-
TIN:
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
15
Open to Public Inspection
For calendar year 2015, or tax year beginning
01-01-2015
, and ending
12-31-2015
Name of foundation
THE JIMMY AND BERTA KHEZRIE
CHARITABLE FOUNDATION
Number and street (or P.O. box number if mail is not delivered to street address)
801 AVENUE I
Room/suite
City or town, state or province, country, and ZIP or foreign postal code
BROOKLYN
,
NY
11230
A Employer identification number
47-6505143
B
Telephone number (see instructions)
(201) 210-5577
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)
$
3,660,593
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)
4,500,000
2
Check
Sch. B
.............
3
Interest on savings and temporary cash investments
129
129
129
4
Dividends and interest from securities
...
5a
Gross rents
............
b
Net rental income or (loss)
6a
Net gain or (loss) from sale of assets not on line 10
b
Gross sales price for all assets on line 6a
7
Capital gain net income (from Part IV, line 2)
...
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)
.......
12
Total.
Add lines 1 through 11
........
4,500,129
129
129
13
Compensation of officers, directors, trustees, etc.
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)
....
17
Interest
...............
18
Taxes (attach schedule) (see instructions)
...
19
Depreciation (attach schedule) and depletion
...
20
Occupancy
..............
21
Travel, conferences, and meetings
.......
22
Printing and publications
..........
23
Other expenses (attach schedule)
.......
24
Total operating and administrative expenses.
Add lines 13 through 23
..........
0
0
0
25
Contributions, gifts, grants paid
.......
839,536
839,536
26
Total expenses and disbursements.
Add lines 24 and 25
839,536
0
839,536
27
Subtract line 26 from line 12:
a
Excess of revenue over expenses and disbursements
3,660,593
b
Net investment income
(if negative, enter -0-)
129
c
Adjusted net income
(if negative, enter -0-)
...
129
For Paperwork Reduction Act Notice, see instructions.
Cat. No. 11289X
Form
990-PF
(2015)
Form 990-PF (2015)
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
.............
157,964
157,964
2
Savings and temporary cash investments
.........
3,500,129
3,500,129
3
Accounts receivable
2,500
Less: allowance for doubtful accounts
2,500
2,500
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)
b
Investments—corporate stock (attach schedule)
.......
c
Investments—corporate bonds (attach schedule)
.......
11
Investments—land, buildings, and equipment: basis
Less: accumulated depreciation (attach schedule)
12
Investments—mortgage loans
.............
13
Investments—other (attach schedule)
..........
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)
3,660,593
3,660,593
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
Total liabilities
(add lines 17 through 22)
.........
0
Foundations that follow SFAS 117, check here
and complete lines 24 through 26 and lines 30 and 31.
24
Unrestricted
..................
3,660,593
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
30
Total net assets or fund balances
(see instructions)
.....
3,660,593
31
Total liabilities and net assets/fund balances
(see instructions)
.
0
3,660,593
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
2
Enter amount from Part I, line 27a
.....................
2
3,660,593
3
Other increases not included in line 2 (itemize)
3
4
Add lines 1, 2, and 3
..........................
4
3,660,593
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
3,660,593
Form
990-PF
(2015)
Form 990-PF (2015)
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.)
1a
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
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
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
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))
2014
2013
2012
2011
2010
2
Total
of line 1, column (d)
.....................
2
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
4
Enter the net value of noncharitable-use assets for 2015 from Part X, line 5
.....
4
5
Multiply line 4 by line 3
......................
5
6
Enter 1% of net investment income (1% of Part I, line 27b)
...........
6
7
Add lines 5 and 6
........................
7
8
Enter qualifying distributions from Part XII, line 4
.............
8
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
(2015)
Form 990-PF (2015)
Page
4
Part VI
Excise Tax Based on Investment Income (Section 4940(a), 4940(b), 4940(e), or 4948—see page 18 of the 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
3
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
3
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
3
6
Credits/Payments:
a
2015 estimated tax payments and 2014 overpayment credited to 2015
6a
b
Exempt foreign organizations—tax withheld at source
......
6b
c
Tax paid with application for extension of time to file (Form 8868)
...
6c
d
Backup withholding erroneously withheld
...........
6d
7
Total credits and payments. Add lines 6a through 6d
..............
7
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
3
10
Overpayment.
If line 7 is more than the total of lines 5 and 8, enter the
amount overpaid
...
