-
TIN:
Form
990-PF
Department of the Treasury
Internal Revenue Service
Return of Private Foundation
or Section 4947(a)(1) Trust Treated as Private Foundation
Do not enter social security numbers on this form as it may be made public.
Go to
www.irs.gov/Form990PF
for instructions and the latest information.
OMB No. 1545-0052
20
19
Open to Public Inspection
For calendar year 2019, or tax year beginning
01-01-2019
, and ending
12-31-2019
Name of foundation
PACIFICSOURCE FOUNDATION FOR HEALTH
IMPROVEMENT
Number and street (or P.O. box number if mail is not delivered to street address)
PO BOX 7068
Room/suite
City or town, state or province, country, and ZIP or foreign postal code
SPRINGFIELD
,
OR
974750068
A Employer identification number
93-1100080
B
Telephone number (see instructions)
(541) 686-1242
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)
$
5,559,656
J
Accounting method:
Cash
Accrual
Other (specify)
(Part I, column (d) must be on cash basis.)
Part I
Analysis of Revenue and Expenses
(The total of amounts in columns (b), (c), and (d) may not necessarily equal the amounts in column (a) (see instructions).)
(a)
Revenue and
expenses per
books
(b)
Net investment
income
(c)
Adjusted net
income
(d)
Disbursements
for charitable
purposes
(cash basis only)
1
Contributions, gifts, grants, etc., received (attach schedule)
1,900,000
2
Check
.............
3
Interest on savings and temporary cash investments
63,728
63,728
4
Dividends and interest from securities
...
32,994
32,994
5a
Gross rents
............
b
Net rental income or (loss)
6a
Net gain or (loss) from sale of assets not on line 10
b
Gross sales price for all assets on line 6a
7
Capital gain net income (from Part IV, line 2)
...
0
8
Net short-term capital gain
.........
9
Income modifications
...........
10a
Gross sales less returns and allowances
b
Less: Cost of goods sold
....
c
Gross profit or (loss) (attach schedule)
.....
11
Other income (attach schedule)
.......
12
Total.
Add lines 1 through 11
........
1,996,722
96,722
0
13
Compensation of officers, directors, trustees, etc.
0
0
0
0
14
Other employee salaries and wages
......
15
Pension plans, employee benefits
.......
16a
Legal fees (attach schedule)
.........
1,654
827
0
827
b
Accounting fees (attach schedule)
.......
c
Other professional fees (attach schedule)
....
17
Interest
...............
18
Taxes (attach schedule) (see instructions)
...
934
467
0
467
19
Depreciation (attach schedule) and depletion
...
20
Occupancy
..............
21
Travel, conferences, and meetings
.......
8,415
2,798
0
5,617
22
Printing and publications
..........
23
Other expenses (attach schedule)
.......
8,929
2,910
0
6,020
24
Total operating and administrative expenses.
Add lines 13 through 23
..........
19,932
7,002
0
12,931
25
Contributions, gifts, grants paid
.......
1,771,649
1,771,649
26
Total expenses and disbursements.
Add lines 24 and 25
1,791,581
7,002
0
1,784,580
27
Subtract line 26 from line 12:
a
Excess of revenue over expenses and disbursements
205,141
b
Net investment income
(if negative, enter -0-)
89,720
c
Adjusted net income
(if negative, enter -0-)
...
0
For Paperwork Reduction Act Notice, see instructions.
Cat. No. 11289X
Form
990-PF
(2019)
Form 990-PF (2019)
Page
2
Part II
Balance Sheets
Attached schedules and amounts in the description column
should be for end-of-year amounts only. (See instructions.)
Beginning of year
End of year
(a)
Book Value
(b)
Book Value
(c)
Fair Market Value
1
Cash—non-interest-bearing
.............
2
Savings and temporary cash investments
.........
2,252,913
2,463,330
2,463,330
3
Accounts receivable
Less: allowance for doubtful accounts
4
Pledges receivable
Less: allowance for doubtful accounts
5
Grants receivable
.................
6
Receivables due from officers, directors, trustees, and other
disqualified persons (attach schedule) (see instructions)
.....
7
Other notes and loans receivable (attach schedule)
Less: allowance for doubtful accounts
8
Inventories for sale or use
..............
9
Prepaid expenses and deferred charges
..........
