Form990-PF
Click to see attachment

Department of the Treasury
Internal Revenue Service

Return of Private Foundation
or Section 4947(a)(1) Trust Treated as Private Foundation
bulletDo not enter social security numbers on this form as it may be made public.
bulletInformation about Form 990-PF and its instructions is at www.irs.gov/form990pf.
OMB No. 1545-0052
2015
Open to Public Inspection
For calendar year 2015, or tax year beginning 01-01-2015 , and ending 12-31-2015
Name of foundation
DAVID B JACOBSON FOUNDATION
 
Number and street (or P.O. box number if mail is not delivered to street address)652 GLENBROOK RD NO 3-303A
  Room/suite
City or town, state or province, country, and ZIP or foreign postal code
STAMFORD, CT06906
A Employer identification number

59-2664074
B Telephone number (see instructions)

(914) 668-2219
C bullet
G Check all that apply:

D 1. bullet
2. bullet
E bullet
H Check type of organization:
F bullet
I Fair market value of all assets at end
of year (from Part II, col. (c),
line 16)bullet$229,582J Accounting method:
 
(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)
Revenue 1 Contributions, gifts, grants, etc., received (attach schedule)  
2 Check bullet Sch. B .............
3 Interest on savings and temporary cash investments 2,316 2,316 2,316
4 Dividends and interest from securities... 2,098 2,098 2,098
5a Gross rents............      
b Net rental income or (loss)  
6a Net gain or (loss) from sale of assets not on line 10 15,499
b Gross sales price for all assets on line 6a 101,093
7 Capital gain net income (from Part IV, line 2)... 15,499
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........ 19,913 19,913 4,414
Operating and Administrative Expenses 13 Compensation of officers, directors, trustees, etc. 0 0 0 0
14 Other employee salaries and wages......        
15 Pension plans, employee benefits.......        
16a Legal fees (attach schedule)......... Click to see attachment 8,474 0 0 8,474
b Accounting fees (attach schedule)....... Click to see attachment 5,550 0 0 5,550
c Other professional fees (attach schedule).... Click to see attachment 16,880 3,230 0 12,430
17 Interest............... 106 106 0 0
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)....... Click to see attachment 5,121 0 0 0
24 Total operating and administrative expenses.
Add lines 13 through 23.......... 36,131 3,336 0 26,454
25 Contributions, gifts, grants paid....... 12,752 12,752
26 Total expenses and disbursements. Add lines 24 and 25 48,883 3,336 0 39,206
27 Subtract line 26 from line 12:
a Excess of revenue over expenses and disbursements -28,970
b Net investment income (if negative, enter -0-) 16,577
c Adjusted net income (if negative, enter -0-)... 4,414
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
Assets 1 Cash—non-interest-bearing............. 3,370 6,221 6,221
2 Savings and temporary cash investments.........      
3 Accounts receivable bullet37,767
Less: allowance for doubtful accounts bullet   25,884 37,767 37,767
4 Pledges receivable bullet  
Less: allowance for doubtful accounts bullet        
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) bullet275
Less: allowance for doubtful accounts bullet0 275 275 275
8 Inventories for sale or use..............      
9 Prepaid expenses and deferred charges..........      
10a Investments—U.S. and state government obligations (attach schedule) 68,426 Click to see attachment44,290 44,290
b Investments—corporate stock (attach schedule)....... 163,658 Click to see attachment130,449 130,449
c Investments—corporate bonds (attach schedule).......      
11 Investments—land, buildings, and equipment: basis bullet  
Less: accumulated depreciation (attach schedule) bullet        
12 Investments—mortgage loans.............      
13 Investments—other (attach schedule)..........      
14 Land, buildings, and equipment: basis bullet  
Less: accumulated depreciation (attach schedule) bullet        
15 Other assets (describe bullet) Click to see attachment10,580 Click to see attachment10,580 Click to see attachment10,580
16 Total assets (to be completed by all filers—see the
instructions. Also, see page 1, item I) 272,193 229,582 229,582
Liabilities 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 bullet)    
23 Total liabilities (add lines 17 through 22)......... 0 0
Net Assets or Fund Balances bullet
and complete lines 24 through 26 and lines 30 and 31.
24 Unrestricted..................    
25 Temporarily restricted...............    
26 Permanently restricted...............    
bullet
and complete lines 27 through 31.
27 Capital stock, trust principal, or current funds........ 339,617 339,617
28 Paid-in or capital surplus, or land, bldg., and equipment fund 0 0
29 Retained earnings, accumulated income, endowment, or other funds -67,424 -110,035
30 Total net assets or fund balances (see instructions)..... 272,193 229,582
31 Total liabilities and net assets/fund balances (see instructions). 272,193 229,582
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
272,193
2
Enter amount from Part I, line 27a .....................
2
-28,970
3
Other increases not included in line 2 (itemize) bullet
3
0
4
Add lines 1, 2, and 3 ..........................
4
243,223
5
Decreases not included in line 2 (itemize) bulletClick to see attachment
5
13,641
6
Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 30 .
6
229,582
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.)
1 a RS INVESTMENTS P    
b RS INVESTMENTS P    
c WELLS FARGO #8984-6766 P    
d WELLS FARGO #8984-6766 P    
e WELLS FARGO #8984-6766 P    
(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 957     957
b 5,210     5,210
c 15,937   17,196 -1,259
d 25,473   20,735 4,738
e 53,516   47,663 5,853
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       957
b       5,210
c       -1,259
d       4,738
e       5,853
2 Capital gain net income or (net capital loss) Bracket If gain, also enter in Part I, line 7
If (loss), enter -0- in Part I, line 7		 Bracket 2 15,499
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 ................... 		Bracket 3 -302
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?
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 45,763 209,461 0.218480
2013 46,710 260,562 0.179266
2012 29,737 296,421 0.100320
2011 33,498 303,911 0.110223
2010 13,029 338,696 0.038468
2
Total of line 1, column (d) .....................
20.646757
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
0.129351
4
Enter the net value of noncharitable-use assets for 2015 from Part X, line 5.....
4
204,360
5
Multiply line 4 by line 3......................
5
26,434
6
Enter 1% of net investment income (1% of Part I, line 27b)...........
6
166
7
Add lines 5 and 6........................
7
26,600
8
Enter qualifying distributions from Part XII, line 4.............
8
39,206
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 Bullet and enter “N/A" on line 1. Bracket
Date of ruling or determination letter:   (attach copy of letter if necessary–see instructions)
b 1 166
hereBulletand 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 0
3 Add lines 1 and 2........................... 3 166
4 Subtitle A (income) tax (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-) 4 0
5 Tax based on investment income. Subtract line 4 from line 3. If zero or less, enter -0- ..... 5 166
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 0
8 Enter any penalty for underpayment of estimated tax. 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.......Bullet 9 166
10 Overpayment. If line 7 is more than the total of lines 5 and 8, enter the amount overpaid...Bullet 10  
11 Enter the amount of line 10 to be: Credited to 2015 estimated taxBullet   RefundedBullet 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. bullet$ 0(2) On foundation managers.bullet$ 0
e
Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed
on foundation managers.bullet$ 0
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)
    bulletCT
    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
     
