TY 2021 Form 990PF

- TIN:

Form990-PF

Department of the Treasury
Internal Revenue Service

Return of Private Foundation

or Section 4947(a)(1) Trust Treated as Private Foundation

Do not enter social security numbers on this form as it may be made public.
bullet

Go to www.irs.gov/Form990PF for instructions and the latest information.

OMB No. 1545-0047

2021

Open to Public Inspection

For calendar year 2021, or tax year beginning 01-01-2021 , and ending 12-31-2021

Name of foundation
SUSAN AND DAVID SAMRICK FAMILY
FOUNDATION

Number and street (or P.O. box number if mail is not delivered to street address)435 ROYAL PLAZA DRIVE
Room/suite

City or town, state or province, country, and ZIP or foreign postal code
FORT LAUDERDALE, FL33301

A Employer identification number

38-3507526

B Telephone number (see instructions)

(954) 523-4991

C If exemption application is pending, check here bullet

G Check all that apply: Initial returnInitial return of a former public charity
Final returnAmended return
Address change Name change

D 1. Foreign organizations, check here............. bullet

2. Foreign organizations meeting the 85%
test, check here and attach computation ... bullet

E If private foundation status was terminated
under section 507(b)(1)(A), check here ....... bullet

H Check type of organization: Section 501(c)(3) exempt private foundation
Section 4947(a)(1) nonexempt charitable trust Other taxable private foundation

F If the foundation is in a 60-month termination
under section 507(b)(1)(B), check here ....... bullet

I Fair market value of all assets at end
of year (from Part II, col. (c),
line 16) bullet

$3,137,907J Accounting method: Cash Accrual
Other (specify)
(Part I, column (d) must be on cash basis.)

	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	(d) Disbursements for charitable purposes (cash basis only)


1	Contributions, gifts, grants, etc., received (attach schedule)
2	Check .............
3	Interest on savings and temporary cash investments	20,421		20,421
4	Dividends and interest from securities...	58,536		58,536
5a	Gross rents............
b	Net rental income or (loss)
6a	Net gain or (loss) from sale of assets not on line 10		138,147
b	Gross sales price for all assets on line 6a 927,351
7	Capital gain net income (from Part IV, line 2)...			138,147
8	Net short-term capital gain.........
9	Income modifications...........
10a	Gross sales less returns and allowances
b	Less: Cost of goods sold....
c	Gross profit or (loss) (attach schedule).....
11	Other income (attach schedule).......
12	Total. Add lines 1 through 11........	217,104		217,104
13	Compensation of officers, directors, trustees, etc.	0		0	0
14	Other employee salaries and wages......
15	Pension plans, employee benefits.......
16a	Legal fees (attach schedule).........
b	Accounting fees (attach schedule).......		16,800	16,800	0
c	Other professional fees (attach schedule)....		28,258	28,258	0
17	Interest...............
18	Taxes (attach schedule) (see instructions)...		219	219	0
19	Depreciation (attach schedule) and depletion...
20	Occupancy..............
21	Travel, conferences, and meetings.......
22	Printing and publications..........
23	Other expenses (attach schedule).......		4,313	4,313	0
24	Total operating and administrative expenses.
	Add lines 13 through 23..........	49,590		49,590	0
25	Contributions, gifts, grants paid.......	152,306			152,306
26	Total expenses and disbursements. Add lines 24 and 25	201,896		49,590	152,306
27	Subtract line 26 from line 12:
a	Excess of revenue over expenses and disbursements	15,208
b	Net investment income (if negative, enter -0-)			167,514
c	Adjusted net income (if negative, enter -0-)...

For Paperwork Reduction Act Notice, see instructions.

Cat. No. 11289X Form 990-PF (2021)

Form 990-PF (2021)

Page 2

Part II		Balance Sheets	Beginning of year	End of year
Part II		Balance Sheets	(a) Book Value	(b) Book Value	(c) Fair Market Value
	1	Cash—non-interest-bearing.............
	2	Savings and temporary cash investments.........	364,054	240,091	240,091
	3	Accounts receivable
		Less: allowance for doubtful accounts
	4	Pledges receivable
		Less: allowance for doubtful accounts
	5	Grants receivable.................
	6	Receivables due from officers, directors, trustees, and other
		disqualified persons (attach schedule) (see instructions).....
	7	Other notes and loans receivable (attach schedule)
		Less: allowance for doubtful accounts
	8	Inventories for sale or use..............
	9	Prepaid expenses and deferred charges..........
	10a	Investments—U.S. and state government obligations (attach schedule)	271,207	247,608	244,833
	b	Investments—corporate stock (attach schedule).......	1,207,482	1,371,438	1,839,025
	c	Investments—corporate bonds (attach schedule).......	276,051	306,281	308,485
	11	Investments—land, buildings, and equipment: basis
		Less: accumulated depreciation (attach schedule)
	12	Investments—mortgage loans.............
	13	Investments—other (attach schedule)..........	468,235	442,705	505,473
	14	Land, buildings, and equipment: basis
		Less: accumulated depreciation (attach schedule)
	15	Other assets (describe )
	16	Total assets (to be completed by all filers—see the
		instructions. Also, see page 1, item I)	2,587,029	2,608,123	3,137,907
	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 )
	23	Total liabilities (add lines 17 through 22).........	0	0
		Foundations that follow FASB ASC 958, check here
		and complete lines 24, 25, 29 and 30.
	24	Net assets without donor restrictions...........	2,587,029	2,608,123
	25	Net assets with donor restrictions............
		Foundations that do not follow FASB ASC 958, check here
		and complete lines 26 through 30.
	26	Capital stock, trust principal, or current funds........
	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).....	2,587,029	2,608,123
	30	Total liabilities and net assets/fund balances (see instructions).	2,587,029	2,608,123

