-
TIN:
Form
990-PF
Department of the Treasury
Internal Revenue Service
Return of Private Foundation
or Section 4947(a)(1) Trust Treated as Private Foundation
Do not enter social security numbers on this form as it may be made public.
Go to
www.irs.gov/Form990PF
for instructions and the latest information.
OMB No. 1545-0052
20
19
Open to Public Inspection
For calendar year 2019, or tax year beginning
09-01-2017
, and ending
08-31-2018
Name of foundation
POLK FAMILY CHARITABLE TRUST
Number and street (or P.O. box number if mail is not delivered to street address)
675 N NORTH COURT SUITE 450
Room/suite
City or town, state or province, country, and ZIP or foreign postal code
PALATINE
,
IL
60067
A Employer identification number
36-3332896
B
Telephone number (see instructions)
(847) 934-0300
C
If exemption application is pending, check here
G
Check all that apply:
Initial return
Initial return of a former public charity
Final return
Amended return
Address change
Name change
D 1.
Foreign organizations, check here.............
2
. Foreign organizations meeting the 85%
test, check here and attach computation ...
E
If private foundation status was terminated
under section 507(b)(1)(A), check here .......
H
Check type of organization:
Section 501(c)(3) exempt private foundation
Section 4947(a)(1) nonexempt charitable trust
Other taxable private foundation
F
If the foundation is in a 60-month termination
under section 507(b)(1)(B), check here .......
I
Fair market value of all assets at end
of year (from Part II, col. (c),
line 16)
$
3,003,843
J
Accounting method:
Cash
Accrual
Other (specify)
(Part I, column (d) must be on cash basis.)
Part I
Analysis of Revenue and Expenses
(The total of amounts in columns (b), (c), and (d) may not necessarily equal the amounts in column (a) (see instructions).)
(a)
Revenue and
expenses per
books
(b)
Net investment
income
(c)
Adjusted net
income
(d)
Disbursements
for charitable
purposes
(cash basis only)
1
Contributions, gifts, grants, etc., received (attach schedule)
2
Check
.............
3
Interest on savings and temporary cash investments
7,618
7,618
7,618
4
Dividends and interest from securities
...
93,404
93,404
93,404
5a
Gross rents
............
b
Net rental income or (loss)
6a
Net gain or (loss) from sale of assets not on line 10
-44,773
b
Gross sales price for all assets on line 6a
110,984
7
Capital gain net income (from Part IV, line 2)
...
8
Net short-term capital gain
.........
12,332
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
........
56,249
101,022
113,354
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)
.......
c
Other professional fees (attach schedule)
....
17
Interest
...............
18
Taxes (attach schedule) (see instructions)
...
301
301
19
Depreciation (attach schedule) and depletion
...
20
Occupancy
..............
21
Travel, conferences, and meetings
.......
22
Printing and publications
..........
23
Other expenses (attach schedule)
.......
13,772
11,590
2,182
24
Total operating and administrative expenses.
Add lines 13 through 23
..........
14,073
11,891
2,182
25
Contributions, gifts, grants paid
.......
194,470
194,470
26
Total expenses and disbursements.
Add lines 24 and 25
208,543
11,891
196,652
27
Subtract line 26 from line 12:
a
Excess of revenue over expenses and disbursements
-152,294
b
Net investment income
(if negative, enter -0-)
89,131
c
Adjusted net income
(if negative, enter -0-)
...
113,354
For Paperwork Reduction Act Notice, see instructions.
Cat. No. 11289X
Form
990-PF
(2019)
Form 990-PF (2019)
Page
2
Part II
Balance Sheets
Attached schedules and amounts in the description column
should be for end-of-year amounts only. (See instructions.)
Beginning of year
End of year
(a)
Book Value
(b)
Book Value
(c)
Fair Market Value
1
Cash—non-interest-bearing
.............
2
Savings and temporary cash investments
.........
20,210
17,002
17,002
3
Accounts receivable
Less: allowance for doubtful accounts
4
Pledges receivable
Less: allowance for doubtful accounts
5
Grants receivable
.................
6
Receivables due from officers, directors, trustees, and other
disqualified persons (attach schedule) (see instructions)
.....
7
Other notes and loans receivable (attach schedule)
Less: allowance for doubtful accounts
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)
.......
1,953,204
1,814,833
2,748,172
c
Investments—corporate bonds (attach schedule)
.......
97,345
84,359
85,211
11
Investments—land, buildings, and equipment: basis
Less: accumulated depreciation (attach schedule)
12
Investments—mortgage loans
.............
13
Investments—other (attach schedule)
..........
185,721
187,992
153,458
14
Land, buildings, and equipment: basis
Less: accumulated depreciation (attach schedule)
15
Other assets (describe
)
16
Total assets
(to be completed by all filers—see the
instructions. Also, see page 1, item I)
2,256,480
2,104,186
3,003,843
17
Accounts payable and accrued expenses
..........
18
Grants payable
.................
19
Deferred revenue
.................
20
Loans from officers, directors, trustees, and other disqualified persons
21
Mortgages and other notes payable (attach schedule)
......
22
Other liabilities (describe
)
23
Total liabilities
(add lines 17 through 22)
.........
0
Foundations that follow FASB ASC 958, check here
and complete lines 24, 25, 29 and 30.
24
Net assets without donor restrictions
...........
25
Net assets with donor restrictions
............
Foundations that do not follow FASB ASC 958, check here
and complete lines 26 through 30.
26
Capital stock, trust principal, or current funds
........
27
Paid-in or capital surplus, or land, bldg., and equipment fund
28
Retained earnings, accumulated income, endowment, or other funds
29
Total net assets or fund balances
(see instructions)
.....