    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 (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
     
    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 addressbulletN/A
    14
    The books are in care ofbulletMICHAEL JACOBSON Telephone no.bullet (914) 668-2219

    Located atbullet652 GLENBROOK RDSTAMFORDCT ZIP+4bullet06906
    15
    Section 4947(a)(1) nonexempt charitable trusts filing Form 990-PF in lieu of Form 1041.......bullet
    and enter the amount of tax-exempt interest received or accrued during the year ......bullet
    15  
    16 At any time during calendar year 2015, did the foundation have an interest in or a signature or other authority over YesNo
    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 bullet  
    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?
    (2) Borrow money from, lend money to, or otherwise extend credit to (or accept it from)
    a disqualified person?......................
    (3) Furnish goods, services, or facilities to (or accept them from) a disqualified person?
    (4) Pay compensation to, or pay or reimburse the expenses of, a disqualified person?
    (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)?...............
    (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.).......
    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
    ........bullet
    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
     
    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 2015, did the foundation have any undistributed income (lines 6d
    and 6e, Part XIII) for tax year(s) beginning before 2015?.............
    If "Yes," list the years bullet20, 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
    Yes
     
    c
    If the provisions of section 4942(a)(2) are being applied to any of the years listed in 2a, list the years here.
    bullet20, 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?......................
    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))?
    (2) Influence the outcome of any specific public election (see section 4955); or to carry
    on, directly or indirectly, any voter registration drive?.............
    (3) Provide a grant to an individual for travel, study, or other similar purposes?
    (4) Provide a grant to an organization other than a charitable, etc., organization described
    in section 4945(d)(4)(A)? (see instructions)................
    (5) Provide for any purpose other than religious, charitable, scientific, literary, or
    educational purposes, or for the prevention of cruelty to children or animals?.....
    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
     
