Form990-PF
Click to see attachment

Department of the Treasury
Internal Revenue Service

Return of Private Foundation
or Section 4947(a)(1) Trust Treated as Private Foundation
bulletDo not enter social security numbers on this form as it may be made public.
bulletGo to www.irs.gov/Form990PF for instructions and the latest information.
OMB No. 1545-0052
2020
Open to Public Inspection
For calendar year 2020, or tax year beginning 01-01-2020 , and ending 12-31-2020
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, OR974750068
A Employer identification number

93-1100080
B Telephone number (see instructions)

(541) 686-1242
C bullet
G Check all that apply:

D 1. Foreign organizations, check here............. bullet
2. Foreign organizations meeting the 85%
test, check here and attach computation ... bullet
E bullet
H Check type of organization:
F bullet
I Fair market value of all assets at end
of year (from Part II, col. (c),
line 16)bullet$3,845,416J Accounting method:
 
(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)
Revenue 1 Contributions, gifts, grants, etc., received (attach schedule) 1,900,000
2 Check bullet.............
3 Interest on savings and temporary cash investments 54,853 54,853  
4 Dividends and interest from securities...      
5a Gross rents............      
b Net rental income or (loss)  
6a Net gain or (loss) from sale of assets not on line 10 -203,045
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........ 1,751,808 54,853  
Operating and Administrative Expenses 13 Compensation of officers, directors, trustees, etc. 32,375 1,619   30,756
14 Other employee salaries and wages......        
15 Pension plans, employee benefits.......        
16a Legal fees (attach schedule)......... Click to see attachment 196 98   98
b Accounting fees (attach schedule)....... Click to see attachment 471 235   235
c Other professional fees (attach schedule)....        
17 Interest...............        
18 Taxes (attach schedule) (see instructions)... Click to see attachment 955 478   478
19 Depreciation (attach schedule) and depletion...      
20 Occupancy..............        
21 Travel, conferences, and meetings....... 54 27   27
22 Printing and publications..........        
23 Other expenses (attach schedule)....... Click to see attachment 8,046 3,958   4,088
24 Total operating and administrative expenses.
Add lines 13 through 23.......... 42,097 6,415   35,682
25 Contributions, gifts, grants paid....... 3,625,250 3,625,250
26 Total expenses and disbursements. Add lines 24 and 25 3,667,347 6,415   3,660,932
27 Subtract line 26 from line 12:
a Excess of revenue over expenses and disbursements -1,915,539
b Net investment income (if negative, enter -0-) 48,438
c Adjusted net income (if negative, enter -0-)...  
For Paperwork Reduction Act Notice, see instructions.
Cat. No. 11289X Form 990-PF (2020)
Form 990-PF (2020)
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
Assets 1 Cash—non-interest-bearing.............      
2 Savings and temporary cash investments......... 2,463,330 834,528 834,528
3 Accounts receivable bullet  
Less: allowance for doubtful accounts bullet        
4 Pledges receivable bullet  
Less: allowance for doubtful accounts bullet        
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) bullet  
Less: allowance for doubtful accounts bullet        
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 bullet  
Less: accumulated depreciation (attach schedule) bullet        
12 Investments—mortgage loans.............      
13 Investments—other (attach schedule).......... 3,090,323 Click to see attachment3,008,991 3,008,991
14 Land, buildings, and equipment: basis bullet  
Less: accumulated depreciation (attach schedule) bullet        
15 Other assets (describe bullet) Click to see attachment6,003 Click to see attachment1,897 Click to see attachment1,897
16 Total assets (to be completed by all filers—see the
instructions. Also, see page 1, item I) 5,559,656 3,845,416 3,845,416
Liabilities 17 Accounts payable and accrued expenses.......... 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 bullet) Click to see attachment-337 Click to see attachment-1,337
23 Total liabilities (add lines 17 through 22)......... 9,493 -1,337
Net Assets or Fund Balances Foundations that follow FASB ASC 958, check here bullet
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 bullet
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 5,550,163 3,846,753
29 Total net assets or fund balances (see instructions)..... 5,550,163 3,846,753
30 Total liabilities and net assets/fund balances (see instructions). 5,559,656 3,845,416
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
5,550,163
2
Enter amount from Part I, line 27a .....................
2
-1,915,539
3
Other increases not included in line 2 (itemize) bulletClick to see attachment
3
212,129
4
Add lines 1, 2, and 3 ..........................
4
3,846,753
5
Decreases not included in line 2 (itemize) bullet
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
3,846,753
Form 990-PF (2020)
Form 990-PF (2020)
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 PUBLICLY TRADED SECURITIES P    
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       -203,045
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       -203,045
b
c
d
e
2 Capital gain net income or (net capital loss) Bracket If gain, also enter in Part I, line 7
If (loss), enter -0- in Part I, line 7		 Bracket 2 -203,045
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 ................... 		Bracket 3  
Part V
Qualification Under Section 4940(e) for Reduced Tax on Net Investment Income
SECTION 4940(e) REPEALED ON DECEMBER 20, 2019 - DO NOT COMPLETE
1 Reserved
(a)
Reserved 		(b)
Reserved 		(c)
Reserved 		(d)
Reserved
2
Reserved...........................
2
3
Reserved...........................
3
4
Reserved...........................
4
5
Reserved...........................
5
6
Reserved...........................
6
7
Reserved...........................
7
8
Reserved,..........................
8
Form 990-PF (2020)
Form 990-PF (2020)
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 Bullet and enter “N/A" on line 1. Bracket for line 1a
Date of ruling or determination letter:   (attach copy of letter if necessary–see instructions)
b Reserved................................ 1 673
c All other domestic foundations enter 1.39% 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........................... 3 673
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- ..... 5 673
6 Credits/Payments:
a 2020 estimated tax payments and 2019 overpayment credited to 2020 6a 240
b Exempt foreign organizations—tax withheld at source...... 6b 0
c Tax paid with application for extension of time to file (Form 8868)... 6c 0
d Backup withholding erroneously withheld ........... 6d 0
7 Total credits and payments. Add lines 6a through 6d.............. 7 240
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.......Bullet 9 433
10 Overpayment. If line 7 is more than the total of lines 5 and 8, enter the amount overpaid...Bullet 10  
11 Enter the amount of line 10 to be: Credited to 2021 estimated taxBullet   RefundedBullet 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 the instructions
for the 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. bullet$ 0(2) On foundation managers.bullet$ 0
e
Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed
on foundation managers.bullet$ 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)
    bulletOR
    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 2020 or the taxable year beginning in 2020? 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 (2020)
    Form 990-PF (2020)
    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 addressbulletWWW.PACIFICSOURCE.COM/COMMUNITY/FOUNDATION
    14
    The books are in care ofbulletPETER DAVIDSON Telephone no.bullet (541) 686-1242

