-
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
FIRST CITIZENS CHARITABLE FOUNDATION INC
Number and street (or P.O. box number if mail is not delivered to street address)
2601 4TH STREET SW PO BOX 1708
Room/suite
City or town, state or province, country, and ZIP or foreign postal code
MASON CITY
,
IA
504021708
A Employer identification number
42-1451615
B
Telephone number (see instructions)
(641) 423-1600
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)
$
1,606,121
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)
360,000
2
Check
.............
3
Interest on savings and temporary cash investments
4
Dividends and interest from securities
...
55,384
55,384
5a
Gross rents
............
b
Net rental income or (loss)
6a
Net gain or (loss) from sale of assets not on line 10
b
Gross sales price for all assets on line 6a
7
Capital gain net income (from Part IV, line 2)
...
44,745
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)
.....
0
11
Other income (attach schedule)
.......
0
12
Total.
Add lines 1 through 11
........
415,384
100,129
0
13
Compensation of officers, directors, trustees, etc.
10,000
5,000
0
5,000
14
Other employee salaries and wages
......
15
Pension plans, employee benefits
.......
16a
Legal fees (attach schedule)
.........
0
b
Accounting fees (attach schedule)
.......
930
930
0
0
c
Other professional fees (attach schedule)
....
8,688
8,688
0
0
17
Interest
...............
18
Taxes (attach schedule) (see instructions)
...
1,196
1,196
0
0
19
Depreciation (attach schedule) and depletion
...
0
20
Occupancy
..............
21
Travel, conferences, and meetings
.......
1,210
0
0
0
22
Printing and publications
..........
23
Other expenses (attach schedule)
.......
0
24
Total operating and administrative expenses.
Add lines 13 through 23
..........
22,024
15,814
0
5,000
25
Contributions, gifts, grants paid
.......
437,740
437,740
26
Total expenses and disbursements.
Add lines 24 and 25
459,764
15,814
0
442,740
27
Subtract line 26 from line 12:
a
Excess of revenue over expenses and disbursements
-44,380
b
Net investment income
(if negative, enter -0-)
84,315
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
.............
0
348
348
2
Savings and temporary cash investments
.........
103,886
379,451
379,451
3
Accounts receivable
Less: allowance for doubtful accounts
4
Pledges receivable
Less: allowance for doubtful accounts
5
Grants receivable
.................
6
Receivables due from officers, directors, trustees, and other
disqualified persons (attach schedule) (see instructions)
.....
0
7
Other notes and loans receivable (attach schedule)
Less: allowance for doubtful accounts
0
8
Inventories for sale or use
..............
9
Prepaid expenses and deferred charges
..........
10a
Investments—U.S. and state government obligations (attach schedule)
b
Investments—corporate stock (attach schedule)
.......
562,379
331,619
427,470
c
Investments—corporate bonds (attach schedule)
.......
147,164
72,164
70,345
11
Investments—land, buildings, and equipment: basis
Less: accumulated depreciation (attach schedule)
0
12
Investments—mortgage loans
.............
13
Investments—other (attach schedule)
..........
540,476
570,976
728,507
14
Land, buildings, and equipment: basis
Less: accumulated depreciation (attach schedule)
0
15
Other assets (describe
)
0
0
0
16
Total assets
(to be completed by all filers—see the
instructions. Also, see page 1, item I)
1,353,905
1,354,558
1,606,121
17
Accounts payable and accrued expenses
..........
18
Grants payable
.................
19
Deferred revenue
.................
20
Loans from officers, directors, trustees, and other disqualified persons
0
21
Mortgages and other notes payable (attach schedule)
......
0
22
Other liabilities (describe
)
0
0
23
Total liabilities
(add lines 17 through 22)
.........
0
Foundations that follow 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
1,353,905
1,354,558
28
Retained earnings, accumulated income, endowment, or other funds
29
Total net assets or fund balances
(see instructions)
.....
1,353,905
1,354,558
30
Total liabilities and net assets/fund balances
(see instructions)
.
1,353,905
1,354,558
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
1,353,905
2
Enter amount from Part I, line 27a
.....................
2
-44,380
3
Other increases not included in line 2 (itemize)
3
45,033
4
Add lines 1, 2, and 3
..........................