     
    .........bullet
    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?..........
    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?.....................
    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?
    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
    DAVID BURTON JACOBSON DIRECTOR
    0.00     		0 0 0
    30 WESTWAY RD
    WESTPORT,CT06831
    MICHAEL JACOBSON EXECUTIVE DIRECTOR
    10.00     		0 0 0
    30 WESTWAY RD
    WESTPORT,CT06831
    NEIL JACOBSON DIRECTOR
    0.00     		0 0 0
    36T PUTNAM GREEN
    GREENWICH,CT06831
    JOANNE JACOBSON ANATOLE DIRECTOR
    2.25     		0 0 0
    187 WEAVER ST
    GREENWICH,CT06831
    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...................bullet 0
    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.............bullet0
    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.........................bullet0
    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
    203,412
    b
    Average of monthly cash balances.......................
    1b
    4,060
    c
    Fair market value of all other assets (see instructions)................
    1c
    0
    d
    Total (add lines 1a, b, and c).........................
    1d
    207,472
    e
    Reduction claimed for blockage or other factors reported on lines 1a and
    1c (attach detailed explanation) .............
    1e
    0
    2
    Acquisition indebtedness applicable to line 1 assets..................
    2
    0
    3
    Subtract line 2 from line 1d.........................
    3
    207,472
    4
    Cash deemed held for charitable activities. Enter 1 1/2% of line 3 (for greater amount, see
    instructions) .............................
    4
    3,112
    5
    Net value of noncharitable-use assets. Subtract line 4 from line 3. Enter here and on Part V, line 4
    5
    204,360
    6
    Minimum investment return. Enter 5% of line 5..................
    6
    10,218
    Part XI
    Distributable Amount bullet
    1
    Minimum investment return from Part X, line 6....................
    1
    10,218
    2a
    Tax on investment income for 2015 from Part VI, line 5......
    2a
    166
    b
    Income tax for 2015. (This does not include the tax from Part VI.)...
    2b
     
    c
    Add lines 2a and 2b............................
    2c
    166
    3
    Distributable amount before adjustments. Subtract line 2c from line 1............
    3
    10,052
    4
    Recoveries of amounts treated as qualifying distributions................
    4
    0
    5
    Add lines 3 and 4............................
    5
    10,052
    6
    Deduction from distributable amount (see instructions).................
    6
    0
    7
    Distributable amount as adjusted. Subtract line 6 from line 5. Enter here and on Part XIII, line 1 ...
    7
    10,052
    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
    39,206
    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
     
    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
    39,206
    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
    166
    6
    Adjusted qualifying distributions. Subtract line 5 from line 4..............
    6
    39,040
    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 10,052
    2 Undistributed income, if any, as of the end of 2015:
    a Enter amount for 2014 only....... 6,353
    b Total for prior years:20, 20, 20 65,161
    3 Excess distributions carryover, if any, to 2015:
    a From 2010......  
    b From 2011......  
    c From 2012...... 127
    d From 2013...... 31,674
    e From 2014...... 27,157
    fTotal of lines 3a through e........ 58,958
    4Qualifying distributions for 2015 from Part
    XII, line 4: bullet$ 39,206
    a Applied to 2014, but not more than line 2a 6,353
    b Applied to undistributed income of prior years
    (Election required—see instructions).....     		0
    c Treated as distributions out of corpus (Election
    required—see instructions)........     		0
    d Applied to 2015 distributable amount..... 10,052
    e Remaining amount distributed out of corpus 22,801
    5 Excess distributions carryover applied to 2015. 0 0
    (If an amount appears in column (d), the
    same amount must be shown in column (a).)
    6Enter the net total of each column as
    indicated below:
    a Corpus. Add lines 3f, 4c, and 4e. Subtract line 5 81,759
    b Prior years’ undistributed income. Subtract
    line 4b from line 2b ..........     		65,161
    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......     		0
    d Subtract line 6c from line 6b. Taxable amount
    —see instructions ...........     		65,161
    e Undistributed income for 2014. Subtract line
    4a from line 2a. Taxable amount—see
    instructions .............     		0
    f Undistributed income for 2016. Subtract
    lines 4d and 5 from line 1. This amount must
    be distributed in 2015 ..........     		0
    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) .......     		0
    8Excess distributions carryover from 2010 not
    applied on line 5 or line 7 (see instructions) ...     		0
    9Excess distributions carryover to 2016.
    Subtract lines 7 and 8 from line 6a ......     		81,759
    10 Analysis of line 9:
    a Excess from 2011....  
    b Excess from 2012.... 127
    c Excess from 2013.... 31,674
    d Excess from 2014.... 27,157
    e Excess from 2015.... 22,801
    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.......bullet
     