2,256,480
2,104,186
30
Total liabilities and net assets/fund balances
(see instructions)
.
2,256,480
2,104,186
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 29 (must agree with end-of-year figure reported on prior year’s return)
...............
1
2,256,480
2
Enter amount from Part I, line 27a
.....................
2
-152,294
3
Other increases not included in line 2 (itemize)
3
4
Add lines 1, 2, and 3
..........................
4
2,104,186
5
Decreases not included in line 2 (itemize)
5
6
Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 29
.
6
2,104,186
Form
990-PF
(2019)
Form 990-PF (2019)
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
SEE ATTACHED
P
b
CAMPBELL STRATEGIC ALLOCATION FUND
P
c
CAMPBELL STRATEGIC ALLOCATION FUND
P
d
WELLS FARGO LTCG DIST
P
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
88,522
146,977
-58,455
b
21,112
21,112
c
8,780
-8,780
d
1,350
1,350
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
-58,455
b
21,112
c
-8,780
d
1,350
e
2
Capital gain net income or (net capital loss)
If gain, also enter in Part I, line 7
If (loss), enter -0- in Part I, line 7
2
-44,773
3
Net short-term capital gain or (loss) as defined in sections 1222(5) and (6):
If gain, also enter in Part I, line 8, column (c) (see instructions). If (loss), enter -0-
in Part I, line 8
...................
3
12,332
Part V
Qualification Under Section 4940(e) for Reduced Tax on Net Investment Income
(For optional use by domestic private foundations subject to the section 4940(a) tax on net investment income.)
If section 4940(d)(2) applies, leave this part blank.
Was the foundation liable for the section 4942 tax on the distributable amount of any year in the base period?
Yes
No
If "Yes," the foundation does not qualify under section 4940(e). Do not complete this part.
1
Enter the appropriate amount in each column for each year; see instructions before making any entries.
(a)
Base period years Calendar
year (or tax year beginning in)
(b)
Adjusted qualifying distributions
(c)
Net value of noncharitable-use assets
(d)
Distribution ratio
(col. (b) divided by col. (c))
2018
246,356
2,817,303
0.087444
2017
240,687
2,977,905
0.080824
2016
258,667
3,015,834
0.085770
2015
258,501
3,217,808
0.080335
2014
259,082
3,125,772
0.082886
2
Total
of line 1, column (d)
.....................
2
0.417259
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
0.083452
4
Enter the net value of noncharitable-use assets for 2019 from Part X, line 5
......
4
2,769,296
5
Multiply line 4 by line 3
......................
5
231,103
6
Enter 1% of net investment income (1% of Part I, line 27b)
...........
6
891
7
Add lines 5 and 6
........................
7
231,994
8
Enter qualifying distributions from Part XII, line 4
,.............
8
196,652
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
(2019)
Form 990-PF (2019)
Page
4
Part VI
Excise Tax Based on Investment Income (Section 4940(a), 4940(b), 4940(e), or 4948—see instructions)
1a
Exempt operating foundations described in section 4940(d)(2), check here
and enter “N/A" on line 1.
Date of ruling or determination letter:
(attach copy of letter if necessary–see instructions)
b
Domestic foundations that meet the section 4940(e) requirements in Part V, check
1
1,783
here
and enter 1% of Part I, line 27b
...................
c
All other domestic foundations enter 2% of line 27b. Exempt foreign organizations enter 4% of Part I, line 12, col. (b)
2
Tax under section 511 (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-)
2
3
Add lines 1 and 2
...........................
3
1,783
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
1,783
6
Credits/Payments:
a
2019 estimated tax payments and 2018 overpayment credited to 2019
6a
1,498
b
Exempt foreign organizations—tax withheld at source
......
6b
c
Tax paid with application for extension of time to file (Form 8868)
...
6c
2,000
d
Backup withholding erroneously withheld
...........
6d
7
Total credits and payments. Add lines 6a through 6d
..............
7
3,498
8
Enter any
penalty
for underpayment of estimated tax.
Check here
if Form 2220 is attached.
8
9
Tax due.
If the total of lines 5 and 8 is more than line 7, enter
amount owed
.......
9
10
Overpayment.
If line 7 is more than the total of lines 5 and 8, enter the
amount overpaid
...
10
1,715
11
Enter the amount of line 10 to be:
Credited to 2020 estimated tax
1,715
Refunded
11
Part VII-A
Statements Regarding Activities
1a
During the tax year, did the foundation attempt to influence any national, state, or local legislation or did
Yes
No
it participate or intervene in any political campaign?
....................
1a
No
b
Did it spend more than $100 during the year (either directly or indirectly) for political purposes? (see Instructions
for definition)
.................................
1b
No
If the answer is "Yes" to
1a
or
1b,
attach a detailed description of the activities and copies of any materials
published or distributed by the foundation in connection with the activities.
c
Did the foundation file
Form 1120-POL
for this year?
.....................
1c
No
d
Enter the amount (if any) of tax on political expenditures (section 4955) imposed during the year:
(1)
On the foundation.
$
(2)
On foundation managers.
$
e
Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed
on foundation managers.
$
2
Has the foundation engaged in any activities that have not previously been reported to the IRS?
.......
2
No
If "Yes," attach a detailed description of the activities.
3
Has the foundation made any changes, not previously reported to the IRS, in its governing instrument, articles
of incorporation, or bylaws, or other similar instruments?
If "Yes," attach a conformed copy of the changes
....
3
No
4a
Did the foundation have unrelated business gross income of $1,000 or more during the year?
