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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
ELVA S SMITH TRUST UW
Number and street (or P.O. box number if mail is not delivered to street address)
ONE CITIZENS BANK WAY JCB115
Room/suite
City or town, state or province, country, and ZIP or foreign postal code
JOHNSTON
,
RI
02919
A Employer identification number
02-6014169
B
Telephone number (see instructions)
(603) 634-7772
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)
$
2,574,005
J
Accounting method:
Cash
Accrual
Other (specify)
(Part I, column (d) must be on cash basis.)
Part I
Analysis of Revenue and Expenses
(The total of amounts in columns (b), (c), and (d) may not necessarily equal the amounts in column (a) (see instructions).)
(a)
Revenue and
expenses per
books
(b)
Net investment
income
(c)
Adjusted net
income
(d)
Disbursements
for charitable
purposes
(cash basis only)
1
Contributions, gifts, grants, etc., received (attach schedule)
2
Check
.............
3
Interest on savings and temporary cash investments
4
Dividends and interest from securities
...
59,745
59,745
5a
Gross rents
............
b
Net rental income or (loss)
6a
Net gain or (loss) from sale of assets not on line 10
109,093
b
Gross sales price for all assets on line 6a
706,688
7
Capital gain net income (from Part IV, line 2)
...
109,093
8
Net short-term capital gain
.........
0
9
Income modifications
...........
10a
Gross sales less returns and allowances
b
Less: Cost of goods sold
....
c
Gross profit or (loss) (attach schedule)
.....
11
Other income (attach schedule)
.......
12
Total.
Add lines 1 through 11
........
168,838
168,838
13
Compensation of officers, directors, trustees, etc.
21,576
10,788
10,788
14
Other employee salaries and wages
......
0
0
0
15
Pension plans, employee benefits
.......
0
0
16a
Legal fees (attach schedule)
.........
0
b
Accounting fees (attach schedule)
.......
725
0
0
725
c
Other professional fees (attach schedule)
....
7,867
7,867
0
17
Interest
...............
0
18
Taxes (attach schedule) (see instructions)
...
2,667
916
0
19
Depreciation (attach schedule) and depletion
...
0
0
20
Occupancy
..............
21
Travel, conferences, and meetings
.......
0
0
22
Printing and publications
..........
0
0
23
Other expenses (attach schedule)
.......
160
160
24
Total operating and administrative expenses.
Add lines 13 through 23
..........
32,995
19,571
0
11,673
25
Contributions, gifts, grants paid
.......
252,444
252,444
26
Total expenses and disbursements.
Add lines 24 and 25
285,439
19,571
0
264,117
27
Subtract line 26 from line 12:
a
Excess of revenue over expenses and disbursements
-116,601
b
Net investment income
(if negative, enter -0-)
149,267
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
.............
2
Savings and temporary cash investments
.........
104,348
41,621
41,621
3
Accounts receivable
Less: allowance for doubtful accounts
0
0
4
Pledges receivable
Less: allowance for doubtful accounts
5
Grants receivable
.................
6
Receivables due from officers, directors, trustees, and other
disqualified persons (attach schedule) (see instructions)
.....
7
Other notes and loans receivable (attach schedule)
Less: allowance for doubtful accounts
0
8
Inventories for sale or use
..............
9
Prepaid expenses and deferred charges
..........
10a
Investments—U.S. and state government obligations (attach schedule)
b
Investments—corporate stock (attach schedule)
.......
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)
..........
2,088,513
2,034,176
2,532,384
14
Land, buildings, and equipment: basis
Less: accumulated depreciation (attach schedule)
15
Other assets (describe
)
16
Total assets
(to be completed by all filers—see the
instructions. Also, see page 1, item I)
2,192,861
2,075,797
2,574,005
17
Accounts payable and accrued expenses
..........
18
Grants payable
.................
19
Deferred revenue
.................
20
Loans from officers, directors, trustees, and other disqualified persons
21
Mortgages and other notes payable (attach schedule)
......
22
Other liabilities (describe
)
23
Total liabilities
(add lines 17 through 22)
.........
0
Foundations that follow FASB ASC 958, check here
and complete lines 24, 25, 29 and 30.
24
Net assets without donor restrictions
...........
25
Net assets with donor restrictions
............
Foundations that do not follow FASB ASC 958, check here
and complete lines 26 through 30.
26
Capital stock, trust principal, or current funds
........
2,192,861
2,075,797
27
Paid-in or capital surplus, or land, bldg., and equipment fund
28
Retained earnings, accumulated income, endowment, or other funds
29
Total net assets or fund balances
(see instructions)
.....
2,192,861
2,075,797
30
Total liabilities and net assets/fund balances
(see instructions)
.
2,192,861
2,075,797
Part III
Analysis of Changes in Net Assets or Fund Balances
1
Total net assets or fund balances at beginning of year—Part II, column (a), line 29 (must agree with end-of-year figure reported on prior year’s return)
...............