    b Check box to indicate whether the organization is a private operating foundation described in section or
    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
             
    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.)
    1Information Regarding Foundation Managers:
    aList 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).)
    bList 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.
    2Information Regarding Contribution, Grant, Gift, Loan, Scholarship, etc., Programs:
    Check here bullet
    aThe name, address, and telephone number or email address of the person to whom applications should be addressed:
    bThe form in which applications should be submitted and information and materials they should include:
    cAny submission deadlines:
    dAny restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other
    factors:
    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)
    aPaid during the year
    NATIONAL WILDLIFE FEDERATION
    11100 WILDLIFE CENTER DRIVE
    RESTON,VA20190     		  PUBL CHARITY CONTRIBUTION 180
    FOOD BANK OF LOWER FAIRFIELD COUNTY
    461 GLENBROOK ROAD
    STAMFORD,CT06906     		  PUBL CHARITY CONTRIBUTION 180
    RANDOM FARMS KIDS THEATER INC
    333 N STATE RD
    BRIARCLIFF MANOR,NY10510     		  PUBL CHARITY CONTRIBUTION 90
    HOBART & WILLIAM SMITH COLLEGE
    300 PULTENEY ST
    GENEVA,NY14456     		  PUBL CHARITY CONTRIBUTION 250
    WINDWARD SCHOOL
    13 WINDWARD AVENUE
    WHITE PLAINS,NY10605     		  PUBL CHARITY CONTRIBUTION 200
    MARINE ANIMAL RESCUE
    821 E EL SEGUNDO BLVD
    EL SEGUNDO,CA90245     		  PUBL CHARITY CONTRIBUTION 54
    PLAY FOR PINK INC
    175 E 74TH ST 17B
    NEW YORK,NY10021     		  PUBL CHARITY CONTRIBUTION 80
    MARCH OF DIMES
    1275 MAMARONECK AVENUE
    NEW YORK,NY10605     		  PUBL CHARITY CONTRIBUTION 90
    SLOAN KETTERING CANCER CENTER
    1275 YORK AVENUE
    NEW YORK,NY10065     		  PUBL CHARITY CONTRIBUTION 36
    THE ASPETUCK LAND TRUST
    18 COLD SPRING ROAD
    EASTON,CT06612     		  PUBL CHARITY CONTRIBUTION 90
    PROJECT RETURN
    124 COMPO RD N
    WESTPORT,CT06880     		  PUBL CHARITY CONTRIBUTION 54
    THE CONNECTICUT HOSPICE
    100 DOUBLE BEACH RD
    BRANFORD,CT06405     		  PUBL CHARITY CONTRIBUTION 180
    AMERICAN CANCER SOCIETY
    PO BOX 907
    WALLINGFORD,CT06492     		  PUBL CHARITY CONTRIBUTION 360
    AMPLEHARVESTORG INC
    24 CLOVER RD
    NEWFOUNDLAND,NJ07435     		  PUBL CHARITY CONTRIBUTION 180
    ASPCA- THE AM SOC PREVENTION OF CRUELTY
    424 EAST 92 STREET
    NEW YORK,NY10128     		  PUBL CHARITY CONTRIBUTION 180
    BIDE-A-WEE
    410 EAST 38TH
    NEW YORK,NY10016     		  PUBL CHARITY CONTRIBUTION 360
    BRANDEIS UNIVERSITY ANNUAL FUND
    415 SOUTH STREET
    WALTHAM,MA02453     		  PUBL CHARITY CONTRIBUTION 180
    CORNELL UNIVERSITY
    CAMPUS RD
    ITHACA,NY14850     		  PUBL CHARITY CONTRIBUTION 2,000
    CT HUMANE SOCIETY
    701 RUSSELL ROAD
    NEWINGTON,CT06111     		  PUBL CHARITY CONTRIBUTION 180
    DOROT USA
    171 W 85TH STREET
    NEW YORK,NY10024     		  PUBL CHARITY CONTRIBUTION 180
    FRIENDS OF KAREN INC
    PO BOX 190
    PURDYS,NY10578     		  PUBL CHARITY CONTRIBUTION 54
    GREENWICH REFORM SYNAGOGUE
    EAST PUTNAM AVE
    RIVERSIDE,CT06878     		  PUBL CHARITY CONTRIBUTION 1,710
    JEWISH HOME FOR THE ELDERLY
    175 JEFFERSON STREET
    FAIRFIELD,CT06825     		  PUBL CHARITY CONTRIBUTION 360
    JEWISH NATIONAL FUND
    42 EAST 69TH STREET
    NEW YORK,NY10021     		  PUBL CHARITY CONTRIBUTION 180
    KING LOW HEYWOOD THOMAS
    1450 NEWFIELD AVE
    STAMFORD,CT06905     		  PUBL CHARITY CONTRIBUTION 200
    MADD
    511 E JOHN CARPENTER FWY STE 700
    IRVING,TX75062     		  PUBL CHARITY CONTRIBUTION 50
    MYSTIC AQUARIUM
    55 COOGAN BLVD
