Form990-PF

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
CLAREMONT S JACKMAN FOUNDATION 752006401
 
Number and street (or P.O. box number if mail is not delivered to street address)JOHNSON BANK 525 JUNCTION ROAD ST
  Room/suite
City or town, state or province, country, and ZIP or foreign postal code
MADISON, WI53717
A Employer identification number

39-1733837
B Telephone number (see instructions)

(608) 203-3953
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$2,151,383J 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      
4 Dividends and interest from securities... 54,261 54,442  
5a Gross rents............      
b Net rental income or (loss)  
6a Net gain or (loss) from sale of assets not on line 10 146,486
b Gross sales price for all assets on line 6a 1,144,502
7 Capital gain net income (from Part IV, line 2)... 146,486
8 Net short-term capital gain......... 0
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)....... Click to see attachment 2,570 974  
12 Total. Add lines 1 through 11........ 203,317 201,902  
Operating and Administrative Expenses 13 Compensation of officers, directors, trustees, etc. 21,003 21,003    
14 Other employee salaries and wages......   0 0 0
15 Pension plans, employee benefits.......   0 0  
16a Legal fees (attach schedule).........       0
b Accounting fees (attach schedule)....... Click to see attachment 750 0 0 750
c Other professional fees (attach schedule)....       0
17 Interest...............       0
18 Taxes (attach schedule) (see instructions)... Click to see attachment 542 542   0
19 Depreciation (attach schedule) and depletion... 0 0  
20 Occupancy..............        
21 Travel, conferences, and meetings.......   0 0  
22 Printing and publications..........   0 0  
23 Other expenses (attach schedule).......        
24 Total operating and administrative expenses.
Add lines 13 through 23.......... 22,295 21,545 0 750
25 Contributions, gifts, grants paid....... 116,874 116,874
26 Total expenses and disbursements. Add lines 24 and 25 139,169 21,545 0 117,624
27 Subtract line 26 from line 12:
a Excess of revenue over expenses and disbursements 64,148
b Net investment income (if negative, enter -0-) 180,357
c Adjusted net income (if negative, enter -0-)... 0
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.............      
2 Savings and temporary cash investments......... 134,906 39,151 39,151
3 Accounts receivable bullet  
Less: allowance for doubtful accounts bullet     0 0
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) bullet  
Less: allowance for doubtful accounts bullet0      
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 bullet  
Less: accumulated depreciation (attach schedule) bullet        
12 Investments—mortgage loans.............      
13 Investments—other (attach schedule).......... 1,979,555 Click to see attachment2,139,128 2,112,232
14 Land, buildings, and equipment: basis bullet  
Less: accumulated depreciation (attach schedule) bullet        
15 Other assets (describe bullet)      
16 Total assets (to be completed by all filers—see the
instructions. Also, see page 1, item I) 2,114,461 2,178,279 2,151,383
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
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........ 2,114,461 2,178,279
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)..... 2,114,461 2,178,279
31 Total liabilities and net assets/fund balances (see instructions). 2,114,461 2,178,279
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
2,114,461
2
Enter amount from Part I, line 27a .....................
2
64,148
3
Other increases not included in line 2 (itemize) bulletClick to see attachment
3
3
4
Add lines 1, 2, and 3 ..........................
4
2,178,612
5
Decreases not included in line 2 (itemize) bulletClick to see attachment
5
333
6
Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 30 .
6
2,178,279
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 4640.413 ALLIANZGI NFJ INTL VAL-INST     2015-03-25
b 129.524 ALLIANZGI NFJ INTL VAL-INST     2015-03-25
c 37.35717 AMER CENT DIVERSIFIED BOND INS   2015-01-30 2015-03-25
d 8772.81583 AMER CENT DIVERSIFIED BOND INS     2015-03-25
e 3412.132 BBH CORE SELECT FUND-N     2015-03-25
22.24 BUFFALO GROWTH FUND   2014-12-18 2015-03-25
158.234 BUFFALO GROWTH FUND   2013-12-18 2015-03-25
152.38186 COLUMBIA DIVIDEND OPPORTUNITY Z     2015-03-25
221.55014 COLUMBIA DIVIDEND OPPORTUNITY Z     2015-03-25
402.252 MFS INTL VALUE-I   2013-12-19 2015-03-25
654.525 MFS VALUE FUND-I   2013-12-19 2015-03-25
418.59046 METROPOLITAN WEST T/R BOND-I     2015-03-25
4913.692 METROPOLITAN WEST T/R BOND-I     2015-03-25
21.61954 METROPOLITAN WEST T/R BOND-I   2015-01-30 2015-03-25
10636.364 PIMCO REAL RETURN FUND-INST   2013-12-19 2015-03-25
14801.444 PIMCO COMMODITY RR STRAT INS   2013-12-19 2015-03-25
9152.872 RIDGEWORTH SEIX TOTAL RETURN BOND I   2013-12-19 2015-03-25
405.739 STERLING CAP EQUITY INC-INS     2015-03-25
8304.758 STERLING CAP EQUITY INC-INS     2015-03-25
3409.091 TEMPLETON GLOBAL BOND FUND-AD   2013-12-19 2015-03-25
474.24 VANGUARD S/C VALUE INDEX-ADM   2013-12-19 2015-03-25
241.859 VOYA LARGE CAP GROWTH-I   2014-12-17 2015-03-25
13543.006 VOYA LARGE CAP GROWTH-I     2015-03-25
CAPITAL GAIN DIVIDENDS 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 101,439   96,966 4,473
b 2,831   3,018 -187
c 411   415 -4
d 96,589   95,025 1,564
e 76,500   61,017 15,483
763   739 24
5,429   5,388 41
1,426   1,532 -106
2,074   2,219 -145
15,000   13,817 1,183
23,000   21,351 1,649
4,613   4,540 73
54,149   52,338 1,811
238   240 -2
118,276   116,667 1,609
64,386   82,000 -17,614
98,393   94,000 4,393
7,616   7,553 63
155,880   120,865 35,015
42,000   44,352 -2,352
22,000   19,596 2,404
3,703   3,490 213
207,343   153,075 54,268
      42,518
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       4,473
b       -187
c       -4
d       1,564
e       15,483
      24
      41
      -106
      -145
      1,183
      1,649
      73
      1,811
      -2
      1,609
      -17,614
      4,393
      63
      35,015
      -2,352
      2,404
      213
      54,268
       