10
11
Enter the amount of line 10 to be:
Credited to 2015 estimated tax
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
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
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
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
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)
NY
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 2015 or the taxable year beginning in 2015 (see instructions for Part XIV)?
If "Yes," complete Part XIV
.............................
9
Yes
10
Did any persons become substantial contributors during the tax year?
If "Yes," attach a schedule listing their names
and addresses.
...............................
10
Yes
Form
990-PF
(2015)
Form 990-PF (2015)
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
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
Website address
N/A
14
The books are in care of
JAMES KHEZRIE
Telephone no.
(201) 210-5577
Located at
801 AVENUE I
BROOKLYN
NY
ZIP+4
11230
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 2015, 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
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 2015?
.............
1c
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 2015, did the foundation have any undistributed income (lines 6d
and 6e, Part XIII) for tax year(s) beginning before 2015?
.............
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 2015 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 2015.)
..................
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 2015?
4b
No
Form
990-PF
(2015)
Form 990-PF (2015)
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
(2015)
Form 990-PF (2015)
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
JAMES KHEZRIE
TRUSTEE
0.00
0
0
0
801 AVENUE I
BROOKLYN
,
NY
11230
BERTA KHEZRIE
TRUSTEE
0.00
0
0
0
801 AVENUE I
BROOKLYN
,
NY
11230
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
NONE
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
NONE
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
DISTRIBUTIONS TO 501(C)(3) ORGANIZATIONS
839,536
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
N/A
2
All other program-related investments. See instructions.
3
Total.
Add lines 1 through 3
.........................
Form
990-PF
(2015)
Form 990-PF (2015)
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
0
b
Average of monthly cash balances
.......................
1b
4,079,047
c
Fair market value of all other assets (see instructions)
................
1c
0
d
Total
(add lines 1a, b, and c)
.........................
1d
4,079,047
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
3
Subtract line 2 from line 1d
.........................
3
4,079,047
4
Cash deemed held for charitable activities. Enter 1 1/2% of line 3 (for greater amount, see
instructions)
.............................
4
61,186
5
Net value of noncharitable-use assets.
Subtract line 4 from line 3. Enter here and on Part V, line 4
5
4,017,861
6
Minimum investment return.
Enter 5% of line 5
..................
6
200,893
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
2a
Tax on investment income for 2015 from Part VI, line 5
......
2a
b
Income tax for 2015. (This does not include the tax from Part VI.)
...
2b
c
Add lines 2a and 2b
............................
2c
3
Distributable amount before adjustments. Subtract line 2c from line 1
............
3
4
Recoveries of amounts treated as qualifying distributions
................
4
5
Add lines 3 and 4
............................
5
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
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
839,536
b
Program-related investments—total from Part IX-B
..................
1b
2
Amounts paid to acquire assets used (or held for use) directly in carrying out charitable, etc.,
purposes
...............................
2
3
Amounts set aside for specific charitable projects that satisfy the:
a
Suitability test (prior IRS approval required)
....................
3a
b
Cash distribution test (attach the required schedule)
.................
3b
4
Qualifying distributions.
Add lines 1a through 3b. Enter here and on Part V, line 8, and Part XIII, line 4
4
839,536
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
6
Adjusted qualifying distributions.
Subtract line 5 from line 4
..............
6
839,536
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
(2015)
Form 990-PF (2015)
Page
9
Part XIII
Undistributed Income
(see instructions)
(a)
Corpus
(b)
Years prior to 2014
(c)
2014
(d)
2015
1
Distributable amount for 2015 from Part XI, line 7
2
Undistributed income, if any, as of the end of 2015:
a
Enter amount for 2014 only
.......
b
Total for prior years:
20
,
20
,
20
3
Excess distributions carryover, if any, to 2015:
a
From 2010
......
b
From 2011
......
c
From 2012
......
d
From 2013
......
e
From 2014
......
f
Total
of lines 3a through e
........
4
Qualifying distributions for 2015 from Part
XII, line 4:
$
839,536
a
Applied to 2014, but not more than line 2a
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 2015 distributable amount
.....
e
Remaining amount distributed out of corpus
839,536
5
Excess distributions carryover applied to 2015.
(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
839,536
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 2014. 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 2015
..........
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 2010 not
applied on line 5 or line 7 (see instructions)
...
9
Excess distributions carryover to 2016.