4
1,354,558
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
1,354,558
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
AT&T INC
P
2011-12-16
2019-12-06
b
ABBVIE INC
P
2016-01-06
2019-12-06
c
ALTRIA GROUP
P
2011-09-13
2019-01-07
d
ALTRIA GROUP
P
2011-09-13
2019-01-07
e
ALTRIA GROUP
P
2011-09-13
2019-01-28
ALTRIA GROUP
P
2011-09-13
2019-09-13
ALTRIA GROUP
P
2011-09-13
2019-12-06
AMERICAN ELEC PWR
P
2012-05-18
2019-03-01
AMERICAN ELEC PWR
P
2012-05-18
2019-06-24
AMERICAN ELEC PWR
P
2012-05-18
2019-06-27
ASTRAZENECA PLC SPON
P
2016-07-21
2019-01-07
ASTRAZENECA PLC SPON
P
2016-07-21
2019-01-10
BCE INC COM NEW
P
2013-12-16
2019-12-06
B P AMOCO SPONSORED ADI
P
2013-01-14
2019-12-06
BRITISH AMERICAN TOBACCO
P
2017-11-16
2019-07-01
BRITISH AMERICAN TOBACCO
P
2017-11-16
2019-07-23
BRITISH AMERICAN TOBACCO
P
2017-11-16
2019-07-26
BRITISH AMERICAN TOBACCO
P
2017-11-16
2019-12-06
CDN IMPERIAL BK COMM TOP
P
2017-07-13
2019-12-06
CHEVRON CORPORATION
P
2015-01-06
2019-12-06
CHEVRON CORPORATION
P
2013-01-31
2019-12-06
CHEVRON CORPORATION
P
2014-12-11
2019-12-06
CHEVRON CORPORATION
P
2016-05-05
2019-12-06
CHEVRON CORPORATION
P
2010-01-22
2019-12-06
CHEVRON CORPORATION
P
2015-07-08
2019-12-06
CHEVRON CORPORATION
P
2014-04-29
2019-12-06
CHEVRON CORPORATION
P
2017-03-22
2019-12-06
COCA COLA COMMON STOCK
P
2010-07-28
2019-01-07
COCA COLA COMMON STOCK
P
2010-07-28
2019-01-28
COCA COLA COMMON STOCK
P
2010-07-28
2019-09-13
COCA COLA COMMON STOCK
P
2010-07-28
2019-12-06
COCA COLA COMMON STOCK
P
2010-07-28
2019-10-10
CROWN CASTLE INTERNATIONAL
P
2016-05-18
2019-03-21
CROWN CASTLE INTERNATIONAL
P
2016-05-18
2019-04-23
CROWN CASTLE INTERNATIONAL
P
2016-05-18
2019-05-29
CROWN CASTLE INTERNATIONAL
P
2016-05-18
2019-06-24
CROWN CASTLE INTERNATIONAL
P
2016-05-18
2019-06-27
CROWN CASTLE INTERNATIONAL
P
2016-05-18
2019-07-11
CROWN CASTLE INTERNATIONAL
P
2016-05-18
2019-07-16
CROWN CASTLE INTERNATIONAL
P
2016-05-18
2019-08-27
CROWN CASTLE INTERNATIONAL
P
2016-05-18
2019-09-18
CROWN CASTLE INTERNATIONAL
P
2016-05-18
2019-09-27
DOMINION ENERGY
P
2011-12-16
2019-09-06
DOMINION ENERGY
P
2011-12-16
2019-12-06
DUKE ENERGY HLDG
P
2013-01-31
2019-12-06
DUKE ENERGY HLDG
P
2012-09-17
2019-12-06
DUKE ENERGY HLDG
P
2012-10-22
2019-12-06
DUKE ENERGY HLDG
P
2011-12-16
2019-12-06
DUKE ENERGY HLDG
P
2012-04-23
2019-12-06
EXXON MOBILE CORP
P
2015-08-26
2019-12-06
GENERAL MILLS
P
2014-12-11
2019-12-06
GENERAL MILLS
P
2014-11-05
2019-04-23
GENERAL MILLS
P
2015-07-08
2019-05-29
GENERAL MILLS
P
2017-06-06
2019-05-29
GENERAL MILLS
P
2017-06-12
2019-05-29
GENERAL MILLS
P
2014-12-11
2019-05-29
GENERAL MILLS
P
2015-10-02
2019-05-29
GENERAL MILLS
P
2017-09-15
2019-07-11
GENERAL MILLS
P
2017-06-12
2019-07-11
GENERAL MILLS
P
2018-03-01
2019-07-16
GENERAL MILLS
P
2017-09-15
2019-07-16
GENERAL MILLS
P
2017-10-17
2019-07-16
GLAXOSMIHKLINE PLC SPC
P
2011-12-16
2019-12-06
HUNTINGTON BANCSHARES
P
2018-11-14
2019-12-06
KIMBERLY CLARK CORP
P
2011-10-20
2019-07-16
KIMBERLY CLARK CORP
P
2011-10-20
2019-07-23
KIMBERLY CLARK CORP
P
2011-10-20
2019-09-06
KIMBERLY CLARK CORP
P
2011-10-20
2019-12-06
NATIONAL GRID PLC
P
2017-05-19
2019-12-06
OCCIDENTAL PETROLEUM
P
2016-10-24
2019-12-06
PNC FINANCIAL SERVICES
P
2018-11-13
2019-12-06
PPL CORP
P
2011-12-16
2019-12-06
PEPSICO
P
2011-12-16
2019-10-03
PEPSICO
P
2011-12-16
2019-10-07
PEPSICO
P
2011-12-16
2019-12-06
PEPSICO
P
2011-12-16
2019-12-10
PHILLIP MORRIS INTL
P
2011-12-16
2019-08-27
PHILLIP MORRIS INTL
P
2011-12-16
2019-12-06
PROCTOR & GAMBLE CO
P
2011-12-16
2019-03-01
PROCTOR & GAMBLE CO
P
2011-12-16
2019-04-23
PROCTOR & GAMBLE CO
P
2011-12-16
2019-05-29
