Form990-PF

Department of the Treasury
Internal Revenue Service

Return of Private Foundation
or Section 4947(a)(1) Trust Treated as Private Foundation
bulletDo not enter social security numbers on this form as it may be made public.
bulletGo to www.irs.gov/Form990PF for instructions and the latest information.
OMB No. 1545-0052
2018
Open to Public Inspection
For calendar year 2018, or tax year beginning 01-01-2018 , and ending 12-31-2018
Name of foundation
PACIFICSOURCE FOUNDATION FOR HEALTH
IMPROVEMENT
Number and street (or P.O. box number if mail is not delivered to street address)PO BOX 7068
  Room/suite
City or town, state or province, country, and ZIP or foreign postal code
SPRINGFIELD, OR974750068
A Employer identification number

93-1100080
B Telephone number (see instructions)

(541) 686-1242
C bullet
G Check all that apply:

D 1. Foreign organizations, check here............. bullet
2. Foreign organizations meeting the 85%
test, check here and attach computation ... 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$5,347,416J 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) 1,900,000
2 Check bullet.............
3 Interest on savings and temporary cash investments 11,388 11,388  
4 Dividends and interest from securities... 62,418 62,418  
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).....    
11 Other income (attach schedule).......      
12 Total. Add lines 1 through 11........ 1,973,806 73,806 0
Operating and Administrative Expenses 13 Compensation of officers, directors, trustees, etc. 0 0 0 0
14 Other employee salaries and wages......        
15 Pension plans, employee benefits.......        
16a Legal fees (attach schedule).........        
b Accounting fees (attach schedule).......        
c Other professional fees (attach schedule)....        
17 Interest...............        
18 Taxes (attach schedule) (see instructions)... Click to see attachment 884 884 0 0
19 Depreciation (attach schedule) and depletion...      
20 Occupancy..............        
21 Travel, conferences, and meetings....... 7,853 3,927 0 3,927
22 Printing and publications..........        
23 Other expenses (attach schedule)....... Click to see attachment 12,063 2,131 0 9,933
24 Total operating and administrative expenses.
Add lines 13 through 23.......... 20,800 6,942 0 13,860
25 Contributions, gifts, grants paid....... 1,402,267 1,402,267
26 Total expenses and disbursements. Add lines 24 and 25 1,423,067 6,942 0 1,416,127
27 Subtract line 26 from line 12:
a Excess of revenue over expenses and disbursements 550,739
b Net investment income (if negative, enter -0-) 66,864
c Adjusted net income (if negative, enter -0-)... 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
Assets 1 Cash—non-interest-bearing.............      
2 Savings and temporary cash investments......... 4,700,808 2,252,913 2,252,913
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).......      
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).......... 140,806 Click to see attachment3,088,027 3,088,027
14 Land, buildings, and equipment: basis bullet  
Less: accumulated depreciation (attach schedule) bullet        
15 Other assets (describe bullet) Click to see attachment3,816 Click to see attachment6,476 Click to see attachment6,476
16 Total assets (to be completed by all filers—see the
instructions. Also, see page 1, item I) 4,845,430 5,347,416 5,347,416
Liabilities 17 Accounts payable and accrued expenses..........   4,426
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) Click to see attachment663 Click to see attachment263
23 Total liabilities (add lines 17 through 22)......... 663 4,689
Net Assets or Fund Balances Foundations that follow SFAS 117, check here bullet
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 bullet
and complete lines 27 through 31.
27 Capital stock, trust principal, or current funds........ 0 0
28 Paid-in or capital surplus, or land, bldg., and equipment fund 0 0
29 Retained earnings, accumulated income, endowment, or other funds 4,844,767 5,342,727
30 Total net assets or fund balances (see instructions)..... 4,844,767 5,342,727
31 Total liabilities and net assets/fund balances (see instructions). 4,845,430 5,347,416
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
4,844,767
2
Enter amount from Part I, line 27a .....................
2
550,739
3
Other increases not included in line 2 (itemize) bullet
3
0
4
Add lines 1, 2, and 3 ..........................
4
5,395,506
5
Decreases not included in line 2 (itemize) bulletClick to see attachment
5
52,779
6
Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 30 .
6
5,342,727
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) Bracket If gain, also enter in Part I, line 7
If (loss), enter -0- in Part I, line 7		 Bracket 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 ................... 		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))
2017 683,345 3,717,063 0.183840
2016 428,760 3,685,854 0.116326
2015 401,872 4,139,203 0.097089
2014 463,269 4,829,509 0.095925
2013 723,961 4,764,100 0.151962
2
Total of line 1, column (d) .....................
2
0.645142
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
0.129028
4
Enter the net value of noncharitable-use assets for 2018 from Part X, line 5......
4
2,363,178
5
Multiply line 4 by line 3......................
5
304,916
6
Enter 1% of net investment income (1% of Part I, line 27b)...........
6
669
7
Add lines 5 and 6........................
7
305,585
8
Enter qualifying distributions from Part XII, line 4,.............
8
1,416,127
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 Bullet and enter “N/A" on line 1. Bracket includes lines 1a and 1b
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 1 669
hereBulletand enter 1% of Part I, line 27b...................
c All other domestic foundations enter 2% of line 27b. Exempt foreign organizations enter 4% of Part I, line 12, col. (b)
2 Tax under section 511 (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-) 2 0
3 Add lines 1 and 2........................... 3 669
4 Subtitle A (income) tax (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-) 4 0
5 Tax based on investment income. Subtract line 4 from line 3. If zero or less, enter -0- ..... 5 669
6 Credits/Payments:
a 2018 estimated tax payments and 2017 overpayment credited to 2018 6a 206
b Exempt foreign organizations—tax withheld at source...... 6b
c Tax paid with application for extension of time to file (Form 8868)... 6c 600
d Backup withholding erroneously withheld ........... 6d 0
7 Total credits and payments. Add lines 6a through 6d.............. 7 806
8 Enter any penalty for underpayment of estimated tax. Check here if Form 2220 is attached. 8 0
9 Tax due. If the total of lines 5 and 8 is more than line 7, enter amount owed.......Bullet 9  
10 Overpayment. If line 7 is more than the total of lines 5 and 8, enter the amount overpaid...Bullet 10 137
11 Enter the amount of line 10 to be: Credited to 2019 estimated taxBullet137 RefundedBullet 11 0
Part VII-A
Statements Regarding Activities
1a
During the tax year, did the foundation attempt to influence any national, state, or local legislation or did
Yes
No
it participate or intervene in any political campaign? ....................
1a
 