Part III

Analysis of Changes in Net Assets or Fund Balances

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) ...............

2,587,029

Enter amount from Part I, line 27a .....................

15,208

Other increases not included in line 2 (itemize) bullet

5,886

Add lines 1, 2, and 3 ..........................

2,608,123

Decreases not included in line 2 (itemize) bullet

Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 29 .

2,608,123

Form 990-PF (2021)

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.)		(c) Date acquired (mo., day, yr.)	(d) Date sold (mo., day, yr.)
1 a	JEFFERIES [3056] RETURN OF PRINCIPLE	2021-01-01	2021-12-31
b	JEFFERIES [4114] PUBLICLY TRADED SECURITIES
c	JEFFERIES [4114] PUBLICLY TRADED SECURITIES
d	JEFFERIES [9493] PUBLICLY TRADED SECURITIES
e	JEFFERIES [9493] PUBLICLY TRADED SECURITIES
	JEFFERIES [9493] PUBLICLY TRADED SECURITIES
	JEFFERIES [1102] PUBLICLY TRADED SECURITIES
	JEFFERIES [1102] PUBLICLY TRADED SECURITIES

(e) Gross sales price		(g) Cost or other basis plus expense of sale	(h) Gain or (loss) (e) plus (f) minus (g)
a	911	910	1
b	282,618	279,442	3,176
c	82,929	80,142	2,787
d	1,921	1,889	32
e	54,820	55,012	-192
	6,818	6,497	321
	249,515	207,502	42,013
	247,819	157,810	90,009

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
b			3,176
c			2,787
d			32
e			-192
			321
			42,013
			90,009

2	Capital gain net income or (net capital loss)	If gain, also enter in Part I, line 7 If (loss), enter -0- in Part I, line 7	2	138,147
3	Net short-term capital gain or (loss) as defined in sections 1222(5) and (6):
	If gain, also enter in Part I, line 8, column (c) (see instructions). If (loss), enter -0- in Part I, line 8 ...................		3

Form 990-PF (2021)

Page 4

Part V

Excise Tax Based on Investment Income (Section 4940(a), 4940(b), 4940(e), or 4948—see instructions)

1a	Exempt operating foundations described in section 4940(d)(2), check here and enter “N/A" on line 1.
	Date of ruling or determination letter: (attach copy of letter if necessary–see instructions)
b	All other domestic foundations enter 1.39% (0.0139) of line 27b. Exempt foreign organizations enter 4% (0.04) 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	2,328
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	2,328
6	Credits/Payments:

a	2021 estimated tax payments and 2020 overpayment credited to 2021	6a	1,559
b	Exempt foreign organizations—tax withheld at source......	6b	0
c	Tax paid with application for extension of time to file (Form 8868)...	6c	0
d	Backup withholding erroneously withheld ...........	6d	0

7	Total credits and payments. Add lines 6a through 6d..............		7	1,559
8	Enter any penalty for underpayment of estimated tax. Check here if Form 2220 is attached.		8	0
9	Tax due. If the total of lines 5 and 8 is more than line 7, enter amount owed.......		9	769
10	Overpayment. If line 7 is more than the total of lines 5 and 8, enter the amount overpaid...		10
11	Enter the amount of line 10 to be: Credited to 2022 estimated tax	Refunded	11

Part VI-A

Statements Regarding Activities

During the tax year, did the foundation attempt to influence any national, state, or local legislation or did

Yes

it participate or intervene in any political campaign? ....................

Did it spend more than $100 during the year (either directly or indirectly) for political purposes? See the instructions

for the definition.................................

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.

Did the foundation file Form 1120-POL for this year?.....................

Enter the amount (if any) of tax on political expenditures (section 4955) imposed during the year:

(1) On the foundation. bullet

$ 0(2) On foundation managers. bullet

$ 0

Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed

on foundation managers. bullet

$ 0

Has the foundation engaged in any activities that have not previously been reported to the IRS?.......

If "Yes," attach a detailed description of the activities.

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....

Did the foundation have unrelated business gross income of $1,000 or more during the year?.........

If "Yes," has it filed a tax return on Form 990-T for this year?...................

Was there a liquidation, termination, dissolution, or substantial contraction during the year?.........