........
4a
No
b
If "Yes," has it filed a tax return on
Form 990-T
for this year?
...................
4b
5
Was there a liquidation, termination, dissolution, or substantial contraction during the year?
.........
5
No
If "Yes," attach the statement required by General Instruction T.
6
Are the requirements of section 508(e) (relating to sections 4941 through 4945) satisfied either:
By language in the governing instrument, or
By state legislation that effectively amends the governing instrument so that no mandatory directions
that conflict with the state law remain in the governing instrument?
................
6
Yes
7
Did the foundation have at least $5,000 in assets at any time during the year?
If "Yes," complete Part II, col. (c),
and Part XV.
.................................
7
Yes
8a
Enter the states to which the foundation reports or with which it is registered (see instructions)
IL
b
If the answer is "Yes" to line 7, has the foundation furnished a copy of Form 990-PF to the Attorney
General (or designate) of each state as required by General Instruction G?
If "No," attach explanation
.
8b
Yes
9
Is the foundation claiming status as a private operating foundation within the meaning of section 4942(j)(3)
or 4942(j)(5) for calendar year 2019 or the taxable year beginning in 2019? 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
(2019)
Form 990-PF (2019)
Page
5
Part VII-A
Statements Regarding Activities
(continued)
11
At any time during the year, did the foundation, directly or indirectly, own a controlled entity within the
meaning of section 512(b)(13)? If "Yes," attach schedule. See instructions
.............
11
No
12
Did the foundation make a distribution to a donor advised fund over which the foundation or a disqualified person had
advisory privileges? If "Yes," attach statement. See instructions
.................
12
No
13
Did the foundation comply with the public inspection requirements for its annual returns and exemption application?
13
Yes
Website address
N/A
14
The books are in care of
MICHAEL L DEMARCO
Telephone no.
(847) 934-0300
Located at
675 N NORTH COURT SUITE 450
PALATINE
IL
ZIP+4
60067
15
Section 4947(a)(1) nonexempt charitable trusts filing Form 990-PF in lieu of
Form 1041
—check here
.........
and enter the amount of tax-exempt interest received or accrued during the year
........
15
16
At any time during calendar year 2019, did the foundation have an interest in or a signature or other authority over
Yes
No
a bank, securities, or other financial account in a foreign country?
.................
16
No
See the instructions for exceptions and filing requirements for FinCEN Form 114. If "Yes", enter the name of the foreign
country
Part VII-B
Statements Regarding Activities for Which Form 4720 May Be Required
File Form 4720 if any item is checked in the "Yes" column, unless an exception applies.
Yes
No
1a
During the year did the foundation (either directly or indirectly):
(1)
Engage in the sale or exchange, or leasing of property with a disqualified person?
Yes
No
(2)
Borrow money from, lend money to, or otherwise extend credit to (or accept it from)
a disqualified person?
......................
Yes
No
(3)
Furnish goods, services, or facilities to (or accept them from) a disqualified person?
Yes
No
(4)
Pay compensation to, or pay or reimburse the expenses of, a disqualified person?
Yes
No
(5)
Transfer any income or assets to a disqualified person (or make any of either available
for the benefit or use of a disqualified person)?
...............
Yes
No
(6)
Agree to pay money or property to a government official? (
Exception.
Check "No"
if the foundation agreed to make a grant to or to employ the official for a period
after termination of government service, if terminating within 90 days.)
.......
Yes
No
b
If any answer is "Yes" to 1a(1)–(6), did
any
of the acts fail to qualify under the exceptions described in Regulations
section 53.4941(d)-3 or in a current notice regarding disaster assistance? See instructions
........
1b
Organizations relying on a current notice regarding disaster assistance check here
........
c
Did the foundation engage in a prior year in any of the acts described in 1a, other than excepted acts,
that were not corrected before the first day of the tax year beginning in 2019?
.............
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 2019, did the foundation have any undistributed income (lines 6d
and 6e, Part XIII) for tax year(s) beginning before 2019?
.............
Yes
No
If "Yes," list the years
20
,
20
,
20
,
20
b
Are there any years listed in 2a for which the foundation is
not
applying the provisions of section 4942(a)(2)
(relating to incorrect valuation of assets) to the year’s undistributed income? (If applying section 4942(a)(2)
to
all
years listed, answer "No" and attach statement—see instructions.)
..............
2b
c
If the provisions of section 4942(a)(2) are being applied to
any
of the years listed in 2a, list the years here.
20
,
20
,
20
,
20
3a
Did the foundation hold more than a 2% direct or indirect interest in any business enterprise at
any time during the year?
......................
Yes
No
b
If "Yes," did it have excess business holdings in 2019 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 2019.)
..................
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 2019?
4b
No
Form
990-PF
(2019)
Form 990-PF (2019)
Page
6
Part VII-B
Statements Regarding Activities for Which Form 4720 May Be Required
(continued)
5a
During the year did the foundation pay or incur any amount to:
Yes
No
(1)
Carry on propaganda, or otherwise attempt to influence legislation (section 4945(e))?
Yes
No
(2)
Influence the outcome of any specific public election (see section 4955); or to carry
on, directly or indirectly, any voter registration drive?
.............
Yes
No
(3)
Provide a grant to an individual for travel, study, or other similar purposes?
Yes
No
(4)
Provide a grant to an organization other than a charitable, etc., organization described
in section 4945(d)(4)(A)? See instructions
................
Yes
No
(5)
Provide for any purpose other than religious, charitable, scientific, literary, or
educational purposes, or for the prevention of cruelty to children or animals?
.....