    MYSTIC,CT06355     		  PUBL CHARITY CONTRIBUTION 180
    NATHANIAL WITHERALL
    70 PARSONAGE ROAD
    GREENWICH,CT06830     		  PUBL CHARITY CONTRIBUTION 100
    NY PHILHARMONIC
    10 LINCOLN CENTER PLAZA
    NEW YORK,NY10023     		  PUBL CHARITY CONTRIBUTION 1,300
    PROMISE PROJECT FCNY
    121 AVENUE OF THE AMERICAS 6TH
    FLOOR
    NEW YORK,NY10013     		  PUBL CHARITY CONTRIBUTION 600
    RIDGEFIELD PLAYHOUSE
    80 E RIDGE RD
    RIDGEFIELD,CT06877     		  PUBL CHARITY CONTRIBUTION 180
    SMILOW CANCER HOSPITAL AT YALE-NEW HAVEN
    PO BOX 7611
    NEW HAVEN,CT06519     		  PUBL CHARITY CONTRIBUTIONCONTRIBUTION 180
    SPECIAL OLYMPICS
    1133 19TH STREET
    WASHINGTON,DC20036     		  PUBL CHARITY CONTRIBUTION 90
    SUSAN G KOMEN FOUNDATION
    PO BOX 96216
    WASHINGTON,DC20090     		  PUBL CHARITY CONTRIBUTION 360
    THE ALDRICH CONTEMPORARY ART MUSEUM
    258 MAIN STREET
    RIDGEFIELD,CT06877     		  PUBL CHARITY CONTRIBUTION 90
    THE LUSTGARTEN FOUNDATION
    1111 STEWART AVENUE BETHPAGE
    BETHPAGE,NY11714     		  PUBL CHARITY CONTRIBUTION 90
    THIRTEENWNET
    825 EIGHTH AVENUE
    NEW YORK,NY10019     		  PUBL CHARITY CONTRIBUTION 90
    US HOLOCAUST MUSEUM
    PO BOX 7023
    ALBERTA LEA,MN56007     		  PUBL CHARITY CONTRIBUTION 180
    WESTCHESTER REFORM TEMPLE
    255 MAMARONECK RD
    SCARSDALE,NY10583     		  PUBL CHARITY CONTRIBUTION 180
    WOUNDED WARRIOR PROJECT
    PO BOX 758517
    TOPEKA,KS66675     		  PUBL CHARITY CONTRIBUTION 90
    PAWS - PET ANIMAL WELFARE SOCIETY INC
    504 MAIN AVE
    NORWALK,CT06851     		  PUBL CHARITY CONTRIBUTION 54
    CLEAN POWER NOW
    PO BOX 2717 569 MAIN STREET
    HYANNIS,MA02601     		  PUBL CHARITY CONTRIBUTION 50
    JEWISH FAMILY SERVICES OF CT
    2370 PARK AVENUE
    BRIDGEPORT,CT06604     		  PUBL CHARITY CONTRIBUTION 360
    ARNOLD & ARLENE SHANBROM FUND
    75 RIMMON ROAD
    WOODBRIDGE,CT06625     		  PUBL CHARITY CONTRIBUTION 720
    BALLENISLES CHARITIES FOUNDATION
    100 BALLENISLES CIRCLE
    PALM BEACH GARDENS,FL33418     		  PUBL CHARITY CONTRIBUTION 200
    Total .................................bullet 3a 12,752
    bApproved for future payment
    Total .................................bullet 3b 0
    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.)
    1Program service revenue: (a)
    Business code     		(b)
    Amount     		(c)
    Exclusion code     		(d)
    Amount
    a
    b
    c
    d
    e
    f
    gFees and contracts from government agencies          
    2 Membership dues and assessments....          
    3
    Interest on savings and temporary cash investments ...........     		        2,316
    4 Dividends and interest from securities....         2,098
    5 Net rental income or (loss) from real estate:
    aDebt-financed property......          
    bNot 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 ............     		        15,499
    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).. 0 0 19,913
    13Total. Add line 12, columns (b), (d), and (e)..................
    1319,913
    (See worksheet in line 13 instructions to verify calculations.)
    Part XVI-B
    Relationship of Activities to the Accomplishment of Exempt Purposes
    Line No.
    DownArrow     		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 INVESTMENT INCOME
    4 INVESTMENT INCOME
    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?...........
    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.
    Bullet Bullet
    May the IRS discuss this return
    with the preparer shown below
    (see instr.)?
    Signature of officer or trustee Date Title
    Paid Preparer Use Only Print/Type preparer's name Preparer's Signature Date PTIN
    Firm's name SmallBullet
    		 Firm's EIN SmallBullet
    Firm's address SmallBullet


