-
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
01-01-2019
, and ending
12-31-2019
Name of foundation
MALTBIE MC COSH DELANO EST XXXXX1000
Number and street (or P.O. box number if mail is not delivered to street address)
10 S DEARBORN IL1-0111
Room/suite
City or town, state or province, country, and ZIP or foreign postal code
CHICAGO
,
IL
60603
A Employer identification number
13-6115977
B
Telephone number (see instructions)
(800) 496-2583
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)
$
4,108,271
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
4
Dividends and interest from securities
...
96,637
96,637
5a
Gross rents
............
b
Net rental income or (loss)
6a
Net gain or (loss) from sale of assets not on line 10
76,461
b
Gross sales price for all assets on line 6a
708,309
7
Capital gain net income (from Part IV, line 2)
...
76,461
8
Net short-term capital gain
.........
0
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
........
173,098
173,098
13
Compensation of officers, directors, trustees, etc.
46,272
28,772
17,500
14
Other employee salaries and wages
......
0
0
0
15
Pension plans, employee benefits
.......
0
0
16a
Legal fees (attach schedule)
.........
0
b
Accounting fees (attach schedule)
.......
c
Other professional fees (attach schedule)
....
0
17
Interest
...............
0
18
Taxes (attach schedule) (see instructions)
...
3,818
2,369
0
19
Depreciation (attach schedule) and depletion
...
0
0
20
Occupancy
..............
21
Travel, conferences, and meetings
.......
0
0
22
Printing and publications
..........
0
0
23
Other expenses (attach schedule)
.......
250
250
24
Total operating and administrative expenses.
Add lines 13 through 23
..........
50,340
31,141
0
17,750
25
Contributions, gifts, grants paid
.......
135,990
135,990
26
Total expenses and disbursements.
Add lines 24 and 25
186,330
31,141
0
153,740
27
Subtract line 26 from line 12:
a
Excess of revenue over expenses and disbursements
-13,232
b
Net investment income
(if negative, enter -0-)
141,957
c
Adjusted net income
(if negative, enter -0-)
...
0
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
.............
14,626
33,283
33,283
2
Savings and temporary cash investments
.........
60,517
46,477
46,477
3
Accounts receivable
Less: allowance for doubtful accounts
0
0
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
0
8
Inventories for sale or use
..............
9
Prepaid expenses and deferred charges
..........
10a
Investments—U.S. and state government obligations (attach schedule)
b
Investments—corporate stock (attach schedule)
.......
2,616,698
2,469,060
3,167,115
c
Investments—corporate bonds (attach schedule)
.......
528,048
656,855
671,112
11
Investments—land, buildings, and equipment: basis
Less: accumulated depreciation (attach schedule)
12
Investments—mortgage loans
.............
13
Investments—other (attach schedule)
..........
189,876
190,729
190,284
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)
3,409,765
3,396,404
4,108,271
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
........
3,409,765
3,396,404
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)
.....
3,409,765
3,396,404
30
Total liabilities and net assets/fund balances
(see instructions)
.
3,409,765
3,396,404
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
3,409,765
2
Enter amount from Part I, line 27a
.....................
2
-13,232
3
Other increases not included in line 2 (itemize)
3
7,021
4
Add lines 1, 2, and 3
..........................
4
3,403,554
5
Decreases not included in line 2 (itemize)
5
7,150
6
Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 29
.