Yes
No
b
If any answer is "Yes" to 5a(1)–(5), did
any
of the transactions fail to qualify under the exceptions described in
Regulations section 53.4945 or in a current notice regarding disaster assistance? See instructions
......
5b
Organizations relying on a current notice regarding disaster assistance check here
.........
c
If the answer is "Yes" to question 5a(4), does the foundation claim exemption from the
tax because it maintained expenditure responsibility for the grant?
..........
Yes
No
If "Yes," attach the statement required by Regulations section 53.4945–5(d).
6a
Did the foundation, during the year, receive any funds, directly or indirectly, to pay premiums on
a personal benefit contract?
.....................
Yes
No
b
Did the foundation, during the year, pay premiums, directly or indirectly, on a personal benefit contract?
....
6b
No
If "Yes" to 6b, file Form 8870.
7a
At any time during the tax year, was the foundation a party to a prohibited tax shelter transaction?
Yes
No
b
If "Yes", did the foundation receive any proceeds or have any net income attributable to the transaction?
....
7b
8
Is the foundation subject to the section 4960 tax on payment(s) of more than $1,000,000 in remuneration or
excess parachute payment during the year?
.................
Yes
No
Part VIII
Information About Officers, Directors, Trustees, Foundation Managers, Highly Paid Employees,
and Contractors
1
List all officers, directors, trustees, foundation managers and their compensation. See instructions
(a)
Name and address
(b)
Title, and average
hours per week
devoted to position
(c)
Compensation
(If not paid, enter
-0-)
(d)
Contributions to employee benefit plans and deferred compensation
(e)
Expense account,
other allowances
BRUCE R BACHMANN
DIRECTOR
000.00
0
0
0
675 N NORTH COURT SUITE 450
PALATINE
,
IL
60067
EDWARD M POLK
DIRECTOR
000.00
0
0
0
675 N NORTH COURT SUITE 450
PALATINE
,
IL
60067
LINDA E CUTLER
TREASURER
000.00
0
0
0
675 N NORTH COURT SUITE 450
PALATINE
,
IL
60067
SANDRA P GUTHMAN
DIRECTOR
000.00
0
0
0
675 N NORTH COURT SUITE 450
PALATINE
,
IL
60067
HOWARD J POLK
DIRECTOR
000.00
0
0
0
675 N NORTH COURT SUITE 450
PALATINE
,
IL
60067
JEFFRY A LEWIS
VICE PRESIDE
000.00
0
0
0
675 N NORTH COURT SUITE 450
PALATINE
,
IL
60067
JEFFREY A POLK
DIRECTOR
000.00
0
0
0
675 N NORTH COURT SUITE 450
PALATINE
,
IL
60067
BARBARA P MILSTEIN
DIRECTOR
000.00
0
0
0
675 N NORTH COURT SUITE 450
PALATINE
,
IL
60067
DR TRAVIS M POLK LT MC USN
DIRECTOR
000.00
0
0
0
675 N NORTH COURT SUITE 450
PALATINE
,
IL
60067
ELLEN P MULTACK
PRESIDENT
000.00
0
0
0
675 N NORTH COURT SUITE 450
PALATINE
,
IL
60067
E RICHARD POLK
DIRECTOR
000.00
0
0
0
675 N NORTH COURT SUITE 450
PALATINE
,
IL
60067
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
...................
Form
990-PF
(2019)
Form 990-PF (2019)
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
.............
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
N/A
2
All other program-related investments. See instructions.
3
Total.
Add lines 1 through 3
.........................
Form
990-PF
(2019)
Form 990-PF (2019)
Page
8
Part X
Minimum Investment Return
(All domestic foundations must complete this part. Foreign foundations, see instructions.)
1
Fair market value of assets not used (or held for use) directly in carrying out charitable, etc.,
purposes:
a
Average monthly fair market value of securities
...................
1a
2,605,430
b
Average of monthly cash balances
.......................
1b
46,439
c
Fair market value of all other assets (see instructions)
................
1c
159,599
d
Total
(add lines 1a, b, and c)
.........................
1d
2,811,468
e
Reduction claimed for blockage or other factors reported on lines 1a and
1c (attach detailed explanation)
.............
1e
2
Acquisition indebtedness applicable to line 1 assets
..................
2
3
Subtract line 2 from line 1d
.........................
3
2,811,468
4
Cash deemed held for charitable activities. Enter 1 1/2% of line 3 (for greater amount, see
instructions)
.............................
4
42,172
5
Net value of noncharitable-use assets.
Subtract line 4 from line 3. Enter here and on Part V, line 4
5
2,769,296
6
Minimum investment return.
Enter 5% of line 5
..................
6
138,465
Part XI
Distributable Amount
(see instructions) (Section 4942(j)(3) and (j)(5) private operating foundations and certain foreign organizations check here
and do not complete this part.)
1
Minimum investment return from Part X, line 6
....................
1
138,465
2a
Tax on investment income for 2019 from Part VI, line 5
......
2a
1,783
b
Income tax for 2019. (This does not include the tax from Part VI.)
...
2b
c
Add lines 2a and 2b
............................
2c
1,783
3
Distributable amount before adjustments. Subtract line 2c from line 1
............
3
136,682
4
Recoveries of amounts treated as qualifying distributions
................
4
5
Add lines 3 and 4
............................
5
136,682
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
136,682
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
196,652
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
196,652
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
196,652
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
(2019)
Form 990-PF (2019)
Page
9
Part XIII
Undistributed Income
(see instructions)
(a)
Corpus
(b)
Years prior to 2018
(c)
2018
(d)
2019
1
Distributable amount for 2019 from Part XI, line 7
136,682
2
Undistributed income, if any, as of the end of 2019:
a
Enter amount for 2018 only
.......
b
Total for prior years:
20
,
20
,
20
3
Excess distributions carryover, if any, to 2019:
a
From 2014
......
