-
TIN:
Form
990-PF
Department of the Treasury
Internal Revenue Service
Return of Private Foundation
or Section 4947(a)(1) Trust Treated as Private Foundation
Do not enter social security numbers on this form as it may be made public.
Go to
www.irs.gov/Form990PF
for instructions and the latest information.
OMB No. 1545-0052
20
18
Open to Public Inspection
For calendar year 2018, or tax year beginning
04-01-2018
, and ending
03-31-2019
Name of foundation
THE GENE ROMAN FAMILY FOUNDATION
Number and street (or P.O. box number if mail is not delivered to street address)
12250 FOXBOROUGH DRIVE
Room/suite
City or town, state or province, country, and ZIP or foreign postal code
MOKENA
,
IL
60448
A Employer identification number
30-0177368
B
Telephone number (see instructions)
(708) 606-1449
C
If exemption application is pending, check here
G
Check all that apply:
Initial return
Initial return of a former public charity
Final return
Amended return
Address change
Name change
D 1.
Foreign organizations, check here.............
2
. Foreign organizations meeting the 85%
test, check here and attach computation ...
E
If private foundation status was terminated
under section 507(b)(1)(A), check here .......
H
Check type of organization:
Section 501(c)(3) exempt private foundation
Section 4947(a)(1) nonexempt charitable trust
Other taxable private foundation
F
If the foundation is in a 60-month termination
under section 507(b)(1)(B), check here .......
I
Fair market value of all assets at end
of year (from Part II, col. (c),
line 16)
$
-349
J
Accounting method:
Cash
Accrual
Other (specify)
(Part I, column (d) must be on cash basis.)
Part I
Analysis of Revenue and Expenses
(The total of amounts in columns (b), (c), and (d) may not necessarily equal the amounts in column (a) (see instructions).)
(a)
Revenue and
expenses per
books
(b)
Net investment
income
(c)
Adjusted net
income
(d)
Disbursements
for charitable
purposes
(cash basis only)
1
Contributions, gifts, grants, etc., received (attach schedule)
26,955
2
Check
.............
3
Interest on savings and temporary cash investments
0
4
Dividends and interest from securities
...
5a
Gross rents
............
b
Net rental income or (loss)
6a
Net gain or (loss) from sale of assets not on line 10
b
Gross sales price for all assets on line 6a
7
Capital gain net income (from Part IV, line 2)
...
0
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)
.....
0
11
Other income (attach schedule)
.......
0
12
Total.
Add lines 1 through 11
........
26,955
0
13
Compensation of officers, directors, trustees, etc.
14
Other employee salaries and wages
......
15
Pension plans, employee benefits
.......
16a
Legal fees (attach schedule)
.........
1,065
b
Accounting fees (attach schedule)
.......
0
c
Other professional fees (attach schedule)
....
0
17
Interest
...............
18
Taxes (attach schedule) (see instructions)
...
0
19
Depreciation (attach schedule) and depletion
...
0
20
Occupancy
..............
21
Travel, conferences, and meetings
.......
22
Printing and publications
..........
23
Other expenses (attach schedule)
.......
10,108
24
Total operating and administrative expenses.
Add lines 13 through 23
..........
11,173
0
0
25
Contributions, gifts, grants paid
.......
20,326
20,326
26
Total expenses and disbursements.
Add lines 24 and 25
31,499
0
20,326
27
Subtract line 26 from line 12:
a
Excess of revenue over expenses and disbursements
-4,544
b
Net investment income
(if negative, enter -0-)
0
c
Adjusted net income
(if negative, enter -0-)
...
For Paperwork Reduction Act Notice, see instructions.
Cat. No. 11289X
Form
990-PF
(2018)
Form 990-PF (2018)
Page
2
Part II
Balance Sheets
Attached schedules and amounts in the description column
should be for end-of-year amounts only. (See instructions.)
Beginning of year
End of year
(a)
Book Value
(b)
Book Value
(c)
Fair Market Value
1
Cash—non-interest-bearing
.............
2
Savings and temporary cash investments
.........
4,195
-349
-349
3
Accounts receivable
Less: allowance for doubtful accounts
4
Pledges receivable
Less: allowance for doubtful accounts
5
Grants receivable
.................
6
Receivables due from officers, directors, trustees, and other
disqualified persons (attach schedule) (see instructions)
.....