    Located atbulletPO BOX 7068SPRINGFIELDOR ZIP+4bullet97475
    15
    Section 4947(a)(1) nonexempt charitable trusts filing Form 990-PF in lieu of Form 1041 —check here .........bullet
    and enter the amount of tax-exempt interest received or accrued during the year ........bullet
    15
     
    16 At any time during calendar year 2020, did the foundation have an interest in or a signature or other authority over YesNo
    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 bullet
    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?
    (2) Borrow money from, lend money to, or otherwise extend credit to (or accept it from)
    a disqualified person?......................
    (3) Furnish goods, services, or facilities to (or accept them from) a disqualified person?
    (4) Pay compensation to, or pay or reimburse the expenses of, a disqualified person?
    (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)?...............
    (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.).......
    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
    ........bullet
    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 2020?.............
    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 2020, did the foundation have any undistributed income (lines 6d
    and 6e, Part XIII) for tax year(s) beginning before 2020?.............
    If "Yes," list the years bullet20, 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.
    bullet20, 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?......................
    b
    If "Yes," did it have excess business holdings in 2020 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 2020.)..................
    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 2020?
    4b
     
    No
    Form 990-PF (2020)
    Form 990-PF (2020)
    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))?
    (2) Influence the outcome of any specific public election (see section 4955); or to carry
    on, directly or indirectly, any voter registration drive?.............
    (3) Provide a grant to an individual for travel, study, or other similar purposes?
    (4) Provide a grant to an organization other than a charitable, etc., organization described
    in section 4945(d)(4)(A)? See instructions................
    (5) Provide for any purpose other than religious, charitable, scientific, literary, or
    educational purposes, or for the prevention of cruelty to children or animals?.....
    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
     
     
    .........bullet
    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?..........
    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?.....................
    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?
    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? .................
    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
    PRISCILLA GOULD PRESIDENT, CHAIR
    1.00     		7,000 0 0
    PO BOX 7068
    SPRINGFIELD,OR97475
    CLARK COMPTON VICE PRESIDENT, SECRETARY
    1.00     		3,500 0 0
    PO BOX 7068
    SPRINGFIELD,OR97475
    TOM SLICK TREASURER
    1.00     		3,500 0 0
    PO BOX 7068
    SPRINGFIELD,OR97475
    PETER DAVIDSON DIRECTOR/CORPORATE TAX OFFICER
    1.00     		0 0 0
    PO BOX 7068
    SPRINGFIELD,OR97475
    VANETTA ABDELLATIF DIRECTOR
    1.00     		875 0 0
    PO BOX 7068
    SPRINGFIELD,OR97475
    ED DAHLBERG DIRECTOR
    1.00     		3,500 0 0
    PO BOX 7068
    SPRINGFIELD,OR97475
    JOHN DEWENTER DIRECTOR
    1.00     		3,500 0 0
    PO BOX 7068
    SPRINGFIELD,OR97475
    MARTIN GABICA DIRECTOR
    1.00     		3,500 0 0
    PO BOX 7068
    SPRINGFIELD,OR97475
    STEVEN MARKS DIRECTOR
    1.00     		3,500 0 0
    PO BOX 7068
    SPRINGFIELD,OR97475
    KENNETH PROVENCHER DIRECTOR
    1.00     		0 0 0
    PO BOX 7068
    SPRINGFIELD,OR97475
    KEN SINGER DIRECTOR
    1.00     		3,500 0 0
    PO BOX 7068
    SPRINGFIELD,OR97475
    MARIAN BLANKENSHIP EXECUTIVE DIRECTOR
    10.00     		0 0 0
    PO BOX 7068
    SPRINGFIELD,OR97475
    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...................bullet 0
    Form 990-PF (2020)
    Form 990-PF (2020)
    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.............bullet0
    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.........................bullet0
    Form 990-PF (2020)
    Form 990-PF (2020)
    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
    3,008,991
    b
    Average of monthly cash balances.......................
    1b
    1,947,076
    c
    Fair market value of all other assets (see instructions)................
    1c
    1,897
    d
    Total (add lines 1a, b, and c).........................
    1d
    4,957,964
    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
    4,957,964
    4
    Cash deemed held for charitable activities. Enter 1 1/2% of line 3 (for greater amount, see
    instructions) .............................
    4
    74,369
    5
    Net value of noncharitable-use assets. Subtract line 4 from line 3. Enter here and on Part V, line 4
    5
    4,883,595
    6
    Minimum investment return. Enter 5% of line 5..................
    6
    244,180
    Part XI
    Distributable Amount (see instructions) (Section 4942(j)(3) and (j)(5) private operating foundations and certain foreign organizations check here right arrow and do not complete this part.)
    1
    Minimum investment return from Part X, line 6....................
    1
    244,180
    2a
    Tax on investment income for 2020 from Part VI, line 5......
    2a
    673
    b
    Income tax for 2020. (This does not include the tax from Part VI.)...
    2b
     
