-
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
The Jacquemin Family Foundation Inc
Number and street (or P.O. box number if mail is not delivered to street address)
8609 Westwood Center Drive Suite
Room/suite
City or town, state or province, country, and ZIP or foreign postal code
Vienna
,
VA
22182
A Employer identification number
54-1887187
B
Telephone number (see instructions)
(703) 917-0707
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)
$
9,774,158
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)
1,546,256
2
Check
.............
3
Interest on savings and temporary cash investments
22,030
22,030
22,030
4
Dividends and interest from securities
...
240,902
240,902
240,902
5a
Gross rents
............
b
Net rental income or (loss)
6a
Net gain or (loss) from sale of assets not on line 10
-137,805
b
Gross sales price for all assets on line 6a
1,597,809
7
Capital gain net income (from Part IV, line 2)
...
8
Net short-term capital gain
.........
9
Income modifications
...........
10a
Gross sales less returns and allowances
b
Less: Cost of goods sold
....
c
Gross profit or (loss) (attach schedule)
.....
11
Other income (attach schedule)
.......
12
Total.
Add lines 1 through 11
........
1,671,383
262,932
262,932
13
Compensation of officers, directors, trustees, etc.
14
Other employee salaries and wages
......
15
Pension plans, employee benefits
.......
16a
Legal fees (attach schedule)
.........
b
Accounting fees (attach schedule)
.......
2,510
2,510
c
Other professional fees (attach schedule)
....
17
Interest
...............
18
Taxes (attach schedule) (see instructions)
...
3,387
3,387
19
Depreciation (attach schedule) and depletion
...
20
Occupancy
..............
21
Travel, conferences, and meetings
.......
22
Printing and publications
..........
23
Other expenses (attach schedule)
.......
202
202
24
Total operating and administrative expenses.
Add lines 13 through 23
..........
6,099
6,099
0
25
Contributions, gifts, grants paid
.......
460,500
460,500
26
Total expenses and disbursements.
Add lines 24 and 25
466,599
6,099
460,500
27
Subtract line 26 from line 12:
a
Excess of revenue over expenses and disbursements
1,204,784
b
Net investment income
(if negative, enter -0-)
256,833
c
Adjusted net income
(if negative, enter -0-)
...
262,932
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
.............
436,928
1,336,865
1,336,865
2
Savings and temporary cash investments
.........
1,026,880
1,352,659
1,352,659
3
Accounts receivable
Less: allowance for doubtful accounts
4
Pledges receivable
Less: allowance for doubtful accounts
5
Grants receivable
.................
6
Receivables due from officers, directors, trustees, and other
disqualified persons (attach schedule) (see instructions)
.....
7
Other notes and loans receivable (attach schedule)
205,228
Less: allowance for doubtful accounts
5,228
205,228
205,228
8
Inventories for sale or use
..............
9
Prepaid expenses and deferred charges
..........
10a
Investments—U.S. and state government obligations (attach schedule)
b
Investments—corporate stock (attach schedule)
.......
5,765,506
6,867,926
6,867,926
c
Investments—corporate bonds (attach schedule)
.......
11
Investments—land, buildings, and equipment: basis
Less: accumulated depreciation (attach schedule)
12
Investments—mortgage loans
.............
13
Investments—other (attach schedule)
..........
11,480
11,480
11,480
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)
7,246,022
9,774,158
9,774,158
17
Accounts payable and accrued expenses
..........
10,000
22,510
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)
.........
10,000
22,510
Foundations that follow FASB ASC 958, check here
and complete lines 24, 25, 29 and 30.
24
Net assets without donor restrictions
...........
7,236,022
25
Net assets with donor restrictions
............
Foundations that do not follow FASB ASC 958, check here
and complete lines 26 through 30.
26
Capital stock, trust principal, or current funds
........
27
Paid-in or capital surplus, or land, bldg., and equipment fund
28
Retained earnings, accumulated income, endowment, or other funds
29
Total net assets or fund balances
(see instructions)
.....