If "Yes," attach the statement required by General Instruction T.

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?................

Yes

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 XIV..................................

Yes

Enter the states to which the foundation reports or with which it is registered (see instructions)

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 .

Yes

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 2021 or the taxable year beginning in 2021? See the instructions for Part XIII.

If "Yes," complete Part XIII .............................

Did any persons become substantial contributors during the tax year? If "Yes," attach a schedule listing their names

and addresses. ...............................

Form 990-PF (2021)

Page 5

Part VI-A

Statements Regarding Activities (continued)

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 .............

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.................

Did the foundation comply with the public inspection requirements for its annual returns and exemption application?

Yes

Website address bullet

N/A

The books are in care of bullet

SUSAN SAMRICK Telephone no. bullet

(954) 523-4991

Located at bullet

435 ROYAL PLAZA DRIVEFT LAUDERDALEFL ZIP+4 bullet

33301

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

16 At any time during calendar year 2021, 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 VI-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

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? ...........

1a(1)

(2) Borrow money from, lend money to, or otherwise extend credit to (or accept it from)

a disqualified person? ..............................

1a(2)

(3) Furnish goods, services, or facilities to (or accept them from) a disqualified person? ...........

1a(3)

(4) Pay compensation to, or pay or reimburse the expenses of, a disqualified person? ............

1a(4)

(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)? ......................

1a(5)

(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.) ...............

1a(6)

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 ..........

Organizations relying on a current notice regarding disaster assistance check here........ bullet

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 2021? .............

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)):

At the end of tax year 2021, did the foundation have any undistributed income (lines 6d

and 6e, Part XII) for tax year(s) beginning before 2021?....................

If "Yes," list the years bullet

20, 20, 20, 20

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.) ..............

If the provisions of section 4942(a)(2) are being applied to any of the years listed in 2a, list the years here.

20, 20, 20, 20

Did the foundation hold more than a 2% direct or indirect interest in any business enterprise at

any time during the year? ..............................

If "Yes," did it have excess business holdings in 2021 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 2021.) .....................

Did the foundation invest during the year any amount in a manner that would jeopardize its charitable purposes?

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 2021? ..

Form 990-PF (2021)

Page 6

Part VI-B

Statements Regarding Activities for Which Form 4720 May Be Required (continued)

During the year did the foundation pay or incur any amount to:

Yes

(1) Carry on propaganda, or otherwise attempt to influence legislation (section 4945(e))? ..........

5a(1)

(2) Influence the outcome of any specific public election (see section 4955); or to carry

on, directly or indirectly, any voter registration drive? ....................

5a(2)

(3) Provide a grant to an individual for travel, study, or other similar purposes? .............

5a(3)

(4) Provide a grant to an organization other than a charitable, etc., organization described

in section 4945(d)(4)(A)? See instructions ........................

5a(4)

(5) Provide for any purpose other than religious, charitable, scientific, literary, or

educational purposes, or for the prevention of cruelty to children or animals? .............

5a(5)

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 ........

Organizations relying on a current notice regarding disaster assistance check here ......... bullet

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).

Did the foundation, during the year, receive any funds, directly or indirectly, to pay premiums on

a personal benefit contract? .............................

Did the foundation, during the year, pay premiums, directly or indirectly, on a personal benefit contract? ....

If "Yes" to 6b, file Form 8870.

At any time during the tax year, was the foundation a party to a prohibited tax shelter transaction?

If "Yes", did the foundation receive any proceeds or have any net income attributable to the transaction? .....

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 VII

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
SUSAN SAMRICK	DIRECTOR 2.00	0	0	0
435 ROYAL PLAZA DRIVE FORT LAUDERDALE,FL33301	DIRECTOR 2.00	0	0	0

2 Compensation of five highest-paid employees (other than those included on line 1—see instructions). If none, enter “NONE."


(a) Name and address of each employee paid more than $50,000	(b) Title, and average hours per week devoted to position	(c) Compensation	(d) Contributions to employee benefit plans and deferred compensation	(e) Expense account, other allowances
NONE









Total number of other employees paid over $50,000...................				0

Form 990-PF (2021)

Page 7

Part VII

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............. bullet

Part VIII-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 VIII-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 (2021)

Page 8

Part IX

Minimum Investment Return (All domestic foundations must complete this part. Foreign foundations, see instructions.)

Fair market value of assets not used (or held for use) directly in carrying out charitable, etc.,

purposes:

Average monthly fair market value of securities...................

2,587,267

Average of monthly cash balances.......................

288,257

Fair market value of all other assets (see instructions)................

Total (add lines 1a, b, and c).........................

2,875,524

Reduction claimed for blockage or other factors reported on lines 1a and

1c (attach detailed explanation) .............

Acquisition indebtedness applicable to line 1 assets..................

Subtract line 2 from line 1d.........................

2,875,524

Cash deemed held for charitable activities. Enter 1.5% (0.015) of line 3 (for greater amount, see

instructions) .............................