No
b
Did it spend more than $100 during the year (either directly or indirectly) for political purposes? (see Instructions
for definition).................................
1b
 
No
If the answer is "Yes" to 1a or 1b, attach a detailed description of the activities and copies of any materials
published or distributed by the foundation in connection with the activities.
c
Did the foundation file Form 1120-POL for this year?.....................
1c
 
No
d
Enter the amount (if any) of tax on political expenditures (section 4955) imposed during the year:
(1) On the foundation. bullet$ 0(2) On foundation managers.bullet$ 0
e
Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed
on foundation managers.bullet$ 0
2
Has the foundation engaged in any activities that have not previously been reported to the IRS?.......
2
 
No
If "Yes," attach a detailed description of the activities.
3
Has the foundation made any changes, not previously reported to the IRS, in its governing instrument, articles
of incorporation, or bylaws, or other similar instruments? If "Yes," attach a conformed copy of the changes....
3
 
No
4a
Did the foundation have unrelated business gross income of $1,000 or more during the year?........
4a
 
No
b
If "Yes," has it filed a tax return on Form 990-T for this year?...................
4b
 
 
5
Was there a liquidation, termination, dissolution, or substantial contraction during the year?.........
5
 
No
If "Yes," attach the statement required by General Instruction T.
6
Are the requirements of section 508(e) (relating to sections 4941 through 4945) satisfied either:
  • By language in the governing instrument, or
  • By state legislation that effectively amends the governing instrument so that no mandatory directions
    • that conflict with the state law remain in the governing instrument?................
    6
    Yes
     
    7
    Did the foundation have at least $5,000 in assets at any time during the year? If "Yes," complete Part II, col. (c),
    and Part XV..................................
    7
    Yes
     
    8a
    Enter the states to which the foundation reports or with which it is registered (see instructions)
    bulletOR
    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. Click to see attachment...............................
    10
    Yes
     
    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 addressbulletWWW.PACIFICSOURCE.COM
    14
    The books are in care ofbulletPETER DAVIDSON Telephone no.bullet (541) 686-1242

    Located atbulletPO BOX 7068SPRINGFIELDOR ZIP+4bullet97475
    15
    Section 4947(a)(1) nonexempt charitable trusts filing Form 990-PF in lieu of Form 1041 —check here .........bullet
    and enter the amount of tax-exempt interest received or accrued during the year ........bullet
    15
     
    16 At any time during calendar year 2018, 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 the instructions for exceptions and filing requirements for FinCEN Form 114. 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 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?.............
    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
     
     
    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 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))?
    (2) Influence the outcome of any specific public election (see section 4955); or to carry
    on, directly or indirectly, any voter registration drive?.............
    (3) Provide a grant to an individual for travel, study, or other similar purposes?
    (4) Provide a grant to an organization other than a charitable, etc., organization described
    in section 4945(d)(4)(A)? See instructions................
    (5) Provide for any purpose other than religious, charitable, scientific, literary, or
    educational purposes, or for the prevention of cruelty to children or animals?.....
    b
    If any answer is "Yes" to 5a(1)–(5), did any of the transactions fail to qualify under the exceptions described in
    Regulations section 53.4945 or in a current notice regarding disaster assistance? See instructions ......
    5b
     
     
    .........bullet
    c
    If the answer is "Yes" to question 5a(4), does the foundation claim exemption from the
    tax because it maintained expenditure responsibility for the grant?..........
    If "Yes," attach the statement required by Regulations section 53.4945–5(d).
    6a
    Did the foundation, during the year, receive any funds, directly or indirectly, to pay premiums on
    a personal benefit contract?.....................
    b
    Did the foundation, during the year, pay premiums, directly or indirectly, on a personal benefit contract? ....
    6b
     
    No
    If "Yes" to 6b, file Form 8870.
    7a
    At any time during the tax year, was the foundation a party to a prohibited tax shelter transaction?
    b
    If yes, did the foundation receive any proceeds or have any net income attributable to the transaction? ....
    7b
     