7,236,022
9,751,648
30
Total liabilities and net assets/fund balances
(see instructions)
.
7,246,022
9,774,158
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
7,236,022
2
Enter amount from Part I, line 27a
.....................
2
1,204,784
3
Other increases not included in line 2 (itemize)
3
1,377,223
4
Add lines 1, 2, and 3
..........................
4
9,818,029
5
Decreases not included in line 2 (itemize)
5
66,381
6
Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 29
.
6
9,751,648
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
5687 Beyond Meat Incorporation
P
2019-11-18
2019-11-18
b
2404 Autoliv Incorporated
P
2013-02-04
2019-11-01
c
1122 Beyond Meat Incorporation
P
2000-01-01
2019-12-05
d
2/4/13 Ryman Hositality PPTYS
P
2013-02-04
2019-11-01
e
2/4/13 Veoneer Incorporated
P
2013-02-04
2019-11-01
4750 Agree Realty Corp
P
2013-07-31
2019-11-01
4100 Diamond Offshore Drilling
P
2012-01-20
2019-10-03
800 Diamond Offshore Drilling
P
2000-01-01
2019-10-03
6700 Dorian LPG LTD
P
2016-12-01
2019-10-03
6300 Dorian LPG LTD
P
2016-12-02
2019-10-03
2000 Dorian LPG LTD
P
2000-01-01
2019-10-03
2400 Transocean LTD
P
2012-01-06
2019-10-03
400 Transocean LTD
P
2012-01-20
2019-10-03
900 Transocean LTD
P
2000-01-01
2019-10-03
900 Diamond Offshore Drilling
P
2011-03-11
2019-10-03
1900 Navios Maritime Holdings Inc
P
2010-07-09
2019-10-03
1300 Transocean LTD
P
2015-05-20
2019-10-03
(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
448,189
454,306
-6,117
b
189,058
112,812
76,246
c
82,257
23,013
59,244
d
255,408
120,674
134,734
e
40,059
43,785
-3,726
372,843
132,800
240,043
20,681
253,634
-232,953
4,038
49,495
-45,457
67,869
47,846
20,023
63,808
46,330
17,478
20,309
14,471
5,838
9,684
168,048
-158,364
1,614
28,008
-26,394
3,631
63,018
-59,387
4,542
62,273
-57,731
8,574
90,440
-81,866
5,245
24,661
-19,416
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
-6,117
b
76,246
c
59,244
d
134,734
e
-3,726
240,043
-232,953
-45,457
20,023
17,478
5,838
-158,364
-26,394
-59,387
-57,731
-81,866
-19,416
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
-137,805
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
-6,117
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
391,825
8,631,290
0.04540
2017
370,420
7,401,640
0.05005
2016
203,674
3,561,376
0.05719
2015
187,125
4,286,415
0.04366
2014
191,418
3,550,235
0.05392
2
Total
of line 1, column (d)
.....................
2
0.250204
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
0.050041
4
Enter the net value of noncharitable-use assets for 2019 from Part X, line 5
......
4
8,170,016
5
Multiply line 4 by line 3
......................
5
408,836
6
Enter 1% of net investment income (1% of Part I, line 27b)
...........
6
2,568
7
Add lines 5 and 6
........................
7
411,404
8
Enter qualifying distributions from Part XII, line 4
,.............
8
460,500
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
2,568
here
and enter 1% of Part I, line 27b
...................
c
All other domestic foundations enter 2% of line 27b. Exempt foreign organizations enter 4% of Part I, line 12, col. (b)
2
Tax under section 511 (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-)
2
3
Add lines 1 and 2
...........................
3
2,568
4
Subtitle A (income) tax (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-)
4
5
Tax based on investment income.
Subtract line 4 from line 3. If zero or less, enter -0-
.....
5
2,568
6
Credits/Payments:
a
2019 estimated tax payments and 2018 overpayment credited to 2019
6a
380
b
Exempt foreign organizations—tax withheld at source
......