PROCTOR & GAMBLE CO
P
2011-12-16
2019-07-23
PROCTOR & GAMBLE CO
P
2011-12-16
2019-07-26
PROCTOR & GAMBLE CO
P
2011-12-16
2019-08-01
PROCTOR & GAMBLE CO
P
2011-12-16
2019-08-05
REALTY INCOME CORP
P
2013-07-03
2019-12-06
SOUTHERN CO
P
2013-01-31
2019-12-06
SOUTHERN CO
P
2013-01-31
2019-08-30
SOUTHERN CO
P
2017-08-17
2019-12-06
SOUTHERN CO
P
2018-01-17
2019-12-06
SOUTHERN CO
P
2016-05-05
2019-12-06
SOUTHERN CO
P
2013-12-23
2019-12-06
SOUTHERN CO
P
2014-10-13
2019-12-06
SOUTHERN CO
P
2015-10-02
2019-12-06
SOUTHERN CO
P
2013-08-08
2019-12-06
SOUTHERN CO
P
2014-04-02
2019-12-06
SOUTHERN CO
P
2013-01-31
2019-12-06
SOUTHERN CO
P
2015-07-08
2019-12-06
SOUTHERN CO
P
2016-10-11
2019-12-06
SOUTHERN CO
P
2015-03-31
2019-12-06
SOUTHERN CO
P
2018-01-30
2019-12-10
SOUTHERN CO
P
2018-01-17
2019-12-10
TOTAL S A SPONS ADR
P
2016-10-24
2019-09-27
TOTAL S A SPONS ADR
P
2016-10-24
2019-10-03
UNITED PARCEL SERVICE
P
2017-07-13
2019-10-03
UNITED PARCEL SERVICE
P
2017-07-13
2019-11-18
UNITED PARCEL SERVICE
P
2017-07-13
2019-11-22
UNITED PARCEL SERVICE
P
2017-07-13
2019-12-06
VENTAS INC
P
2013-09-16
2019-10-07
VENTAS INC
P
2013-09-16
2019-12-06
VERIZON COMM
P
2013-01-31
2019-01-10
VERIZON COMM
P
2013-12-23
2019-01-10
VERIZON COMM
P
2013-08-08
2019-01-10
VERIZON COMM
P
2014-02-24
2019-01-10
VERIZON COMM
P
2014-02-24
2019-01-28
VERIZON COMM
P
2014-07-16
2019-12-06
VERIZON COMM
P
2016-05-05
2019-12-06
VERIZON COMM
P
2015-07-08
2019-12-06
VERIZON COMM
P
2015-03-31
2019-12-06
VERIZON COMM
P
2016-11-16
2019-12-06
VERIZON COMM
P
2014-04-02
2019-12-06
VERIZON COMM
P
2016-01-06
2019-12-06
VERIZON COMM
P
2016-10-11
2019-12-06
VERIZON COMM
P
2014-10-13
2019-12-06
VERIZON COMM
P
2015-10-02
2019-12-06
VERIZON COMM
P
2014-02-24
2019-12-06
VODAFONE GROUP
P
2011-12-16
2019-03-01
VODAFONE GROUP
P
2011-12-16
2019-03-21
VODAFONE GROUP
P
2011-12-16
2019-12-06
WELLTOWER INC
P
2011-12-16
2019-12-06
INVESCO LTD
P
2018-06-18
2019-12-06
AMGEN INC
P
2019-10-03
2019-12-06
CISCO SYSTEMS INC
P
2019-11-18
2019-12-06
ENBRIDGE INC COM
P
2019-04-23
2019-12-06
GENERAL MILLS INC
P
2019-02-04
2019-07-16
GENERAL MILLS INC
P
2018-08-06
2019-07-16
GENERAL MILLS INC
P
2018-12-26
2019-07-16
GILEAD SCINECES INC
P
2019-07-23
2019-12-06
KRAFT HEINZ CO COM
P
2018-05-04
2019-02-22
PRFIZER INC COMMON STOCK
P
2019-06-24
2019-12-06
REGIONS FINL CORP
P
2019-04-23
2019-12-06
ROYAL DUTCH SHELL PLC
P
2019-09-27
2019-12-06
TC ENERGY CROP COM
P
2019-08-27
2019-12-06
AMCOR PLC ORD
P
2019-06-24
2019-12-06
LYONDELLBASELL INDUSTRIES
P
2019-09-06
2019-12-06
ROYAL BANK OF CANADA
P
2014-03-24
2019-03-15
WELLS FARGO & CO
P
2008-10-28
2019-04-12
CAPITAL GAIN DISTRIBUTION
P
2019-12-31
2019-12-31
(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
12,765
0
11,337
1,428
b
11,958
0
11,112
846
c
1,567
0
1,416
151
d
1,474
0
1,327
147
e
2,127
0
2,079
48
4,399
0
5,443
-1,044
3,889
0
4,030
-141
1,937
0
1,078
859
2,721
0
1,348
1,373
2,377
0
1,213
1,164
2,669
0
2,137
532
2,474
0
2,013
461
8,923
0
8,433
490
9,516
0
10,376
-860
2,326
0
3,090
-764
1,826
0
2,281
-455
1,872
0
2,377
-505
3,534
0
4,268
-734
9,714
0
9,931
-217
1,662
0
1,518
144
1,187
0
1,161
26
2,374
0
2,095
279
356
0
307
49
1,424
0
907
517
356
0
281
75
1,068
0
1,142
-74
831
0
755
76
2,110
0
1,844
266
2,492
0
2,172
320
2,109
0
1,721
388
9,025
0
7,336
1,689
1,182
0
972
210
2,282
0
1,747
535
2,226
0
1,747
479
2,382
0
1,844
538
2,298
0
1,655
643
2,359
0
1,753
606
2,280
0
1,744
536
2,388
0
1,847
541
2,206
0
1,539
667
2,380
0
1,744
636
2,091
0
1,539
552
2,139
0
1,834
305
9,112
0
7,353
1,759
1,880
0
1,436
444
268
0
192
76
1,343
0
979
364
5,642
0
3,987
1,655
89
0
62
27
10,359