10a
Investments—U.S. and state government obligations (attach schedule)
b
Investments—corporate stock (attach schedule)
.......
c
Investments—corporate bonds (attach schedule)
.......
11
Investments—land, buildings, and equipment: basis
Less: accumulated depreciation (attach schedule)
12
Investments—mortgage loans
.............
13
Investments—other (attach schedule)
..........
3,088,027
3,090,323
3,090,323
14
Land, buildings, and equipment: basis
Less: accumulated depreciation (attach schedule)
15
Other assets (describe
)
6,476
6,003
6,003
16
Total assets
(to be completed by all filers—see the
instructions. Also, see page 1, item I)
5,347,416
5,559,656
5,559,656
17
Accounts payable and accrued expenses
..........
4,426
9,830
18
Grants payable
.................
19
Deferred revenue
.................
20
Loans from officers, directors, trustees, and other disqualified persons
21
Mortgages and other notes payable (attach schedule)
......
22
Other liabilities (describe
)
263
-337
23
Total liabilities
(add lines 17 through 22)
.........
4,689
9,493
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
5,342,727
5,550,163
29
Total net assets or fund balances
(see instructions)
.....
5,342,727
5,550,163
30
Total liabilities and net assets/fund balances
(see instructions)
.
5,347,416
5,559,656
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
5,342,727
2
Enter amount from Part I, line 27a
.....................
2
205,141
3
Other increases not included in line 2 (itemize)
3
2,295
4
Add lines 1, 2, and 3
..........................
4
5,550,163
5
Decreases not included in line 2 (itemize)
5
0
6
Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 29
.
6
5,550,163
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.)
1a
b
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
b
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
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
1,415,458
2,363,178
0.598964
2017
683,345
3,717,063
0.183840
2016
428,760
3,685,854
0.116326
2015
401,872
4,139,203
0.097089
2014
463,269
4,829,509
0.095925
2
Total
of line 1, column (d)
.....................
2
1.092144
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
0.218429
4
Enter the net value of noncharitable-use assets for 2019 from Part X, line 5
......
4
5,250,160
5
Multiply line 4 by line 3
......................
5
1,146,787
6
Enter 1% of net investment income (1% of Part I, line 27b)
...........
6
897
7
Add lines 5 and 6
........................
7
1,147,684
8
Enter qualifying distributions from Part XII, line 4
,.............
8
1,784,580
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
897
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
897
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
897
6
Credits/Payments:
a
2019 estimated tax payments and 2018 overpayment credited to 2019
6a
137
b
Exempt foreign organizations—tax withheld at source
......
6b
c
Tax paid with application for extension of time to file (Form 8868)
...
6c
1,000
d
Backup withholding erroneously withheld
...........
6d
0
7
Total credits and payments. Add lines 6a through 6d
..............
7
1,137
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
240
11
Enter the amount of line 10 to be:
Credited to 2020 estimated tax
240
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
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)
OR
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.PACIFICSOURCE.COM
14
The books are in care of
PETER DAVIDSON
Telephone no.
(541) 686-1242
Located at
PO BOX 7068
SPRINGFIELD
OR
ZIP+4
97475
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
KENNETH PROVENCHER
DIRECTOR
1.00
0
0
0
PO BOX 7068
SPRINGFIELD
,
OR
97475
STEVEN MARKS
DIRECTOR
1.00
0
0
0
PO BOX 7068
SPRINGFIELD
,
OR
97475
TOM SLICK
TREASURER
1.00
0
0
0
PO BOX 7068
SPRINGFIELD
,
OR
97475
ED DAHLBERG
DIRECTOR
1.00
0
0
0
PO BOX 7068
SPRINGFIELD
,
OR
97475
CLARK COMPTON
VICE PRESIDENT, SECRETARY
1.00
0
0
0
PO BOX 7068
SPRINGFIELD
,
OR
97475
JOHN DEWENTER
DIRECTOR
1.00
0
0
0
PO BOX 7068
SPRINGFIELD
,
OR
97475
MARIAN BLANKENSHIP
EXECUTIVE DIRECTOR
10.00
0
0
0
PO BOX 7068
SPRINGFIELD
,
OR
97475
MARTIN GABICA
DIRECTOR
1.00
0
0
0
PO BOX 7068
SPRINGFIELD
,
OR
97475
PRISCILLA GOULD
PRESIDENT, CHAIR
1.00
0
0
0
PO BOX 7068
SPRINGFIELD
,
OR
97475
PETER DAVIDSON
DIRECTOR/CORPORATE TAX OFFICER
1.00
0
0
0
PO BOX 7068
SPRINGFIELD
,
OR
97475
VANETTA ABDELLATIF
DIRECTOR
1.00
0
0
0
PO BOX 7068
SPRINGFIELD
,
OR
97475
KEN SINGER
DIRECTOR
1.00
0
0
0
PO BOX 7068
SPRINGFIELD
,
OR
97475
2
Compensation of five highest-paid employees (other than those included on line 1—see instructions). If none, enter “NONE."