6b
c
Tax paid with application for extension of time to file (Form 8868)
...
6c
d
Backup withholding erroneously withheld
...........
6d
7
Total credits and payments. Add lines 6a through 6d
..............
7
380
8
Enter any
penalty
for underpayment of estimated tax.
Check here
if Form 2220 is attached.
8
78
9
Tax due.
If the total of lines 5 and 8 is more than line 7, enter
amount owed
.......
9
2,266
10
Overpayment.
If line 7 is more than the total of lines 5 and 8, enter the
amount overpaid
...
10
11
Enter the amount of line 10 to be:
Credited to 2020 estimated tax
Refunded
11
Part VII-A
Statements Regarding Activities
1a
During the tax year, did the foundation attempt to influence any national, state, or local legislation or did
Yes
No
it participate or intervene in any political campaign?
....................
1a
No
b
Did it spend more than $100 during the year (either directly or indirectly) for political purposes? (see Instructions
for definition)
.................................
1b
No
If the answer is "Yes" to
1a
or
1b,
attach a detailed description of the activities and copies of any materials
published or distributed by the foundation in connection with the activities.
c
Did the foundation file
Form 1120-POL
for this year?
.....................
1c
No
d
Enter the amount (if any) of tax on political expenditures (section 4955) imposed during the year:
(1)
On the foundation.
$
(2)
On foundation managers.
$
e
Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed
on foundation managers.
$
2
Has the foundation engaged in any activities that have not previously been reported to the IRS?
.......
2
No
If "Yes," attach a detailed description of the activities.
3
Has the foundation made any changes, not previously reported to the IRS, in its governing instrument, articles
of incorporation, or bylaws, or other similar instruments?
If "Yes," attach a conformed copy of the changes
....
3
No
4a
Did the foundation have unrelated business gross income of $1,000 or more during the year?
........
4a
No
b
If "Yes," has it filed a tax return on
Form 990-T
for this year?
...................
4b
5
Was there a liquidation, termination, dissolution, or substantial contraction during the year?
.........
5
No
If "Yes," attach the statement required by General Instruction T.
6
Are the requirements of section 508(e) (relating to sections 4941 through 4945) satisfied either:
By language in the governing instrument, or
By state legislation that effectively amends the governing instrument so that no mandatory directions
that conflict with the state law remain in the governing instrument?
................
6
Yes
7
Did the foundation have at least $5,000 in assets at any time during the year?
If "Yes," complete Part II, col. (c),
and Part XV.
.................................
7
Yes
8a
Enter the states to which the foundation reports or with which it is registered (see instructions)
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
John M Jacquemin
Telephone no.
(703) 917-0289
Located at
8609 Westwood Center Drive Suite 45
Vienna
VA
ZIP+4
22182
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
John M Jacquemin
Manager
0.00
0
8609 Westwood Center Dr 450
Vienna
,
VA
22182
Tracie J Jaquemin
Secretary
1.00
0
8609 Westwood Center Dr 450
Vienna
,
VA
22182
2
Compensation of five highest-paid employees (other than those included on line 1—see instructions). If none, enter “NONE."
(a)
Name and address of each employee paid more than $50,000
(b)
Title, and average
hours per week
devoted to position
(c)
Compensation
(d)
Contributions to
employee benefit
plans and deferred
compensation
(e)
Expense account,
other allowances
NONE
Total
number of other employees paid over $50,000
...................
Form
990-PF
(2019)
Form 990-PF (2019)
Page
7
Part VIII
Information About Officers, Directors, Trustees, Foundation Managers, Highly Paid Employees,
and Contractors
(continued)
3
Five highest-paid independent contractors for professional services (see instructions). If none, enter "NONE".
(a)
Name and address of each person paid more than $50,000
(b)
Type of service
(c)
Compensation
NONE
Total
number of others receiving over $50,000 for professional services
.............