0
7
Other notes and loans receivable (attach schedule)
Less: allowance for doubtful accounts
0
8
Inventories for sale or use
..............
9
Prepaid expenses and deferred charges
..........
10a
Investments—U.S. and state government obligations (attach schedule)
b
Investments—corporate stock (attach schedule)
.......
c
Investments—corporate bonds (attach schedule)
.......
11
Investments—land, buildings, and equipment: basis
Less: accumulated depreciation (attach schedule)
0
12
Investments—mortgage loans
.............
13
Investments—other (attach schedule)
..........
0
14
Land, buildings, and equipment: basis
Less: accumulated depreciation (attach schedule)
0
15
Other assets (describe
)
0
0
0
16
Total assets
(to be completed by all filers—see the
instructions. Also, see page 1, item I)
4,195
-349
-349
17
Accounts payable and accrued expenses
..........
18
Grants payable
.................
19
Deferred revenue
.................
20
Loans from officers, directors, trustees, and other disqualified persons
0
21
Mortgages and other notes payable (attach schedule)
......
0
22
Other liabilities (describe
)
0
0
23
Total liabilities
(add lines 17 through 22)
.........
0
Foundations that follow SFAS 117, check here
and complete lines 24 through 26 and lines 30 and 31.
24
Unrestricted
..................
25
Temporarily restricted
...............
26
Permanently restricted
...............
Foundations that do not follow SFAS 117, check here
and complete lines 27 through 31.
27
Capital stock, trust principal, or current funds
........
4,195
-349
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)
.....
4,195
-349
31
Total liabilities and net assets/fund balances
(see instructions)
.
4,195
-349
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
4,195
2
Enter amount from Part I, line 27a
.....................
2
-4,544
3
Other increases not included in line 2 (itemize)
3
4
Add lines 1, 2, and 3
..........................
4
-349
5
Decreases not included in line 2 (itemize)
5
6
Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 30
.
6
-349
Form
990-PF
(2018)
Form 990-PF (2018)
Page
3
Part IV
Capital Gains and Losses for Tax on Investment Income
(a)
List and describe the kind(s) of property sold (e.g., real estate,
2-story brick warehouse; or common stock, 200 shs. MLC Co.)
(b)
How acquired
P—Purchase
D—Donation
(c)
Date acquired
(mo., day, yr.)
(d)
Date sold
(mo., day, yr.)
1a
b
c
d
e
(e)
Gross sales price
(f)
Depreciation allowed
(or allowable)
(g)
Cost or other basis
plus expense of sale
(h)
Gain or (loss)
(e) plus (f) minus (g)
a
b
c
d
e
Complete only for assets showing gain in column (h) and owned by the foundation on 12/31/69
(l)
Gains (Col. (h) gain minus
col. (k), but not less than -0-)
or
Losses (from col.(h))
(i)
F.M.V. as of 12/31/69
(j)
Adjusted basis
as of 12/31/69
(k)
Excess of col. (i)
over col. (j), if any
a
b
c
d
e
2
Capital gain net income or (net capital loss)
If gain, also enter in Part I, line 7
If (loss), enter -0- in Part I, line 7
2
3
Net short-term capital gain or (loss) as defined in sections 1222(5) and (6):
If gain, also enter in Part I, line 8, column (c) (see instructions). If (loss), enter -0-
in Part I, line 8
...................
3
Part V
Qualification Under Section 4940(e) for Reduced Tax on Net Investment Income
(For optional use by domestic private foundations subject to the section 4940(a) tax on net investment income.)
If section 4940(d)(2) applies, leave this part blank.
Was the foundation liable for the section 4942 tax on the distributable amount of any year in the base period?
Yes
No
If "Yes," the foundation does not qualify under section 4940(e). Do not complete this part.
1
Enter the appropriate amount in each column for each year; see instructions before making any entries.
(a)
Base period years Calendar
year (or tax year beginning in)
(b)
Adjusted qualifying distributions
(c)
Net value of noncharitable-use assets
(d)
Distribution ratio
(col. (b) divided by col. (c))
2017
21,693
14,808
1.464951
2016
10,242
12,321
0.831264
2015
19,221
10,139
1.895749
2014
18,332
10,929
1.677372
2013
14,700
17,927
0.819992
2
Total
of line 1, column (d)
.....................