0
10,661
-302
1,591
0
1,627
-36
616
0
638
-22
143
0
171
-28
1,004
0
1,210
-206
47
0
57
-10
334
0
367
-33
143
0
167
-24
479
0
499
-20
1,813
0
1,946
-133
105
0
101
4
634
0
665
-31
1,163
0
1,136
27
9,770
0
9,655
115
6,343
0
5,684
659
2,217
0
1,512
705
2,297
0
1,607
690
4,552
0
3,120
1,432
2,758
0
1,891
867
7,348
0
7,574
-226
3,569
0
5,971
-2,402
5,394
0
4,764
630
7,501
0
6,468
1,033
2,222
0
1,605
617
2,370
0
1,706
664
5,486
0
4,014
1,472
1,092
0
802
290
4,021
0
4,606
-585
9,673
0
9,542
131
2,249
0
1,839
410
2,058
0
1,599
459
2,592
0
1,999
593
1,713
0
1,219
494
1,936
0
1,381
555
2,616
0
1,788
828
2,182
0
1,544
638
2,972
0
1,680
1,292
2,085
0
1,580
505
2,316
0
1,756
560
188
0
145
43
3,196
0
2,303
893
188
0
153
35
188
0
123
65
188
0
138
50
376
0
265
111
188
0
132
56
376
0
260
116
1,566
0
1,097
469
188
0
133
55
188
0
148
40
188
0
133
55
1,083
0
800
283
60
0
45
15
4,709
0
4,947
-238
6,279
0
6,904
-625
2,210
0
2,080
130
2,333
0
2,080
253
2,519
0
2,299
220
4,351
0
4,050
301
2,230
0
1,731
499
4,679
0
4,674
5
1,378
0
1,051
327
172
0
146
26
172
0
149
23
401
0
338
63
2,035
0
1,786
249
1,587
0
1,324
263
366
0
305
61
366
0
280
86
183
0
147
36
1,342
0
1,046
296
183
0
144
39
2,380
0
1,788
592
183
0
149
34
732
0
585
147
183
0
127
56
3,296
0
2,598
698
2,205
0
4,232
-2,027
2,270
0
4,029
-1,759
4,497
0
6,815
-2,318
5,823
0
4,213
1,610
2,414
0
3,422
-1,008
3,033
0
2,551
482
1,182
0
1,216
-34
4,782
0
4,526
256
105
0
87
18
158
0
142
16
158
0
112
46
7,432
0
7,198
234
3,837
0
5,970
-2,133
9,860
0
10,464
-604
2,823
0
2,462
361
2,353
0
2,441
-88
2,386
0
2,354
32
2,249
0
2,388
-139
3,896
0
3,535
361
75,000
0
75,000
0
50,854
0
34,193
16,661
232
0
0
232
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
0
0
0
1,428
b
0
0
0
846
c
0
0
0
151
d
0
0
0
147
e
0
0
0
48
0
0
0
-1,044
0
0
0
-141
0
0
0
859
0
0
0
1,373
0
0
0
1,164
0
0
0
532
0
0
0
461
0
0
0
490
0
0
0
-860
0
0
0
-764
0
0
0
-455
0
0
0
-505
0
0
0
-734
0
0
0
-217
0
0
0
144
0
0
0
26
0
0
0
279
0
0
0
49
0
0
0
517
0
0
0
75
0
0
0
-74
0
0
0
76
0
0
0
266
0
0
0
320
0
0
0
388
0
0
0
1,689
0
0
0
210
0
0
0
535
0
0
0
479
0
0
0
538
0
0
0
643
0
0
0
606
0
0
0
536
0
0
0
541
0
0
0
667
0
0
0
636
0
0
0
552
0
0
0
305
0
0
0
1,759
0
0
0
444
0
0
0
76
0
0
0
364
0
0
0
1,655
0
0
0
27
0
0
0
-302
0
0
0
-36
0
0
0
-22
0
0
0
-28
0
0
0
-206
0
0
0
-10
0
0
0
-33
0
0
0
-24
0
0
0
-20
0
0
0
-133
0
0
0
4
0
0
0
-31
0
0
0
27
0
0
0
115
0
0
0
659
0
0
0
705
0
0
0
690
0
0
0
1,432
0
0
0
867
0
0
0
-226
0
0
0
-2,402
0
0
0
630
0
0
0
1,033
0
0
0
617
0
0
0
664
0
0
0
1,472
0
0
0
290
0
0
0
-585
0
0
0
131
0
0
0
410
0
0
0
459
0
0
0
593
0
0
0
494
0
0
0
555
0
0
0
828
0
0
0
638
0
0
0
1,292
0
0
0
505
0
0
0
560
0
0
0
43
0
0
0
893
0
0
0
35
0
0
0
65
0
0
0
50
0
0
0
111
0
0
0
56
0
0
0
116
0
0
0
469
0
0
0
55
0
0
0
40
0
0
0
55
0
0
0
283
0
0
0
15
0
0
0
-238
0
0
0
-625
0
0
0
130
0
0
0
253
0
0
0
220
0
0
0
301
0
0
0
499
0
0
0
5
0
0
0
327
0
0
0
26
0
0
0
23
0
0
0
63
0
0
0
249
0
0
0
263
0
0
0
61
0
0
0
86
0
0
0
36
0
0
0
296
0
0
0
39
0
0
0
592
0
0
0
34
0
0
0
147
0
0
0
56
0
0
0
698
0
0
0
-2,027
0
0
0
-1,759
0
0
0
-2,318
0
0
0
1,610
0
0
0
-1,008
0
0
0
482
0
0
0
-34
0
0
0
256
0
0
0
18
0
0
0
16
0
0
0
46
0
0
0
234
0
0
0
-2,133
0
0
0
-604
0
0
0
361
0
0
0
-88
0
0
0
32
0
0
0
-139
0
0
0
361
0
0
0
0
0
0
0
16,661
0
0
0
232
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
44,745
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
-960
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
490,637
1,519,510
0.322892
2017
372,600
1,538,886
0.242123
2016
367,645
1,383,419
0.265751
2015
401,839
1,318,872
0.304684
2014
335,400
1,309,718
0.256086
2
Total
of line 1, column (d)
.....................