    		 Phone no.
    Form 990-PF (2015)
    Additional Data


    Software ID:  
    Software Version:  


    Form 990PF - Special Condition Description:
    Special Condition Description

    TY 2015 AccountingFeesSchedule
    Name:
    DAVID B JACOBSON FOUNDATION
    EIN:
    59-2664074
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    TAX & RELATED 5,550 0 0 5,550

    TY 2015 GeneralExplanationAttachment
    Name:
    DAVID B JACOBSON FOUNDATION
    EIN:
    59-2664074
    Identifier Return Reference Explanation
      ADDITIONAL NOTE 1: REVIEW OF PRIOR RECORDS DUE TO INQUIRY BY STATE OF CONNECTICUT IN SEPTEMBER 2016, FOUNDATION MANAGER AND OUTSIDE ACCOUNTANTS UNDERTOOK REVIEW OF ACCOUNTING AND FINANCIAL INFORMATION FOR TAX YEARS 2010-2015, AND THRU 10-31-2016.DETERMINATION WAS MADE THAT A SINGLE BILLING ERROR OCCURRED IN TAX YEAR 2015. INDEPENDENT CONTRACTOR ISSUED CREDIT AND WILL MAKE CASH REFUND BY END OF TAX YEAR 2016.FOUNDATION HAS ISSUED OR WILL ISSUE AMENDED FORM 990-PF RETURNS FOR THE TAX YEARS 2012,2013,2014,AND AS REQUIRED, 2015 WITH COPIES TO THE STATE OF CONNECTICUT. FOUNDATION WILL NOT ISSUE AMENDED FORM 990-PF RETURNS OR NY CHAR500 FOR TAX YEARS 2010 OR 2011.
      ADDITIONAL NOTE 2: NO ACCESS TO BANK ACCOUNTS DUE TO CONTACT FROM TRUSTEE ANATOLE, WELLS FARGO ADVISORS HAS PREVENTED ACCESS TO FUND. FOUNDATION HAS BEEN UNABLE TO MAKE DONATIONS SINCE MAY 2016. FOUNDATION MANAGER CANNOT PREDICT A FUTURE DATE WHEN WELLS FARGO WILL REVERSE PREVIOUS ACTION, ENABLING RESTORATION OF NORMAL OPERATIONS.DUE TO INABILITY TO ACCESS FOUNDATION'S FUNDS, REFUNDS FROM INDEPENDENT CONTRACTOR WILL BE REDUCED BY IN-KIND PAYMENTS MADE FOR REIMBURSED AND PROFESSIONAL EXPENSES.
      ADDITIONAL NOTE 3: CHANGES IN GOVERNANCE DUE TO INQUIRY BY STATE OF CONNECTICUT, FOUNDATION MANAGER HAS DETERMINED NEED TO ENGAGE QUALIFIED LEGAL COUNSEL TO ADVISE AND DRAFT A CONFLICT OF INTEREST POLICY STATEMENT COMPLIANT WITH IRS FORM 1023.DUE TO PASSING OF GRANTOR AND CONDUCT OF TRUSTEE ANATOLE, FOUNDTAION MANAGER HAS DETERMINED NEED TO ENGAGE QUALIFIED LEGAL COUNSEL TO ADVISE ON FUTURE ADMINISTRATION OF ORGANIZATION.DUE TO INQUIRY BY STATE OF CONNECTICUT, FOUNDATION MANAGER WILL PROVIDE TO ALL TRUSTEES COPIES OF IRS "PUBLICATION 1771" & "PUBLICATION 526", GRANT THORTON "TAX GUIDE FOR PRIVATE FOUNDATIONS", COUNSEL ON FOUNDATION "FIVE PERCENT MINIMUM PAYOUT REQUIREMENTS AND "GRANTMAKING COMPLIANCE & BEST PRACTICES". OTHER DOCUMENTS WILL BE FORWARDED AS SOON AS PRACTICABLE.
      ADDITIONAL NOTE 4:POTENTIAL LIABILITY DUE TO INQUIRY BY STATE OF CONNECTICUT, DETERMINATION HAS BEEN MADE THAT DONATIONS MADE PERSONALLY BY TRUSTEE ANATOLE LACK THE CONTEMPORANEOUS WRITTEN ACKNOWLEDGEMENTS REQUIRED PER IRS SECTION 170(F)(8);MAY VIOLATE IRS REGULATIONS ASSOCIATED WITH THE RECEIPT OF SERVICES OR GOODS IN EXCHANGE FOR A DONATION; AND INCLUDE DONATIONS MADE TO A DONOR ADVISED FUND. SUBSTANTIATION DEFINED IN PUBLICATION 1771 HAS BEEN REQUESTED FROM TRUSTEE ANATOLE. LEGAL COUNSEL WILL ADVISE FOUNDATION AS TO ANY REMEDIES, IF APPLICABLE.
