Form990-PF

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
Assurity Life Foundation
 
% Thomas Henning
Number and street (or P.O. box number if mail is not delivered to street address)2000 Q Street
  Room/suite
City or town, state or province, country, and ZIP or foreign postal code
Lincoln, NE68503
A Employer identification number

47-0775374
B Telephone number (see instructions)

(402) 476-6500
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$4,681,957J 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)  
2 Check bullet.............
3 Interest on savings and temporary cash investments 95 95  
4 Dividends and interest from securities... 86,870 86,870  
5a Gross rents............      
b Net rental income or (loss)  
6a Net gain or (loss) from sale of assets not on line 10 Click to see attachment 251,931
b Gross sales price for all assets on line 6a 751,000
7 Capital gain net income (from Part IV, line 2)... 251,931
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)..... 0  
11 Other income (attach schedule)....... 0    
12 Total. Add lines 1 through 11........ 338,896 338,896  
Operating and Administrative Expenses 13 Compensation of officers, directors, trustees, etc.        
14 Other employee salaries and wages......        
15 Pension plans, employee benefits.......        
16a Legal fees (attach schedule)......... 0      
b Accounting fees (attach schedule)....... 0      
c Other professional fees (attach schedule).... Click to see attachment 105 105    
17 Interest...............        
18 Taxes (attach schedule) (see instructions)... Click to see attachment 3,103 563    
19 Depreciation (attach schedule) and depletion... 0    
20 Occupancy..............        
21 Travel, conferences, and meetings.......        
22 Printing and publications..........        
23 Other expenses (attach schedule)....... 0      
24 Total operating and administrative expenses.
Add lines 13 through 23.......... 3,208 668   0
25 Contributions, gifts, grants paid....... 240,249 240,249
26 Total expenses and disbursements. Add lines 24 and 25 243,457 668   240,249
27 Subtract line 26 from line 12:
a Excess of revenue over expenses and disbursements 95,439
b Net investment income (if negative, enter -0-) 338,228
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............. 71,960 54,162 54,162
2 Savings and temporary cash investments.........      
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).....   0  
7 Other notes and loans receivable (attach schedule) bullet  
Less: allowance for doubtful accounts bullet     0  
8 Inventories for sale or use..............      
9 Prepaid expenses and deferred charges..........      
10a Investments—U.S. and state government obligations (attach schedule)   0  
b Investments—corporate stock (attach schedule)....... 3,235,099 Click to see attachment3,348,336 4,627,795
c Investments—corporate bonds (attach schedule).......   0  
11 Investments—land, buildings, and equipment: basis bullet  
Less: accumulated depreciation (attach schedule) bullet     0  
12 Investments—mortgage loans.............      
13 Investments—other (attach schedule)..........   0  
14 Land, buildings, and equipment: basis bullet  
Less: accumulated depreciation (attach schedule) bullet     0  
15 Other assets (describe bullet) 0 0 0
16 Total assets (to be completed by all filers—see the
instructions. Also, see page 1, item I) 3,307,059 3,402,498 4,681,957
Liabilities 17 Accounts payable and accrued expenses..........    
18 Grants payable.................    
19 Deferred revenue.................    
20 Loans from officers, directors, trustees, and other disqualified persons   0
21 Mortgages and other notes payable (attach schedule)......   0
22 Other liabilities (describe bullet)    
23 Total liabilities (add lines 17 through 22).........   0
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........ 3,307,059 3,402,498
27 Paid-in or capital surplus, or land, bldg., and equipment fund    
28 Retained earnings, accumulated income, endowment, or other funds    
29 Total net assets or fund balances (see instructions)..... 3,307,059 3,402,498
30 Total liabilities and net assets/fund balances (see instructions). 3,307,059 3,402,498
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
3,307,059
2
Enter amount from Part I, line 27a .....................
2
95,439
3
Other increases not included in line 2 (itemize) bullet
3
0
4
Add lines 1, 2, and 3 ..........................
4
3,402,498
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
3,402,498
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.)
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) Bracket If gain, also enter in Part I, line 7
If (loss), enter -0- in Part I, line 7		 Bracket 2 251,931
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 4,701
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 4,701
4 Subtitle A (income) tax (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-) 4  
5 Tax based on investment income. Subtract line 4 from line 3. If zero or less, enter -0- ..... 5 4,701
6 Credits/Payments:
a 2020 estimated tax payments and 2019 overpayment credited to 2020 6a 2,680
b Exempt foreign organizations—tax withheld at source...... 6b  
c Tax paid with application for extension of time to file (Form 8868)... 6c  
d Backup withholding erroneously withheld ........... 6d  
7 Total credits and payments. Add lines 6a through 6d.............. 7 2,680
8 Enter any penalty for underpayment of estimated tax. Check here if Form 2220 is attached. Click to see attachment 8 4
9 Tax due. If the total of lines 5 and 8 is more than line 7, enter amount owed.......Bullet 9 2,025
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$   (2) On foundation managers.bullet$  
e
Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed
on foundation managers.bullet$  
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
 