104,977
b
From 2015
......
99,519
c
From 2016
......
111,775
d
From 2017
......
93,857
e
From 2018
......
107,285
f
Total
of lines 3a through e
........
517,413
4
Qualifying distributions for 2019 from Part
XII, line 4:
$
196,652
a
Applied to 2018, 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)
........
d
Applied to 2019 distributable amount
.....
136,682
e
Remaining amount distributed out of corpus
59,970
5
Excess distributions carryover applied to 2019.
(If an amount appears in column (d), the
same amount must be shown in column (a).)
6
Enter the net total of each column as
indicated below:
a
Corpus. Add lines 3f, 4c, and 4e. Subtract line 5
577,383
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 2018. Subtract line
4a from line 2a. Taxable amount—see
instructions
.............
f
Undistributed income for 2019. Subtract
lines 4d and 5 from line 1. This amount must
be distributed in 2020
..........
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 2014 not
applied on line 5 or line 7 (see instructions)
...
104,977
9
Excess distributions carryover to 2020.
Subtract lines 7 and 8 from line 6a
......
472,406
10
Analysis of line 9:
a
Excess from 2015
....
99,519
b
Excess from 2016
....
111,775
c
Excess from 2017
....
93,857
d
Excess from 2018
....
107,285
e
Excess from 2019
....
59,970
Form
990-PF
(2019)
Form 990-PF (2019)
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 2019, enter the date of the ruling
.......
b
Check box to indicate whether the organization is a private operating foundation described in section
4942(j)(3)
or
4942(j)(5)
2a
Enter the lesser of the adjusted net
income from Part I or the minimum
investment return from Part X for each
year listed
..........
Tax year
Prior 3 years
(e) Total
(a)
2019
(b)
2018
(c)
2017
(d)
2016
b
85% of line 2a
.........
c
Qualifying distributions from Part XII,
line 4 for each year listed
.....
d
Amounts included in line 2c not used directly
for active conduct of exempt activities
..........
e
Qualifying distributions made directly
for active conduct of exempt activities.
Subtract line 2d from line 2c
....
3
Complete 3a, b, or c for the
alternative test relied upon:
a
“Assets" alternative test—enter:
(1)
Value of all assets
......
(2)
Value of assets qualifying
under section 4942(j)(3)(B)(i)
b
“Endowment" alternative test— enter 2/3
of minimum investment return shown in
Part X, line 6 for each year listed
...
c
“Support" alternative test—enter:
(1)
Total support other than gross
investment income (interest,
dividends, rents, payments
on securities loans (section
512(a)(5)), or royalties)
....
(2)
Support from general public
and 5 or more exempt
organizations as provided in
section 4942(j)(3)(B)(iii)
....
(3)
Largest amount of support
from an exempt organization
(4)
Gross investment income
Part XV
Supplementary Information (Complete this part only if the foundation had $5,000 or more in
assets at any time during the year—see instructions.)
1
Information Regarding Foundation Managers:
a
List any managers of the foundation who have contributed more than 2% of the total contributions received by the foundation
before the close of any tax year (but only if they have contributed more than $5,000). (See section 507(d)(2).)
b
List any managers of the foundation who own 10% or more of the stock of a corporation (or an equally large portion of the
ownership of a partnership or other entity) of which the foundation has a 10% or greater interest.
2
Information Regarding Contribution, Grant, Gift, Loan, Scholarship, etc., Programs:
Check here
if the foundation only makes contributions to preselected charitable organizations and does not accept
unsolicited requests for funds. If the foundation makes gifts, grants, etc. to individuals or organizations under
other conditions, complete items 2a, b, c, and d. See instructions
a
The name, address, and telephone number or email address of the person to whom applications should be addressed:
b
The form in which applications should be submitted and information and materials they should include:
c
Any submission deadlines:
d
Any restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other
factors:
Form
990-PF
(2019)
Form 990-PF (2019)
Page
11
Part XV
Supplementary Information
(continued)
3
Grants and Contributions Paid During the Year or Approved for Future Payment
Recipient
If recipient is an individual,
show any relationship to
any foundation manager
or substantial contributor
Foundation
status of
recipient
Purpose of grant or
contribution
Amount
Name and address (home or business)
a
Paid during the year
987 WFMT
5400 N ST LOUIS AVE
CHICAGO
,
IL
60625
NONE
CHARITABLE
GRANT AWARD
500
ALEX'S LEMONADE STAND
111 PRESIDENTIAL BLVD
STE 203
BALA CYNWYD
,
PA
19004
NONE
CHARITABLE
GRANT AWARD
600
AMERICAN COMMITTEE FOR WEIZMANN
INSTITUTE OF SCIENCE
180 N LASALLE ST
STE 3110
CHICAGO
,
IL
60601
NONE
CHARITABLE
GRANT AWARD
500
ATKINSON MEMORIAL CHURCH
710 SIXTH ST
OREGON CITY
,
OR
97045
NONE
CHARITABLE
GRANT AWARD
1,000
AUTISTIC KIDS FOUNDATION
1200 MILWAUKEE AVE
GLENVIEW
,
IL
60025
NONE
CHARITABLE
GRANT AWARD
600
AZ FRATERNAL ORDER OF POLICE
FOUNDATION
6401 S TUCSON BLVD
TUCSON
,
AZ
85706
NONE
CHARITABLE
GRANT AWARD
10,000
AZ HPDPS HERITAGE MUSEUM
2029 W CAMBRIDGE AVE
PHOENIX
,
AZ
850091949
NONE
CHARITABLE
GRANT AWARD
1,000
BERNIE'S BOOK BANK
917 NORTH SHORE DR
LAKE BLUFF
,
IL
60044
NONE
CHARITABLE
GRANT AWARD
2,900
BETTER GOVERNMENT ASSOCIATION
223 W JACKSON BLVD
STE 300
CHICAGO
,
IL
60606
NONE
CHARITABLE
GRANT AWARD
5,000
BOULDER BUILDING BLOCKS FUND
637 S BROADWAY ST
STE 227
BOULDER
,
CO
80305
NONE
CHARITABLE
GRANT AWARD
1,000
BOULDER COMMUNITY HEALTH FOUNDATION
PO BOX 9010
BOULDER
,
CO
80301
NONE
CHARITABLE
GRANT AWARD
2,000
BOULDER HISTORY MUSEUM
1206 EUCLID AVE
BOULDER
,
CO
80302
NONE
CHARITABLE
GRANT AWARD
2,500
BOULDER HUMANE SOCIETY
2323 55TH ST
BOULDER
,
CO
80301
NONE
CHARITABLE
GRANT AWARD
500
BOULDER ROTARY CLUB
5390 MANHATTAN CIRCLE
STE 101
BOULDER
,
CO
80303
NONE
CHARITABLE
GRANT AWARD
1,000
BRIDGE HOUSE
31979 N FISH LAKE RD
ROUND LAKE
,
IL
60073
NONE
CHARITABLE
GRANT AWARD
2,000
CANADIAN OPERA CO INC
12 FOUNTAIN PLAZA
STE 800
BUFFALO
,
NY
142022292
NONE
CHARITABLE
GRANT AWARD
5,000
CANCER WELLNESS CENTER
215 REVERE DR
NORTHBROOK
,
IL
60062
NONE
CHARITABLE
GRANT AWARD
1,000
CHICAGO BOTANIC GARDEN
1000 LAKE COOK RD
GLENCOE
,
IL
600221613
NONE
CHARITABLE
GRANT AWARD
500
CHICAGO PARK DISTRICT
541 N FAIRBANKS
CHICAGO
,
IL
60611
NONE
CHARITABLE
GRANT AWARD
1,000
CHICAGO POLICE MEMORIAL FOUNDATION
1407 W WASHINGTON BLVD
CHICAGO
,
IL
60607
NONE
CHARITABLE
GRANT AWARD
6,000
CHURCH OF CHRIST
C/O LANDON WEEKS
3404 CONSOLIDATION
BELLINGHAM
,
WA
98225
NONE
CHARITABLE
GRANT AWARD
1,500
CLACKAMAS COUNTY 4-H LEADERS
ASSOCIATION
200 WARNER MILNE RD
OREGON CITY
,
OR
97045
NONE
CHARITABLE
GRANT AWARD
1,000
CLACKAMAS COUNTY FRIENDS OF
THE LIBRARY
16201 SE MCLAUGHLIN BLVD
OAK GROVE
,
OR
97267
NONE
CHARITABLE
GRANT AWARD
1,000
COLORADO MUSIC FESTIVAL
900 BASELINE RD
BOULDER
,
CO
80302
NONE
CHARITABLE
GRANT AWARD
1,500
COMMUNITY FIRST FOUNDATION
5855 WADSWORTH BYPASS
UNIT A
ARVADA
,
CO
80003
NONE
CHARITABLE
GRANT AWARD
4,000
COMMUNITY TRANSITIONAL SCHOOL
6601 NE KILLINGSWORTH ST
PORTLAND
,
OR
97218
NONE
CHARITABLE
GRANT AWARD
1,000
DAIRY CENTER FOR THE ARTS
2590 WALNUT ST
BOULDER
,
CO
80302
NONE
CHARITABLE
GRANT AWARD
220
DANIEL MURPHY SCHOLARSHIP FUND
309 W WASHINGTON
STE 1250
CHICAGO
,
IL
60606
NONE
CHARITABLE
GRANT AWARD
250
DEPRESSION & BIPOLAR SUPPORT
ALLIANCE
55 E JACKSON BLVD
STE 490
CHICAGO
,
IL
60604
NONE
CHARITABLE
GRANT AWARD
750
DOWNTOWN BOULDER FOUNDATION INC
1942 BROADWAY
STE 301
BOULDER
,
CO
80302
NONE
CHARITABLE
GRANT AWARD
2,000
EAST VALLEY JCC
908 N ALMA SCHOOL RD
CHANDLER
,
AZ
85224
NONE
CHARITABLE
GRANT AWARD
500
EASTERN ASSOCIATION OF SURGERY OF
TRAUMA
633 NORTH SAINT CLAIR ST
CHICAGO
,
IL
60611
NONE
CHARITABLE
GRANT AWARD
10,000
FOUNDATION OF RETIRED POLICE OFFICE
517 W MONTE VISTA RD
PHOENIX
,
AZ
85003
NONE
CHARITABLE
GRANT AWARD
2,000
FRIENDS OF THE MULTNOMAH COUNTY
LIBRARY
919 SW TAYLOR
STE 220
PORTLAND
,
OR
97205
NONE
CHARITABLE
GRANT AWARD
1,000
FRIENDS OF THE OREGON CITY LIBRARY
502 7TH ST
OREGON CITY