    c
    Add lines 2a and 2b............................
    2c
    673
    3
    Distributable amount before adjustments. Subtract line 2c from line 1............
    3
    243,507
    4
    Recoveries of amounts treated as qualifying distributions................
    4
    0
    5
    Add lines 3 and 4............................
    5
    243,507
    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
    243,507
    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
    3,660,932
    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
    3,660,932
    5
    Foundations that qualify under section 4940(e) for the reduced rate of tax on net investment
    income. Enter 1% of Part I, line 27b. See instructions.................
    5
    0
    6
    Adjusted qualifying distributions. Subtract line 5 from line 4..............
    6
    3,660,932
    Note: The amount on line 6 will be used in Part V, column (b), in subsequent years when calculating whether the foundation qualifies for
    the section 4940(e) reduction of tax in those years.
    Form 990-PF (2020)
    Form 990-PF (2020)
    Page 9
    Part XIII
    Undistributed Income (see instructions)
    (a)
    Corpus     		(b)
    Years prior to 2019     		(c)
    2019     		(d)
    2020
    1 Distributable amount for 2020 from Part XI, line 7 243,507
    2 Undistributed income, if any, as of the end of 2020:
    a Enter amount for 2019 only....... 0
    b Total for prior years:20, 20, 20 0
    3 Excess distributions carryover, if any, to 2020:
    a From 2015...... 194,965
    b From 2016...... 244,662
    c From 2017...... 498,008
    d From 2018...... 1,298,637
    e From 2019...... 1,522,969
    fTotal of lines 3a through e........ 3,759,241
    4Qualifying distributions for 2020 from Part
    XII, line 4: bullet$ 3,660,932
    a Applied to 2019, 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 2020 distributable amount..... 243,507
    e Remaining amount distributed out of corpus 3,417,425
    5 Excess distributions carryover applied to 2020. 0 0
    (If an amount appears in column (d), the
    same amount must be shown in column (a).)
    6Enter the net total of each column as
    indicated below:
    a Corpus. Add lines 3f, 4c, and 4e. Subtract line 5 7,176,666
    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 2019. Subtract line
    4a from line 2a. Taxable amount—see
    instructions .............     		0
    f Undistributed income for 2020. Subtract
    lines 4d and 5 from line 1. This amount must
    be distributed in 2021 ..........     		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 2015 not
    applied on line 5 or line 7 (see instructions) ...     		194,965
    9Excess distributions carryover to 2021.
    Subtract lines 7 and 8 from line 6a ......     		6,981,701
    10 Analysis of line 9:
    a Excess from 2016.... 244,662
    b Excess from 2017.... 498,008
    c Excess from 2018.... 1,298,637
    d Excess from 2019.... 1,522,969
    e Excess from 2020.... 3,417,425
    Form 990-PF (2020)
    Form 990-PF (2020)
    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 2020, enter the date of the ruling....... bullet
     
    b Check box to indicate whether the organization is a private operating foundation described in section or
    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) 2020 (b) 2019 (c) 2018 (d) 2017
             
