efile Public Visual Render
ObjectId: 201733079349100328 - Submission: 2017-11-03
TIN: 77-6140213
Form
990-PF
Department of the Treasury
Internal Revenue Service
Return of Private Foundation
or Section 4947(a)(1) Trust Treated as Private Foundation
Do not enter social security numbers on this form as it may be made public.
Information about Form 990-PF and its instructions is at
www.irs.gov/form990pf
.
OMB No. 1545-0052
20
16
Open to Public Inspection
For calendar year 2016, or tax year beginning
01-01-2016
, and ending
12-31-2016
Name of foundation
Michael and Ina Korek Foundation Trust
% Foundation Source
Number and street (or P.O. box number if mail is not delivered to street address)
Foundation Source 501 Silverside Rd
Room/suite
City or town, state or province, country, and ZIP or foreign postal code
Wilmington
,
DE
198091377
A Employer identification number
77-6140213
B
Telephone number (see instructions)
(800) 839-1754
C
If exemption application is pending, check here
G
Check all that apply:
Initial return
Initial return of a former public charity
Final return
Amended return
Address change
Name change
D 1.
Foreign organizations, check here .............
2.
Foreign organizations meeting the 85%
test, check here and attach computation ...
E
If private foundation status was terminated
under section 507(b)(1)(A), check here .......
H
Check type of organization:
Section 501(c)(3) exempt private foundation
Section 4947(a)(1) nonexempt charitable trust
Other taxable private foundation
F
If the foundation is in a 60-month termination
under section 507(b)(1)(B), check here .......
I
Fair market value of all assets at end
of year
(from Part II, col. (c),
line 16)
$
8,433,040
J
Accounting method:
Cash
Accrual
Other (specify)
(Part I, column (d) must be on cash basis.)
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).)
(a)
Revenue and
expenses per
books
(b)
Net investment
income
(c)
Adjusted net
income
(d)
Disbursements
for charitable
purposes
(cash basis only)
1
Contributions, gifts, grants, etc., received (attach schedule)
336
2
Check
Sch. B
.............
3
Interest on savings and temporary cash investments
116
116
4
Dividends and interest from securities
...
180,949
177,006
5a
Gross rents
............
b
Net rental income or (loss)
6a
Net gain or (loss) from sale of assets not on line 10
77,237
b
Gross sales price for all assets on line 6a
3,838,133
7
Capital gain net income (from Part IV, line 2)
...
73,473
8
Net short-term capital gain
.........
9
Income modifications
...........
10a
Gross sales less returns and allowances
b
Less: Cost of goods sold
....
c
Gross profit or (loss) (attach schedule)
.....
11
Other income (attach schedule)
.......
3,006
2
12
Total.
Add lines 1 through 11
........
261,644
250,597
13
Compensation of officers, directors, trustees, etc.
108,000
108,000
14
Other employee salaries and wages
......
15
Pension plans, employee benefits
.......
16a
Legal fees (attach schedule)
.........
b
Accounting fees (attach schedule)
.......
c
Other professional fees (attach schedule)
....
58,058
58,058
17
Interest
...............
125
125
18
Taxes (attach schedule) (see instructions)
...
1,860
360
19
Depreciation (attach schedule) and depletion
...
20
Occupancy
..............
21
Travel, conferences, and meetings
.......
9,445
9,445
22
Printing and publications
..........
23
Other expenses (attach schedule)
.......
43,697
1,348
42,349
24
Total operating and administrative expenses.
Add lines 13 through 23
..........
221,185
59,891
159,794
25
Contributions, gifts, grants paid
.......
274,000
274,000
26
Total expenses and disbursements.
Add lines 24 and 25
495,185
59,891
433,794
27
Subtract line 26 from line 12:
a
Excess of revenue over expenses and disbursements
-233,541
b
Net investment income
(if negative, enter -0-)
190,706
c
Adjusted net income
(if negative, enter -0-)
...
For Paperwork Reduction Act Notice, see instructions.
Cat. No. 11289X
Form
990-PF
(2016)
Page 2
Form 990-PF (2016)
Page
2
Part II
Balance Sheets
Attached schedules and amounts in the description column
should be for end-of-year amounts only. (See instructions.)
Beginning of year
End of year
(a)
Book Value
(b)
Book Value
(c)
Fair Market Value
1
Cash—non-interest-bearing
.............
2
Savings and temporary cash investments
.........
1,332,140
1,039,121
1,039,121
3
Accounts receivable
Less: allowance for doubtful accounts
4
Pledges receivable
Less: allowance for doubtful accounts
5
Grants receivable
.................
6
Receivables due from officers, directors, trustees, and other
disqualified persons (attach schedule) (see instructions)
.....
7
Other notes and loans receivable (attach schedule)
Less: allowance for doubtful accounts
8
Inventories for sale or use
..............
9
Prepaid expenses and deferred charges
..........
10a
Investments—U.S. and state government obligations (attach schedule)
912,907
1,149,958
1,148,848
b
Investments—corporate stock (attach schedule)
.......
5,257,337
5,375,504
5,493,639
c
Investments—corporate bonds (attach schedule)
.......
1,263,470
944,590
741,529
11
Investments—land, buildings, and equipment: basis
Less: accumulated depreciation (attach schedule)
12
Investments—mortgage loans
.............
13
Investments—other (attach schedule)
..........
75,000
75,000
9,903
14
Land, buildings, and equipment: basis
Less: accumulated depreciation (attach schedule)
15
Other assets (describe
)
16
Total assets
(to be completed by all filers—see the
instructions. Also, see page 1, item I)
8,840,854
8,584,173
8,433,040
17
Accounts payable and accrued expenses
..........
18
Grants payable
..................
19
Deferred revenue
.................
20
Loans from officers, directors, trustees, and other disqualified persons
21
Mortgages and other notes payable (attach schedule)
......
22
Other liabilities (describe
)
23,140
23
Total liabilities
(add lines 17 through 22)
.........
23,140
0
Foundations that follow SFAS 117, check here
and complete lines 24 through 26 and lines 30 and 31.
24
Unrestricted
..................
25
Temporarily restricted
...............
26
Permanently restricted
...............
Foundations that do not follow SFAS 117, check here
and complete lines 27 through 31.
27
Capital stock, trust principal, or current funds
........
28
Paid-in or capital surplus, or land, bldg., and equipment fund
29
Retained earnings, accumulated income, endowment, or other funds
8,817,714
8,584,173
30
Total net assets or fund balances
(see instructions)
.....