     
    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? .................
    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
    KENNETH PROVENCHER DIRECTOR
    1.00     		0 0 0
    PO BOX 7068
    SPRINGFIELD,OR97475
    STEVEN MARKS DIRECTOR
    1.00     		0 0 0
    PO BOX 7068
    SPRINGFIELD,OR97475
    TOM SLICK DIRECTOR
    1.00     		0 0 0
    PO BOX 7068
    SPRINGFIELD,OR97475
    ED DAHLBERG DIRECTOR
    1.00     		0 0 0
    PO BOX 7068
    SPRINGFIELD,OR97475
    CLARK COMPTON SECRETARY
    1.00     		0 0 0
    PO BOX 7068
    SPRINGFIELD,OR97475
    JOHN DEWENTER DIRECTOR
    1.00     		0 0 0
    PO BOX 7068
    SPRINGFIELD,OR97475
    MARIAN BLANKENSHIP EXECUTIVE DIRECTOR
    10.00     		0 0 0
    PO BOX 7068
    SPRINGFIELD,OR97475
    MARTIN GABICA DIRECTOR
    1.00     		0 0 0
    PO BOX 7068
    SPRINGFIELD,OR97475
    PRISCILLA GOULD PRESIDENT, CHAIR
    1.00     		0 0 0
    PO BOX 7068
    SPRINGFIELD,OR97475
    PETER DAVIDSON DIRECTOR/CORPORATE TAX OFFICER
    1.00     		0 0 0
    PO BOX 7068
    SPRINGFIELD,OR97475
    VANETTA ABDELLATIF DIRECTOR
    1.00     		0 0 0
    PO BOX 7068
    SPRINGFIELD,OR97475
    KEN SINGER DIRECTOR
    1.00     		0 0 0
    PO BOX 7068
    SPRINGFIELD,OR97475
    2 Compensation of five highest-paid employees (other than those included on line 1—see instructions). If none, enter “NONE."
    (a) Name and address of each employee paid more than $50,000 (b) Title, and average
    hours per week
    devoted to position     		(c) Compensation (d) Contributions to
    employee benefit
    plans and deferred
    compensation     		(e) Expense account,
    other allowances
    NONE
    Total number of other employees paid over $50,000...................bullet 0
    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.............bullet0
    Part IX-A
    Summary of Direct Charitable Activities
    List the foundation’s four largest direct charitable activities during the tax year. Include relevant statistical information such as the number of organizations and other beneficiaries served, conferences convened, research papers produced, etc. Expenses
    1  
    2  
    3  
    4  
    Part IX-B
    Summary of Program-Related Investments (see instructions)
    Describe the two largest program-related investments made by the foundation during the tax year on lines 1 and 2. Amount
    1  
    2  
    All other program-related investments. See instructions.
    3  
    Total. Add lines 1 through 3.........................bullet0
    Form 990-PF (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
    208,165
    b
    Average of monthly cash balances.......................
    1b
    2,191,000
    c
    Fair market value of all other assets (see instructions)................
    1c
    0
    d
    Total (add lines 1a, b, and c).........................
    1d
    2,399,165
    e
    Reduction claimed for blockage or other factors reported on lines 1a and
    1c (attach detailed explanation) .............
    1e
    0
    2
    Acquisition indebtedness applicable to line 1 assets..................
    2
    0
    3
    Subtract line 2 from line 1d.........................
    3
    2,399,165
    4
    Cash deemed held for charitable activities. Enter 1 1/2% of line 3 (for greater amount, see
    instructions) .............................
    4
    35,987
    5
    Net value of noncharitable-use assets. Subtract line 4 from line 3. Enter here and on Part V, line 4
    5
    2,363,178
    6
    Minimum investment return. Enter 5% of line 5..................
    6
    118,159
    Part XI
    Distributable Amount (see instructions) (Section 4942(j)(3) and (j)(5) private operating foundations and certain foreign organizations check here bullet and do not complete this part.)
    1
    Minimum investment return from Part X, line 6....................
    1
    118,159
    2a
    Tax on investment income for 2018 from Part VI, line 5......
    2a
    669
    b
    Income tax for 2018. (This does not include the tax from Part VI.)...
    2b
     
    c
    Add lines 2a and 2b............................
    2c
    669
    3
    Distributable amount before adjustments. Subtract line 2c from line 1............
    3
    117,490
    4
    Recoveries of amounts treated as qualifying distributions................
    4
    0
    5
    Add lines 3 and 4............................
    5
    117,490
    6
    Deduction from distributable amount (see instructions).................
    6
    0
    7
    Distributable amount as adjusted. Subtract line 6 from line 5. Enter here and on Part XIII, line 1 ...
    7
    117,490
    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
    1,416,127
    b
    Program-related investments—total from Part IX-B..................
    1b
    0
    2
    Amounts paid to acquire assets used (or held for use) directly in carrying out charitable, etc.,
    purposes...............................
    2
     
    3
    Amounts set aside for specific charitable projects that satisfy the:
    a
    Suitability test (prior IRS approval required)....................
    3a
     
    b
    Cash distribution test (attach the required schedule) .................
    3b
     