Subtract lines 7 and 8 from line 6a
......
10
Analysis of line 9:
a
Excess from 2011
....
b
Excess from 2012
....
c
Excess from 2013
....
d
Excess from 2014
....
e
Excess from 2015
....
Form
990-PF
(2015)
Form 990-PF (2015)
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 2015, enter the date of the ruling
.......
2015-03-04
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)
2015
(b)
2014
(c)
2013
(d)
2012
129
129
b
85% of line 2a
.........
110
110
c
Qualifying distributions from Part XII,
line 4 for each year listed
.....
839,536
839,536
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
....
839,536
839,536
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
...
133,929
133,929
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).)
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 e-mail address of the person to whom applications should be addressed:
JAMES KHEZRIE
801 AVENUE I
BROOKLYN
,
NY
11230
(201) 210-5577
b
The form in which applications should be submitted and information and materials they should include:
FORMAL REQUEST IN WRITING; COMPLETE INFO ON BACKGROUND OF ORGANIZATION
c
Any submission deadlines:
NONE
d
Any restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other
factors:
NONE
Form
990-PF
(2015)
Form 990-PF (2015)
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
KOLLEL OHR MOSHE
1891 EAST 7TH ST
BROOKLYN
,
NY
11223
NONE
GENERAL CHARITABLE PURPOSE
2,000
KETER TORAH
600 ROEMER AVENUE
TEANEC K
,
NJ
07666
NONE
GENERAL CHARITABLE PURPOSE
30,000
YESHIVAT SHAARE TORAH
222 OCEAN PARKWAY
BROOKLYN
,
NY
11218
NONE
GENERAL CHARITABLE PURPOSE
26,000
OHEL SHULAMIT
38 SPRUCE DRIVE
LAKEWOOD
,
NJ
08701
NONE
GENERAL CHARITABLE PURPOSE
25,000
BET YAAKOV OF JERSEY SHORE
200 WALL ST
WEST LONG BRANCH
,
NJ
07764
NONE
GENERAL CHARITABLE PURPOSE
51,000
OHR NAAVA
2201 EAST 23RD ST
BROOKLYN
,
NY
10018
NONE
GENERAL CHARITABLE PURPOSE
13,000
SEPHARADIC FOOD FUND
8 WEST ST
NEW YORK
,
NY
10018
NONE
GENERAL CHARITABLE PURPOSE
14,400
KHT MESILAT
1616 EAST 10TH ST
BROOKLYN
,
NY
11223
NONE
GENERAL CHARITABLE PURPOSE
10,000
YESHIVA KETER TORAH
296 JERSEY AVE
LONG BRANCH
,
NJ
07740
NONE
GENERAL CHARITABLE PURPOSE
30,000
GATEWAYS ORGANIZATION
11 WALLENBERG CIRCLE
MONSEY
,
NY
10952
NONE
GENERAL CHARITABLE PURPOSE
5,000
MA-OR YESHIVA
36 CEDAR AVE
LONG BRANCH
,
NJ
07440
NONE
GENERAL CHARITABLE PURPOSE
3,600
LEV CHANA
291 MEADOWVIEW AVE
HEWLETT BAY PARK
,
NY
11557
NONE
GENERAL CHARITABLE PURPOSE
1,000
ZICHRON BINYOMIN
PO BOX 54085
TORONTO
,
ONTARIO
CA
NONE
GENERAL CHARITABLE PURPOSE
85,000
AMERICAN FRIEDS OF SANHEDRIA
1121 WEST LAURELTON PARKW
TEANECK
,
NJ
07666
NONE
GENERAL CHARITABLE PURPOSE
1,000
YESHIVAT OR HATORAH
2119 HOMECREST AVE
BROOKLYN
,
NY
11229
NONE
GENERAL CHARITABLE PURPOSE
13,000
KOLLEL CHAFETZ
24 HIGHVIEW
SUFFERN
,
NY
10901
NONE
GENERAL CHARITABLE PURPOSE
7,920
MIKDASH MELECH
1326 OCEAN PARKWAY
BROOKLYN
,
NY
11230
NONE
GENERAL CHARITABLE PURPOSE