      ADDITIONAL NOTE 5:TAX EXEMPT STATUS FOUNDATION MANAGER AND OUTSIDE COUNSEL WERE SUCCESSFUL IN OBTAINING REINSTATEMENT OF TAX EXEMPT STATUS, EFFECTIVE MARCH 12,2015, AND RETROACTIVE TO THE DATE OF SUSPENSION.
      EXPLANATIONS RELATED TO SPECIFIC PARTS OR LINES OF FORM 990-PF FORM 990-PF, PART II, LINE 3:DUE TO PASSING OF GRANTOR DAVID BURTON JACOBSON AND FATHER OF EACH TRUSTEE,INDEPENDENT CONTRACTOR HAS PROVIDED A ONE-TIME PROFESSIONAL COURTESY ADJUSTMENT IN HONOR OF GRANTOR.INDEPENDENT CONTRACTOR ISSUED CREDITS TO 2012-2015 CHARGES AND WILL MAKE A CASH REFUND BY END OF TAX YEAR 2016.FORM 990-PF, PART II, LINE 10A:DUE TO INQUIRY BY STATE OF CONNECTICUT,FOUNDATION OBTAINED EVIDENCE OF PREVIOUSLY LOST INVESTMENT.FORM 990-PF, PART II, LINE 15:DUE TO INQUIRY BY STATE OF CONNECTICUT,FOUNDATION LOCATED MISPLACED APPRAISALS PROVIDING EVIDENCE OF ARTWORK PURCHASED BY GRANTOR. APPRAISER REPORTS IT REQUIRES AT LEAST EIGHT ADDITIONAL WEEKS.FORM 990-PF, PART VII-A, LINE 3:DUE TO INQUIRY BY STTE OF CONNECTICUT,FOUNDATION MANAGER HAS ENGAGED COUNSEL TO ASSIST IN THE DEVELOPMENT OF AN APPROPRIATE CONFLICT OF INTEREST POLICY. REFERENCE TO IRS FORM 1023,SAMPLE CONFLICT OF INTEREST POLICY,IS MADE HEREIN,BUT NOT ATTACHED.FORM 990-PF, PART VII-A, LINE 8A:DUE TO INQUIRY BY STATE OF CONNECTICUT, COPIES OF PREVIOUSLY FILED RETURNS AND AMENDED RETURNS TO BE FILED WITH THE STATE OF CONNECTICUT.FORM 990-PF, PART VII-A, LINE 13:DUE TO INQUIRY BY STATE OF CONNECTICUT,TYPOGRAPHICAL CORRECTION HAS BEEN MADE. RETURNS HAVE ALWASY BEEN AVAILABLE FOR REVIEW,UPON WRITTEN REQUEST.FORM 990-PF, PART VII-B, LINE 1A(3):FACILITIES ARE PROVIDED TO FOUNDATION BY CORPORATION OWENED BY FOUNDATION MANAGER.SERVICES ARE PROVIDED TO FOUNDATION BY CORPORATION OWNED BY FOUNDATION MANAGER.NO GOODS ARE PROVIDED TO FOUNDATION BY CORPORATION OWNED BY FOUNDATION MANAGER.FORM 990-PF, PART VII-B, LINE 1A(4):FOUNDATION DOES NOT MAKE PAYMENTS TO CORPORATION OWNED BY FOUNDATION MANAGER FOR USE OF FACILITIES.FOUNDATION DOES NOT REGULARLY MAKE PAYMENT TO CORPORATION OWNED BY FOUNDATION MANAGER FOR REIMBURSABLE EXPENSES.FOUNDATION DOES NOT REGULARLY MAKE PAYMENT TO CORPORATION OWNED BY FOUNDATION MANAGER FOR SERVICES.FORM 990-PF, PART VII-B, LINE 1B:NONE OF THE ACTS FAILED TO QUALIFY UNDER THE EXCEPTIONS DESCRIBED IN REGULATIONS SECTION 53.4941(D)-3.FORM 990-PF, PART VIII, LINE 1A:DUE TO INQUIRY BY STATE OF CONNECTICUT,FOUNDATION MANAGER HAS REVISED ADDRESS OF ONE DIRECTOR.FORM 990-PF, PART VIII, LINE 1B:DUE TO INQUIRY BY STATE OF CONNECTICUT,FOUNDATION MANAGER HAS CORRECTED ESTIMATES OF AVERAGE HOURS WORKED PER WEEK.

