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
FOUNDATION FOR HOSPICE NORTHERN UT
 
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

87-0541883
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$1,804,186J 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... 39,456 39,456  
5a Gross rents............      
b Net rental income or (loss)  
6a Net gain or (loss) from sale of assets not on line 10 72,345
b Gross sales price for all assets on line 6a 548,487
7 Capital gain net income (from Part IV, line 2)... 72,345
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)....... Click to see attachment 1,080 1,080  
12 Total. Add lines 1 through 11........ 112,881 112,881  
Operating and Administrative Expenses 13 Compensation of officers, directors, trustees, etc. 12,115 9,086   3,029
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).......        
c Other professional fees (attach schedule)....       0
17 Interest...............       0
18 Taxes (attach schedule) (see instructions)... Click to see attachment 1,924 491   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).......        
24 Total operating and administrative expenses.
Add lines 13 through 23.......... 14,039 9,577 0 3,029
25 Contributions, gifts, grants paid....... 160,000 160,000
26 Total expenses and disbursements. Add lines 24 and 25 174,039 9,577 0 163,029
27 Subtract line 26 from line 12:
a Excess of revenue over expenses and disbursements -61,158
b Net investment income (if negative, enter -0-) 103,304
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......... 52,701 55,873 55,873
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).......      
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).......... 1,404,711 Click to see attachment1,338,416 1,748,313
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) 1,457,412 1,394,289 1,804,186
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........ 1,457,412 1,394,289
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)..... 1,457,412 1,394,289
30 Total liabilities and net assets/fund balances (see instructions). 1,457,412 1,394,289
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
1,457,412
2
Enter amount from Part I, line 27a .....................
2
-61,158
3
Other increases not included in line 2 (itemize) bulletClick to see attachment
3
13
4
Add lines 1, 2, and 3 ..........................
4
1,396,267
5
Decreases not included in line 2 (itemize) bulletClick to see attachment
5
1,978
6
Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 29 .
6
1,394,289
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 44.121 INVESCO SMALL CAP GROWTH FD-R5 4764   2013-10-04 2020-01-17
b 17.795 INV OPP DEVELOP MRKTS-R6 7038   2019-12-13 2020-01-17
c 18.553 INV OPP DEVELOP MRKTS-R6 7038   2018-09-21 2020-01-17
d .977 DODGE & COX STOCK FUND #145   2017-12-18 2020-01-17
e 71.726 T ROWE PRICE LARGE/CAP GRW-I 139     2020-01-17
8.979 VANGUARD 500 INDEX FD- ADM #540     2020-01-17
112.478 VOYA LARGE-CAP GROWTH FND-I     2020-01-17
9.322 INVESCO SMALL CAP GROWTH FD-R5 4764   2013-10-04 2020-01-21
21.439 INV OPP DEVELOP MRKTS-R6 7038     2020-01-21
28.847 ACADIAN EMG MRKTS PORT-I #1960   2019-12-30 2020-01-21
92.161 ACADIAN EMG MRKTS PORT-I #1960   2018-09-21 2020-01-21
76.249 CAUSEWAY INTL VALUE FD-I 1271   2014-07-17 2020-01-21
38.087 DODGE & COX INCOME FD COM #147   2019-11-18 2020-01-21
198.659 DODGE & COX INCOME FD COM #147   2019-09-06 2020-01-21