1
2,192,861
2
Enter amount from Part I, line 27a
.....................
2
-116,601
3
Other increases not included in line 2 (itemize)
3
0
4
Add lines 1, 2, and 3
..........................
4
2,076,260
5
Decreases not included in line 2 (itemize)
5
463
6
Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 29
.
6
2,075,797
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
15. AT&T INC
2013-10-16
2019-01-10
b
65. AT&T INC
2013-10-16
2019-12-23
c
5. ADOBE SYS INC
2016-10-04
2019-12-23
d
2. ALPHABET INC CL A
2010-04-06
2019-12-23
e
5. AMERICAN EXPRESS CO
2018-08-28
2019-01-10
15. AMERICAN EXPRESS CO
2018-08-28
2019-12-23
5. AMERICAN TOWER CORP
2019-11-05
2019-12-23
5. APPLE COMPUTER INC
2010-08-04
2019-12-23
20. BANK OF AMERICA CORP NEW
2018-07-19
2019-01-10
145. BANK OF AMERICA CORP NEW
2018-07-19
2019-09-11
50. BANK OF AMERICA CORP NEW
2018-07-19
2019-12-23
37. BERKSHIRE HATHAWAY INC DEL CL B NEW
2016-04-25
2019-05-07
5. BERKSHIRE HATHAWAY INC DEL CL B NEW
2016-04-25
2019-12-23
5. BIOGEN INC
2018-06-20
2019-12-23
5. BOEING CO
2015-08-18
2019-12-23
10. BOSTON SCIENTIFIC CORP
2015-02-05
2019-01-10
355. BOSTON SCIENTIFIC CORP
2015-02-05
2019-05-07
75. CIGNA CORPORATION
2018-05-30
2019-03-26
95. CATERPILLAR INC
2017-08-08
2019-11-05
5. CHEVRONTEXACO CORP
2018-10-31
2019-01-10
80. CHEVRONTEXACO CORP
2018-10-31
2019-12-12
5. CISCO SYSTEMS
2018-12-12
2019-01-10
30. CISCO SYSTEMS
2018-12-12
2019-12-23
19. CINTAS CORPORATION
2013-10-16
2019-06-11
5. CINTAS CORPORATION
2013-10-16
2019-12-23
5. CITIGROUP INC
2016-12-09
2019-01-10
20. CITIGROUP INC
2016-12-09
2019-12-23
65. CLOROX CO
2015-09-02
2019-08-13
10. COMCAST CORP
2015-08-18
2019-01-10
30. COMCAST CORP
2015-08-18
2019-12-23
5. CONOCOPHILLIPS
2016-06-07
2019-01-10
30. CONOCOPHILLIPS
2016-06-07
2019-12-23
5. COSTCO WHSL CORP NEW
2017-11-07
2019-12-23
5. DISNEY WALT CO
2018-05-09
2019-01-10
30. DISNEY WALT CO
2018-05-09
2019-06-11
15. DISNEY WALT CO
2018-05-09
2019-12-23
5. DOLLAR GEN CORP NEW
2018-01-09
2019-01-10
10. DOLLAR GEN CORP NEW
2018-01-09
2019-12-23
10. EDWARDS LIFESCIENCES CORP
2018-03-06
2019-12-23
15. EQUITY RESIDENTIAL PPTYS TR
2019-09-11
2019-12-23
55. EXXON MOBIL CORP
2019-03-13
2019-12-23
25. FACEBOOK INC
2016-02-22
2019-02-13
5. FACEBOOK INC
2016-02-22
2019-12-23
75000. FED HOME LN BKS 1.750% 6/14/19
2014-07-21
2019-06-14
3999.675 FIDELITY ADVISOR FLOAT RATE HI INI
2017-12-08
2019-04-05
1329.787 FIDELITY US BOND INDEX INSTL PREM
2018-09-11
2019-01-10
5. FISERV INC
2014-10-30
2019-01-10
40. FISERV INC
2014-10-30
2019-08-27
95. FISERV INC
2014-10-30
2019-10-08
395. THE GAP INC
2019-05-07
2019-08-27
10. HCA HEALTHCARE INC
2019-07-16
2019-12-23
5. HERSHEY FOODS
2018-09-11
2019-01-10
10. HERSHEY FOODS
2018-09-11
2019-12-23
30. HOME DEPOT INC
2016-08-03
2019-01-29
10. HOME DEPOT INC
2016-08-03
2019-12-23
10. HONEYWELL INTL INC
2016-10-04
2019-12-23
70. ILLINOIS TOOL WORKS
2017-09-12
2019-01-29
10. INTEL CORP.
2018-02-07
2019-01-10
105. INTEL CORP.
2018-02-07
2019-07-16
25. INTEL CORP.
2018-02-07
2019-12-23
5. JP MORGAN CHASE & CO
2015-05-06
2019-01-10
50. JP MORGAN CHASE & CO
2015-05-06
2019-02-13
50. JP MORGAN CHASE & CO
2016-11-14
2019-06-18
40. JP MORGAN CHASE & CO
2016-11-14
2019-12-12
5. JP MORGAN CHASE & CO
2016-11-14
2019-12-23
1784.264 JPMORGAN HEDGED EQUITY I
