-
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
04-01-2019
, and ending
03-31-2020
Name of foundation
THE CHELSEA HEALTH AND WELLNESS
FOUNDATION
Number and street (or P.O. box number if mail is not delivered to street address)
14800 E OLD US 12
Room/suite
City or town, state or province, country, and ZIP or foreign postal code
CHELSEA
,
MI
48118
A Employer identification number
26-3040367
B
Telephone number (see instructions)
(734) 433-4599
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)
$
39,563,490
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
328
328
4
Dividends and interest from securities
...
584,610
584,610
5a
Gross rents
............
330,063
330,063
b
Net rental income or (loss)
249,755
6a
Net gain or (loss) from sale of assets not on line 10
b
Gross sales price for all assets on line 6a
7
Capital gain net income (from Part IV, line 2)
...
484,083
8
Net short-term capital gain
.........
9
Income modifications
...........
10a
Gross sales less returns and allowances
94,019
b
Less: Cost of goods sold
....
54,837
c
Gross profit or (loss) (attach schedule)
.....
39,182
39,182
11
Other income (attach schedule)
.......
5,751,324
139,112
5,612,212
12
Total.
Add lines 1 through 11
........
6,705,507
1,538,196
5,651,394
13
Compensation of officers, directors, trustees, etc.
150,986
60,394
0
90,592
14
Other employee salaries and wages
......
3,291,882
103,224
2,947,802
240,856
15
Pension plans, employee benefits
.......
56,565
1,211
0
55,354
16a
Legal fees (attach schedule)
.........
216,912
0
0
216,912
b
Accounting fees (attach schedule)
.......
43,905
4,391
0
39,515
c
Other professional fees (attach schedule)
....
615,690
175,322
169,109
271,259
17
Interest
...............
293,504
0
293,504
0
18
Taxes (attach schedule) (see instructions)
...
70,181
25,846
0
137
19
Depreciation (attach schedule) and depletion
...
1,012,662
0
1,007,331
20
Occupancy
..............
21,772
0
0
21,772
21
Travel, conferences, and meetings
.......
24,425
0
17,731
6,694
22
Printing and publications
..........
70,015
0
0
1,812
23
Other expenses (attach schedule)
.......
1,340,160
80,348
1,067,159
302,773
24
Total operating and administrative expenses.
Add lines 13 through 23
..........
7,208,659
450,736
5,502,636
1,247,676
25
Contributions, gifts, grants paid
.......
371,658
375,301
26
Total expenses and disbursements.
Add lines 24 and 25
7,580,317
450,736
5,502,636
1,622,977
27
Subtract line 26 from line 12:
a
Excess of revenue over expenses and disbursements
-874,810
b
Net investment income
(if negative, enter -0-)
1,087,460
c
Adjusted net income
(if negative, enter -0-)
...
148,758
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
.............
4,891
1,942
1,942
2
Savings and temporary cash investments
.........
382,640
252,398
252,398
3
Accounts receivable
44,768
Less: allowance for doubtful accounts
4,000
50,573
40,768
40,768
4
Pledges receivable
Less: allowance for doubtful accounts
5
Grants receivable
.................
6
Receivables due from officers, directors, trustees, and other
disqualified persons (attach schedule) (see instructions)
.....
7
Other notes and loans receivable (attach schedule)
Less: allowance for doubtful accounts
8
Inventories for sale or use
..............
18,723
22,631
22,631
9
Prepaid expenses and deferred charges
..........
17,458
19,319
19,319
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)
..........
23,176,124
19,523,313
19,523,313
14
Land, buildings, and equipment: basis
28,139,011
Less: accumulated depreciation (attach schedule)
8,435,892
20,285,282
19,703,119
19,703,119
15
Other assets (describe
)
16
Total assets
(to be completed by all filers—see the
instructions. Also, see page 1, item I)
43,935,691
39,563,490
39,563,490
17
Accounts payable and accrued expenses
..........
155,309
186,204
18
Grants payable
.................
3,642
19
Deferred revenue
.................