12.648 DODGE & COX STOCK FUND #145   2017-12-18 2020-01-21
38.778 AMER FNDS EUROPAC GROW-F3716   2018-03-16 2020-01-21
291.487 FEDERATED TOTAL RET BD-IS 328     2020-01-21
23.84 T ROWE PRICE LARGE/CAP GRW-I 139   2019-08-16 2020-01-21
30.769 T ROWE PRICE LARGE/CAP GRW-I 139   2013-10-04 2020-01-21
29.443 JPMORGAN SMALL CAP EQTY-I 367     2020-01-21
6.857 JPMORGAN SMALL CAP EQTY-I 367     2020-01-21
105.245 LAZARD INTL EQTY PORT-INSTL 632     2020-01-21
2.258 LAZARD INTL EQTY PORT-INSTL 632   2019-12-20 2020-01-21
51.571 MFS VALUE FUND-R6 4810   2013-10-04 2020-01-21
29.094 MFS VALUE FUND-R6 4810   2019-12-19 2020-01-21
294.853 MET WEST TOTAL RETURN BOND CL I #512     2020-01-21
240.954 NORTHERN MID CAP INDEX #629     2020-01-21
43.728 NORTHERN MID CAP INDEX #629   2018-09-24 2020-01-21
61.023 T ROWE PRICE EQUITY INCOME #71     2020-01-21
11.377 VANGUARD 500 INDEX FD- ADM #540   2013-10-04 2020-01-21
16.987 VANGUARD 500 INDEX FD- ADM #540     2020-01-21
17.974 VOYA LARGE-CAP GROWTH FND-I   2019-12-16 2020-01-21
33.446 VOYA LARGE-CAP GROWTH FND-I   2017-06-07 2020-01-21
.343 WF CORE BD FD-I 944   2016-09-13 2020-01-21
17.62807 WF CORE BD FD-I 944     2020-01-21
227.27493 WF CORE BD FD-I 944   2019-09-06 2020-01-21
41.078 WF GROWTH FUND - I 3105     2020-01-21
51.522 T ROWE PRICE LARGE/CAP GRW-I 139   2013-10-04 2020-02-10
56.737 VANGUARD 500 INDEX FD- ADM #540   2013-10-04 2020-02-10
48.384 VOYA LARGE-CAP GROWTH FND-I   2017-06-07 2020-02-10
630.989 DODGE & COX INCOME FD COM #147     2020-03-17
915.5982 DODGE & COX INCOME FD COM #147   2014-12-16 2020-03-17
62.2948 DODGE & COX INCOME FD COM #147   2014-12-16 2020-03-17
832.73 FEDERATED TOTAL RET BD-IS 328     2020-03-17
1274.43175 FEDERATED TOTAL RET BD-IS 328   2013-10-04 2020-03-17
25.84125 FEDERATED TOTAL RET BD-IS 328   2013-10-04 2020-03-17
958.64083 MET WEST TOTAL RETURN BOND CL I #512     2020-03-17
19.07917 MET WEST TOTAL RETURN BOND CL I #512   2019-08-09 2020-03-17
1380.786 MET WEST TOTAL RETURN BOND CL I #512     2020-03-17
719.98464 WF CORE BD FD-I 944     2020-03-17
12.90436 WF CORE BD FD-I 944   2019-08-09 2020-03-17
1143.84 WF CORE BD FD-I 944     2020-03-17
.343 WF CORE BD FD-I 944   2016-08-23 2020-03-17
135.271 T ROWE PRICE LARGE/CAP GRW-I 139   2020-03-17 2020-04-17
46.521 T ROWE PRICE LARGE/CAP GRW-I 139   2013-10-04 2020-04-17
129.702 NORTHERN MID CAP INDEX #629   2019-08-16 2020-04-17
44.914 VANGUARD 500 INDEX FD- ADM #540     2020-04-17
87.17 VOYA LARGE-CAP GROWTH FND-I   2020-03-17 2020-04-17
44.767 VOYA LARGE-CAP GROWTH FND-I   2017-06-07 2020-04-17
89.661 WF GROWTH FUND - I 3105     2020-04-17
80.2447 INVESCO SMALL CAP GROWTH FD-R5 4764   2013-10-04 2020-05-19
18.5803 INVESCO SMALL CAP GROWTH FD-R5 4764   2013-10-04 2020-05-19
11.427 DODGE & COX STOCK FUND #145   2017-12-18 2020-05-19
46.287 AMER FNDS EUROPAC GROW-F3716   2018-03-16 2020-05-19
58.634 T ROWE PRICE LARGE/CAP GRW-I 139   2013-10-04 2020-05-19
47.791 JPMORGAN SMALL CAP EQTY-I 367   2013-10-04 2020-05-19
19.117 NORTHERN MID CAP INDEX #629   2019-08-16 2020-05-19
559.505 NORTHERN MID CAP INDEX #629   2013-10-04 2020-05-19
7.107 VANGUARD 500 INDEX FD- ADM #540   2020-03-17 2020-05-19
59.439 WF GROWTH FUND - I 3105   2014-12-11 2020-05-19
439.704 CAUSEWAY INTL VALUE FD-I 1271   2014-07-17 2020-06-16
43.024 AMER FNDS EUROPAC GROW-F3716   2018-03-16 2020-06-16
71.348 LAZARD INTL EQTY PORT-INSTL 632   2019-12-20 2020-06-16
