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
VOLLMER M FBO POLYCLINIC IR TUA
 
Number and street (or P.O. box number if mail is not delivered to street address)6325 S RAINBOW BLVD STE 300
  Room/suite
City or town, state or province, country, and ZIP or foreign postal code
LAS VEGAS, NV89118
A Employer identification number

23-6645698
B Telephone number (see instructions)

(888) 730-4933
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$797,554J 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      
4 Dividends and interest from securities... 19,789 19,734  
5a Gross rents............      
b Net rental income or (loss)  
6a Net gain or (loss) from sale of assets not on line 10 13,353
b Gross sales price for all assets on line 6a 355,241
7 Capital gain net income (from Part IV, line 2)... 13,353
8 Net short-term capital gain......... 0
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........ 33,142 33,087  
Operating and Administrative Expenses 13 Compensation of officers, directors, trustees, etc. 11,103 9,993   1,110
14 Other employee salaries and wages......   0 0 0
15 Pension plans, employee benefits.......   0 0  
16a Legal fees (attach schedule).........       0
b Accounting fees (attach schedule)....... Click to see attachment 958 0 0 958
c Other professional fees (attach schedule)....       0
17 Interest...............       0
18 Taxes (attach schedule) (see instructions)... Click to see attachment 838 315   0
19 Depreciation (attach schedule) and depletion... 0 0  
20 Occupancy..............        
21 Travel, conferences, and meetings.......   0 0  
22 Printing and publications..........   0 0  
23 Other expenses (attach schedule)....... Click to see attachment 4 4    
24 Total operating and administrative expenses.
Add lines 13 through 23.......... 12,903 10,312 0 2,068
25 Contributions, gifts, grants paid....... 28,000 28,000
26 Total expenses and disbursements. Add lines 24 and 25 40,903 10,312 0 30,068
27 Subtract line 26 from line 12:
a Excess of revenue over expenses and disbursements -7,761
b Net investment income (if negative, enter -0-) 22,775
c Adjusted net income (if negative, enter -0-)... 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......... 25,327 18,452 18,452
3 Accounts receivable bullet  
Less: allowance for doubtful accounts bullet     0 0
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 bullet0      
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).......   Click to see attachment146,738 249,157
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).......... 599,348 Click to see attachment451,496 529,945
14 Land, buildings, and equipment: basis bullet  
Less: accumulated depreciation (attach schedule) bullet        
15 Other assets (describe bullet)      
16 Total assets (to be completed by all filers—see the
instructions. Also, see page 1, item I) 624,675 616,686 797,554
Liabilities 17 Accounts payable and accrued expenses..........    
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)    
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........ 624,675 616,686
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)..... 624,675 616,686
30 Total liabilities and net assets/fund balances (see instructions). 624,675 616,686
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
624,675
2
Enter amount from Part I, line 27a .....................
2
-7,761
3
Other increases not included in line 2 (itemize) bullet
3
0
4
Add lines 1, 2, and 3 ..........................
4
616,914
5
Decreases not included in line 2 (itemize) bulletClick to see attachment
5
228
6
Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 29 .