496,000
494,068
20
Loans from officers, directors, trustees, and other disqualified persons
21
Mortgages and other notes payable (attach schedule)
......
9,297,995
8,748,899
22
Other liabilities (describe
)
279,126
433,245
23
Total liabilities
(add lines 17 through 22)
.........
10,232,072
9,862,416
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
........
0
0
27
Paid-in or capital surplus, or land, bldg., and equipment fund
0
0
28
Retained earnings, accumulated income, endowment, or other funds
33,703,619
29,701,074
29
Total net assets or fund balances
(see instructions)
.....
33,703,619
29,701,074
30
Total liabilities and net assets/fund balances
(see instructions)
.
43,935,691
39,563,490
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
33,703,619
2
Enter amount from Part I, line 27a
.....................
2
-874,810
3
Other increases not included in line 2 (itemize)
3
0
4
Add lines 1, 2, and 3
..........................
4
32,828,809
5
Decreases not included in line 2 (itemize)
5
3,127,735
6
Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 29
.
6
29,701,074
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
FROM K-1 RUSSELL MULTI ASSET CORE PLUS FUND
P
b
FROM K-1 RUSSELL MULTI ASSET CORE PLUS FUND
P
c
FROM K-1 RUSSELL CORE BOND FUND
P
d
FROM K-1 RUSSELL CORE BOND FUND
P
e
RUSSELL TTL RETURN Q CL B
P
2016-01-01
2019-07-30
FROM K-1 - RUSSELL REAL ESTATE EQUITY FUND
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
378,022
378,022
b
20,137
-20,137
c
51,306
51,306
d
46,554
46,554
e
2,676,335
2,660,000
16,335
12,003
12,003
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
378,022
b
-20,137
c
51,306
d
46,554
e
16,335
12,003
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
484,083
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
26,417
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
2,634,367
23,293,574
0.113094
2017
2,161,131
24,802,298
0.087134
2016
2,380,799
24,570,979
0.096895
2015
2,885,243
27,031,264
0.106737
2014
2,074,568
30,616,055
0.067761
2
Total
of line 1, column (d)
.....................
2
0.471621
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
0.094324
4
Enter the net value of noncharitable-use assets for 2019 from Part X, line 5
......
4
23,173,782
5
Multiply line 4 by line 3
......................
5
2,185,844
6
Enter 1% of net investment income (1% of Part I, line 27b)
...........
6
10,875
7
Add lines 5 and 6
........................
7
2,196,719
8
Enter qualifying distributions from Part XII, line 4
,.............
8
2,058,664
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
21,749
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
21,749
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
21,749
6
Credits/Payments:
a
2019 estimated tax payments and 2018 overpayment credited to 2019
6a
24,500
b
Exempt foreign organizations—tax withheld at source
......
6b
c
Tax paid with application for extension of time to file (Form 8868)
...
6c
6,500
d
Backup withholding erroneously withheld
...........
6d
0
7
Total credits and payments. Add lines 6a through 6d
..............
7
31,000
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
9,251
11
Enter the amount of line 10 to be:
Credited to 2020 estimated tax
9,251
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.
$
0
(2)
On foundation managers.
$
0
e
Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed
on foundation managers.
$
0
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
Yes
b
If "Yes," has it filed a tax return on
Form 990-T
for this year?
...................
4b
Yes
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)
MI
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
WWW.5HEALTHYTOWNS.ORG
14
The books are in care of
AMY HEYDLAUFF
Telephone no.