Part IX-A
Summary of Direct Charitable Activities
List the foundation’s four largest direct charitable activities during the tax year. Include relevant statistical information such as the number of organizations and other beneficiaries served, conferences convened, research papers produced, etc.
Expenses
1
2
3
4
Part IX-B
Summary of Program-Related Investments
(see instructions)
Describe the two largest program-related investments made by the foundation during the tax year on lines 1 and 2.
Amount
1
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
6,389,146
b
Average of monthly cash balances
.......................
1b
1,893,806
c
Fair market value of all other assets (see instructions)
................
1c
11,480
d
Total
(add lines 1a, b, and c)
.........................
1d
8,294,432
e
Reduction claimed for blockage or other factors reported on lines 1a and
1c (attach detailed explanation)
.............
1e
0
2
Acquisition indebtedness applicable to line 1 assets
..................
2
3
Subtract line 2 from line 1d
.........................
3
8,294,432
4
Cash deemed held for charitable activities. Enter 1 1/2% of line 3 (for greater amount, see
instructions)
.............................
4
124,416
5
Net value of noncharitable-use assets.
Subtract line 4 from line 3. Enter here and on Part V, line 4
5
8,170,016
6
Minimum investment return.
Enter 5% of line 5
..................
6
408,501
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
408,501
2a
Tax on investment income for 2019 from Part VI, line 5
......
2a
2,568
b
Income tax for 2019. (This does not include the tax from Part VI.)
...
2b
c
Add lines 2a and 2b
............................
2c
2,568
3
Distributable amount before adjustments. Subtract line 2c from line 1
............
3
405,933
4
Recoveries of amounts treated as qualifying distributions
................
4
5
Add lines 3 and 4
............................
5
405,933
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
405,933
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
460,500
b
Program-related investments—total from Part IX-B
..................
1b
2
Amounts paid to acquire assets used (or held for use) directly in carrying out charitable, etc.,
purposes
...............................
2
3
Amounts set aside for specific charitable projects that satisfy the:
a
Suitability test (prior IRS approval required)
....................
3a
b
Cash distribution test (attach the required schedule)
.................
3b
4
Qualifying distributions.
Add lines 1a through 3b. Enter here and on Part V, line 8, and Part XIII, line 4
4
460,500
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
2,568
6
Adjusted qualifying distributions.
Subtract line 5 from line 4
..............
6
457,932
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
405,933
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
......
b
From 2015
......
c
From 2016
......
d
From 2017
......
2,246
e
From 2018
......
f
Total
of lines 3a through e
........
2,246
4
Qualifying distributions for 2019 from Part
XII, line 4:
$
460,500
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
.....
405,933
e
Remaining amount distributed out of corpus
54,567
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
56,813
b
Prior years’ undistributed income. Subtract
line 4b from line 2b
..........
c
Enter the amount of prior years’ undistributed
income for which a notice of deficiency has
been issued, or on which the section 4942(a)
tax has been previously assessed
......
d
Subtract line 6c from line 6b. Taxable amount
—see instructions
...........
e
Undistributed income for 2018. Subtract line
4a from line 2a. Taxable amount—see
instructions
.............
f
Undistributed income for 2019. Subtract
lines 4d and 5 from line 1. This amount must
be distributed in 2020
..........
0
7
Amounts treated as distributions out of
corpus to satisfy requirements imposed by
section 170(b)(1)(F) or 4942(g)(3) (Election may
be required - see instructions)
.......
8
Excess distributions carryover from 2014 not
applied on line 5 or line 7 (see instructions)
...
9
Excess distributions carryover to 2020.
Subtract lines 7 and 8 from line 6a
......
56,813
10
Analysis of line 9:
a
Excess from 2015
....
b
Excess from 2016
....
c
Excess from 2017
....
2,246
d
Excess from 2018
....
e
Excess from 2019
....
54,567
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).)