6
616,686
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 21. ZOETIS INC   2017-04-25 2020-02-03
b 35.523 AMER CENT SMALL CAP GRWTH INST 336   2019-10-25 2020-02-14
c 25.477 AMER CENT SMALL CAP GRWTH INST 336   2018-02-09 2020-02-14
d 15.051 ARTISAN MID CAP FUND-INS 1333   2019-10-25 2020-02-14
e 52.949 ARTISAN MID CAP FUND-INS 1333   2012-09-19 2020-02-14
1.926 JPMORGAN MID CAP VALUE-R6 #2335   2019-08-08 2020-02-14
623.183 JPMORGAN MID CAP VALUE-R6 #2335   2014-01-30 2020-02-14
233.638 T ROWE PR REAL ESTATE-I #432   2016-01-25 2020-02-14
171. SPDR DJ WILSHIRE INTERNATIONAL R ETF   2017-01-20 2020-02-14
4. APPLE INC   2019-08-09 2020-02-18
3. CME GROUP INC   2013-07-29 2020-02-18
10. CVS HEALTH CORPORATION   2017-08-09 2020-02-18
8. CELANESE CORP   2013-07-29 2020-02-18
4. CELANESE CORP   2019-02-26 2020-02-18
4. DIAGEO PLC - ADR   2019-08-09 2020-02-18
6. EOG RESOURCES, INC   2019-08-09 2020-02-18
4. ELECTRONIC ARTS INC   2019-12-24 2020-02-18
5. FIDELITY NATL INFORMATION SVCS INC   2019-10-21 2020-02-18
17. HAIN CELESTIAL GROUP INC   2016-01-04 2020-02-18
2. LAM RESEARCH CORP COM   2018-11-19 2020-02-18
7. LAS VEGAS SANDS CORP   2014-09-10 2020-02-18
10. MICROSOFT CORP   2019-08-09 2020-02-18
8. MONDELEZ INTERNATIONAL INC   2019-08-09 2020-02-18
7. NIKE INC CL B   2019-08-09 2020-02-18
3. PNC FINANCIAL SERVICES GROUP   2019-08-09 2020-02-18
2. THERMO FISHER SCIENTIFIC INC   2013-07-29 2020-02-18
8. TORONTO DOMINION BK ONT COM NEW   2019-06-20 2020-02-18
6. UNITEDHEALTH GROUP INC   2019-08-09 2020-02-18
49. FLEXTRONICS INTL LTD   2018-03-07 2020-02-18
111.973 INV OPP DEVELOP MRKTS-R6 7038   2012-09-19 2020-04-03
10.39 INV OPP DEVELOP MRKTS-R6 7038   2020-02-20 2020-04-03
196.841 EATON VANCE GLOB MACRO ADV-I 208   2017-10-26 2020-04-03
21.657 FIDELITY NEW MRKTS INC-Z #3323   2020-02-20 2020-04-03
1.244 FIDELITY NEW MRKTS INC-Z #3323   2015-11-20 2020-04-03
281. ISHARES CORE MSCI EMERGING ETF   2019-08-08 2020-04-03
1811.794 METROPOLITAN WEST T/R BD-PLN #712   2019-08-08 2020-04-03
1650.481 METROPOLITAN WEST T/R BD-PLN #712   2019-10-25 2020-04-03
952.772 PIMCO TOTAL RET FD-INST #35   2019-08-08 2020-04-03
132.008 PIMCO TOTAL RET FD-INST #35   2020-02-20 2020-04-03
170.884 PIMCO HIGH YIELD FD-INST #108   2019-10-11 2020-04-03
13.17 T ROWE PR OVERSEAS STOCK-I #521   2020-02-20 2020-04-03
1736.486 T ROWE PR OVERSEAS STOCK-I #521   2017-04-26 2020-04-03
6. HOME DEPOT INC   2019-08-09 2020-04-06
8. HOME DEPOT INC   2017-03-31 2020-04-06
4. PNC FINANCIAL SERVICES GROUP   2019-08-09 2020-04-06
16. PNC FINANCIAL SERVICES GROUP   2015-05-27 2020-04-06
6. EATON CORP PLC   2019-08-09 2020-04-06
37. EATON CORP PLC   2013-07-29 2020-04-06
.687 RAYTHEON TECHNOLOGIES CORP   2019-09-10 2020-04-29
12.368 INV OPP DEVELOP MRKTS-R6 7038   2012-09-19 2020-05-15
168.228 AMER CENT SMALL CAP GRWTH INST 336   2020-04-03 2020-05-15
1120.189 AMER CENT SMALL CAP GRWTH INST 336   2015-07-24 2020-05-15
69.071 ARTISAN MID CAP FUND-INS 1333   2012-09-19 2020-05-15
2276.409 PIMCO HIGH YIELD FD-INST #108   2019-10-11 2020-05-15
24.256 T ROWE PR OVERSEAS STOCK-I #521   2017-04-26 2020-05-15
7.818 STERLING CAPITAL STRATTON SMALL CAP   2019-08-08 2020-05-15