6
3,396,404
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
100. VANGUARD BD INDEX FD INC
2018-12-17
2019-01-07
b
2. GILEAD SCIENCES INC
2016-02-10
2019-01-23
c
1. GILEAD SCIENCES INC
2016-02-10
2019-01-23
d
1. MASTERCARD INC - CLASS A
2009-07-16
2019-01-23
e
2. WORLDPAY INC CL A
2018-10-08
2019-01-23
3. GILEAD SCIENCES INC
2016-02-10
2019-01-24
1. MASTERCARD INC - CLASS A
2009-07-16
2019-01-24
2. MASTERCARD INC - CLASS A
2009-07-16
2019-01-24
4. WORLDPAY INC CL A
2018-10-08
2019-01-24
1. GILEAD SCIENCES INC
2016-02-10
2019-01-25
2. MASTERCARD INC - CLASS A
2009-07-16
2019-01-25
1. WORLDPAY INC CL A
2018-10-08
2019-01-25
4. WORLDPAY INC CL A
2017-09-22
2019-01-25
1. GILEAD SCIENCES INC
2016-02-10
2019-01-28
3. WORLDPAY INC CL A
2017-09-22
2019-01-28
1. GILEAD SCIENCES INC
2016-02-10
2019-01-29
1. WORLDPAY INC CL A
2017-09-22
2019-01-29
1. GILEAD SCIENCES INC
2016-02-10
2019-01-30
3. WORLDPAY INC CL A
2017-09-22
2019-01-30
1. GILEAD SCIENCES INC
2016-02-10
2019-02-01
5609.789 DODGE & COX INCOME FUND
2019-02-07
360. VANGUARD BD INDEX FD INC
2018-12-17
2019-02-07
4302.653 AMG MG PICTET INTL-Z
2016-02-01
2019-02-14
3. ANALOG DEVICES INC
2018-09-13
2019-02-19
1. ANALOG DEVICES INC
2018-09-13
2019-02-19
4. ANALOG DEVICES INC
2018-09-13
2019-02-19
5. ANALOG DEVICES INC
2016-10-27
2019-02-19
4. ANALOG DEVICES INC
2019-02-19
1. ANALOG DEVICES INC
2016-10-27
2019-02-19
5. ANALOG DEVICES INC
2016-10-27
2019-02-20
271. JPMORGAN BETABUILDERS JAPAN ETF
2018-07-19
2019-03-05
1409. JPMORGAN BETABUILDERS JAPAN ETF
2019-03-05
1. BIOGEN IDEC INC
2018-10-08
2019-03-14
2. BIOGEN IDEC INC
2010-06-18
2019-03-14
37. BRISTOL MYERS SQUIBB CO
2019-03-14
8. DISNEY WALT CO
2019-03-14
. BANK OF AMERICA CORPORATION
2019-03-20
3. ADOBE SYS INC
2012-08-03
2019-04-02
1. ALEXION PHARMACEUTICALS INC
2019-03-14
2019-04-02
1. ALPHABET INC-CL C
2012-07-11
2019-04-02
1. ALPHABET INC-CL A
2012-07-11
2019-04-02
1. AMAZON COM INC
2015-02-02
2019-04-02
2. AMERICAN EXPRESS CO
2018-07-18
2019-04-02
9. APPLE COMPUTER INC
2006-04-07
2019-04-02
3. AUTOMATIC DATA PROCESSING INC
2018-12-03
2019-04-02
33. BANK OF AMERICA CORPORATION
2012-10-23
2019-04-02
4. BERKSHIRE HATHAWAY INC DEL CL B
2018-09-11
2019-04-02
17. BOSTON SCIENTIFIC CORP
2016-12-05
2019-04-02
3. BROADCOM INC
2013-05-23
2019-04-02
4. CELGENE CORP.
2019-03-14
2019-04-02
2. CHARTER COMMUNICATIONS INC-A
2016-02-09
2019-04-02
12. CITIGROUP INC NEW
2011-08-09
2019-04-02
8. COCA-COLA CO
2018-04-13
2019-04-02
20. COMCAST CORP NEW CL A
2019-03-14
2019-04-02
5. DELTA AIR LINES INC DEL NEW
2017-12-13
2019-04-02
2. DIAMONDBACK ENERGY INC
2019-04-02
1. DIAMONDBACK ENERGY INC
2017-05-15
2019-04-02
6. DISNEY WALT CO
2016-10-07
2019-04-02
4. DOLLAR TREE INC
2019-04-02
7. EOG RESOURCES INC
2016-03-07
2019-04-02
5. ELECTRONIC ARTS
2018-09-20
2019-04-02
3. FACEBOOK INC-A
2014-10-13
2019-04-02
5. FIDELITY NATL INFORMATION SVCS INC