John M Jacquemin
b
List any managers of the foundation who own 10% or more of the stock of a corporation (or an equally large portion of the
ownership of a partnership or other entity) of which the foundation has a 10% or greater interest.
2
Information Regarding Contribution, Grant, Gift, Loan, Scholarship, etc., Programs:
Check here
if the foundation only makes contributions to preselected charitable organizations and does not accept
unsolicited requests for funds. If the foundation makes gifts, grants, etc. to individuals or organizations under
other conditions, complete items 2a, b, c, and d. See instructions
a
The name, address, and telephone number or e-mail address of the person to whom applications should be addressed:
John M Jacquemin
8609 Westwood Center Drive Suite 45
Vienna
,
VA
22182
(703) 917-0707
b
The form in which applications should be submitted and information and materials they should include:
No form required
c
Any submission deadlines:
None
d
Any restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other
factors:
no
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
Main Street Child Development Cente
4401 Sideburn Road
Fairfax
,
VA
22030
None
501(c)(3)
Main Street provides 3,000 hours of nationally-accredited educational instruction and enrichment for at-risk children (ages 2 to 5) each year.
5,000
Bright Beginnings
128 M Street NW Ste 150
Washington
,
DC
20001
None
501(c)(3)
Provides safe, nurturing environment and childcare for homeless infants, toddlers, and preschoolers and helps their parents to end their homelessness.
20,000
Kenya Education Fund KEF
PO Box 7015
Mclean
,
VA
22106
None
501(c)(3)
Funds the high school education of 40 needy and nomadic students in Kenya.
25,000
Kid Pan Alley
PO Box 38
Washington
,
VA
22747
None
501(c)(3)
Funds the process of inspiring and empowering children to work together to become creators of their own music and rekindles creativity as a core value in education.
10,000
Inner City Inner Child
3133 Dumbarton Street NW
Washington
,
DC
20007
None
501(c)(3)
Provides books for childrenigniting a passion for reading and creating a literacy-rich environment for the youngest children by working with child care centers where the kids spends most of their day.
10,000
University at Buffalo BNAC
PO Box 730
Buffalo
,
NY
14226
None
501(c)(3)
Supports the Buffalo Neuroimaging Analysis Center Fund in the School of Medicine and Biomedical Sciences in particular research in multiple sclerosis. This research allows clinicians, researchers and medical students from around the world to advance their understanding of multiple sclerosis and other diseases of the brain, spinal cord and optic nerve .
40,000
Second Story
PO Box 694
Dun Loring
,
VA
22027
None
501(c)(3)
Funds shelter for runaway, abused and homeless teens by offering safe and accessible places where teens can get help, development important life skills, and improve family relationships.
20,000
Homestretch
303 South Maple Ave Suite 400
Falls Church
,
VA
22046
None
501(c)(3)
Empowers homeless families to return to stable housing and self-sufficiency by providing them with the skills to become productive participants in Northern Virginia.
10,000
Tuck School of Business
100 Tuck Hall
Hanover
,
NH
03755
None
501(c)(3)
University (Business school)
60,000
George Mason
4400 University Dr
Fairfax
,
VA
22030
None
501(c)(3)
University
65,000
The Elephant Sanctuary
27 East Main St
Hohenwald
,
TN
38462
None
501(c)(3)
The nations largest natural habitat refuge developed specifically for African and Asian elephants. It provides captive elephants a natural habitat, individualized care and the opportunity to live out their lives in a safe haven dedicated to their wellbeing.
5,000
Hopecam
12100 Sunset Hills Rd C10
Reston
,
VA
20190
None
501(c)(3)
Hopecam connects children undergoing treatment for cancer with their friends at school usingtablet computers, high speed internet connections and web cameras.
5,000
Rappahannock Pantry
602 Mt Salem Ave
Washington
,
VA
22747
None
501(c)(3)
distributes food to residents in need.
1,000
The Arc of Northern Virginia
2755 Harland Road Suite 200
Falls Church
,
VA
22043
None
501(c)(3)
To promotes and protect the human right of people.