83.971 STERLING CAPITAL STRATTON SMALL CAP   2020-02-20 2020-05-15
260.922 STERLING CAPITAL STRATTON SMALL CAP   2014-07-10 2020-05-15
15. VANGUARD MIDCAP VIPER   2020-02-14 2020-05-15
1. BOEING CO   2019-11-11 2020-05-21
4. BOEING CO   2019-02-26 2020-05-21
33. EOG RESOURCES, INC   2019-08-09 2020-05-21
928.525 JAMES ALPHA GL REAL EST-I   2020-02-20 2020-06-25
8. TJX COMPANIES INC   2019-08-09 2020-07-07
16. TJX COMPANIES INC   2020-04-06 2020-07-07
32. TJX COMPANIES INC   2013-07-29 2020-07-07
1. APPLE INC   2019-08-09 2020-08-25
21. HAIN CELESTIAL GROUP INC   2016-01-04 2020-08-25
13. TORONTO DOMINION BK ONT COM NEW   2019-06-20 2020-08-25
5. UNITED PARCEL SERVICE-CL B   2017-03-24 2020-08-25
10. APPLE INC   2013-07-29 2020-09-14
20. CVS HEALTH CORPORATION   2019-09-27 2020-09-14
11. CVS HEALTH CORPORATION   2013-07-29 2020-09-14
8. TE CONNECTIVITY LTD   2017-05-23 2020-09-14
56.868 INV OPP DEVELOP MRKTS-R6 7038   2012-09-19 2020-09-25
54.966 ARTISAN MID CAP FUND-INS 1333   2012-09-19 2020-09-25
132. INVESCO OPTIMUM YIELD DIVERS   2020-04-03 2020-09-25
1779.194 METROPOLITAN WEST T/R BD-PLN #712   2015-06-15 2020-09-25
500.657 METROPOLITAN WEST T/R BD-PLN #712   2020-05-15 2020-09-25
987.479 METROPOLITAN WEST T/R BD-PLN #712   2019-12-10 2020-09-25
292.784 PIMCO TOTAL RET FD-INST #35   2020-05-15 2020-09-25
316.832 PIMCO TOTAL RET FD-INST #35   2019-08-08 2020-09-25
360.33 PIMCO TOTAL RET FD-INST #35   2019-10-25 2020-09-25
136.049 T ROWE PR OVERSEAS STOCK-I #521   2017-04-26 2020-09-25
86.949 TCW EMRG MKTS INCM-I 4721   2019-10-25 2020-09-25
67.661 TOUCHSTONE MID CAP-INST #353   2020-02-20 2020-09-25
42. APPLE INC   2013-07-29 2020-09-28
2. BLACKROCK INC   2019-04-01 2020-09-28
12. CVS HEALTH CORPORATION   2013-07-29 2020-09-28
10. COGNIZANT TECH SOLUTIONS CRP COM   2019-08-09 2020-09-28
2. GILEAD SCIENCES INC   2019-08-09 2020-09-28
9. GILEAD SCIENCES INC   2020-04-06 2020-09-28
20. HAIN CELESTIAL GROUP INC   2017-06-27 2020-09-28
7. JPMORGAN CHASE & CO   2018-11-19 2020-09-28
2. LAM RESEARCH CORP COM   2019-08-09 2020-09-28
14. LAS VEGAS SANDS CORP   2014-09-10 2020-09-28
5. MICROSOFT CORP   2020-04-06 2020-09-28
3. MICROSOFT CORP   2019-08-09 2020-09-28
8. MONDELEZ INTERNATIONAL INC   2020-04-06 2020-09-28
22. MONDELEZ INTERNATIONAL INC   2018-11-19 2020-09-28
15. NIKE INC CL B   2017-10-30 2020-09-28
21. UNILEVER N.V. - ADR   2020-02-03 2020-09-28
10. UNITED PARCEL SERVICE-CL B   2013-07-29 2020-09-28
4. VISA INC-CLASS A SHRS   2020-04-06 2020-09-28
7. TE CONNECTIVITY LTD   2016-11-09 2020-09-28
24.993 INV OPP DEVELOP MRKTS-R6 7038   2012-09-19 2020-12-09
541.322 EV GL MACR ABS RTRN ADV-R6 #1072   2017-10-26 2020-12-09
476. INVESCO OPTIMUM YIELD DIVERS   2020-04-03 2020-12-09
248.775 PIMCO TOTAL RET FD-INST #35   2019-12-10 2020-12-09
40.047 T ROWE PR OVERSEAS STOCK-I #521   2017-04-26 2020-12-09
46.898 TOUCHSTONE MID CAP-INST #353   2020-02-20 2020-12-09
103.144 TRIBUTARY SMALL CO-INST PLUS #1705   2020-05-15 2020-12-09
19. VANGUARD MIDCAP VIPER   2020-02-14 2020-12-09
2. CME GROUP INC   2013-07-29 2020-12-14
3. CME GROUP INC   2020-04-06 2020-12-14
9. GILEAD SCIENCES INC   2013-07-29 2020-12-14
38. SPIRIT AEROSYTSEMS HOLD-CL A   2016-10-03 2020-12-14
27. SUNCOR ENERGY INC NEW F   2018-11-19 2020-12-14