    4
    Qualifying distributions. Add lines 1a through 3b. Enter here and on Part V, line 8, and Part XIII, line 4
    4
    1,416,127
    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
    669
    6
    Adjusted qualifying distributions. Subtract line 5 from line 4..............
    6
    1,415,458
    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 7 117,490
    2 Undistributed income, if any, as of the end of 2018:
    a Enter amount for 2017 only....... 0
    b Total for prior years:20, 20, 20 0
    3 Excess distributions carryover, if any, to 2018:
    a From 2013...... 485,870
    b From 2014...... 221,805
    c From 2015...... 194,965
    d From 2016...... 244,662
    e From 2017...... 498,008
    fTotal of lines 3a through e........ 1,645,310
    4Qualifying distributions for 2018 from Part
    XII, line 4: bullet$ 1,416,127
    a Applied to 2017, but not more than line 2a 0
    b Applied to undistributed income of prior years
    (Election required—see instructions).....     		0
    c Treated as distributions out of corpus (Election
    required—see instructions)........     		0
    d Applied to 2018 distributable amount..... 117,490
    e Remaining amount distributed out of corpus 1,298,637
    5 Excess distributions carryover applied to 2018. 0 0
    (If an amount appears in column (d), the
    same amount must be shown in column (a).)
    6Enter the net total of each column as
    indicated below:
    a Corpus. Add lines 3f, 4c, and 4e. Subtract line 5 2,943,947
    b Prior years’ undistributed income. Subtract
    line 4b from line 2b ..........     		0
    c Enter the amount of prior years’ undistributed
    income for which a notice of deficiency has
    been issued, or on which the section 4942(a)
    tax has been previously assessed......     		0
    d Subtract line 6c from line 6b. Taxable amount
    —see instructions ...........     		0
    e Undistributed income for 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 ..........     		0
    7 Amounts treated as distributions out of
    corpus to satisfy requirements imposed by
    section 170(b)(1)(F) or 4942(g)(3) (Election may
    be required - see instructions) .......     		0
    8 Excess distributions carryover from 2013 not
    applied on line 5 or line 7 (see instructions) ...     		485,870
    9Excess distributions carryover to 2019.
    Subtract lines 7 and 8 from line 6a ......     		2,458,077
    10 Analysis of line 9:
    a Excess from 2014.... 221,805
    b Excess from 2015.... 194,965
    c Excess from 2016.... 244,662
    d Excess from 2017.... 498,008
    e Excess from 2018.... 1,298,637
    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....... 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) 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.)
    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:
    MARIAN BLANKENSHIP EXECUTIVE DIRECT
    PO BOX 7068
    SPRINGFIELD,OR97475
    (541) 686-1242
    CHARITABLEFOUNDATION@PACIFICSOURCE.COM
    bThe form in which applications should be submitted and information and materials they should include:
    MICROSOFT WORD DOCUMENT. ATTACH PROGRAM BUDGET AND MOST RECENT ANNUAL FINANCIAL STATEMENT.
    cAny submission deadlines:
    SUBMISSION DEADLINES ARE ROLLING. THE COMMITTEE MEETS SEMI-ANNUALLY TO REVIEW APPLICATIONS.
    dAny restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other
    factors:
    PROGRAMS MUST ADDRESS ONE OR MORE OF THE FOLLOWING AREAS: HEALTH CARE ACCESS INITIATIVES THAT ADDRESS THE HEALTHCARE NEEDS OF CHILDREN AND YOUTH, AS WELL AS ADULTS WHO HAVE BARRIERS TO CARE AND/OR ADVANCE AND PROMOTE STRATEGIES THAT: IMPROVE ACCESS TO HIGH QUALITY HEALTHCARE, TEST AND IMPLEMENT INNOVATIVE CARE MODELS, IMPROVE COMMUNITY HEALTH, AND/OR LOWER COSTS ACROSS THE SYSTEM AND/OR WORK IN PARTNERSHIP WITH PACIFICSOURCE HEALTH PLANS AND ITS MANY BUSINESS PARTNERS AND CUSTOMERS, INCLUDING PHYSICIANS AND OTHER HEALTHCARE PROVIDERS, TO IMPROVE COMMUNITY HEALTH.
    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)
    aPaid during the year
    ADELANTE MUJERES
    2030 MAIN ST SUITE A
    FOREST GROVE,OR97116     		NONE PC BUILDING HEALTH EQUITY IN WASHINGTON COUNTY, OR FOR THE LATINO COMMUNITY. 25,000
    BETHEL SCHOOL DISTRICT
    4640 BARGER DRIVE
    EUGENE,OR97402     		NONE GOV PRODUCE STIPEND FOR HEALTHY SCHOOLS CHALLENGE 2,500
    BETHEL STUDENT HEALTH CENTER
    1525 ECHO HOLLOW RD SUITE A
    EUGENE,OR97402     		NONE GOV MENTAL HEALTH PROGRAM 28,000
    BILLINGS CLINIC FOUNDATION
    PO BOX 31031
    BILLINGS,MT59107     		NONE PC PROVIDES PROFESSIONAL CLINICAL EDUCATION, MENTORING, GUIDANCE, AND FEEDBACK TO PRIMARY CARE CLINICIANS. 10,000