2
6.689328
3
Average distribution ratio for the 5-year base period—divide the total on line 2 by 5.0, or by the number of years the foundation has been in existence if less than 5 years
......
3
1.337866
4
Enter the net value of noncharitable-use assets for 2018 from Part X, line 5
......
4
7,631
5
Multiply line 4 by line 3
......................
5
10,209
6
Enter 1% of net investment income (1% of Part I, line 27b)
...........
6
7
Add lines 5 and 6
........................
7
10,209
8
Enter qualifying distributions from Part XII, line 4
,.............
8
20,326
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
(2018)
Form 990-PF (2018)
Page
4
Part VI
Excise Tax Based on Investment Income (Section 4940(a), 4940(b), 4940(e), or 4948—see instructions)
1a
Exempt operating foundations described in section 4940(d)(2), check here
and enter “N/A" on line 1.
Date of ruling or determination letter:
(attach copy of letter if necessary–see instructions)
b
Domestic foundations that meet the section 4940(e) requirements in Part V, check
1
0
here
and enter 1% of Part I, line 27b
...................
c
All other domestic foundations enter 2% of line 27b. Exempt foreign organizations enter 4% of Part I, line 12, col. (b)
2
Tax under section 511 (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-)
2
0
3
Add lines 1 and 2
...........................
3
0
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
0
6
Credits/Payments:
a
2018 estimated tax payments and 2017 overpayment credited to 2018
6a
b
Exempt foreign organizations—tax withheld at source
......
6b
c
Tax paid with application for extension of time to file (Form 8868)
...
6c
d
Backup withholding erroneously withheld
...........
6d
7
Total credits and payments. Add lines 6a through 6d
..............
7
8
Enter any
penalty
for underpayment of estimated tax.
Check here
if Form 2220 is attached.
8
9
Tax due.
If the total of lines 5 and 8 is more than line 7, enter
amount owed
.......
9
0
10
Overpayment.
If line 7 is more than the total of lines 5 and 8, enter the
amount overpaid
...
10
11
Enter the amount of line 10 to be:
Credited to 2019 estimated tax
0
Refunded
11
Part VII-A
Statements Regarding Activities
1a
During the tax year, did the foundation attempt to influence any national, state, or local legislation or did
Yes
No
it participate or intervene in any political campaign?
....................
1a
No
b
Did it spend more than $100 during the year (either directly or indirectly) for political purposes? (see Instructions
for definition)
.................................
1b
No
If the answer is "Yes" to
1a
or
1b,
attach a detailed description of the activities and copies of any materials
published or distributed by the foundation in connection with the activities.
c
Did the foundation file
Form 1120-POL
for this year?
.....................
1c
No
d
Enter the amount (if any) of tax on political expenditures (section 4955) imposed during the year:
(1)
On the foundation.
$
(2)
On foundation managers.
$
e
Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed
on foundation managers.
$
2
Has the foundation engaged in any activities that have not previously been reported to the IRS?
.......
2
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)
IL
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 2018 or the taxable year beginning in 2018? See the 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
(2018)
Form 990-PF (2018)
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 address
www.generoman.org
14
The books are in care of
SANDRA L PECCIA
Telephone no.
(708) 606-1449
Located at
12250 FOXBOROUGH DRIVE
MOKENA
IL
ZIP+4
60448
15
Section 4947(a)(1) nonexempt charitable trusts filing Form 990-PF in lieu of
Form 1041
—check here
.........
and enter the amount of tax-exempt interest received or accrued during the year
........
15
16
At any time during calendar year 2018, did the foundation have an interest in or a signature or other authority over
Yes
No
a bank, securities, or other financial account in a foreign country?
.................
16
No
See the instructions for exceptions and filing requirements for FinCEN Form 114. If "Yes", enter the name of the foreign
country
Part VII-B
Statements Regarding Activities for Which Form 4720 May Be Required
File Form 4720 if any item is checked in the "Yes" column, unless an exception applies.
Yes
No
1a
During the year did the foundation (either directly or indirectly):
(1)
Engage in the sale or exchange, or leasing of property with a disqualified person?
Yes
No
(2)
Borrow money from, lend money to, or otherwise extend credit to (or accept it from)
a disqualified person?
......................
Yes
No
(3)
Furnish goods, services, or facilities to (or accept them from) a disqualified person?
Yes
No
(4)
Pay compensation to, or pay or reimburse the expenses of, a disqualified person?