43,133

Net value of noncharitable-use assets. Subtract line 4 from line 3. .......

2,832,391

Minimum investment return. Enter 5% (0.05) of line 5................

141,620

Part X

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.)

Minimum investment return from Part IX, line 6..................

141,620

Tax on investment income for 2021 from Part V, line 5.......

2,328

Income tax for 2021. (This does not include the tax from Part V.) ...

Add lines 2a and 2b............................

2,328

Distributable amount before adjustments. Subtract line 2c from line 1............

139,292

Recoveries of amounts treated as qualifying distributions................

Add lines 3 and 4............................

139,292

Deduction from distributable amount (see instructions).................

Distributable amount as adjusted. Subtract line 6 from line 5. Enter here and on Part XII, line 1 ...

139,292

Part XI

Qualifying Distributions (see instructions)

Amounts paid (including administrative expenses) to accomplish charitable, etc., purposes:

Expenses, contributions, gifts, etc.—total from Part I, column (d), line 26 ..........

Program-related investments—total from Part VIII-B..................

Amounts paid to acquire assets used (or held for use) directly in carrying out charitable, etc.,

purposes...............................

Amounts set aside for specific charitable projects that satisfy the:

Suitability test (prior IRS approval required)....................

Cash distribution test (attach the required schedule) .................

Qualifying distributions. Add lines 1a through 3b. Enter here and on Part XII, line 4.

Form 990-PF (2021)

Page 9

Part XII

Undistributed Income (see instructions)

		(a) Corpus	(b) Years prior to 2020	(c) 2020	(d) 2021
1 Distributable amount for 2021 from Part X, line 7					139,292
2 Undistributed income, if any, as of the end of 2021:
a Enter amount for 2020 only.......				0
b Total for prior years:20, 20, 20			0
3 Excess distributions carryover, if any, to 2021:
a From 2016......	229,231
b From 2017......	86,665
c From 2018......	263,309
d From 2019......	261,046
e From 2020......	130,421
f Total of lines 3a through e ........		970,672
4Qualifying distributions for 2021 from Part
XI, line 4: $ 152,306
a Applied to 2020, but not more than line 2a				0
b Applied to undistributed income of prior years (Election required—see instructions).....			0
c Treated as distributions out of corpus (Election required—see instructions)........		0
d Applied to 2021 distributable amount.....					139,292
e Remaining amount distributed out of corpus		13,014
5 Excess distributions carryover applied to 2021.		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		983,686
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 2021. Subtract lines 4d and 5 from line 1. This amount must be distributed in 2022 ..........					0
7 Amounts treated as distributions out of corpus to satisfy requirements imposed by section 170(b)(1)(F) or 4942(g)(3) (Election may be required - see instructions) .......		0
8 Excess distributions carryover from 2016 not applied on line 5 or line 7 (see instructions) ...		229,231
9 Excess distributions carryover to 2022. Subtract lines 7 and 8 from line 6a ......		754,455
10 Analysis of line 9:
a Excess from 2017....	86,665
b Excess from 2018....	263,309
c Excess from 2019....	261,046
d Excess from 2020....	130,421
e Excess from 2021....	13,014

Form 990-PF (2021)

Page 10

Part XIII

Private Operating Foundations (see instructions and Part VI-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 2021, enter the date of the ruling ....... bullet

b Check box to indicate whether the organization is a private operating foundation described in section 4942(j)(3) or4942(j)(5)

2a Enter the lesser of the adjusted net income from Part I or the minimum investment return from Part X for each year listed ..........	Tax year	Prior 3 years			(e) Total
	(a) 2021	(b) 2020	(c) 2019	(d) 2018	(e) Total

b 85% (0.85) of line 2a .........
c Qualifying distributions from Part XI, 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 IX, 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 XIV

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).)

SUSAN SAMRICK

bList any managers of the foundation who own 10% or more of the stock of a corporation (or an equally large portion of the
ownership of a partnership or other entity) of which the foundation has a 10% or greater interest.

2Information Regarding Contribution, Grant, Gift, Loan, Scholarship, etc., Programs:

Check here bullet

if the foundation only makes contributions to preselected charitable organizations and does not accept
unsolicited requests for funds. If the foundation makes gifts, grants, etc. to individuals or organizations under
other conditions, complete items 2a, b, c, and d. See instructions

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 (2021)