No
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)
    bulletNE
    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 addressbullet  
    14
    The books are in care ofbulletJenny Oelke Telephone no.bullet (402) 437-4382

    Located atbullet2000 Q StreetLincolnNE ZIP+4bullet685033608
    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
     
    No
    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
     
    No
    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
     
    No
    .........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
     
    No
    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
    THOMAS E HENNING CEOPresidentDirector
    1.000     		0    
    2000 Q Street
    Lincoln,NE68503
    DAVID D LOCKWOOD Vice PresDirector
    1.000     		0    
    2000 Q Street
    Lincoln,NE68503
    KEVIN G FALTIN TreasurerDirector
    1.000     		0    
    2000 Q Street
    Lincoln,NE68503
    WILLIAM R CINTANI Director
    1.000     		0    
    2929 Cornhusker Highway
    Lincoln,NE68504
    DAVID S GRAFF Director
    1.000     		0    
    151 N 8th Street
    Lincoln,NE68508
    ANGELA L MUHLEISEN Director
    1.000     		0    
    7100 Pioneers Blvd
    Lincoln,NE68506
    LYN W ZIEGENBEIN Director
    1.000     		0    
    10057 Fieldcrest Dr
    Omaha,NE68114
    2 Compensation of five highest-paid employees (other than those included on line 1—see instructions). If none, enter “NONE."
    (a) Name and address of each employee paid more than $50,000 (b) Title, and average
    hours per week
    devoted to position     		(c) Compensation (d) Contributions to
    employee benefit
    plans and deferred
    compensation     		(e) Expense account,
    other allowances
     
    Total number of other employees paid over $50,000...................bullet  
    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
     
    Total number of others receiving over $50,000 for professional services.............bullet  
    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 0
    Total. Add lines 1 through 3.........................bullet  
    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
    4,180,907
    b
    Average of monthly cash balances.......................
    1b
    54,011
    c
    Fair market value of all other assets (see instructions)................
    1c
    0
    d
    Total (add lines 1a, b, and c).........................
    1d
    4,234,918
    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
     
    3
    Subtract line 2 from line 1d.........................
    3
    4,234,918
    4
    Cash deemed held for charitable activities. Enter 1 1/2% of line 3 (for greater amount, see
    instructions) .............................
    4
    63,524
    5
    Net value of noncharitable-use assets. Subtract line 4 from line 3. Enter here and on Part V, line 4
    5
    4,171,394
    6
    Minimum investment return. Enter 5% of line 5..................
    6
    208,570
    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
    208,570
    2a
    Tax on investment income for 2020 from Part VI, line 5......
    2a
    4,701
    b
    Income tax for 2020. (This does not include the tax from Part VI.)...
    2b
     
    c
    Add lines 2a and 2b............................
    2c
    4,701
    3
    Distributable amount before adjustments. Subtract line 2c from line 1............
    3
    203,869
    4
    Recoveries of amounts treated as qualifying distributions................
    4
     