Yes
No
(5)
Transfer any income or assets to a disqualified person (or make any of either available
for the benefit or use of a disqualified person)?
...............
Yes
No
(6)
Agree to pay money or property to a government official? (
Exception.
Check "No"
if the foundation agreed to make a grant to or to employ the official for a period
after termination of government service, if terminating within 90 days.)
.......
Yes
No
b
If any answer is "Yes" to 1a(1)–(6), did
any
of the acts fail to qualify under the exceptions described in Regulations
section 53.4941(d)-3 or in a current notice regarding disaster assistance? See instructions
........
1b
Organizations relying on a current notice regarding disaster assistance check here
........
c
Did the foundation engage in a prior year in any of the acts described in 1a, other than excepted acts,
that were not corrected before the first day of the tax year beginning in 2018?
.............
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 2018, did the foundation have any undistributed income (lines 6d
and 6e, Part XIII) for tax year(s) beginning before 2018?
.............
Yes
No
If "Yes," list the years
20
,
20
,
20
,
20
b
Are there any years listed in 2a for which the foundation is
not
applying the provisions of section 4942(a)(2)
(relating to incorrect valuation of assets) to the year’s undistributed income? (If applying section 4942(a)(2)
to
all
years listed, answer "No" and attach statement—see instructions.)
..............
2b
c
If the provisions of section 4942(a)(2) are being applied to
any
of the years listed in 2a, list the years here.
20
,
20
,
20
,
20
3a
Did the foundation hold more than a 2% direct or indirect interest in any business enterprise at
any time during the year?
......................
Yes
No
b
If "Yes," did it have excess business holdings in 2018 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 2018.)
..................
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 2018?
4b
No
Form
990-PF
(2018)
Form 990-PF (2018)
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:
Yes
No
(1)
Carry on propaganda, or otherwise attempt to influence legislation (section 4945(e))?
Yes
No
(2)
Influence the outcome of any specific public election (see section 4955); or to carry
on, directly or indirectly, any voter registration drive?
.............
Yes
No
(3)
Provide a grant to an individual for travel, study, or other similar purposes?
Yes
No
(4)
Provide a grant to an organization other than a charitable, etc., organization described
in section 4945(d)(4)(A)? See instructions
................
Yes
No
(5)
Provide for any purpose other than religious, charitable, scientific, literary, or
educational purposes, or for the prevention of cruelty to children or animals?
.....
Yes
No
b
If any answer is "Yes" to 5a(1)–(5), did
any
of the transactions fail to qualify under the exceptions described in
Regulations section 53.4945 or in a current notice regarding disaster assistance? See instructions
......
5b
Organizations relying on a current notice regarding disaster assistance check here
.........
c
If the answer is "Yes" to question 5a(4), does the foundation claim exemption from the
tax because it maintained expenditure responsibility for the grant?
..........
Yes
No
If "Yes," attach the statement required by Regulations section 53.4945–5(d).
6a
Did the foundation, during the year, receive any funds, directly or indirectly, to pay premiums on
a personal benefit contract?
.....................
Yes
No
b
Did the foundation, during the year, pay premiums, directly or indirectly, on a personal benefit contract?
....
6b
No
If "Yes" to 6b, file Form 8870.
7a
At any time during the tax year, was the foundation a party to a prohibited tax shelter transaction?
Yes
No
b
If yes, did the foundation receive any proceeds or have any net income attributable to the transaction?
....
7b
8
Is the foundation subject to the section 4960 tax on payment(s) of more than $1,000,000 in remuneration or
excess parachute payment during the year?
.................
Yes
No
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
SANDRA L PECCIA
PRES/SECTR/TREAS
4.50
0
0
0
12250 FOXBOROUGH DRIVE
MOKENA
,
IL
60448
ANGELA ISBELL
V. PRES.
0.50
0
0
0
437 ANN LANE
NEW LENOX
,
IL
60451
CINDY HILL
BOARD MEMBER
0.25
0
0
0
2255 PALMER RANCH DR
NEW LENOX
,
IL
60451
ROBERT SLOVIN
BOARD MEMBER
0.25
0
0
0
21620 WILLIAMSBURG CT
FRANKFORT
,
IL
60423
GERRY BERZINS
BOARD MEMBER
0.75
0
0
0
6173 PRINCETON LANE
PALOS HEIGHTS
,
IL
60465
MICHELE ROMAN
BOARD MEMBER
0.75
0
0
0
22943 S BIG RUN DRIVE
FRANKFORT
,
IL
60423
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
...................