100.011 LAZARD INTL EQTY PORT-INSTL 632     2020-06-16
191.366 NORTHERN MID CAP INDEX #629   2013-10-04 2020-06-16
39.101 AMER FNDS EUROPAC GROW-F3716   2018-03-16 2020-07-17
41.641 T ROWE PRICE LARGE/CAP GRW-I 139   2013-10-04 2020-07-17
.837 JPMORGAN SMALL CAP EQTY-I 367   2013-10-04 2020-07-17
7.041 VANGUARD 500 INDEX FD- ADM #540     2020-07-17
29.2 VOYA LARGE-CAP GROWTH FND-I   2017-06-07 2020-07-17
21.434 WF GROWTH FUND - I 3105   2014-12-11 2020-07-17
41.91 JPMORGAN SMALL CAP EQTY-I 367   2013-10-04 2020-08-18
97.78 LAZARD INTL EQTY PORT-INSTL 632   2014-09-17 2020-08-18
211.111 NORTHERN MID CAP INDEX #629   2013-10-04 2020-08-18
13.591 VANGUARD 500 INDEX FD- ADM #540   2020-03-17 2020-08-18
40.644 VOYA LARGE-CAP GROWTH FND-I   2017-06-07 2020-08-18
273.39 DODGE & COX INCOME FD COM #147     2020-09-17
48.413 AMER FNDS EUROPAC GROW-F3716   2018-03-16 2020-09-17
346.296 FEDERATED TOTAL RET BD-IS 328     2020-09-17
20.714 FEDERATED TOTAL RET BD-IS 328   2020-07-31 2020-09-17
12.743 MET WEST TOTAL RETURN BOND CL I #512   2020-07-31 2020-09-17
327.599 MET WEST TOTAL RETURN BOND CL I #512     2020-09-17
276.161 WF CORE BD FD-I 944     2020-09-17
11.651 WF CORE BD FD-I 944   2020-07-31 2020-09-17
44.689 INVESCO SMALL CAP GROWTH FD-R5 4764   2020-09-17 2020-10-16
74.774 T ROWE PRICE LARGE/CAP GRW-I 139   2013-10-04 2020-10-16
30.512 JPMORGAN SMALL CAP EQTY-I 367   2020-09-17 2020-10-16
83.932 NORTHERN MID CAP INDEX #629   2013-10-04 2020-10-16
246.243 NORTHERN MID CAP INDEX #629   2020-09-17 2020-10-16
6.814 VANGUARD 500 INDEX FD- ADM #540     2020-10-16
4.833 VANGUARD 500 INDEX FD- ADM #540   2013-10-04 2020-10-16
65.255 WF GROWTH FUND - I 3105     2020-10-16
1.959 INV OPP DEVELOP MRKTS-R6 7038   2016-09-19 2020-11-17
45.094 INV OPP DEVELOP MRKTS-R6 7038   2020-03-17 2020-11-17
41.67422 CAUSEWAY INTL VALUE FD-I 1271   2014-07-17 2020-11-17
2748.17978 CAUSEWAY INTL VALUE FD-I 1271     2020-11-17
11.557 DODGE & COX STOCK FUND #145   2017-12-18 2020-11-17
537.781 AMER FNDS EUROPAC GROW-F3716   2018-03-16 2020-11-17
2.23541 GOLDMAN SACHS SMALL CAP VALUE I 651   2013-10-04 2020-11-17
44.98159 GOLDMAN SACHS SMALL CAP VALUE I 651   2013-10-04 2020-11-17
36.937 JPMORGAN SMALL CAP EQTY-I 367   2020-09-17 2020-11-17
128.858 LAZARD INTL EQTY PORT-INSTL 632     2020-11-17
1839.028 LAZARD INTL EQTY PORT-INSTL 632   2014-09-17 2020-11-17
244.04 NORTHERN MID CAP INDEX #629   2013-10-04 2020-11-17
7.34639 T ROWE PRICE EQUITY INCOME #71   2019-09-26 2020-11-17
60.281 T ROWE PRICE EQUITY INCOME #71   2019-12-12 2020-11-17
52.51261 T ROWE PRICE EQUITY INCOME #71     2020-11-17
6.083 INVESCO SMALL CAP GROWTH FD-R5 4764   2020-09-17 2020-12-11
34.337 INVESCO SMALL CAP GROWTH FD-R5 4764   2013-10-04 2020-12-11
105.42 ACADIAN EMG MRKTS PORT-I #1960     2020-12-11
54.762 CAUSEWAY INTL VALUE FD-I 1271     2020-12-11
225.712 CAUSEWAY INTL VALUE FD-I 1271   2019-12-19 2020-12-11
233.177 DODGE & COX INCOME FD COM #147   2020-11-17 2020-12-11
7.12337 DODGE & COX STOCK FUND #145   2017-12-18 2020-12-11
8.90063 DODGE & COX STOCK FUND #145   2017-12-18 2020-12-11
49.476 AMER FNDS EUROPAC GROW-F3716   2018-03-16 2020-12-11
319.66 FEDERATED TOTAL RET BD-IS 328     2020-12-11
127.099 FIDELITY INTL INDX-INST PRM #2363   2020-11-17 2020-12-11
35.942 GOLDMAN SACHS SMALL CAP VALUE I 651   2013-10-04 2020-12-11
43.886 T ROWE PRICE LARGE/CAP GRW-I 139   2013-10-04 2020-12-11
41.331 JPMORGAN SMALL CAP EQTY-I 367   2020-09-17 2020-12-11