    TY 2015 InvestmentsCorpStockSchedule
    Name:
    DAVID B JACOBSON FOUNDATION
    EIN:
    59-2664074
    Name of Stock End of Year Book Value End of Year Fair Market Value
    WELLS FARGO SECURITIES 54,592 54,592
    PUTNAM MASTER FUNDS 2,664 2,664
    WELLS FARGO SECURITIES MF 9,076 9,076
    RS INVESTMENTS #372401 64,117 64,117

    TY 2015 InvestmentsGovtObligationsSch
    Name:
    DAVID B JACOBSON FOUNDATION
    EIN:
    59-2664074
    US Government Securities - End of Year Book Value:

    44,290
    US Government Securities - End of Year Fair Market Value:

    44,290
    State & Local Government Securities - End of Year Book Value:


    0
    State & Local Government Securities - End of Year Fair Market Value:


    0


    TY 2015 LegalFeesSchedule
    Name:
    DAVID B JACOBSON FOUNDATION
    EIN:
    59-2664074
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    LEGAL & RELATED 8,474 0 0 8,474


    TY 2015 OtherAssetsSchedule
    Name:
    DAVID B JACOBSON FOUNDATION
    EIN:
    59-2664074
    Description Beginning of Year - Book Value End of Year - Book Value End of Year - Fair Market Value
    ARTWORK 10,580 10,580 10,580


    TY 2015 OtherDecreasesSchedule
    Name:
    DAVID B JACOBSON FOUNDATION
    EIN:
    59-2664074
    Description Amount
    UNREALIZED LOSS 13,641


    TY 2015 OtherExpensesSchedule
    Name:
    DAVID B JACOBSON FOUNDATION
    EIN:
    59-2664074
    Description Revenue and Expenses per Books Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    POSTAGE AND DELIVERY 23 0 0 0
    SECRETARIAL AND OFFICE SERVICES 3,733 0 0 0
    SUPPLIES AND MATERIALS 1,125 0 0 0
    BANKING & RELATED CHARGES 240 0 0 0


    TY 2015 OtherProfessionalFeesSchedule
    Name:
    DAVID B JACOBSON FOUNDATION
    EIN:
    59-2664074
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    BOOKKEEPING 4,450 0 0 0
    FINANCIAL & RELATED 12,430 3,230 0 12,430