0
Form
990-PF
(2018)
Form 990-PF (2018)
Page
7
Part VIII
Information About Officers, Directors, Trustees, Foundation Managers, Highly Paid Employees,
and Contractors
(continued)
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
.............
0
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
FUNDS ARE DISTRIBUTED TO CANCER VICTIMS TO PAY MEDICAL EXPENSES AND OTHER ITEMS RELATING TO THEIR WELL-BEING. SIXTY-FIVE INDIVIDUALS HAVE BEEN OUR BENEFICIARIES THIS FISCAL YEAR.
11,173
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
.........................
Form
990-PF
(2018)
Form 990-PF (2018)
Page
8
Part X
Minimum Investment Return
(All domestic foundations must complete this part. Foreign foundations,see instructions.)
1
Fair market value of assets not used (or held for use) directly in carrying out charitable, etc.,
purposes:
a
Average monthly fair market value of securities
...................
1a
0
b
Average of monthly cash balances
.......................
1b
7,747
c
Fair market value of all other assets (see instructions)
................
1c
0
d
Total
(add lines 1a, b, and c)
.........................
1d
7,747
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
7,747
4
Cash deemed held for charitable activities. Enter 1 1/2% of line 3 (for greater amount, see
instructions)
.............................
4
116
5
Net value of noncharitable-use assets.
Subtract line 4 from line 3. Enter here and on Part V, line 4
5
7,631
6
Minimum investment return.
Enter 5% of line 5
..................
6
382
Part XI
Distributable Amount
(see instructions) (Section 4942(j)(3) and (j)(5) private operating foundations and certain foreign organizations check here
and do not complete this part.)
1
Minimum investment return from Part X, line 6
....................
1
382
2a
Tax on investment income for 2018 from Part VI, line 5
......
2a
0
b
Income tax for 2018. (This does not include the tax from Part VI.)
...
2b
c
Add lines 2a and 2b
............................
2c
0
3
Distributable amount before adjustments. Subtract line 2c from line 1
............
3
382
4
Recoveries of amounts treated as qualifying distributions
................
4
5
Add lines 3 and 4
............................
5
382
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
382
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
20,326
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
20,326
5
Foundations that qualify under section 4940(e) for the reduced rate of tax on net investment
income. Enter 1% of Part I, line 27b. See instructions
.................
5
6
Adjusted qualifying distributions.
Subtract line 5 from line 4
..............
6
20,326
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
(2018)
Form 990-PF (2018)
Page
9
Part XIII
Undistributed Income
(see instructions)
(a)
Corpus
(b)
Years prior to 2017
(c)
2017
(d)
2018
1
Distributable amount for 2018 from Part XI, line 7
382
2
Undistributed income, if any, as of the end of 2018:
a
Enter amount for 2017 only
.......
b
Total for prior years:
20
,
20
,
20
3
Excess distributions carryover, if any, to 2018:
a
From 2013
......
14,700
b
From 2014
......
18,332
c
From 2015
......
19,221
d
From 2016
......
10,242
e
From 2017
......
21,693
f
Total
of lines 3a through e
........
84,188
4
Qualifying distributions for 2018 from Part
XII, line 4:
$
20,326
a
Applied to 2017, but not more than line 2a
b
Applied to undistributed income of prior years
(Election required—see instructions)
.....
c
Treated as distributions out of corpus (Election
required—see instructions)
........
0
d
Applied to 2018 distributable amount
.....
e
Remaining amount distributed out of corpus
20,326
5
Excess distributions carryover applied to 2018.
(If an amount appears in column (d), the
same amount must be shown in column (a).)
6
Enter the net total of each column as
indicated below:
a
Corpus. Add lines 3f, 4c, and 4e. Subtract line 5
104,514
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
......
d
Subtract line 6c from line 6b. Taxable amount
—see instructions
...........
0
e
Undistributed income for 2017. Subtract line
4a from line 2a. Taxable amount—see
instructions
.............
0
f
Undistributed income for 2018. Subtract
lines 4d and 5 from line 1. This amount must
be distributed in 2019
..........
