-
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
08-01-2019
, and ending
07-31-2020
Name of foundation
THE JOSEPH HENRY EDMONDSON FOUNDATION
% HEATHER CARROLL
Number and street (or P.O. box number if mail is not delivered to street address)
13 SOUTH TEJON STREET Suite 200
Room/suite
City or town, state or province, country, and ZIP or foreign postal code
COLORADO SPRINGS
,
CO
80903
A Employer identification number
84-1090456
B
Telephone number (see instructions)
(719) 471-1241
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)
$
23,543,227
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)
0
2
Check
.............
3
Interest on savings and temporary cash investments
128
128
4
Dividends and interest from securities
...
449,777
447,318
5a
Gross rents
............
b
Net rental income or (loss)
6a
Net gain or (loss) from sale of assets not on line 10
481,214
b
Gross sales price for all assets on line 6a
2,457,926
7
Capital gain net income (from Part IV, line 2)
...
481,214
8
Net short-term capital gain
.........
9
Income modifications
...........
10a
Gross sales less returns and allowances
b
Less: Cost of goods sold
....
c
Gross profit or (loss) (attach schedule)
.....
11
Other income (attach schedule)
.......
12
Total.
Add lines 1 through 11
........
931,119
928,660
13
Compensation of officers, directors, trustees, etc.
232,885
256,445
14
Other employee salaries and wages
......
15
Pension plans, employee benefits
.......
24,000
24,000
16a
Legal fees (attach schedule)
.........
b
Accounting fees (attach schedule)
.......
16,200
0
0
16,200
c
Other professional fees (attach schedule)
....
34,346
34,158
17
Interest
...............
18
Taxes (attach schedule) (see instructions)
...
52,940
11,780
19
Depreciation (attach schedule) and depletion
...
1,491
20
Occupancy
..............
2,860
2,860
21
Travel, conferences, and meetings
.......
7,307
7,307
22
Printing and publications
..........
23
Other expenses (attach schedule)
.......
44,754
44,754
24
Total operating and administrative expenses.
Add lines 13 through 23
..........
416,783
34,158
0
363,346
25
Contributions, gifts, grants paid
.......
742,000
682,000
26
Total expenses and disbursements.
Add lines 24 and 25
1,158,783
34,158
0
1,045,346
27
Subtract line 26 from line 12:
a
Excess of revenue over expenses and disbursements
-227,664
b
Net investment income
(if negative, enter -0-)
894,502
c
Adjusted net income
(if negative, enter -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
.............
10,994
503,966
503,966
2
Savings and temporary cash investments
.........
87,583
95,812
95,812
3
Accounts receivable
Less: allowance for doubtful accounts
4
Pledges receivable
Less: allowance for doubtful accounts
5
Grants receivable
.................
2,449,000
2,531,000
2,531,000
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
..............
9
Prepaid expenses and deferred charges
..........
3,667
8,050
8,050
10a
Investments—U.S. and state government obligations (attach schedule)
614,032
520,237
520,237
b
Investments—corporate stock (attach schedule)
.......
4,583,097
4,539,936
4,539,936
c
Investments—corporate bonds (attach schedule)
.......
1,941,691
1,732,660
1,732,660
11
Investments—land, buildings, and equipment: basis
Less: accumulated depreciation (attach schedule)
12
Investments—mortgage loans
.............
13
Investments—other (attach schedule)
..........
13,545,839
13,677,807
13,588,012
14
Land, buildings, and equipment: basis
14,091
Less: accumulated depreciation (attach schedule)
6,639
6,813
7,452
7,452
15
Other assets (describe
)
18,621
16,102
16,102
16
Total assets
(to be completed by all filers—see the
instructions. Also, see page 1, item I)
23,261,337
23,633,022
23,543,227
17
Accounts payable and accrued expenses
..........
18
Grants payable
.................
70,000
130,000
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
)
164,153
123,385
23
Total liabilities
(add lines 17 through 22)
.........