8,817,714
8,584,173
31
Total liabilities and net assets/fund balances
(see instructions)
.
8,840,854
8,584,173
Part III
Analysis of Changes in Net Assets or Fund Balances
1
Total net assets or fund balances at beginning of year—Part II, column (a), line 30 (must agree with end-of-year figure reported on prior year’s return)
...............
1
8,817,714
2
Enter amount from Part I, line 27a
.....................
2
-233,541
3
Other increases not included in line 2 (itemize)
3
4
Add lines 1, 2, and 3
..........................
4
8,584,173
5
Decreases not included in line 2 (itemize)
5
6
Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 30
.
6
8,584,173
Form
990-PF
(2016)
Page 3
Form 990-PF (2016)
Page
3
Part IV
Capital Gains and Losses for Tax on Investment Income
(a)
List and describe the kind(s) of property sold (e.g., real estate,
2-story brick warehouse; or common stock, 200 shs. MLC Co.)
(b)
How acquired
P—Purchase
D—Donation
(c)
Date acquired
(mo., day, yr.)
(d)
Date sold
(mo., day, yr.)
1 a
Publicly-traded Securities
b
c
d
e
(e)
Gross sales price
(f)
Depreciation allowed
(or allowable)
(g)
Cost or other basis
plus expense of sale
(h)
Gain or (loss)
(e) plus (f) minus (g)
a
3,838,133
3,764,660
73,473
b
c
d
e
Complete only for assets showing gain in column (h) and owned by the foundation on 12/31/69
(l)
Gains (Col. (h) gain minus
col. (k), but not less than -0-)
or
Losses (from col.(h))
(i)
F.M.V. as of 12/31/69
(j)
Adjusted basis
as of 12/31/69
(k)
Excess of col. (i)
over col. (j), if any
a
73,473
b
c
d
e
2
Capital gain net income or (net capital loss)
If gain, also enter in Part I, line 7
If (loss), enter -0- in Part I, line 7
2
73,473
3
Net short-term capital gain or (loss) as defined in sections 1222(5) and (6):
If gain, also enter in Part I, line 8, column (c) (see instructions). If (loss), enter -0-
in Part I, line 8
...................
3
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.
Was the foundation liable for the section 4942 tax on the distributable amount of any year in the base period?
Yes
No
If "Yes," the foundation does not qualify under section 4940(e). Do not complete this part.
1
Enter the appropriate amount in each column for each year; see instructions before making any entries.
(a)
Base period years Calendar
year (or tax year beginning in)
(b)
Adjusted qualifying distributions
(c)
Net value of noncharitable-use assets
(d)
Distribution ratio
(col. (b) divided by col. (c))
2015
446,173
8,991,499
0.049622
2014
271,259
9,092,893
0.029832
2013
131,827
6,775,764
0.019456
2012
55,598
1,156,197
0.048087
2011
44,597
988,079
0.045135
2
Total
of line 1, column (d)
.....................
2
0.192132
3
Average distribution ratio for the 5-year base period—divide the total on line 2 by 5, or by the number of years the foundation has been in existence if less than 5 years
......
3
0.038426
4
Enter the net value of noncharitable-use assets for 2016 from Part X, line 5
......
4
8,773,753
5
Multiply line 4 by line 3
......................
5
337,140
6
Enter 1% of net investment income (1% of Part I, line 27b)
...........
6
1,907
7
Add lines 5 and 6
........................
7
339,047
8
Enter qualifying distributions from Part XII, line 4
,.............
8
433,794
If line 8 is equal to or greater than line 7, check the box in Part VI, line 1b, and complete that part using a 1% tax rate. See the Part VI instructions.
Form
990-PF
(2016)
Page 4
Form 990-PF (2016)
Page
4
Part VI
Excise Tax Based on Investment Income (Section 4940(a), 4940(b), 4940(e), or 4948—see instructions)
1a
Exempt operating foundations described in section 4940(d)(2), check here
and enter “N/A" on line 1.
Date of ruling or determination letter:
(attach copy of letter if necessary–see instructions)
b
Domestic foundations that meet the section 4940(e) requirements in Part V, check
1
1,907
here
and enter 1% of Part I, line 27b
...................
c
All other domestic foundations enter 2% of line 27b. Exempt foreign organizations enter 4% of Part I, line 12, col. (b)
2
Tax under section 511 (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-)
2
3
Add lines 1 and 2
...........................
3
1,907
4
Subtitle A (income) tax (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-)
4
5
Tax based on investment income.
Subtract line 4 from line 3. If zero or less, enter -0-
.....
5
1,907
6
Credits/Payments:
a
2016 estimated tax payments and 2015 overpayment credited to 2016
6a
3,100
b
Exempt foreign organizations—tax withheld at source
......
6b
c
Tax paid with application for extension of time to file (Form 8868)
...
6c
809
d
Backup withholding erroneously withheld
...........
6d
7
Total credits and payments. Add lines 6a through 6d
..............
7
3,909
8
Enter any
penalty
for underpayment of estimated tax.
Check here
if Form 2220 is attached.
8
9
Tax due.
If the total of lines 5 and 8 is more than line 7, enter
amount owed
.......
9
10
Overpayment.
If line 7 is more than the total of lines 5 and 8, enter the
amount overpaid
...
10
2,002
11
Enter the amount of line 10 to be:
Credited to 2017 estimated tax
2,002
Refunded
11
Part VII-A
Statements Regarding Activities
1a
During the tax year, did the foundation attempt to influence any national, state, or local legislation or did
Yes
No
it participate or intervene in any political campaign?
....................
1a
No
b
Did it spend more than $100 during the year (either directly or indirectly) for political purposes (see Instructions
for definition)?
.................................
1b
No
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.
c
Did the foundation file
Form 1120-POL
for this year?
.....................
1c
No
d
Enter the amount (if any) of tax on political expenditures (section 4955) imposed during the year:
(1)
On the foundation.
$
(2)
On foundation managers.
$
e
Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed
on foundation managers.
$
2
Has the foundation engaged in any activities that have not previously been reported to the IRS?
.......
2
No
If "Yes," attach a detailed description of the activities.
3
Has the foundation made any changes, not previously reported to the IRS, in its governing instrument, articles
of incorporation, or bylaws, or other similar instruments?
If "Yes," attach a conformed copy of the changes
....
