Form990-PF
Click to see attachment

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
The Jacquemin Family Foundation Inc
 
Number and street (or P.O. box number if mail is not delivered to street address)8609 Westwood Center Drive Suite
  Room/suite
City or town, state or province, country, and ZIP or foreign postal code
Vienna, VA22182
A Employer identification number

54-1887187
B Telephone number (see instructions)

(703) 917-0707
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$7,252,553J Accounting method:
 
(Part I, column (d) must be on cash basis.)
Part I Analysis of Revenue and Expenses (The total of amounts in columns (b), (c), and (d) may not necessarily equal the amounts in column (a) (see instructions).) (a) Revenue and
expenses per
books 		(b) Net investment
income 		(c) Adjusted net
income 		(d) Disbursements
for charitable
purposes
(cash basis only)
Revenue 1 Contributions, gifts, grants, etc., received (attach schedule)  
2 Check bullet.............
3 Interest on savings and temporary cash investments 18,740 18,740 18,740
4 Dividends and interest from securities... 174,853 174,853 174,853
5a Gross rents............      
b Net rental income or (loss)  
6a Net gain or (loss) from sale of assets not on line 10 6,536
b Gross sales price for all assets on line 6a 75,530
7 Capital gain net income (from Part IV, line 2)... 6,536
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........ 200,129 200,129 193,593
Operating and Administrative Expenses 13 Compensation of officers, directors, trustees, etc.        
14 Other employee salaries and wages......        
15 Pension plans, employee benefits.......        
16a Legal fees (attach schedule).........        
b Accounting fees (attach schedule)....... Click to see attachment 2,510 2,510    
c Other professional fees (attach schedule)....        
17 Interest...............        
18 Taxes (attach schedule) (see instructions)... Click to see attachment 3,460 3,460    
19 Depreciation (attach schedule) and depletion...      
20 Occupancy..............        
21 Travel, conferences, and meetings.......        
22 Printing and publications..........        
23 Other expenses (attach schedule)....... Click to see list of attachments 1,767 1,767    
24 Total operating and administrative expenses.
Add lines 13 through 23.......... 7,737 7,737   0
25 Contributions, gifts, grants paid....... 391,825 391,825
26 Total expenses and disbursements. Add lines 24 and 25 399,562 7,737   391,825
27 Subtract line 26 from line 12:
a Excess of revenue over expenses and disbursements -199,433
b Net investment income (if negative, enter -0-) 192,392
c Adjusted net income (if negative, enter -0-)... 193,593
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............. 227,065 436,928 436,928
2 Savings and temporary cash investments......... 1,432,964 1,026,880 1,026,880
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) bullet5,228
Less: allowance for doubtful accounts bullet   4,503 Click to see attachment5,228 5,228
8 Inventories for sale or use..............      
9 Prepaid expenses and deferred charges..........      
10a Investments—U.S. and state government obligations (attach schedule)      
b Investments—corporate stock (attach schedule)....... 7,341,338 5,765,506 5,772,037
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).......... 11,480 11,480 11,480
14 Land, buildings, and equipment: basis bullet  
Less: accumulated depreciation (attach schedule) bullet        
15 Other assets (describe bullet)      
16 Total assets (to be completed by all filers—see the
instructions. Also, see page 1, item I) 9,017,350 7,246,022 7,252,553
Liabilities 17 Accounts payable and accrued expenses..........   10,000
18 Grants payable.................    
19 Deferred revenue.................    
20 Loans from officers, directors, trustees, and other disqualified persons    
21 Mortgages and other notes payable (attach schedule)......    
22 Other liabilities (describe bullet)    
23 Total liabilities (add lines 17 through 22).........   10,000
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.................. 9,017,350 7,236,022
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........    
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)..... 9,017,350 7,236,022
31 Total liabilities and net assets/fund balances (see instructions). 9,017,350 7,246,022
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
9,017,350
2
Enter amount from Part I, line 27a .....................
2
-199,433
3
Other increases not included in line 2 (itemize) bullet
3
 