    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.)
    1Information Regarding Foundation Managers:
    aList 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).)
    bList 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.
    2Information Regarding Contribution, Grant, Gift, Loan, Scholarship, etc., Programs:
    Check here bullet
    aThe 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,OR97475
    (541) 686-1242
    CHARITABLEFOUNDATION@PACIFICSOURCE.COM
    bThe form in which applications should be submitted and information and materials they should include:
    APPLICATIONS MAY BE SUBMITTED ONLINE USING THE ONLINE GRANT PORTAL LOCATED AT THE FOLLOWING WEBSITE: HTTPS://WWW.GRANTINTERFACE.COM/HOME/LOGON?URLKEY=PACIFICSOURCE. THE APPLICATION PROCESS BEGINS WITH THE SUBMISSION OF A LETTER OF INTENT (LOI). LOIS ARE REVIEWED SEMIANNUALLY (GENERALLY ON A QUARTERLY BASIS) AND SOME ORGANIZATIONS ARE INVITED TO SUBMIT A COMPLETE APPLICATION WITHIN THE PORTAL. APPLICATIONS INCLUDE A DESCRIPTION OF THE ORGANIZATION, THE POPULATION SERVED, THE PROPOSED PROJECT, AND THE SUBMISSION OF RECENT FINANCIAL STATEMENTS AND RELEVANT PROGRAM BUDGETS. MORE INFORMATION MAY BE FOUND HERE: HTTPS://PACIFICSOURCE.COM/COMMUNITY/FOUNDATION.
    cAny submission deadlines:
    SEE STATEMENT 10 FOR SUBMISSION DEADLINES
    dAny restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other
    factors:
    SEE STATEMENT 11 FOR RESTRICTIONS AND LIMITATIONS ON AWARDS.
    Form 990-PF (2020)
    Form 990-PF (2020)
    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)
    aPaid during the year
    ADELANTE MUJERES
    2030 MAIN ST SUITE A
    FOREST GROVE,OR97116     		N/A PC BUILDING HEALTH EQUITY IN WASHINGTON COUNTY, OR FOR THE LATINO COMMUNITY. 30,000
    ALLUVION HEALTH DBA
    601 1ST AVE N
    GREAT FALLS,MT59401     		N/A PC FUNDING OF A COMMUNITY HEALTH CENTER. 27,750
    BATTLE GROUND HEALTHCARE
    11117 NE 189TH ST 216
    BATTLE GROUND,WA98604     		N/A PC TO IMPROVE THE MEDICAL AND DENTAL HEALTH IN THE COMMUNITIES WE SERVE. 25,000
    BOISE RESCUE MISSION
    PO BOX 1494
    BOISE,ID83701     		N/A PC PROVIDING HOMELESS INDIVIDUALS WITH ACCESS TO FREE, QUALITY, MENTAL HEALTHCARE SERVICES AND CASE MANAGEMENT. 10,000
    CARRY IT FORWARD
    PO BOX 50121
    EUGENE,OR97405     		N/A PC PROVIDE SHELTER SERVICES. 50,000
    CASCADE AIDS PROJECT
    520 NW DAVIS ST SUITE 215
    PORTLAND,OR97209     		N/A PC PROVIDE SHORT-TERM AND LONG-TERM HOUSING, HIV SUPPORT, AND SUPPORT THE LGBTQ+ COMMUNITY. 25,000
    CATCH INC DBA
    1421 OREGON AVENUE
    PHILADELPHIA,PA19145     		N/A PC SUPPORTING MEMBERS OF THE COMMUNITY WITH MENTAL HEALTH ISSUES AND COGNITIVE DELAYS. 20,000
    CATHOLIC CHARITIES
    2740 SE POWELL BOULEVARD
    PORTLAND,OR97202     		N/A PC SUPPORT REFUGEE RESETTLEMENT PROGRAM. 20,000
    CATHOLIC COMMUNITY SERVICES OF THE
    1464 W 6TH AVE
    EUGENE,OR97402     		N/A PC OFFERING FOOD, CLOTHIN, HOUSING, AND ENERGY ASSISTANCE TO LANE COUNTY INDIVIDUALS. 200,000
    CENTER FOR COMMUNITY COUNSELING
    1465 COBURG RD
    EUGENE,OR97401     		N/A PC PROVIDE MENTAL HEALTH COUNSELING FOR THOSE WITH LIMITED INCOME, UNDERINSURED, OR LACKING HEALTH INSURANCE. 95,000
    CENTRAL OREGON FUSE
    PO BOX 8481
    BEND,OR97708     		N/A PC PROVIDE HOUSING SOLUTIONS TO HIGH-RISK HOMELESS POPULATION. 50,000
    CENTRO DE AYUDA
    410 SW 9TH ST
    NEWPORT,OR97365     		N/A PC TO SUPPORT IMMIGRANT FAMILIES. 30,000
    CHANCE RECOVERY
    231 LYON ST S
    ALBANY,OR97321     		N/A PC ASSISTING THE COMMUNITY WITH MENTAL HEALTH AND ADDICTION SERVICES. 30,000
    CHILDREN'S HOME SOCIETY OF IDAHO
    740 WARM SPRINGS AVE
    BOISE,ID83712     		N/A PC PROVIDE MENTAL HEALTH SERVICES FOR KIDS ON MEDICAID. 65,000
    CLACKAMAS VOLUNTEERS IN MEDICINE
    700 MOLALLA AVENUE
    OREGON CITY,OR97045     		N/A PC CLINIC COORDINATION TO SUPPORT PATIENT PROGRAMS SERVING CLACKAMAS COUNTY'S LOW-INCOME RESIDENTS 30,000
    CLATSOP COMMUNITY ACTION
    364 9TH ST
    ASTORIA,OR97103     		N/A PC FOOD, HOUSING AND ENERGY ASSISTANCE. 10,000
    COLLEGE OF SOUTHERN IDAHO REFUGEE PROGRAMS DBA
    1526 HIGHLAND AVE E
    TWIN FALLS,OR83301     		N/A PC REFUGEE SUPPORT SERVICES. 30,000
    COMMUNITY ACTION
    1001 SW BASELINE STREET
    HILLSBORO,OR97123     		N/A PC TO ELIMINATE CONDITIONS OF POVERTY AND CREATE OPPORTUNITIES FOR PEOPLE TO THRIVE. 50,000
    COMMUNITY FOOD AND AGRICULTURE COALITION
    1535 WYOMING ST
    MISSOULA,MT59801     		N/A PC SUPPORT FOR LOCAL FOOD GROWERS. 25,000
    COMMUNITY OUTREACH
    865 REIMAN AVE
    CORVALLIS,OR97730     		N/A PC PROVIDE MEDICAL SERVICES UNINSURED, LOW INCOME, OR NEWLY INSURED ADULTS. 60,000
    COMPASS HOUSE INC
    37 N IVY ST
    MEDFORD,OR97501     		N/A PC PROMOTE NON-CLINICAL MENTAL HEALTH SUPPORT PROJECT FOR VULNERABLE POPULATIONS IN SOUTHERN OREGON. 10,000
    CONFERENCE OF ST VINCENT DE PAUL
    2890 CHAD DRIVE
    EUGENE,OR97402     		N/A PC PROVIDE AFFORDABLE HOUSING, EMERGENCY SERVICES, AND HOMLESS SERVICES. 10,000
    CORNERSTONE WHOLE HEALTHCARE ORGANIZATION INC
    11485 PAYETTE HEIGHTS RD
    PAYETTE,ID83661     		N/A PC IMPROVE HEALTHCARE ACCESS TO ALL POPULATIONS. 30,000
    DAISY CHAIN
    PO BOX 10375
    EUGENE,OR97440     		N/A PC INCREASE EQUITABLE ACCESS TO PREVENTATIVE PRE AND POST-NATAL PROGRAMS IN LANE COUNTY. 40,000
    DE PAUL TREATMENT CENTERS
    PO BOX 16040
    PORTLAND,OR97292     		N/A PC SUBSTANCE ABUSE TREATMENT CENTER 100,000
    DESCHUTES CHILDRENS FOUNDATION
    1010 NW 14TH ST
    BEND,OR97703     		N/A PC PROVIDE RESOURCES TO CHILDREN TO HELP THEM THRIVE AND SUCCEED IN LIFE. 50,000
    DIABETES COMMUNITY CARE TEAM
    207 E 5TH AVE SUITE 223
    EUGENE,OR97401     		N/A PC DIABETES SUPPORT SERVICES. 15,000
    DIRECTION SERVICE INC
    1144 GATEWAY LOOP STE 200
    SPRINGFIELD,OR97477     		N/A PC PROVIDE HEALTHCARE OPPORTUNITIES TO THE MENTALLY DISABLED IN LANE COUNTY. 20,000