3
No
4a
Did the foundation have unrelated business gross income of $1,000 or more during the year?
........
4a
No
b
If "Yes," has it filed a tax return on
Form 990-T
for this year?
...................
4b
5
Was there a liquidation, termination, dissolution, or substantial contraction during the year?
.........
5
No
If "Yes," attach the statement required by General Instruction T.
6
Are the requirements of section 508(e) (relating to sections 4941 through 4945) satisfied either:
By language in the governing instrument, or
By state legislation that effectively amends the governing instrument so that no mandatory directions
that conflict with the state law remain in the governing instrument?
................
6
Yes
7
Did the foundation have at least $5,000 in assets at any time during the year?
If "Yes," complete Part II, col. (c),
and Part XV.
.................................
7
Yes
8a
Enter the states to which the foundation reports or with which it is registered (see instructions)
CA
b
If the answer is "Yes" to line 7, has the foundation furnished a copy of Form 990-PF to the Attorney
General (or designate) of each state as required by General Instruction G?
If "No," attach explanation
.
8b
Yes
9
Is the foundation claiming status as a private operating foundation within the meaning of section 4942(j)(3)
or 4942(j)(5) for calendar year 2016 or the taxable year beginning in 2016 (see instructions for Part XIV)?
If "Yes," complete Part XIV
.............................
9
No
10
Did any persons become substantial contributors during the tax year?
If "Yes," attach a schedule listing their names
and addresses.
...............................
10
No
Form
990-PF
(2016)
Page 5
Form 990-PF (2016)
Page
5
Part VII-A
Statements Regarding Activities
(continued)
11
At any time during the year, did the foundation, directly or indirectly, own a controlled entity within the
meaning of section 512(b)(13)? If "Yes," attach schedule. (see instructions)
.............
11
No
12
Did the foundation make a distribution to a donor advised fund over which the foundation or a disqualified person had
advisory privileges? If "Yes," attach statement (see instructions)
.................
12
No
13
Did the foundation comply with the public inspection requirements for its annual returns and exemption application?
13
Yes
Website address
14
The books are in care of
Foundation Source
Telephone no.
(800) 839-1754
Located at
501 Silverside Road Suite 123
Wilmington
DE
ZIP+4
198091377
15
Section 4947(a)(1) nonexempt charitable trusts filing Form 990-PF in lieu of
Form 1041
—Check here
.........
and enter the amount of tax-exempt interest received or accrued during the year
........
15
16
At any time during calendar year 2016, did the foundation have an interest in or a signature or other authority over
Yes
No
a bank, securities, or other financial account in a foreign country?
16
No
See instructions for exceptions and filing requirements for FinCEN Form 114, Report of Foreign Bank and Financial Accounts (FBAR). If "Yes", enter the name of the foreign country
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.
Yes
No
1a
During the year did the foundation (either directly or indirectly):
(1)
Engage in the sale or exchange, or leasing of property with a disqualified person?
Yes
No
(2)
Borrow money from, lend money to, or otherwise extend credit to (or accept it from)
a disqualified person?
......................
Yes
No
(3)
Furnish goods, services, or facilities to (or accept them from) a disqualified person?
Yes
No
(4)
Pay compensation to, or pay or reimburse the expenses of, a disqualified person?
Yes
No
(5)
Transfer any income or assets to a disqualified person (or make any of either available
for the benefit or use of a disqualified person)?
...............
Yes
No
(6)
Agree to pay money or property to a government official? (
Exception.
Check "No"
if the foundation agreed to make a grant to or to employ the official for a period
after termination of government service, if terminating within 90 days.)
.......
Yes
No
b
If any answer is "Yes" to 1a(1)–(6), did
any
of the acts fail to qualify under the exceptions described in Regulations
section 53.4941(d)-3 or in a current notice regarding disaster assistance (see instructions)?
........
1b
No
Organizations relying on a current notice regarding disaster assistance check here
........
c
Did the foundation engage in a prior year in any of the acts described in 1a, other than excepted acts,
that were not corrected before the first day of the tax year beginning in 2016?
.............
1c
No
2
Taxes 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)):
a
At the end of tax year 2016, did the foundation have any undistributed income (lines 6d
and 6e, Part XIII) for tax year(s) beginning before 2016?
.............
Yes
No
If "Yes," list the years
20
,
20
,
20
,
20
b
Are there any years listed in 2a for which the foundation is
not
applying the provisions of section 4942(a)(2)
(relating to incorrect valuation of assets) to the year’s undistributed income? (If applying section 4942(a)(2)
to
all
years listed, answer "No" and attach statement—see instructions.)
..............
2b
c
If the provisions of section 4942(a)(2) are being applied to
any
of the years listed in 2a, list the years here.
20
,
20
,
20
,
20
3a
Did the foundation hold more than a 2% direct or indirect interest in any business enterprise at
any time during the year?
......................
Yes
No
b
If "Yes," did it have excess business holdings in 2016 as a result of
(1)
any purchase by the foundation
or disqualified persons after May 26, 1969;
(2)
the lapse of the 5-year period (or longer period approved
by the Commissioner under section 4943(c)(7)) to dispose of holdings acquired by gift or bequest; or
(3)
the lapse of the 10-, 15-, or 20-year first phase holding period?
(Use Schedule C, Form 4720, to determine
if the foundation had excess business holdings in 2016.)
..................
3b
4a
Did the foundation invest during the year any amount in a manner that would jeopardize its charitable purposes?
4a
No
b
Did the foundation make any investment in a prior year (but after December 31, 1969) that could jeopardize its
charitable purpose that had not been removed from jeopardy before the first day of the tax year beginning in 2016?
4b
No
Form
990-PF
(2016)
Page 6
Form 990-PF (2016)
Page
6
Part VII-B
Statements Regarding Activities for Which Form 4720 May Be Required
(Continued)
5a
During the year did the foundation pay or incur any amount to:
(1)
Carry on propaganda, or otherwise attempt to influence legislation (section 4945(e))?
Yes
No
(2)
Influence the outcome of any specific public election (see section 4955); or to carry
on, directly or indirectly, any voter registration drive?
.............
Yes
No
(3)
Provide a grant to an individual for travel, study, or other similar purposes?
Yes
No
(4)
Provide a grant to an organization other than a charitable, etc., organization described
in section 4945(d)(4)(A)? (see instructions)
................