(734) 433-4599
Located at
14800 E OLD US 12
CHELSEA
MI
ZIP+4
48118
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
AMY HEYDLAUFF
CEO
50.00
150,986
24,572
0
14800 OLD US 12
CHELSEA
,
MI
48118
SCOTT BROSHAR
BOARD MEMBER
6.00
0
0
0
14800 OLD US 12
CHELSEA
,
MI
48118
KASIE COUSINO
BOARD MEMBER
8.00
0
0
0
14800 OLD US 12
CHELSEA
,
MI
48118
PATRICK CONLIN
BOARD MEMBER
3.00
0
0
0
14800 OLD US 12
CHELSEA
,
MI
48118
SALLY DEVOL
VICE CHAIR
10.00
0
0
0
14800 OLD US 12
CHELSEA
,
MI
48118
KEVIN DOMBKOWSKI
SECRETARY
6.00
0
0
0
14800 OLD US 12
CHELSEA
,
MI
48118
CINDY DRESCH
TREASURER
10.00
0
0
0
14800 OLD US 12
CHELSEA
,
MI
48118
NANCY GRAEBNER
EX-OFFICIO
3.00
0
0
0
14800 OLD US 12
CHELSEA
,
MI
48118
DOUGLAS LANCE
BOARD MEMBER
4.00
0
0
0
14800 OLD US 12
CHELSEA
,
MI
48118
NICOLE O'BRIEN
BOARD MEMBER
12.00
0
0
0
14800 OLD US 12
CHELSEA
,
MI
48118
COY VAUGHN
BOARD MEMBER
4.00
0
0
0
14800 OLD US 12
CHELSEA
,
MI
48118
JEFF WALLACE
CHAIR
12.00
0
0
0
14800 OLD US 12
CHELSEA
,
MI
48118
KATY HARMES
BOARD MEMBER
4.00
0
0
0
14800 OLD US 12
CHELSEA
,
MI
48118
DILLON BURNS
BOARD MEMBER
2.00
0
0
0
14800 OLD US 12
CHELSEA
,
MI
48118
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
ASHLEY TOMASI
COALITION COORDINATO
40.00
62,443
9,595
0
14800 OLD US 12
CHELSEA
,
MI
48118
MATT PEGOUSKIE
COMMUNITY RESOURCE M
40.00
62,795
3,229
0
14800 OLD US 12
CHELSEA
,
MI
48118
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
RUSSELL INVESTMENTS
INVESTMENT MANAGEMENT FEES
175,322
1301 SECOND AVENUE
SEATTLE
,
WA
98101
SCHIFF HARDIN LLP
ATTORNEY FEES
163,336
350 S MAIN STREET SUITE 210
ANN ARBOR
,
MI
48104
ALTECH MECHANICAL SERVICES
BUILDING MAINTENANCE / IMPROVEMENTS
80,692
7885 JACKSON RD SUITE 4
ANN ARBOR
,
MI
48106
RILEY SAFER HOLMES & CANCILA LLP
ATTORNEY FEES
50,324
70 W MADISON STREET SUITE 2900
CHICAGO
,
IL
60602
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
OVERSIGHT OF THE CHELSEA, DEXTER, MANCHESTER & STOCKBRIDGE WELLNESS CENTERS WHICH SERVE APPROXIMATELY 7,300 SERVICE AREA RESIDENTS. THE WELLNESS CENTERS ARE MEDICALLY INTEGRATED WELLNESS FACILITIES THAT INCLUDE ORTHOPEDIC AND PHYSICAL THERAPY SERVICES OPEN TO THE PUBLIC. THERAPY POOLS AND WORKOUT EQUIPMENT. THEY ALSO PROVIDE FREE CLASSES TO DEVELOPMENTALLY DISABLED ADULTS AND OTHER COMMUNITY MEMBERS PLUS FEE BASED CLASSES TO ANYONE IN THE COMMUNITY. HEALTH LECTURES ARE FREE FOR THE COMMUNITY. CHELSEA WELLNESS CENTER IS THE FIRST CERTIFIED MEDICAL INTEGRATION CENTER IN MI.
6,253,402
2
ESTABLISHED FIVE COMMUNITES WELLNESS COALITIONS. OUR TECHNICAL SUPPORT INCLUDES IDENTIFYING LOCAL/ STATE & NATIONAL RESOURCES, IDENTIFYING PREVENTION BEST PRACTICES, PLANNING & FUNDING ACTIVITIES & MEETINGS, ARCHIVING DOCUMENTS, DEVELOPING MARKETING & EDUCATIONAL MATERIAL, PUBLICITY, EDUCATING ON THE ROLE OF COALITIONS & PROJECT DEVELOPMENT, HOSTING WORKSHOPS, PROBLEM SOLVING AND GENERAL SUPPORT OF VOLUNTEERS (COALITION MEMBERS). FUNDS ARE AVAILABLE FOR COMPREHENSIVE WELLNESS PLANS IN EACH OF THE FIVE COMMUNITIES IN THE SERVICE AREA.