2018-09-11
2019-11-13
15. JOHNSON & JOHNSON
2013-05-23
2019-12-23
5. L3HARRIS TECHNOLOGIES INC
2016-11-14
2019-12-23
5. LILLY ELI & CO
2018-06-20
2019-01-10
10. LILLY ELI & CO
2018-06-20
2019-12-23
5. M & T BANK CORP
2019-05-07
2019-12-23
5. MARSH & MCLENNAN
2013-07-16
2019-01-10
10. MARSH & MCLENNAN
2013-07-16
2019-12-23
85. MCDONALDS CORP
2017-10-25
2019-11-20
40. MICROSOFT CORP
2013-06-04
2019-12-23
285. MOSAIC CO NEW
2019-01-17
2019-09-11
5. MOTOROLA SOLUTIONS INC
2018-05-30
2019-01-10
25. MOTOROLA SOLUTIONS INC
2018-05-30
2019-07-16
5. MOTOROLA SOLUTIONS INC
2018-05-30
2019-12-23
25. NEXTERA ENERGY INC COM
2016-10-18
2019-06-11
5. NEXTERA ENERGY INC COM
2016-10-18
2019-12-23
5. NIKE INC
2018-10-31
2019-01-10
25. NIKE INC
2018-10-31
2019-12-23
15. ONEOK INC. COMM
2019-12-12
2019-12-23
10. ORACLE SYSTEMS CORP.
2018-05-09
2019-01-10
60. ORACLE SYSTEMS CORP.
2018-05-09
2019-12-23
50000. ORACLE CORP 2.375% 1/15/19
2013-08-06
2019-01-15
5. P N C FINL CORP
2013-07-24
2019-01-10
80. P N C FINL CORP
2013-07-24
2019-01-17
5. PAYPAL HLDGS INC
2018-12-12
2019-01-10
35. PAYPAL HLDGS INC
2018-12-12
2019-12-23
5. PEPSICO INC
1988-12-02
2019-01-10
15. PEPSICO INC
1988-12-02
2019-12-23
10. PFIZER INC
2018-09-19
2019-01-10
260. PFIZER INC
2018-09-19
2019-09-24
15. PHILLIPS 66
2019-03-13
2019-12-23
5. PROGRESSIVE CORP OHIO
2018-12-06
2019-01-10
15. PROGRESSIVE CORP OHIO
2018-12-06
2019-12-23
60. S&P GLOBAL INC COM
2015-11-13
2019-03-26
35. CHARLES SCHWAB CORP NEW
2019-01-17
2019-12-23
10. SELECT SEC SPDR MATLS
2014-01-10
2019-01-10
270. SELECT SEC SPDR MATLS
2016-10-18
2019-03-13
290. SELECT SECTOR SPDR ENERGY
2016-12-09
2019-03-13
50. SELECT SECTOR SPDR UTILITIES
2019-03-26
2019-12-23
15. STARBUCKS CORP
2019-01-29
2019-12-23
5. STRYKER CORP
2019-03-26
2019-12-23
5. SYSCO CORP
2017-02-14
2019-01-10
125. SYSCO CORP
2017-03-22
2019-01-17
5. TARGET CORP
2018-09-19
2019-01-10
15. TARGET CORP
2018-09-19
2019-12-23
5. TEXAS INSTRUMENTS CORP
2014-09-24
2019-01-10
15. TEXAS INSTRUMENTS CORP
2014-09-24
2019-12-23
5. THERMO ELECTRON CORP
2012-10-26
2019-12-23
50000. UNILEVER CAP 2.200% 3/06/19
2014-01-06
2019-03-06
10. UNION PACIFIC CORPORATION
2018-08-28
2019-12-23
35. UNITED AIRLINES HOLDINGS INC
2019-11-20
2019-12-23
15. UNITED PARCEL SERVICE
2019-08-27
2019-12-23
10. UNITEDHEALTH GROUP INC
2015-03-17
2019-12-23
5. VALERO ENERGY CORP NEW
2015-05-01
2019-01-10
110. VALERO ENERGY CORP NEW
2015-07-15
2019-05-07
931.099 VANGUARD GLOBAL MIN VOLATILITY ADMR
2018-03-07
2019-04-05
61.132 VANGUARD GLOBAL MIN VOLATILITY ADMR
2018-12-18
2019-04-05
346.021 VANGUARD GLOBAL MIN VOLATILITY ADMR
2018-09-11
2019-04-05
5. VERIZON COMMUNICATIONS
2013-12-26
2019-01-10
35. VERIZON COMMUNICATIONS
2013-12-26
2019-12-23
.069 VIACOMCBS INC COM CL B
2019-02-13
2019-12-10
75. VIACOMCBS INC COM CL B
2019-02-13
2019-12-23
15. VISA INC
2011-09-23
2019-12-23
5. WAL-MART STORES INC
2017-09-06
2019-01-10
15. WAL-MART STORES INC
2017-09-06
2019-12-23
5. WASTE MGMT INC
2016-11-02
2019-01-10
10. WASTE MGMT INC
2016-11-02
2019-12-23
5. YUM BRANDS INC
2017-11-07
2019-01-10
115. YUM BRANDS INC
2017-11-15
2019-01-17
5. ZOETIS INC
2018-03-20
2019-01-10
10. ZOETIS INC
2018-03-20
2019-12-23
5. AON PLC CL A
2016-06-07
2019-12-23
5. ACCENTURE PLC IRELAND
2013-11-19