Page 11

Part XIV

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)		Foundation status of recipient	Purpose of grant or contribution	Amount
aPaid during the year
B'NAI AVIV 1410 INDIAN TRACE WESTON,FL33326	NONE	PC	GENERAL PURPOSE	7,706
B'NAI ZION 750 UNITED STREET KEY WEST,FL33040	NONE	PC	GENERAL PURPOSE	1,800
CHABAD LUBAVITCH OF PHOENIX 2110 EAST LINCOLN DRIVE PHOENIX,AZ85016	NONE	PC	GENERAL PURPOSE	500
CHABAD OF SUNRISE 3457 NW 122 AVE SUNRISE,FL33323	NONE	PC	GENERAL PURPOSE	5,000
CHABAD OF WESTERN MICHIGAN 2615 MICHIGAN NE GRAND RAPIDS,MI49506	NONE	PC	GENERAL PURPOSE	72,000
HILLEL OF BROWARD & PALM BEACH 777 GLADES ROAD BLDG LY-3A BOCA RATON,FL33431	NONE	PC	COMMUNITY WELFARE	15,500
JEWISH FEDERATION OF GRAND RAPIDS 4127 EMBASSY DRIVE SE GRAND RAPIDS,MI49546	NONE	PC	GENERAL PURPOSE	25,000
METZAD CONGREGATION 1371 S BEVERLY HILLS BLVD 206 LOS ANGELES,CA90024	NONE	PC	GENERAL PURPOSE	10,000
NOVA SOUTHEASTERN UNIVERSITY MUSEUM OF ART 3301 COLLEGE AVE FORT LAUDERDALE,FL333147796	NONE	PC	EDUCATION	14,800
Total ................................. 3a				152,306

bApproved for future payment

Total ................................. 3b				0

Form 990-PF (2021)

Page 12

Part XV-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	(e) Related or exempt function income (See instructions.)
a
b
c
d
e
f
gFees and contracts from government agencies
2 Membership dues and assessments ....
3 Interest on savings and temporary cash investments ...........			14	20,421
4 Dividends and interest from securities ....
5 Net rental income or (loss) from real estate:
aDebt-financed property......
bNot debt-financed property.....
6 Net rental income or (loss) from personal property
7 Other investment income .....
8 Gain or (loss) from sales of assets other than inventory ............			18	138,147
9 Net income or (loss) from special events:
10 Gross profit or (loss) from sales of inventory
11 Other revenue: a
b
c
d
e
12 Subtotal. Add columns (b), (d), and (e) ..		0		217,104	0

13Total. Add line 12, columns (b), (d), and (e)..................

217,104

(See worksheet in line 13 instructions to verify calculations.)

Part XV-B

Relationship of Activities to the Accomplishment of Exempt Purposes

Line No.	Explain below how each activity for which income is reported in column (e) of Part XV-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 (2021)

Page 13

Part XVI

Information Regarding Transfers To and Transactions and Relationships With Noncharitable Exempt Organizations

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

Transfers from the reporting foundation to a noncharitable exempt organization of:

(1) Cash...................................

1a(1)

(2) Other assets.................................

1a(2)

Other transactions:

(1) Sales of assets to a noncharitable exempt organization....................

1b(1)

(2) Purchases of assets from a noncharitable exempt organization..................

1b(2)

(3) Rental of facilities, equipment, or other assets.......................

1b(3)

(4) Reimbursement arrangements...........................

1b(4)

(5) Loans or loan guarantees.............................

1b(5)

(6) Performance of services or membership or fundraising solicitations................

1b(6)

Sharing of facilities, equipment, mailing lists, other assets, or paid employees..............

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

Is the foundation directly or indirectly affiliated with, or related to, one or more tax-exempt organizations
described in section 501(c) (other than section 501(c)(3)) or in section 527? ...........Yes No

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.
				May the IRS discuss this return with the preparer shown below? See instructions. Yes No
	Signature of officer or trustee	Date	Title

Paid Preparer Use Only	Print/Type preparer's name	Preparer's Signature	Date	Check if self- employed	PTIN
	Firm's name				Firm's EIN
	Firm's address				Phone no.

Form 990-PF (2021)

Additional Data

Software ID:
Software Version:

Form 990PF - Special Condition Description:

Special Condition Description

- TIN:

TY 2021 AccountingFeesSchedule

Name:

SUSAN AND DAVID SAMRICK FAMILY

FOUNDATION

EIN:

38-3507526

Category	Amount	Net Investment Income	Adjusted Net Income	Disbursements for Charitable Purposes
TAX PREP FEES	16,800	16,800		0

- TIN:

TY 2021 InvestmentsCorpBondsSchedule

Name:

SUSAN AND DAVID SAMRICK FAMILY

FOUNDATION

EIN:

38-3507526

Name of Bond	End of Year Book Value	End of Year Fair Market Value
BANK AMER CORP FLTG RATE SR NT SER M	14,063	14,644
BANK AMER CORP FXD TO FLTG RT SR NT SER	13,708	14,091
CHARTER COMMUNICATIONS OPER LLC	13,490	13,206
CHENIERE CORPUS CHRISTI HLDGS LLC GTD FXT RT SR SECD NT	13,842	14,413
CITIGROUP INC FLTG RATE SR NT 1.600%	14,160	14,102
CITIGROUP INC SR NT FLTG RATE 1.257%	14,142	14,140
ENERGY TRANSFERS PARTNERS L P	13,041	13,689
FNMA GTD PASS THRU POOL#534179	600	220
G N M A PASS THRU POOL 510989X	847	200
G N M A PASS THRU POOL 544853X	3,146	2,485
G N M A PASS THRU POOL 781289X	1,832	954
GENERAL MTRS CO SR NT 6.125%	26,715	26,432
GINNIE MAE CMO/SERIES 2005-3 JD-MX-FIXED RT	1,702	1,323
GOLDMAN SACHS GROUP INC FLOATING RT NT 2.905%	13,637	14,158
GOLDMAN SACHS GROUP INC SR NT FIXED/FLTG 0.925%	14,000	13,941
HOLLYFRONTIER CORP FXD RT SR NT	26,715	29,173
J P MORGAN CHASE & CO FIXED TO FLOATING RT SR NOTE	25,805	26,870
KEURIG DR PEPPER INC SR NT 0.750%	13,000	12,912
LENNAR CORP FIXED 4.750%	13,378	13,293
MORGAN STANLEY SR NT FIXED / FLOATING	14,000	13,892
MYLAN N V ISN#U62854AA246 3.950%	27,090	26,969
T-MOBILE USA INC SR SECD NT 3.875%	27,368	27,378

- TIN:

TY 2021 InvestmentsCorpStockSchedule

Name:

SUSAN AND DAVID SAMRICK FAMILY

FOUNDATION

EIN:

38-3507526

Name of Stock	End of Year Book Value	End of Year Fair Market Value
ABBOTT LABS COM	11,457	13,933
ABBVIE INC COM	11,732	18,414
ACCENTURE PLC IRELAND CLASS SHS	1,431	4,975
ACTIVISION BLIZZARD INC COM	7,665	6,387
ADYEN N V ADR	2,418	3,158
AGCO CORP	15,226	12,878
AIA GROUP LTD SPONSORED ADR	5,241	6,291
AIR LEASE CORP NON CUM PERP	6,151	6,827
AKAMAI TECHNOLOGIES INC COM	11,280	14,981
ALCON SA ACT NOM	2,986	4,254
ALLSTATE CORP SUB DEB FIXED TO FLTG RATE JAN 15	4,369	4,516
ALPHABET INC CAP STK CL A	13,506	37,662
ALPHABET INC CAP STK CL C	10,118	23,149
AMADEUS IT HLDG SA ADS	2,468	2,235
AMAZON COM INC	12,361	16,672
AMERICAN FINL GROUP INC OHIO SUB 4.50%	3,003	3,023
AMERICAN FINL GROUP INC OHIO SUB 5.125%	8,232	8,308
AMERICAN FINL GROUP INC OHIO SUB 5.625%	2,505	2,655
AMPHENOL CORP	3,399	4,023
AON PLC REGISTERED	2,031	3,006
APPLE INC COM	8,843	44,748
APPLIED MATERIALS INC	11,243	14,792
APTIV PLC SHS COM	2,212	5,608
ARCH CAP GROUP LTD	7,137	7,293
ARCHER DANIELS MIDLAND CO	8,589	11,625
ASML HLDG N V N Y REGISTRY SHS NEW	1,667	7,165
ASPEN INS HLDGS LTD DEP SHS #BMGC53842040	2,582	2,633
ASPEN INS HLDGS LTD VAR NON CUM	13,362	13,448
AT&T INC COM	9,923	6,002
AT&T INC DEP SHS REPSTG	5,429	5,646
ATHENE HLDG LTD DEP SH REPSTG	10,425	11,838
ATHENE HLDG LTD DEP SHS	10,330	11,722
ATLAS COPCO AB SPON ADR NEW REPSTG	1,975	4,921
ATLASSIAN CORPORATION PLC	2,780	2,669
AUTOZONE INC COM	5,005	8,386
BALL CORP COM	8,398	11,264
BANK AMER CORP DEP MAY 16	5,740	5,870
BANK AMER CORP DEP SHS JUNE 25	11,008	11,747
BANK AMER CORP DEP SHS NV 3	3,796	3,888
BANK AMER CORP DEP SHS SEPT 17	6,528	6,937
BERKLEY W R CORP	4,815	4,993
BOEING CO COM	13,602	7,449
BRISTOL MYERS SQUIBB CO COM	22,093	24,379
CANADIAN PAC RY LTD COM	8,589	16,474
CAPITAL ONE FINL CORP COM	4,325	7,545
CAPITAL ONE FINL CORP DEP	10,250	11,315
CBRE GROUP INC CL A	13,690	23,113
CENTERPOINT ENERGY INC COM	10,644	13,062
CISCO SYSTEMS INC	5,822	9,379
CITIGROUP INC DEP SHS NOV 15	6,460	6,495
CITIGROUP INC DEP SHS SEPT 30	19,676	19,426
CITIZENS FINL GP INC START APRIL 6	3,638	3,722
CITIZENS FINL GROUP INC	2,623	2,779
CITIZENS FINL GROUP INC COM	10,334	11,671
CMS ENERGY CORP	5,776	5,650
CNH INDL	9,749	14,771
COMCAST CORP CL A	17,321	20,686
COMERICA INC COM	5,928	12,963
CORTEVA INC COM	13,194	12,766
CSL LTD SPONSORED ADR ISIN#US12637N2045	3,223	5,184
DANAHER CORP COM	4,266	17,438
DEVON ENERGY CORP	4,521	14,052
DISNEY WALT CO DISNEY COM	9,041	10,687
DOW INC COM	10,289	9,983
DSV AS ADR ISIN#US26251A1088	1,415	6,339
DTE ENERGY CORP JR	5,485	5,642
DUKE ENERGY CORP DEP SHS	8,452	8,783
DUKE ENERGY CORP JR	3,230	3,340
ENBRIDGE INC PFD	5,534	5,747
EOG RES INC COM	12,377	15,012
EPAM SYS INC COM	3,394	4,679
EQUITABLE HLDGS INC DEP	7,861	8,374
EVOLUTION AB ADR	4,412	3,431
EXPERIAN PLC SPON ADR	2,905	6,953
F5 NETWORKS INC COM	7,506	12,970
FEDEX CORP COM	4,988	7,759
FERRARI N V SHS	3,718	5,691
FIFTH THIRD BANCORP	13,713	13,308
FISERV INC COM	11,976	11,728
FULTON FINL CORP PA DEP	2,714	2,783
GENERAL DYNAMICS CORP COM	5,154	7,296
GLOBAL PMTS INC COM	12,255	9,868
GOLDMAN SACHS GROUP	24,303	24,678
GOLDMAN SACHS GROUP INC COM	12,912	12,624
HARTFORD FINL SVCS GROUP	12,543	11,682
HCA HEALTHCARE INC COM	20,063	32,886
HEWLETT PACKARD ENTERPRISE CO COM	12,753	13,184
HOLOGIC INC COM	11,949	11,637
HUNTINGTON BANCSHARES INC	6,240	6,728
ICON PLC LTD SHS	1,354	5,265
INTERPUBLIC GROUP COS INC COM	12,558	12,508
INTUIT INCORPORATED COM	2,954	16,081
JPMORGAN CHASE & CO DEP 4.75% AFT DEC 1	5,258	5,531
JPMORGAN CHASE & CO DEP SH 6.0% AFT MARCH 1	15,549	16,023
KEYCORP NEW DEP	12,367	13,457
LAM RESEARCH CORP	11,382	13,664
LASERTEC CORP ADR	4,030	6,250
LENNAR CORP CL A	3,232	7,318
LINING CO LTD ADR	1,401	1,356
LONZA GROUP AG	2,496	3,340
LULULEMON ATHLETICA INC COM	13,581	16,832
LVMH MOET HENNESSY LOUIS VUITTON ADR	1,407	5,296
META PLATFORMS INC	9,131	20,517
METLIFE INC COM	12,703	12,748
METTLER-TOLEDO INTL INC COM	2,769	6,789
MICROSOFT CORP COM	12,693	47,085
MORGAN STANLEY DEP SHS FXD TO FLT NON CUM DIV 6.375	2,174	2,256
MORGAN STANLEY DEP SHS JAN 15	5,761	5,803
MORGAN STANLEY DEP SHS OCT 15	12,477	12,553
MORGAN STANLEY DEP SHS QRTLY BASIS	10,888	10,890
NATIONAL RURAL UTILIS COOP	4,993	5,431
NESTLE SA SPONSORED ADR REPSTG	2,919	5,194
NEXTERA ENERGY CAP HLDGS INC	4,235	4,582
NISOURCE INC DEP SHS	7,210	7,268
NOVO NORDISK A.S. ADR FORMERLY NOVO	4,618	15,232
NVIDIA CORP COM	2,279	12,059
NXP SEMICONDUCTORS NV COM	6,759	17,311
ONEOK INC NEW COM	13,178	12,163
PACKAGING CORP AMER COM	12,547	11,709
PERKINELMER INC COM	9,296	14,677
PERNOD RICHARD S A ADR	3,678	5,284
PFIZER INC COM	17,708	29,112
PNC FINL SVCS GROUP INC	11,475	11,068
PRUDENTIAL FINL INC	7,417	7,768
PRUDENTIAL FINL INC JR SEPT 1	5,916	6,041
PS BUSINESS PKS INC	2,616	2,868
PTC INC COM	5,099	9,207
PUBLIC STORAGE DEP SHS JUNE 17	1,703	1,687
PUBLIC STORAGE DEP SHS MARCH 11	8,514	8,915
QUALCOMM INC	4,336	13,898
REGENERON PHARMACEUTICALS INC	17,324	20,840
REGIONS FINL CORP NEW	11,015	12,398
REINSURANCE GROUP AMER INC SUB DEB FXD/FLTG EXP JUNE 15	11,401	12,314
RESMED INC COM	1,694	3,907
ROBERT HALF INTL INC COM	9,943	13,382
S&P GLOBAL INC COM	7,079	8,967
SCHWAB CHARLES CORP NEW COM	4,510	9,167
SELECTIVE INS GROUP INC DEP	5,571	5,594
SHENZHOU INTL GROUP HLDGS LTD ADR	3,890	3,226
SHOPIFY INC CL A	405	4,132
SIKA AG ADR	2,728	6,151
SOUTHERN CO COM	2,669	2,738
SOUTHERN CO JR SUB NTS	8,383	8,788
SPIRE INC DEP SHS REPSTG	2,480	2,627
STATE STR CORP	21,083	21,711
STERIS PLC SHS	1,746	3,651
SVB FINL GROUP DEP	4,318	4,326
TAIWAN SEMICONDUCTOR MFG CO SPONSORED ADR ISIN#US8740391003	1,692	6,136
TAPESTRY INC COM	13,263	12,342
TELEFLEX INC	3,227	3,285
TEXTRON INC COM	8,351	13,278
T-MOBILE US INC COM	3,334	3,363
TRANSUNION COM	9,589	12,451
TRUIST FINL CORP	11,097	11,354
UNDER ARMOUR INC CL A	13,103	10,447
UNION PAC CORP COM	4,606	10,329
UNITED PARCEL SVC INC CL B	20,273	33,437
UNITEDHEALTH GROUP INC COM	6,664	18,579
UNUM GROUP JR	5,039	5,071
US BANCORP DEL DEP	10,588	10,000
VALLEY NATL BANCORP NON CUM	6,167	6,184
VALLEY NATL BANCORP PERP PFD	4,614	5,040
VERISK ANALYTICS INC COM	5,304	12,809
VERIZON COMMUNICATIONS INC	9,671	10,184
VISA INC COM CL A	21,980	34,674
VOYA FINL INC	19,019	21,823
WELLSFARGO & CO	11,055	11,680
WELLSFARGO & CO	16,724	16,648
WELLSFARGO & CO NEW DEP DEC 15	2,692	2,812
WELLSFARGO & CO NEW DEP SH	3,472	3,439
WEST PHARMACEUTICAL SVCS INC COM	9,764	14,070
WESTERN ALLIANCE BANCORPORATION	4,309	4,375
WILLIAMS SONOMA INC COM	12,419	11,670
WINTRUST FNL CORP DEP	9,285	9,640
WUXI BIOLOGICS CAYMAN INC ADR	2,965	2,297