2
1.391536
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
0.278307
4
Enter the net value of noncharitable-use assets for 2019 from Part X, line 5
......
4
1,579,911
5
Multiply line 4 by line 3
......................
5
439,700
6
Enter 1% of net investment income (1% of Part I, line 27b)
...........
6
843
7
Add lines 5 and 6
........................
7
440,543
8
Enter qualifying distributions from Part XII, line 4
,.............
8
442,740
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
843
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
843
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
843
6
Credits/Payments:
a
2019 estimated tax payments and 2018 overpayment credited to 2019
6a
882
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
882
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
39
11
Enter the amount of line 10 to be:
Credited to 2020 estimated tax
39
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
No
5
Was there a liquidation, termination, dissolution, or substantial contraction during the year?
.........
5
No
If "Yes," attach the statement required by General Instruction T.
6
Are the requirements of section 508(e) (relating to sections 4941 through 4945) satisfied either:
By language in the governing instrument, or
By state legislation that effectively amends the governing instrument so that no mandatory directions
that conflict with the state law remain in the governing instrument?
................
6
Yes
7
Did the foundation have at least $5,000 in assets at any time during the year?
If "Yes," complete Part II, col. (c),
and Part XV.
.................................
7
Yes
8a
Enter the states to which the foundation reports or with which it is registered (see instructions)
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
FIRST CITIZENS TRUST COMPANY
Telephone no.
(641) 422-1600
Located at
2601 4TH STREET SW
MASON CITY
IA
ZIP+4
50401
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
PATRICIA A TOMSON
EXEC DIRECTOR
2.00
10,000
0
0
PO BOX 1708
MASON CITY
,
IA
50402
O JAY TOMSON
PRESIDENT
1.00
0
0
0
PO BOX 1708
MASON CITY
,
IA
50402
GORDON ANDERSON
DIRECTOR
1.00
0
0
0
501 MAIN ST
OSAGE
,
IA
50461
CATHERINE ROTTINGHAUS
DIRECTOR
1.00
0
0
0
300 MAIN ST
CHARLES CITY
,
IA
50616
MARTI RODAMAKER
VICE PRESIDENT
1.00
0
0
0
PO BOX 1708
MASON CITY
,
IA
50402
MARY NORDENSTROM
DIRECTOR
1.00
0
0
0
PO BOX 1708
MASON CITY
,
IA
50402
ELAINE ABERG
SECRETARY
1.00
0
0
0
PO BOX 1708
MASON CITY
,
IA
50402
JAMES ANDERSON
TREASURER
1.00
0
0
0
PO BOX 1708
MASON CITY
,
IA
50402
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
GRANTS PAID TO NONPROFIT ORGANIZATIONS THAT MEET ESTABLSIHED CRITERIA. SEE LISTING ON PAGE 11, PART XV.
437,740
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
NONE
0
2
All other program-related investments. See instructions.
3
Total.
Add lines 1 through 3
.........................
0
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
1,383,492
b
Average of monthly cash balances
.......................
1b
220,479
c
Fair market value of all other assets (see instructions)
................
1c
0
d
Total
(add lines 1a, b, and c)
.........................
1d
1,603,971
e
Reduction claimed for blockage or other factors reported on lines 1a and
1c (attach detailed explanation)
.............
1e
0
2
Acquisition indebtedness applicable to line 1 assets
..................
2
3
Subtract line 2 from line 1d
.........................
3
1,603,971
4
Cash deemed held for charitable activities. Enter 1 1/2% of line 3 (for greater amount, see
instructions)
.............................
4
24,060
5
Net value of noncharitable-use assets.
Subtract line 4 from line 3. Enter here and on Part V, line 4
5
1,579,911
6
Minimum investment return.
Enter 5% of line 5
..................
6
78,996
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
78,996
2a
Tax on investment income for 2019 from Part VI, line 5
......
2a
843
b
Income tax for 2019. (This does not include the tax from Part VI.)
...
2b
c
Add lines 2a and 2b
............................
2c
843
3
Distributable amount before adjustments. Subtract line 2c from line 1
............
3
78,153
4
Recoveries of amounts treated as qualifying distributions
................
4
5
Add lines 3 and 4
............................
5
78,153
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
78,153
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
442,740
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
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
442,740
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
843
6
Adjusted qualifying distributions.
Subtract line 5 from line 4
..............
6
441,897
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
78,153
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
......
335,400
b
From 2015
......
401,839
c
From 2016
......
367,645
d
From 2017
......
228,938
e
From 2018
......
416,387
f
Total
of lines 3a through e
........
1,750,209
4
Qualifying distributions for 2019 from Part
XII, line 4:
$
442,740
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)
........
0
d
Applied to 2019 distributable amount
.....
78,153
e
Remaining amount distributed out of corpus
364,587
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
2,114,796
b
Prior years’ undistributed income. Subtract
line 4b from line 2b
..........
0
c
Enter the amount of prior years’ undistributed
income for which a notice of deficiency has
been issued, or on which the section 4942(a)
tax has been previously assessed
......
d
Subtract line 6c from line 6b. Taxable amount
—see instructions
...........
0
e
Undistributed income for 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
..........
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)
...
335,400
9
Excess distributions carryover to 2020.
Subtract lines 7 and 8 from line 6a
......
1,779,396
10
Analysis of line 9:
a
Excess from 2015
....
401,839
b
Excess from 2016
....
367,645
c
Excess from 2017
....
228,938
d
Excess from 2018
....
416,387
e
Excess from 2019
....
364,587
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.