(a)
Name and address of each employee paid more than $50,000
(b)
Title, and average
hours per week
devoted to position
(c)
Compensation
(d)
Contributions to
employee benefit
plans and deferred
compensation
(e)
Expense account,
other allowances
NONE
Total
number of other employees paid over $50,000
...................
0
Form
990-PF
(2019)
Form 990-PF (2019)
Page
7
Part VIII
Information About Officers, Directors, Trustees, Foundation Managers, Highly Paid Employees,
and Contractors
(continued)
3
Five highest-paid independent contractors for professional services (see instructions). If none, enter "NONE".
(a)
Name and address of each person paid more than $50,000
(b)
Type of service
(c)
Compensation
NONE
Total
number of others receiving over $50,000 for professional services
.............
0
Part IX-A
Summary of Direct Charitable Activities
List the foundation’s four largest direct charitable activities during the tax year. Include relevant statistical information such as the number of organizations and other beneficiaries served, conferences convened, research papers produced, etc.
Expenses
1
2
3
4
Part IX-B
Summary of Program-Related Investments
(see instructions)
Describe the two largest program-related investments made by the foundation during the tax year on lines 1 and 2.
Amount
1
2
All other program-related investments. See instructions.
3
Total.
Add lines 1 through 3
.........................
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
3,088,854
b
Average of monthly cash balances
.......................
1b
2,241,258
c
Fair market value of all other assets (see instructions)
................
1c
0
d
Total
(add lines 1a, b, and c)
.........................
1d
5,330,112
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
5,330,112
4
Cash deemed held for charitable activities. Enter 1 1/2% of line 3 (for greater amount, see
instructions)
.............................
4
79,952
5
Net value of noncharitable-use assets.
Subtract line 4 from line 3. Enter here and on Part V, line 4
5
5,250,160
6
Minimum investment return.
Enter 5% of line 5
..................
6
262,508
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
262,508
2a
Tax on investment income for 2019 from Part VI, line 5
......
2a
897
b
Income tax for 2019. (This does not include the tax from Part VI.)
...
2b
c
Add lines 2a and 2b
............................
2c
897
3
Distributable amount before adjustments. Subtract line 2c from line 1
............
3
261,611
4
Recoveries of amounts treated as qualifying distributions
................
4
0
5
Add lines 3 and 4
............................
5
261,611
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
261,611
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
1,784,580
b
Program-related investments—total from Part IX-B
..................
1b
0
2
Amounts paid to acquire assets used (or held for use) directly in carrying out charitable, etc.,
purposes
...............................
2
3
Amounts set aside for specific charitable projects that satisfy the:
a
Suitability test (prior IRS approval required)
....................
3a
b
Cash distribution test (attach the required schedule)
.................
3b
4
Qualifying distributions.
Add lines 1a through 3b. Enter here and on Part V, line 8, and Part XIII, line 4
4
1,784,580
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
897
6
Adjusted qualifying distributions.
Subtract line 5 from line 4
..............
6
1,783,683
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
261,611
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
......
221,805
b
From 2015
......
194,965
c
From 2016
......
244,662
d
From 2017
......
498,008
e
From 2018
......
1,298,637
f
Total
of lines 3a through e
........
2,458,077
4
Qualifying distributions for 2019 from Part
XII, line 4:
$
1,784,580
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
.....
261,611
e
Remaining amount distributed out of corpus
1,522,969
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
3,981,046
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)
...
221,805
9
Excess distributions carryover to 2020.
Subtract lines 7 and 8 from line 6a
......