5,000
ArtStream
620 Pershing Dr
Silver Spring
,
MD
20910
None
501(c)(3)
To creates artistic opportunities for communities underserved by the arts, mainly individuals with disabilities.
2,000
Headwaters
12018 Lee Hwy
Sperryville
,
VA
22740
None
PF
To foster educational excellence in Rappahannock County by cultivating the cooperative spirit and resources of the whole community to benefit all students.
5,000
Inova Kellar
11204 Waples Mill Rd
Fairfax
,
VA
22030
None
501(c)(3)
Inova Kellar Center has provided behavioral health services for children, adolescents and their families for twenty years. Our comprehensive mental health and substance abuse treatment programs and an innovative special education school support families throughout Northern Virginia and continue to expand to meet future needs.
5,000
RAAC
PO Box 24
Washington
,
VA
22747
None
501(c)(3)
RAAC is an organization in Rappahannock country that focuses on enhancing the lives of the community through exposure to and participation in the arts.
1,000
SAGWA Suzuki Association
2349 Belleview Ave
Cheverly
,
MD
20785
None
501(c)(3)
To improving childrens lives through music education. Our mission is to inspire an appreciation for the untapped possibilities of children through promoting the understanding and use of the music teaching approach and educational philosophy of Dr. Shinichi Suzuki for the greater happiness of all children.
2,000
A Forever Home Rescue
PO Box 22801
Chantilly
,
VA
20153
None
501(c)(3)
To rescue puppies and dogs from hoaders and backyard breeders, owner surrenders and shelters.
1,000
Castleton Festival
7 Castleton Meadows Lane
Castleton
,
VA
22716
None
501(c)(3)
Host the artists, singers, musicians, conductors,designers,directors and stage technician on the picturesque where they create and produce world.class performances.
4,000
Child Care Learning Center of Rappa
12763 Lee Highway PO Box 520
Washington
,
VA
22747
None
501(c)(3)
To provide early childhood programs.
5,000
Rappahannock Animal Welfare League
PP Box 396
Amissville
,
VA
20106
None
501(c)(3)
To rescue and provide shelter for animals.
1,000
SafeSpot Children's Advocacy Center
4021 Chain Bridge Rd Suite 200
Fairfax
,
VA
22030
None
501(c)(3)
To provide direct services to child victims of sexual abuse and severe physical abuse.
5,000
Woft Trap Institute for Early Learn
1635 Trap Rd
Vienna
,
VA
22182
None
501(c)(3)
To provide innovative arts-based teaching strategies and services to early chilhood teachers, caregivers, parents, and their children through the disciplines of drama, music, and movement.
5,000
Assistance League of Northern Virgi
PO Box 209
Herdon
,
VA
20172
None
501(c)(3)
To feed, cloth and educate children in need in our community.
4,000
Crossways Community
3015 Upton Dr
Kensington
,
MD
20895
None
501(c)(3)
Crossway Community is a prepared environment, intentionally designed and maintained to be conducive to healthy family interaction healthy development for all ages.
2,000
Fairfax County Animal Shelter
PO Box 905
Elkins
,
WV
26241
None
501(c)(3)
To provide a safe-haven for dogs, cats, and small animals like guinea pigs, rabbits and pet birds
1,000
RappCats
PO Box 307
Washington
,
VA
22747
None
501(c)(3)
To manage the daily operations of the Rappahannock County animal shelter
1,000
Animal Place
17314 McCourney Ave
Grass Valley
,
CA
95949
None
501(c)(3)
Animal Places California animal shelters fills a much-needed niche of farm animal rescue, sanctuary, education and adoption.
500
Friend of Guest House
1 E Luray Ave
Alexandria
,
VA
22301
None
501(c)(3)
Guest House helps Northern Virginia women make successful transitions from incarceration back into the community. The program focuses on issues ranging from trauma and addiction to housing and employment, in order to prevent the women from reoffending in the future. Fewer than 10% of Guest House graduates re-offend.