2019-12-23
5. LINDE PLC COM USD
2019-03-13
2019-12-23
CAPITAL GAIN DIVIDENDS
P
(e)
Gross sales price
(f)
Depreciation allowed
(or allowable)
(g)
Cost or other basis
plus expense of sale
(h)
Gain or (loss)
(e) plus (f) minus (g)
a
454
570
-116
b
2,542
2,461
81
c
1,645
515
1,130
d
2,697
782
1,915
e
492
535
-43
1,858
1,606
252
1,133
1,025
108
1,420
296
1,124
513
584
-71
4,240
4,235
5
1,758
1,460
298
7,728
5,104
2,624
1,129
690
439
1,507
1,469
38
1,689
837
852
358
146
212
13,056
5,182
7,874
12,109
13,002
-893
13,927
10,058
3,869
564
560
4
9,470
8,954
516
215
239
-24
1,443
1,417
26
4,425
857
3,568
1,355
225
1,130
282
294
-12
1,578
1,178
400
10,344
7,164
3,180
358
318
40
1,326
954
372
336
249
87
1,939
1,604
335
1,469
835
634
562
518
44
4,078
3,106
972
2,171
1,553
618
580
470
110
1,554
939
615
2,373
1,366
1,007
1,195
1,263
-68
3,854
4,427
-573
4,130
2,533
1,597
1,031
507
524
75,000
74,955
45
38,077
38,717
-640
14,973
14,885
88
370
171
199
4,269
1,371
2,898
9,805
3,257
6,548
6,256
9,899
-3,643
1,488
1,407
81
533
522
11
1,466
1,044
422
5,378
4,091
1,287
2,196
1,364
832
1,770
1,250
520
9,422
7,365
2,057
482
479
3
5,177
5,028
149
1,486
1,197
289
502
254
248
5,173
2,542
2,631
5,535
2,542
2,993
5,494
2,034
3,460
686
254
432
37,398
35,000
2,398
2,200
1,202
998
1,010
435
575
578
434
144
1,312
868
444
844
839
5
405
220
185
1,115
439
676
16,510
12,832
3,678
6,297
2,060
4,237
6,171
9,097
-2,926
585
550
35
4,296
2,750
1,546
812
550
262
5,042
2,136
2,906
1,193
427
766
380
376
4
2,502
1,900
602
1,140
1,098
42
477
464
13
3,229
2,906
323
50,000
50,420
-420
598
387
211
9,693
6,186
3,507
450
439
11
3,799
3,291
508
540
200
340
2,058
601
1,457
422
433
-11
9,431
11,266
-1,835
1,687
1,536
151
308
319
-11
1,077
956
121
12,330
5,701
6,629
1,703
1,557
146
523
428
95
15,148
11,556
3,592
19,065
22,036
-2,971
3,196
2,942
254
1,328
1,004
324
1,063
981
82
315
263
52
7,766
6,570
1,196
339
438
-99
1,927
1,314
613
487
245
242
1,928
734
1,194
1,638
479
1,159
50,000
50,279
-279
1,796
1,505
291
3,132
3,212
-80
1,785
1,730
55
2,955
1,338
1,617
386
297
89
9,211
6,541
2,670
25,698
25,420
278
1,687
1,669
18
9,550
9,447
103
287
151
136
2,150
1,394
756
3
3
3,168
3,589
-421
2,810
340
2,470
473
410
63
1,788
1,231
557
465
326
139
1,128
653
475
458
402
56
10,423
9,242
1,181
430
421
9
1,326
843
483
1,040
549
491
1,053
389
664
1,057
873
184
7,904
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
-116
b
81
c
1,130
d
1,915
e
-43
252
108
1,124
-71
5
298
2,624
439
38
852
212
7,874
-893
3,869
4
516
-24
26
3,568
1,130
-12
400
3,180
40
372
87
335
634
44
972
618
110
615
1,007
-68
-573
1,597
524
45
-640
88
199
2,898
6,548
-3,643
81
11
422
1,287
832
520
2,057
3
149
289
248
2,631
2,993
3,460
432
2,398
998
575
144
444
5
185
676
3,678
4,237
-2,926
35
1,546
262
2,906
766
4
602
42
13
323
-420
211
3,507
11
508
340
1,457
-11
-1,835
151
-11
121
6,629
146
95
3,592
-2,971
254
324
82
52
1,196
-99
613
242
1,194
1,159
-279
291
-80
55
1,617
89
2,670
278
18
103
136
756
-421
2,470
63
557
139
475
56
1,181
9
483
491
664
184
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
109,093
3
Net short-term capital gain or (loss) as defined in sections 1222(5) and (6):
If gain, also enter in Part I, line 8, column (c) (see instructions). If (loss), enter -0-
in Part I, line 8
...................