146.295 LAZARD INTL EQTY PORT-INSTL 632   2014-09-17 2020-12-11
78.031 MFS VALUE FUND-R6 4810     2020-12-11
287.892 MET WEST TOTAL RETURN BOND CL I #512     2020-12-11
534.272 NORTHERN MID CAP INDEX #629   2013-10-04 2020-12-11
175.742 T ROWE PRICE EQUITY INCOME #71   2013-10-04 2020-12-11
22.713 VANGUARD 500 INDEX FD- ADM #540   2013-10-04 2020-12-11
41.248 VOYA LARGE-CAP GROWTH FND-I   2017-06-07 2020-12-11
241.251 WF CORE BD FD-I 944     2020-12-11
96.737 NORTHERN MID CAP INDEX #629   2013-10-04 2020-12-16
73.443 WF GROWTH FUND - I 3105     2020-12-16
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(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 1,886   1,826 60
b 838   798 40
c 874   760 114
d 194   207 -13
e 3,323   3,118 205
2,761   2,567 194
5,668   5,328 340
397   386 11
986   806 180
606   598 8
1,934   1,834 100
1,186   1,237 -51
539   538 1
2,811   2,823 -12
2,494   2,678 -184
2,175   2,254 -79
3,247   3,245 2
1,102   989 113
1,422   754 668
1,804   1,742 62
420   329 91
1,974   1,964 10
42   42  
2,329   1,585 744
1,314   1,282 32
3,246   3,282 -36
4,706   4,564 142
854   782 72
1,973   1,996 -23
3,489   1,773 1,716
5,210   4,564 646
906   851 55
1,686   1,310 376
5   5  
235   236 -1
3,025   3,036 -11
1,886   2,226 -340
2,441   1,262 1,179
17,582   8,844 8,738
2,495   1,895 600
8,663   8,908 -245
12,571   12,727 -156
855   866 -11
8,977   9,235 -258
13,738   13,981 -243
279   283 -4
10,516   10,582 -66
209   211 -2
15,147   14,688 459
9,482   9,567 -85
170   171 -1
15,064   14,470 594
5   5  
5,772   4,770 1,002
1,985   1,140 845
1,908   2,313 -405
11,928   10,551 1,377
4,056   3,445 611
2,083   1,753 330
3,707   4,717 -1,010
3,109   3,321 -212
720   769 -49
1,716   2,420 -704
2,207   2,690 -483
2,671   1,437 1,234
2,338   2,290 48
298   341 -43
8,723   9,176 -453
1,923   1,658 265
2,694   2,947 -253
5,743   7,132 -1,389
2,256   2,501 -245
1,185   1,321 -136
1,661   1,772 -111
3,297   3,138 159
2,169   2,273 -104
2,123   1,020 1,103
46   40 6
2,097   1,829 268
1,553   1,143 410
1,099   1,063 36
2,448   2,008 440
1,752   1,724 28
3,870   3,462 408
4,261   3,171 1,090
2,305   1,592 713
4,052   4,039 13
2,851   2,814 37
4,045   4,040 5
242   243 -1
148   149 -1
3,817   3,813 4
3,886   3,883 3
164   165 -1
2,328   2,078 250
4,219   1,832 2,387
1,849   1,744 105
1,591   1,376 215
4,666   4,408 258
2,192   1,846 346
1,555   753 802
3,823   2,968 855
99   65 34
2,268   1,562 706
640   676 -36
42,212   44,476 -2,264
2,201   2,447 -246
34,273   31,256 3,017
116   126 -10
2,335   2,537 -202
2,464   2,111 353
2,443   2,297 146
34,868   32,422 2,446
5,008   4,002 1,006
223   233 -10
1,827   1,903 -76
1,591   1,676 -85
357   283 74
2,012   1,421 591
2,334   2,030 304
878   831 47
3,618   3,514 104
3,486   3,463 23
1,424   1,508 -84
1,779   1,885 -106
3,307   2,876 431
3,756   3,732 24
5,647   5,589 58
1,952   2,027 -75
2,620   1,075 1,545
2,770   2,362 408
2,863   2,579 284
3,488   2,728 760
3,210   3,355 -145
11,380   8,762 2,618
5,448   5,502 -54
7,703   3,541 4,162
2,498   1,615 883
3,240   3,388 -148
2,097   1,586 511
4,224   4,124 100
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
      28,805
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       60
b       40
c       114
d       -13
e       205
      194
      340
      11
      180
      8
      100
      -51
      1
      -12
      -184
      -79
      2
      113
      668
      62
      91
      10
       