10,000
Piedmont Environmental Council
45 Horner St
Warrenton
,
VA
20186
None
501(c)(3)
To promote and protect the Piedmont area's rural economy, natural resources, history, and beauty. The organization was founded in 1972.
10,000
RappU
11669 Lee Highway
Sperryville
,
VA
22740
None
501(c)(3)
To provide lifelong learning and workforce training in Rappahannock County, Virginia.
5,000
Reach Incorporated
300 M Street SE Suite 803
Washington
,
DC
20003
None
501(c)(3)
To provide highly-successful out-of-school-time program serving 350 participants at 8 sites in the District of Columbia. We hire teens to be elementary school reading tutors, creating academic benefit for both the students and their tutors.
5,000
RLEP
PO Box 9
Washington
,
VA
22747
None
501(c)(3)
To preserving the natural resources and rural character of Rappahannock County, Virginia.
2,500
Smithsonian Conservation Biology In
1500 Remount Rd
Front Royal
,
VA
22630
None
501(c)(3)
To save wildlife species from extinction and train future generations of conservationists.
30,000
THEARC
1901 Mississippi Ave SE
Washington
,
DC
20020
None
501(c)(3)
To improve the quality of life for residents of Ward 8, and is home to eleven of Washington, DC's best nonprofit agencies, all of which share the goal of helping children and adults reach their full potential.
5,000
World Central Kitchen
1875 Connecticut Ave NW 10th Fl
Washington
,
DC
20009
None
501(c)(3)
A group of chefs creating smart solutions to hunger and poverty.
1,000
CASA
6811 Kenilworth Ave Ste 402
Riverdale
,
MD
20737
None
501(c)(3)
Court Appointed Special Advocate (CASA)/ Prince Georges County, Inc. is a volunteer-based organization that partners with the juvenile court to improve the lives of children living in foster care who have suffered from abuse and neglect.
5,000
Homeless Children's Playtime Projec
1525 Newton St NW
Washington
,
DC
20010
None
501(c)(3)
The Homeless Children's Playtime Project cultivates resilience in children experiencing family homelessness by providing and expanding access to transformative play experiences. They partner with transitional housing and emergency shelters across the city, where we create safe and fun play spaces in the shelters where the children live.
2,000
Kiss the Ground
4312 W Jefferson Blvd
Los Angeles
,
CA
90016
None
501(c)(3)
Kiss the Ground is a California-based 501(c)(3) environmental non-profit telling a new story about our ability to regenerate land and reverse climate change by building back healthy soil. We create media, campaigns and educational curriculum that raise awareness and empower individuals to take action.
3,000
Castleton Community Volunteer Fire
593 Castleton View Road
Castleton
,
VA
22716
None
501(c)(3)
Castleton Community Volunteer Fire Company was established in 1956 as a Fire Company and later added EMS Transport capabilities and continues today as a Fire and Rescue Company.
2,500
Common Good City Farm
PO Box 26030
Washington
,
DC
20001
None
501(c)(3)
Common Good City Farm (CGCF) is a place where community members can source fresh food, see sustainable urban agriculture in action, and gain exposure to concepts and skills to lead healthy lives. Their mission is to create a vibrant, informed, and well-nourished community through urban farming.
5,000
NPCF
PO Box 3549
Warrenton
,
VA
20188
None
501(c)(3)
The mission of the Northern Piedmont Community Foundation: To build philanthropic capital, to enhance and preserve the quality of life in Culpeper, Fauquier, Madison and Rappahannock Counties and to strengthen the region's nonprofit organizations.
10,000
Orphan Kitten Project
1 Schields Ave
Davis
,
CA
95617
None
501(c)(3)
The Orphan Kitten Project is an entirely student run rescue organization based out of the UC Davis School of Veterinary Medicine. Their mission is to rescue kittens that are too young to be taken into shelters (less than 8 weeks of age) and raise them in foster homes until they are old enough to be adopted.