    EUGENE-SPRINGFIELD NAACP DBA
    330 HIGH ST
    EUGENE,OR97401     		N/A PC TO SUPPORT THE ADVANCEMENT OF ETHNIC PEOPLES. 20,000
    FAMILIAS EN ACCION
    2710 NE 14TH AVE
    PORTLAND,OR97212     		N/A PC PROMOTE HOLISTIC FAMILY WELL-BEING FOR LATINOS 50,000
    FAMILY ADVOCATES
    3010 WEST STATE STREET
    BOISE,ID83703     		N/A PC MITIGATING ADVERSE CHILDHOOD EXPERIENCES TO STRENGTHEN FAMILIES AND PROMOTE HEALTH. 50,000
    FAMILY BUILDING BLOCKS INC
    2425 LANCASTER DR NE
    SALEM,OR97305     		N/A PC RELIEF NURSERY SERVICES TO FAMILIES WITH CHILDREN AGES PRENATAL THROUGH FIVE. 25,000
    FARMERS MARKET FUND
    240 N BROADWAY SUITE 129
    PORTLAND,OR97227     		N/A PC DOUBLE UP FOOD BUCKS FOR SNAP 15,000
    FOOD FOR LANE COUNTY
    770 BAILEY HILL RD
    EUGENE,OR97402     		N/A PC TO REDUCE HUNGER IN LANE COUNTY, OR. 25,000
    FREE CLINIC OF SOUTHWEST WASHINGTON
    4100 PLOMONDON STREET
    VANCOUVER,WA98661     		N/A PC PROVIDING FREE HEALTHCARE WITH A FOCUS ON DIABETIC PATIENTS. 40,000
    FRIENDS OF THE CHILDREN - CENTRAL OREGON
    20354 NE EMPIRE AVE STE D2A
    BEND,OR97701     		N/A PC PROVIDE MENTORING TO AT-RISK CHILDREN. 5,000
    GENESIS COMMUNITY HEALTH
    215 W 35TH ST
    GARDEN CITY,ID83714     		N/A PC PROVIDE TRANSITIONAL PRIMARY HEALTHCARE, SOCIAL AND SPIRITUAL SUPPORT TO LOW-INCOME UNINSURED INDIVIDUALS IN IDAHO'S TREASURE VALLEY. 95,000
    HEALTHY BEGINNINGS
    1029 NW 14TH STREET
    BEND,OR97703     		N/A PC HEALTH, DEVELOPMENT, AND BEHAVIORAL SCREENING TO CHILDREN IN CENTRAL OREGON UNDER AGE 5. 20,000
    HIV ALLIANCE
    1195A CITY VIEW
    EUGENE,OR97403     		N/A PC STI TESTING AND OPIOID RESPONSE FOR HIGH RISK MEMBERS OF SUBURBAN AND RURAL WESTERN OREGON. 50,000
    HUERTO DE LA FAMILIA
    944 W 5TH AVENUE
    EUGENE,OR97402     		N/A PC TO INCREASE THE HEALTH AND ECONOMIC SECURITY OF LATINOS IN LANE COUNTY 50,000
    IDAHO HUNGER RELIEF TASK FORCE
    963 S ORCHARD ST
    BOISE,ID83705     		N/A PC IMPROVE HEALTH, WELLNESS, AND FOOD SECURITY OF 120 PATIENT HOUSEHOLDS BY INCREASING ACCESS TO FRESH FRUITS & VEGETABLES. 25,000
    JANUS YOUTH PROGRAMS
    738 NE DAVIS ST
    PORTLAND,OR97232     		N/A PC PROVIDE RESIDENTIAL SUPPORT SERVICES TO OREGON RESIDENTS 45,000
    JESSE TREE OF IDAHO
    1121 W MILLER ST
    BOISE,ID83702     		N/A PC PROVIDE HOUSING SOLUTIONS TO HIGH-RISK HOMELESS POPULATION. 80,000
    LANE COUNTY OR
    151 WEST 7TH AVENUE
    EUGENE,OR97401     		N/A PC DEVELOPMENT OF A SUPPORTIVE HOUSING PROJECT. 90,000
    LEGACY HEALTH FOUNDATION
    PO BOX 4484
    PORTLAND,OR97208     		N/A PC UNITY CENTER PEER SUPPORT PROGRAM 100,000
    LOOKING GLASS COMMUNITY SERVICES
    1790 W 11TH AVE SUITE 200
    EUGENE,OR97402     		N/A 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,OR97224     		N/A PC DENTAL CARE FOR RURAL COUNTIES IN OREGON. 50,000
    MENTAL HEALTH AMERICA OF MONTANA
    PO BOX 88
    BOZEMAN,MT59771     		N/A PC PROVIDE ACCESS TO RECOVERY ORIENTED TELEPHONIC AND SOCIAL MEDIA TOOLS TO PROVIDE SUPPORT, EDUCATION, AND GUIDANCE FOR YOUNG ADULTS. 15,000
    MICRONESIAN ISLANDER COMMUNITY
    PO BOX 18606
    SALEM,OR97305     		N/A PC TO RESPECTFULLY LEAD THE WAY TO EMPOWER MICRONESIAN AND PACIFIC ISLANDER COMMUNITIES TO BE SUCCESSFUL WHILE PRESERVING HERITAGE. 25,000
    MID-WILLAMETTE VALLEY COMMUNITY ACTION AGENCY INC
    2475 CENTER ST NE
    SALEM,OR97301     		N/A PC PROVIDE PRESCHOOL AND LEARNING SERVICES FOR THE WHOLE FAMILY. 50,000
    MOUNTAIN HOME MONTANA
    2606 SOUTH AVE W
    MISSOULA,MT59804     		N/A PC ACCESS TO TRAUMA-INFORMED MENTAL HEALTHCARE FOR YOUNG FAMILIES AT MOUNTAIN HOME. 45,000
    NAMI LANE COUNTY
    2411 MARTIN LUTHER KING JR BLVD
    EUGENE,OR97401     		N/A PC PROMOTE MENTAL HEALTH SUPPORT PROGRAMMING IN HISTORICALLY UNDERSERVED RURAL COMMUNITIES. 15,000
    NAMI SOUTHWEST WASHINGTON
    2500 MAIN ST 120
    VANCOUVER,WA98660     		N/A PC TO PROVIDE MENTAL HEALTH RESOURCES TO THE COMMUNITY. 10,000
    NATIVE AMERICAN YOUTH AND FAMILY
    5135 NE COLUMBIA BLVD
    PORTLAND,OR97218     		N/A PC TO ENRICH THE LIVES OF NATIVE AMERICAN YOUTH IN THE PORTLAND, OR AREA. 10,000
    NEIGHBORHOOD CLINIC
    7320 SW HUNZIKER RD SUITE 300
    PORTLAND,OR97223     		N/A PC TO SUPPORT A COMMUNITY HEALTH CLINIC. 20,000
    NORTH BY NORTHEAST COMMUNITY HEALTH CENTER
    714 NE ALBERTA ST
    PORTLAND,OR97211     		N/A PC PROVIDE INCREASED EQUITY IN ACCESS TO HEALTHCARE AND EQUITY IN HEALTHCARE OUTCOMES FOR AFRICAN AMERICAN COMMUNITY MEMBERS. 55,000
    NORTHWEST CATHOLIC COUNSELING
    8383 NW SANDY BLVD 205
    PORTLAND,OR97220     		N/A PC MENTAL HEALTH CARE FOR LOWER INCOME OLDER WOMEN 40,000
    OHSU
    1121 SW SALMON STREET SUITE 100
    PORTLAND,OR97205     		N/A PC TO PROVIDE SUPPORT TO CANCER RESEARCH, PREVENTABLE BLINDNESS, AND CHILDREN'S HEALTH. 100,000
    OLD MILL CENTER FOR CHILDREN AND FAMILIES
    1650 SW 45TH PLACE
    CORVALLIS,OR97333     		N/A PC TRAUMA INFORMED CARE TRAINING AND SUPPORT FOR COMMUNITY ORGANIZATIONS 30,000
    OSLC DEVELOPMENTS INC
    10 SHELTON MCMURPHEY BLVD
    EUGENE,OR97401     		N/A PC HEALTHY DEVELOPMENT OF CHILDREN AND FAMILIES 20,000
    PARENTING NOW
    86 CENTENNIAL LOOP
    EUGENE,OR97401     		N/A PC FUND PARENTAL EDUCATIONAL PROGRAM FOR VULNERABLE FAMILIES. 55,000
    PEARL BUCK CENTER INC
    3690 W 1ST AVE
    EUGENE,OR97402     		N/A PC TO SUPPORT FAMILIES LED BY PARENTS WITH COGNITIVE CHALLENGES. 12,500
    PLANNED PARENTHOOD OF MONTANA
    1116 GRAND AVE SUITE 201
    BILLINGS,MT59102     		N/A PC PROVIDE QUALITY HEALTHCARE, MEDICAL EDUCATION, AND ADVOCACY FOR INDIVIDUAL RIGHTS. 65,000
    PORTLAND STREET MEDICINE
    825 NW MULTNOMAH STREET SUITE 240
    PORTLAND,OR97232     		N/A PC FUNDING TO IMPROVE HEALTHCARE OF HOMELESS PEOPLE IN OREGON. 75,000
    PROJECT ACCESS NOW
    PO BOX 10953
    PORTLAND,OR97296     		N/A PC COORDINATE CARE FOR THE REGIONAL COMMUNITY HEALTH NETWORK 50,000