105. FLEXTRONICS INTL LTD   2018-03-07 2020-12-14
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
CAPITAL GAIN DIVIDENDS P    
(e)
Gross sales price 		(f)
Depreciation allowed
(or allowable) 		(g)
Cost or other basis
plus expense of sale 		(h)
Gain or (loss)
(e) plus (f) minus (g)
a 2,846   1,331 1,515
b 710   638 72
c 510   436 74
d 656   624 32
e 2,309   2,189 120
77   73 4
25,027   21,205 3,822
6,332   6,056 276
6,744   6,228 516
1,277   801 476
638   224 414
717   794 -77
859   422 437
429   414 15
648   655 -7
447   479 -32
438   435 3
775   643 132
446   677 -231
650   288 362
477   481 -4
1,873   1,375 498
477   440 37
714   573 141
454   393 61
674   181 493
454   465 -11
1,809   1,483 326
646   903 -257
3,825   3,777 48
355   466 -111
1,880   2,102 -222
275   332 -57
16   19 -3
11,071   13,582 -2,511
18,969   18,850 119
17,281   17,054 227
10,042   10,005 37
1,391   1,394 -3
1,328   1,537 -209
106   145 -39
13,996   17,417 -3,421
1,127   1,252 -125
1,502   1,176 326
377   523 -146
1,506   1,398 108
463   465 -2
2,856   2,096 760
46   57 -11
458   417 41
2,986   2,298 688
19,883   17,040 2,843
2,978   2,855 123
18,621   20,231 -1,610
213   243 -30
429   603 -174
4,609   4,538 71
14,322   20,577 -6,255
2,193   2,785 -592
139   368 -229
554   1,714 -1,160
1,715   2,633 -918
14,541   17,060 -2,519
409   427 -18
817   736 81
1,634   830 804
495   200 295
647   792 -145
634   755 -121
793   547 246
1,146   160 986
1,162   1,238 -76
639   697 -58
796   689 107
2,528   1,918 610
2,928   2,272 656
1,790   1,570 220
19,447   18,104 1,343
5,472   5,337 135
10,793   10,171 622
3,203   3,124 79
3,466   3,317 149
3,942   3,758 184
1,409   1,365 44
693   750 -57
2,622   2,847 -225
4,825   673 4,152
1,118   874 244
696   741 -45
693   625 68
125   130 -5
564   689 -125
672   584 88
673   773 -100
674   391 283
666   818 -152
1,046   807 239
628   413 215
456   418 38
1,253   1,082 171
1,866   907 959
1,272   1,236 36
1,687   939 748
801   657 144
680   490 190
1,291   843 448
5,911   5,792 119
6,937   5,663 1,274
2,627   2,595 32
476   402 74
2,089   1,973 116
3,046   2,053 993
3,874   3,528 346
358   149 209
538   545 -7
541   572 -31
1,388   2,329 -941
492   890 -398
1,750   1,788 -38
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
      3,897
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       1,515
b       72
c       74
d       32
e       120
      4
      3,822
      276
      516
      476
      414
      -77
      437
      15
      -7
      -32
      3
      132
      -231
      362
      -4
      498
      37
      141
      61
      493
      -11
      326
      -257
      48
      -111
      -222
      -57
      -3
      -2,511
      119
      227
      37
      -3
      -209
      -39
      -3,421
      -125
      326
      -146
      108
      -2
      760
      -11
      41
      688
      2,843
      123
      -1,610
      -30
      -174
      71
      -6,255
      -592
      -229
      -1,160
      -918
      -2,519
      -18
      81
      804
      295
      -145
      -121
      246
      986
      -76
      -58
      107
      610
      656
      220
      1,343
      135
      622
      79
      149
      184
