
20, 20, 20, 20
b2b
c 20, 20, 20, 20
3a Yes   No
b3b
4a4a
4b4a
5aDuring the year did the foundation pay or incur any amount to:
(1) Yes   No
(2) Yes   No
(3) Yes   No
(4) Yes   No
(5) Yes   No
b
5b
c Yes   No
If “Yes,” attach the statement required by Regulations section 53.4945–5(d).
6a Yes   No
b
If “Yes” to 6b, file Form 8870.
6b
7a Yes   No
b7b
Part VIII Information About Officers, Directors, Trustees, Foundation Managers, Highly Paid Employees, and Contractors
1   List all officers, directors, trustees, foundation managers and their compensation (see instructions).




2   Compensation of five highest-paid employees (other than those included on line 1—see instructions). If none, enter “NONE.”
(a) Name and address of each employee paid more than $50000(b) Title, and average hours per week devoted to position(c) Compensation(d) Contributions to employee benefit plans and deferred compensation(e) Expense account, other allowances





Part VIII Information About Officers, Directors, Trustees, Foundation Managers, Highly Paid Employees, and Contractors (continued)
3   Five highest-paid independent contractors for professional services (see instructions). If none, enter “NONE.”




Part IX-A Summary of Direct Charitable Activities
List the foundation’s four largest direct charitable activities during the tax year. Include relevant statistical information such as the number of organizations and other beneficiaries served, conferences convened, research papers produced, etc.Expenses
1

1

1

1

Part IX-B Summary of Program-Related Investments (see instructions)
Describe the two largest program-related investments made by the foundation during the tax year on lines 1 and 2.Amount
1

2

All other program-related investments. See instructions.
3

Part X Minimum Investment Return (All domestic foundations must complete this part. Foreign foundations, see instructions.)
1Fair market value of assets not used (or held for use) directly in carrying out charitable, etc., purposes:
a1a
b1b
c1c
d1d
e1e
22
33
44
55
66
Part XI (see instructions) (Section 4942(j)(3) and (j)(5) private operating foundations and certain foreign organizations check here ▸ and do not complete this part.)
11
2a2a
b2b
c2c
33
44
55
66
77
Part XII Qualifying Distributions (see instructions)
1Amounts paid (including administrative expenses) to accomplish charitable, etc., purposes:
a1a
b1b
22
3Amounts set aside for specific charitable projects that satisfy the:
a3a
b3b
44
55
6
Note: The amount on line 6 will be used in Part V, column (b), in subsequent years when calculating whether the foundation qualifies for the section 4940(e) reduction of tax in those years.
6
Part XIII Undistributed Income (see instructions)
1
2
a
b
3
a
b
c
d
e
f
4 $
a
b
c
d
e
5
6
a
b
c
d
e
f
7
8
9
10
a
b
c
d
e
Part XIV Private Operating Foundations (see instructions and Part VII-A, question 9)
1a
bCheck box to indicate whether the foundation is a private operating foundation described in section or
2aTax yearPrior 3 years
b
c
d
e
3Complete 3a, b, or c for the alternative test relied upon:
a“Assets” alternative test—enter:
b
c“Support” alternative test—enter:
Part XV Supplementary Information (Complete this part only if the foundation had $5000 or more in assets at any time during the year—see instructions.)
1Information Regarding Foundation Managers:
a
b
2Information Regarding Contribution, Grant, Gift, Loan, Scholarship, etc., Programs:
if the foundation only makes contributions to preselected charitable organizations and does not accept unsolicited requests for funds. If the foundation makes gifts, grants, etc. (see instructions) to individuals or organizations under other conditions, complete items 2a, b, c, and d.
a
b
c
d
Part XV Supplementary Information (continued)
3   Grants and Contributions Paid During the Year or Approved for Future Payment
Recipient
Name and address (home or business)
If recipient is an individual, show any relationship to any foundation manager or substantial contributorFoundation status of recipientPurpose of grant or contributionAmount
Part XVI-A Analysis of Income-Producing Activities
Enter gross amounts unless otherwise indicated.Unrelated business incomeExcluded by section 512, 513, or 514
1Program service revenue:
a
b
c
d
e
f
g
2
3
4
5Net rental income or (loss) from real estate:
a
b
6
7
8
9
10
11Other revenue:
a
b
c
d
e
12
1313
(See worksheet in line 13 instructions to verify calculations.)
Part XVI-B Relationship of Activities to the Accomplishment of Exempt Purposes
Line No.Explain below how each activity for which income is reported in column (e) of Part XVI-A contributed importantly to the accomplishment of the foundation’s exempt purposes (other than by providing funds for such purposes). (See instructions.)
Part XVII Information Regarding Transfers To and Transactions and Relationships With Noncharitable Exempt Organizations
1Did the organization directly or indirectly engage in any of the following with any other organization described in section 501(c) of the Code (other than section 501(c)(3) organizations) or in section 527, relating to political organizations?
aTransfers from the reporting foundation to a noncharitable exempt organization of:
(1)1a(1)
(2)1a(2)
bOther transactions:
(1)1b(1)
(2)1b(2)
(3)1b(3)
(4)1b(4)
(5)1b(5)
(6)1b(6)
c1c
dIf the answer to any of the above is “Yes,” complete the following schedule. Column (b) should always show the fair market value of the goods, other assets, or services given by the reporting foundation. If the foundation received less than fair market value in any transaction or sharing arrangement, show in column (d) the value of the goods, other assets, or services received.
2aIs the foundation directly or indirectly affiliated with, or related to, one or more tax-exempt organizations described in section 501(c) of the Code (other than section 501(c)(3)) or in section 527?
bIf “Yes,” complete the following schedule.

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