    5
    Add lines 3 and 4............................
    5
    203,869
    6
    Deduction from distributable amount (see instructions).................
    6
     
    7
    Distributable amount as adjusted. Subtract line 6 from line 5. Enter here and on Part XIII, line 1 ...
    7
    203,869
    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
    240,249
    b
    Program-related investments—total from Part IX-B..................
    1b
     
    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
    0
    4
    Qualifying distributions. Add lines 1a through 3b. Enter here and on Part V, line 8, and Part XIII, line 4
    4
    240,249
    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
     
    6
    Adjusted qualifying distributions. Subtract line 5 from line 4..............
    6
    240,249
    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 7 203,869
    2 Undistributed income, if any, as of the end of 2020:
    a Enter amount for 2019 only.......  
    b Total for prior years:20, 20, 20  
    3 Excess distributions carryover, if any, to 2020:
    a From 2015...... 99,731
    b From 2016...... 249,308
    c From 2017...... 301,408
    d From 2018...... 274,731
    e From 2019...... 273,624
    fTotal of lines 3a through e........ 1,198,802
    4Qualifying distributions for 2020 from Part
    XII, line 4: bullet$ 240,249
    a Applied to 2019, but not more than line 2a  
    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..... 203,869
    e Remaining amount distributed out of corpus 36,380
    5 Excess distributions carryover applied to 2020.    
    (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 1,235,182
    b Prior years’ undistributed income. Subtract
    line 4b from line 2b ..........     		 
    c Enter the amount of prior years’ undistributed
    income for which a notice of deficiency has
    been issued, or on which the section 4942(a)
    tax has been previously assessed......     		 
    d Subtract line 6c from line 6b. Taxable amount
    —see instructions ...........     		 
    e Undistributed income for 2019. Subtract line
    4a from line 2a. Taxable amount—see
    instructions .............     		 
    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) .......     		 
    8 Excess distributions carryover from 2015 not
    applied on line 5 or line 7 (see instructions) ...     		99,731
    9Excess distributions carryover to 2021.
    Subtract lines 7 and 8 from line 6a ......     		1,135,451
    10 Analysis of line 9:
    a Excess from 2016.... 249,308
    b Excess from 2017.... 301,408
    c Excess from 2018.... 274,731
    d Excess from 2019.... 273,624
    e Excess from 2020.... 36,380
    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
    0       0
    b 85% of line 2a .........          
    c Qualifying distributions from Part XII,
    line 4 for each year listed .....     		        0
    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 ......         0
    (2) Value of assets qualifying
    under section 4942(j)(3)(B)(i)    		         0
    b “Endowment" alternative test— enter 2/3
    of minimum investment return shown in
    Part X, line 6 for each year listed...     		        0
    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) ....     		        0
    (2) Support from general public
    and 5 or more exempt
    organizations as provided in
    section 4942(j)(3)(B)(iii)....     		        0
    (3) Largest amount of support
    from an exempt organization    		         0