,
OR
97045
NONE
CHARITABLE
GRANT AWARD
1,500
HEARTLAND ANIMAL SHELTER
2975 MILWAUKEE AVE
NORTHBROOK
,
IL
60062
NONE
CHARITABLE
GRANT AWARD
500
IMAGINE FOUNDATION
1400 DIXON ST
LAFAYETTE
,
CO
80026
NONE
CHARITABLE
GRANT AWARD
1,000
JEWISH COUNCIL ON URBAN AFFAIRS
610 S MICHIGAN
STE 400
CHICAGO
,
IL
60605
NONE
CHARITABLE
GRANT AWARD
5,000
JEWISH FAMILY SERVICES OF COLORADO
3201 S TAMARAC DR
DENVER
,
CO
80231
NONE
CHARITABLE
GRANT AWARD
5,850
JORDAN MICHAEL FILLER FOUNDATION
2421 SHADOW CREEK LN
RIVERWOODS
,
IL
60015
NONE
CHARITABLE
GRANT AWARD
1,000
LATINO UNION
4811 N CENTRAL PARK AVE
CHICAGO
,
IL
60625
NONE
CHARITABLE
GRANT AWARD
5,500
LAURI S BAUER FOUNDATION
P O BOX 5368
VERNON HILLS
,
IL
60061
NONE
CHARITABLE
GRANT AWARD
900
LURIE CHILDREN'S FOUNDATION
225 E CHICAGO AVE
BOX 4
CHICAGO
,
IL
60611
NONE
CHARITABLE
GRANT AWARD
5,850
MARICOPA COUNTY SHERIFF'S OFFICE
MEMORIAL FUND
29455 N CAVE CREEK RD
PHOENIX
,
AZ
850153203
NONE
CHARITABLE
GRANT AWARD
2,500
MORIAH CONGREGATION
200 TAUB DR
DEERFIELD
,
IL
60015
NONE
CHARITABLE
GRANT AWARD
1,225
MOTHER'S TRUST FOUNDATION
400 E ILLINOIS RD
LAKE FOREST
,
IL
60045
NONE
CHARITABLE
GRANT AWARD
250
NA'AMAT USA
8707 N SKOKIE BLVD
STE 222
SKOKIE
,
IL
60077
NONE
CHARITABLE
GRANT AWARD
500
NAVY SEAL FOUNDATION
1619 D ST
VIRGINIA BEACH
,
VA
23455
NONE
CHARITABLE
GRANT AWARD
1,500
NEW AVENUES FOR YOUTH INC
1220 SW COLUMBIA ST
PORTLAND
,
OR
97201
NONE
CHARITABLE
GRANT AWARD
700
NORTH SUBURBAN SYNAGOGUE BETH EL
1175 SHERIDAN RD
HIGHLAND PARK
,
IL
60035
NONE
CHARITABLE
GRANT AWARD
3,000
OPERATION WARM
6 DICKINSON DR
STE 314
CHADDS FORD
,
PA
19317
NONE
CHARITABLE
GRANT AWARD
1,750
OREGON CITY PARKS AND RECREATION
DEPARTMENT
615 FIFTH ST
OREGON CITY
,
OR
97045
NONE
CHARITABLE
GRANT AWARD
1,000
ORT AMERICA
3701 COMMERCIAL AVE
STE 13
NORTHBROOK
,
IL
600621830
NONE
CHARITABLE
GRANT AWARD
8,500
PERFORMANCE WORKS NORTHWEST INC
4625 SE 67TH AVE
PORTLAND
,
OR
97206
NONE
CHARITABLE
GRANT AWARD
500
PHOENIX LAW ENFORCEMENT ASSOCIATION
1102 W ADAMS ST
PHOENIX
,
AZ
85007
NONE
CHARITABLE
GRANT AWARD
1,000
PHOENIX POLICE SERGEANTS AND
LIEUTENANTS ASSOCIATION
2220 N CENTRAL AVE
STE 103
PHOENIX
,
AZ
85004
NONE
CHARITABLE
GRANT AWARD
1,000
PLAYWRIGHTS WEST
4404 NE 22ND AVE
PORTLAND
,
OR
97211
NONE
CHARITABLE
GRANT AWARD
1,000
PORTLAND STATE UNIVERSITY
DEPT OF MATHEMATICAL SCIENCE
P O BOX 751
PORTLAND
,
OR
97207
NONE
CHARITABLE
GRANT AWARD
1,500
PORTLAND STORY THEATER
3333 NE 15TH AVE
PORTLAND
,
OR
97212
NONE
CHARITABLE
GRANT AWARD
1,000
RAVINIA FESTIVAL ASSOCIATION
400 IRIS LN
HIGHLAND PARK
,
IL
60035
NONE
CHARITABLE
GRANT AWARD
17,500
RESPONSE CENTER
3033 W TOUHY AVE
CHICAGO
,
IL
60645
NONE
CHARITABLE
GRANT AWARD
1,000
ROYAL ONTARIO MUSEUM FOUNDATION
100 QUEENS PARK CIRCLE
TORONTO
,
ONTARIO
M5S 2C6
CA
NONE
CHARITABLE
GRANT AWARD
8,500
SCHOOL ALTERNATIVES
7215 SE 22ND AVE
PORTLAND
,
OR
97202
NONE
CHARITABLE
GRANT AWARD
800
SCRAP
2915 NE MLK BLVD
PORTLAND
,
OR
97212
NONE
CHARITABLE
GRANT AWARD
500
SHAW FESTIVAL FOUNDATION
12 FOUNTAIN PLAZA
STE 800
BUFFALO
,
NY
142022292
NONE
CHARITABLE
GRANT AWARD
2,000
SILENT WITNESS
620 W WASHINGTON
PHOENIX
,
AZ
85007
NONE
CHARITABLE
GRANT AWARD
2,000
STRATFORD FESTIVAL
55 QUEEN ST
P O BOX 520
STRATFORD
,
ONTARIO
N5A 6V2
CA
NONE
CHARITABLE
GRANT AWARD
2,000
SUBUD PORTLAND
3185 NE REGENTS DR
PORTLAND
,
OR
97212
NONE
CHARITABLE
GRANT AWARD
1,000
SUFFOLK UNIVERSITY
8 ASHBURTON PL
BOSTON
,
MA
02108
NONE
CHARITABLE
GRANT AWARD
7,300
THE ARK
6450 N CALIFORNIA AVE
CHICAGO
,
IL
60645
NONE
CHARITABLE
GRANT AWARD
625
THE ART CENTER
1957 SHERIDAN RD
HIGHLAND PARK
,
IL
60035
NONE
CHARITABLE
GRANT AWARD
1,000
THEATRE VERTIGO
4110 SE HAWTHORNE BLVD
PORTLAND
,
OR
97214
NONE
CHARITABLE
GRANT AWARD
1,000
TRUTHOUT
P O BOX 276414
SACRAMENTO
,
CA
95827
NONE
CHARITABLE
GRANT AWARD
1,000
WELLESLEY COLLEGE
106 CENTRAL ST
WELLESLEY
,
MA
02481
NONE
CHARITABLE
GRANT AWARD
17,500
WOUNDED WARRIOR PROJECT
4899 BELFORT RD
STE 300
JACKSONVILLE
,
FL
32256
NONE
CHARITABLE
GRANT AWARD
2,500
YOGA GARDEN
2722 W LEXINGTON
CHICAGO
,
IL
60612
NONE
CHARITABLE
GRANT AWARD
2,900
Total
.................................