Yes
No
(5)
Provide for any purpose other than religious, charitable, scientific, literary, or
educational purposes, or for the prevention of cruelty to children or animals?
.....
Yes
No
b
If any answer is "Yes" to 5a(1)–(5), did
any
of the transactions fail to qualify under the exceptions described in
Regulations section 53.4945 or in a current notice regarding disaster assistance (see instructions)?
......
5b
Organizations relying on a current notice regarding disaster assistance check here
.........
c
If the answer is "Yes" to question 5a(4), does the foundation claim exemption from the
tax because it maintained expenditure responsibility for the grant?
..........
Yes
No
If "Yes," attach the statement required by Regulations section 53.4945–5(d).
6a
Did the foundation, during the year, receive any funds, directly or indirectly, to pay premiums on
a personal benefit contract?
.....................
Yes
No
b
Did the foundation, during the year, pay premiums, directly or indirectly, on a personal benefit contract?
....
6b
No
If "Yes" to 6b, file Form 8870.
7a
At any time during the tax year, was the foundation a party to a prohibited tax shelter transaction?
Yes
No
b
If yes, did the foundation receive any proceeds or have any net income attributable to the transaction?
....
7b
Form
990-PF
(2016)
Page 7
Form 990-PF (2016)
Page
7
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).
(a)
Name and address
(b)
Title, and average
hours per week
devoted to position
(c)
Compensation
(If not paid, enter
-0-)
(d)
Contributions to employee benefit plans and deferred compensation
(e)
Expense account,
other allowances
Teresa Babb
Managing Trustee
30.0
88,000
0
0
Foundation Source 501 Silverside Rd
Wilmington
,
DE
198091377
Brian Korek
Executive Dir
15.0
20,000
0
0
Foundation Source 501 Silverside Rd
Wilmington
,
DE
198091377
Brock Peterlin
Trustee
0
0
0
0
Foundation Source 501 Silverside Rd
Wilmington
,
DE
198091377
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 $50,000
(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
Total
number of other employees paid over $50,000
...................
3
Five highest-paid independent contractors for professional services (see instructions). If none, enter "NONE".
(a)
Name and address of each person paid more than $50,000
(b)
Type of service
(c)
Compensation
Beacon Pointe Wealth Advisors
Investment MGMT
55,954
99 S Almaden blvd ste 880
SAN JOSE
,
CA
95133
Total
number of others receiving over $50,000 for professional services
.............
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
2
3
4
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
Total.
Add lines 1 through 3
.........................
Form
990-PF
(2016)
Page 8
Form 990-PF (2016)
Page
8
Part X
Minimum Investment Return
(All domestic foundations must complete this part. Foreign foundations,see instructions.)
1
Fair market value of assets not used (or held for use) directly in carrying out charitable, etc.,
purposes:
a
Average monthly fair market value of securities
...................
1a
7,809,525
b
Average of monthly cash balances
.......................
1b
1,087,935
c
Fair market value of all other assets (see instructions)
................
1c
9,903
d
Total
(add lines 1a, b, and c)
.........................
1d
8,907,363
e
Reduction claimed for blockage or other factors reported on lines 1a and
1c (attach detailed explanation)
.............
1e
2
Acquisition indebtedness applicable to line 1 assets
..................
2
0
3
Subtract line 2 from line 1d
.........................
3
8,907,363
4
Cash deemed held for charitable activities. Enter 1 1/2% of line 3 (for greater amount, see
instructions)
.............................
4
133,610
5
Net value of noncharitable-use assets.
Subtract line 4 from line 3. Enter here and on Part V, line 4
5
8,773,753
6
Minimum investment return.
Enter 5% of line 5
..................
6
438,688
Part XI
Distributable Amount
(see instructions) (Section 4942(j)(3) and (j)(5) private operating foundations and certain foreign organizations check here
and do not complete this part.)
1
Minimum investment return from Part X, line 6
....................
1
438,688
2a
Tax on investment income for 2016 from Part VI, line 5
......
2a
1,907
b
Income tax for 2016. (This does not include the tax from Part VI.)
...
2b
c
Add lines 2a and 2b
............................
2c
1,907
3
Distributable amount before adjustments. Subtract line 2c from line 1
............
3
436,781
4
Recoveries of amounts treated as qualifying distributions
................
4
5
Add lines 3 and 4
............................
5
436,781
6
Deduction from distributable amount (see instructions)
.................
6
7
Distributable amount
as adjusted. Subtract line 6 from line 5. Enter here and on Part XIII, line 1
...
7
436,781
Part XII
Qualifying Distributions
(see instructions)
1
Amounts paid (including administrative expenses) to accomplish charitable, etc., purposes:
a
Expenses, contributions, gifts, etc.—total from Part I, column (d), line 26
..........
1a
433,794
b
Program-related investments—total from Part IX-B
..................
1b
0
2
Amounts paid to acquire assets used (or held for use) directly in carrying out charitable, etc.,
purposes
...............................
2
0
3
Amounts set aside for specific charitable projects that satisfy the:
a
Suitability test (prior IRS approval required)
....................
3a
0
b
Cash distribution test (attach the required schedule)
.................
3b
0
4
Qualifying distributions.
Add lines 1a through 3b. Enter here and on Part V, line 8, and Part XIII, line 4
4
433,794
5
Foundations that qualify under section 4940(e) for the reduced rate of tax on net investment
income. Enter 1% of Part I, line 27b (see instructions)
.................
5
1,907
6
Adjusted qualifying distributions.
Subtract line 5 from line 4
..............
6
431,887
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.
Form
990-PF
(2016)
Page 9
Form 990-PF (2016)
Page
9
Part XIII
Undistributed Income
(see instructions)
(a)
Corpus
(b)
Years prior to 2015
(c)
2015
(d)
2016
1
Distributable amount for 2016 from Part XI, line 7
436,781
2
Undistributed income, if any, as of the end of 2016:
a
Enter amount for 2015 only
.......
420,023
b
Total for prior years:
2014
,
2013
,
2012
3
Excess distributions carryover, if any, to 2016:
a
From 2011
......
b
From 2012
......
c
From 2013
......
d
From 2014
......
e
From 2015
......
f
Total
of lines 3a through e
........
4
Qualifying distributions for 2016 from Part
XII, line 4:
$
433,794
a
Applied to 2015, but not more than line 2a
420,023
b
Applied to undistributed income of prior years
(Election required—see instructions)
.....
c
Treated as distributions out of corpus (Election
required—see instructions)
........
d
Applied to 2016 distributable amount
.....