44,000
KIHILET B'NAI YAAKOV
176 WEST SIDE AVE
JERSEY CITYJERSEWY
,
NJ
07305
NONE
GENERAL CHARITABLE PURPOSE
3,600
DEAL SEPHARDIC YOUTH CENTER
244 NORWOOD AVE
OAKHURST
,
NJ
07755
NONE
GENERAL CHARITABLE PURPOSE
1,800
STELLAS RAINBOW FOUNDATION
PO BOX 300
BROOKLYN
,
NY
11230
NONE
GENERAL CHARITABLE PURPOSE
500
BNEI ARAM SOBA
1616 OCEAN PKWY
BROOKLYN
,
NY
11223
NONE
GENERAL CHARITABLE PURPOSE
100
MEKOR HAIM YESHIVAT
2710 AVE X
BROOKLYN
,
NY
11235
NONE
GENERAL CHARITABLE PURPOSE
12,000
YAD YOSEF FOUNDATION
4 MALKA WAY
LAKEWOOD
,
NJ
08701
NONE
GENERAL CHARITABLE PURPOSE
20,000
YESHIVA ZICHRAN MOSHE
84 LAUREL PARK ROAD
S FALLSBURG
,
NY
12779
NONE
GENERAL CHARITABLE PURPOSE
10,000
NEHOR BAIS YAAKOV
700 NS ROAD
ST LOUIS
,
MO
63130
NONE
GENERAL CHARITABLE PURPOSE
25,000
AMERICAN FRIENDS OF HERZOG
57 WEST 57TH ST
NEW YORK
,
NY
10019
NONE
GENERAL CHARITABLE PURPOSE
50,000
KOL ISRAEL CONGREGATION
2504 AVENUE K
BROOKLYN
,
NY
11210
NONE
GENERAL CHARITABLE PURPOSE
2,001
CONGREGATION MAGEN DAVID
395 DEAL ROAD
OCEAN
,
NJ
07712
NONE
GENERAL CHARITABLE PURPOSE
1,164
ATARET TORAH
901 QUETIN ROAD
BROOKLYN
,
NY
11223
NONE
GENERAL CHARITABLE PURPOSE
10,000
YDE
49 AVENUE T
BROOKLYN
,
NY
11223
NONE
GENERAL CHARITABLE PURPOSE
10,000
YESHIVA LEV AHARON
1127 EAST 5TH ST
BROOKLYN
,
NY
11230
NONE
GENERAL CHARITABLE PURPOSE
10,000
YESHIVA OHR HATORAH
5822 11TH AVE
BROOKLYN
,
NY
11219
NONE
GENERAL CHARITABLE PURPOSE
13,000
BIRCAS YECHEZKEL
289 NOWLAN PLACE
LAKEWOOD
,
NJ
08701
NONE
GENERAL CHARITABLE PURPOSE
1,000
CONGREGATION OHR TORAH
48 EDGEMOUNT ROAD
EDISON
,
NJ
08817
NONE
GENERAL CHARITABLE PURPOSE
100
AFULA EDUCATIONAL CENTER
49 DAKOTA ST
PASSAIC
,
NJ
07055
NONE
GENERAL CHARITABLE PURPOSE
2,000
SHAAR TORAH
222 OCEAN PARKWAY
BROOKLYN
,
NY
11218
NONE
GENERAL CHARITABLE PURPOSE
3,000
YAKIR YERUSHALAYM
10 SAFRA SQUARE
JERUSALEM
IS
NONE
GENERAL CHARITABLE PURPOSE
25,000
YESHIVA OHR YITZCHAK
1373 EAST 13TH ST
BROOKLYN
,
NY
11230
NONE
GENERAL CHARITABLE PURPOSE
5,000
TORAT HANNCHAL
303 PARK AVE
ELBERON
,
NJ
07740
NONE
GENERAL CHARITABLE PURPOSE
1,000
YESHIVAT BINAT CHAIM
9603 69TH AVE
FOREST HILLS
,
NY
11375
NONE
GENERAL CHARITABLE PURPOSE
500
AVENUE R SEPHARDIC CONGREGATION
2208 AVENUE S
BROOKLYN
,
NY
11229
NONE
GENERAL CHARITABLE PURPOSE
1,800
ANAHIM
46 MABRO DRIVE
DENVILLE
,
NJ
07834
NONE
GENERAL CHARITABLE PURPOSE
900
AMERICAN FRIENDS YESHIVAS
1412 EAST 7TH ST
BROOKLYN
,
NY
11230
NONE
GENERAL CHARITABLE PURPOSE
122,000
ATERET AHARON
39 HARAV KUK ST
RAMAT HASHARON
IS
NONE
GENERAL CHARITABLE PURPOSE
1,000
YAD ELIEZER
1102 EAST 26TH ST
BROOKLYN
,
NY
11210
NONE
GENERAL CHARITABLE PURPOSE
500
CONGREGATION CHEMDAT SHLOMO
1243 43RD ST
BROOKLYN
,
NY
11219
NONE
GENERAL CHARITABLE PURPOSE
500
AMER FRIENDS SHAAREI SIMCHA
24 ENGLEWOOD TERRACE
LAKEWOOD
,
NJ
08701
NONE
GENERAL CHARITABLE PURPOSE
1,800
CHESED FUND
7045 N RIDGEWOOD AVE
LINCONWOOD
,
IL
60712
NONE
GENERAL CHARITABLE PURPOSE
1,500