204,554
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
.........................
0
Form
990-PF
(2019)
Form 990-PF (2019)
Page
8
Part X
Minimum Investment Return
(All domestic foundations must complete this part. Foreign foundations, see instructions.)
1
Fair market value of assets not used (or held for use) directly in carrying out charitable, etc.,
purposes:
a
Average monthly fair market value of securities
...................
1a
23,229,691
b
Average of monthly cash balances
.......................
1b
296,991
c
Fair market value of all other assets (see instructions)
................
1c
0
d
Total
(add lines 1a, b, and c)
.........................
1d
23,526,682
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
23,526,682
4
Cash deemed held for charitable activities. Enter 1 1/2% of line 3 (for greater amount, see
instructions)
.............................
4
352,900
5
Net value of noncharitable-use assets.
Subtract line 4 from line 3. Enter here and on Part V, line 4
5
23,173,782
6
Minimum investment return.
Enter 5% of line 5
..................
6
1,158,689
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
1,158,689
2a
Tax on investment income for 2019 from Part VI, line 5
......
2a
21,749
b
Income tax for 2019. (This does not include the tax from Part VI.)
...
2b
c
Add lines 2a and 2b
............................
2c
21,749
3
Distributable amount before adjustments. Subtract line 2c from line 1
............
3
1,136,940
4
Recoveries of amounts treated as qualifying distributions
................
4
659,891
5
Add lines 3 and 4
............................
5
1,796,831
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
1,796,831
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
1,622,977
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
435,687
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
2,058,664
5
Foundations that qualify under section 4940(e) for the reduced rate of tax on net investment
income. Enter 1% of Part I, line 27b. See instructions
.................
5
0
6
Adjusted qualifying distributions.
Subtract line 5 from line 4
..............
6
2,058,664
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
1,796,831
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
......
549,326
b
From 2015
......
1,574,343
c
From 2016
......
1,159,235
d
From 2017
......
942,405
e
From 2018
......
564,334
f
Total
of lines 3a through e
........
4,789,643
4
Qualifying distributions for 2019 from Part
XII, line 4:
$
2,058,664
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
.....
1,796,831
e
Remaining amount distributed out of corpus
261,833
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
5,051,476
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)
...
549,326
9
Excess distributions carryover to 2020.
Subtract lines 7 and 8 from line 6a
......
4,502,150
10
Analysis of line 9:
a
Excess from 2015
....
1,574,343
b
Excess from 2016
....
1,159,235
c
Excess from 2017
....
942,405
d
Excess from 2018
....
564,334
e
Excess from 2019
....
261,833
Form
990-PF
(2019)
Form 990-PF (2019)
Page
10
Part XIV
Private Operating Foundations
(see instructions and Part VII-A, question 9)
1a
If the foundation has received a ruling or determination letter that it is a private operating
foundation, and the ruling is effective for 2019, enter the date of the ruling
.......
b
Check box to indicate whether the organization is a private operating foundation described in section
4942(j)(3)
or
4942(j)(5)
2a
Enter the lesser of the adjusted net
income from Part I or the minimum
investment return from Part X for each
year listed
..........
Tax year
Prior 3 years
(e) Total
(a)
2019
(b)
2018
(c)
2017
(d)
2016
b
85% of line 2a
.........
c
Qualifying distributions from Part XII,
line 4 for each year listed
.....
d
Amounts included in line 2c not used directly
for active conduct of exempt activities
..........
e
Qualifying distributions made directly
for active conduct of exempt activities.
Subtract line 2d from line 2c
....