    BOISE SCHOOLS EDUCATION FOUNDATION
    8169 WEST VICTORY ROAD
    BOISE,ID83709     		NONE PC SUPPORT INNOVATIVE AND MOTIVATING PROGRAMS IN THE BOISE SCHOOL DISTRICT. 25,000
    BOYS AND GIRLS CLUB CORVALLIS
    1112 NW CIRCLE BLVD
    CORVALLIS,OR97330     		NONE PC HEALTHY LIFESTYLES EXPANSION 15,000
    BUTTE SCHOOL DISTRICT
    2600 GRAND AVENUE
    BUTTE,MT59701     		NONE GOV PRODUCE STIPEND FOR HEALTHY SCHOOLS CHALLENGE 750
    BUTTE TEACHERS UNION
    2600 GRAND AVENUE
    BUTTE,MT59701     		NONE NC HEALTHY LIFE SCHOOLS CHALLENGE AWARD 3,600
    CANYON COUNTY COMMUNITY CLINIC
    524 CLEVELAND BLVD SUITE 110
    CALDWELL,ID83605     		NONE PC PROVIDING MEDICAL SERVICES TO THE UNDERSERVED. 25,000
    CASCADE MIDDLE SCHOOL
    1525 ECHO HOLLOW RD
    EUGENE,OR97402     		NONE GOV HEALTHY LIFE SCHOOLS CHALLENGE AWARD 300
    CATHOLIC CHARITIES
    2740 SW POWELL BLVD
    PORTLAND,OR97202     		NONE PC TO PROVIDE SUPPORT AND COUNSELING SERVICES TO OREGONIANS. 50,000
    CENTER FOR COMMUNITY COUNSELING
    1465 COBURG RD
    EUGENE,OR97401     		NONE PC PROVIDE MENTAL HEALTH COUNSELING FOR THOSE WITH LIMITED INCOME, UNDERINSURED, OR LACKING HEALTH INSURANCE. 35,000
    CENTRAL CITY CONCERN
    232 NW 6TH AVE
    PORTLAND,OR97209     		NONE PC FUNDING TO OPEN HANSEN SHELTER URGENT CARE CLINIC 30,000
    CENTRAL POINT SCHOOL DISTRICT #6
    300 ASH ST
    CENTRAL POINT,OR97502     		NONE GOV BUILDING HEALTHY FAMILIES - A SCHOOL BASED HEALTH CENTER AT HANBY MIDDLE SCHOOL 30,000
    CHILDREN'S HOME SOCIETY OF IDAHO
    740 WARM SPRINGS AVE
    BOISE,ID83712     		NONE PC PROVIDE MENTAL HEALTH SERVICES FOR KIDS ON MEDICAID. 20,000
    CLACKAMAS VOLUNTEERS IN MEDICINE
    700 MOLALLA AVENUE
    OREGON CITY,OR97045     		NONE PC CLINIC COORDINATION TO SUPPORT PATIENT PROGRAMS SERVING CLACKAMAS COUNTY'S LOW-INCOME RESIDENTS 30,000
    COMMUNITY FOOD AND AGRICULTURE COALITION
    PO BOX 7025
    MISSOULA,MT59807     		NONE PC DOUBLE SNAP DOLLARS FOR HEALTHY COMMUNITIES 15,000
    COMMUNITY OUTREACH
    865 REIMAN AVE
    CORVALLIS,OR97730     		NONE PC PROVIDE MEDICAL SERVICES UNINSURED, LOW INCOME, OR NEWLY INSURED ADULTS. 30,000
    CORNERSTONE COMMUNITY HOUSING
    PO BOX 11923
    EUGENE,OR97440     		NONE PC HEALTHY HOMES PROGRAM TO PROVIDE AFFORDABLE HOUSING IN LANE COUNTY 25,000
    DAISY CHAIN CREATING HEALTHY
    PO BOX 10375
    EUGENE,OR97440     		NONE PC INCREASE EQUITABLE ACCESS TO PREVENTATIVE PRE AND POST-NATAL PROGRAMS IN LANE COUNTY. 21,682
    FAMILIAS EN ACCION
    2710 NE 14TH AVE
    PORTLAND,OR97212     		NONE PC PROMOTE HOLISTIC FAMILY WELL-BEING FOR LATINOS 58,838
    FAMILY ADVOCATES
    3010 WEST STATE STREET
    BOISE,ID83703     		NONE PC MITIGATING ADVERSE CHILDHOOD EXPERIENCES TO STRENGTHEN FAMILIES AND PROMOTE HEALTH. 30,000
    FARMERS MARKET FUND
    240 N BROADWAY SUITE 129
    PORTLAND,OR97227     		NONE PC DOUBLE UP FOOD BUCKS FOR SNAP 10,000
    FOOD FOR LANE COUNTY
    770 BAILEY HILL ROAD
    EUGENE,OR97402     		NONE PC COMPREHENSIVE CHILD AND FAMILY NUTRITION FOR AT RISK MEMBERS IN LANE COUNTY. 25,000
    GENESIS COMMUNITY HEALTH
    215 W 35TH ST
    GARDEN CITY,ID83714     		NONE PC PROVIDE TRANSITIONAL PRIMARY HEALTHCARE, SOCIAL AND SPIRITUAL SUPPORT TO LOW-INCOME UNINSURED INDIVIDUALS IN IDAHO'S TREASURE VALLEY. 35,000
    HEALTHY BEGINNINGS
    1029 NW 14TH STREET
    BEND,OR97703     		NONE PC HEALTH, DEVELOPMENT, AND BEHAVIORAL SCREENING TO CHILDREN IN CENTRAL OREGON UNDER AGE 5. 25,000
    HIGH DESERT FOOD AND FARM ALLIANCE
    PO BOX 1782
    BEND,OR97709     		NONE PC IMPLEMENT INNOVATIVE CARE MODELS AND IMPROVE COMMUNITY HEALTH 58,529
    KEMPLE MEMORIAL CHILDRENS DENTAL CLINIC
    1029 NW 14TH STREET SUITE 101
    BEND,OR97703     		NONE PC PROVIDE ORAL HEALTH SERVICES FOR CHILDREN AND YOUNG ADULTS (AGES 3-25) WHO ARE AT RISK 20,000
    LEGACY HEALTH FOUNDATION
    PO BOX 4484
    PORTLAND,OR97208     		NONE PC UNITY CENTER PEER SUPPORT PROGRAM 100,000
    MEALS ON WHEELS PEOPLE
    7710 SW 31ST AVE
    PORTLAND,OR97219     		NONE PC MEAL DELIVERY FOR SENIORS IN MULTNOMAH, WASHINGTON, AND CLARK COUNTIES. 5,000
    MEDICAL TEAMS INTERNATIONAL
    14150 SW MILTON CT
    TIGARD,OR97224     		NONE PC DENTAL CARE FOR RURAL COUNTIES IN OREGON. 25,000
    MIKE PROGRAM
    91555 SW BARNES RD SUITE 219
    PORTLAND,OR97209     		NONE PC IMPROVE MY HEALTHY PLANNER WORKBOOKS 30,000
    MOUNTAIN HOME MONTANA
    2606 SOUTH AVE W
    MISSOULA,MT59804     		NONE PC ACCESS TO TRAUMA-INFORMED MENTAL HEALTHCARE FOR YOUNG FAMILIES AT MOUNTAIN HOME. 30,000
    MT VERNON ELEMENTARY SCHOOL
    935 FILBERT LANE
    SPRINGFIELD,OR97478     		NONE GOV HEALTHY LIFE SCHOOLS CHALLENGE AWARD 300
    NORTHWEST CATHOLIC COUNSELING