4
Add lines 1, 2, and 3 ..........................
4
8,817,917
5
Decreases not included in line 2 (itemize) bulletClick to see attachment
5
1,581,895
6
Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 30 .
6
7,236,022
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.)
1 a 0.448 Williams COS INC P 2018-08-10 2018-08-13
b 1592 Williams Partners LP P 2000-01-01 2018-08-13
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 14   14  
b 75,516   68,980 6,536
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       6,536
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 6,536
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 370,420 7,401,640 0.05005
2016 203,674 3,561,376 0.05719
2015 187,125 4,286,415 0.04366
2014 191,418 3,550,235 0.05392
2013 213,053 3,884,301 0.05485
2
Total of line 1, column (d) .....................
2
0.259658
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
0.051932
4
Enter the net value of noncharitable-use assets for 2018 from Part X, line 5......
4
8,631,290
5
Multiply line 4 by line 3......................
5
448,240
6
Enter 1% of net investment income (1% of Part I, line 27b)...........
6
1,924
7
Add lines 5 and 6........................
7
450,164
8
Enter qualifying distributions from Part XII, line 4,.............
8
391,825
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 3,848
hereBulletand enter 1% of Part I, line 27b...................
c All other domestic foundations enter 2% of line 27b. Exempt foreign organizations enter 4% of Part I, line 12, col. (b)
2 Tax under section 511 (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-) 2  
3 Add lines 1 and 2........................... 3 3,848
4 Subtitle A (income) tax (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-) 4  
5 Tax based on investment income. Subtract line 4 from line 3. If zero or less, enter -0- ..... 5 3,848
6 Credits/Payments:
a 2018 estimated tax payments and 2017 overpayment credited to 2018 6a 4,228
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 4,228
8 Enter any penalty for underpayment of estimated tax. Check here if Form 2220 is attached. Click to see attachment 8  
9 Tax due. If the total of lines 5 and 8 is more than line 7, enter amount owed.......Bullet 9  
10 Overpayment. If line 7 is more than the total of lines 5 and 8, enter the amount overpaid...Bullet 10 380
11 Enter the amount of line 10 to be: Credited to 2019 estimated taxBullet380 RefundedBullet 11  
Part VII-A
Statements Regarding Activities
1a
During the tax year, did the foundation attempt to influence any national, state, or local legislation or did
Yes
No
it participate or intervene in any political campaign? ....................
1a
 
No
b
Did it spend more than $100 during the year (either directly or indirectly) for political purposes? (see Instructions
for definition).................................
1b
 
No
If the answer is "Yes" to 1a or 1b, attach a detailed description of the activities and copies of any materials
published or distributed by the foundation in connection with the activities.
c
Did the foundation file Form 1120-POL for this year?.....................
1c
 
No
d
Enter the amount (if any) of tax on political expenditures (section 4955) imposed during the year:
(1) On the foundation. bullet$   (2) On foundation managers.bullet$  
e
Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed
on foundation managers.bullet$  
2
Has the foundation engaged in any activities that have not previously been reported to the IRS?.......
2
 
No
If "Yes," attach a detailed description of the activities.
3
Has the foundation made any changes, not previously reported to the IRS, in its governing instrument, articles
of incorporation, or bylaws, or other similar instruments? If "Yes," attach a conformed copy of the changes....
3
 
No
4a
Did the foundation have unrelated business gross income of $1,000 or more during the year?........
4a
 
No
b
If "Yes," has it filed a tax return on Form 990-T for this year?...................
4b
 
No
5
Was there a liquidation, termination, dissolution, or substantial contraction during the year?.........
5
 
No
If "Yes," attach the statement required by General Instruction T.
6
Are the requirements of section 508(e) (relating to sections 4941 through 4945) satisfied either:
  • By language in the governing instrument, or
  • By state legislation that effectively amends the governing instrument so that no mandatory directions
    • that conflict with the state law remain in the governing instrument?................
    6
    Yes
     
    7
    Did the foundation have at least $5,000 in assets at any time during the year? If "Yes," complete Part II, col. (c),
    and Part XV..................................
    7
    Yes
     
    8a
    Enter the states to which the foundation reports or with which it is registered (see instructions)
    bullet
    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 addressbulletN/A
    14
    The books are in care ofbulletJohn M Jacquemin Telephone no.bullet (703) 917-0289

    Located atbullet8609 Westwood Center Drive Suite 45ViennaVA ZIP+4bullet22182
    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
     