3
Complete 3a, b, or c for the
alternative test relied upon:
a
“Assets" alternative test—enter:
(1)
Value of all assets
......
(2)
Value of assets qualifying
under section 4942(j)(3)(B)(i)
b
“Endowment" alternative test— enter 2/3
of minimum investment return shown in
Part X, line 6 for each year listed
...
c
“Support" alternative test—enter:
(1)
Total support other than gross
investment income (interest,
dividends, rents, payments
on securities loans (section
512(a)(5)), or royalties)
....
(2)
Support from general public
and 5 or more exempt
organizations as provided in
section 4942(j)(3)(B)(iii)
....
(3)
Largest amount of support
from an exempt organization
(4)
Gross investment income
Part XV
Supplementary Information (Complete this part only if the foundation had $5,000 or more in
assets at any time during the year—see instructions.)
1
Information Regarding Foundation Managers:
a
List any managers of the foundation who have contributed more than 2% of the total contributions received by the foundation
before the close of any tax year (but only if they have contributed more than $5,000). (See section 507(d)(2).)
b
List any managers of the foundation who own 10% or more of the stock of a corporation (or an equally large portion of the
ownership of a partnership or other entity) of which the foundation has a 10% or greater interest.
2
Information Regarding Contribution, Grant, Gift, Loan, Scholarship, etc., Programs:
Check here
if the foundation only makes contributions to preselected charitable organizations and does not accept
unsolicited requests for funds. If the foundation makes gifts, grants, etc. to individuals or organizations under
other conditions, complete items 2a, b, c, and d. See instructions
a
The name, address, and telephone number or e-mail address of the person to whom applications should be addressed:
AMY HEYDLAUFF
14800 E OLD US 12
CHELSEA
,
MI
48118
(734) 433-4599
b
The form in which applications should be submitted and information and materials they should include:
ELECTRONIC SUBMISSION THROUGH THE "GRANTS" TAB ON THE WEBSITE. ALL INFORMATION RELATED TO GRANT APPLICATION IS POSTED ON THE WEBSITE. APPLICANTS WILL BE REQUIRED TO PROVIDE PROOF OF NON-PROFIT STATUS, RESPONSIBLE CONTACT, DEMONSTRATED NEED, PURPOSE, MISSION, BUDGET, METHOD OF MEASUREMENT, AND SUSTAINABILITY PLAN.
c
Any submission deadlines:
APPROXIMATELY THE FIRST OF FEBRUARY, APRIL, JUNE, AUGUST, OCTOBER & DECEMBER.
d
Any restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other
factors:
GRANTS ARE LIMITED TO NON-PROFITS IN THE ORGANIZATION'S SERVICE AREA. INCLUDING CHELSEA, DEXTER, GRASS LAKE, MANCHESTER, AND STOCKBRIDGE. THE ORGANIZATION ONLY GRANTS TO NON-PROFITS RELATED TO THE ORGANIZATION'S VISION (EAT BETTER, MOVE MORE, AVOID UNHEALTHY SUBSTANCES, AND CONNECT WITH OTHERS IN HEALTHY WAYS).