2019-04-02
5. FISERV INC
2019-04-02
2. GENERAL DYNAMICS CORP
2018-12-13
2019-04-02
4. HOME DEPOT INC
2011-09-29
2019-04-02
6. HONEYWELL INTL INC
2009-12-16
2019-04-02
3. INTERCONTINENTALEXCHANGE GROUP, INC
2017-01-31
2019-04-02
23. KEYCORP NEW
2019-04-02
5. LILLY ELI & CO
2016-12-16
2019-04-02
5. LOWES COS INC
2011-09-22
2019-04-02
8. MARATHON PETROLEUM CORPORATION
2019-04-02
5. MASTERCARD INC - CLASS A
2009-07-16
2019-04-02
10. MERCK & CO INC
2019-03-14
2019-04-02
21. MICROSOFT CORP
2009-01-29
2019-04-02
12. MONDELEZ INTERNATIONAL-W/I
2011-08-16
2019-04-02
19. MORGAN STANLEY DEAN WITTER & CO NEW
2013-04-19
2019-04-02
1. NETFLIX.COM INC
2018-09-13
2019-04-02
2. NEXTERA ENERGY INC
2018-07-18
2019-04-02
11. NISOURCE INC
2019-04-02
4. NORFOLK SOUTHN CORP
2018-03-09
2019-04-02
1. NORTHROP GRUMMAN CORP
2017-09-22
2019-04-02
3. NVIDIA CORP
2018-10-08
2019-04-02
1. O'REILLY AUTOMOTIVE INC
2017-05-05
2019-04-02
11. OCCIDENTAL PETE CORP
2007-01-12
2019-04-02
1. PARKER HANNIFIN CORP
2018-01-11
2019-04-02
7. PAYPAL HOLDINGS INC
2019-01-23
2019-04-02
7. PEPSICO INC
2014-10-07
2019-04-02
12. PFIZER INC
2018-10-30
2019-04-02
11. PFIZER INC
2017-01-03
2019-04-02
5. PHILIP MORRIS INTERNATIONAL
2017-04-24
2019-04-02
2. PIONEER NAT RES CO
2019-04-02
1. PIONEER NAT RES CO
2018-12-21
2019-04-02
3. PRUDENTIAL FINL INC
2019-04-02
1. REGENERON PHARMACEUTICALS INC
2019-01-31
2019-04-02
4. ROSS STORES INC
2018-12-11
2019-04-02
1. SVB FINANCIAL GROUP
2015-02-05
2019-04-02
4. SALESFORCE.COM INC
2018-10-08
2019-04-02
6. SCHWAB CHARLES CORP NEW
2019-04-02
3. STANLEY BLACK & DECKER,INC.
2016-02-11
2019-04-02
7. TEXAS INSTRS INC
2019-02-19
2019-04-02
5. UNION PAC CORP
2017-05-18
2019-04-02
3. UNITED TECHNOLOGIES CORP
2019-04-02
6. UNITEDHEALTH GROUP INC
2010-12-01
2019-04-02
2. VERTEX PHARMACEUTICALS INC
2011-12-15
2019-04-02
3. VISA INC CLASS A SHARES
2015-12-11
2019-04-02
4. WASTE CONNECTIONS INC
2019-04-02
14. WELLS FARGO & CO NEW
2009-03-13
2019-04-02
2. WEX INC
2016-05-03
2019-04-02
3. YUM BRANDS INC
2019-04-02
1. ZIMMER HLDGS INC
2017-11-20
2019-04-02
5. ZIMMER HLDGS INC
2019-04-02
4. ALLEGION PLC
2019-04-02
4. ACCENTURE PLC
2014-04-03
2019-04-02
2. LINDE PLC
2018-12-11
2019-04-02
5. MEDTRONIC PLC
2019-04-02
1. APTIV PLC
2017-05-18
2019-04-02
3. APTIV PLC
2019-04-02
4. CHUBB LTD
2008-11-19
2019-04-02
3. NXP SEMICONDUCTORS NV
2019-04-02
3260.779 AMG MG PICTET INTL-Z
2016-02-01
2019-04-03
2223.936 ARTISAN INTL VAL-INST
2019-04-03
1804.657 DODGE & INTERNATIONAL STOCK FUND
2013-10-09
2019-04-03
5. DOW INC
2017-02-22
2019-04-03
14. DOWDUPONT INC
2017-02-22
2019-04-03
81. SPDR TR UNIT SER 1
2019-04-03
6. DOW INC
2019-04-08
1. DOW INC
2015-07-15
2019-04-08
7. DOW INC
2015-07-15
2019-04-08
3. DOW INC
2015-07-15
2019-04-08
1. DOW INC
2015-07-15
2019-04-09
13. OCCIDENTAL PETE CORP
2007-01-12
2019-04-25
13. OCCIDENTAL PETE CORP
2007-01-12
2019-04-25
3. OCCIDENTAL PETE CORP