3,759,241
10
Analysis of line 9:
a
Excess from 2015
....
194,965
b
Excess from 2016
....
244,662
c
Excess from 2017
....
498,008
d
Excess from 2018
....
1,298,637
e
Excess from 2019
....
1,522,969
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:
MARIAN BLANKENSHIP EXECUTIVE DIRECT
PO BOX 7068
SPRINGFIELD
,
OR
97475
(541) 686-1242
CHARITABLEFOUNDATION@PACIFICSOURCE.COM
b
The form in which applications should be submitted and information and materials they should include:
MICROSOFT WORD DOCUMENT. ATTACH PROGRAM BUDGET AND MOST RECENT ANNUAL FINANCIAL STATEMENT.
c
Any submission deadlines:
SUBMISSION DEADLINES ARE ROLLING. THE COMMITTEE MEETS SEMI-ANNUALLY TO REVIEW APPLICATIONS.
d
Any restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other
factors:
PROGRAMS MUST ADDRESS ONE OR MORE OF THE FOLLOWING AREAS: HEALTH CARE ACCESS INITIATIVES THAT ADDRESS THE HEALTHCARE NEEDS OF CHILDREN AND YOUTH, AS WELL AS ADULTS WHO HAVE BARRIERS TO CARE AND/OR ADVANCE AND PROMOTE STRATEGIES THAT: IMPROVE ACCESS TO HIGH QUALITY HEALTHCARE, TEST AND IMPLEMENT INNOVATIVE CARE MODELS, IMPROVE COMMUNITY HEALTH, AND/OR LOWER COSTS ACROSS THE SYSTEM AND/OR WORK IN PARTNERSHIP WITH PACIFICSOURCE HEALTH PLANS AND ITS MANY BUSINESS PARTNERS AND CUSTOMERS, INCLUDING PHYSICIANS AND OTHER HEALTHCARE PROVIDERS, TO IMPROVE COMMUNITY HEALTH.
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
ADELANTE MUJERES
2030 MAIN ST SUITE A
FOREST GROVE
,
OR
97116
NONE
PC
BUILDING HEALTH EQUITY IN WASHINGTON COUNTY, OR FOR THE LATINO COMMUNITY.
15,000
BETHEL SCHOOL DISTRICT
4640 BARGER DRIVE
EUGENE
,
OR
97402
NONE
GOV
PRODUCE STIPEND FOR HEALTHY SCHOOLS CHALLENGE
2,500
BETHEL STUDENT HEALTH CENTER
1525 ECHO HOLLOW RD SUITE A
EUGENE
,
OR
97402
NONE
GOV
MENTAL HEALTH PROGRAM
22,000
BOISE RESCUE MISSION
PO BOX 1494
BOISE
,
ID
83701
NONE
PC
PROVIDING HOMELESS INDIVIDUALS WITH ACCESS TO FREE, QUALITY, MENTAL HEALTHCARE SERVICES AND CASE MANAGEMENT.
40,000
BOYS AND GIRLS CLUB CORVALLIS
1112 NW CIRCLE BLVD
CORVALLIS
,
OR
97330
NONE
PC
HEALTHY LIFESTYLES EXPANSION
15,000
BOYS AND GIRLS CLUB OF ALBANY
1215 HILL STREET SE
ALBANY
,
OR
97322
NONE
PC
IMPROVE ACCESS TO HEALTH CARE FOR VULNERABLE AND UNDERSERVED POPULATIONS.
8,000
CANYON COUNTY COMMUNITY CLINIC
524 CLEVELAND BLVD SUITE 110
CALDWELL
,
ID
83605
NONE
PC
PROVIDING MEDICAL SERVICES TO THE UNDERSERVED.
25,000
CASCADE MIDDLE SCHOOL
1525 ECHO HOLLOW RD
EUGENE
,
OR
97402
NONE
GOV
HEALTHY LIFE SCHOOLS CHALLENGE AWARD
300
CATHOLIC COMMUNITY SERVICES OF THE MID-WILLAMETTE VALLEY AND CENTRAL COAST
PO BOX 20400
SALEM
,
OR
97307
NONE
PC
COMMUNITY INITIATIVE TO ENSURE SAFETY AND HEALTH OF CHILDREN IN HIGH NEED NEIGHBORHOODS.