382
7
Amounts treated as distributions out of
corpus to satisfy requirements imposed by
section 170(b)(1)(F) or 4942(g)(3) (Election may
be required - see instructions)
.......
8
Excess distributions carryover from 2013 not
applied on line 5 or line 7 (see instructions)
...
14,700
9
Excess distributions carryover to 2019.
Subtract lines 7 and 8 from line 6a
......
89,814
10
Analysis of line 9:
a
Excess from 2014
....
18,332
b
Excess from 2015
....
19,221
c
Excess from 2016
....
10,242
d
Excess from 2017
....
21,693
e
Excess from 2018
....
20,326
Form
990-PF
(2018)
Form 990-PF (2018)
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 2018, enter the date of the ruling
.......
b
Check box to indicate whether the organization is a private operating foundation described in section
4942(j)(3)
or
4942(j)(5)
2a
Enter the lesser of the adjusted net
income from Part I or the minimum
investment return from Part X for each
year listed
..........
Tax year
Prior 3 years
(e) Total
(a)
2018
(b)
2017
(c)
2016
(d)
2015
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 foundation had $5,000 or more in
assets at any time during the year—see instructions.)
1
Information Regarding Foundation Managers:
a
List any managers of the foundation who have contributed more than 2% of the total contributions received by the foundation
before the close of any tax year (but only if they have contributed more than $5,000). (See section 507(d)(2).)
NONE
b
List any managers of the foundation who own 10% or more of the stock of a corporation (or an equally large portion of the
ownership of a partnership or other entity) of which the foundation has a 10% or greater interest.
NONE
2
Information Regarding Contribution, Grant, Gift, Loan, Scholarship, etc., Programs:
Check here
if the foundation only makes contributions to preselected charitable organizations and does not accept
unsolicited requests for funds. If the foundation makes gifts, grants, etc. to individuals or organizations under
other conditions, complete items 2a, b, c, and d. See instructions
a
The name, address, and telephone number or e-mail address of the person to whom applications should be addressed:
SANDRA L PECCIA
12250 FOXBOROUGH DRIVE
MOKENA
,
IL
60448
(708) 606-1449
b
The form in which applications should be submitted and information and materials they should include:
REQUEST FOR ASSISTANCE FORM AND DOCTOR OR CLINIC REFERRAL.
c
Any submission deadlines:
NONE
d
Any restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other
factors:
THIS FOUNDATION ONLY PROVIDES ASSISTANCE FOR CANCER PATIENTS.
Form
990-PF
(2018)
Form 990-PF (2018)
Page
11
Part XV
Supplementary Information
(continued)
3
Grants and Contributions Paid During the Year or Approved for Future Payment
Recipient
If recipient is an individual,
show any relationship to
any foundation manager
or substantial contributor
Foundation
status of
recipient
Purpose of grant or
contribution
Amount
Name and address (home or business)
a
Paid during the year
DEMETREUS BAILEY
218 S 9th AVENUE
MAYWOOD
,
IL
60153
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
500
MONICA SMITH
10517 S INDIANA APT 1
CHICAGO
,
IL
60628
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
500
CELESTE SULLIVAN
1401 MAIN ST UNIT 7
CRETE
,
IL
60417
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
500
LORRAINE MATTHEWS
1820 S CENTRAL PARK
CHICAGO
,
IL
60623
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
500
TOMMIE TATE
4124 W ADAMS
CHICAGO
,
IL
60624
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
500
TERRY BROWN
5126 W VAN BUREN BSMT
CHICAGO
,
IL
60644
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
425
ANN WHITE
530 IRVING PLACE
UNIVERSITY PARK
,
IL
60484
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
350
DONALD KARP
9355 RIDGELAND
OAK LAWN
,
IL
60453
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
300
KEVIN WRIGHT
7806 S EUCLID
CHICAGO
,
IL
60649
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
500
LISA JACKSON
9802 S CLAREMONT
CHICAGO
,
IL
60634
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
300
ISHMEL TUTWILER
1403 12th AVENUE APT 3
ROCKFORD
,
IL
61016
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
200
SHARON JONES
2013 N 74th AVENUE
ELMWOOD PARK
,
IL
60707
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
350
STEVEN SIEBERT
7317 CHERTFIELD ROAD