234,153
253,385
Foundations that follow FASB ASC 958, check here
and complete lines 24, 25, 29 and 30.
24
Net assets without donor restrictions
...........
25
Net assets with donor restrictions
............
Foundations that do not follow FASB ASC 958, check here
and complete lines 26 through 30.
26
Capital stock, trust principal, or current funds
........
27
Paid-in or capital surplus, or land, bldg., and equipment fund
28
Retained earnings, accumulated income, endowment, or other funds
23,027,184
23,379,637
29
Total net assets or fund balances
(see instructions)
.....
23,027,184
23,379,637
30
Total liabilities and net assets/fund balances
(see instructions)
.
23,261,337
23,633,022
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
23,027,184
2
Enter amount from Part I, line 27a
.....................
2
-227,664
3
Other increases not included in line 2 (itemize)
3
580,117
4
Add lines 1, 2, and 3
..........................
4
23,379,637
5
Decreases not included in line 2 (itemize)
5
6
Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 29
.
6
23,379,637
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
SHORT-TERM CAPITAL GAINS - DETAIL AVAIILABLE UPON REQUEST
b
LONG-TERM CAPITAL GAINS - DETAIL AVAILABLE UPON REQUEST
c
d
e
(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
38,630
b
442,584
c
d
e
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
b
c
d
e
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
481,214
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
940,577
18,749,339
0.050166
2017
991,672
20,069,725
0.049411
2016
931,896
19,122,746
0.048732
2015
887,484
18,121,170
0.048975
2014
876,717
19,134,165
0.045819
2
Total
of line 1, column (d)
.....................
2
0.243103
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
0.048621
4
Enter the net value of noncharitable-use assets for 2019 from Part X, line 5
......
4
20,215,123
5
Multiply line 4 by line 3
......................
5
982,879
6
Enter 1% of net investment income (1% of Part I, line 27b)
...........
6
8,945
7
Add lines 5 and 6
........................
7
991,824
8
Enter qualifying distributions from Part XII, line 4
,.............
8
1,045,346
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
8,945
here
and enter 1% of Part I, line 27b
...................
c
All other domestic foundations enter 2% of line 27b. Exempt foreign organizations enter 4% of Part I, line 12, col. (b)
2
Tax under section 511 (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-)
2
3
Add lines 1 and 2
...........................
3
8,945
4
Subtitle A (income) tax (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-)
4
5
Tax based on investment income.
Subtract line 4 from line 3. If zero or less, enter -0-
.....
5
8,945
6
Credits/Payments:
a
2019 estimated tax payments and 2018 overpayment credited to 2019
6a
9,088
b
Exempt foreign organizations—tax withheld at source
......
6b
c
Tax paid with application for extension of time to file (Form 8868)
...
6c
d
Backup withholding erroneously withheld
...........
6d
7
Total credits and payments. Add lines 6a through 6d
..............
7
9,088
8
Enter any
penalty
for underpayment of estimated tax.
Check here
if Form 2220 is attached.
8
9
Tax due.
If the total of lines 5 and 8 is more than line 7, enter
amount owed
.......
9
10
Overpayment.
If line 7 is more than the total of lines 5 and 8, enter the
amount overpaid
...
10
143
11
Enter the amount of line 10 to be:
Credited to 2020 estimated tax
143
Refunded
11
Part VII-A
Statements Regarding Activities
1a
During the tax year, did the foundation attempt to influence any national, state, or local legislation or did
Yes
No
it participate or intervene in any political campaign?
....................
1a
No
b
Did it spend more than $100 during the year (either directly or indirectly) for political purposes? (see Instructions
for definition)
.................................
1b
No
If the answer is "Yes" to
1a
or
1b,
attach a detailed description of the activities and copies of any materials
published or distributed by the foundation in connection with the activities.
c
Did the foundation file
Form 1120-POL
for this year?
.....................
1c
No
d
Enter the amount (if any) of tax on political expenditures (section 4955) imposed during the year:
(1)
On the foundation.