175,000
CENTER FOR COMMUNITY COUNSELING
1465 COBURG RD
EUGENE
,
OR
97401
NONE
PC
PROVIDE MENTAL HEALTH COUNSELING FOR THOSE WITH LIMITED INCOME, UNDERINSURED, OR LACKING HEALTH INSURANCE.
35,000
CENTRAL CITY CONCERN
232 NW 6TH AVE
PORTLAND
,
OR
97209
NONE
PC
FUNDING TO OPEN HANSEN SHELTER URGENT CARE CLINIC
16,000
CENTRAL POINT SCHOOL DISTRICT #6
300 ASH ST
CENTRAL POINT
,
OR
97502
NONE
GOV
BUILDING HEALTHY FAMILIES - A SCHOOL BASED HEALTH CENTER AT HANBY MIDDLE SCHOOL
15,000
CHILDREN'S HOME SOCIETY OF IDAHO
740 WARM SPRINGS AVE
BOISE
,
ID
83712
NONE
PC
PROVIDE MENTAL HEALTH SERVICES FOR KIDS ON MEDICAID.
15,000
CLACKAMAS VOLUNTEERS IN MEDICINE
700 MOLALLA AVENUE
OREGON CITY
,
OR
97045
NONE
PC
CLINIC COORDINATION TO SUPPORT PATIENT PROGRAMS SERVING CLACKAMAS COUNTY'S LOW-INCOME RESIDENTS
30,000
COMMUNITY OUTREACH
865 REIMAN AVE
CORVALLIS
,
OR
97730
NONE
PC
PROVIDE MEDICAL SERVICES UNINSURED, LOW INCOME, OR NEWLY INSURED ADULTS.
30,000
COMPASS HOUSE INC
37 N IVY ST
MEDFORD
,
OR
97501
NONE
PC
PROMOTE NON-CLINICAL MENTAL HEALTH SUPPORT PROJECT FOR VULNERABLE POPULATIONS IN SOUTHERN OREGON.
10,000
CORNERSTONE COMMUNITY HOUSING
PO BOX 11923
EUGENE
,
OR
97440
NONE
PC
EXPAND AND DEVELOP WELLNESS PROGRAM TARGETED TO LOW-INCOME HOUSEHOLDS IN AFFORDABLE HOUSING COMMUNITY CENTERS ACROSS LANE COUNTY.
25,000
DAISY CHAIN
PO BOX 10375
EUGENE
,
OR
97440
NONE
PC
INCREASE EQUITABLE ACCESS TO PREVENTATIVE PRE AND POST-NATAL PROGRAMS IN LANE COUNTY.
25,000
FAIRFIELD ELMENTARY SCHOOL
3455 ROYAL AVE
EUGENE
,
OR
97407
NONE
GOV
HEALTHY SCHOOLS CHALLENGE GRANT
1,000
FAMILIAS EN ACCION
2710 NE 14TH AVE
PORTLAND
,
OR
97212
NONE
PC
PROMOTE HOLISTIC FAMILY WELL-BEING FOR LATINOS
58,500
FAMILY ADVOCATES
3010 WEST STATE STREET
BOISE
,
ID
83703
NONE
PC
MITIGATING ADVERSE CHILDHOOD EXPERIENCES TO STRENGTHEN FAMILIES AND PROMOTE HEALTH.
30,000
FARMERS MARKET FUND
240 N BROADWAY SUITE 129
PORTLAND
,
OR
97227
NONE
PC
DOUBLE UP FOOD BUCKS FOR SNAP
10,000
FREE CLINIC OF SOUTHWEST WASHINGTON
4100 PLOMONDON STREET
VANCOUVER
,
WA
98661
NONE
PC
PROVIDING FREE HEALTHCARE WITH A FOCUS ON DIABETIC PATIENTS.
30,000
GENESIS COMMUNITY HEALTH
215 W 35TH ST
GARDEN CITY
,
ID
83714
NONE
PC
PROVIDE TRANSITIONAL PRIMARY HEALTHCARE, SOCIAL AND SPIRITUAL SUPPORT TO LOW-INCOME UNINSURED INDIVIDUALS IN IDAHO'S TREASURE VALLEY.