NOT APPLICABLE
2
Information Regarding Contribution, Grant, Gift, Loan, Scholarship, etc., Programs:
Check here
if the foundation only makes contributions to preselected charitable organizations and does not accept
unsolicited requests for funds. If the foundation makes gifts, grants, etc. to individuals or organizations under
other conditions, complete items 2a, b, c, and d. See instructions
a
The name, address, and telephone number or e-mail address of the person to whom applications should be addressed:
PATRICIA A TOMSON
FIRST CITIZENS CHARITABLE FOUNDATIO
MASON CITY
,
IA
50402
(641) 422-1600
b
The form in which applications should be submitted and information and materials they should include:
SEE ATTACHED APPLICATION FORM.
c
Any submission deadlines:
APPLICATIONS ARE REVIEWED QUARTERLY.
d
Any restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other
factors:
SEE CRITERIA INCLUDED IN THE APPLICATION FORM ATTACHED.
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
BELMOND AREA ARTS COUNCIL
1179 TAYLOR AVE
BELMOND
,
IA
50421
EXEMPT
CONSTRUCTION OFCANOPY FORARTS CENTER
1,000
BIG BROTHERSSISTERS OF NE IA
101 S Main ST
CHARLES CITY
,
IA
50616
EXEMPT
MENTORING PROGRAM
5,000
BUILD A BETTER BELMOND
1233 HEGINGER DR
BELMOND
,
IA
50421
EXEMPT
CONCRETE PAVINGFOR CHILD ACTIVITY/RECREATION AREA
5,000
CENTRAL GARDENS OF NORTH IA
800 2ND AVE N
CLEAR LAKE
,
IA
50428
EXEMPT
UPGRADE2020 PROJECT
2,500
CHARLES CITY COMMUNITY SCHOOLS
500 NORTH GRAND AVE
CHARLES CITY
,
IA
50616
EXEMPT
CONSTRUCTION OF SOFTBALL& BASEBALL FIELD
10,000
CITY OF FLOYD
617 MONROE ST
FLOYD
,
IA
50435
EXEMPT
ACCESS TO CEDAR RIVERIN FLOYD
1,000
CITY OF MASON CITY
10 1ST ST NW
MASON CITY
,
IA
50401
EXEMPT
HIGH LINETRAIL IMPROVEMENTS
5,000
CLEAR LAKE AREA CHAMBER
205 MAIN AVE
CLEAR LAKE
,
IA
50428
EXEMPT
2019 THURSDAY'SON MAINSPONSORSHIP
2,500
CLEAR LAKE PUBLIC LIBRARY
200 N 4TH ST
CLEAR LAKE
,
IA
50428
EXEMPT
HANDICAP-ACCESSIBLEDOORS FOR CHILDREN'SDEPARTMENT
1,000
COMM HEALTH CENTER OF FORT DODGE INC
126 N 10TH ST
FORT DODGE
,
IA
50501
EXEMPT
BLOOD PRESSUREMONITORS
2,650
COMMUNITY HEALTH CENTER OF FORT DODGE INC
126 N 10TH ST
FORT DODGE
,
IA
50501
EXEMPT
SPOT VISIONSCREENER
7,500
COMMUNITY POLICING ADVISORY BOARD
78 S GEORGIA AVE
MASON CITY
,
IA
50401
EXEMPT
"NATIONAL NIGHT OUT"EVENT
1,500
COMMUNITY KITCHEN OF NORTH IOWA
606 NORTH MONROE
MASON CITY
,
IA
50401
PUBLICCHARITY
MATCHINGGIFT
250
COMPREHENSIVE SYSTEMS INC
1316 18TH ST SW
MASON CITY
,
IA
50401
EXEMPT
PAL LIFTS
5,000
ELDERBRIDGE AGENCY ON AGING
22 N GEORGIA AVE 216
MASON CITY
,
IA
50401
EXEMPT
MATERIAL AID FUNDS
5,000
ELDERBRIDGE AGENCY ON AGING
22 N GEORGIA AVE 216
MASON CITY
,
IA
50401
EXEMPT
AUTOMATIC DOORS& FURNISHING OF RECEPTION AREA
5,000
EPIPHANY PARISH SOCIAL JUSTICE COMMITTEE
302 5TH ST SE
MASON CITY
,
IA
50401
EXEMPT
MASON CITY DRUGTREATMENT COURT
1,000
FLOYD COUNTY SHERIFF'S OFFICE
101 S MAIN ST STE 501
CHARLES CITY
,
IA
50616
EXEMPT
MATCHING GIFT
1,000
FOSSIL & PRAIRIE CENTER FDN
1227 215TH ST
ROCKFORD
,
IA
50468
PUBLICCHARITY
MAPLE SYRUPPRODUCTION
1,000
GOOD SHEPHERD HEALTH CENTER
304 3RD STREET NE
MASON CITY
,
IA
50401
PUBLICCHARITY
TELEPHONEREASSURANCE
1,000
GREATER IOWA YOUTH FOR CHRIST
2210 S FEDERAL AVE
MASON CITY
,
IA
50401
EXEMPT
FISCAL LITERACYPROGRAM
10,000
IOOF HOME AND COMMUNITY THERAPY CENTER
1037 19TH ST SW
MASON CITY
,
IA
50401
EXEMPT
MATCHING GIFT
1,000
IOOF HOME AND COMMUNITY THERAPY CENTER