$
(2)
On foundation managers.
$
e
Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed
on foundation managers.
$
2
Has the foundation engaged in any activities that have not previously been reported to the IRS?
.......
2
No
If "Yes," attach a detailed description of the activities.
3
Has the foundation made any changes, not previously reported to the IRS, in its governing instrument, articles
of incorporation, or bylaws, or other similar instruments?
If "Yes," attach a conformed copy of the changes
....
3
No
4a
Did the foundation have unrelated business gross income of $1,000 or more during the year?
........
4a
No
b
If "Yes," has it filed a tax return on
Form 990-T
for this year?
...................
4b
5
Was there a liquidation, termination, dissolution, or substantial contraction during the year?
.........
5
No
If "Yes," attach the statement required by General Instruction T.
6
Are the requirements of section 508(e) (relating to sections 4941 through 4945) satisfied either:
By language in the governing instrument, or
By state legislation that effectively amends the governing instrument so that no mandatory directions
that conflict with the state law remain in the governing instrument?
................
6
Yes
7
Did the foundation have at least $5,000 in assets at any time during the year?
If "Yes," complete Part II, col. (c),
and Part XV.
.................................
7
Yes
8a
Enter the states to which the foundation reports or with which it is registered (see instructions)
CO
b
If the answer is "Yes" to line 7, has the foundation furnished a copy of Form 990-PF to the Attorney
General (or designate) of each state as required by General Instruction G?
If "No," attach explanation
.
8b
Yes
9
Is the foundation claiming status as a private operating foundation within the meaning of section 4942(j)(3)
or 4942(j)(5) for calendar year 2019 or the taxable year beginning in 2019? See the instructions for Part XIV.
If "Yes," complete Part XIV
.............................
9
No
10
Did any persons become substantial contributors during the tax year?
If "Yes," attach a schedule listing their names
and addresses.
...............................
10
No
Form
990-PF
(2019)
Form 990-PF (2019)
Page
5
Part VII-A
Statements Regarding Activities
(continued)
11
At any time during the year, did the foundation, directly or indirectly, own a controlled entity within the
meaning of section 512(b)(13)? If "Yes," attach schedule. See instructions
.............
11
No
12
Did the foundation make a distribution to a donor advised fund over which the foundation or a disqualified person had
advisory privileges? If "Yes," attach statement. See instructions
.................
12
No
13
Did the foundation comply with the public inspection requirements for its annual returns and exemption application?
13
Yes
Website address
N/A
14
The books are in care of
HEATHER CARROLL
Telephone no.
(719) 471-1241
Located at
13 SOUTH TEJON STREET STE 200
COLORADO SPRINGS
CO
ZIP+4
80903
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
HEATHER CARROLL
President/EXEC. DIR.
50.0
198,885
24,000
0
10 LAKE CIRCLE
COLORADO SPRINGS
,
CO
80906
BRUCE T BUELL
VICE CHAIR
1.0
0
0
0
10 LAKE CIRCLE
COLORADO SPRINGS
,
CO
80906
SHARON HIGGINS
SECRETARY & Treasurer
2.5
4,500
0
0
10 LAKE CIRCLE
COLORADO SPRINGS
,
CO
80906
CHRISTOPHER DUFF
MEMBER
1.0
5,500
0
0
10 LAKE CIRCLE
COLORADO SPRINGS
,
CO
80906
SEAN DUFF
Vice Chair
1.5
5,500
0
0
10 LAKE CIRCLE
COLORADO SPRINGS
,
CO
80906
SUSAN RAMSAY
MEMBER
1.0
5,500
0
0
10 LAKE CIRCLE
COLORADO SPRINGS
,
CO
80906
BEN SPARKS
Chairman
4.0
5,500
0
0
10 LAKE CIRCLE
COLORADO SPRINGS
,
CO
80906
LARRY GADDIS
Member
2.5
5,500
0
0
10 LAKE CIRCLE
COLORADO SPRINGS
,
CO
80906
Kat Miller-Stevens
Member
1.0
2,000
0
0
10 Lake Circle
COLORADO SPRINGS
,
CO
80906
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
Total
number of other employees paid over $50,000
...................