      44
      -57
      -225
      4,152
      244
      -45
      68
      -5
      -125
      88
      -100
      283
      -152
      239
      215
      38
      171
      959
      36
      748
      144
      190
      448
      119
      1,274
      32
      74
      116
      993
      346
      209
      -7
      -31
      -941
      -398
      -38
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
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 13,353
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................................ 1 317
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........................... 3 317
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- ..... 5 317
6 Credits/Payments:
a 2020 estimated tax payments and 2019 overpayment credited to 2020 6a 444
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  
7 Total credits and payments. Add lines 6a through 6d.............. 7 444
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  
10 Overpayment. If line 7 is more than the total of lines 5 and 8, enter the amount overpaid...Bullet 10 127
11 Enter the amount of line 10 to be: Credited to 2021 estimated taxBullet127 RefundedBullet 11 0
Part VII-A
Statements Regarding Activities
1a
During the tax year, did the foundation attempt to influence any national, state, or local legislation or did
Yes
No
it participate or intervene in any political campaign? ....................
1a
 
No
b
Did it spend more than $100 during the year (either directly or indirectly) for political purposes? See 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
 
 
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)
    bulletPA
    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 addressbulletN/A
    14
    The books are in care ofbulletWELLS FARGO BANK NA Telephone no.bullet (888) 730-4933

    Located atbullet100 N MAIN ST MAC D4001-117WINSTON SALEMNC ZIP+4bullet27101
    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
    WELLS FARGO BANK N A TRUSTEE
    1     		11,103    
    100 N MAIN ST MAC D4001-117
    WINSTON SALEM,NC27101
    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.........................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
    677,899
    b
    Average of monthly cash balances.......................
    1b
    28,717
    c
    Fair market value of all other assets (see instructions)................
    1c
    0
    d
    Total (add lines 1a, b, and c).........................
    1d
    706,616
    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
    706,616
    4
    Cash deemed held for charitable activities. Enter 1 1/2% of line 3 (for greater amount, see
    instructions) .............................
    4
    10,599
    5
    Net value of noncharitable-use assets. Subtract line 4 from line 3. Enter here and on Part V, line 4
    5
    696,017
    6
    Minimum investment return. Enter 5% of line 5..................
    6
    34,801
    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
    34,801
    2a
    Tax on investment income for 2020 from Part VI, line 5......
    2a
    317
    b
    Income tax for 2020. (This does not include the tax from Part VI.)...