    8383 NW SANDY BLVD 205
    PORTLAND,OR97220     		NONE PC MENTAL HEALTH CARE FOR LOWER INCOME OLDER WOMEN 15,000
    OLD MILL CENTER FOR CHILDREN AND FAMILIES
    1650 SW 45TH PLACE
    CORVALLIS,OR97333     		NONE PC TRAUMA INFORMED CARE TRAINING AND SUPPORT FOR COMMUNITY ORGANIZATIONS 22,000
    OSLC DEVELOPMENTS INC
    10 SHELTON MCMURPHEY BLVD
    EUGENE,OR97401     		NONE PC HEALTHY DEVELOPMENT OF CHILDREN AND FAMILIES 30,000
    PLANNED PARENTHOOD OF MONTANA
    1116 GRAND AVE SUITE 201
    BILLINGS,MT59102     		NONE PC PROVIDE QUALITY HEALTHCARE, MEDICAL EDUCATION, AND ADVOCACY FOR INDIVIDUAL RIGHTS. 15,000
    PROJECT ACCESS NOW
    PO BOX 10953
    PORTLAND,OR97296     		NONE PC COORDINATE CARE FOR THE REGIONAL COMMUNITY HEALTH NETWORK 50,000
    RETURNING VETERANS PROJECT
    883 SE MAIN ST
    PORTLAND,OR97214     		NONE PC FREE AND CONFIDENTIAL MEDICAL SERVICES FOR RETURNING VETERANS AND SERVICE MEMBERS. 7,000
    RIVERBEND ELEMENTARY SCHOOL
    320 51ST ST
    SPRINGFIELD,OR97478     		NONE GOV HEALTHY LIFE SCHOOLS CHALLENGE AWARD 1,000
    SALEM FREE CLINICS
    1300 BROADWAY ST NE SUITE 104
    SALEM,OR97301     		NONE PC COMPREHENSIVE HEALTH SERVICES TO THE UNINSURED AND UNDERINSURED. 40,000
    SHASTA MIDDLE SCHOOL
    4656 BARGER DR
    EUGENE,OR97402     		NONE GOV HEALTHY LIFE SCHOOLS CHALLENGE AWARD 1,000
    SHELTERCARE
    499 WEST 4TH
    EUGENE,OR97401     		NONE PC PROVIDE SHELTER TO FAMILIES WITH CHILDREN WHO ARE HOMELESS BY THE UHLHORN PROGRAM EVOLUTION. 60,000
    SNAKE RIVER COMMUNITY CLINIC
    215 10TH ST
    LEWISTON,ID83501     		NONE PC PROVIDE ACUTE CARE TO THE HOMELESS. 40,000
    SOUTH LANE MENTAL HEALTH
    1345 BIRCH AVE
    COTTAGE GROVE,OR97424     		NONE PC PROVIDE CARE TO COTTAGE GROVE ADULT AND CHILDREN'S OUTPATIENT MENTAL HEALTH SERVICES. 30,000
    SOUTHWEST COMMUNITY HEALTH CENTER
    7754 SW CAPITOL HWY
    PORTLAND,OR97219     		NONE PC PROVIDE BASIC HEALTHCARE TO LOW INCOME, UNINSURED MEMBERS OF THE SW PORTLAND AND HILLSBORO COMMUNITY. 25,000
    SPRINGFIELD HIGH SCHOOL
    875 7TH STREET
    SPRINGFIELD,OR97477     		NONE GOV HEALTHY LIFE SCHOOLS CHALLENGE AWARD 1,000
    SPRINGFIELD SCHOOL DISTRICT
    525 MILL ST
    SPRINGFIELD,OR97477     		NONE GOV PRODUCE STIPEND FOR HEALTHY SCHOOLS CHALLENGE 3,000
    SW COMMUNITY HEALTH CENTER
    7754 SW CAPITOL HWY
    PORTLAND,OR97219     		NONE PC EXPAND HOURS AND SERVICES TO LOW INCOME UNINSURED INDIVIDUALS. 10,000
    THE FRIENDSHIP CLINIC INC
    704 S LATAH ST
    BOISE,ID83705     		NONE PC OFFER FREE BASIC HEALTHCARE TO UNINSURED OR UNDERINSURED, EMPHASIZING HEALTH PROMOTION AND DISEASE PREVENTION. 10,000
    THE WALLACE MEDICAL CONCERN
    124 NE 188TH AVE SUITE 103
    PORTLAND,OR97230     		NONE PC PROVIDE ACCESS TO CARE AND INNOVATIONS TO YOUTH AND ADULTS WITH BARRIERS TO CARE. 20,000
    VOLUNTEERS IN MEDICINE CLINIC OF THE CASCADES
    2300 NW NEFF RD
    BEND,OR97701     		NONE PC OUTREACH, REFERRAL, ACUTE CARE, AND ONGOING HEALTHCARE TO FOR UNINSURED OR UNINSURED WORKERS. 40,000
    VOLUNTEERS IN MEDICINE
    2260 MARCOLA RD
    SPRINGFIELD,OR97477     		NONE PC OUTREACH, REFERRAL, ACUTE CARE, AND ONGOING HEALTHCARE TO FOR UNINSURED OR UNINSURED WORKERS. 40,000
    WELLMAMA INC
    150 SHELTON MCMURPHEY BLVD SUITE
    208
    EUGENE,OR97401     		NONE PC PROVIDE PREGNANCY AND POSTPARTUM MENTAL HEALTH SUPPORT SERVICES TO WOMEN AND THEIR FAMILIES IN LANE COUNTY. 12,468
    WILLAMETTE HIGH SCHOOL
    1801 ECHO HOLLOW ROAD
    EUGENE,OR97402     		NONE GOV HEALTHY LIFE SCHOOLS CHALLENGE AWARD 300
    WOMENS AND CHILDRENS ALLIANCE INC
    720 W WASHINGTON ST
    BOISE,ID83702     		NONE PC SERVING CHILD VICTIMS OF DOMESTIC VIOLENCE THROUGH INDIVIDUAL COUNSELING. 30,000
    YOUTH HOMES
    550 N CALIFORNIA STREET
    MISSOULA,MT59801     		NONE PC PROVIDE COMMUNITY BASED MENTAL HEALTH SERVICES FOR WESTERN MONTANA FAMILIES. 25,000
    Total .................................bullet 3a 1,402,267
    bApproved for future payment
    Total .................................bullet 3b 0
    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.)
    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 11,388  
    4 Dividends and interest from securities....     14 62,418  
    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 ............     		         
    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 73,806 0
    13Total. Add line 12, columns (b), (d), and (e)..................
    13
    73,806
    (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 (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? ...........
    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 (2018)
    Additional Data