    RETURNING VETERANS PROJECT
    883 SE MAIN ST
    PORTLAND,OR97214     		N/A PC FREE AND CONFIDENTIAL MEDICAL SERVICES FOR RETURNING VETERANS AND SERVICE MEMBERS. 35,000
    SALEM FREE CLINICS
    1300 BROADWAY ST NE SUITE 104
    SALEM,OR97301     		N/A PC COMPREHENSIVE HEALTH SERVICES TO THE UNINSURED AND UNDERINSURED. 65,000
    SHARE OUR STRENGTHS INC
    2401 COLONIAL DR 3RD FL
    HELENA,MT59601     		N/A PC IMPROVING FOOD ACCESS AND NUTRITION IN ORDER TO END CHILDHOOD HUNGER IN MONTANA. 25,000
    SHELTERCARE
    499 WEST 4TH AVENUE
    EUGENE,OR97401     		N/A PC TO PROVIDE HOUSING SOLUTIONS AND HOUSING-LOSS PREVENTION. 25,000
    SNAKE RIVER COMMUNITY CLINIC
    215 10TH ST
    LEWISTON,ID83501     		N/A PC PROVIDE ACUTE CARE TO THE HOMELESS. 80,000
    SOUTH LANE MENTAL HEALTH
    1345 BIRCH AVE
    COTTAGE GROVE,OR97424     		N/A PC PROVIDE CARE TO COTTAGE GROVE ADULT AND CHILDREN'S OUTPATIENT MENTAL HEALTH SERVICES. 30,000
    SPOON
    135 SE MAIN ST SUITE 201
    PORTLAND,OR97214     		N/A PC SUPPORT FOSTER FAMILIES WITH RESOURCES SUPPORTING COMPLEX NUTRITIONAL AND FEEDING NEEDS OF CHILDREN IN FOSTER CARE. 10,000
    ST VINCENT DE PAUL SOCIETY OF
    2890 CHAD DRIVE
    EUGENE,OR97402     		N/A PC PROVIDE AFFORDABLE HOUSING, EMERGENCY SERVICES, AND HOMLESS SERVICES. 50,000
    THE CHILD CENTER
    1713 PENN LANE
    OREGON CITY,OR97045     		N/A PC PROVIDE HEALTH AND COUNSELING SERVICES TO CHILDREN WHO ARE VICTIMS OF ABUSE/NEGLECT. 10,000
    THE EUGENE MISSION
    1542 W 1ST AVE
    EUGENE,OR97402     		N/A PC HOMELESS SHELTER FOR THE EUGENE, OR COMMUNITY. 5,000
    THE FOUNDATION FOR MEDICAL EXCELLENCE
    11740 SW 68TH PARKWAY SUITE 125
    PORTLAND,OR97223     		N/A PC SUPPORTS THE MEDICAL ISSUES FACING HEALTH CARE PROFESSIONALS. 50,000
    THE FRIENDSHIP CLINIC INC
    704 S LATAH ST ALL SAINTS EPISCOPAL
    CHURCH
    BOISE,ID83705     		N/A PC PROVIDE FREE BASIC HEALTH CARE SERVICE TO LOW INCOME INDIVIDUALS AND FAMILIES. 40,000
    THE GIVING PLATE INC
    1245 SE 3RD STREET SUITE C7
    BEND,OR97702     		N/A PC TO FIGHT HUNGER IN BEND, OR. 45,000
    THE POVERELLO CENTER INC
    PO BOX 7644
    MISSOULA,MT59807     		N/A PC TO SUPPORT THE HUNGRY AND HOMELESS. 55,000
    UNITED WAY OF THE COLUMBIA - WILLAMETTE
    619 SW 11TH AVE
    PORTLAND,OR97205     		N/A PC FUND CENSUS EQUITY FUNDERS COMMITTEE COORDINATION OF EQUITABLE CENSUS 2020 COUNT. 50,000
    UPPER SNAKE RIVER TRIBES FOUNDATION
    413 W IDAHO ST STE 101
    BOISE,ID83702     		N/A PC TO ENSURE THE PROTECTION, ENHANCEMENT, AND RESTORATIO OF NATURAL AND CULTURAL RESOURCES. 20,000
    VOLUNTEERS IN MEDICINE
    2260 MARCOLA RD
    SPRINGFIELD,OR97477     		N/A PC OUTREACH, REFERRAL, ACUTE CARE, AND ONGOING HEALTHCARE TO FOR UNINSURED OR UNINSURED WORKERS. 105,000
    VOLUNTEERS IN MEDICINE CLINIC OF THE CASCADES
    2300 NW NEFF RD
    BEND,OR97701     		N/A PC OUTREACH, REFERRAL, ACUTE CARE, AND ONGOING HEALTHCARE TO FOR UNINSURED OR UNINSURED WORKERS. 40,000
    VOLUNTEERS IN MEDICINE FOUNDERS CLINIC CLACKAMAS
    700 MOLALLA AVENUE
    OREGON CITY,OR97045     		N/A PC CLINIC COORDINATION TO SUPPORT PATIENT PROGRAMS SERVING CLACKAMAS COUNTY'S LOW-INCOME RESIDENTS 30,000
    WELLMAMA INC
    150 SHELTON MCMURPHEY BLVD SUITE
    208
    EUGENE,OR97401     		N/A PC PROVIDE PREGNANCY AND POSTPARTUM MENTAL HEALTH SUPPORT SERVICES TO WOMEN AND THEIR FAMILIES IN LANE COUNTY. 20,000
    WELLNESS TREE CLINIC
    173 MARTIN STREET
    TWIN FALLS,ID83301     		N/A PC FREE COMMUNITY HEALTH CLINIC. 30,000
    WEST MONT
    2708 BOZEMAN AVE
    HELENA,MT59601     		N/A PC CREATING OPPORTUNITIES THAT PROMOTE RESPECT AND QUALITY OF LIFE FOR PEOPLE WITH DISABILITIES. 5,000
    WHITE BIRD CLINIC
    341 E 12TH AVE
    EUGENE,OR97401     		N/A PC TO PROVIDE COMMUNITY HEALTH SERVICES 25,000
    YOUTH ERA
    PO BOX 583
    EUGENE,OR97440     		N/A PC WORKS TO EMPOWER YOUNG PEOPLE AND CREATE BREAKTHROUGHS WITH DEDICATED SYSTEMS. 15,000
    YOUTH HOMES
    550 N CALIFORNIA STREET
    MISSOULA,MT59801     		N/A PC PROVIDE COMMUNITY BASED MENTAL HEALTH SERVICES FOR WESTERN MONTANA FAMILIES. 25,000
    Total .................................bullet 3a 3,625,250
    bApproved for future payment
    Total .................................bullet 3b 0
    Form 990-PF (2020)
    Form 990-PF (2020)
    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.)
    1Program service revenue: (a)
    Business code     		(b)
    Amount     		(c)
    Exclusion code     		(d)
    Amount
    a
    b
    c
    d
    e
    f
    gFees and contracts from government agencies          
    2 Membership dues and assessments....          
    3 Interest on savings and temporary cash
    investments ...........     		    14 54,853  
    4 Dividends and interest from securities....          
    5 Net rental income or (loss) from real estate:
    aDebt-financed property......          
    bNot 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 -203,045  
    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 -148,192 0
    13Total. Add line 12, columns (b), (d), and (e)..................
    13
    -148,192
    (See worksheet in line 13 instructions to verify calculations.)
    Part XVI-B
    Relationship of Activities to the Accomplishment of Exempt Purposes
    Line No.
    DownArrow     		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 (2020)
    Form 990-PF (2020)
    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? ...........
    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.
    Bullet Bullet
    May the IRS discuss this return
    with the preparer shown below?
    See instructions.
    Signature of officer or trustee Date Title
    Paid Preparer Use Only Print/Type preparer's name Preparer's Signature Date PTIN
    Firm's name SmallBullet
    		 Firm's EIN SmallBullet
    Firm's address SmallBullet