KTA
50 MONTGOMERY AVE
BALA CYNWYD
,
PA
19004
NONE
GENERAL CHARITABLE PURPOSE
2,600
TORAT CHESED
8233 VENTRAL PARK AVE
SKOKIE
,
IL
60076
NONE
GENERAL CHARITABLE PURPOSE
300
CHASAN SOFER
1876 50TH ST
BROOKLYN
,
NY
11204
NONE
GENERAL CHARITABLE PURPOSE
1,000
YESHIVA BAYONNE
735 AVENUE C
BAYONE
,
NJ
07002
NONE
GENERAL CHARITABLE PURPOSE
1,000
YAD NAFTALI
1268 48TH ST
BROOKLYN
,
NY
11219
NONE
GENERAL CHARITABLE PURPOSE
1,800
ATERES YISRAEL
8101 AVE K
BROOKLYN
,
NY
11236
NONE
GENERAL CHARITABLE PURPOSE
2,600
KEHILAT BNEI YAAKOV
630 AVENUE S
BROOKLYN
,
NY
11230
NONE
GENERAL CHARITABLE PURPOSE
1,800
OROT SARAH
1123 AVE N
BROOKLYN
,
NY
11230
NONE
GENERAL CHARITABLE PURPOSE
10,000
DARCHEI CHINUCH
257 BEACH 17TH ST
FAR ROCKAWAY
,
NY
11691
NONE
GENERAL CHARITABLE PURPOSE
1,000
NEVEI HACHESED
411 AVE F
BROOKLYN
,
NY
11218
NONE
GENERAL CHARITABLE PURPOSE
1,000
BNAT YISRAEL
2 BANKSVILLE RD
ARMONK
,
NY
10504
NONE
GENERAL CHARITABLE PURPOSE
30,000
YESIVA BIRRAI YOSEF
JERUSALEM
JERUSALEM
IS
NONE
GENERAL CHARITABLE PURPOSE
500
MIFAL TERUMAH
JERUSALEM
JERUSALEM
IS
NONE
GENERAL CHARITABLE PURPOSE
14,000
REACH FOR THE STARS
1523 AVE M
BROOKLYN
,
NY
11230
NONE
GENERAL CHARITABLE PURPOSE
3,600
EXCEED NETWORK
379 KINGS HIGHWAY
BROOKLYN
,
NY
11223
NONE
GENERAL CHARITABLE PURPOSE
3,600
MITZVAH MAN
PO BOX 290690
BROOKLYN
,
NY
11229
NONE
GENERAL CHARITABLE PURPOSE
3,600
EMUNAH DAILY
361 SPOOK ROCK ROAD
SUFFERN
,
NY
10901
NONE
GENERAL CHARITABLE PURPOSE
1,000
CONGREGATION BETH TORAH
1601 OCEAN PARKWAY
BROOKLYN
,
NY
11230
NONE
GENERAL CHARITABLE PURPOSE
1,151
SAM LEBY INC
TEL AVIV
TEL AVIV
IS
NONE
GENERAL CHARITABLE PURPOSE
1,800
AMUDEI HESED
1616 OCEAN PARKWAY
BROOKLYN
,
NY
11223
NONE
GENERAL CHARITABLE PURPOSE
600
CHABAD OF HOBOKEN
80 PARK AVE
HOBOKEN
,
NJ
07030
NONE
GENERAL CHARITABLE PURPOSE
500
MEKOR HAIM
2710 AVE X
BROOKLYN
,
NY
11235
NONE
GENERAL CHARITABLE PURPOSE
4,000
BET YOSEF
AVE U OCEAN PARKWAY
BROOKLYN
,
NY
11223
NONE
GENERAL CHARITABLE PURPOSE
1,000
AMUDIM
11 BROADWAY
NEW YORK
,
NY
10004
NONE
GENERAL CHARITABLE PURPOSE
500
SHOP SMART
2640 NOSTRAND AVE
BROOKLYN
,
NY
11210
NONE
GENERAL CHARITABLE PURPOSE
500
KOLLEL KEHILAT YAKOV
10 YOSEF MATITYAHU ST
JERUSALEM
IS
NONE
GENERAL CHARITABLE PURPOSE
500
KOLLEL OF JERSEY SHORE
1616 OCEAN PARKWAY
BROOKLYN
,
NY
11223
NONE
GENERAL CHARITABLE PURPOSE
1,000
AMER FRIENDS OF MEIR YISA BRACHA
5014 16TH AVE
BROOKLYN
,
NY
11204
NONE
GENERAL CHARITABLE PURPOSE
1,000
CHILD LIFE SOCIETY
1347 43RD ST
BROOKLYN
,
NY
11219
NONE
GENERAL CHARITABLE PURPOSE
500
JERUSALEM OPEN HOUSE
3014 AVE L
BROOKLYN
,
NY
11210
NONE
GENERAL CHARITABLE PURPOSE
500
SHEVES ACHIM GAM YACHAD
8166 EASTERN PARKWAY
BROOKLYN
,
NY
11213
NONE
GENERAL CHARITABLE PURPOSE
500
AVI EZRI
1260 48TH STREET
BROOKLYN
,
NY
11219
NONE
GENERAL CHARITABLE PURPOSE
4,600
YAD YOSEF
1032 OCEAN PARKWAY
BROOKLYN
,
NY
11230
NONE
GENERAL CHARITABLE PURPOSE
42,800
Total
.................................