3
Part V
Qualification Under Section 4940(e) for Reduced Tax on Net Investment Income
(For optional use by domestic private foundations subject to the section 4940(a) tax on net investment income.)
If section 4940(d)(2) applies, leave this part blank.
Was the foundation liable for the section 4942 tax on the distributable amount of any year in the base period?
Yes
No
If "Yes," the foundation does not qualify under section 4940(e). Do not complete this part.
1
Enter the appropriate amount in each column for each year; see instructions before making any entries.
(a)
Base period years Calendar
year (or tax year beginning in)
(b)
Adjusted qualifying distributions
(c)
Net value of noncharitable-use assets
(d)
Distribution ratio
(col. (b) divided by col. (c))
2018
136,061
2,491,477
0.054611
2017
235,567
2,553,697
0.092245
2016
30,423
2,434,217
0.012498
2015
121,650
2,454,369
0.049565
2014
119,907
2,428,445
0.049376
2
Total
of line 1, column (d)
.....................
2
0.258295
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
0.051659
4
Enter the net value of noncharitable-use assets for 2019 from Part X, line 5
......
4
2,472,278
5
Multiply line 4 by line 3
......................
5
127,715
6
Enter 1% of net investment income (1% of Part I, line 27b)
...........
6
1,493
7
Add lines 5 and 6
........................
7
129,208
8
Enter qualifying distributions from Part XII, line 4
,.............
8
264,117
If line 8 is equal to or greater than line 7, check the box in Part VI, line 1b, and complete that part using a 1% tax rate. See the Part VI instructions.
Form
990-PF
(2019)
Form 990-PF (2019)
Page
4
Part VI
Excise Tax Based on Investment Income (Section 4940(a), 4940(b), 4940(e), or 4948—see instructions)
1a
Exempt operating foundations described in section 4940(d)(2), check here
and enter “N/A" on line 1.
Date of ruling or determination letter:
(attach copy of letter if necessary–see instructions)
b
Domestic foundations that meet the section 4940(e) requirements in Part V, check
1
1,493
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
1,493
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
1,493
6
Credits/Payments:
a
2019 estimated tax payments and 2018 overpayment credited to 2019
6a
2,290
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
2,290
8
Enter any
penalty
for underpayment of estimated tax.
Check here
if Form 2220 is attached.
8
0
9
Tax due.
If the total of lines 5 and 8 is more than line 7, enter
amount owed
.......
9
10
Overpayment.
If line 7 is more than the total of lines 5 and 8, enter the
amount overpaid
...
10
797
11
Enter the amount of line 10 to be:
Credited to 2020 estimated tax
797
Refunded
11
0
Part VII-A
Statements Regarding Activities
1a
During the tax year, did the foundation attempt to influence any national, state, or local legislation or did
Yes
No
it participate or intervene in any political campaign?
....................
1a
No
b
Did it spend more than $100 during the year (either directly or indirectly) for political purposes? (see Instructions
for definition)
.................................
1b
No
If the answer is "Yes" to
1a
or
1b,
attach a detailed description of the activities and copies of any materials
published or distributed by the foundation in connection with the activities.
c
Did the foundation file
Form 1120-POL
for this year?
.....................
1c
No
d
Enter the amount (if any) of tax on political expenditures (section 4955) imposed during the year:
(1)
On the foundation.
$
(2)
On foundation managers.
$
e
Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed
on foundation managers.
$
2
Has the foundation engaged in any activities that have not previously been reported to the IRS?
.......
2
No
If "Yes," attach a detailed description of the activities.
3
Has the foundation made any changes, not previously reported to the IRS, in its governing instrument, articles
of incorporation, or bylaws, or other similar instruments?
If "Yes," attach a conformed copy of the changes
....
3
No
4a
Did the foundation have unrelated business gross income of $1,000 or more during the year?
........
4a
No
b
If "Yes," has it filed a tax return on
Form 990-T
for this year?
...................
4b
5
Was there a liquidation, termination, dissolution, or substantial contraction during the year?