2007-01-12
2019-05-01
1. OCCIDENTAL PETE CORP
2007-01-12
2019-05-01
2. REGENERON PHARMACEUTICALS INC
2019-05-01
7. OCCIDENTAL PETE CORP
2007-01-12
2019-05-02
1. OCCIDENTAL PETE CORP
2007-01-12
2019-05-02
2. OCCIDENTAL PETE CORP
2007-01-12
2019-05-02
1. OCCIDENTAL PETE CORP
2007-01-12
2019-05-02
1. OCCIDENTAL PETE CORP
2007-01-12
2019-05-03
2. OCCIDENTAL PETE CORP
2007-01-12
2019-05-03
6. PRUDENTIAL FINL INC
2018-12-21
2019-05-14
3. PRUDENTIAL FINL INC
2018-12-21
2019-05-14
1. PRUDENTIAL FINL INC
2018-12-21
2019-05-14
2. PRUDENTIAL FINL INC
2018-12-21
2019-05-14
9. SCHWAB CHARLES CORP NEW
2015-01-15
2019-05-15
8. SCHWAB CHARLES CORP NEW
2015-01-15
2019-05-16
2. SCHWAB CHARLES CORP NEW
2015-01-15
2019-05-16
5. SCHWAB CHARLES CORP NEW
2019-05-16
7. MEDTRONIC PLC
2019-05-16
6. MEDTRONIC PLC
2019-05-16
3. MEDTRONIC PLC
2018-04-06
2019-05-17
4. MEDTRONIC PLC
2018-04-06
2019-05-17
2. PARKER HANNIFIN CORP
2018-01-11
2019-05-20
2. PARKER HANNIFIN CORP
2018-01-11
2019-05-20
1. PARKER HANNIFIN CORP
2018-01-11
2019-05-20
8. DELTA AIR LINES INC DEL NEW
2019-06-05
3. DELTA AIR LINES INC DEL NEW
2019-06-05
1. PHILIP MORRIS INTERNATIONAL
2018-10-24
2019-06-05
9. PHILIP MORRIS INTERNATIONAL
2017-04-24
2019-06-05
1. DELTA AIR LINES INC DEL NEW
2017-12-13
2019-06-06
2. DELTA AIR LINES INC DEL NEW
2017-12-13
2019-06-06
3. DELTA AIR LINES INC DEL NEW
2017-12-13
2019-06-06
1. DELTA AIR LINES INC DEL NEW
2017-12-13
2019-06-07
1. DELTA AIR LINES INC DEL NEW
2017-12-13
2019-06-07
24. BANK OF AMERICA CORPORATION
2012-10-23
2019-06-10
5. DOLLAR TREE INC
2019-06-10
19. WELLS FARGO & CO NEW
2009-03-13
2019-06-10
3. DOLLAR TREE INC
2018-12-17
2019-06-11
5. DOLLAR TREE INC
2019-06-11
2. DOLLAR TREE INC
2018-12-17
2019-06-11
. CORTEVA INC
2019-06-13
. DUPONT DE NEMOURS INC-WI
2019-06-13
1407.052 DIAMOND HILL LONG/SHORT-Y
2019-06-14
1. ADOBE SYS INC
2012-08-03
2019-06-27
49. SPDR TR UNIT SER 1
2017-03-07
2019-08-06
2. SVB FINANCIAL GROUP
2015-02-05
2019-08-14
1. SVB FINANCIAL GROUP
2015-02-05
2019-08-14
3. APTIV PLC
2017-05-18
2019-08-14
2. APTIV PLC
2017-05-18
2019-08-14
4. APTIV PLC
2017-05-18
2019-08-14
2. SVB FINANCIAL GROUP
2015-02-05
2019-08-15
7. APTIV PLC
2019-08-15
. GENERAL MOTORS CO
2019-09-05
356. ISHARES TR BARCLAYS MBS BD FD
2019-09-24
483. VANGUARD BD INDEX FD INC
2019-09-24
130. SPDR TR UNIT SER 1
2017-03-07
2019-10-17
10. DISNEY WALT CO
2016-10-07
2019-10-25
2. ACCENTURE PLC
2014-04-03
2019-10-25
3. ACCENTURE PLC
2014-04-03
2019-10-28
6. NISOURCE INC
2019-11-11
8. NISOURCE INC
2019-11-11
6. NISOURCE INC
2013-02-26
2019-11-12
16. NISOURCE INC
2013-02-26
2019-11-12
1. NISOURCE INC
2013-02-26
2019-11-12
2. NISOURCE INC
2013-02-26
2019-11-13
24. CELGENE CORP.
2019-11-21
13. CELGENE CORP.
2009-04-01
2019-11-21
403.285 FIDELITY 500 INDEX-INST PRM
2018-07-10
2019-11-21
14. RTS BRISTOL-MYERS SQUIBB-CVR
2019-11-21
2019-11-25
2. RTS BRISTOL-MYERS SQUIBB-CVR