13,771
e
Remaining amount distributed out of corpus
0
5
Excess distributions carryover applied to 2016.
(If an amount appears in column (d), the
same amount must be shown in column (a).)
6
Enter the net total of each column as
indicated below:
a
Corpus. Add lines 3f, 4c, and 4e. Subtract line 5
0
b
Prior years’ undistributed income. Subtract
line 4b from line 2b
..........
c
Enter the amount of prior years’ undistributed
income for which a notice of deficiency has
been issued, or on which the section 4942(a)
tax has been previously assessed
......
d
Subtract line 6c from line 6b. Taxable amount
—see instructions
...........
e
Undistributed income for 2015. Subtract line
4a from line 2a. Taxable amount—see
instructions
.............
f
Undistributed income for 2016. Subtract
lines 4d and 5 from line 1. This amount must
be distributed in 2017
..........
423,010
7
Amounts treated as distributions out of
corpus to satisfy requirements imposed by
section 170(b)(1)(F) or 4942(g)(3) (Election may
be required - see instructions)
.......
8
Excess distributions carryover from 2011 not
applied on line 5 or line 7 (see instructions)
...
9
Excess distributions carryover to 2017.
Subtract lines 7 and 8 from line 6a
......
0
10
Analysis of line 9:
a
Excess from 2012
....
b
Excess from 2013
....
c
Excess from 2014
....
d
Excess from 2015
....
e
Excess from 2016
....
0
Form
990-PF
(2016)
Page 10
Form 990-PF (2016)
Page
10
Part XIV
Private Operating Foundations
(see instructions and Part VII-A, question 9)
1a
If the foundation has received a ruling or determination letter that it is a private operating
foundation, and the ruling is effective for 2016, enter the date of the ruling
.......
b
Check box to indicate whether the organization is a private operating foundation described in section
4942(j)(3)
or
4942(j)(5)
2a
Enter the lesser of the adjusted net
income from Part I or the minimum
investment return from Part X for each
year listed
..........
Tax year
Prior 3 years
(e) Total
(a)
2016
(b)
2015
(c)
2014
(d)
2013
b
85% of line 2a
.........
c
Qualifying distributions from Part XII,
line 4 for each year listed
.....
d
Amounts included in line 2c not used directly
for active conduct of exempt activities
..........
e
Qualifying distributions made directly
for active conduct of exempt activities.
Subtract line 2d from line 2c
....
3
Complete 3a, b, or c for the
alternative test relied upon:
a
“Assets" alternative test—enter:
(1)
Value of all assets
......
(2)
Value of assets qualifying
under section 4942(j)(3)(B)(i)
b
“Endowment" alternative test— enter 2/3
of minimum investment return shown in
Part X, line 6 for each year listed
...
c
“Support" alternative test—enter:
(1)
Total support other than gross
investment income (interest,
dividends, rents, payments
on securities loans (section
512(a)(5)), or royalties)
....
(2)
Support from general public
and 5 or more exempt
organizations as provided in
section 4942(j)(3)(B)(iii)
....
(3)
Largest amount of support
from an exempt organization
(4)
Gross investment income
Part XV
Supplementary Information (Complete this part only if the organization had $5,000 or more in
assets at any time during the year—see instructions.)
1
Information Regarding Foundation Managers:
a
List any managers of the foundation who have contributed more than 2% of the total contributions received by the foundation
before the close of any tax year (but only if they have contributed more than $5,000). (See section 507(d)(2).)
NONE
b
List any managers of the foundation who own 10% or more of the stock of a corporation (or an equally large portion of the
ownership of a partnership or other entity) of which the foundation has a 10% or greater interest.
2
Information Regarding Contribution, Grant, Gift, Loan, Scholarship, etc., Programs:
Check here
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
The name, address, and telephone number or email address of the person to whom applications should be addressed:
b
The form in which applications should be submitted and information and materials they should include:
c
Any submission deadlines:
d
Any restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other
factors:
Form
990-PF
(2016)
Page 11
Form 990-PF (2016)
Page
11
Part XV
Supplementary Information
(continued)
3 Grants and Contributions Paid During the Year or Approved for Future Payment
Recipient
If recipient is an individual,
show any relationship to
any foundation manager
or substantial contributor
Foundation
status of
recipient
Purpose of grant or
contribution
Amount
Name and address (home or business)
a
Paid during the year
A SAFE PLACE
PO BOX 23006
OAKLAND
,
CA
94623
N/A
PC
General & Unrestricted
1,000
ALIVE INSIDE FOUNDATION INC
237 ELDRIDGE ST