    No
    c
    If the provisions of section 4942(a)(2) are being applied to any of the years listed in 2a, list the years here.
    bullet20, 20, 20, 20
    3a
    Did the foundation hold more than a 2% direct or indirect interest in any business enterprise at
    any time during the year?......................
    b
    If "Yes," did it have excess business holdings in 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
     
    No
    4a
    Did the foundation invest during the year any amount in a manner that would jeopardize its charitable purposes?
    4a
     
    No
    b
    Did the foundation make any investment in a prior year (but after December 31, 1969) that could jeopardize its
    charitable purpose that had not been removed from jeopardy before the first day of the tax year beginning in 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
     
    No
    .........bullet
    c
    If the answer is "Yes" to question 5a(4), does the foundation claim exemption from the
    tax because it maintained expenditure responsibility for the grant?..........
    If "Yes," attach the statement required by Regulations section 53.4945–5(d).
    6a
    Did the foundation, during the year, receive any funds, directly or indirectly, to pay premiums on
    a personal benefit contract?.....................
    b
    Did the foundation, during the year, pay premiums, directly or indirectly, on a personal benefit contract? ....
    6b
     
    No
    If "Yes" to 6b, file Form 8870.
    7a
    At any time during the tax year, was the foundation a party to a prohibited tax shelter transaction?
    b
    If yes, did the foundation receive any proceeds or have any net income attributable to the transaction? ....
    7b
     
    No
    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
    John M Jacquemin Manager
    0.00     		0    
    8609 Westwood Center Dr 450
    Vienna,VA22182
    Tracie J Jaquemin Secretary
    1.00     		0    
    8609 Westwood Center Dr 450
    Vienna,VA22182
    Claude Jacquemin Director
    1.00     		0    
    8609 Westwood Center Dr 450
    Vienna,VA22182
    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  
    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.............bullet  
    Part IX-A
    Summary of Direct Charitable Activities
    List the foundation’s four largest direct charitable activities during the tax year. Include relevant statistical information such as the number of organizations and other beneficiaries served, conferences convened, research papers produced, etc. Expenses
    1  
    2  
    3  
    4  
    Part IX-B
    Summary of Program-Related Investments (see instructions)
    Describe the two largest program-related investments made by the foundation during the tax year on lines 1 and 2. Amount
    1  
    2  
    All other program-related investments. See instructions.
    3  
    Total. Add lines 1 through 3.........................bullet  
    Form 990-PF (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
    7,055,300
    b
    Average of monthly cash balances.......................
    1b
    1,695,951
    c
    Fair market value of all other assets (see instructions)................
    1c
    11,480
    d
    Total (add lines 1a, b, and c).........................
    1d
    8,762,731
    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
    8,762,731
    4
    Cash deemed held for charitable activities. Enter 1 1/2% of line 3 (for greater amount, see
    instructions) .............................
    4
    131,441
    5
    Net value of noncharitable-use assets. Subtract line 4 from line 3. Enter here and on Part V, line 4
    5
    8,631,290
    6
    Minimum investment return. Enter 5% of line 5..................
    6
    431,565
    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
    431,565
    2a
    Tax on investment income for 2018 from Part VI, line 5......
    2a
    3,848
    b
    Income tax for 2018. (This does not include the tax from Part VI.)...
    2b
     
    c
    Add lines 2a and 2b............................
    2c
    3,848
    3
    Distributable amount before adjustments. Subtract line 2c from line 1............
    3
    427,717
    4
    Recoveries of amounts treated as qualifying distributions................
    4
     