2019-11-21
2019-11-25
1. RTS BRISTOL-MYERS SQUIBB-CVR
2019-11-21
2019-11-25
17. RTS BRISTOL-MYERS SQUIBB-CVR
2019-11-21
2019-11-26
3. RTS BRISTOL-MYERS SQUIBB-CVR
2019-11-21
2019-11-27
1902.884 EQUINOX IMP SYSTEM MACRO-I
2018-11-09
2019-12-09
CAPITAL GAIN DIVIDENDS
P
(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
7,853
7,835
18
b
137
178
-41
c
68
89
-21
d
198
18
180
e
165
194
-29
203
267
-64
200
18
182
398
36
362
329
388
-59
69
89
-20
405
36
369
83
97
-14
332
288
44
68
89
-21
250
216
34
69
89
-20
82
72
10
69
89
-20
251
216
35
70
88
-18
75,620
76,414
-794
28,382
28,205
177
37,304
38,132
-828
314
276
38
104
92
12
420
369
51
522
316
206
417
368
49
105
63
42
530
316
214
6,120
6,504
-384
31,790
33,813
-2,023
320
342
-22
640
92
548
1,820
1,418
402
915
741
174
18
18
814
96
718
139
135
4
1,192
285
907
1,197
286
911
1,814
361
1,453
222
206
16
1,734
89
1,645
484
442
42
951
311
640
817
856
-39
654
350
304
911
102
809
376
350
26
691
365
326
777
359
418
373
356
17
800
797
3
279
268
11
207
210
-3
104
104
675
555
120
415
368
47
678
506
172
508
570
-62
519
224
295
568
312
256
447
423
24
341
344
-3
777
135
642
964
234
730
232
174
58
382
460
-78
646
364
282
546
95
451
479
643
-164
1,193
90
1,103
832
814
18
2,500
375
2,125
594
261
333
830
390
440
365
371
-6
379
339
40
310
107
203
775
579
196
273
281
-8
550
805
-255
393
252
141
734
470
264
177
208
-31
735
633
102
852
652
200
516
511
5
473
363
110
442
561
-119
300
268
32
150
128
22
288
240
48
415
429
-14
375
322
53
234
120
114
641
605
36
266
161
105
415
270
145
764
753
11
848
537
311
396
366
30
1,463
225
1,238
378
63
315
472
229
243
348
200
148
677
188
489
392
182
210
300
276
24
127
112
15
636
567
69
370
257
113
699
316
383
354
321
33
452
431
21
83
71
12
248
260
-12
562
169
393
279
282
-3
30,521
28,898
1,623
78,238
52,492
25,746
75,254
72,277
2,977
278
319
-41
518
589
-71
23,199
19,533
3,666
343
353
-10
57
53
4
401
369
32
172
158
14
57
53
4
808
555
253
807
555
252
173
128
45
58
43
15
682
830
-148
401
299
102
57
43
14
115
85
30
57
43
14
58
43
15
116
85
31
591
478
113
297
239
58
98
80
18
198
159
39
385
241
144
349
214
135
87
54
33
217
134
83
617
554
63
530
473
57
264
233
31
353
310
43
326
416
-90
326
416
-90
163
208
-45
439
428
11
165
160
5
77
89
-12
695
1,010
-315
55
53
2
110
107
3
164
160
4
55
53
2
55
53
2
677
227
450
519
459
60
882
255
627
320
259
61
533
457
76
213
173
40
9
9
25
25
37,132
37,193
-61
294
32
262
14,057
11,635
2,422
382
240
142
190
120
70
239
212
27
161
142
19
319
283
36
373
240
133
555
496
59
24
24
38,494
37,416
1,078
39,012
38,082
930
38,879
30,868
8,011
1,313
926
387
366
158
208
551
237
314
157
58
99
209
77
132
156
58
98
416
155
261
26
10
16
52
19
33
2,593
2,259
334
1,404
252
1,152
43,607
39,385
4,222
29
32
-3
4
5
-1
2
2
36
39
-3
6
7
-1
18,477
19,257
-780
1,422
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
18
b
-41
c
-21
d
180
e
-29
-64
182
362
-59
-20
369
-14
44
-21
34
-20
10