- TIN:

TY 2021 InvestmentsGovtObligationsSch

Name:

SUSAN AND DAVID SAMRICK FAMILY

FOUNDATION

EIN:

38-3507526

US Government Securities - End of Year Book Value:

247,608

US Government Securities - End of Year Fair Market Value:

244,833

State & Local Government Securities - End of Year Book Value:

State & Local Government Securities - End of Year Fair Market Value:

- TIN:

TY 2021 InvestmentsOtherSchedule2

Name:

SUSAN AND DAVID SAMRICK FAMILY

FOUNDATION

EIN:

38-3507526

Category/ Item	Listed at Cost or FMV	Book Value	End of Year Fair Market Value
AMERICAN TOWER REIT COM	AT COST	11,806	29,835
CAPITAL DYNAMICS GLOBAL	AT COST	69,921	69,921
CROWN CASTLE INTL CORP NEW COM	AT COST	13,983	24,840
DIGITAL RLTY TR INC COM	AT COST	12,318	15,388
EXTRA SPACE STORAGE	AT COST	5,836	14,964
MILLER CONVERTIBLE BOND FUND CLASS I	AT COST	203,223	224,925
MONROE CAPITAL OPPORTUNISTIC PRIVATE CREDIT CAYMAN FEEDER FUND LP	AT COST	27,668	27,668
PUBLIC STORAGE DEP	AT COST	4,032	4,014
FLORIDA FUND II LLC	AT COST	93,918	93,918

- TIN:

TY 2021 OtherExpensesSchedule

Name:

SUSAN AND DAVID SAMRICK FAMILY

FOUNDATION

EIN:

38-3507526

Description	Revenue and Expenses per Books	Net Investment Income	Adjusted Net Income	Disbursements for Charitable Purposes
INVESTMENT EXPENSES	19	19		0
K1 FLORIDA FUND II	4,294	4,294		0

- TIN:

TY 2021 OtherIncreasesSchedule

Name:

SUSAN AND DAVID SAMRICK FAMILY

FOUNDATION

EIN:

38-3507526

Description	Amount
OTHER ADJUSTMENT TO COST BASIS	5,886

- TIN:

TY 2021 OtherProfessionalFeesSchedule

Name:

SUSAN AND DAVID SAMRICK FAMILY

FOUNDATION

EIN:

38-3507526

Category	Amount	Net Investment Income	Adjusted Net Income	Disbursements for Charitable Purposes
INVESTMENT FEES	28,258	28,258		0

- TIN:

TY 2021 TaxesSchedule

Name:

SUSAN AND DAVID SAMRICK FAMILY

FOUNDATION

EIN:

38-3507526

Category	Amount	Net Investment Income	Adjusted Net Income	Disbursements for Charitable Purposes
FOREIGN TAX WITHHELD	219	219		0