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
ACORN FARMERS MARKET AND CAFE
18451 W PLEASANT LAKE RD
MANCHESTER
,
MI
48158
NONE
PC
FARM STOP TRAINING AND GENERAL SUPPORT
25,500
BALLET CHELSEA-YDT
PO BOX 591
CHELSEA
,
MI
48118
NONE
PC
ADAPTIVE MOVEMENT PLAN SUPPORT
25,000
CHELSEA CHILDREN'S COOPERATIVE INC
14600 E OLD US HIGHWAY 12
CHELSEA
,
MI
48118
NONE
PC
CO-OP PRESCHOOL PLAYGROUND
12,000
CHELSEA SCHOOL DISTRICT
500 WASHINGTON STREET
CHELSEA
,
MI
48118
NONE
PC
EDUCATIONAL & CLUB SUPPORT
500
CHELSEA SENIOR CENTER
512 E WASHINGTON STREET
CHELSEA
,
MI
48118
NONE
PC
GRASS LAKE SENIOR SOCIAL CONNECTIONS, SENIOR CENTER ACTIVITIES
10,000
COMMUNITY BIBLE CHURCH OF MANCHESTER
8400 SHARON HOLLOW RD
MANCHESTER
,
MI
48158
NONE
PC
REBOOT COMBAT RECOVERY
500
CROSSROADS COMMUNITY CHURCH
950 S CLINTON ST
STOCKBRIDGE
,
MI
49285
NONE
PC
TEEN CENTER SUPPORT
750
DEXTER COALTION
14800 E OLD US HWY 12
CHELSEA
,
MI
48118
NONE
PC
DEXTER FARM TO SCHOOL
31,340
DEXTER SENIOR CENTER
7720 DEXTER-ANN ARBOR RD
DEXTER
,
MI
48130
NONE
PC
WINTER MARKET
4,860
DEXTER WELLNESS CENTER
2810 BAKER RD
DEXTER
,
MI
48130
NONE
PC
ALTERNATIVE ED FITNESS, OUTDOOR ACTIVITIES
7,242
FRIENDS OF CHELSEA DISTRICT LIBRARY
221 S MAIN ST
CHELSEA
,
MI
48118
NONE
PC
STORYBOOK TRAIL
5,400
FRIENDS OF THE DEXTER DISTRICT LIBRARY
3255 ALPINE ST
DEXTER
,
MI
48130
NONE
PC
LIBRARY SPEAKER SERIES
971
GRASS LAKE CHARTER TOWNSHIP
373 LAKESIDE DR
GRASS LAKE
,
MI
49240
NONE
PC
SHUFFLEBOARD
750
GRASS LAKE COMMUNITY SCHOOLS
899 UNION STREET
GRASS LAKE
,
MI
49240
NONE
PC
PROJECT SAFE GRADUATION, GRASS LAKE ELEMENTARY HEALTHY FOOD, HYDROPONIC GARDEN, GRASS LAKE HIGH SCHOOL FRUIT TREES
2,500
GRASS LAKE FARMERS MARKET
PO BOX 446
GRASS LAKE
,
MI
49240
NONE
PC
MINDFUL MONKEYS
10,500
GRASS LAKE SENIOR CENTER
PO BOX 216
GRASS LAKE
,
MI
49240
NONE
PC
AGING IN PLACE
1,150
GRASS LAKE UNITED METHODIST CHURCH
449 E MICHIGAN AVE
GRASS LAKE
,
MI
49240
NONE
PC
FOOD WITH FRIENDS, HOT FUN IN THE SUMMER, VACATION BIBLE SCHOOL
3,730
GRASS LAKE WELLNESS COALITION
14800 E OLD US HWY 12
CHELSEA
,
MI
48118
NONE
PC
FRESH AIR YOGA SERIES
2,250
GRASS LAKE WHISTLESTOP PARK ASSOCIATION
210 E MICHIGAN AVE
GRASS LAKE
,
MI
49240
NONE
PC
CONNECTIONS FORUM SERIES
3,100
HURON WATERLOO PATHWAYS INITIATIVE
14800 E OLD US HWY 12
CHELSEA
,
MI
48118
NONE
PC
HWPI RENT PAYMENTS & HWPI TRAIL SUPPORT
29,268
HUTAN
9434 HURON RIVER DR
DEXTER
,
MI
48130
NONE
PC
MONKEY PLAY
5,691
MANCHESTER COALITION
14800 E OLD US HWY 12
CHELSEA
,
MI
48118
NONE
PC
SR2S AND MARKETING
6,500
MANCHESTER COMMUNITY RESOURCE CENTER
PO BOX 833
MANCHESTER
,
MI
48158
NONE
PC
WORTH REPEATING, ACORN FARMERS MARKET & CAFE
750
MANCHESTER COMMUNITY SCHOOLS
410 CITY RD
MANCHESTER
,
MI
48158
NONE
PC
LINK CREW, COMMUNITY AND SCHOOL GARDENS, RIVERSIDE INTERMEDIATE GARDENS, RUN MANCHESTER