    (4) Gross investment income         0
    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:
    TAMMY HALVORSEN
    2000 Q Street
    Lincoln,NE68503
    (402) 437-3504
    bThe form in which applications should be submitted and information and materials they should include:
    None
    cAny submission deadlines:
    None
    dAny restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other
    factors:
    None
    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
    GREATER LINCOLN CHAMBER FOUNDATION
    PO BOX 83006
    LINCOLN,NE68501     		  PC PROMOTESUPPORT LOCAL BUSINESS 16,000
    12 HILLS DOG RESCUE
    3175 H AVE
    WALTHILL,NE68067     		  PC ANIMAL RESCUE 250
    AMERICAN SOCIETY FOR THE PREVENTION OF CRUELTY TO ANIMALS
    PO BOX 86929
    WASHINGTON,DC200077127     		  PC PREVENTIONCRUELTY TO ANIMALS 100
    BEAGLE FREEDOM PROJECT
    4804 LAUREL CANYON BLVD 534
    VALLEY VILLAGE,CA91607     		  PC ELIMINATE SUFFERING OF ANIMALS 50
    BEST FRIENDS ANIMAL SOCIETY
    5001 ANGEL CANYON RD
    KANAB,UT84741     		  PC GOAL FOR NO MORE HOMELSS PETS 50
    CAPITAL HUMANE SOCIETY
    2320 PARK BLVD
    LINCOLN,NE685023329     		  PC SHELTERS PROTECTS ANIMALS 125
    CEDARS YOUTH SERVICES
    6601 PIONEERS 2
    LINCOLN,NE68506     		  PC HELP CHILDRENSAFETY STABILITY 12,500
    CENTERPOINTE
    2633 P ST
    LINCOLN,NE68503     		  PC PROVIDE MENTAL DRUG TREATMENT 500
    CLINIC WITH A HEART
    1701 S 17TH ST
    LINCOLN,NE68502     		  PC HELP HOMELESS ABUSED CHILDREN 125
    COMIC RELIEF INC
    28 LIBERTY ST 35TH FLOOR
    NEW YORK,NY10005     		  PC WORLD FREE FROM POVERTY 100
    COMPASSION INTERNATIONAL
    PO BOX 65000
    COLORADO SPRINGS,CO80962     		  PC HELPING CHILDREN IN POVERTY 442
    CORNHUSKER COUNCIL BSA
    600 2 120TH ST
    WALTON,NE68461     		  PC PREPARE YOUNG PEOPLE MAKING ETHICAL DECISIONS 1,000
    DOANE
    1014 BOSWELL AVE
    CRETE,NE68333     		  PC COLLEGELIBERAL ARTS EDUCATION 1,006
    EPWORTH VILLAGE
    PO BOX 503
    YORK,NE68467     		  PC PROVIDE COMPREHENSIVE FAMILY CENTERED SERVICES 200
    FARM SANCTUARY
    2100 AIKENS ROAD
    WATKINS GLEN,NY14891     		  PC PROTECT FARM ANIMALS FROM CRUELTY 200
    FOOD BANK OF LINCOLN
    4840 DORIS BAIR CIR STE A
    LINCOLN,NE68504     		  PC ALLEVIATE HUNGER IN SE NEBRASKA 346
    FOUNDATION FOR LPS
    PO BOX 82889
    LINCOLN,NE68501     		  PC INSPIRECREATE ACADEMIC SUCCESS 5,000
    FOUNDATION FOR LPS
    5905 O ST
    LINCOLN,NE68510     		  PC NEEDS OF FAMILIESCOVID19 RESPONSE FUND 30,000
    FRESH START HOME
    6433 HAVELOCK AVE
    LINCOLN,NE68507     		  PC TRANSITIONAL SHELTER EMPOWERING WOMEN 20
    FRIENDS OF THE EARTH
    1101 15TH ST NW 11TH FLOOR
    WASHINGTON,DC20005     		  PC ENVIRONMENTHEALTHY WORLD 20
    FRIENDSHIP HOME
    PO BOX 85358
    LINCOLN,NE68501     		  PC PROVIDE EMERGENCY SHELTER 170
    GFWC RAYMOND WOMANS CLUB
    PO BOX 184
    RAYMOND,NE68428     		  PC COMMUNITY IMPROVEMENT 402
    GIRL SCOUTS SPIRIT OF NEBRASKA
    8230 BEECHWOOD DR
    LINCOLN,NE68510     		  PC GIRL SCOUTINGBUILD CONFIDENCE 500
    HOPE VENTURE
    315 S 9TH ST
    LINCOLN,NE68508     		  PC WORLDWIDE HEALTH EDUCATION PROJECTS 500
    HOPESPOKE
    2444 O ST
    LINCOLN,NE68510     		  PC MEETING MENTAL HEALTH NEEDS 1,250
    IGNITE LINCOLN (FIRESPRING FOUNDATION)
    1201 INFINITY COURT
    LINCOLN,NE68512     		  PC EVENTS DESIGNED TO BUILD COMMUNITY 500
    JUNIOR ACHIEVEMENT OF LINCOLN
    3005 S 68TH ST PLACE S-110