1,000
Rapp at Home
PO Box 193
Washington
,
VA
22747
None
501(c)(3)
Rapp at Homes mission is to sustain and enrich Rappahannock County residents who are members of Rapp at Home to age in the community comfortably, safely, independently and with peace of mind by fostering the community supports and services needed to do so.
1,000
Safe Shores
429 O Street NW
Washington
,
DC
20001
None
501(c)(3)
Safe Shores is dedicated to working with and advocating for children and adolescents affected by trauma and violence.
3,000
The Scrabble School Preservation Fo
PO Box 356
Sperryville
,
VA
22740
None
501(c)(3)
The Scrabble School Preservation Foundation's mission is to preserve the school's history and to share its legacy through public outreach and educational programs.
1,000
Doctors Without Borders USA
PO Box 5030
Hagerstown
,
MD
21741
None
501(c)(3)
Doctors Without Borders/Mdecins Sans Frontires (MSF) provides impartial medical relief to the victims of war, disease, and natural or man-made disaster, without regard to race, religion, or political affiliation.
3,000
Belle Meade Montessory School
353 FT Valley Rd
Sperryville
,
VA
22740
None
501(c)(3)
Belle Meade Montessori School provides an exceptional education that emphasizes individual responsibility as well as social and environmental consciousness through experiential learning.
10,000
Boston Home
2049 Dorchester Ave
Boston
,
MA
02124
None
501(c)(3)
The Boston Home is a national model for the care of adults with advanced progressive neurological diseases, primarily Multiple Sclerosis. It provides the highest level of care in a specialized residential facility and is one of few in the nation that does so.
5,000
Foothills Forum
311 Gay St PO Box 153
Washington
,
VA
22747
None
501(c)(3)
Foothills Forum is an independent, nonpartisan civic news organization, a 501(c)3 nonprofit, serving Rappahannock County, Va. Foothills raises community support for local news.
5,000
Mental Health Association of Fauqui
321 Walker Dr
Warrenton
,
VA
20186
None
501(c)(3)
Mental Health Assocation of Fauquier County provides mental health and addiction and substance use resources in Fauquier, Rappahannock, and nearby areas. They promote and facilitate mental wellness in the communities they serve primarily Fauquier and Rappahannock counties in Virginia.
5,000
Multiple Myeloma Research Foundatio
PO Box 414238
Boston
,
MA
02241
None
501(c)(3)
The Multiple Myeloma Research Foundation (MMRF) drives discoveries for new treatments, accelerates groundbreaking clinical trials and fuels the most robust data-driven initiatives in cancer research. Their goal is to find a cure for each and every patient diagnosed with multiple myeloma.
5,000
Total
.................................
3a
460,500
b
Approved for future payment
Total
.................................
3b
Form
990-PF
(2019)
Form 990-PF (2019)
Page
12
Part XVI-A
Analysis of Income-Producing Activities
Enter gross amounts unless otherwise indicated.
Unrelated business income
Excluded by section 512, 513, or 514
(e)
Related or exempt
function income
(See instructions.)
1
Program service revenue:
(a)
Business code
(b)
Amount
(c)
Exclusion code
(d)
Amount
a
b
c
d
e
f
g
Fees and contracts from government agencies
2
Membership dues and assessments
....
3
Interest on savings and temporary cash
investments
...........
14
22,030
4
Dividends and interest from securities
....
14
240,902
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
............
-137,805
9
Net income or (loss) from special events:
10
Gross profit or (loss) from sales of inventory
11
Other revenue:
a
Inv fee reimbursement
b
c
d
e
12
Subtotal. Add columns (b), (d), and (e)
..
262,932
-137,805
13
Total.
Add line 12, columns (b), (d), and (e)
..................
13
125,127
(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.)
4
Safe investments of assets
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:
19009920
Software Version:
2019v5.0
Form 990PF - Special Condition Description:
Special Condition Description