-20
35
-18
-794
177
-828
38
12
51
206
49
42
214
-384
-2,023
-22
548
402
174
18
718
4
907
911
1,453
16
1,645
42
640
-39
304
809
26
326
418
17
3
11
-3
120
47
172
-62
295
256
24
-3
642
730
58
-78
282
451
-164
1,103
18
2,125
333
440
-6
40
203
196
-8
-255
141
264
-31
102
200
5
110
-119
32
22
48
-14
53
114
36
105
145
11
311
30
1,238
315
243
148
489
210
24
15
69
113
383
33
21
12
-12
393
-3
1,623
25,746
2,977
-41
-71
3,666
-10
4
32
14
4
253
252
45
15
-148
102
14
30
14
15
31
113
58
18
39
144
135
33
83
63
57
31
43
-90
-90
-45
11
5
-12
-315
2
3
4
2
2
450
60
627
61
76
40
9
25
-61
262
2,422
142
70
27
19
36
133
59
24
1,078
930
8,011
387
208
314
99
132
98
261
16
33
334
1,152
4,222
-3
-1
-3
-1
-780
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
76,461
3
Net short-term capital gain or (loss) as defined in sections 1222(5) and (6):
If gain, also enter in Part I, line 8, column (c) (see instructions). If (loss), enter -0-
in Part I, line 8
...................
3
Part V
Qualification Under Section 4940(e) for Reduced Tax on Net Investment Income
(For optional use by domestic private foundations subject to the section 4940(a) tax on net investment income.)
If section 4940(d)(2) applies, leave this part blank.
Was the foundation liable for the section 4942 tax on the distributable amount of any year in the base period?
Yes
No
If "Yes," the foundation does not qualify under section 4940(e). Do not complete this part.
1
Enter the appropriate amount in each column for each year; see instructions before making any entries.
(a)
Base period years Calendar
year (or tax year beginning in)
(b)
Adjusted qualifying distributions
(c)
Net value of noncharitable-use assets
(d)
Distribution ratio
(col. (b) divided by col. (c))
2018
153,506
3,852,751
0.039843
2017
139,076
3,740,094
0.037185
2016
145,993
3,376,142
0.043243
2015
209,367
3,602,761
0.058113
2014
189,524
3,755,092
0.050471
2
Total
of line 1, column (d)
.....................
2
0.228855
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
0.045771
4
Enter the net value of noncharitable-use assets for 2019 from Part X, line 5
......
4
3,805,723
5
Multiply line 4 by line 3
......................
5
174,192
6
Enter 1% of net investment income (1% of Part I, line 27b)
...........
6
1,420
7
Add lines 5 and 6
........................
7
175,612
8
Enter qualifying distributions from Part XII, line 4
,.............
8
153,740
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
2,839
here
and enter 1% of Part I, line 27b
...................
c
All other domestic foundations enter 2% of line 27b. Exempt foreign organizations enter 4% of Part I, line 12, col. (b)
2
Tax under section 511 (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-)
2
0
3
Add lines 1 and 2
...........................
3
2,839
4
Subtitle A (income) tax (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-)
4
0
5
Tax based on investment income.