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 2 146,486
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  
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 109,706 2,385,750 0.045984
2013 107,028 2,307,567 0.046381
2012 106,858 2,181,351 0.048987
2011 100,939 2,163,670 0.046652
2010 95,754 2,108,905 0.045405
2
Total of line 1, column (d) .....................
20.233409
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
0.046682
4
Enter the net value of noncharitable-use assets for 2015 from Part X, line 5.....
4
2,283,690
5
Multiply line 4 by line 3......................
5
106,607
6
Enter 1% of net investment income (1% of Part I, line 27b)...........
6
1,804
7
Add lines 5 and 6........................
7
108,411
8
Enter qualifying distributions from Part XII, line 4.............
8
117,624
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 1,804
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 1,804
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 1,804
6 Credits/Payments:
a 2015 estimated tax payments and 2014 overpayment credited to 2015 6a 1,664
b Exempt foreign organizations—tax withheld at source...... 6b
c Tax paid with application for extension of time to file (Form 8868)... 6c 0
d Backup withholding erroneously withheld ........... 6d  
7 Total credits and payments. Add lines 6a through 6d.............. 7 1,664
8 Enter any penalty for underpayment of estimated tax. if Form 2220 is attached. 8 0
9 Tax due. If the total of lines 5 and 8 is more than line 7, enter amount owed.......Bullet 9 140
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 taxBullet0 RefundedBullet 11 0
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$   (2) On foundation managers.bullet$  
e
Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed
on foundation managers.bullet$  
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)
    bulletWI
    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 addressbullet  
    14
    The books are in care ofbulletJOHNSON BANK - TRUST DEPT Telephone no.bullet (608) 743-1594

    Located atbullet1 S MAIN STJANESVILLEWI ZIP+4bullet53545
    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
    JOHNSON BANK - TRUST DEPT TRUSTEE
    2     		21,003    
    1 S MAIN ST
    JANESVILLE,WI53545
    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.........................bullet  
    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
    2,205,452
    b
    Average of monthly cash balances.......................
    1b
    113,015
    c
    Fair market value of all other assets (see instructions)................
    1c
    0
    d
    Total (add lines 1a, b, and c).........................
    1d
    2,318,467
    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
    2,318,467
    4
    Cash deemed held for charitable activities. Enter 1 1/2% of line 3 (for greater amount, see
    instructions) .............................
    4
    34,777
    5
    Net value of noncharitable-use assets. Subtract line 4 from line 3. Enter here and on Part V, line 4
    5
    2,283,690
    6
    Minimum investment return. Enter 5% of line 5..................
    6
    114,185
    Part XI
    Distributable Amount bullet
    1
    Minimum investment return from Part X, line 6....................
    1
    114,185
    2a
    Tax on investment income for 2015 from Part VI, line 5......
    2a
    1,804
    b
    Income tax for 2015. (This does not include the tax from Part VI.)...
    2b
     
    c
    Add lines 2a and 2b............................
    2c
    1,804
    3
    Distributable amount before adjustments. Subtract line 2c from line 1............
    3
    112,381
    4
    Recoveries of amounts treated as qualifying distributions................
    4
    0
    5
    Add lines 3 and 4............................
    5
    112,381
    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
    112,381
    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
    117,624
    b
    Program-related investments—total from Part IX-B..................
    1b
    0
    2
    Amounts paid to acquire assets used (or held for use) directly in carrying out charitable, etc.,
    purposes...............................
    2
    0
    3
    Amounts set aside for specific charitable projects that satisfy the:
    a
    Suitability test (prior IRS approval required)....................
    3a
    0
    b
    Cash distribution test (attach the required schedule) .................
    3b
    0
    4
    Qualifying distributions. Add lines 1a through 3b. Enter here and on Part V, line 8, and Part XIII, line 4
    4
    117,624
    5
    Foundations that qualify under section 4940(e) for the reduced rate of tax on net investment
    income. Enter 1% of Part I, line 27b (see instructions).................
    5
    1,804
    6
    Adjusted qualifying distributions. Subtract line 5 from line 4..............
    6
    115,820
    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 7 112,381
    2 Undistributed income, if any, as of the end of 2015:
    a Enter amount for 2014 only....... 116,874
    b Total for prior years:20, 20, 20 0
    3 Excess distributions carryover, if any, to 2015:
    a From 2010...... 0
    b From 2011...... 0
    c From 2012...... 0
    d From 2013...... 0
    e From 2014...... 0
    fTotal of lines 3a through e........ 0
    4Qualifying distributions for 2015 from Part
    XII, line 4: bullet$ 117,624
    a Applied to 2014, but not more than line 2a 116,874
    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..... 750
    e Remaining amount distributed out of corpus 0
    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 0
    b Prior years’ undistributed income. Subtract
    line 4b from line 2b ..........     		0
    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 ...........     		0
    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 ..........     		111,631
    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 ......     		0
    10 Analysis of line 9:
    a Excess from 2011.... 0
    b Excess from 2012.... 0
    c Excess from 2013.... 0
    d Excess from 2014.... 0
    e Excess from 2015.... 0
    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).)
    NONE
    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.
    NONE
    2Information Regarding Contribution, Grant, Gift, Loan, Scholarship, etc., Programs:
    Check here bullet
    aThe name, address, and telephone number or e-mail address of the person to whom applications should be addressed:
    JOHNSON BANK - TRUST DEPT
    1 S MAIN ST
    JANESVILLE,WI53545
    (608) 743-1594
    bThe form in which applications should be submitted and information and materials they should include:
    NONE
    cAny submission deadlines:
    NONE
    dAny 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)
    aPaid during the year
    Madison 32 Masonic Learning Center
    301 WISCONSIN AVENUE
    Madison,WI53703     		NONE PC PROGRAM SUPPORT 5,000
    Braille Library & Transcribing
    Service
    517 N SEGOE RD 200
    Madison,WI53705     		NONE PC PROGRAM SUPPORT 1,000
    Mercy Foundation
    1000 MINERAL PT AVENUE
    Janesville,WI53545     		NONE PC PROGRAM SUPPORT 1,750
    Young Men's Christian Association
    221 DODGE STREET
    Janesville,WI53545     		NONE SOUNK PROGRAM SUPPORT 4,500
    Start Foundation
    2532 FOSTER AVENUE
    Janesville,WI53545     		NONE PC PROGRAM SUPPORT 2,000
    Rock Communities Youth Network Inc
    205 N MAIN STREET
    Janesville,WI53545     		NONE PC PROGRAM SUPPORT 1,500
    Salvation Army
    PO BOX 8867
    Madison,WI53708     		NONE PC PROGRAM SUPPORT 6,500
    Girl Scouts of Wisconsin
    22710 SKI LANE
    Madison,WI53713     		NONE PC PROGRAM SUPPORT 3,500
    YWCA of North Rock County
    1735 S WASHINGTON STREET
    Janesville,WI53546     		NONE PC PROGRAM SUPPORT 4,500
    Wisconsin Masonic Home Inc
    36275 SUNSET DRVIE
    Dousman,WI53118     		NONE PC PROGRAM SUPPORT 1,000
    Easter Seals Wisconsin Inc
    101 NOB HILL ROAD
    Madison,WI53713     		NONE PC PROGRAM SUPPORT 1,000
    Rock County Historical Society
    426 N JACKSON STREET
    Janesville,WI53545     		NONE PC PROGRAM SUPPORT 1,500
    Wisconsin Council of the Blind Inc
    421 WILLIAMSON STREET
    Madison,WI53703     		NONE PC PROGRAM SUPPORT 750
    Cedar Crest
    1705 S RIVER ROAD
    Janesville,WI53546     		NONE PC PROGRAM SUPPORT 2,500
    Wisconsin Badger Camp Inc
    PO BOX 240
    Platteville,WI53818     		NONE PC PROGRAM SUPPORT 1,250
    Folklore Village Farm Inc
    3210 CTY HWY BB
    Dodgeville,WI53533     		NONE PC PROGRAM SUPPORT 1,250
    Wisconsin Special Olympics Inc
    2310 CROSS ROADS DRIVE STE 1000
    Madison,WI53718     		NONE PC PROGRAM SUPPORT 1,250
    Agrace Hospice Inc
    5395 E CHERLY PARKWAY
    Madison,WI53711     		NONE PC PROGRAM SUPPORT 2,500
    UW-Rock County Foundation Inc
    2909 KELLOGG AVENUE
    Janesville,WI53546     		NONE PC PROGRAM SUPPORT 1,750
    MADISON MASONIC CENTER FD
    301 WISCONSIN AVE
    MADISON,WI53702     		NONE PC PROGRAM SUPPORT 40,874
    Friends of Norwegian Culture Inc
    PO BOX 314
    Stoughton,WI53589     		NONE PC PROGRAM SUPPORT 1,000
    Friends of the Arboretum Inc
    1207 SEMINOLE HWY
    Madison,WI53711     		NONE PC PROGRAM SUPPORT 1,500
    Retired Senior Volunteer Program of
    Rock County Inc
    2433 S RIVERSIE DRIVE
    Beloit,WI53511     		NONE PC PROGRAM SUPPORT 2,500
    Boys & Girls Club of Janesville
    200 W COURT ST
    Janesvile,WI53545     		NONE PC PROGRAM SUPPORT 3,500
    The Fdn of WI Auto & Truck DLRS
    PO BOX 5345
    Madison,WI53705     		NONE PC PROGRAM SUPPORT 1,500
    Rotary Gardens Inc
    1455 PALMER DRIVE
    Janesville,WI53546     		NONE PC PROGRAM SUPPORT 1,750
    Healthnet of Rock County Inc
    23 W MILWAUKEE ST
    Janesville,WI53545     		NONE PC PROGRAM SUPPORT 3,750
    Wisconsin Masonic Soccer Fdn
    36275 SUNSET DRIVE
    Dousman,WI53118     		NONE PC SUPPORT OPERATIONS 2,250
    Goshen Children's Home Inc
    2911 CARROUSEL LANE
    Janesville,WI53545     		NONE PC PROGRAM SUPPORT 1,000
    Wisconsin Academic Decathlon Fd
    524 DAISY CT
    Verona,WI53593     		NONE PC PROGRAM SUPPORT 1,250
    Janesville Performing Arts Center
    Inc
    PO BOX 8104
    Janesville,WI53545     		NONE PC PROGRAM SUPPORT 1,750
    WISCONSIN CENTER FOR THE BLIND
    AND VISUALLY IMPAIRED
    1700 W STATE STREET
    Janesville,WI53545     		NONE PC PROGRAM SUPPORT 1,000
    Wisconsin Masonic Foundation
    36275 SUNSET DRIVE
    Dousman,WI53118     		NONE PC PROGRAM SUPPORT 3,500
    Job's Daughters Memorial FD of WI
    5015 HARRISON ROAD
    Kenosha,WI53142     		NONE PC PROGRAM SUPPORT 1,250
    Boy Souts of America 620 Glaciers
    Edge Council Inc
    2300 E RACINE STREET
    Janesville,WI53545     		NONE PC PROGRAM SUPPORT 3,500
    Total .................................bullet 3a 116,874
    bApproved for future payment
    Total .................................bullet 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.)
    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 ...........     		         
    4 Dividends and interest from securities....     14 54,261  
    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 ............     		    18 146,486  
    9 Net income or (loss) from special events:          
    10 Gross profit or (loss) from sales of inventory..          
    11 Other revenue:
    aEXCISE TAX REFUND     		    1 1,596  
    bMISC INCOME     1 974  
    c
    d
    e
    12 Subtotal. Add columns (b), (d), and (e)..   203,317  
    13Total. Add line 12, columns (b), (d), and (e)..................
    13203,317
    (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.)
    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:
    CLAREMONT S JACKMAN FOUNDATION 752006401
    EIN:
    39-1733837
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    TAX PREPARATION FEE (ALLOCABLE 750     750

    TY 2015 InvestmentsOtherSchedule2
    Name:
    CLAREMONT S JACKMAN FOUNDATION 752006401
    EIN:
    39-1733837
    Category/ Item Listed at Cost or FMV Book Value End of Year Fair Market Value
    DODGE & COX INCOME FUND AT COST 119,000 113,451
    METROPOLITAN WEST T/R BOND AT COST 123,121 140,320
    AMER CENT DIVERSIFIED BOND INS AT COST 142,727 140,215
    BAIRD CORE PLUS BOND FUND-IS AT COST 47,500 45,730
    TEMPLETON GLOBAL BOND AT COST 49,648 44,000
    JPMORGAN CORE BOND FUND-SEL AT COST 143,000 138,791
    NUVEEN HIGH INCOME BOND FD-I AT COST 119,000 98,218
    MFS CORPORATE BOND I AT COST 48,000 45,395
    OPPENHEIMER SR FLOAT RATE-I AT COST 48,000 44,753
    GOLDMAN SACHS GLOBAL INCOME FU AT COST 48,000 45,026
    BBH CORE SELECT FUND-N AT COST 119,134 138,310
    COLUMBIA DIVIDENDS OPPOR-R4 AT COST 146,912 161,043
    CREDIT SUISE COMM RET ST-CO AT COST 71,500 55,886
    LAUDUS TRUST US LARGE CAP AT COST 71,500 69,043
    MFS VALUE FUND-I AT COST 130,649 132,011
    TOUCHSTONE SANDS CAP INC GRW AT COST 71,500 67,787
    VANGUARD S/C VALUE- AD AT COST 167,000 158,919
    VANGUARYD S/C VALUE - INDEX-AD AT COST 62,404 64,126
    VANGUARD SELECTED VALUE F IV AT COST 71,500 64,580
    ABERDEEN EMERG MKTS INST-INS AT COST 47,500 38,626
    ARTISAN INTL VALUE FUND-ADV AT COST 76,850 106,635
    MFS INTL VALUE- I AT COST 92,183 95,859
    OPPENHEIMER DEVELOOPING MTK-I AT COST 75,000 61,371
    SCHWAB LAUDUS INTL AT COST 47,500 42,137

    TY 2015 OtherDecreasesSchedule
    Name:
    CLAREMONT S JACKMAN FOUNDATION 752006401
    EIN:
    39-1733837
    Description Amount
    ADJUST FOR RETURN OF CAPITAL 333


    TY 2015 OtherIncomeSchedule2
    Name:
    CLAREMONT S JACKMAN FOUNDATION 752006401
    EIN:
    39-1733837
    Description Revenue And Expenses Per Books Net Investment Income Adjusted Net Income
    EXCISE TAX REFUND 1,596 0  
    MISC INCOME 974 974  


    TY 2015 OtherIncreasesSchedule
    Name:
    CLAREMONT S JACKMAN FOUNDATION 752006401
    EIN:
    39-1733837
    Description Amount
    ROUNDING WITH SALES 3


    TY 2015 TaxesSchedule
    Name:
    CLAREMONT S JACKMAN FOUNDATION 752006401
    EIN:
    39-1733837
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    FOREIGN TAXES ON QUALIFIED FOR 480 480   0
    FOREIGN TAXES ON NONQUALIFIED 62 62   0