      744
      32
      -36
      142
      72
      -23
      1,716
      646
      55
      376
       
      -1
      -11
      -340
      1,179
      8,738
      600
      -245
      -156
      -11
      -258
      -243
      -4
      -66
      -2
      459
      -85
      -1
      594
       
      1,002
      845
      -405
      1,377
      611
      330
      -1,010
      -212
      -49
      -704
      -483
      1,234
      48
      -43
      -453
      265
      -253
      -1,389
      -245
      -136
      -111
      159
      -104
      1,103
      6
      268
      410
      36
      440
      28
      408
      1,090
      713
      13
      37
      5
      -1
      -1
      4
      3
      -1
      250
      2,387
      105
      215
      258
      346
      802
      855
      34
      706
      -36
      -2,264
      -246
      3,017
      -10
      -202
      353
      146
      2,446
      1,006
      -10
      -76
      -85
      74
      591
      304
      47
      104
      23
      -84
      -106
      431
      24
      58
      -75
      1,545
      408
      284
      760
      -145
      2,618
      -54
      4,162
      883
      -148
      511
      100
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
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 72,345
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 1,436
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 1,436
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 1,436
6 Credits/Payments:
a 2020 estimated tax payments and 2019 overpayment credited to 2020 6a 1,092
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 1,092
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 9 344
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 taxBullet0 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)
    bulletUT
    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     		12,115    
    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
    1,578,955
    b
    Average of monthly cash balances.......................
    1b
    44,083
    c
    Fair market value of all other assets (see instructions)................
    1c
    0
    d
    Total (add lines 1a, b, and c).........................
    1d
    1,623,038
    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
    1,623,038
    4
    Cash deemed held for charitable activities. Enter 1 1/2% of line 3 (for greater amount, see
    instructions) .............................
    4
    24,346
    5
    Net value of noncharitable-use assets. Subtract line 4 from line 3. Enter here and on Part V, line 4
    5
    1,598,692
    6
    Minimum investment return. Enter 5% of line 5..................
    6
    79,935
    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
    79,935
    2a
    Tax on investment income for 2020 from Part VI, line 5......
    2a
    1,436
    b
    Income tax for 2020. (This does not include the tax from Part VI.)...
    2b
     