NEW YORK
,
NY
10002
N/A
PC
General & Unrestricted
2,000
AMERICAN BIRD CONSERVANCY
PO BOX 249
THE PLAINS
,
VA
20198
N/A
PC
General & Unrestricted
1,000
AMERICAN LUNG ASSOCIATION
1301 PENNSYLVANIA AVE NW STE 800
WASHINGTON
,
DC
20004
N/A
PC
General & Unrestricted
2,000
ANIMAL LEGAL DEFENSE FUND
170 E COTATI AVE
COTATI
,
CA
94931
N/A
PC
General & Unrestricted
1,000
BAT WORLD SANCTUARY
299 HIGH POINT RD
WEATHERFORD
,
TX
76088
N/A
PC
General & Unrestricted
2,000
BAY AREA CANCER CONNECTIONS
2335 EL CAMINO REAL
PALO ALTO
,
CA
94306
N/A
PC
General & Unrestricted
2,000
BEST FRIENDS ANIMAL SOCIETY
5001 ANGEL CANYON RD
KANAB
,
UT
84741
N/A
PC
General & Unrestricted
5,000
BOYS TOWN JERUSALEM FOUNDATION OF AMERICA INC
1 PENN PLZ NO 6250
NEW YORK
,
NY
10119
N/A
PC
General & Unrestricted
1,000
CALIFORNIA ACADEMY OF SCIENCES
55 MUSIC CONCOURSE DR
SAN FRANCISCO
,
CA
94118
N/A
PC
General & Unrestricted
1,000
CENTER FOR PUBLIC INTEGRITY
910 17TH ST NW 7TH FL
WASHINGTON
,
DC
20006
N/A
PC
General & Unrestricted
5,000
CHABAD OF CALIFORNIA
741 GAYLEY AVE
LOS ANGELES
,
CA
90024
N/A
PC
General & Unrestricted
1,000
CHAC
590 W EL CAMINO REAL
MOUNTAIN VIEW
,
CA
94040
N/A
PC
General & Unrestricted
4,000
CHARITY GLOBAL INC - CHARITY WATER
40 WORTH ST STE 330
NEW YORK
,
NY
10013
N/A
PC
General & Unrestricted
2,000
CHEETAH CONSERVATION FUND
PO BOX 2496
ALEXANDRIA
,
VA
22301
N/A
PC
General & Unrestricted
2,000
CHILD ADVOCATES OF SILICON VALLEY INC
509 VALLEY WAY
MILPITAS
,
CA
95035
N/A
PC
General & Unrestricted
3,000
CITY COLLEGE FUND
160 CONVENT AVE
NEW YORK
,
NY
10031
N/A
PC
General & Unrestricted
1,000
COMMITTEE FOR ACCURACY IN MIDDLE EAST REPORTING IN
PO BOX 35040
BOSTON
,
MA
02135
N/A
PC
General & Unrestricted
1,000
COMMONWEALTH CLUB OF CALIFORNIA
555 POST ST
SAN FRANCISCO
,
CA
94102
N/A
PC
General & Unrestricted
1,000
COMMUNITY SCHOOL OF MUSIC AND ARTS
230 SAN ANTONIO CIR
MOUNTAIN VIEW
,
CA
94040
N/A
PC
General & Unrestricted
5,000
COMMUNITY SERVICES AGENCY
204 STIERLIN RD
MOUNTAIN VIEW
,
CA
94043
N/A
PC
General & Unrestricted
2,000
CONFLICT RESOLUTION CENTER OF SANTA CRUZ COUNTY
1414 SOQUEL AVE STE 216
SANTA CRUZ
,
CA
95062
N/A
PC
General & Unrestricted
5,000
CONGREGATION SHIR HADASH
20 CHERRY BLOSSOM LN
LOS GATOS
,
CA
95032
N/A
PC
General & Unrestricted
1,000
CONSUMER REPORTS INC
PO BOX 96552
WASHINGTON
,
DC
20090
N/A
PC
General & Unrestricted
1,000
COVENANT HOUSE CALIFORNIA
1325 N WESTERN AVE
LOS ANGELES
,
CA
90027
N/A
PC
General & Unrestricted
1,000
DIAN FOSSEY GORILLA FUND
800 CHEROKEE AVE
ATLANTA
,
GA
30315
N/A
PC
General & Unrestricted
1,000
DOCTORS WITHOUT BORDERS USA INC
333 7TH AVE 2ND FL
NEW YORK
,
NY
10001
N/A
PC
General & Unrestricted
2,000
EARTHJUSTICE
50 CALIFORNIA ST STE 500
SAN FRANCISCO
,
CA
94111
N/A
PC
General & Unrestricted
2,000
ENVIRONMENT CALIFORNIA RESEARCH & POLICY CENTER IN
1314 H ST NW STE 100
SACRAMENTO
,
CA
95814
N/A
PC
General & Unrestricted
1,000
ENVIRONMENTAL DEFENSE FUND INCORPORATED
1875 CONNECTICUT AVE NW STE 600
WASHINGTON
,
DC
20009
N/A
PC
General & Unrestricted
1,000
FARM SANCTUARY INC
PO BOX 150
WATKINS GLEN
,
NY
14891
N/A
PC
General & Unrestricted
1,000
FINCA INTERNATIONAL INC
1201 15TH ST NW 8TH FL
WASHINGTON
,
DC
20005
N/A
PC
General & Unrestricted
1,000
FOOTHILL-DE ANZA COMMUNITY COLLEGES FOUNDATION
12345 S EL MONTE RD
LOS ALTOS HLS
,
CA
94022
N/A
PC
General & Unrestricted
1,000
GLAUCOMA RESEARCH FOUNDATION
251 POST ST STE 600
SAN FRANCISCO
,
CA
94108
N/A
PC
General & Unrestricted
2,000
GREENPEACE FUND INC
702 H ST NW STE 300
WASHINGTON
,
DC
20001
N/A
PC
General & Unrestricted
5,000
H E R WEEKEND INC
PO BOX 77
WOODLAND HLS
,
CA
91365
N/A
PC
General & Unrestricted
2,000
HEALTH CONNECTED
480 JAMES AVE
REDWOOD CITY
,
CA
94062
N/A
PC
General & Unrestricted
1,000
HIAS INC
411 5TH AVE 10TH FL
NEW YORK
,
NY
10016
N/A
PC
General & Unrestricted
1,000
HONEST REPORTING COM INC
10024 SKOKIE BLVD STE 201
SKOKIE
,
IL
60077
N/A
PC
General & Unrestricted
1,000
HOPE FOR PAWS
8950 W OLYMPIC BLVD 525
LOS ANGELES
,
CA
90211
N/A
PC
General & Unrestricted
2,000
IEEE FOUNDATION INC
445 HOES LN
PISCATAWAY
,
NJ
08854
N/A
PC
General & Unrestricted
1,000
INSTITUTE OF HEARTMATH
PO BOX 1463
BOULDER CREEK
,
CA
95006
N/A
PC
General & Unrestricted
1,000
INSTITUTE OF NOETIC SCIENCES
625 2ND ST STE 200
PETALUMA
,
CA
94952
N/A
PC
General & Unrestricted
1,000
INTERNATIONAL MEDIA PROJECT
1714 FRANKLIN ST STE 100-251
OAKLAND
,
CA
94612
N/A
PC
General & Unrestricted
1,000
INTERNATIONAL PLANNED PARENTHOOD FEDERATION
125 MAIDEN LN FL 9
NEW YORK
,
NY
10038
N/A
PC
General & Unrestricted
1,000
INTERNATIONAL RESCUE COMMITTEE INC
122 E 42ND ST
NEW YORK
,
NY
10168
N/A
PC
General & Unrestricted
2,000
ISRAEL EMERGENCY ALLIANCE
6505 WILSHIRE BLVD 5TH FL
LOS ANGLELES