CRYSTAL LAKE
,
IL
60012
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
320
TERESA SAUCEDO
9235 S MARQUETTE
CHICAGO
,
IL
60617
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
300
ANTHONY FATA
905 INDIANA AVENUE
ST CHARLES
,
IL
60174
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
300
VICTOR MARTINEZ DELEON
7516 KESTREL STREET
HOBART
,
IN
46342
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
198
JEWEL McCULLOUGH
4339 W 17th STREET
CHICAGO
,
IL
60623
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
300
MERCEDES WILLIAMS TAYLOR
902 E 82nd STREET APT 3
CHICAGO
,
IL
60619
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
300
DONNA KUGLER
1347 CRABAPPLE CT APT 101
NAPERVILLE
,
IL
60540
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
300
QAMAR MIRZA
4040 W 99th PLACE
OAK LAWN
,
IL
60453
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
174
MICHAEL GUIDO
9026 POPLAR ROAD
ORLAND PARK
,
IL
60462
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
300
EDNA LEE
145 BRAIRWOOD COURT
MATTESON
,
IL
60443
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
300
EVALINE HUGHES
1548 N MEADE
CHICAGO
,
IL
60639
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
100
THERESA BRADLEY
7316 S COLES APT 2N
CHICAGO
,
IL
60649
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
300
TABITHA BIVENS
22418 BATTERFIELD RD APT 306
RICHTON PARK
,
IL
60471
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
300
LAKEYSHA BEAUCHAMP
17535 COMMUNITY STREET
LANSING
,
IL
60438
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
300
SHIRLEY TREMBLE
1133 W ROOSEVELT APT 103
CHICAGO
,
IL
60618
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
300
FLOYD JEFFERSON
8715 W FRONTAGE TERRACE
JUSTICE
,
IL
60458
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
100
RENITA KING
7249 S PHILLIPS APT 2
CHICAGO
,
IL
60649
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
300
MARTIN MUNOZ
5443 S NAGLE
CHICAGO
,
IL
60638
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
200
JENNIFER VEGA
6031 W 127th STREET
PALOS HEIGHTS
,
IL
60463
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
300
GREGORIA ESPINOSA
5024 N AVERS
CHICAGO
,
IL
60625
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
300
ALLEN JONES
8455 S ESCANABA
CHICAGO
,
IL
60617
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
100
ALVIN COLEMAN
157 SHABBONA
PARK FOREST
,
IL
60466
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
300
ISTER PERSON
18036 VISTA DRIVE
COUNTRY CLUB HILLS
,
IL
60478
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
230
BOB WIRKUS
25 BELMONT DRIVE
ROMEOVILLE
,
IL
60446
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
400
ELLIE DeFOY
39 W 352 BAKER DRIVE
GENEVA
,
IL
60134
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
150
RAQUEL TREVINO
1512 W 19th STREET
CHICAGO
,
IL
60608
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
500
KRISTY HILL
3632 W 116th STREET
ALSIP
,
IL
60803
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
356
MARTIN LEON
1601 MAIN STREET
MELROSE PARK
,
IL
60106
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
420
ALYCE SCHMID
16715 ELDERBERRY LANE
ORLAND PARK
,
IL
60467
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
500
MARIAH MITCHELL
701 E 91st ST APT 1A
CHICAGO
,
IL
60619
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
255
HIGGINS PAJARITO
1361 BRANDEN LANE
BARTLETT
,
IL
60103
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
300
BILL GERL
17818 OAK PARK APT 1S
TINLEY PARK
,
IL
60477
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
300
DANIEL SCUREK
2790 PACKFORD LANE
AURORA
,
IL
60504
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
130
JACKIE GAGE
505 PRESTON DR APT 119
BOLINGBROOK
,
IL
60440
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
300
FLORENCE JONES CLANTON
19 W MAIN ST UNIT 216
GLENWOOD
,
IL
60425
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
500
CAROL PEREZ
112 BOLZANO COURT
LYNWOOD
,
IL
60411
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
500
BRENDA HUNTER
5604 S PRAIRIE APT 1
CHICAGO
,
IL
60637
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
250
NORMAN CAMPBELL
1659 ALGIN AVE APT 1
JOLIET
,
IL
60433
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
500
TYRINE MASON
779 INLAND CIR APT 101
NAPERVILLE
,
IL
60563
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