    		 Phone no.
    Form 990-PF (2020)
    Additional Data


    Software ID:  
    Software Version:  


    Form 990PF - Special Condition Description:
    Special Condition Description
    Schedule B
    (Form 990, 990-EZ,
    or 990-PF)
    Department of the Treasury
    Internal Revenue Service
    Schedule of Contributors

    Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
    Arrow Bullet Go to www.irs.gov/Form990 for the latest information.
    OMB No. 1545-0047
    2020
    Name of the organization
    PACIFICSOURCE FOUNDATION FOR HEALTH
    IMPROVEMENT
    Employer identification number

    93-1100080
    Organization type (check one):
    Filers of:
    Section:
    Form 990 or 990-EZ






    Form 990-PF




    Check if your organization is covered by the General Rule or a Special Rule.  
    Note: Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.
    General Rule
    Special Rules
    ......... Arrow Bullet $  
    Caution: An organization that isn't covered by the General Rule and/or the Special Rules doesn't file Schedule B (Form 990,
    990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2, of its Form 990; or check the box on line H of its Form 990-EZ
    or on its Form 990PF, Part I, line 2, to certify that it doesn't meet the filing requirements of Schedule B (Form 990,
    990-EZ, or 990-PF).
    For Paperwork Reduction Act Notice, see the Instructions
    for Form 990, 990-EZ, or 990-PF.
    Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2020)
    Schedule B (Form 990, 990-EZ, or 990-PF) (2020) Page 2
    Name of organization
    PACIFICSOURCE FOUNDATION FOR HEALTH
    IMPROVEMENT         		Employer identification number
    93-1100080
    Part I
    Contributors
    Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
    1
    PACIFIC HEALTH ASSOCIATES
     
    555 INTERNATIONAL WAY
     
    SPRINGFIELD, OR97477

    		$ 1,900,000


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
     
     
     
     

    		$  


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
     
     
     
     

    		$  


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
     
     
     
     

    		$  


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
     
     
     
     

    		$  


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
     
     
     
     

    		$  


    (Complete Part II for noncash contributions.)
    Schedule B (Form 990, 990-EZ, or 990-PF) (2020)
    Schedule B (Form 990, 990-EZ, or 990-PF) (2020)
    Page 3
    Name of organization
    PACIFICSOURCE FOUNDATION FOR HEALTH
    IMPROVEMENT         		Employer identification number

    93-1100080
    Part II
    Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
    (a)
    No. from Part I    		 (b)
    Description of noncash property given    		 (c)
    FMV (or estimate)
    (See instructions)     		(d)
    Date received
     
    		$    
    (a)
    No. from Part I    		 (b)
    Description of noncash property given    		 (c)
    FMV (or estimate)
    (See instructions)     		(d)
    Date received
     
    		$    
    (a)
    No. from Part I    		 (b)
    Description of noncash property given    		 (c)
    FMV (or estimate)
    (See instructions)     		(d)
    Date received
     
    		$    
    (a)
    No. from Part I    		 (b)
    Description of noncash property given    		 (c)
    FMV (or estimate)
    (See instructions)     		(d)
    Date received
     
    		$    
    (a)
    No. from Part I    		 (b)
    Description of noncash property given    		 (c)
    FMV (or estimate)
    (See instructions)     		(d)
    Date received
     
    		$    
    (a)
    No. from Part I    		 (b)
    Description of noncash property given    		 (c)
    FMV (or estimate)
    (See instructions)     		(d)
    Date received
     
    		$    
    Schedule B (Form 990, 990-EZ, or 990-PF) (2020)
    Schedule B (Form 990, 990-EZ, or 990-PF) (2020)
    Page 4
    Name of organization
    PACIFICSOURCE FOUNDATION FOR HEALTH
    IMPROVEMENT         		Employer identification number

    93-1100080
    Part III
    Exclusively religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10) that total more than $1,000 for the year from any one contributor. Complete columns (a) through (e) and the following line entry. For organizations completing Part III, enter the total of exclusively religious, charitable, etc., contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet$  
    Use duplicate copies of Part III if additional space is needed.
    (a)
    No. from Part I    		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
     
    (e) Transfer of gift
    Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
     
     
         
     
    (a)
    No. from Part I    		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
     
    (e) Transfer of gift
    Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
     
     
         
     
    (a)
    No. from Part I    		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
     