Form
990-PF
(2019)
Form 990-PF (2019)
Page
7
Part VIII
Information About Officers, Directors, Trustees, Foundation Managers, Highly Paid Employees,
and Contractors
(continued)
3
Five highest-paid independent contractors for professional services (see instructions). If none, enter "NONE".
(a)
Name and address of each person paid more than $50,000
(b)
Type of service
(c)
Compensation
Total
number of others receiving over $50,000 for professional services
.............
Part IX-A
Summary of Direct Charitable Activities
List the foundation’s four largest direct charitable activities during the tax year. Include relevant statistical information such as the number of organizations and other beneficiaries served, conferences convened, research papers produced, etc.
Expenses
1
2
3
4
Part IX-B
Summary of Program-Related Investments
(see instructions)
Describe the two largest program-related investments made by the foundation during the tax year on lines 1 and 2.
Amount
1
2
All other program-related investments. See instructions.
3
Total.
Add lines 1 through 3
.........................
Form
990-PF
(2019)
Form 990-PF (2019)
Page
8
Part X
Minimum Investment Return
(All domestic foundations must complete this part. Foreign foundations, see instructions.)
1
Fair market value of assets not used (or held for use) directly in carrying out charitable, etc.,
purposes:
a
Average monthly fair market value of securities
...................
1a
20,190,203
b
Average of monthly cash balances
.......................
1b
316,805
c
Fair market value of all other assets (see instructions)
................
1c
15,960
d
Total
(add lines 1a, b, and c)
.........................
1d
20,522,968
e
Reduction claimed for blockage or other factors reported on lines 1a and
1c (attach detailed explanation)
.............
1e
2
Acquisition indebtedness applicable to line 1 assets
..................
2
0
3
Subtract line 2 from line 1d
.........................
3
20,522,968
4
Cash deemed held for charitable activities. Enter 1 1/2% of line 3 (for greater amount, see
instructions)
.............................
4
307,845
5
Net value of noncharitable-use assets.
Subtract line 4 from line 3. Enter here and on Part V, line 4
5
20,215,123
6
Minimum investment return.
Enter 5% of line 5
..................
6
1,010,756
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
1,010,756
2a
Tax on investment income for 2019 from Part VI, line 5
......
2a
8,945
b
Income tax for 2019. (This does not include the tax from Part VI.)
...
2b
c
Add lines 2a and 2b
............................
2c
8,945
3
Distributable amount before adjustments. Subtract line 2c from line 1
............
3
1,001,811
4
Recoveries of amounts treated as qualifying distributions
................
4
5
Add lines 3 and 4
............................
5
1,001,811
6
Deduction from distributable amount (see instructions)
.................
6
7
Distributable amount
as adjusted. Subtract line 6 from line 5. Enter here and on Part XIII, line 1
...
7
1,001,811
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
1,045,346
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
1,045,346
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
8,945
6
Adjusted qualifying distributions.
Subtract line 5 from line 4
..............
6
1,036,401
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
1,001,811
2
Undistributed income, if any, as of the end of 2019:
a
Enter amount for 2018 only
.......
0
b
Total for prior years:
2017
,
2016
,
2015
0
3
Excess distributions carryover, if any, to 2019:
a
From 2014
......
b
From 2015
......
c
From 2016
......
d
From 2017
......
13,356
e
From 2018
......
21,286
f
Total
of lines 3a through e
........
34,642
4
Qualifying distributions for 2019 from Part
XII, line 4:
$
1,045,346
a
Applied to 2018, but not more than line 2a
0
b
Applied to undistributed income of prior years
(Election required—see instructions)
.....
c
Treated as distributions out of corpus (Election
required—see instructions)
........
d
Applied to 2019 distributable amount
.....