    LINCOLN,NE68510     		  PC PROVIDE EDUCATIONAL EXPERIENCE 1,820
    LEADERSHIP LINCOLN INC
    211 N 14TH ST
    LINCOLN,NE68508     		  PC DEVELOP COMMUNITY LEADERSHIP 1,000
    LINCOLN COMMUNITY FOUNDATION
    215 CENTENNIAL MALL S-100
    LINCOLN,NE68508     		  PC PROVIDE LEADERSHIP RESOURCES 6,000
    LINCOLN CONTINENTALS
    5120 MYRTLE ST
    LINCOLN,NE68506     		  PC PRESERVATION BARBERSHOP QUARTET 500
    LINCOLN PARKS & RECREATION FOUNDATION
    3131 O ST SUITE 301
    LINCOLN,NE68510     		  PC PRAIRIE CORRIDOR 10,000
    LIVE WELL GO FISH
    2400 S 22ND STREET
    LINCOLN,NE68502     		  PC PROVIDE RECREATIONAL THERAPY 350
    LUTHERAN FAMILY SERVICES OF NE
    124 S 24TH ST 230
    OMAHA,NE68102     		  PC PROVIDE HUMAN CARE SERVICES 250
    MADONNA FOUNDATION
    5401 SOUTH STREET
    LINCOLN,NE68506     		  PC INVEST IN REHABILITATION 2,500
    MATT TALBOT KITCHEN & OUTREACH
    2121 N 27TH ST
    LINCOLN,NE68503     		  PC MEALS FOR WORKING POOR HOMELESS 20
    MOSAIC
    4980 S 118TH ST
    OMAHA,NE68137     		  PC ADVOCATES FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES 500
    MOURNING HOPE
    4919 BALDWIN AVE
    LINCOLN,NE68504     		  PC GRIEF CENTERSUPPORT GROUPS 8,333
    NE COUNCIL ON ECONOMIC EDUCATION
    PO BOX 880404
    LINCOLN,NE68588     		  PC ADVANCE ECONOMIC LITERACY 1,000
    NEBRASKA TRANSITION COLLEGE
    6901 N 13TH ST
    LINCOLN,NE68521     		  PC EMPOWER INDIVIDUALS WITH AUTISM 150
    NEBRASKA WESLEYAN UNIVERSITY
    500 ST PAUL AVE
    LINCOLN,NE68504     		  PC UNIVERSITYACADEMIC COMMUNITY 26,000
    NEBRASKALAND FOUNDATION
    PO BOX 94961
    LINCOLN,NE685094961     		  PC ENRICH QUALITY OF LIFE FOR NE CITIZENS 1,000
    PEOPLE'S CITY MISSION
    PO BOX 80636
    LINCOLN,NE68501     		  PC SUPPORT CITY MISSIONSHELTER 295
    SALVATION ARMY
    PO BOX 94786
    LINCOLN,NE68509     		  PC MEET HUMAN NEEDS 70
    SCC EDUCATIONAL FOUNDATION
    301 S 68TH ST PLACE-FIFTH FLOOR
    LINCOLN,NE68510     		  PC STUDENT EMERGENCY FUNDCOVID 19 5,000
    SPRING CREEK PRAIRIE AUDUBON CENTER
    PO BOX 117
    DENTON,NE68339     		  PC CONSERVE NATURAL ECOSYSTEMS 1,000
    TABITHA FOUNDATION
    4720 RANDOLPH ST
    LINCOLN,NE68510     		  NC SUPPORT TABITHA INCELDER CARE 10,000
    THE CAT HOUSE
    3633 O ST
    LINCOLN,NE68510     		  PC PROVIDE SAFE ADOPTION OF CATS 50
    THE HUMANE SOCIETY OF THE US
    PO BOX 96930
    WASHINGTON,DC20009     		  PC PREVENT CRUELTY TO ANIMALS 75
    UNITED WAY OF LINCOLN
    238 S 13TH STREET
    LINCOLN,NE68508     		  PC IMPROVE PEOPLES LIVES 78,822
    UNIVERSITY OF NEBRASKA FOUNDATION
    PO BOX 82555
    LINCOLN,NE68501     		  PC PROVIDE SUPPORT TO UNIVERSITY 14,138
    WACHISKA AUDUBON SOCIETY
    4547 CALVERT ST S-10
    LINCOLN,NE68506     		  PC PRESERVE NATIVE GRASSLANDS 20
    Total .................................bullet 3a 240,249
    bApproved for future payment
    Total .................................bullet 3b  
    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 95  
    4 Dividends and interest from securities....     14 86,870  
    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 ............     		    18 251,931  
    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)..   338,896  
    13Total. Add line 12, columns (b), (d), and (e)..................
    13
    338,896
    (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
    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: 20011376
    Software Version: ta20mefv1.0