    5
    Add lines 3 and 4............................
    5
    427,717
    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
    427,717
    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
    391,825
    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
    391,825
    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
    391,825
    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 7 427,717
    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......  
    b From 2014...... 7,947
    c From 2015......  
    d From 2016...... 26,557
    e From 2017...... 3,634
    fTotal of lines 3a through e........ 38,138
    4Qualifying distributions for 2018 from Part
    XII, line 4: bullet$ 391,825
    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..... 391,825
    e Remaining amount distributed out of corpus  
    5 Excess distributions carryover applied to 2018. 35,892 35,892
    (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 2,246
    b Prior years’ undistributed income. Subtract
    line 4b from line 2b ..........     		 
    c Enter the amount of prior years’ undistributed
    income for which a notice of deficiency has
    been issued, or on which the section 4942(a)
    tax has been previously assessed......     		 
    d Subtract line 6c from line 6b. Taxable amount
    —see instructions ...........     		 
    e Undistributed income for 2017. Subtract line
    4a from line 2a. Taxable amount—see
    instructions .............     		 
    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) .......     		 
    8 Excess distributions carryover from 2013 not
    applied on line 5 or line 7 (see instructions) ...     		 
    9Excess distributions carryover to 2019.
    Subtract lines 7 and 8 from line 6a ......     		2,246
    10 Analysis of line 9:
    a Excess from 2014....  
    b Excess from 2015....  
    c Excess from 2016....  
    d Excess from 2017.... 2,246
    e Excess from 2018....  
    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).)
    John M Jacquemin
    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:
    John M Jacquemin
    8609 Westwood Center Drive Suite 45
    Vienna,VA22182
    (703) 917-0707
    bThe form in which applications should be submitted and information and materials they should include:
    No form required
    cAny submission deadlines:
    None
    dAny restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other
    factors:
    no
    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
    Levine School of Music
    2801 Upton Street NW
    Washington,DC20008     		None 501(c)(3) Non-for-profit community music school. 10,000
    Main Street Child Development Cente
    4401 Sideburn Road
    Fairfax,VA22030     		None 501(c)(3) Main Street provides 3,000 hours of nationally-accredited educational instruction and enrichment for at-risk children (ages 2 to 5) each year. 5,000
    Martha's Table Inc
    2114 14th Street NW
    Washington DC,DC20009     		None 501(c)(3) Marthas Table transforms lives by engaging the community in developing sustainable solutions to poverty. They meet core needs of their clients with education, nutrition, clothing, and family support programs that prepare young people, from infancy through adulthood, for a promising future. 5,000
    Bright Beginnings
    128 M Street NW Ste 150
    Washington,DC20001     		None 501(c)(3) Provides safe, nurturing environment and childcare for homeless infants, toddlers, and preschoolers and helps their parents to end their homelessness. 10,000
    Kenya Education Fund KEF
    PO Box 7015
    Mclean,VA22106     		None 501(c)(3) Funds the high school education of 40 needy and nomadic students in Kenya. 25,000
    Kid Pan Alley
    PO Box 38
    Washington,VA22747     		None 501(c)(3) Funds the process of inspiring and empowering children to work together to become creators of their own music and rekindles creativity as a core value in education. 20,000
    Inner City Inner Child
    3133 Dumbarton Street NW
    Washington,DC20007     		None 501(c)(3) Provides books for childrenigniting a passion for reading and creating a literacy-rich environment for the youngest children by working with child care centers where the kids spends most of their day. 5,000
    University at Buffalo BNAC
    PO Box 730
    Buffalo,NY14226     		None 501(c)(3) Supports the Buffalo Neuroimaging Analysis Center Fund in the School of Medicine and Biomedical Sciences in particular research in multiple sclerosis. This research allows clinicians, researchers and medical students from around the world to advance their understanding of multiple sclerosis and other diseases of the brain, spinal cord and optic nerve . 30,000
    Second Story
    PO Box 694
    Dun Loring,VA22027     		None 501(c)(3) Funds shelter for runaway, abused and homeless teens by offering safe and accessible places where teens can get help, development important life skills, and improve family relationships. 15,000
    Homestretch
    303 South Maple Ave Suite 400
    Falls Church,VA22046     		None 501(c)(3) Empowers homeless families to return to stable housing and self-sufficiency by providing them with the skills to become productive participants in Northern Virginia. 7,500
    George Mason
    4400 University Dr
    Fairfax,VA22030     		None 501(c)(3) University 91,775
    The Elephant Sanctuary
    27 East Main St
    Hohenwald,TN38462     		None 501(c)(3) The nations largest natural habitat refuge developed specifically for African and Asian elephants. It provides captive elephants a natural habitat, individualized care and the opportunity to live out their lives in a safe haven dedicated to their wellbeing. 5,000
    Sitar Arts Center
    1700 Kalorama Rd NW 101
    Washington,DC20009     		None 501(c)(3) Sitar Arts Center provides after-school, weekend and summer classes in the visual arts, music, drama, dance, digital arts and creative writing to over 700 students a year. 5,000