1,001,811
e
Remaining amount distributed out of corpus
43,535
5
Excess distributions carryover applied to 2019.
(If an amount appears in column (d), the
same amount must be shown in column (a).)
6
Enter the net total of each column as
indicated below:
a
Corpus. Add lines 3f, 4c, and 4e. Subtract line 5
78,177
b
Prior years’ undistributed income. Subtract
line 4b from line 2b
..........
0
c
Enter the amount of prior years’ undistributed
income for which a notice of deficiency has
been issued, or on which the section 4942(a)
tax has been previously assessed
......
d
Subtract line 6c from line 6b. Taxable amount
—see instructions
...........
0
e
Undistributed income for 2018. Subtract line
4a from line 2a. Taxable amount—see
instructions
.............
0
f
Undistributed income for 2019. Subtract
lines 4d and 5 from line 1. This amount must
be distributed in 2020
..........
0
7
Amounts treated as distributions out of
corpus to satisfy requirements imposed by
section 170(b)(1)(F) or 4942(g)(3) (Election may
be required - see instructions)
.......
8
Excess distributions carryover from 2014 not
applied on line 5 or line 7 (see instructions)
...
9
Excess distributions carryover to 2020.
Subtract lines 7 and 8 from line 6a
......
78,177
10
Analysis of line 9:
a
Excess from 2015
....
b
Excess from 2016
....
c
Excess from 2017
....
13,356
d
Excess from 2018
....
21,286
e
Excess from 2019
....
43,535
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:
HEATHER CARROLL
13 South Tejon Street St 200
COLORADO SPRINGS
,
CO
80903
(719) 471-1241
b
The form in which applications should be submitted and information and materials they should include:
FOR DETAILS REGARDING THE APPLICATION PROCESS, PLEASE SEE THE FOUNDATION'S WEBSITE AT: WWW.JHEDMONDSON.ORG
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:
NONE
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
Atlas Preparatory School
1602 South Murray Blvd
Colorado Springs
,
CO
80916
N/A
PC
Atlas Capital Expansion, Holiday Grant,General Operating Support
52,000
Big Brothers Big Sisters
111 S Tejon Street
Colorado Springs
,
CO
80903
N/A
PC
Holiday Grant, Colorado Springs Programming
11,000
Care & Share
2605 Preamble Point
Colorado Springs
,
CO
80915
N/A
PC
Holiday Grant, General Operating Support
26,500
Catholic Charities of Central Colorado
228 N Cascade Ave
Colorado Springs
,
CO
80903
N/A
PC
Holiday Grant, General Operating Support
16,000
Centro de la Familia
1287 Lake Plaza Drive
Suite 200
Colorado Springs
,
CO
80906
N/A
PC
Holiday Grant
1,000
Colorado Outward Bound School
5161 Sheridan Blvd
Denver
,
CO
80212
N/A
PC
Robert H. Ramsay Scholarships
15,000
Colorado Springs Fine Arts Center at CC
30 West Dale Street
Colorado Springs
,
CO
80903
N/A
PC
General Operating Support
500
Colorado Springs Philharmonic
PO Box 1266
Colorado Springs
,
CO
80901
N/A
PC
Becoming Heroes Festival and Perlman concert
15,000
Community Partnership for Child Development
2330 Robinson Street
Colorado Springs
,
CO
80904
N/A
PC
Holiday Grant and General Operating Support
12,000
Converge Lecture Series
733 East Boulder Street
Colorado Springs
,
CO
80903
N/A
PC
General Operating Support
3,000
Crossfire Ministries
307 North Union Blvd
B
Colorado Springs