    Software ID:  
    Software Version:  


    Form 990PF - Special Condition Description:
    Special Condition Description
    Schedule B
    (Form 990, 990-EZ,
    or 990-PF)
    Department of the Treasury
    Internal Revenue Service
    Schedule of Contributors

    Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
    Arrow Bullet Go to www.irs.gov/Form990 for the latest information.
    OMB No. 1545-0047
    2018
    Name of the organization
    PACIFICSOURCE FOUNDATION FOR HEALTH
    IMPROVEMENT
    Employer identification number

    93-1100080
    Organization type (check one):
    Filers of:
    Section:
    Form 990 or 990-EZ






    Form 990-PF




    Check if your organization is covered by the General Rule or a Special Rule.  
    Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.
    General Rule
    Special Rules
    ......... Arrow Bullet $  
    Caution. An organization that isn't covered by the General Rule and/or the Special Rules doesn't file Schedule B (Form 990,
    990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2, of its Form 990; or check the box on line H of its
    Form 990-EZ or on its Form 990PF, Part I, line 2, to certify that it doesn't meet the filing requirements of Schedule B (Form 990,
    990-EZ, or 990-PF).
    For Paperwork Reduction Act Notice, see the Instructions
    for Form 990, 990-EZ, or 990-PF.
    Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2018)
    Schedule B (Form 990, 990-EZ, or 990-PF) (2018) Page 2
    Name of organization
    PACIFICSOURCE FOUNDATION FOR HEALTH
    IMPROVEMENT         		Employer identification number
    93-1100080
    Part I
    Contributors (See instructions). Use duplicate copies of Part I if additional space is needed.
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
    1
    PACIFIC HEALTH ASSOCIATES
     
    110 INTERNATIONAL WAY
     
    SPRINGFIELD, OR97477

    		$ 1,900,000


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
     
     
     
     

    		$  


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
     
     
     
     