    Hopecam
    12100 Sunset Hills Rd C10
    Reston,VA20190     		None 501(c)(3) Hopecam connects children undergoing treatment for cancer with their friends at school usingtablet computers, high speed internet connections and web cameras. 500
    Rappahannock Pantry
    602 Mt Salem Ave
    Washington,VA22747     		None 501(c)(3) distributes food to residents in need. 2,000
    The Arc of Northern Virginia
    2755 Harland Road Suite 200
    Falls Church,VA22043     		None 501(c)(3) To promotes and protect the human right of people. 5,000
    Headwaters
    12018 Lee Hwy
    Sperryville,VA22740     		None PF To foster educational excellence in Rappahannock County by cultivating the cooperative spirit and resources of the whole community to benefit all students. 5,000
    Inova Kellar
    11204 Waples Mill Rd
    Fairfax,VA22030     		None 501(c)(3) Inova Kellar Center has provided behavioral health services for children, adolescents and their families for twenty years. Our comprehensive mental health and substance abuse treatment programs and an innovative special education school support families throughout Northern Virginia and continue to expand to meet future needs. 5,000
    RAAC
    PO Box 24
    Washington,VA22747     		None 501(c)(3) RAAC is an organization in Rappahannock country that focuses on enhancing the lives of the community through exposure to and participation in the arts. 1,000
    SAGWA Suzuki Association
    2349 Belleview Ave
    Cheverly,MD20785     		None 501(c)(3) To improving childrens lives through music education. Our mission is to inspire an appreciation for the untapped possibilities of children through promoting the understanding and use of the music teaching approach and educational philosophy of Dr. Shinichi Suzuki for the greater happiness of all children. 2,000
    A Forever Home Rescue
    PO Box 22801
    Chantilly,VA20153     		None 501(c)(3) To rescue puppies and dogs from hoaders and backyard breeders, owner surrenders and shelters. 1,000
    Castleton Festival
    7 Castleton Meadows Lane
    Castleton,VA22716     		None 501(c)(3) Host the artists, singers, musicians, conductors,designers,directors and stage technician on the picturesque where they create and produce world.class performances. 5,000
    Child Care Learning Center of Rappa
    12763 Lee Highway PO Box 520
    Washington,VA22747     		None 501(c)(3) To provide early childhood programs. 1,000
    Rappahannock Animal Welfare League
    PP Box 396
    Amissville,VA20106     		None 501(c)(3) To rescue and provide shelter for animals. 2,500
    SafeSpot Children's Advocacy Center
    4021 Chain Bridge Rd Suite 200
    Fairfax,VA22030     		None 501(c)(3) To provide direct services to child victims of sexual abuse and severe physical abuse. 5,000
    Woft Trap Institute for Early Learn
    1635 Trap Rd
    Vienna,VA22182     		None 501(c)(3) To provide innovative arts-based teaching strategies and services to early chilhood teachers, caregivers, parents, and their children through the disciplines of drama, music, and movement. 5,000
    Assistance League of Northern Virgi
    PO Box 209
    Herdon,VA20172     		None 501(c)(3) To feed, cloth and educate children in need in our community. 2,500
    Crossways Community
    3015 Upton Dr
    Kensington,MD20895     		None 501(c)(3) Crossway Community is a prepared environment, intentionally designed and maintained to be conducive to healthy family interaction healthy development for all ages. 2,000
    Fairfax County Animal Shelter
    PO Box 905
    Elkins,WV26241     		None 501(c)(3) To provide a safe-haven for dogs, cats, and small animals like guinea pigs, rabbits and pet birds 1,000
    RappCats
    PO Box 307
    Washington,VA22747     		None 501(c)(3) To manage the daily operations of the Rappahannock County animal shelter 1,000
    Friend of Guest House
    1 E Luray Ave
    Alexandria,VA22301     		None 501(c)(3) Guest House helps Northern Virginia women make successful transitions from incarceration back into the community. The program focuses on issues ranging from trauma and addiction to housing and employment, in order to prevent the women from reoffending in the future. Fewer than 10% of Guest House graduates re-offend. 10,000
    Piedmont Environmental Council
    45 Horner St
    Warrenton,VA20186     		None 501(c)(3) To promote and protect the Piedmont area's rural economy, natural resources, history, and beauty. The organization was founded in 1972. 10,000
    RappU
    11669 Lee Highway
    Sperryville,VA22740     		None 501(c)(3) To provide lifelong learning and workforce training in Rappahannock County, Virginia. 5,000
    Reach Incorporated
    300 M Street SE Suite 803
    Washington,DC20003     		None 501(c)(3) To provide highly-successful out-of-school-time program serving 350 participants at 8 sites in the District of Columbia. We hire teens to be elementary school reading tutors, creating academic benefit for both the students and their tutors. 5,000
    RLEP
    PO Box 9
    Washington,VA22747     		None 501(c)(3) To preserving the natural resources and rural character of Rappahannock County, Virginia. 2,500
    Shenandoah National Park Trust
    PO Box 2977
    Charlottesville,VA22902     		None 501(c)(3) To help protect what we love about Shenandoah National Park, while creating programs to inspire the next generation of national park stewards. 5,000
    Smithsonian Conservation Biology In
    1500 Remount Rd
    Front Royal,VA22630     		None 501(c)(3) To save wildlife species from extinction and train future generations of conservationists. 6,300
    THEARC
    1901 Mississippi Ave SE
    Washington,DC20020     		None 501(c)(3) To improve the quality of life for residents of Ward 8, and is home to eleven of Washington, DC's best nonprofit agencies, all of which share the goal of helping children and adults reach their full potential. 5,000
    Vegan Outreach
    PO Box 1916