    Form 990PF - Special Condition Description:
    Special Condition Description

    Note: To capture the full content of this document, please select landscape mode (11" x 8.5") when printing.

    TY 2020 GainLossSaleOtherAssetsSch
    Name:
    Assurity Life Foundation
    EIN:
    47-0775374
    Software ID:
    20011376
    Software Version:
    ta20mefv1.0
    Name Date Acquired How Acquired Date Sold Purchaser Name Gross Sales Price Basis Basis Method Sales Expenses Total (net) Accumulated Depreciation
    Vanguard Funds 2019-01 Purchase 2020-03 03052020 70,000 64,551     5,449  
    Vanguard Funds 2019-01 Purchase 2020-04 04032020 165,000 154,432     10,568  
    Vanguard Funds 2019-01 Purchase 2020-05 05112020 65,000 29,514     35,486  
    Vanguard Funds 2019-01 Purchase 2020-06 06052020 135,000 81,833     53,167  
    Vanguard Funds 2019-01 Purchase 2020-07 07062020 40,000 15,960     24,040  
    Vanguard Funds 2019-01 Purchase 2020-08 08052020 55,000 49,868     5,132  
    Vanguard Funds 2019-01 Purchase 2020-09 09032020 55,000 20,083     34,917  
    Vanguard Funds 2019-01 Purchase 2020-10 10072020 20,000 18,396     1,604  
    Vanguard Dev Mkt Index 2019-01 Purchase 2020-11 11032020 20,000 8,001     11,999  
    Vanguard Emergin Mkt Inst 2019-01 Purchase 2020-12 12032020 126,000 56,431     69,569  

    TY 2020 InvestmentsCorpStockSchedule
    Name:
    Assurity Life Foundation
    EIN:
    47-0775374
    Software ID:
    20011376
    Software Version:
    ta20mefv1.0
    Name of Stock End of Year Book Value End of Year Fair Market Value
    Vanguard Total Bond Market Index Fund 1,634,164 1,740,199
    Vanguard Developed Markets Index Fund 374,049 484,407
    Vanguard Emerging Markets Stock Index Fund 184,807 249,565
    Vanguard Large Cap Index Fund 462,936 947,287
    Vanguard Mid Cap Index Fund 240,075 479,854
    Vanguard Real Estate Index Fund 181,752 234,337
    Vanguard Small Cap Index Fund 270,553 492,146

    TY 2020 OtherProfessionalFeesSchedule
    Name:
    Assurity Life Foundation
    EIN:
    47-0775374
    Software ID:
    20011376
    Software Version:
    ta20mefv1.0
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    Investment Expenses 105 105    


    TY 2020 TaxesSchedule
    Name:
    Assurity Life Foundation
    EIN:
    47-0775374
    Software ID:
    20011376
    Software Version:
    ta20mefv1.0
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    Excise TaxInvestment Inc 2,540      
    Foreign Taxes Paid 563 563