3a
839,536
b
Approved for future payment
Total
.................................
3b
Form
990-PF
(2015)
Form 990-PF (2015)
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
129
4
Dividends and interest from securities
....
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
............
9
Net income or (loss) from special events:
10
Gross profit or (loss) from sales of inventory
..
11
Other revenue:
a
b
c
d
e
12
Subtotal. Add columns (b), (d), and (e)
..
129
13
Total.
Add line 12, columns (b), (d), and (e)
..................
13
129
(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.)
3
SOURCE OF CHARITABLE CONTRIBUTIONS TO 501(C)(3) ORGS
Form
990-PF
(2015)
Form 990-PF (2015)
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.
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
Preparer's Signature
Date
Check if self-
employed
PTIN
Firm's name
Firm's EIN
Firm's address
Phone no.
Form
990-PF
(2015)
Additional Data
Software ID:
Software Version:
Form 990PF - Special Condition Description:
Special Condition Description
-
TIN:
Schedule B
(Form 990, 990-EZ,
or 990-PF)
Department of the Treasury
Internal Revenue Service
Schedule of Contributors
Attach to Form 990, 990-EZ, or 990-PF.
Information about Schedule B (Form 990, 990-EZ, or 990-PF) and its instructions is at
www.irs.gov/form990
.
OMB No. 1545-0047
20
15
Name of the organization
THE JIMMY AND BERTA KHEZRIE
CHARITABLE FOUNDATION
Employer identification number
47-6505143
Organization type
(check one):
Filers of:
Section:
Form 990 or 990-EZ
501(c)(
) (enter number) organization
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.
General Rule
For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, contributions totaling $5,000 or more (in money or other property) from any one contributor. Complete Parts I and II. See instructions for determining a contributor's total contributions.
Special Rules
For an organization described in section 501(c)(3) 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), that checked Schedule A (Form 990 or 990-EZ), Part II, line 13, 16a, or 16b, and that received from any one contributor, during the year, total contributions 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 an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, total contributions of more than $1,000
exclusively
for religious, charitable, scientific, literary, or educational purposes, or for the prevention of cruelty to children or animals. Complete Parts I, II, and III.
For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, contributions
exclusively
for religious, charitable, etc., purposes, but no such contributions totaled 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 totaling $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 its Form 990PF, Part I, line 2, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).
For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.