    Davis,CA95617     		None 501(c)(3) To end violence towards animals. They seek a future when sentient animals are no longer exploited as commodities. 10,000
    World Central Kitchen
    1875 Connecticut Ave NW 10th Fl
    Washington,DC20009     		None 501(c)(3) A group of chefs creating smart solutions to hunger and poverty. 1,000
    CASA
    6811 Kenilworth Ave Ste 402
    Riverdale,MD20737     		None 501(c)(3) Court Appointed Special Advocate (CASA)/ Prince Georges County, Inc. is a volunteer-based organization that partners with the juvenile court to improve the lives of children living in foster care who have suffered from abuse and neglect. 3,000
    Homeless Children's Playtime Projec
    1525 Newton St NW
    Washington,DC20010     		None 501(c)(3) The Homeless Children's Playtime Project cultivates resilience in children experiencing family homelessness by providing and expanding access to transformative play experiences. They partner with transitional housing and emergency shelters across the city, where we create safe and fun play spaces in the shelters where the children live. 1,000
    Kiss the Ground
    4312 W Jefferson Blvd
    Los Angeles,CA90016     		None 501(c)(3) Kiss the Ground is a California-based 501(c)(3) environmental non-profit telling a new story about our ability to regenerate land and reverse climate change by building back healthy soil. We create media, campaigns and educational curriculum that raise awareness and empower individuals to take action. 3,000
    Castleton Community Volunteer Fire
    593 Castleton View Road
    Castleton,VA22716     		None 501(c)(3) Castleton Community Volunteer Fire Company was established in 1956 as a Fire Company and later added EMS Transport capabilities and continues today as a Fire and Rescue Company. 2,500
    Common Good City Farm
    PO Box 26030
    Washington,DC20001     		None 501(c)(3) Common Good City Farm (CGCF) is a place where community members can source fresh food, see sustainable urban agriculture in action, and gain exposure to concepts and skills to lead healthy lives. Their mission is to create a vibrant, informed, and well-nourished community through urban farming. 5,000
    NPCF
    PO Box 3549
    Warrenton,VA20188     		None 501(c)(3) The mission of the Northern Piedmont Community Foundation: To build philanthropic capital, to enhance and preserve the quality of life in Culpeper, Fauquier, Madison and Rappahannock Counties and to strengthen the region's nonprofit organizations. 5,000
    Orphan Kitten Project
    1 Schields Ave
    Davis,CA95617     		None 501(c)(3) The Orphan Kitten Project is an entirely student run rescue organization based out of the UC Davis School of Veterinary Medicine. Their mission is to rescue kittens that are too young to be taken into shelters (less than 8 weeks of age) and raise them in foster homes until they are old enough to be adopted. 3,000
    Piedmont Area Soapbox Foundationl
    PO Box 108
    Brandy Station,VA22714     		None 501(c)(3) The Soap Box Derby is an international nonprofit organization whose mission is to build knowledge and character, and to create meaningful experiences through collaboration and fair and honest competition. 250
    Rapp at Home
    PO Box 193
    Washington,VA22747     		None 501(c)(3) Rapp at Homes mission is to sustain and enrich Rappahannock County residents who are members of Rapp at Home to age in the community comfortably, safely, independently and with peace of mind by fostering the community supports and services needed to do so. 1,000
    Rappahannock Benevolent Fund
    PO Box 133
    Washington,VA22747     		None 501(c)(3) The Rappahannock Benevolent Fund provides financial and supportive services in a confidential and compassionate manner to residents of Rappahannock County in times of crisis. 20,000
    Rappahannock Trails Coalition
    710 Battle Mountain Road
    Amissville,VA20106     		None 501(c)(3) Rappahannock Trails Coalitions (RappTrails) mission is to make the outdoors accessible for Rappahannock County residents and visitors of all ages to safely enjoy walking, jogging, and biking for education, health, fitness, and community through establishment of a public trail system. 1,000
    Safe Shores
    429 O Street NW
    Washington,DC20001     		None 501(c)(3) Safe Shores is dedicated to working with and advocating for children and adolescents affected by trauma and violence. 3,000
    The Scrabble School Preservation Fo
    PO Box 356
    Sperryville,VA22740     		None 501(c)(3) The Scrabble School Preservation Foundation's mission is to preserve the school's history and to share its legacy through public outreach and educational programs. 500
    Doctors Without Borders USA
    PO Box 5030
    Hagerstown,MD21741     		None 501(c)(3) Doctors Without Borders/Mdecins Sans Frontires (MSF) provides impartial medical relief to the victims of war, disease, and natural or man-made disaster, without regard to race, religion, or political affiliation. 3,000
    Total .................................bullet 3a 391,825
    bApproved for future payment
    Total .................................bullet 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.)
    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 18,740  
    4 Dividends and interest from securities....     14 174,853  
    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 ............     		        6,536
    9 Net income or (loss) from special events:          
    10 Gross profit or (loss) from sales of inventory          
    11 Other revenue:
    aInv fee reimbursement     		         
    b
    c
    d
    e
    12 Subtotal. Add columns (b), (d), and (e)..   193,593 6,536
    13Total. Add line 12, columns (b), (d), and (e)..................
    13
    200,129
    (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.)
    4 Safe investments of assets
    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: 18007218
    Software Version: 2018v3.1