Subtract line 4 from line 3. If zero or less, enter -0-
.....
5
2,839
6
Credits/Payments:
a
2019 estimated tax payments and 2018 overpayment credited to 2019
6a
4,744
b
Exempt foreign organizations—tax withheld at source
......
6b
c
Tax paid with application for extension of time to file (Form 8868)
...
6c
0
d
Backup withholding erroneously withheld
...........
6d
7
Total credits and payments. Add lines 6a through 6d
..............
7
4,744
8
Enter any
penalty
for underpayment of estimated tax.
Check here
if Form 2220 is attached.
8
0
9
Tax due.
If the total of lines 5 and 8 is more than line 7, enter
amount owed
.......
9
10
Overpayment.
If line 7 is more than the total of lines 5 and 8, enter the
amount overpaid
...
10
1,905
11
Enter the amount of line 10 to be:
Credited to 2020 estimated tax
1,905
Refunded
11
0
Part VII-A
Statements Regarding Activities
1a
During the tax year, did the foundation attempt to influence any national, state, or local legislation or did
Yes
No
it participate or intervene in any political campaign?
....................
1a
No
b
Did it spend more than $100 during the year (either directly or indirectly) for political purposes? (see Instructions
for definition)
.................................
1b
No
If the answer is "Yes" to
1a
or
1b,
attach a detailed description of the activities and copies of any materials
published or distributed by the foundation in connection with the activities.
c
Did the foundation file
Form 1120-POL
for this year?
.....................
1c
No
d
Enter the amount (if any) of tax on political expenditures (section 4955) imposed during the year:
(1)
On the foundation.
$
(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)
NY
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
14
The books are in care of
JP MORGAN CHASE BANK NA
Telephone no.
(800) 496-2583
Located at
10 S DEARBORN ST MC IL 1-0111
CHICAGO
IL
ZIP+4
60603
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
No
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
JP MORGAN CHASE BANK NA
TRUSTEE
2
46,272
10 S DEARBORN ST MC IL 1-0111
CHICAGO
,
IL
60603
2
Compensation of five highest-paid employees (other than those included on line 1—see instructions). If none, enter “NONE."
(a)
Name and address of each employee paid more than $50,000
(b)
Title, and average
hours per week
devoted to position
(c)
Compensation
(d)
Contributions to
employee benefit
plans and deferred
compensation
(e)
Expense account,
other allowances
NONE
Total
number of other employees paid over $50,000
...................
0
Form
990-PF
(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
.............
0
Part IX-A
Summary of Direct Charitable Activities
List the foundation’s four largest direct charitable activities during the tax year. Include relevant statistical information such as the number of organizations and other beneficiaries served, conferences convened, research papers produced, etc.
Expenses
1
2
3
4
Part IX-B
Summary of Program-Related Investments
(see instructions)
Describe the two largest program-related investments made by the foundation during the tax year on lines 1 and 2.
Amount
1
2
All other program-related investments. See instructions.
3
Total.
Add lines 1 through 3
.........................
Form
990-PF
(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
3,820,757
b
Average of monthly cash balances
.......................
1b
42,921
c
Fair market value of all other assets (see instructions)
................
1c
0
d
Total
(add lines 1a, b, and c)
.........................
1d
3,863,678
e
Reduction claimed for blockage or other factors reported on lines 1a and
1c (attach detailed explanation)
.............
1e
0
2
Acquisition indebtedness applicable to line 1 assets
..................
2
0
3
Subtract line 2 from line 1d
.........................
3
3,863,678
4
Cash deemed held for charitable activities. Enter 1 1/2% of line 3 (for greater amount, see
instructions)
.............................
4
57,955
5
Net value of noncharitable-use assets.
Subtract line 4 from line 3. Enter here and on Part V, line 4
5
3,805,723
6
Minimum investment return.
Enter 5% of line 5
..................
6
190,286
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
190,286
2a
Tax on investment income for 2019 from Part VI, line 5
......
2a
2,839
b
Income tax for 2019. (This does not include the tax from Part VI.)
...
2b
c
Add lines 2a and 2b
............................
2c
2,839
3
Distributable amount before adjustments. Subtract line 2c from line 1
............