    2b
     
    c
    Add lines 2a and 2b............................
    2c
    317
    3
    Distributable amount before adjustments. Subtract line 2c from line 1............
    3
    34,484
    4
    Recoveries of amounts treated as qualifying distributions................
    4
    0
    5
    Add lines 3 and 4............................
    5
    34,484
    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
    34,484
    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
    30,068
    b
    Program-related investments—total from Part IX-B..................
    1b
    0
    2
    Amounts paid to acquire assets used (or held for use) directly in carrying out charitable, etc.,
    purposes...............................
    2
    0
    3
    Amounts set aside for specific charitable projects that satisfy the:
    a
    Suitability test (prior IRS approval required)....................
    3a
    0
    b
    Cash distribution test (attach the required schedule) .................
    3b
    0
    4
    Qualifying distributions. Add lines 1a through 3b. Enter here and on Part V, line 8, and Part XIII, line 4
    4
    30,068
    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
    30,068
    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 34,484
    2 Undistributed income, if any, as of the end of 2020:
    a Enter amount for 2019 only....... 9,455
    b Total for prior years:20, 20, 20 0
    3 Excess distributions carryover, if any, to 2020:
    a From 2015...... 0
    b From 2016...... 0
    c From 2017...... 0
    d From 2018...... 0
    e From 2019...... 0
    fTotal of lines 3a through e........ 0
    4Qualifying distributions for 2020 from Part
    XII, line 4: bullet$ 30,068
    a Applied to 2019, but not more than line 2a 9,455
    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..... 20,613
    e Remaining amount distributed out of corpus 0
    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 0
    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 ..........     		13,871
    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) ...     		0
    9Excess distributions carryover to 2021.
    Subtract lines 7 and 8 from line 6a ......     		0
    10 Analysis of line 9:
    a Excess from 2016.... 0
    b Excess from 2017.... 0
    c Excess from 2018.... 0
    d Excess from 2019.... 0
    e Excess from 2020.... 0
    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).)
    NONE
    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.
    NONE
    2Information Regarding Contribution, Grant, Gift, Loan, Scholarship, etc., Programs:
    Check here bullet
    aThe name, address, and telephone number or email address of the person to whom applications should be addressed:
    bThe form in which applications should be submitted and information and materials they should include:
    cAny submission deadlines:
    dAny restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other
    factors:
    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
    PINNACLE HEALTH SYSTEM
    409 S 2ND ST ATTN BONNIE MILLER
    HARRISBURG,PA171058700     		NONE PC GENERAL OPERATING 28,000
    Total .................................bullet 3a 28,000
    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 ...........     		         
    4 Dividends and interest from securities....     14 19,789  
    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 13,353  
    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)..   33,142  
    13Total. Add line 12, columns (b), (d), and (e)..................