    (e) Transfer of gift
    Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
     
     
         
     
    (a)
    No. from Part I    		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
     
    (e) Transfer of gift
    Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
     
     
         
     
    Schedule B (Form 990, 990-EZ, or 990-PF) (2020)
    Additional Data


    Software ID:  
    Software Version:  

    TY 2020 AccountingFeesSchedule
    Name:
    PACIFICSOURCE FOUNDATION FOR HEALTH
     
    IMPROVEMENT
    EIN:
    93-1100080
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    ACCOUNTING FEES 471 235   235

    TY 2020 GeneralExplanationAttachment
    Name:
    PACIFICSOURCE FOUNDATION FOR HEALTH
     
    IMPROVEMENT
    EIN:
    93-1100080
    Identifier Return Reference Explanation
    ANY SUBMISSION DEADLINES 990-PF, PART XV, LINE 2C SUBMISSION DEADLINES ARE ROLLING. THE COMMITTEE MEETS SEMI-ANNUALLY (GENERALLY ON A QUARTERLY BASIS) TO REVIEW APPLICATIONS FROM ORGANIZATIONS THAT WERE INVITED TO APPLY FOLLOWING THE SUBMISSION OF AN LOI. DEADLINES AND UPDATES MAY BE FOUND HERE: HTTPS://PACIFICSOURCE.COM/COMMUNITY/FOUNDATION.
    RESTRICTIONS AND LIMITATIONS ON AWARDS FORM 990-PF, PART XV, LINE 2D PROPOSALS MUST ADDRESS ONE OR MORE OF THE FOLLOWING FUNDING PRIORITY AREAS, LISTED BY GRANT PROGRAM, UNLESS OTHERWISE APPROVED BY THE BOARD. COVID-RELATED FUNDING IS RESPONSIVE AND MAY NOT BE ONGOING. THESE FUNDING PRIORITY AREAS ARE SUBJECT TO CHANGE PERIODICALLY. UPDATES MAY BE FOUND HERE: HTTPS://PACIFICSOURCE.COM/COMMUNITY/FOUNDATION.STRATEGIC & COMMUNITY-BASED GRANTS-HEALTHCARE ACCESS: ACCESS TO HEALTHCARE SERVICES FOR CHILDREN, YOUTH, AND ADULTS WITH BARRIERS TO CARE.-HEALTHCARE INNOVATION: TO IMPROVE QUALITY AND REDUCE COST OF HEALTHCARE SERVICES FOCUSED ON INTEGRATED HEALTHCARE SERVICES, PATIENT-CENTERED, MEDICAL HOME MODELS, EVIDENCE-BASED CARE FOR CHRONIC DISEASE, CARE COORDINATION, AND PRE- AND POST-NATAL CARE FOR INFANTS AND PARENTS. THIS MAY INCLUDE TECHNOLOGY FOR ENHANCING CERTAIN INNOVATIONS, IN ADDITION TO INNOVATIVE APPROACHES TO SYSTEMS, POLICIES, AND PROVIDER CAPACITIES TO IMPROVE CARE.-HEALTH AND WELLNESS: TO IMPROVE HEALTH AND WELLNESS FOCUSED ON PHYSICAL ACTIVITY, HEALTHY NUTRITION, TOBACCO CESSATION, AND PARENTING AND EARLY CHILDHOOD DEVELOPMENT.COVID-19 RELIEF & RECOVERY GRANTS-SUPPORTING ACCESS TO DIRECT HEALTH CARE SERVICES FOR VULNERABLE POPULATIONS. THIS COULD INCLUDE SUPPORT FOR CLINICAL OR OPERATIONAL STAFF, EQUIPMENT AND SUPPLIES THAT ENABLE EXPANDED OR ENHANCED ACCESS. INCREASED PRIORITY GIVEN TO REQUESTS FOR BEHAVIORAL HEALTH.-SUPPORTING ORGANIZATIONS SERVING VULNERABLE POPULATIONS, DISPROPORTIONATELY IMPACTED BY COVID-19. THIS COULD INCLUDE ASSISTANCE WITH SOCIAL DETERMINANTS OF HEALTH AND BASIC NEEDS SUPPORT AMONG HIGH-RISK POPULATIONS, SUCH AS THOSE WHO ARE UNHOUSED OR HOUSING INSECURE, FOOD INSECURE, AT-RISK OF EXPOSURE TO VIOLENCE OR FAMILY INSTABILITY, ETC.

    TY 2020 InvestmentsOtherSchedule2
    Name:
    PACIFICSOURCE FOUNDATION FOR HEALTH
     
    IMPROVEMENT
    EIN:
    93-1100080
    Category/ Item Listed at Cost or FMV Book Value End of Year Fair Market Value
    WELLS CAPITAL FMV 3,008,991 3,008,991

    TY 2020 LegalFeesSchedule
    Name:
    PACIFICSOURCE FOUNDATION FOR HEALTH
     
    IMPROVEMENT
    EIN:
    93-1100080
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    LEGAL FEES 196 98   98


    TY 2020 OtherAssetsSchedule
    Name:
    PACIFICSOURCE FOUNDATION FOR HEALTH
     
    IMPROVEMENT
    EIN:
    93-1100080
    Description Beginning of Year - Book Value End of Year - Book Value End of Year - Fair Market Value
    INTEREST RECEIVABLE 6,003 1,897 1,897


    TY 2020 OtherExpensesSchedule
    Name:
    PACIFICSOURCE FOUNDATION FOR HEALTH
     
    IMPROVEMENT
    EIN:
    93-1100080
    Description Revenue and Expenses per Books Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    TAX CONSULTING FEES 7,916 3,958   3,958
    AUTO EXPENSE 130 0   130


    TY 2020 OtherIncreasesSchedule
    Name:
    PACIFICSOURCE FOUNDATION FOR HEALTH
     
    IMPROVEMENT
    EIN:
    93-1100080
    Description Amount
    UNREALIZED GAINS 212,129


    TY 2020 OtherLiabilitiesSchedule
    Name:
    PACIFICSOURCE FOUNDATION FOR HEALTH
     
    IMPROVEMENT
    EIN:
    93-1100080
    Description Beginning of Year - Book Value End of Year - Book Value
    INCOME TAX PAYABLE -337 -1,337


    TY 2020 TaxesSchedule
    Name:
    PACIFICSOURCE FOUNDATION FOR HEALTH
     
    IMPROVEMENT
    EIN:
    93-1100080
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    STATE FILING FEES 955 478   478