35,000
HEALTHY BEGINNINGS
1029 NW 14TH STREET
BEND
,
OR
97703
NONE
PC
HEALTH, DEVELOPMENT, AND BEHAVIORAL SCREENING TO CHILDREN IN CENTRAL OREGON UNDER AGE 5.
10,000
HEALTHY MOVES
115 W 8TH AVE STE 216
EUGENE
,
OR
97401
NONE
PC
EXPANSION OF FREE PHYSICAL EDUCATION AND PROFESSIONAL DEVELOPMENT PROGRAM FOR TEACHERS IN LANE COUNTY TO K-8 STUDENTS.
10,000
HIV ALLIANCE
1195A CITY VIEW
EUGENE
,
OR
97403
NONE
PC
STI TESTING AND OPIOID RESPONSE FOR HIGH RISK MEMBERS OF SUBURBAN AND RURAL WESTERN OREGON.
25,000
IDAHO HUNGER RELIEF TASK FORCE
963 S ORCHARD ST
BOISE
,
ID
83705
NONE
PC
IMPROVE HEALTH, WELLNESS, AND FOOD SECURITY OF 120 PATIENT HOUSEHOLDS BY INCREASING ACCESS TO FRESH FRUITS & VEGETABLES.
35,000
INTERLINK VOLUNTEER CAREGIVERS
650 ADDISON AVE WEST SUITE 201
TWIN FALLS
,
ID
83301
NONE
PC
FUNDING "ACCESS TO HEALTHCARE" MEDICAL TRANSPORTATION PROGRAM FOR SENIOR CITIZENS.
7,749
LEGACY HEALTH FOUNDATION
PO BOX 4484
PORTLAND
,
OR
97208
NONE
PC
UNITY CENTER PEER SUPPORT PROGRAM
100,000
LOOKING GLASS COMMUNITY SERVICES
1790 W 11TH AVE SUITE 200
EUGENE
,
OR
97402
NONE
PC
FUND REGIONAL CRISIS CENTER, A PSYCHIATRIC RESIDENTIAL FACILITY PROVIDING PSYCHIATRIC RESIDENTIAL CARE TO VULNERABLE AND DIFFICULT YOUTH.
50,000
MEDICAL TEAMS INTERNATIONAL
14150 SW MILTON CT
TIGARD
,
OR
97224
NONE
PC
DENTAL CARE FOR RURAL COUNTIES IN OREGON.
25,000
MENTAL HEALTH AMERICA OF MONTANA
PO BOX 88
BOZEMAN
,
MT
59771
NONE
PC
PROVIDE ACCESS TO RECOVERY ORIENTED TELEPHONIC AND SOCIAL MEDIA TOOLS TO PROVIDE SUPPORT, EDUCATION, AND GUIDANCE FOR YOUNG ADULTS.
30,000
MISSOULA AGING SERVICES
337 STEPHENS AVE
MISSOULA
,
MT
59808
NONE
PC
SERVING HIGHEST RISK COMMUNITY MEMBERS AND CONNECTING THEM TO COMMUNITY SERVICES, AS WELL AS CARE TRANSITION PROGRAM SERVICES.
25,000
MORRISON CHILD AND FAMILY SERVICES
11035 NE SANDY BLVD
PORTLAND
,
OR
97220
NONE
PC
FUNDING FOR ROTARY YOUTH CENTER.
100,000
MOUNTAIN HOME MONTANA
2606 SOUTH AVE W
MISSOULA
,
MT
59804
NONE
PC
ACCESS TO TRAUMA-INFORMED MENTAL HEALTHCARE FOR YOUNG FAMILIES AT MOUNTAIN HOME.
30,000
NAMI LANE COUNTY
2411 MARTIN LUTHER KING JR BLVD
EUGENE
,
OR
97401
NONE
PC
PROMOTE MENTAL HEALTH SUPPORT PROGRAMMING IN HISTORICALLY UNDERSERVED RURAL COMMUNITIES.
20,000
NORTH BY NORTHEAST COMMUNITY HEALTH CENTER
714 NE ALBERTA ST
PORTLAND
,
OR
97211
NONE
PC
PROVIDE INCREASED EQUITY IN ACCESS TO HEALTHCARE AND EQUITY IN HEALTHCARE OUTCOMES FOR AFRICAN AMERICAN COMMUNITY MEMBERS.