3a
194,470
b
Approved for future payment
Total
.................................
3b
Form
990-PF
(2019)
Form 990-PF (2019)
Page
12
Part XVI-A
Analysis of Income-Producing Activities
Enter gross amounts unless otherwise indicated.
Unrelated business income
Excluded by section 512, 513, or 514
(e)
Related or exempt
function income
(See instructions.)
1
Program service revenue:
(a)
Business code
(b)
Amount
(c)
Exclusion code
(d)
Amount
a
b
c
d
e
f
g
Fees and contracts from government agencies
2
Membership dues and assessments
....
3
Interest on savings and temporary cash
investments
...........
14
7,618
4
Dividends and interest from securities
....
14
93,404
5
Net rental income or (loss) from real estate:
a
Debt-financed property
......
b
Not debt-financed property
.....
6
Net rental income or (loss) from personal property
7
Other investment income
.....
8
Gain or (loss) from sales of assets other than
inventory
............
18
-44,773
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)
..
56,249
13
Total.
Add line 12, columns (b), (d), and (e)
..................
13
56,249
(See worksheet in line 13 instructions to verify calculations.)
Part XVI-B
Relationship of Activities to the Accomplishment of Exempt Purposes
Line No.
Explain below how each activity for which income is reported in column (e) of Part XVI-A contributed importantly to
the accomplishment of the foundation’s exempt purposes (other than by providing funds for such purposes). (See
instructions.)
Form
990-PF
(2019)
Form 990-PF (2019)
Page
13
Part XVII
Information Regarding Transfers To and Transactions and Relationships With Noncharitable Exempt Organizations
1
Did the organization directly or indirectly engage in any of the following with any other organization described in section 501(c) (other than section 501(c)(3) organizations) or in section 527, relating to political organizations?
Yes
No
a
Transfers from the reporting foundation to a noncharitable exempt organization of:
(1)
Cash
...................................
1a(1)
No
(2)
Other assets
.................................
1a(2)
No
b
Other transactions:
(1)
Sales of assets to a noncharitable exempt organization
....................
1b(1)
No
(2)
Purchases of assets from a noncharitable exempt organization
..................
1b(2)
No
(3)
Rental of facilities, equipment, or other assets
.......................
1b(3)
No
(4)
Reimbursement arrangements
...........................
1b(4)
No
(5)
Loans or loan guarantees
.............................
1b(5)
No
(6)
Performance of services or membership or fundraising solicitations
................
1b(6)
No
c
Sharing of facilities, equipment, mailing lists, other assets, or paid employees
..............
1c
No
d
If the answer to any of the above is "Yes," complete the following schedule. Column
(b)
should always show the fair market value
of the goods, other assets, or services given by the reporting foundation. If the foundation received less than fair market value
in any transaction or sharing arrangement, show in column
(d)
the value of the goods, other assets, or services received.
(a)
Line No.
(b)
Amount involved
(c)
Name of noncharitable exempt organization
(d)
Description of transfers, transactions, and sharing arrangements
2a
Is the foundation directly or indirectly affiliated with, or related to, one or more tax-exempt organizations
described in section 501(c) (other than section 501(c)(3)) or in section 527?
...........
Yes
No
b
If "Yes," complete the following schedule.
(a)
Name of organization
(b)
Type of organization
(c)
Description of relationship
Sign Here
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
May the IRS discuss this return
with the preparer shown below
(see instr.)
Yes
No
Signature of officer or trustee
Date
Title
Paid Preparer Use Only
Print/Type preparer's name
Preparer's Signature
Date
Check if self-
employed
PTIN
Firm's name
Firm's EIN
Firm's address
Phone no.
Form
990-PF
(2019)
Additional Data
Software ID:
Software Version:
Form 990PF - Special Condition Description:
Special Condition Description