,
CO
80909
N/A
PC
Holiday Grant
1,000
Empty Stocking Fund
PO Box 400
3rd floor
Colorado Springs
,
CO
80901
N/A
PC
General Program Support
3,000
Global Livingston Institute
3001 Brighton Blvd
Suite 200
Denver
,
CO
80216
N/A
PC
General Operating Support
2,000
Impact360
1325 Glenarm Place
Denver
,
CO
80204
N/A
PC
General Operating Support
2,500
INDYGIVE
c/o Colorado Springs Independent 23
Colorado Springs
,
CO
80903
N/A
PC
General Program Support, Matching Grant Funds
6,000
Ithaka Land Trust
321 Mesa Rd
Colorado Springs
,
CO
80905
N/A
PC
Holiday Grant
1,000
KCME
1921 North Weber
Colorado Springs
,
CO
80907
N/A
PC
General Operating Support
2,000
KRCC
912 North Weber
Colorado Springs
,
CO
80903
N/A
PC
General Operating Support
1,000
Pikes Peak Community Foundation
102 S Tejon Street
Suite 530
Colorado Springs
,
CO
80903
N/A
PC
Emergency Relief Fund, Artist Recovery Fund
36,000
Prison Fellowship Ministries
44180 Riverside Parkway
Landsdowne
,
VA
20176
N/A
PC
Holiday Grant - CO Programs, Colorado Springs Program Support
3,000
Project Angel Heart
4950 Washington St
Denver
,
CO
80216
N/A
PC
Colorado Springs Programming Suppport
1,000
Reach Pikes Peak
31 North Tejon Street
Suite 310
Colorado Springs
,
CO
80903
N/A
PC
Holiday Grant
3,000
Rocky Mountain Women's Film Institute
2727 North Cascade Street
Suite 140
Colorado Springs
,
CO
80907
N/A
PC
Strategic Planning - Capacity Building, General Operating Support
25,500
Salvation Army
910 Yuma
Suite 333
Colorado Springs
,
CO
80906
N/A
PC
Holiday Grant
4,500
Silver Key Senior Services
1625 S Murray Blvd
251
Colorado Springs
,
CO
80228
N/A
PC
Holiday Grant, General Operating Support
5,000
Southern Colorado Aids Project
1301 South Eighth Street
Colorado Springs
,
CO
80916
N/A
PC
Holiday Grant
1,000
Springs Rescue Mission
5 West Las Vegas St
Ste 300
Colorado Springs
,
CO
80904
N/A
PC
Holiday Grant
1,000
TESSA
435 Gold Pass Heights
Colorado Springs
,
CO
80903
N/A
PC
Holiday Grant
1,000
Urban Peak
423 East Cucharras
Colorado Springs
,
CO
80208
N/A
PC
Holiday Grant and General Operating Support
3,500
A Woman's Work
PO Box 817
Longmont
,
CO
80502
N/A
PC
General Operating Support
500
The Colorado Springs Conservatory
415 S Sahwatch Street
Colorado Springs
,
CO
80903
N/A
PC
Innovation Fund,General Operating Support
16,000
Westside Cares
2808 West Colorado Avenue
Colorado Springs
,
CO
80904
N/A
PC
Westside CARES Emergency Services
10,000
Wrestle Like A Girl
9518 Penstemon Court
Colorado Springs
,
CO
80920
N/A
PC
Colorado Springs Program Support
1,000
Adaptive Sports Center
PO Box 1639
Crested Butte
,
CO
81224
N/A
PC
General Operating Support
2,000
Legacy Institute
6 North Tejon Street
Suite 510
Colorado Springs
,
CO
80903
N/A
PC
Face Shields Production
6,000
National Alliance for the Mentally Ill
510 E Willamette Street
Colorado Springs
,
CO
80903
N/A
PC
General Operating Support
500
El Paso County Bar Foundation
PO Box 429
Colorado Springs
,
CO
80901
N/A
PC
The Justice Center/Tree Planting ,Ruth Rouss Scholarship Fund
10,500
COLORADO COLLEGE
14 E Cache La Poudre Street
Colorado Springs
,
CO
80903
n/a
PC
Correctional Facilities Project, Nonprofit Initiative, The QUAD, Shannon McGhee Scholarship Fund
65,500
American Red Cross
1040 S 8th St