30,000
NORTHWEST CATHOLIC COUNSELING
8383 NW SANDY BLVD 205
PORTLAND
,
OR
97220
NONE
PC
MENTAL HEALTH CARE FOR LOWER INCOME OLDER WOMEN
10,000
OLD MILL CENTER FOR CHILDREN AND FAMILIES
1650 SW 45TH PLACE
CORVALLIS
,
OR
97333
NONE
PC
TRAUMA INFORMED CARE TRAINING AND SUPPORT FOR COMMUNITY ORGANIZATIONS
20,000
OPHELIAS PLACE
1577 PEARL STREET SUITE 100
EUGENE
,
OR
97401
NONE
PC
FUND GIRLS TRAUMA INTERVENTION AND BEHAVIORAL HEALTH EMPOWERMENT PROGRAM.
30,000
OSLC DEVELOPMENTS INC
10 SHELTON MCMURPHEY BLVD
EUGENE
,
OR
97401
NONE
PC
HEALTHY DEVELOPMENT OF CHILDREN AND FAMILIES
30,000
PARENTING NOW
86 CENTENNIAL LOOP
EUGENE
,
OR
97401
NONE
PC
FUND PARENTAL EDUCATIONAL PROGRAM FOR VULNERABLE FAMILIES.
25,000
PLANNED PARENTHOOD OF MONTANA
1116 GRAND AVE SUITE 201
BILLINGS
,
MT
59102
NONE
PC
PROVIDE QUALITY HEALTHCARE, MEDICAL EDUCATION, AND ADVOCACY FOR INDIVIDUAL RIGHTS.
35,000
PORTLAND STREET MEDICINE
825 NW MULTNOMAH STREET SUITE 240
PORTLAND
,
OR
97232
NONE
PC
FUNDING TO IMPROVE HEALTHCARE OF HOMELESS PEOPLE IN OREGON.
30,000
PROJECT ACCESS NOW
PO BOX 10953
PORTLAND
,
OR
97296
NONE
PC
COORDINATE CARE FOR THE REGIONAL COMMUNITY HEALTH NETWORK
40,000
RETURNING VETERANS PROJECT
883 SE MAIN ST
PORTLAND
,
OR
97214
NONE
PC
FREE AND CONFIDENTIAL MEDICAL SERVICES FOR RETURNING VETERANS AND SERVICE MEMBERS.
10,000
RIVERBEND ELEMENTARY SCHOOL
320 51ST ST
SPRINGFIELD
,
OR
97478
NONE
GOV
HEALTHY LIFE SCHOOLS CHALLENGE AWARD
300
RONAN SCHOOL DISTRICT
421 ANDREW ST NW
RONAN
,
MT
59864
NONE
GOV
FUNDING COMPLETION OF RONAN HIGH SCHOOL NATIVE PLANT GARDEN TO CONNECT CULTURE/GOALS OF STUDENTS' HOMES TO THE SCHOOL.
5,000
SALEM FREE CLINICS
1300 BROADWAY ST NE SUITE 104
SALEM
,
OR
97301
NONE
PC
COMPREHENSIVE HEALTH SERVICES TO THE UNINSURED AND UNDERINSURED.
40,000
SHARE OUR STRENGTHS INC
2401 COLONIAL DR 3RD FL
HELENA
,
MT
59601
NONE
PC
IMPROVING FOOD ACCESS AND NUTRITION IN ORDER TO END CHILDHOOD HUNGER IN MONTANA.
25,000
SHASTA MIDDLE SCHOOL
4656 BARGER DR
EUGENE
,
OR
97402
NONE
GOV
HEALTHY LIFE SCHOOLS CHALLENGE AWARD
1,000
SNAKE RIVER COMMUNITY CLINIC
215 10TH ST
LEWISTON
,
ID
83501
NONE
PC
PROVIDE ACUTE CARE TO THE HOMELESS.
40,000
SOUTH LANE MENTAL HEALTH
1345 BIRCH AVE
COTTAGE GROVE
,
OR
97424
NONE
PC
PROVIDE CARE TO COTTAGE GROVE ADULT AND CHILDREN'S OUTPATIENT MENTAL HEALTH SERVICES.