    13
    33,142
    (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:  
    Software Version:  


    Form 990PF - Special Condition Description:
    Special Condition Description

    TY 2020 AccountingFeesSchedule
    Name:
    VOLLMER M FBO POLYCLINIC IR TUA
    EIN:
    23-6645698
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    TAX PREPARATION FEE (NON-ALLOC 958     958

    TY 2020 InvestmentsCorpStockSchedule
    Name:
    VOLLMER M FBO POLYCLINIC IR TUA
    EIN:
    23-6645698
    Name of Stock End of Year Book Value End of Year Fair Market Value
    02079K107 ALPHABET INC CL C 7,678 14,015
    285512109 ELECTRONIC ARTS INC 3,664 5,888
    037833100 APPLE INC 3,572 18,577
    25243Q205 DIAGEO PLC - ADR 4,426 5,400
    11135F101 BROADCOM INC 4,845 7,881
    150870103 CELANESE CORP 2,415 5,587
    09260D107 BLACKSTONE GROUP INC 3,261 3,953
    58933Y105 MERCK & CO INC NEW 2,615 3,845
    126650100 CVS HEALTH CORPORATI 2,870 3,278
    891160509 TORONTO DOMINION BK 4,400 4,626
    31620M106 FIDELITY NATL INFORM 3,212 3,678
    097023105 BOEING CO 2,273 3,425
    254687106 WALT DISNEY CO 2,061 5,254
    172967424 CITIGROUP INC. 6,061 7,091
    594918104 MICROSOFT CORP 3,119 18,683
    911312106 UNITED PARCEL SERVIC 2,801 5,220
    91324P102 UNITEDHEALTH GROUP I 2,992 9,118
    00206R102 AT & T INC 6,799 5,723
    92826C839 VISA INC-CLASS A SHR 2,628 3,500
    375558103 GILEAD SCIENCES INC 1,004 932
    867224107 SUNCOR ENERGY INC NE 3,528 2,383
    G5960L103 MEDTRONIC PLC 3,927 4,568
    H2906T109 GARMIN LTD 2,969 3,590
    871829107 SYSCO CORP 3,118 4,827
    09857L108 BOOKING HOLDINGS INC 1,349 2,227
    75513E101 RAYTHEON TECHNOLOGIE 2,645 2,288
    192446102 COGNIZANT TECH SOLUT 3,254 4,753
    Y2573F102 FLEX LTD 2,462 4,279
    907818108 UNION PACIFIC CORP 2,294 6,038
    89151E109 TOTAL S.A. - ADR 4,839 3,940
    56501R106 MANULIFE FINANCIAL C 4,164 5,007
    405217100 HAIN CELESTIAL GROUP 1,266 2,329
    17275R102 CISCO SYSTEMS INC 3,587 5,325
    883556102 THERMO FISHER SCIENT 905 4,658
    031162100 AMGEN INC 2,462 2,299
    512807108 LAM RESEARCH CORP CO 2,027 5,195
    H84989104 TE CONNECTIVITY LTD 1,825 3,390
    532457108 ELI LILLY & CO COM 2,150 4,559
    654106103 NIKE INC CL B 2,656 6,083
    12572Q105 CME GROUP INC 668 1,638
    904767704 UNILEVER PLC - ADR 2,232 2,414
    87612E106 TARGET CORP 1,800 5,119
    09247X101 BLACKROCK INC 2,661 5,772
    609207105 MONDELEZ INTERNATION 2,923 3,976
    94106L109 WASTE MANAGEMENT INC 3,468 4,128
    46625H100 JPMORGAN CHASE & CO 4,762 7,751
    517834107 LAS VEGAS SANDS CORP 4,101 4,947

    TY 2020 InvestmentsOtherSchedule2
    Name:
    VOLLMER M FBO POLYCLINIC IR TUA
    EIN:
    23-6645698
    Category/ Item Listed at Cost or FMV Book Value End of Year Fair Market Value
    25243Q205 DIAGEO PLC - ADR      
    56501R106 MANULIFE FINANCIAL C      
    46625H100 JPMORGAN CHASE & CO      
    98978V103 ZOETIS INC      
    87234N765 TCW EMRG MKTS INCM-I AT COST 29,845 31,780
    02079K107 ALPHABET INC/CA      
    H84989104 TE CONNECTIVITY LTD      
    097023105 BOEING COMPANY      
    17275R102 CISCO SYSTEMS INC      
    437076102 HOME DEPOT INC      
    654106103 NIKE INC CL B      
    26875P101 EOG RESOURCES, INC      
    911312106 UNITED PARCEL SERVIC      
    04314H600 ARTISAN MID CAP FUND AT COST 18,479 24,833
    025083320 AMER CENT SMALL CAP      
    172967424 CITIGROUP INC      
    848574109 SPIRIT AEROSYTSEMS H      
    46434G103 ISHARES CORE MSCI EM      
    G29183103 EATON CORP PLC      
    12572Q105 CME GROUP INC      
    037833100 APPLE COMPUTER INC C      
    872540109 TJX COS INC NEW      
    867224107 SUNCOR ENERGY INC NE      
    Y2573F102 FLEXTRONICS INTL LTD      
    512807108 LAM RESEARCH CORP CO      
    91324P102 UNITEDHEALTH GROUP I      
    85917K546 STERLING CAPITAL STR      
    609207105 MONDELEZ INTERNATION      
    594918104 MICROSOFT CORP      
    87612E106 TARGET CORP      
    339128100 JP MORGAN MID CAP VA      
    150870103 CELANESE CORP      
    192446102 COGNIZANT TECH SOLUT      
    254687106 WALT DISNEY CO      
    89151E109 TOTAL FINA ELF S.A.      