    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
    The Jacquemin Family Foundation Inc
     
    Employer identification number

    54-1887187
    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
    The Jacquemin Family Foundation Inc
          		Employer identification number
    54-1887187
    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
    Mooring Intrepid Opportunity Fund
     
    8609 Westwood Center Dr 450
     
    Vienna, VA22182

    		$ 1,562,000


    (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
    The Jacquemin Family Foundation Inc
          		Employer identification number

    54-1887187
    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
    The Jacquemin Family Foundation Inc
          		Employer identification number

    54-1887187
    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: 18007218
    Software Version: 2018v3.1

    TY 2018 AccountingFeesSchedule
    Name:
    The Jacquemin Family Foundation Inc
    EIN:
    54-1887187
    Software ID:
    18007218
    Software Version:
    2018v3.1
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    Acctg Fees Paid 2,510 2,510 0 0

    TY 2018 OtherDecreasesSchedule
    Name:
    The Jacquemin Family Foundation Inc
    EIN:
    54-1887187
    Software ID:
    18007218
    Software Version:
    2018v3.1
    Description Amount
    Unrealized loss on investments 1,581,895


    TY 2018 OtherExpensesSchedule
    Name:
    The Jacquemin Family Foundation Inc
    EIN:
    54-1887187
    Software ID:
    18007218
    Software Version:
    2018v3.1
    Description Revenue and Expenses per Books Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    Bank Service Charges 8 8    
    Dividend expense 209 209    
    Filing Fees 50 50    
    Membership Dues 1,500 1,500    


    TY 2018 TaxesSchedule
    Name:
    The Jacquemin Family Foundation Inc
    EIN:
    54-1887187
    Software ID:
    18007218
    Software Version:
    2018v3.1
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    Foreign witholding tax 3,460 3,460