G Check all that apply: Initial returnInitial return of a former public charity
Final returnAmended return
Address changeName change 2. Foreign organizations meeting the 85%
test, check here and attach computation ...

H Check type of organization: Section 501(c)(3) exempt private foundation
Section 4947(a)(1) nonexempt charitable trustOther taxable private foundation

I Fair market value of all assets at end
of year (from Part II, col. (c),
line 16)$877,853J Accounting method: Cash Accrual
Other (specify)  
(Part I, column (d) must be on cash basis.)

Was the foundation liable for the section 4942 tax on the distributable amount of any year in the base period? Yes No

1 Enter the appropriate amount in each column for each year; see instructions before making any entries.

15  

1 List all officers, directors, trustees, foundation managers and their compensation (see instructions).

2 Compensation of five highest-paid employees (other than those included on line 1—see instructions). If none, enter “NONE."

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: