Form990-PF
Click to see list of attachments

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 12-01-2015 , and ending 11-30-2016
Name of foundation
The Sam S Bloom Foundation
 
Number and street (or P.O. box number if mail is not delivered to street address)P O Box 2413
  Room/suite
City or town, state or province, country, and ZIP or foreign postal code
Littleton, CO80161
A Employer identification number

84-0929690
B Telephone number (see instructions)

(303) 771-2266
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$9,424,204J 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 19 19 19
4 Dividends and interest from securities... 162,389 162,389 162,389
5a Gross rents............      
b Net rental income or (loss)  
6a Net gain or (loss) from sale of assets not on line 10 229,453
b Gross sales price for all assets on line 6a 688,177
7 Capital gain net income (from Part IV, line 2)... 229,453
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........ 391,861 391,861 162,408
Operating and Administrative Expenses 13 Compensation of officers, directors, trustees, etc. 58,729 29,365 29,365 29,365
14 Other employee salaries and wages......        
15 Pension plans, employee benefits.......        
16a Legal fees (attach schedule).........        
b Accounting fees (attach schedule)....... Click to see attachment 2,460 2,460 2,460  
c Other professional fees (attach schedule).... Click to see attachment 45,760 45,760 45,760  
17 Interest...............        
18 Taxes (attach schedule) (see instructions)... Click to see attachment 5,000 5,000 5,000  
19 Depreciation (attach schedule) and depletion...      
20 Occupancy..............        
21 Travel, conferences, and meetings....... 1,042 521 521 521
22 Printing and publications.......... 495 248 248 248
23 Other expenses (attach schedule)....... Click to see list of attachments 6,604 3,302 3,302 3,302
24 Total operating and administrative expenses.
Add lines 13 through 23.......... 120,090 86,656 86,656 33,436
25 Contributions, gifts, grants paid....... 456,000 456,000
26 Total expenses and disbursements. Add lines 24 and 25 576,090 86,656 86,656 489,436
27 Subtract line 26 from line 12:
a Excess of revenue over expenses and disbursements -184,229
b Net investment income (if negative, enter -0-) 305,205
c Adjusted net income (if negative, enter -0-)... 75,752
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............. 20,817 17,781 17,782
2 Savings and temporary cash investments.........      
3 Accounts receivable bullet  
Less: allowance for doubtful accounts bullet        
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 bullet        
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)....... 7,829,320 7,648,127 9,406,422
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)      
16 Total assets (to be completed by all filers—see the
instructions. Also, see page 1, item I) 7,850,137 7,665,908 9,424,204
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........ 48,379 48,379
28 Paid-in or capital surplus, or land, bldg., and equipment fund    
29 Retained earnings, accumulated income, endowment, or other funds 7,801,758 7,617,529
30 Total net assets or fund balances (see instructions)..... 7,850,137 7,665,908
31 Total liabilities and net assets/fund balances (see instructions). 7,850,137 7,665,908
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
7,850,137
2
Enter amount from Part I, line 27a .....................
2
-184,229
3
Other increases not included in line 2 (itemize) bullet
3
 
4
Add lines 1, 2, and 3 ..........................
4
7,665,908
5
Decreases not included in line 2 (itemize) bullet
5
 
6
Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 30 .
6
7,665,908
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 2726.388 Loomis Sayles Intermediate Duration Fund P 2014-11-01 2016-01-04
b 3179.191 Loomis Sayles Intermediate Duration Fund P 2014-11-01 2016-04-04
c 1821.387 RidgeWorth Seix Floating Rate High Income Fund P 2014-11-01 2016-07-05
d 2008.032 Blackstone Alternative Multi-Strategy P 2014-11-01 2016-07-05
e 140.704 Vanguard 500 Index Fund P 2014-11-01 2016-10-11
1002.525 Vanguard 500 Index Fund P 2014-11-01 2016-11-08
5258.126 Loomis Sayles Intermediate Duration Fund P 2014-11-01 2016-11-08
4046.243 RidgeWorth Seix Floating Rate High Income Fund P 2014-11-01 2016-11-08
599.88 Vanguard Extended Market Fund P 2014-11-01 2016-11-08
2446.184 Blackstone Alternative Multi-Strategy P 2014-11-01 2016-11-08
2589.261 New Perspective Fund P 2014-11-01 2016-11-08
Capital Gain Dividends      
(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 28,000   28,432 -432
b 33,000   33,152 -152
c 15,500   16,473 -973
d 20,000   20,829 -829
e 28,000   17,244 10,756
198,500   122,866 75,634
55,000   54,834 166
35,000   36,559 -1,559
40,000   33,336 6,664
25,000   25,374 -374
95,000   69,625 25,375
      115,177
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       -432
b       -152
c       -973
d       -829
e       10,756
      75,634
      166
      -1,559
      6,664
      -374
      25,375
       
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 2 229,453
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 492,787 9,949,565 0.04953
2013 444,072 10,022,075 0.04431
2012 409,282 9,102,131 0.04497
2011 412,270 8,303,015 0.04965
2010 379,896 8,265,168 0.04596
2
Total of line 1, column (d) .....................
20.234419
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
0.046884
4
Enter the net value of noncharitable-use assets for 2015 from Part X, line 5.....
4
9,354,388
5
Multiply line 4 by line 3......................
5
438,571
6
Enter 1% of net investment income (1% of Part I, line 27b)...........
6
3,052
7
Add lines 5 and 6........................
7
441,623
8
Enter qualifying distributions from Part XII, line 4.............
8
489,436
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 3,052
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  
3 Add lines 1 and 2........................... 3 3,052
4 Subtitle A (income) tax (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-) 4  
5 Tax based on investment income. Subtract line 4 from line 3. If zero or less, enter -0- ..... 5 3,052
6 Credits/Payments:
a 2015 estimated tax payments and 2014 overpayment credited to 2015 6a 5,932
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 5,932
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  
10 Overpayment. If line 7 is more than the total of lines 5 and 8, enter the amount overpaid...Bullet 10 2,880
11 Enter the amount of line 10 to be: Credited to 2015 estimated taxBullet2,880 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$   (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
 
No
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)
    bulletCO
    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 addressbullethttp://www.guidestar.org/
    14
    The books are in care ofbulletC Crowley Telephone no.bullet (303) 771-2266

    Located atbulletP O Box 2413LittletonCO ZIP+4bullet801612413
    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
     
    No
    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
     
    No
    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
     
    No
    .........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
     
    No
    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
    Donald R Jacobs President
    1.00     		0    
    P O Box 2413
    Littleton,CO801612413
    L Jay Labe Vice President
    1.00     		0    
    P O Box 2413
    Littleton,CO801612413
    Edward N Kesselman Secretary
    1.00     		0    
    P O Box 2413
    Littleton,CO801612413
    A Marvin Strait Treasurer
    1.00     		0    
    P O Box 2413
    Littleton,CO801612413
    Cheryl M Caldwell Director
    1.00     		0    
    P O Box 2413
    Littleton,CO801612413
    Mary T Carraher Director
    1.00     		0    
    P O Box 2413
    Littleton,CO801612413
    Tonie L Gatch Director
    1.00     		0    
    P O Box 2413
    Littleton,CO801612413
    Debbie Strait Gonzales Director
    1.00     		0    
    P O Box 2413
    Littleton,CO801612413
    Roger A Hara Director
    1.00     		0    
    P O Box 2413
    Littleton,CO801612413
    Sasha Jacobs-Lowry Director
    1.00     		0    
    P O Box 2413
    Littleton,CO801612413
    Jon Ludwigson Director
    1.00     		0    
    P O Box 2413
    Littleton,CO801612413
    JoAnn Radetsky Director
    1.00     		0    
    P O Box 2413
    Littleton,CO801612413
    Nancy J Saltzman Director
    1.00     		0    
    P O Box 2413
    Littleton,CO801612413
    C Crowley Foundation Mgr.
    27.00     		58,729    
    P O Box 2413
    Littleton,CO801612413
    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  
    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.............bullet  
    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 None 0
    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
    9,478,506
    b
    Average of monthly cash balances.......................
    1b
    18,335
    c
    Fair market value of all other assets (see instructions)................
    1c
    0
    d
    Total (add lines 1a, b, and c).........................
    1d
    9,496,841
    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
     
    3
    Subtract line 2 from line 1d.........................
    3
    9,496,841
    4
    Cash deemed held for charitable activities. Enter 1 1/2% of line 3 (for greater amount, see
    instructions) .............................
    4
    142,453
    5
    Net value of noncharitable-use assets. Subtract line 4 from line 3. Enter here and on Part V, line 4
    5
    9,354,388
    6
    Minimum investment return. Enter 5% of line 5..................
    6
    467,719
    Part XI
    Distributable Amount bullet
    1
    Minimum investment return from Part X, line 6....................
    1
    467,719
    2a
    Tax on investment income for 2015 from Part VI, line 5......
    2a
    3,052
    b
    Income tax for 2015. (This does not include the tax from Part VI.)...
    2b
     
    c
    Add lines 2a and 2b............................
    2c
    3,052
    3
    Distributable amount before adjustments. Subtract line 2c from line 1............
    3
    464,667
    4
    Recoveries of amounts treated as qualifying distributions................
    4
     
    5
    Add lines 3 and 4............................
    5
    464,667
    6
    Deduction from distributable amount (see instructions).................
    6
     
    7
    Distributable amount as adjusted. Subtract line 6 from line 5. Enter here and on Part XIII, line 1 ...
    7
    464,667
    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
    489,436
    b
    Program-related investments—total from Part IX-B..................
    1b
     
    2
    Amounts paid to acquire assets used (or held for use) directly in carrying out charitable, etc.,
    purposes...............................
    2
     
    3
    Amounts set aside for specific charitable projects that satisfy the:
    a
    Suitability test (prior IRS approval required)....................
    3a
     
    b
    Cash distribution test (attach the required schedule) .................
    3b
     
    4
    Qualifying distributions. Add lines 1a through 3b. Enter here and on Part V, line 8, and Part XIII, line 4
    4
    489,436
    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
    3,052
    6
    Adjusted qualifying distributions. Subtract line 5 from line 4..............
    6
    486,384
    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 7 464,667
    2 Undistributed income, if any, as of the end of 2015:
    a Enter amount for 2014 only....... 454,445
    b Total for prior years:20, 20, 20  
    3 Excess distributions carryover, if any, to 2015:
    a From 2010......  
    b From 2011......  
    c From 2012......  
    d From 2013......  
    e From 2014......  
    fTotal of lines 3a through e........  
    4Qualifying distributions for 2015 from Part
    XII, line 4: bullet$ 489,436
    a Applied to 2014, but not more than line 2a 454,445
    b Applied to undistributed income of prior years
    (Election required—see instructions).....     		 
    c Treated as distributions out of corpus (Election
    required—see instructions)........     		0
    d Applied to 2015 distributable amount..... 34,991
    e Remaining amount distributed out of corpus  
    5 Excess distributions carryover applied to 2015.    
    (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  
    b Prior years’ undistributed income. Subtract
    line 4b from line 2b ..........     		 
    c Enter the amount of prior years’ undistributed
    income for which a notice of deficiency has
    been issued, or on which the section 4942(a)
    tax has been previously assessed......     		 
    d Subtract line 6c from line 6b. Taxable amount
    —see instructions ...........     		 
    e Undistributed income for 2014. Subtract line
    4a from line 2a. Taxable amount—see
    instructions .............     		 
    f Undistributed income for 2016. Subtract
    lines 4d and 5 from line 1. This amount must
    be distributed in 2015 ..........     		429,676
    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) .......     		 
    8Excess distributions carryover from 2010 not
    applied on line 5 or line 7 (see instructions) ...     		 
    9Excess distributions carryover to 2016.
    Subtract lines 7 and 8 from line 6a ......     		 
    10 Analysis of line 9:
    a Excess from 2011....  
    b Excess from 2012....  
    c Excess from 2013....  
    d Excess from 2014....  
    e Excess from 2015....  
    Form 990-PF (2015)
    Form 990-PF (2015)
    Page 10
    Part XIV
    Private Operating Foundations (see instructions and Part VII-A, question 9)
    1a If the foundation has received a ruling or determination letter that it is a private operating
    foundation, and the ruling is effective for 2015, enter the date of the ruling.......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 e-mail address of the person to whom applications should be addressed:
    Sam S Bloom Foundation
    P O Box 2413
    Littleton,CO801612413
    (303) 771-2266
    bThe form in which applications should be submitted and information and materials they should include:
    See attached guidelines and applications procedures.
    cAny submission deadlines:
    See attached guidelines and applications procedures.
    dAny restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other
    factors:
    See attached guidelines and applications procedures.
    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
    ABILITY CONNECTION COLORADO
    801 YOSEMITE ST
    DENVER,CO80230     		NONE PC EARLY CHILDHOOD EDUCATION 3,000
    AMERICAN JEWISH WORLD SERVICE
    45 W 36TH ST 11TH FLOOR
    NEW YORK,NY10018     		NONE PC SOCIAL WELFARE 500
    ARAPAHOE HOUSE
    8801 LIPAN ST
    THORNTON,CO80260     		NONE PC SOCIAL WELFARE 2,500
    BOULDER COMMUNITY HOUSING CORPORATI
    PO BOX 471
    BOULDER,CO80306     		NONE PC EDUCATION AND JOB SKILLS TRAINING PROGRAM 2,500
    BOULDER HOUSING PARTNERS
    4800 N BROADWAY
    BOULDER,CO80304     		NONE PC EDUCATION AND SUPPORT PROGRAMS 3,000
    BRIGHT BY THREE
    3605 MARTIN LUTHER KING BLVD
    DENVER,CO80205     		NONE PC PARENTING EDUCATION FOR LOW INCOME FAMILIES 9,000
    BRIGHT FUTURES FOR EARLY CHILDHOOD
    P O BOX 4216
    TELLURIDE,CO81435     		NONE PC PARENTING EDUCATION FOR LOW INCOME FAMILIES 4,500
    BRISTLECONE MONTESSORI SCHOOL
    272 N MAIN ST
    ALMA,CO80420     		NONE PC FINANCIAL AID PROGRAM 3,500
    CATHOLIC CHARITIES AND COMMUNITY SE
    4045 PECOS ST
    DENVER,CO80211     		NONE PC EARLY CHILDHOOD EDUCATION AND CHILD CARE PROGRAM FOR LOW INCOME FAMILIES 5,500
    CATHOLIC CHARITIES OF DIOCESE PUEBL
    429 W 10TH ST
    PUEBLO,CO81003     		NONE PC PARENTING EDUCATION 5,000
    COLORADO HOMELESS FAMILIES
    P O BOX 740130
    ARVADA,CO80006     		NONE PC HOUSING AND SUPPORT SERVICES FOR FAMILIES WORKING TOWARD SELF SUFFICIENCY 30,000
    COLORADO STATEWIDE PARENT COALITION
    7150 HOOKER STE B
    WESTMINSTER,CO80030     		NONE PC TRAINING AND RESOURCES FOR PARENTS AND TEACHERS 5,000
    COMMUNITY PARTNERSHIP FAMILY RESOUR
    P O BOX 396
    DIVIDE,CO80814     		NONE PC EARLY CHILDHOOD AND PARENTING EDUCATION 4,000
    COMMUNITY PARTNERSHIP FOR CHILD DEV
    2330 ROBINSON ST
    COLORADO SPRINGS,CO80904     		NONE PC PRESCHOOL FOR AT RISK CHILDREN AND FAMILY SUPPORT SERVICES 5,500
    CONGREGATION RODEF SHALOM
    450 S KEARNEY ST
    DENVER,CO80224     		NONE PC YOUTH SCHOLARSHIP FUNDING 3,500
    DENVER PUBLIC SCHOOLS FOUNDATION
    1860 LINCOLN ST 9TH FLOOR
    DENVER,CO80203     		NONE PC LITERACY INTERVENTION PROGRAM FOR PRE-K STUDENTS 6,000
    DENVER ZOO
    2300 STEELE ST
    DENVER,CO80205     		NONE PC NATURE EDUCATION PROGRAM FOR YOUNG CHILDREN PARENTS AND TEACHERS 2,000
    DENVERWORKS
    5725 E 39TH AVE
    DENVER,CO80207     		NONE PC CAREER PREPARATION AND PLACEMENT SERVICES 3,000
    DISCOVER GOODWILL OF S W COLORADO
    1400 GARDEN OF THE GODS ROAD
    COLORADO SPRINGS,CO80907     		NONE PC FINANCIAL EDUCATION FOR LOW INCOME PARTICIPANTS 2,000
    DRESS FOR SUCCESS DENVER
    1510 HIGH ST 2ND FLOOR
    DENVER,CO80218     		NONE PC JOB READINESS AND JOB RETENTION PROGRAM 4,500
    DUMB FRIENDS LEAGUE
    2080 S QUEBEC ST
    DENVER,CO80231     		NONE PC ANIMAL WELFARE 2,500
    EARLY CONNECTIONS LEARNING CENTERS
    104 E RIO GRANDE
    COLORADO SPRINGS,CO80903     		NONE PC EDUCATION AND CHILD CARE SERVING LOW INCOME PARENTS 3,500
    EARLY EXCELLENCE PROGRAM OF DENVER
    3580 FRANKLIN ST
    DENVER,CO80205     		NONE PC EARLY CHILDHOOD EDUCTION FOR AT RISK CHILDREN 7,000
    EMERGENCY FAMILY ASSISTNCE ASSOCIAT
    1575 YARMOUTH AVE
    BOULDER,CO80304     		NONE PC CASE MANAGEMENT SERVICES FOR FAMILIES WORKING TOWARD SELF SUFFICIENCY 4,500
    EMILY GRIFFITH FOUNDATION
    1860 LINCOLN ST SUITE 605
    DENVER,CO80203     		NONE PC STIPENDS FOR ADULT STUDENTS 5,000
    FAMILIES FIRST
    2163 S YOSEMITE ST
    DENVER,CO80231     		NONE PC PARENTING EDUCATION 5,000
    FAMILY LEARNING CENTER
    31626 HIGHWAY 6
    EDWARDS,CO81632     		NONE PC TUITION ASSISTANCE FOR EARLY CHILDHOOD EDUCATION PROGRAMS 3,000
    FAMILY STAR
    2246 FEDERAL BLVD
    DENVER,CO80211     		NONE PC EARLY CHILDHOOD EDUCATION AND FAMILY SUPPORT SERVICES 4,000
    FAMILY VISITOR PROGRAMS
    P O BOX 1845
    GLENWOOD SPRINGS,CO81602     		NONE PC PARENTING EDUCATION 6,000
    FLORENCE CRITTENTON SERVICES OF COL
    96 S ZUNI ST
    DENVER,CO80223     		NONE PC HIGH SCHOOL AND PROGRAM FAMILY SUPPORT FOR PREGNANT AND PARENTING TEENS 30,000
    FOCUS POINTS FAMILY RESOURCE CENTER
    2501 E 48TH AVE
    DENVER,CO80216     		NONE PC EARLY CHILDHOOD EDUCATION AND PARENTING PROGRAMS 5,500
    GRECCIO HOUSING
    1808 W COLORADO AVE
    COLORADO SPRINGS,CO80904     		NONE PC LIFE SKILLS TRAINING AND JOB READINESS SKILLS 3,000
    GREELEY TRANSITIONAL HOUSE
    1206 10TH ST
    GREELEY,CO80631     		NONE PC CASE MANAGEMENT SERVICES FOR HOMELESS FAMILIES WORKING TOWARD SELF SUFFICIENCY 3,500
    GROWING HOME
    3489 W 72ND AVE STE 112
    WESTMINSTER,CO80030     		NONE PC EARLY CHILDHOOD PROGRAMS AND PARENTING EDUCATION 5,000
    HILLTOP COMMUNITY RESOURCES
    1311 HERMOSA AVE
    GRAND JUNCTION,CO81506     		NONE PC PARENTING EDUCATION 6,000
    HOPE COMMUNITIES
    2543 CALIFORNIA ST
    DENVER,CO80205     		NONE PC RESIDENT SERVICES PROGRAM FOR FAMILIES ON A PATH TO SELF SUFFICIENCY 3,000
    HOUSE OF NEIGHBORLY SERVICE
    15112 E 11TH ST STE 100
    LOVELAND,CO80537     		NONE PC FAMILY STABILIZATION PROGRAM FOR HOMELESS 3,000
    INN BETWEEN OF LONGMONT
    515 KIMBARK ST STE 107
    LONGMONT,CO80501     		NONE PC SUPPORT SERVICES FOR HOMELESS WORKING TOWARD SELF SUFFICIENCY 2,500
    JEWISH SOCIAL SERVICE AGENCY
    6123 MONTROSE ROAD
    ROCKVILLE,MD20852     		NONE PC SOCIAL SERVICES 1,250
    LA LLAVE FAMILY RESOURCE CENTER
    P O BOX 508
    ALAMOSA,CO81101     		NONE PC PARENTING EDUCATION 5,500
    LAPUENTE HOME
    P O BOX 1235
    ALAMOSA,CO81101     		NONE PC TRANSITIONAL LIVING PROGRAM FOR HOMELESS FAMILIES 30,000
    METROPOLITAN STATE UNIVERSITY OF DE
    P O BOX 173362
    DENVER,CO80217     		NONE PC PARENTING EDUCATION 3,500
    MI CASA RESOURCE CENTER
    360 ACOMA ST
    DENVER,CO80223     		NONE PC CAREER DEVELOPMENT 10,000
    MOUNTAIN RESOURCE CENTER
    P O BOX 425
    CONIFER,CO80433     		NONE PC PARENTING EDUCATION 4,000
    MT AIRY COMMUNITY SERVICES
    6601 GREENE ST
    PHILADELPHIA,PA19119     		NONE PC COMMUNITY FUND 500
    NER TAMID SYNAGOGUE
    15318 POMERADO ROAD
    POWAY,CA92064     		NONE PC RELIGIOUS EDUCATION 10,000
    NER TAMID SYNAGOGUE
    15318 POMERADO ROAD
    POWAY,CA92064     		NONE PC RELIGIOUS COMMUNITY 1,250
    PARTNERS IN HOUSING
    455 GOLD PASS HEIGHTS
    COLORADO SPRING,CO80906     		NONE PC TRANSITIONAL PROGRAM SUPPORT SERVICES FOR HOMELESS 6,000
    PASSAGE CHARTER SCHOOL
    703 S 9TH ST
    MONTROSE,CO81401     		NONE PC HIGH SCHHOL FOR PREGNANT AND PARENTING YOUNG PEOPLE 5,500
    PEAK VISTA COMMINTY HEALTH CENTERS
    3205 N ACADEMY BLVD STE 130
    COLORADO SPRINGS,CO80917     		NONE PC PARENTING EDUCATION 5,000
    PHILLIPS COUNTY FAMILY EDUCATION SE
    P O BOX 365
    HOLYOKE,CO80734     		NONE PC ADULT EDUCATION 2,500
    PROJECT SELF SUFFICIENCY OF LOVELAN
    375 W 37 ST STE 150
    LOVELAND,CO80538     		NONE PC LIFE SKILLS TRAINING JOB READINESS PROGRAM FOR SINGLE PARENT FAMILIES WORKING TOWARD SELF SUFFICIENCY 30,000
    QUALISTAR COLORADO
    3607 MARTIN LUTHER KING BLVD
    DENVER,CO80205     		NONE PC TRAINING AND SUPPORT SERVICES TO EARLY CHILDHOOD EDUCATION PROVIDERS 8,000
    REACH OUT AND READ COLORADO
    1660 S ALBION ST STE 905
    DENVER,CO80222     		NONE PC READING PROGRAM FOR YOUNG CHILDREN 6,000
    REACH PIKES PEAK
    312 S WEBER ST STE A
    COLORADO SPRINGS,CO80903     		NONE PC JOB READINESS AND LIFE SKILLS TRAINING 4,500
    READ TO ME
    P O BOX 1654
    CASTLE ROCK,CO80104     		NONE PC EARLY READING EDUCATIONAL MATERIALS 3,000
    REDLINE
    2350 ARAPAHOE ST
    DENVER,CO80205     		NONE PC ARTS EDUCATION PROGRAM SERVING LOW INCOME FAMILIES 2,500
    ROCKY MOUNTAIN MICROFINANCE INSTITU
    P O BOX 48138
    DENVER,CO80204     		NONE PC BUSINESS DEVELOPMENT PROGRAM TO SUPPORT ENTREPRENEURS 5,500
    SAFEHOUSE DENVER
    1649 DOWNING ST
    DENVER,CO80218     		NONE PC PARENTING EDUCATION 9,000
    SEWALL CHILD DEVELOPMENT CENTER
    940 FILLMORE ST
    DENVER,CO80206     		NONE PC EARLY CHILDHOOD EDUCATION 6,000
    SPRING INSTITUTE FOR INTERCULTURAL
    1373 GRANT ST
    DENVER,CO80203     		NONE PC EARLY CHILDHOOD EDUCATION AND PARENTING EDUCATION RPOGRAMS 5,000
    THE DENVER FOUNDATION
    55 MADISON ST ST 800
    DENVER,CO80206     		NONE PC HOMELESSNESS AND HOUSING INITIATIVES 15,000
    THE GATHERING PLACE
    1535 HIGH ST
    DENVER,CO80218     		NONE PC EDUCATION AND JOB READINESS 3,500
    THE MATTHEWS HOUSE
    415 MASON ST 1
    FORT COLLINS,CO80524     		NONE PC EDUCATION AND EMPLOYMENT CENTER 3,500
    THE PINON PROJECT FAMILY RESOURCE C
    P O BOX 1510
    CORTEZ,CO81321     		NONE PC FAMILY SELF SUFFICIENCY 30,000
    THOMPSON VALLEY PRESCHOOL
    803 E 16TH ST
    LOVELAND,CO80538     		NONE PC EARLY CHILDHOOD EDUCATION 3,000
    TRI COUNTY FAMILY CARE CENTER
    512 1/2 MAIN ST
    ROCKY FORD,CO81067     		NONE PC PARENTING EDUCATION 4,000
    VOLUNTEERS OF AMERICA COLORADO BRAN
    2660 LARIMER ST
    DENVER,CO80205     		NONE PC EARLY CHILDHOOD EDUCATION 2,500
    WOMEN'S BEAN PROJECT
    3201 CURTIS ST
    DENVER,CO80205     		NONE PC JOB READINESS AND LIFE SKILLS EMPLOYMENT TRAINING 5,000
    WOMEN'S RESOURCE AGENCY
    750 CITADEL DRIVE EAST STE 3125
    COLORADO SPRINGS,CO80909     		NONE PC CAREER READINESS 3,000
    WORK OPTIONS FOR WOMEN
    1200 FEDRAL BLVD
    DENVER,CO80204     		NONE PC JOB READINESS AND LIFE SKILLS CAREER EDUCATION TRAINING 6,000
    YWCA OF BOULDER COUNTY
    2222 14TH ST
    BOULDER,CO80302     		NONE PC EARLY CHILDHOOD AND PARENTING EDUCATION PROGRAMS 2,500
    FAMILY TREE
    3805 MARSHALL ST STE 100
    WHEAT RIDGE,CO80033     		NONE PC EMPLOYMENT READINESS 7,000
    Total .................................bullet 3a 456,000
    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 ...........     		    14 19  
    4 Dividends and interest from securities....     14 162,389  
    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 ............     		    18 229,453  
    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)..   391,861  
    13Total. Add line 12, columns (b), (d), and (e)..................
    13391,861
    (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: 15000324
    Software Version: 2015v3.0


    Form 990PF - Special Condition Description:
    Special Condition Description

    TY 2015 AccountingFeesSchedule
    Name:
    The Sam S Bloom Foundation
    EIN:
    84-0929690
    Software ID:
    15000324
    Software Version:
    2015v3.0
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    Tax return preparation 2,460 2,460 2,460 0

    TY 2015 OtherExpensesSchedule
    Name:
    The Sam S Bloom Foundation
    EIN:
    84-0929690
    Software ID:
    15000324
    Software Version:
    2015v3.0
    Description Revenue and Expenses per Books Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    Archival 2,149 1,074 1,074 1,075
    Bank charges 66 33 33 33
    Filing fee 10 5 5 5
    Insurance 776 388 388 388
    Membership dues 1,415 708 708 707
    Miscellaneous 1     1
    Office expense 542 271 271 271
    Postage & delivery 832 416 416 416
    Telephone 813 407 407 406


    TY 2015 OtherProfessionalFeesSchedule
    Name:
    The Sam S Bloom Foundation
    EIN:
    84-0929690
    Software ID:
    15000324
    Software Version:
    2015v3.0
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    Investment advisory fees 40,709 40,709 40,709 0
    Investment custodial fees 5,051 5,051 5,051 0


    TY 2015 TaxesSchedule
    Name:
    The Sam S Bloom Foundation
    EIN:
    84-0929690
    Software ID:
    15000324
    Software Version:
    2015v3.0
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    Federal excise tax 5,000 5,000 5,000