12,100
POTAWATOMI MOUNTAIN BIKING ASSOCIATION
PO BOX 217
DEXTER
,
MI
48130
NONE
PC
DTE ENERGY FOUNDATION TRAIL
17,136
PROGRAMS TO EDUCATE ALL CYCLISTS (PEAC)
32 N WASHINGTON STREET STE 1
YPSILANTI
,
MI
48197
NONE
PC
PEAC - DEXTER
4,000
RIVERFOLK MUSIC & ARTS ASSOCIATION
PO BOX 133
MANCHESTER
,
MI
48104
NONE
PC
GAZEBO CONCERTS, DANCE MANCHESTER
4,000
ST JOSEPH MERCY CHELSEA
775 S MAIN STREET
CHELSEA
,
MI
48118
NONE
PC
CHELSEA FARMERS MARKET, HEART & SOLE, MINISTERING FOR WHOLISTIC HEALTH, SENIOR FRESH PRODUCE ACCESS, SRSLY SUPPORT
66,800
ST JOSEPH MERCY HOSPITAL
775 S MAIN STREET
CHELSEA
,
MI
48118
NONE
PC
SJMHS RENTAL PAYMENTS
3,643
STOCKBRIDGE COMMUNITY OUTREACH
PO BOX 682
STOCKBRIDGE
,
MI
49285
NONE
PC
KARAOKE DODGEBALL, PRACTICAL COOKING WITH A PRO, TRAIL MAINTENANCE, TIDE ME OVER
23,300
STOCKBRIDGE COMMUNITY SCHOOLS
305 W ELIZABETH STREET
STOCKBRIDGE
,
MI
49285
NONE
PC
GO GREEN DRINK CLEAN, SMITH HEALTH SNACKS, SMITH SENSORY HALLWAY, ENGINEERING DRAWINGS
17,320
VILLAGE OF GRASS LAKE
119 NORTH LAKE
GRASS LAKE
,
MI
49240
NONE
PC
FARMERS MARKET PAVILLION
11,750
VILLAGE OF MANCHESTER
912 CITY RD
MANCHESTER
,
MI
48158
NONE
PC
MANCHESTER FARMERS MARKET, SHARED USE TRAIL PHASE 2
25,000
Total
.................................
3a
375,301
b
Approved for future payment
Total
.................................
3b
0
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
MEMBERSHIP FEES
4,911,187
b
PROGRAM SERVICES
11,041
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
328
4
Dividends and interest from securities
....
18
584,610
5
Net rental income or (loss) from real estate:
a
Debt-financed property
......
16
4,584
b
Not debt-financed property
.....
16
245,171
6
Net rental income or (loss) from personal property
7
Other investment income
.....
8
Gain or (loss) from sales of assets other than
inventory
............
9
Net income or (loss) from special events:
10
Gross profit or (loss) from sales of inventory
03
39,182
11
Other revenue:
a
MAGAZINE ADVERTISING REVENUE
900099
30,093
0
0
b
K-1 OTHER INCOME RUSSELL MULTI ASSET CORE FUND
900099
0
14
117,158
0
c
K-1 OTHER INCOME RUSSELL CORE BOND FUND
900099
0
14
-4,222
0
d
PROPERTY TAX REFUNDS
900099
0
01
0
659,891
e
INTEREST PAID ON PROPERTY TAX REFUNDS
900099
0
14
47,630
0
f
K-1 OTHER INCOME RUSSELL REAL ESTATE EQUITY FUND
900099
0
14
-21,454
0
12
Subtotal. Add columns (b), (d), and (e)
..
30,093
1,012,987
5,582,119
13
Total.
Add line 12, columns (b), (d), and (e)
..................
13
6,625,199
(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.)
1A
FEES GENERATED FROM OPERATION OF MEDICALLY-INTEGRATED COMMUNITY
1B
WELLNESS CENTER
11D
CHELSEA CITY REAL ESTATE PROPERTY REFUND
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