    58933Y105 MERCK & CO INC NEW      
    517834107 LAS VEGAS SANDS CORP      
    00206R102 AT & T INC      
    592905764 METROPOLITAN WEST T/ AT COST 65,124 68,185
    78463X863 SPDR DJ WILSHIRE INT      
    126650100 CVS/CAREMARK CORPORA      
    375558103 GILEAD SCIENCES INC      
    532457108 ELI LILLY & CO COM      
    693475105 PNC FINANCIAL SERVIC      
    09247X101 BLACKROCK INC      
    277923264 EATON VANCE GLOB MAC      
    883556102 THERMO FISHER SCIENT      
    907818108 UNION PACIFIC CORP      
    405217100 HAIN CELESTIAL GROUP      
    77956H435 T ROWE PR OVERSEAS S AT COST 19,991 23,998
    779919307 T ROWE PR REAL ESTAT      
    31620M106 FIDELITY NATL INFORM      
    G5960L103 MEDTRONIC PLC      
    31641Q755 FIDELITY NEW MRKTS I AT COST 15,719 15,982
    00143W859 INV OPP DEVELOP MRKT AT COST 19,929 32,416
    693390700 PIMCO TOTAL RET FD-I AT COST 36,508 38,139
    11135F101 BROADCOM INC      
    922908629 VANGUARD MIDCAP VIPE AT COST 40,437 55,828
    755111507 RAYTHEON CO      
    285512109 ELECTRONIC ARTS INC      
    891160509 TORONTO DOMINION BK      
    693390841 PIMCO HIGH YIELD FD-      
    27830W108 EV GL MACR ABS RTRN AT COST 15,327 14,938
    74440Y884 PGIM HIGH YIELD-Q 10 AT COST 80,685 86,834
    89155T649 TOUCHSTONE MID CAP-I AT COST 36,901 46,866
    89154Q562 TOUCHSTONE SANDS EM AT COST 23,639 24,710
    89609H704 TRIBUTARY SMALL CO-I AT COST 10,784 16,198
    464287655 ISHARES RUSSELL 2000 AT COST 25,286 32,742
    46090F100 INVESCO OPTIMUM YIEL AT COST 12,842 16,496

    TY 2020 OtherDecreasesSchedule
    Name:
    VOLLMER M FBO POLYCLINIC IR TUA
    EIN:
    23-6645698
    Description Amount
    MUTUAL FUND TIMING ADJ 87
    TAX LOT ADJUSTMENT 109
    COST BASIS ADJUSTMENT 32


    TY 2020 OtherExpensesSchedule
    Name:
    VOLLMER M FBO POLYCLINIC IR TUA
    EIN:
    23-6645698
    Description Revenue and Expenses per Books Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    INVESTMENT EXPENSES - ADR FEES 4 4   0


    TY 2020 TaxesSchedule
    Name:
    VOLLMER M FBO POLYCLINIC IR TUA
    EIN:
    23-6645698
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    FOREIGN TAXES 299 299   0
    FEDERAL TAX PAYMENT - PRIOR YE 79 0   0
    FEDERAL ESTIMATES - PRINCIPAL 444 0   0
    FOREIGN TAXES ON NONQUALIFIED 16 16   0