3
187,447
4
Recoveries of amounts treated as qualifying distributions
................
4
0
5
Add lines 3 and 4
............................
5
187,447
6
Deduction from distributable amount (see instructions)
.................
6
0
7
Distributable amount
as adjusted. Subtract line 6 from line 5. Enter here and on Part XIII, line 1
...
7
187,447
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
153,740
b
Program-related investments—total from Part IX-B
..................
1b
0
2
Amounts paid to acquire assets used (or held for use) directly in carrying out charitable, etc.,
purposes
...............................
2
0
3
Amounts set aside for specific charitable projects that satisfy the:
a
Suitability test (prior IRS approval required)
....................
3a
0
b
Cash distribution test (attach the required schedule)
.................
3b
0
4
Qualifying distributions.
Add lines 1a through 3b. Enter here and on Part V, line 8, and Part XIII, line 4
4
153,740
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
0
6
Adjusted qualifying distributions.
Subtract line 5 from line 4
..............
6
153,740
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
187,447
2
Undistributed income, if any, as of the end of 2019:
a
Enter amount for 2018 only
.......
79,191
b
Total for prior years:
20
,
20
,
20
0
3
Excess distributions carryover, if any, to 2019:
a
From 2014
......
0
b
From 2015
......
0
c
From 2016
......
0
d
From 2017
......
0
e
From 2018
......
0
f
Total
of lines 3a through e
........
0
4
Qualifying distributions for 2019 from Part
XII, line 4:
$
153,740
a
Applied to 2018, but not more than line 2a
79,191
b
Applied to undistributed income of prior years
(Election required—see instructions)
.....
0
c
Treated as distributions out of corpus (Election
required—see instructions)
........
0
d
Applied to 2019 distributable amount
.....
74,549
e
Remaining amount distributed out of corpus
0
5
Excess distributions carryover applied to 2019.
0
0
(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
0
b
Prior years’ undistributed income. Subtract
line 4b from line 2b
..........
0
c
Enter the amount of prior years’ undistributed
income for which a notice of deficiency has
been issued, or on which the section 4942(a)
tax has been previously assessed
......
0
d
Subtract line 6c from line 6b. Taxable amount
—see instructions
...........
0
e
Undistributed income for 2018. Subtract line
4a from line 2a. Taxable amount—see
instructions
.............
0
f
Undistributed income for 2019. Subtract
lines 4d and 5 from line 1. This amount must
be distributed in 2020
..........
112,898
7
Amounts treated as distributions out of
corpus to satisfy requirements imposed by
section 170(b)(1)(F) or 4942(g)(3) (Election may
be required - see instructions)
.......
0
8
Excess distributions carryover from 2014 not
applied on line 5 or line 7 (see instructions)
...
0
9
Excess distributions carryover to 2020.
Subtract lines 7 and 8 from line 6a
......
0
10
Analysis of line 9:
a
Excess from 2015
....
0
b
Excess from 2016
....
0
c
Excess from 2017
....
0
d
Excess from 2018
....
0
e
Excess from 2019
....
0
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).)
NONE
b
List any managers of the foundation who own 10% or more of the stock of a corporation (or an equally large portion of the
ownership of a partnership or other entity) of which the foundation has a 10% or greater interest.
NONE
2
Information Regarding Contribution, Grant, Gift, Loan, Scholarship, etc., Programs:
Check here
if the foundation only makes contributions to preselected charitable organizations and does not accept
unsolicited requests for funds. If the foundation makes gifts, grants, etc. to individuals or organizations under
other conditions, complete items 2a, b, c, and d. See instructions
a
The name, address, and telephone number or 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
THE PINEY WOODS COUNTRY SCHOOL
ATTN MR LEE A UNGER TREASURER
5096 US 49
PINEY WOODS
,
MS
39148
NONE
PC
GENERAL
64,995
UPPER IOWA UNIVERSITY
605 WASHINGTON ST
FAYETTE
,
IA
52142
NONE
PC
GENERAL
70,995
Total
.................................
3a
135,990
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
...........
4
Dividends and interest from securities
....
14
96,637
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
76,461
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)
..
173,098
13
Total.
Add line 12, columns (b), (d), and (e)
..................
13
173,098
(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