Cat. No. 30613X
Schedule B (Form 990, 990-EZ, or 990-PF) (2015)
Schedule B (Form 990, 990-EZ, or 990-PF) (2015)
Page
2
Name of organization
THE JIMMY AND BERTA KHEZRIE
CHARITABLE FOUNDATION
Employer identification number
47-6505143
Part I
Contributors
(see instructions). Use duplicate copies of Part I if additional space is needed.
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Total contributions
(d)
Type of contribution
1
JAMES BERTA KHEZRIE
801 AVENUE I
BROOKLYN
,
NY
11230
$
4,500,000
Person
Payroll
Noncash
(Complete Part II for noncash contributions.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Total contributions
(d)
Type of contribution
$
Person
Payroll
Noncash
(Complete Part II for noncash contributions.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Total contributions
(d)
Type of contribution
$
Person
Payroll
Noncash
(Complete Part II for noncash contributions.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Total contributions
(d)
Type of contribution
$
Person
Payroll
Noncash
(Complete Part II for noncash contributions.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Total contributions
(d)
Type of contribution
$
Person
Payroll
Noncash
(Complete Part II for noncash contributions.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Total contributions
(d)
Type of contribution
$
Person
Payroll
Noncash
(Complete Part II for noncash contributions.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2015)
Schedule B (Form 990, 990-EZ, or 990-PF) (2015)
Page
3
Name of organization
THE JIMMY AND BERTA KHEZRIE
CHARITABLE FOUNDATION
Employer identification number
47-6505143
Part II
Noncash Property
(see instructions). Use duplicate copies of Part II if additional space is needed.
(a)
No.from Part I
(b)
Description of noncash property given
(c)
FMV (or estimate)
(see instructions)
(d)
Date received
$
(a)
No.from Part I
(b)
Description of noncash property given
(c)
FMV (or estimate)
(see instructions)
(d)
Date received
$
(a)
No.from Part I
(b)
Description of noncash property given
(c)
FMV (or estimate)
(see instructions)
(d)
Date received
$
(a)
No.from Part I
(b)
Description of noncash property given
(c)
FMV (or estimate)
(see instructions)
(d)
Date received
$
(a)
No.from Part I
(b)
Description of noncash property given
(c)
FMV (or estimate)
(see instructions)
(d)
Date received
$
(a)
No.from Part I
(b)
Description of noncash property given
(c)
FMV (or estimate)
(see instructions)
(d)
Date received
$
Schedule B (Form 990, 990-EZ, or 990-PF) (2015)
Schedule B (Form 990, 990-EZ, or 990-PF) (2015)
Page
4
Name of organization
THE JIMMY AND BERTA KHEZRIE
CHARITABLE FOUNDATION
Employer identification number
47-6505143
Part III
Exclusively
religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10) that total more than $1,000 for the year from any one contributor. Complete columns
(a)
through
(e) and
the following line entry. For organizations completing Part III, enter the total of
exclusively
religious, charitable, etc., contributions of
$1,000 or less
for the year. (Enter this information once. See instructions.)
$
Use duplicate copies of Part III if additional space is needed.
(a)
No.from Part I
(b) Purpose of gift
(c) Use of gift
(d) Description of how gift is held
(e) Transfer of gift
Transferee's name, address, and ZIP 4
Relationship of transferor to transferee
(a)
No.from Part I
(b) Purpose of gift
(c) Use of gift
(d) Description of how gift is held
(e) Transfer of gift
Transferee's name, address, and ZIP 4
Relationship of transferor to transferee
(a)
No.from Part I
(b) Purpose of gift
(c) Use of gift
(d) Description of how gift is held
(e) Transfer of gift
Transferee's name, address, and ZIP 4
Relationship of transferor to transferee
(a)
No.from Part I
(b) Purpose of gift
(c) Use of gift
(d) Description of how gift is held
(e) Transfer of gift
Transferee's name, address, and ZIP 4
Relationship of transferor to transferee
Schedule B (Form 990, 990-EZ, or 990-PF) (2015)
Additional Data
Software ID:
Software Version:
-
TIN:
TY 2015 SubstantialContributorsSch
Name:
THE JIMMY AND BERTA KHEZRIE
CHARITABLE FOUNDATION
EIN:
47-6505143
Name
Address
JAMES BERTA KHEZRIE
801 AVENUE I
BROOKLYN
,
NY
11230