.........
5
No
If "Yes," attach the statement required by General Instruction T.
6
Are the requirements of section 508(e) (relating to sections 4941 through 4945) satisfied either:
By language in the governing instrument, or
By state legislation that effectively amends the governing instrument so that no mandatory directions
that conflict with the state law remain in the governing instrument?
................
6
Yes
7
Did the foundation have at least $5,000 in assets at any time during the year?
If "Yes," complete Part II, col. (c),
and Part XV.
.................................
7
Yes
8a
Enter the states to which the foundation reports or with which it is registered (see instructions)
NH
b
If the answer is "Yes" to line 7, has the foundation furnished a copy of Form 990-PF to the Attorney
General (or designate) of each state as required by General Instruction G?
If "No," attach explanation
.
8b
Yes
9
Is the foundation claiming status as a private operating foundation within the meaning of section 4942(j)(3)
or 4942(j)(5) for calendar year 2019 or the taxable year beginning in 2019? See the instructions for Part XIV.
If "Yes," complete Part XIV
.............................
9
No
10
Did any persons become substantial contributors during the tax year?
If "Yes," attach a schedule listing their names
and addresses.
...............................
10
No
Form
990-PF
(2019)
Form 990-PF (2019)
Page
5
Part VII-A
Statements Regarding Activities
(continued)
11
At any time during the year, did the foundation, directly or indirectly, own a controlled entity within the
meaning of section 512(b)(13)? If "Yes," attach schedule. See instructions
.............
11
No
12
Did the foundation make a distribution to a donor advised fund over which the foundation or a disqualified person had
advisory privileges? If "Yes," attach statement. See instructions
.................
12
No
13
Did the foundation comply with the public inspection requirements for its annual returns and exemption application?
13
Yes
Website address
14
The books are in care of
CITIZENS BANK NA
Telephone no.
(603) 634-7772
Located at
900 ELM STREET
MANCHESTER
NH
ZIP+4
03101
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
CITIZENS BANK N A
TRUSTEE
5
21,576
900 ELM STREET
MANCHESTER
,
NH
03101
2
Compensation of five highest-paid employees (other than those included on line 1—see instructions). If none, enter “NONE."
(a)
Name and address of each employee paid more than $50,000
(b)
Title, and average
hours per week
devoted to position
(c)
Compensation
(d)
Contributions to
employee benefit
plans and deferred
compensation
(e)
Expense account,
other allowances
NONE
Total
number of other employees paid over $50,000
...................
0
Form
990-PF
(2019)
Form 990-PF (2019)
Page
7
Part VIII
Information About Officers, Directors, Trustees, Foundation Managers, Highly Paid Employees,
and Contractors
(continued)
3
Five highest-paid independent contractors for professional services (see instructions). If none, enter "NONE".
(a)
Name and address of each person paid more than $50,000
(b)
Type of service
(c)
Compensation
NONE
Total
number of others receiving over $50,000 for professional services
.............
0
Part IX-A
Summary of Direct Charitable Activities
List the foundation’s four largest direct charitable activities during the tax year. Include relevant statistical information such as the number of organizations and other beneficiaries served, conferences convened, research papers produced, etc.
Expenses
1
2
3
4
Part IX-B
Summary of Program-Related Investments
(see instructions)
Describe the two largest program-related investments made by the foundation during the tax year on lines 1 and 2.
Amount
1
2
All other program-related investments. See instructions.
3
Total.
Add lines 1 through 3
.........................
Form
990-PF
(2019)
Form 990-PF (2019)
Page
8
Part X
Minimum Investment Return
(All domestic foundations must complete this part. Foreign foundations, see instructions.)
1
Fair market value of assets not used (or held for use) directly in carrying out charitable, etc.,
purposes:
a
Average monthly fair market value of securities
...................
1a
2,466,837
b
Average of monthly cash balances
.......................
1b
43,090
c
Fair market value of all other assets (see instructions)
................
1c
0
d
Total
(add lines 1a, b, and c)
.........................
1d
2,509,927
e
Reduction claimed for blockage or other factors reported on lines 1a and
1c (attach detailed explanation)
.............
1e
0
2
Acquisition indebtedness applicable to line 1 assets
..................
2
0
3
Subtract line 2 from line 1d
.........................
3
2,509,927
4
Cash deemed held for charitable activities. Enter 1 1/2% of line 3 (for greater amount, see
instructions)
.............................
4
37,649
5
Net value of noncharitable-use assets.
Subtract line 4 from line 3. Enter here and on Part V, line 4
5
2,472,278
6
Minimum investment return.
Enter 5% of line 5
..................
6
123,614
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
123,614
2a
Tax on investment income for 2019 from Part VI, line 5
......
2a
1,493
b
Income tax for 2019. (This does not include the tax from Part VI.)
...
2b
c
Add lines 2a and 2b
............................