,
CA
90048
N/A
PC
General & Unrestricted
1,000
JEWISH FAMILY & CHILDRENS SERVICES
2150 POST ST
SAN FRANCISCO
,
CA
94115
N/A
PC
General & Unrestricted
1,000
JEWISH FEDERATION OF SILICON VALLEY
14855 OKA RD
LOS GATOS
,
CA
95032
N/A
PC
General & Unrestricted
1,000
JEWISH NATIONAL FUND-KEREN KAYEMETH LEISRAEL INC
42 E 69TH ST
NEW YORK
,
NY
10021
N/A
PC
General & Unrestricted
1,000
KIDNEY CANCER ASSOCIATION
PO BOX 25250
MIAMI
,
FL
33102
N/A
PC
General & Unrestricted
1,000
MARINE MAMMAL CENTER
2000 BUNKER RD FORT CRONKHITE
SAUSALITO
,
CA
94965
N/A
PC
General & Unrestricted
1,000
MENTOR TUTOR CONNECTION
PO BOX 1473
LOS ALTOS
,
CA
94023
N/A
PC
General & Unrestricted
1,000
MONO LAKE FOUNDATION
PO BOX 29
LEE VINING
,
CA
93541
N/A
PC
General & Unrestricted
1,000
MONTEREY BAY AQUARIUM FOUNDATION
886 CANNERY ROW
MONTEREY
,
CA
93940
N/A
PC
General & Unrestricted
1,000
MOTHERS AGAINST DRUNK DRIVING
511 E JOHN CARPENTER FREEWAY STE 70
IRVING
,
TX
75062
N/A
PC
Restricted use for Northern California Division
20,000
NATIONAL ASSOCIATION OF STATE BOATING LAW ADMINIST
1648 MCGRATHIANA PKWY STE 360
LEXINGTON
,
KY
40511
N/A
PC
NASBLA for Operation Drywater Campaign, Lake Englebright California for Operation Drywater campaign and safe boating related issues
10,000
NATURAL RESOURCES DEFENSE COUNCIL INC
40 W 20TH ST
NEW YORK
,
NY
10011
N/A
PC
General & Unrestricted
1,000
NIKE ANIMAL RESCUE FOUNDATION
5463 SHERIDAN RD
SUNOL
,
CA
94586
N/A
PC
General & Unrestricted
1,000
ONE CHILD
1900 MOWRY AVE STE 103
FREMONT
,
CA
94538
N/A
PC
General & Unrestricted
2,000
ORGANIC CONSUMERS ASSOCIATION
6771 S SILVER HILL DR
FINLAND
,
MN
55603
N/A
PC
General & Unrestricted
5,000
PAACT INC
11555 JADON CT NE
SPARTA
,
MI
49345
N/A
PC
General & Unrestricted
1,000
PACIFIC WHALE FOUNDATION
300 MAALAEA RD
WAILUKU
,
HI
96793
N/A
PC
General & Unrestricted
2,000
PALACE OF FINE ARTS LEAGUE INC
3301 LYON ST
SAN FRANCISCO
,
CA
94123
N/A
PC
General & Unrestricted
1,000
PATHWAYS HOME HEALTH AND HOSPICE
585 N MARY AVE
SUNNYVALE
,
CA
94085
N/A
PC
General & Unrestricted
2,000
PENINSULA HUMANE SOCIETY & SPCA
1450 ROLLINS RD
BURLINGAME
,
CA
94010
N/A
PC
General & Unrestricted
2,000
PEOPLE FOR THE AMERICAN WAY FOUNDATION
1101 15TH ST NW STE 600
WASHINGTON
,
DC
20005
N/A
PC
General & Unrestricted
2,000
PETS IN NEED
871 5TH AVE
REDWOOD CITY
,
CA
94063
N/A
PC
General & Unrestricted
5,000
POPULATION CONNECTION
2120 L ST NW STE 500
WASHINGTON
,
DC
20037
N/A
PC
General & Unrestricted
1,000
PRIDE INDUSTRIES
10030 FOOTHILLS BLVD
ROSEVILLE
,
CA
95747
N/A
PC
General & Unrestricted
1,000
PROJECT OPEN HAND
730 POLK ST 3RD FL
SAN FRANCISCO
,
CA
94109
N/A
PC
General & Unrestricted
1,000
PROSTATE CANCER RESEARCH INSTITUTE
5777 W CENTURY BLVD STE 800
LOS ANGELES
,
CA
90045
N/A
PC
General & Unrestricted
1,000
SAN FRANCISCO AIDS FOUNDATION
1035 MARKET ST STE 400
SAN FRANCISCO
,
CA
94103
N/A
PC
General & Unrestricted
1,000
SAN FRANCISCO BAY BIRD OBSERVATORY
524 VALLEY WAY
MILPITAS
,
CA
95035
N/A
PC
General & Unrestricted
1,000
SAN FRANCISCO SYMPHONY
201 VAN NESS AVE
SAN FRANCISCO
,
CA
94102
N/A
PC
General & Unrestricted
1,000
SAN JOSE MUSEUM OF ART ASSOCIATION
110 S MARKET ST
SAN JOSE
,
CA
95113
N/A
PC
General & Unrestricted
1,000
SECOND HARVEST FOOD BANK OF SANTA CLARA AND SAN MA
750 CURTNER AVE
SAN JOSE
,
CA
95125
N/A
PC
General & Unrestricted
4,000
SIERRA CLUB FOUNDATION
2101 WEBSTER ST STE 1250
OAKLAND
,
CA
94612
N/A
PC
General & Unrestricted
2,000
SILICON VALLEY JEWISH FILM FESTIVAL
PO BOX 2190
CUPERTINO
,
CA
95015
N/A
PC
General & Unrestricted
1,000
SIMON WIESENTHAL CENTER
1399 S ROXBURY 2ND FL
LOS ANGELES
,
CA
90035
N/A
PC
General & Unrestricted
1,000
SMART LIFE FORUM INC
14436 ESTERLEE DR
SARATOGA
,
CA
95070
N/A
PC
General & Unrestricted
4,000
SOLAR COOKERS INTERNATIONAL
2400 22ND ST STE 210
SACRAMENTO
,
CA
95818
N/A
PC
General & Unrestricted
2,000
TAWONGA JEWISH COMMUNITY CORPORATION
131 STEUART ST STE 460
SAN FRANCISCO
,
CA
94105
N/A
PC
General & Unrestricted
2,000
THE ELEPHANT SANCTUARY IN TENNESSEE
PO BOX 393
HOHENWALD
,
TN
38462
N/A
PC
General & Unrestricted
10,000
THE GARDINER FOUNDATION
3227 LURTING AVE APT 3
BRONX
,
NY
10469
N/A
PC
General & Unrestricted
66,000
THE HEALTH TRUST Meals-on-Wheels Program
2105 S BASCOM AVE STUITE 220
CAMPBELL
,
CA
95125
N/A
PC
General & Unrestricted
1,000
THE MANKIND PROJECT
PO BOX 383
KAYSVILLE
,
UT
84037
N/A
PC
NorCal Next Man Fund
1,000
THE MANKIND PROJECT
PO BOX 383
KAYSVILLE
,
UT
84037
N/A
PC
Lead Conversion Initiative
10,000
THE SALVATION ARMY - SANTA CLARA COUNTY
359 N 4TH ST
SAN JOSE
,
CA
95109
N/A
PC
General & Unrestricted
1,000
THE TECH MUSEUM OF INNOVATION
201 S MARKET ST
SAN JOSE
,
CA
95113
N/A
PC
General & Unrestricted
1,000
THEATREWORKS SILICON VALLEY