1037 19TH ST SW
MASON CITY
,
IA
50401
EXEMPT
WHELL-CHAIRACCESSIBLE TRANSPORTATIONVEHICLE
5,000
IOWA COLLEGE FOUNDATION
505 5TH AVE STE 1034
DES MOINES
,
IA
50309
PUBLICCHARITY
SCHOLARSHIPPROGRAM
5,000
IOWA LEGAL AID
202 1ST ST SE SUITE 112
MASON CITY
,
IA
50401
EXEMPT
TECHNOLOGY FOR LEGALSERVICES FOR LOW-INCOMECLIENTS
5,000
JORDAN RIVER INC DBA MESSIAH FOOD PANTRY
705 3RD AVE
CHARLES CITY
,
IA
50616
EXEMPT
FOOD FOR POVERTY-LEVELINDIVIDUALS
5,000
JUNIOR ACHIEVEMENT OF EASTERN IA
324 3RD ST SE
CEDAR RAPIDS
,
IA
52401
EXEMPT
JUNIR ACHIEVEMENTPROGRAMS
2,500
KANABEC HISTORICAL SOCIETY
805 FOREST AVE W
MORA
,
MN
55051
EXEMPT
KANABEC COUNTYHISTORICAL WORK
5,000
KANAWHA SWIMMING POOL
220 W 6TH ST
KANAWHA
,
IA
50447
EXEMPT
POOL HEATER& REPAIRS
4,000
KINNEY PIONEER MUSEUM
SUITE G 9184 265TH ST
CLEAR LAKE
,
IA
50428
EXEMPT
REPAIRS TO ROOFSOF TWO MUSEUM BUILDINGS
2,500
LAWLER LIONS
302 E GROVE ST
LAWLER
,
IA
52154
EXEMPT
REPLACE SHELTER& ADD RESTROOMS TOCROELL PARK
1,000
LIME CREEK NATURE CENTER
3501 LIME CREEK RD
MASON CITY
,
IA
50401
EXEMPT
EXHIBIT RENOVATIONPROJECT
5,000
LUTHERAN ISLAND CAMP INC
45011 230TH ST
HENNING
,
MN
56551
EXEMPT
EQUINE THERAPYPROGRAM
15,000
LUTHERAN SERVICES IN IOWA
2502 SOUTH JEFFERSON
MASON CITY
,
IA
50401
PUBLICCHARITY
FAMILIES TOGETHERPROGRAM
5,000
MASON CITY CHAMBER OF COMMERCE
9 N FEDERAL AVE
MASON CITY
,
IA
50401
EXEMPT
2019 BAND FESTIVALDRUM MAJORSPONSOR
5,000
MASON CITY FAMILY YMCA
1840 S MONROE
MASON CITY
,
IA
50401
PUBLICCHARITY
MATCHING GIFT
1,000
MASON CITY FAMILY YMCA
1840 S MONROE
MASON CITY
,
IA
50401
PUBLICCHARITY
MATCHING GIFT
750
MASON CITY FIRE DEPT
350 5TH ST SW
MASON CITY
,
IA
50401
EXEMPT
THERMAL IMAGINGCAMERA
5,000
MAYRA
701 SOUTH UNION ST
MORA
,
MN
55051
EXEMPT
LED LIGHTS FOR MORACIVIC CENTER
1,000
MERCY MEDICAL CENTER FOUNDATION
1000 4TH STREET SW
MASON CITY
,
IA
50401
PUBLICCHARITY
MATCHINGGIFT
1,000
MERCY MEDICAL CENTER FOUNDATION
1000 4TH ST SW
MASON CITY
,
IA
50401
PUBLICCHARITY
MATCHING GIFT
1,000
MISSION 61 INC
122 N BUCHANAN ST
CAMBRIDGE
,
MN
55008
EXEMPT
ESTABLISH HOUSING WITHSERVICES FACILITY
17,500
MITCHELL COUNTRY MEMORIAL FDN
616 N 8TH ST
OSAGE
,
IA
50461
EXEMPT
MATCHINGGIFT
1,000
MITCHELL COUNTY MEMORIAL FDN
616 N 8TH ST
OSAGE
,
IA
50461
EXEMPT
EXPANSION/RENOVATIONOF MITCHELL COUNTYREGIONAL HEALTH CENTER
25,000
MOHAWK MARKET
122 S ADAMS AVE
MASON CITY
,
IA
50402
EXEMPT
SCHOOL FOODPANTRY
2,640
NORTHERN LIGHTS ALLIANCE FOR THE HOMELESS
SOUTH ADAMS
MASON CITY
,
IA
50401
PUBLICCHARITY
MATCHINGGIFT
1,000
NORTHERN LIGHTS ALLIANCE FOR HOMELESS
2 SOUTH ADAMS
MASON CITY
,
IA
50401
PUBLICCHARITY
SHELTER FOR HOMELESS& PERMANENT SUPPORTIVEHOUSING
10,000
NORTHERN LIGHTS ALLIANCE FOR HOMELESS
2 SOUTH ADAMS
MASON CITY
,
IA
50401
PUBLICCHARITY
SHELTER OPERATINGEXPENSES
10,000
NIACOG HOUSING TRUST FUND
525 6TH ST SW
MASON CITY
,
IA
50401
PUBLICCHARITY
HOMEREPAIR PROGRAM
5,000
NO IOWA AREA COMM COLLEGE FDN
500 COLLEGE DR
MASON CITY
,
IA
50401
PUBLICCHARITY
LIFE LONG LEARNERSPONSORSHIP
10,000
NO IOWA AREA COMM COLLEGE FDN
500 COLLEGE
MASON CITY
,
IA
50401
PUBLICCHARITY
SCHOLARSHIPSPERFORMING ARTSSPONSORSHIP
3,950
NO IOWA AREA COMM COLLEGE FDN
500 COLLEGE
MASON CITY
,
IA
50401
EXEMPT
$1000SCHOLARSHIPS
3,000
NORTH IOWA AREA COMM COLLEGE FDN
500 COLLEGE DR
MASON CITY
,
IA
50401
EXEMPT
MATCHING GIFT
1,000
NO IOWA AREA COMM COLLEGE
500 COLLEGE
MASON CITY
,
IA
50401
EXEMPT