500
DARIUS OWENS
15049 WABASH
SOUTH HOLLAND
,
IL
60473
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
336
CHERRITA MITCHELL
6337 S ST LAWRENCE
CHICAGO
,
IL
60637
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
200
MIGUEL ROMERO
515 PARKSIDE AVENUE
WEST CHICAGO
,
IL
60185
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
300
JANET FILEWICZ
587 NORTHERN LIGHTS WAY
NEW LENOX
,
IL
60451
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
300
OLGA KARUNDI SERUMAGA-YOUNG
1029 DES PLAINES AVE APT 50
FOREST PARK
,
IL
60130
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
200
KAREN TILLMAN
5113 W LEXINGTON ST 1st FL
CHICAGO
,
IL
60644
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
51
ROBERT DONERSON
903 E 8th ST APT 2
CHICAGO
,
IL
60619
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
200
JILL LaVANT
16001 S 88th AVE UNIT 106
ORLAND PARK
,
IL
60462
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
300
CHAUHAN DEVESH
1101 DAVIS ST 1199
EVANSTON
,
IL
60204
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
300
THERESA CLEARY
313 A WOODCREEK DR 216
BOLINGBROOK
,
IL
60440
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
300
WILBUR HUGHART
338 LAKE STREET
CRYSTAL LAKE
,
IL
60014
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
300
SHANNON MILLARD
9544 DAVIS STREET
FRANKLIN PARK
,
IL
60131
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
300
JEFFREY JOHNSON
9208 SALLY LANE 2E
SCHILLER PARK
,
IL
60176
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
231
MELONDY REED
13664 S LOWE
RIVERDALE
,
IL
60827
NONE
PUBLIC
AS DETERMINED BYBENEFICIARY OF GRANT
300
Total
.................................
3a
20,326
b
Approved for future payment
Total
.................................
3b
Form
990-PF
(2018)
Form 990-PF (2018)
Page
12
Part XVI-A
Analysis of Income-Producing Activities
Enter gross amounts unless otherwise indicated.
Unrelated business income
Excluded by section 512, 513, or 514
(e)
Related or exempt
function income
(See instructions.)
1
Program service revenue:
(a)
Business code
(b)
Amount
(c)
Exclusion code
(d)
Amount
a
b
c
d
e
f
g
Fees and contracts from government agencies
2
Membership dues and assessments
....
3
Interest on savings and temporary cash
investments
...........
900003
0
14
0
4
Dividends and interest from securities
....
5
Net rental income or (loss) from real estate:
a
Debt-financed property
......
b
Not debt-financed property
.....
6
Net rental income or (loss) from personal property
7
Other investment income
.....
8
Gain or (loss) from sales of assets other than
inventory
............
9
Net income or (loss) from special events:
10
Gross profit or (loss) from sales of inventory
11
Other revenue:
a
b
c
d
e
12
Subtotal. Add columns (b), (d), and (e)
..
0
0
13
Total.
Add line 12, columns (b), (d), and (e)
..................
13
0
(See worksheet in line 13 instructions to verify calculations.)
Part XVI-B
Relationship of Activities to the Accomplishment of Exempt Purposes
Line No.
Explain below how each activity for which income is reported in column (e) of Part XVI-A contributed importantly to
the accomplishment of the foundation’s exempt purposes (other than by providing funds for such purposes). (See
instructions.)
Form
990-PF
(2018)
Form 990-PF (2018)
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) (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) (other than section 501(c)(3)) or in section 527?
...........
Yes
No
b
If "Yes," complete the following schedule.
(a)
Name of organization
(b)
Type of organization
(c)
Description of relationship
Sign Here
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
May the IRS discuss this return
with the preparer shown below
(see instr.)?
Yes
No
Signature of officer or trustee
Date
Title
Paid Preparer Use Only
Print/Type preparer's name
Preparer's Signature
Date
Check if self-
employed
PTIN
Firm's name
Firm's EIN
Firm's address
Phone no.
Form
990-PF
(2018)
Additional Data
Software ID:
Software Version:
Form 990PF - Special Condition Description:
Special Condition Description
-
TIN:
TY 2018 OtherExpensesSchedule
Name:
THE GENE ROMAN FAMILY FOUNDATION
EIN:
30-0177368
Description
Revenue and Expenses per Books
Net Investment Income
Adjusted Net Income
Disbursements for Charitable Purposes
POSTAGE
700
OFFICE EXPENSES
520
FUNDRAISING EVENT COSTS
8,541
TELEPHONE
347