Colorado Springs
,
CO
80905
N/A
PC
Bed Shaker Alarms
5,000
Capital Sisters International Inc
601 16th St
Suite C 310
Golden
,
CO
80401
N/A
PC
General Operating Support
1,000
Catamount Institue
740 W Caramillo St
Colorado Springs
,
CO
80907
N/A
PC
General Operating Support
4,000
Challenge America
207 Basalt Center Cirle 104
Basalt
,
CO
81621
N/A
PC
General Operating Support
1,000
Cheyenne Village Inc
6275 Lehman Dr
Colorado Springs
,
CO
80918
N/A
PC
Capital Campaign, General Operating Support
21,500
Children's Literacy Center
2928 Straus Ln STE 100
Colorado Springs
,
CO
80907
N/A
PC
General Operating Support
10,000
Colorado Legal Services
617 S Nevada
Colorado Springs
,
CO
80903
N/A
PC
General Operating Support
500
Colorado Nonprofit Association
789 Sherman Street
Suite 240
Denver
,
CO
80203
N/A
PC
Donate to Colorado Nonprofit Fund Public Action Campaign
10,000
Colorado Sprigns Choral Society
16 E Platte Ave
Colorado Springs
,
CO
80903
N/A
PC
General Operating Support
500
Downtown Ventures
111 South Tejon Street
Ste 703
Colorado Springs
,
CO
80903
N/A
PC
General Operating Support
500
Family Independence Institue
727 E 16th Ave
Denver
,
CO
80203
N/A
PC
Launch a Colorado Springs Fund
25,000
Family Life Services
1800 S Cascade Ave
Colorado Springs
,
CO
80905
N/A
PC
General Operating Support
7,000
Fostering Hope
111 S Tejon St
Suite 112
Colorado Springs
,
CO
80903
N/A
PC
General Operating Support
10,000
Franciscan Community Counseling
228 N Cascade Ave
Colorado Springs
,
CO
80903
N/A
PC
General Operating Support
10,000
Global Leaders Inc
405 E Prospect RT
STE 4
Fort COllins
,
CO
80525
N/A
PC
General Operating Support
2,000
Humane Society of the Pikes Peak Region
610 Abbot Ln
Colorado Springs
,
CO
80905
N/A
PC
General Operating Support
2,000
Inside Out Youth Services
223 N Wahsatch Ave
Suite 101
Colorado Springs
,
CO
80903
N/A
PC
General Operating Support
2,000
Meadows Park Community Center
1943 S EL Paso Ave
Colorado Springs
,
CO
80905
N/A
PC
Meadows Park Action Coalition
11,000
Nature Conservancy of Colorado
2424 Spruce Street
Boulder
,
CO
80302
N/A
PC
BoHart Ranch Program Support, General Operating Support
16,000
One Nation Walking Togeather
3150 N Nevada Ave
Colorado Springs
,
CO
80907
N/A
PC
General Operating Support
1,000
Palmer Land Trust
102 S Tejon St
Unit 360
Colorado Springs
,
CO
80903
N/A
PC
General Operating Support
10,000
Peak Education
730 N Nevada Ave
Colorado Springs
,
CO
80903
N/A
PC
General Operating Support
30,000
Pikes Peak Community College Foundation
5676 S Academy Blvd
Colorado Springs
,
CO
80906
N/A
PC
Holiday Grant
1,000
Pikes Peak Golf Links
103 E Cheyenne Road
Colorado Springs
,
CO
80906
N/A
PC
Carl Donner Memorial Grant
15,000
Pikes Peak Habitat for Humanity
2802 N Propect St
Colorado Springs
,
CO
80907
N/A
PC
Restare Air Conditioner Upgrade
10,000
Pikes Peak Hospice
2550 Tenderfoot Hill St
Colorado Springs
,
CO
80906
N/A
PC
General Operating Support
1,000
Pikes Peak Outdoor Recreation Alliance
102 S Tejon St
Colorado Springs
,
CO
80903
N/A
PC
General Operating Support
5,000
Pikes Peak United Way
518 N Nevada Ave
Colorado Springs
,
CO
80903
N/A
PC
General Operating Support
3,000
Project Healing Waters Fly Fishing
530 Communication Circle