350 TWIN DOLPHIN DR STE 127
REDWOOD CITY
,
CA
94065
N/A
PC
General & Unrestricted
1,000
TIBET AID
34 TINKER ST
WOODSTOCK
,
NY
12498
N/A
PC
General & Unrestricted
1,000
TIDES CENTER
100 LARKIN ST
SAN FRANCISCO
,
CA
94102
N/A
PC
General & Unrestricted
1,000
US TOO INTERNATIONAL INC
2720 S RIVER RD STE 112
DES PLAINES
,
IL
60018
N/A
PC
General & Unrestricted
1,000
UTILITY REFORM NETWORK
268 BUSH ST STE 3933
SAN FRANCISCO
,
CA
94104
N/A
PC
General & Unrestricted
1,000
VIETNAM VETERANS OF CALIFORNIA INC
PO BOX 378
SANTA ROSA
,
CA
95402
N/A
PC
General & Unrestricted
1,000
WILDERNESS SOCIETY
1615 M ST NW LBBY 2
WASHINGTON
,
DC
20036
N/A
PC
General & Unrestricted
2,000
WILDLIFE CONSERVATION NETWORK INC
209 MISSISSIPPI ST
SAN FRANCISCO
,
CA
94107
N/A
PC
General & Unrestricted
1,000
WILDLIFE CONSERVATION SOCIETY
2300 SOUTHERN BLVD
BRONX
,
NY
10460
N/A
PC
General & Unrestricted
1,000
WORLD AFFAIRS COUNCIL OF NORTHERN CALIFORNIA
312 SUTTER ST STE 200
SAN FRANCISCO
,
CA
94108
N/A
PC
General & Unrestricted
1,000
WORLD WILDLIFE FUND INC
1250 24TH ST NW
WASHINGTON
,
DC
20037
N/A
PC
General & Unrestricted
1,000
YOUNG MENS CHRISTIAN ASSOCIATION SILICON VALLEY
80 SARATOGA AVE
SANTA CLARA
,
CA
95051
N/A
PC
General & Unrestricted
1,000
Total
.................................
3a
274,000
b
Approved for future payment
Total
.................................
3b
Form
990-PF
(2016)
Page 12
Form 990-PF (2016)
Page
12
Part XVI-A
Analysis of Income-Producing Activities
Enter gross amounts unless otherwise indicated.
Unrelated business income
Excluded by section 512, 513, or 514
(e)
Related or exempt
function income
(See instructions.)
1
Program service revenue:
(a)
Business code
(b)
Amount
(c)
Exclusion code
(d)
Amount
a
b
c
d
e
f
g
Fees and contracts from government agencies
2
Membership dues and assessments
....
3
Interest on savings and temporary cash investments
...........
14
116
4
Dividends and interest from securities
....
14
180,949
5
Net rental income or (loss) from real estate:
a
Debt-financed property
......
b
Not debt-financed property
.....
6
Net rental income or (loss) from personal property
7
Other investment income
.....
8
Gain or (loss) from sales of assets other than inventory
............
18
77,237
9
Net income or (loss) from special events:
10
Gross profit or (loss) from sales of inventory
11
Other revenue:
a
K-1 Inc/Loss
14
2
b
Federal Tax Refund
01
3,004
c
d
e
12
Subtotal. Add columns (b), (d), and (e)
..
261,308
13
Total.
Add line 12, columns (b), (d), and (e)
..................
13
261,308
(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.)
Form
990-PF
(2016)
Page 13
Form 990-PF (2016)
Page
13
Part XVII
Information Regarding Transfers To and Transactions and Relationships With Noncharitable Exempt Organizations
1
Did 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?
Yes
No
a
Transfers from the reporting foundation to a noncharitable exempt organization of:
(1)
Cash
...................................
1a(1)
No
(2)
Other assets
.................................
1a(2)
No
b
Other transactions:
(1)
Sales of assets to a noncharitable exempt organization
....................
1b(1)
No
(2)
Purchases of assets from a noncharitable exempt organization
..................
1b(2)
No
(3)
Rental of facilities, equipment, or other assets
.......................
1b(3)
No
(4)
Reimbursement arrangements
...........................
1b(4)
No
(5)
Loans or loan guarantees
.............................
1b(5)
No
(6)
Performance of services or membership or fundraising solicitations
................
1b(6)
No
c
Sharing of facilities, equipment, mailing lists, other assets, or paid employees
..............
1c
No
d
If 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.
(a)
Line No.
(b)
Amount involved
(c)
Name of noncharitable exempt organization
(d)
Description of transfers, transactions, and sharing arrangements
2a
Is 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?
...........
Yes
No
b
If "Yes," complete the following schedule.
(a)
Name of organization
(b)
Type of organization
(c)
Description of relationship
Sign Here
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 taxpayer) is based on all information of which preparer has any knowledge.
2017-10-11
May the IRS discuss this return
with the preparer shown below
(see instr.)?
Yes
No
Signature of officer or trustee
Date
Title
Paid Preparer Use Only
Print/Type preparer's name
Jeffrey D Haskell
Preparer's Signature
Date
Check if self-
employed
PTIN
P01345770
Firm's name
Foundation Source
Firm's EIN
Firm's address
One Hollow Ln Ste 212
Lake Success
,
NY
11042
Phone no.
(800) 839-1754
Form
990-PF
(2016)
Additional Data
Software ID:
Software Version:
Form 990PF - Special Condition Description:
Special Condition Description