    		$  


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
     
     
     
     

    		$  


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
     
     
     
     

    		$  


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
     
     
     
     

    		$  


    (Complete Part II for noncash contributions.)
    Schedule B (Form 990, 990-EZ, or 990-PF) (2018)
    Schedule B (Form 990, 990-EZ, or 990-PF) (2018)
    Page 3
    Name of organization
    PACIFICSOURCE FOUNDATION FOR HEALTH
    IMPROVEMENT         		Employer identification number

    93-1100080
    Part II
    Noncash Property (See instructions). Use duplicate copies of Part II if additional space is needed.
    (a)
    No. from Part I    		 (b)
    Description of noncash property given    		 (c)
    FMV (or estimate)
    (See instructions)     		(d)
    Date received
     
    		$    
    (a)
    No. from Part I    		 (b)
    Description of noncash property given    		 (c)
    FMV (or estimate)
    (See instructions)     		(d)
    Date received
     
    		$    
    (a)
    No. from Part I    		 (b)
    Description of noncash property given    		 (c)
    FMV (or estimate)
    (See instructions)     		(d)
    Date received
     
    		$    
    (a)
    No. from Part I    		 (b)
    Description of noncash property given    		 (c)
    FMV (or estimate)
    (See instructions)     		(d)
    Date received
     
    		$    
    (a)
    No. from Part I    		 (b)
    Description of noncash property given    		 (c)
    FMV (or estimate)
    (See instructions)     		(d)
    Date received
     
    		$    
    (a)
    No. from Part I    		 (b)
    Description of noncash property given    		 (c)
    FMV (or estimate)
    (See instructions)     		(d)
    Date received
     
    		$    
    Schedule B (Form 990, 990-EZ, or 990-PF) (2018)
    Schedule B (Form 990, 990-EZ, or 990-PF) (2018)
    Page 4
    Name of organization
    PACIFICSOURCE FOUNDATION FOR HEALTH
    IMPROVEMENT         		Employer identification number

    93-1100080
    Part III
    Exclusively religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10) that total more than $1,000 for the year from any one contributor. Complete columns (a) through (e) and the following line entry. For organizations completing Part III, enter the total of exclusively religious, charitable, etc., contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet$  
    Use duplicate copies of Part III if additional space is needed.
    (a)
    No. from Part I    		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
     
    (e) Transfer of gift
    Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
     
     
         
     
    (a)
    No. from Part I    		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
     
    (e) Transfer of gift
    Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
     
     
         
     
    (a)
    No. from Part I    		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
     
    (e) Transfer of gift
    Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
     
     
         
     
    (a)
    No. from Part I    		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
     
    (e) Transfer of gift
    Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
     
     
         
     
    Schedule B (Form 990, 990-EZ, or 990-PF) (2018)

    Additional Data


    Software ID:  
    Software Version:  

    TY 2018 InvestmentsOtherSchedule2
    Name:
    PACIFICSOURCE FOUNDATION FOR HEALTH
     
    IMPROVEMENT
    EIN:
    93-1100080
    Category/ Item Listed at Cost or FMV Book Value End of Year Fair Market Value
    COMPASS GLOBAL EQUITY AT COST 24,274 24,274
    AZURE FIXED INCOME FUND AT COST 78,739 78,739
    WELLS CAPITAL AT COST 2,985,014 2,985,014

    TY 2018 OtherAssetsSchedule
    Name:
    PACIFICSOURCE FOUNDATION FOR HEALTH
     
    IMPROVEMENT
    EIN:
    93-1100080
    Description Beginning of Year - Book Value End of Year - Book Value End of Year - Fair Market Value
    INTEREST RECEIVABLE 3,816 6,476 6,476


    TY 2018 OtherDecreasesSchedule
    Name:
    PACIFICSOURCE FOUNDATION FOR HEALTH
     
    IMPROVEMENT
    EIN:
    93-1100080
    Description Amount
    UNREALIZED LOSSES 52,779


    TY 2018 OtherExpensesSchedule
    Name:
    PACIFICSOURCE FOUNDATION FOR HEALTH
     
    IMPROVEMENT
    EIN:
    93-1100080
    Description Revenue and Expenses per Books Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    AUTO EXPENSE 1,078 539 0 539
    PENALTIES 0 0 0 0
    AUDITING FEES 3,183 1,592 0 1,592
    PURCHASED SERVICES 5,000 0 0 5,000
    CONTINUING EDUCATION 2,802 0 0 2,802


    TY 2018 OtherLiabilitiesSchedule
    Name:
    PACIFICSOURCE FOUNDATION FOR HEALTH
     
    IMPROVEMENT
    EIN:
    93-1100080
    Description Beginning of Year - Book Value End of Year - Book Value
    INCOME TAX PAYABLE 663 263


    TY 2018 SubstantialContributorsSch
    Name:
    PACIFICSOURCE FOUNDATION FOR HEALTH
     
    IMPROVEMENT
    EIN:
    93-1100080
    Name Address
    PACIFIC HEALTH ASSOCIATES 110 INTERNATIONAL WAY
    SPRINGFIELD,OR97477


    TY 2018 TaxesSchedule
    Name:
    PACIFICSOURCE FOUNDATION FOR HEALTH
     
    IMPROVEMENT
    EIN:
    93-1100080
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    STATE FILING FEES 884 884 0 0