Colorado Springs
,
CO
80905
N/A
PC
General Operating Support
500
Rocky Mountain Field Institute
815 S 25th St
101
Colorado Springs
,
CO
80904
N/A
PC
General Operating Support
11,000
Springs Recovery Connection
1930 W Colorado Ave
Colorado Springs
,
CO
80904
N/A
PC
General Operating Support
16,000
The Colorado Springs Child Nursery Centers Inc
104 E Rio Grande St
Colorado Springs
,
CO
80903
N/A
PC
Holiday Grant
1,000
The Home Front Cares
1120 N Circle Dr
230
Colorado Springs
,
CO
80909
N/A
PC
General Operating Support
12,000
The Justice Center
102 S Tejon St
Ste 1050 E
Colorado Springs
,
CO
80903
N/A
PC
General Operating Support
1,000
Tri-Lakes Cares
235 Jeferson St
Unit B
Monument Colorado
,
CO
80132
N/A
PC
General Operating Support
10,000
Trust for Public Land Colorado
1410 Grant St
D210
Denver
,
CO
80203
N/A
PC
Parks for People and Land Protection in El Paso County
15,000
Twocor Projects
625 Arrawanna St
Colorado Springs
,
CO
80909
N/A
PC
General Operating Support
500
United States Olympic and Paralympic Museum
200 S Sierra Madre St
Colorado Springs
,
CO
80903
N/A
PC
Capital Campaign
15,000
University of Colorado at Colorado Springs
1420 Austin Bluffs Pkwy
Colorado Springs
,
CO
80918
N/A
PC
Chancellor's Leadership Class
10,000
University of Denver Sturm College of Law
2255 E Evans Ave
Denver
,
CO
80210
N/A
PC
Tribal Wills Project
1,000
UpaDowna
335 Manitou Ave
5
Manitou Springs
,
CO
80829
N/A
PC
Bike Clinic Too
5,000
Working Dogs for Conservation
611 W Main St
Bozeman
,
MT
59715
N/A
PC
General Operating Support
1,000
Big City Mountaineers
710 10th St 120
Golden
,
CO
80401
N/A
PC
General Operating Support
1,000
Total
.................................
3a
682,000
b
Approved for future payment
Legacy Institute
6 North Tejon Street
Suite 510
Colorado Springs
,
CO
80903
N/A
PC
General Operating
25,000
El Paso County Bar Association
405 S Cascade Ave
Ste 103
Colorado Springs
,
CO
80903
N/A
PC
General Operating
10,000
Atlas Prepatory School
1602 South Murray Blvd
Colorado Springs
,
CO
80916
N/A
PC
Food Pantry, Books for the Library, General Operating Support, and Internship Program
50,000
Peak Education
1645 S Murray Blvd
Colorado Springs
,
CO
80916
N/A
PC
General Operating Support
30,000
Colorado Outward Bound School
5161 Sheridan Blvd
Denver
,
CO
80212
N/A
PC
Ramsay Scholarships
15,000
Total
.................................
3b
130,000
Form
990-PF
(2019)
Form 990-PF (2019)
Page
12
Part XVI-A
Analysis of Income-Producing Activities
Enter gross amounts unless otherwise indicated.
Unrelated business income
Excluded by section 512, 513, or 514
(e)
Related or exempt
function income
(See instructions.)
1
Program service revenue:
(a)
Business code
(b)
Amount
(c)
Exclusion code
(d)
Amount
a
b
c
d
e
f
g
Fees and contracts from government agencies
2
Membership dues and assessments
....
3
Interest on savings and temporary cash
investments
...........
14
128
4
Dividends and interest from securities
....
14
449,777
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
481,214
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)
..
931,119
13
Total.
Add line 12, columns (b), (d), and (e)
..................
13
931,119
(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