LAB EQUIPMENT FORPHYSICS PROGRAM
5,000
NORTH IOWA CHRISTIAN SCHOOL
680 6TH ST SE
MASON CITY
,
IA
50461
EXEMPT
ADDITION OFGYM/LOCKER ROOMS
12,500
NORTH IA FAIR ASSOCIATION
3700 4TH ST SW
MASON CITY
,
IA
50401
EXEMPT
ANNUAL CERRO GORDOCOUNTY FAIR
10,000
NE IOWA FOOD BANK
1605 LAFAYETTE ST
WATERLOO
,
IA
50703
EXEMPT
BACKPACKPROGRAM
10,000
ONE HEARTLAND
2101 HENNEPIN AVE S
MINNEAPOLIS
,
MN
55405
PUBLICCHARITY
CAMP NORTHSTARPROGRAM
5,000
OSAGE COMMUNITY DAYCARE
915 PINE ST
OSAGE
,
IA
50461
EXEMPT
CONSTRUCTION OFNEW DAYCARE
15,000
OUR DAILY BREAD FOOD PANTRY
201 9TH ST NE
ALTOONA
,
IA
50009
EXEMPT
MATCHING GIFT
1,000
PARADISE COMMUNITY THEATRE
237 S UNION ST
MORA
,
IA
55051
EXEMPT
PARKING LOTREPAIRS
2,500
PHEASANTS FOREVER
805 PENN BLVD
OSKALOOSA
,
IA
52577
EXEMPT
MATCHING GIFT
1,000
PRAIRIE RIDGE INTEGRATED BEHAVIOR HEALTHCARE
320 N EISENHOWER AVE
MASON CITY
,
IA
50401
EXEMPT
ADDIION FOR WOMEN'S PROGRAM
15,000
PROJECT FLO ASSOCIATION
PO BOX 604
SHELL ROCK
,
IA
50670
EXEMPT
REPAIRING/SHINGLING/RENOVATINGFAMILY RESIDENCES
2,000
POST 733 SAN JUAN-MARNE VFW
1603 S MONROE AVE
MASON CITY
,
IA
50401
EXEMPT
WALK-INCOOLER
2,000
POST 733 SAN JUAN-MARNE VFW
1603 S MONROE AVE
MASON CITY
,
IA
50401
EXEMPT
EXIT DOORS AND REFURBISHINGOF FRONT DOORS ATALL VETS CENTER
1,000
ROCKWELL LIONS CLUB
PO BOX 57
ROCKWELL
,
IA
50469
PUBLICCHARITY
DEBT REDUCTION-ROCKWELL AQUATICCENTER BATH HOUSE
2,000
THE WORLD FOOD PRIZE FOUNDATION
666 GRAND AVENUE PO BOX 1700
DES MOINES
,
IA
50309
PUBLICCHARITY
SUSTAINABILITYFUND
10,000
THE SALVATION ARMY
747 VILLAGE GREEN DR
MASON CITY
,
IA
50401
PUBLICCHARITY
MATCHING GIFT
1,000
SALVATION ARMY ADULT DAY HEALTH CENTER
747 VILLAGE GREEN DR
MASON CITY
,
IA
50401
PUBLICCHARITY
HANDS-ON ARTACTIVITIES
1,000
SALVATION ARMY OF NORTH IA
747 VILLAGE GREEN DR
MASON CITY
,
IA
50401
EXEMPT
OPERATING EXPENSESFOR ADULT DAY HEALTHCENTER
5,000
SPIN DEVO
4700 4TH ST SW
MASON CITY
,
IA
50401
EXEMPT
YOUTH CYCLING DEVELOPMENTAND WOMENS CYCLING
2,500
STACYVILLE KIDS CARE
603 N BROAD ST
STACYVILLE
,
IA
50476
EXEMPT
CHILDREN'S PLAYCENTERS
1,000
VASALOPPET INC
100 S UNION ST
MORA
,
MN
55051
EXEMPT
CONSTRUCT STORAGEFOR SNOW-MAKINGEQUIPMENT
7,500
WEST HANCOCK COMM SCHOOL DISTRICT
420 9TH AVE SW
BRITT
,
IA
50423
EXEMPT
OUTSIDE DIGITAL SCOREBOARDAND SIGNAGE
5,000
YSS FOUNDATION
50 N EISENHOWER
MASON CITY
,
IA
50401
EXEMPT
RECOVERY CENTER
40,000
YSS FRANCIS LAUER
50 N EISENHOWER AVE
MASON CITY
,
IA
50401
EXEMPT
RECOVERY CENTER
40,000
ZION LUTHERAN CHURCH AND PRESCHOOL
1005 11TH AVE N
HUMBOLDT
,
IA
50548
EXEMPT
INDOOR PLAY EQUIPMENT/DIE CUT LETTERS&NUMBERS
1,000
Total
.................................
3a
437,740
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
55,384
5
Net rental income or (loss) from real estate:
a
Debt-financed property
......
b
Not debt-financed property
.....
6
Net rental income or (loss) from personal property
7
Other investment income
.....
8
Gain or (loss) from sales of assets other than
inventory
............
9
Net income or (loss) from special events:
10
Gross profit or (loss) from sales of inventory
11
Other revenue:
a
b
c
d
e
12
Subtotal. Add columns (b), (d), and (e)
..
55,384
13
Total.
Add line 12, columns (b), (d), and (e)
..................
13
55,384
(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:
Part VI Line 7 -Original Return Overpayment:
-882
Form 990PF - Special Condition Description:
Special Condition Description