2c
1,493
3
Distributable amount before adjustments. Subtract line 2c from line 1
............
3
122,121
4
Recoveries of amounts treated as qualifying distributions
................
4
0
5
Add lines 3 and 4
............................
5
122,121
6
Deduction from distributable amount (see instructions)
.................
6
0
7
Distributable amount
as adjusted. Subtract line 6 from line 5. Enter here and on Part XIII, line 1
...
7
122,121
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
264,117
b
Program-related investments—total from Part IX-B
..................
1b
0
2
Amounts paid to acquire assets used (or held for use) directly in carrying out charitable, etc.,
purposes
...............................
2
0
3
Amounts set aside for specific charitable projects that satisfy the:
a
Suitability test (prior IRS approval required)
....................
3a
0
b
Cash distribution test (attach the required schedule)
.................
3b
0
4
Qualifying distributions.
Add lines 1a through 3b. Enter here and on Part V, line 8, and Part XIII, line 4
4
264,117
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
1,493
6
Adjusted qualifying distributions.
Subtract line 5 from line 4
..............
6
262,624
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
122,121
2
Undistributed income, if any, as of the end of 2019:
a
Enter amount for 2018 only
.......
0
b
Total for prior years:
20
,
20
,
20
0
3
Excess distributions carryover, if any, to 2019:
a
From 2014
......
0
b
From 2015
......
0
c
From 2016
......
0
d
From 2017
......
7,238
e
From 2018
......
16,059
f
Total
of lines 3a through e
........
23,297
4
Qualifying distributions for 2019 from Part
XII, line 4:
$
264,117
a
Applied to 2018, but not more than line 2a
0
b
Applied to undistributed income of prior years
(Election required—see instructions)
.....
0
c
Treated as distributions out of corpus (Election
required—see instructions)
........
0
d
Applied to 2019 distributable amount
.....
122,121
e
Remaining amount distributed out of corpus
141,996
5
Excess distributions carryover applied to 2019.
0
0
(If an amount appears in column (d), the
same amount must be shown in column (a).)
6
Enter the net total of each column as
indicated below:
a
Corpus. Add lines 3f, 4c, and 4e. Subtract line 5
165,293
b
Prior years’ undistributed income. Subtract
line 4b from line 2b
..........
0
c
Enter the amount of prior years’ undistributed
income for which a notice of deficiency has
been issued, or on which the section 4942(a)
tax has been previously assessed
......
0
d
Subtract line 6c from line 6b. Taxable amount
—see instructions
...........
0
e
Undistributed income for 2018. Subtract line
4a from line 2a. Taxable amount—see
instructions
.............
0
f
Undistributed income for 2019. Subtract
lines 4d and 5 from line 1. This amount must
be distributed in 2020
..........
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)
.......
0
8
Excess distributions carryover from 2014 not
applied on line 5 or line 7 (see instructions)
...
0
9
Excess distributions carryover to 2020.
Subtract lines 7 and 8 from line 6a
......
165,293
10
Analysis of line 9:
a
Excess from 2015
....
0
b
Excess from 2016
....
0
c
Excess from 2017
....
7,238
d
Excess from 2018
....
16,059
e
Excess from 2019
....
141,996
Form
990-PF
(2019)
Form 990-PF (2019)
Page
10
Part XIV
Private Operating Foundations
(see instructions and Part VII-A, question 9)
1a
If the foundation has received a ruling or determination letter that it is a private operating
foundation, and the ruling is effective for 2019, enter the date of the ruling
.......
b
Check box to indicate whether the organization is a private operating foundation described in section
4942(j)(3)
or
4942(j)(5)
2a
Enter the lesser of the adjusted net
income from Part I or the minimum
investment return from Part X for each
year listed
..........
Tax year
Prior 3 years
(e) Total
(a)
2019
(b)
2018
(c)
2017
(d)
2016
b
85% of line 2a
.........
c
Qualifying distributions from Part XII,
line 4 for each year listed
.....
d
Amounts included in line 2c not used directly
for active conduct of exempt activities
..........
e
Qualifying distributions made directly
for active conduct of exempt activities.
Subtract line 2d from line 2c
....
3
Complete 3a, b, or c for the
alternative test relied upon:
a
“Assets" alternative test—enter:
(1)
Value of all assets
......
(2)
Value of assets qualifying
under section 4942(j)(3)(B)(i)
b
“Endowment" alternative test— enter 2/3
of minimum investment return shown in
Part X, line 6 for each year listed
...
c
“Support" alternative test—enter:
(1)
Total support other than gross
investment income (interest,
dividends, rents, payments
on securities loans (section
512(a)(5)), or royalties)
....
(2)
Support from general public
and 5 or more exempt
organizations as provided in
section 4942(j)(3)(B)(iii)
....
(3)
Largest amount of support
from an exempt organization
(4)
Gross investment income
Part XV
Supplementary Information (Complete this part only if the foundation had $5,000 or more in
assets at any time during the year—see instructions.)