    c
    Add lines 2a and 2b............................
    2c
    1,436
    3
    Distributable amount before adjustments. Subtract line 2c from line 1............
    3
    78,499
    4
    Recoveries of amounts treated as qualifying distributions................
    4
    0
    5
    Add lines 3 and 4............................
    5
    78,499
    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
    78,499
    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
    163,029
    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
    163,029
    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
    163,029
    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 78,499
    2 Undistributed income, if any, as of the end of 2020:
    a Enter amount for 2019 only....... 107,768
    b Total for prior years:2018, 20, 20 14,313
    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$ 163,029
    a Applied to 2019, but not more than line 2a 107,768
    b Applied to undistributed income of prior years
    (Election required—see instructions).....     		Click to see attachment14,313
    c Treated as distributions out of corpus (Election
    required—see instructions)........     		0
    d Applied to 2020 distributable amount..... 40,948
    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 ..........     		37,551
    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
    INTERMOUNTAIN FOUNDATION
    11520 S REDWOOD RD
    SOUTH JORDAN,UT84095     		NONE PC GENERAL OPERATING 130,000
    COMMUNITY NURSING SERVICES INC
    2830 SOUTH REDWOOD RD
    WEST VALLEY CITY,UT84119     		NONE PC GENERAL OPERATING 30,000
    Total .................................bullet 3a 160,000
    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 39,456  
    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 72,345  
    9 Net income or (loss) from special events:          
    10 Gross profit or (loss) from sales of inventory          
    11 Other revenue:
    aOTHER INCOME     		    8 1,080  
    b
    c
    d
    e
    12 Subtotal. Add columns (b), (d), and (e)..   112,881  
    13Total. Add line 12, columns (b), (d), and (e)..................
    13
    112,881
    (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 AppliedToPriorYearElection
    Name:
    FOUNDATION FOR HOSPICE NORTHERN UT
    EIN:
    87-0541883
    Election:
    THE FOUNDATION HEREBY ELECTS TO TREAT CURRENT YEAR QUALIFYING DISTRIBUTIONS IN EXCESS OF THE IMMEDIATELY PRECEDING TAX YEARS UNDISTRIBUTED INCOME AS BEING MADE OUT OF UNDISTRIBUTED INCOME FROM THE TAX YEAR ENDING 2018 IN THE AMOUNT OF $14,313.

    TY 2020 InvestmentsOtherSchedule2
    Name:
    FOUNDATION FOR HOSPICE NORTHERN UT
    EIN:
    87-0541883
    Category/ Item Listed at Cost or FMV Book Value End of Year Fair Market Value
    45775L408 T ROWE PRICE LARGE/C AT COST 32,808 81,460
    31428Q101 FEDERATED TOTAL RET AT COST 111,669 117,731
    00769G188 ACADIAN EMG MRKTS PO AT COST 23,541 31,662
    92913K504 VOYA LARGE-CAP GROWT AT COST 59,918 82,333
    592905509 MET WEST TOTAL RETUR AT COST 115,707 119,889
    00141M622 INVESCO SMALL CAP GR AT COST 19,855 28,257
    14949P208 CAUSEWAY INTL VALUE AT COST 38,853 49,971
    4812A1373 JPMORGAN SMALL CAP E AT COST 35,066 51,086
    922908710 VANGUARD 500 INDEX F AT COST 120,487 266,593
    38142V209 GOLDMAN SACHS SMALL AT COST 21,629 25,265
    949915714 WF GROWTH FUND - I 3 AT COST 28,083 41,173
    55273H353 MFS VALUE FUND-R6 48 AT COST 55,801 80,479
    256210105 DODGE & COX INCOME F AT COST 114,074 120,134
    665130100 NORTHERN MID CAP IND AT COST 133,498 176,059
    94975J581 WF CORE BD FD-I 944 AT COST 113,719 119,780
    779547108 T ROWE PRICE EQUITY AT COST 74,859 79,521
    52106N400 LAZARD INTL EQTY POR AT COST 41,821 50,885
    256219106 DODGE & COX STOCK FU AT COST 38,895 39,586
    298706110 AMER FNDS EUROPAC GR AT COST 39,795 51,516
    00143W859 INV OPP DEVELOP MRKT AT COST 20,745 33,721
    315911727 FIDELITY INTL INDX-I AT COST 97,593 101,212

    TY 2020 OtherDecreasesSchedule
    Name:
    FOUNDATION FOR HOSPICE NORTHERN UT
    EIN:
    87-0541883
    Description Amount
    MUTUAL FUND TIMING ADJ 1,978


    TY 2020 OtherIncomeSchedule2
    Name:
    FOUNDATION FOR HOSPICE NORTHERN UT
    EIN:
    87-0541883
    Description Revenue And Expenses Per Books Net Investment Income Adjusted Net Income
    OTHER INCOME 1,080 1,080  


    TY 2020 OtherIncreasesSchedule
    Name:
    FOUNDATION FOR HOSPICE NORTHERN UT
    EIN:
    87-0541883
    Description Amount
    ROUNDING 13


    TY 2020 TaxesSchedule
    Name:
    FOUNDATION FOR HOSPICE NORTHERN UT
    EIN:
    87-0541883
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    FOREIGN TAXES 327 327   0
    FEDERAL TAX PAYMENT - PRIOR YE 341 0   0
    FEDERAL ESTIMATES - PRINCIPAL 1,092 0   0
    FOREIGN TAXES ON NONQUALIFIED 164 164   0