30,000
SPOON
135 SE MAIN ST SUITE 201
PORTLAND
,
OR
97214
NONE
PC
SUPPORT FOSTER FAMILIES WITH RESOURCES SUPPORTING COMPLEX NUTRITIONAL AND FEEDING NEEDS OF CHILDREN IN FOSTER CARE.
25,000
SPRINGFIELD HIGH SCHOOL
875 7TH STREET
SPRINGFIELD
,
OR
97477
NONE
GOV
HEALTHY LIFE SCHOOLS CHALLENGE AWARD
300
SPRINGFIELD SCHOOL DISTRICT
525 MILL ST
SPRINGFIELD
,
OR
97477
NONE
GOV
PRODUCE STIPEND FOR HEALTHY SCHOOLS CHALLENGE
3,000
THE WALLACE MEDICAL CONCERN
124 NE 188TH AVE SUITE 103
PORTLAND
,
OR
97230
NONE
PC
PROVIDE ACCESS TO CARE AND INNOVATIONS TO YOUTH AND ADULTS WITH BARRIERS TO CARE.
10,000
UNITED WAY OF DESCHUTES COUNTY
1130 NW HARRIMAN ST UNIT A
BEND
,
OR
97703
NONE
PC
FUNDING FOR TRAUMA, RESILIENCE, AND ADVERSE CHILDHOOD EXPERIENCES PROGRAM.
10,000
UNITED WAY OF THE COLUMBIA - WILLAMETTE
619 SW 11TH AVE
PORTLAND
,
OR
97205
NONE
PC
FUND CENSUS EQUITY FUNDERS COMMITTEE COORDINATION OF EQUITABLE CENSUS 2020 COUNT.
50,000
VOLUNTEERS IN MEDICINE CLINIC OF THE CASCADES
2300 NW NEFF RD
BEND
,
OR
97701
NONE
PC
OUTREACH, REFERRAL, ACUTE CARE, AND ONGOING HEALTHCARE TO FOR UNINSURED OR UNINSURED WORKERS.
40,000
VOLUNTEERS IN MEDICINE
2260 MARCOLA RD
SPRINGFIELD
,
OR
97477
NONE
PC
OUTREACH, REFERRAL, ACUTE CARE, AND ONGOING HEALTHCARE TO FOR UNINSURED OR UNINSURED WORKERS.
40,000
WELLMAMA INC
150 SHELTON MCMURPHEY BLVD SUITE
208
EUGENE
,
OR
97401
NONE
PC
PROVIDE PREGNANCY AND POSTPARTUM MENTAL HEALTH SUPPORT SERVICES TO WOMEN AND THEIR FAMILIES IN LANE COUNTY.
10,000
WILLAMETTE HIGH SCHOOL
1801 ECHO HOLLOW ROAD
EUGENE
,
OR
97402
NONE
GOV
HEALTHY LIFE SCHOOLS CHALLENGE AWARD
1,000
WOMENS AND CHILDRENS ALLIANCE INC
720 W WASHINGTON ST
BOISE
,
ID
83702
NONE
PC
SERVING CHILD VICTIMS OF DOMESTIC VIOLENCE THROUGH INDIVIDUAL COUNSELING.
20,000
YOUTH HOMES
550 N CALIFORNIA STREET
MISSOULA
,
MT
59801
NONE
PC
PROVIDE COMMUNITY BASED MENTAL HEALTH SERVICES FOR WESTERN MONTANA FAMILIES.
25,000
Total
.................................
3a
1,771,649
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
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
63,728
4
Dividends and interest from securities
....
14
32,994
5
Net rental income or (loss) from real estate:
a
Debt-financed property
......
b
Not debt-financed property
.....
6
Net rental income or (loss) from personal property
7
Other investment income
.....
8
Gain or (loss) from sales of assets other than
inventory
............
9
Net income or (loss) from special events:
10
Gross profit or (loss) from sales of inventory
11
Other revenue:
a
b
c
d
e
12
Subtotal. Add columns (b), (d), and (e)
..
0
96,722
0
13
Total.
Add line 12, columns (b), (d), and (e)
..................
13
96,722
(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
PACIFIC HEALTH ASSOCIATES
501(C)(4)
ORGANIZATIONS SHARE PARTIAL BOARD OVERLAP; PSFHI RECEIVES ANNUAL RESTRICTED GRANT FUNDS FROM PHA.
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