1
Information Regarding Foundation Managers:
a
List any managers of the foundation who have contributed more than 2% of the total contributions received by the foundation
before the close of any tax year (but only if they have contributed more than $5,000). (See section 507(d)(2).)
NONE
b
List any managers of the foundation who own 10% or more of the stock of a corporation (or an equally large portion of the
ownership of a partnership or other entity) of which the foundation has a 10% or greater interest.
NONE
2
Information Regarding Contribution, Grant, Gift, Loan, Scholarship, etc., Programs:
Check here
if the foundation only makes contributions to preselected charitable organizations and does not accept
unsolicited requests for funds. If the foundation makes gifts, grants, etc. to individuals or organizations under
other conditions, complete items 2a, b, c, and d. See instructions
a
The name, address, and telephone number or e-mail address of the person to whom applications should be addressed:
UNIV OF PITTSBURG ATTN M WASHIN
509 SLIS BLDG
PITTSBURG
,
PA
15260
(412) 624-5230
b
The form in which applications should be submitted and information and materials they should include:
CONTACT TONI CARBO BEARMAN, DEAN, AT THE ADDRESS AND PHONE NUMBER ABOVE
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:
FULL SCHOLARSHIP TO THE UNIVERSITY OF PITTSBURG EACH YEAR
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
UNIVERSITY OF PITTSBURGH
SCHOOL
509 SLIS BUILDING
PITTSBURGH
,
PA
15260
NONE
N/A
SCHOLARSHIP
146,331
VERMONT DEPT OF LIBRARIES
ATTN MARTHA REID
PAVILLION OFFICE BLDG
MONTPELIER
,
VT
05602
NONE
N/A
UNRESTRICTED GIFT
106,113
Total
.................................
3a
252,444
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
59,745
5
Net rental income or (loss) from real estate:
a
Debt-financed property
......
b
Not debt-financed property
.....
6
Net rental income or (loss) from personal property
7
Other investment income
.....
8
Gain or (loss) from sales of assets other than
inventory
............
18
109,093
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)
..
168,838
13
Total.
Add line 12, columns (b), (d), and (e)
..................
13
168,838
(See worksheet in line 13 instructions to verify calculations.)
Part XVI-B
Relationship of Activities to the Accomplishment of Exempt Purposes
Line No.
Explain below how each activity for which income is reported in column (e) of Part XVI-A contributed importantly to
the accomplishment of the foundation’s exempt purposes (other than by providing funds for such purposes). (See
instructions.)
Form
990-PF
(2019)
Form 990-PF (2019)
Page
13
Part XVII
Information Regarding Transfers To and Transactions and Relationships With Noncharitable Exempt Organizations
1
Did the organization directly or indirectly engage in any of the following with any other organization described in section 501(c) (other than section 501(c)(3) organizations) or in section 527, relating to political organizations?
Yes
No
a
Transfers from the reporting foundation to a noncharitable exempt organization of:
(1)
Cash
...................................
1a(1)
No
(2)
Other assets
.................................
1a(2)
No
b
Other transactions:
(1)
Sales of assets to a noncharitable exempt organization
....................
1b(1)
No
(2)
Purchases of assets from a noncharitable exempt organization
..................
1b(2)
No
(3)
Rental of facilities, equipment, or other assets
.......................
1b(3)
No
(4)
Reimbursement arrangements
...........................
1b(4)
No
(5)
Loans or loan guarantees
.............................
1b(5)
No
(6)
Performance of services or membership or fundraising solicitations
................
1b(6)
No
c
Sharing of facilities, equipment, mailing lists, other assets, or paid employees
..............
1c
No
d
If the answer to any of the above is "Yes," complete the following schedule. Column
(b)
should always show the fair market value
of the goods, other assets, or services given by the reporting foundation. If the foundation received less than fair market value
in any transaction or sharing arrangement, show in column
(d)
the value of the goods, other assets, or services received.
(a)
Line No.
(b)
Amount involved
(c)
Name of noncharitable exempt organization
(d)
Description of transfers, transactions, and sharing arrangements
2a
Is the foundation directly or indirectly affiliated with, or related to, one or more tax-exempt organizations
described in section 501(c) (other than section 501(c)(3)) or in section 527?
...........
Yes
No
b
If "Yes," complete the following schedule.
(a)
Name of organization
(b)
Type of organization
(c)
Description of relationship
Sign Here
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
May the IRS discuss this return
with the preparer shown below
(see instr.)
Yes
No
Signature of officer or trustee
Date
Title
Paid Preparer Use Only
Print/Type preparer's name
Preparer's Signature
Date
Check if self-
employed
PTIN
Firm's name
Firm's EIN
Firm's address
Phone no.
Form
990-PF
(2019)
Additional Data
Software ID:
Software Version:
Form 990PF - Special Condition Description:
Special Condition Description