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
LEWIS CATHY K CHARITABLE FOUNDATION

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

83-1872703

B Telephone number (see instructions)

(888) 730-4933

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

$6,038,380J 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	(c) Adjusted net 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
4	Dividends and interest from securities...	104,493		87,871
5a	Gross rents............
b	Net rental income or (loss)
6a	Net gain or (loss) from sale of assets not on line 10		167,317
b	Gross sales price for all assets on line 6a 510,199
7	Capital gain net income (from Part IV, line 2)...			167,317
8	Net short-term capital gain.........				0
9	Income modifications...........
10a	Gross sales less returns and allowances
b	Less: Cost of goods sold....
c	Gross profit or (loss) (attach schedule).....
11	Other income (attach schedule).......
12	Total. Add lines 1 through 11........	271,810		255,188
13	Compensation of officers, directors, trustees, etc.	68,406		61,565		6,841
14	Other employee salaries and wages......			0	0	0
15	Pension plans, employee benefits.......			0	0
16a	Legal fees (attach schedule).........		7,540	0	0	7,540
b	Accounting fees (attach schedule).......		1,011	0	0	1,011
c	Other professional fees (attach schedule)....					0
17	Interest...............					0
18	Taxes (attach schedule) (see instructions)...		288	288		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..........	77,245		61,853	0	15,392
25	Contributions, gifts, grants paid.......	195,000				195,000
26	Total expenses and disbursements. Add lines 24 and 25	272,245		61,853	0	210,392
27	Subtract line 26 from line 12:
a	Excess of revenue over expenses and disbursements	-435
b	Net investment income (if negative, enter -0-)			193,335
c	Adjusted net income (if negative, enter -0-)...				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.........	194,468	52,909	52,909
	3	Accounts receivable
		Less: allowance for doubtful accounts		0	0
	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 0
	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).......	870,235	3,313,475	5,479,621
	c	Investments—corporate bonds (attach schedule).......	430,246	445,317	505,850
	11	Investments—land, buildings, and equipment: basis
		Less: accumulated depreciation (attach schedule)
	12	Investments—mortgage loans.............
	13	Investments—other (attach schedule)..........	2,649,657		0
	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)	4,144,606	3,811,701	6,038,380
	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
		Foundations that follow FASB ASC 958, check here
		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
		and complete lines 26 through 30.
	26	Capital stock, trust principal, or current funds........	4,144,606	3,811,701
	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).....	4,144,606	3,811,701
	30	Total liabilities and net assets/fund balances (see instructions).	4,144,606	3,811,701

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

4,144,606

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

-435

Other increases not included in line 2 (itemize) bullet

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

4,144,171

Decreases not included in line 2 (itemize) bullet

2,470

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

4,141,701

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.)		(b) How acquired P—Purchase D—Donation	(c) Date acquired (mo., day, yr.)	(d) Date sold (mo., day, yr.)
1 a	636. ISHARES CORE S & P 500 ETF			2021-04-05
b	352. ISHARES RUSSELL MID-CAP ETF		2018-04-02	2021-04-05
c	250. ISHARES CORE S&P MIDCAP ETF		2020-03-30	2021-04-05
d	622. ISHARES SELECT DIVIDEND ETF		2018-04-02	2021-07-07
e	374. HP INC		2018-04-02	2021-09-09
	156. METLIFE INC		2018-04-02	2021-09-09
	133. INTERNATIONAL PAPER CO		2018-04-02	2021-09-17
	.71 ANALOG DEVICES INC		2018-04-02	2021-09-22
	238. ISHARES S&P 500 GROWTH ETF		2021-07-07	2021-09-28
	1709.823 T ROWE PRICE INST FLOAT RATE 170		2020-12-22	2021-11-30
	77. CORESITE REALTY CORP		2018-04-02	2021-12-27
	CAPITAL GAIN DIVIDENDS	P
	CAPITAL GAIN DIVIDENDS	P
	CAPITAL GAIN DIVIDENDS	P
	CAPITAL GAIN DIVIDENDS	P
	CAPITAL GAIN DIVIDENDS	P
	CAPITAL GAIN DIVIDENDS	P
	CAPITAL GAIN DIVIDENDS	P
	CAPITAL GAIN DIVIDENDS	P
	CAPITAL GAIN DIVIDENDS	P
	CAPITAL GAIN DIVIDENDS	P
	CAPITAL GAIN DIVIDENDS	P

(e) Gross sales price		(g) Cost or other basis plus expense of sale	(h) Gain or (loss) (e) plus (f) minus (g)
a	259,506	167,356	92,150
b	26,541	17,873	8,668
c	66,290	35,464	30,826
d	72,177	58,461	13,716
e	10,509	8,004	2,505
	9,482	7,058	2,424
	7,606	6,895	711
	124	66	58
	17,725	17,756	-31
	16,602	16,534	68
	13,090	7,415	5,675
			10,547
			10,547
			10,547
			10,547
			10,547
			10,547
			10,547
			10,547
			10,547
			10,547
			10,547

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			92,150
b			8,668
c			30,826
d			13,716
e			2,505
			2,424
			711
			58
			-31
			68
			5,675

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	167,317
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	2,687
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	2,687
6	Credits/Payments:

a	2021 estimated tax payments and 2020 overpayment credited to 2021	6a
b	Exempt foreign organizations—tax withheld at source......	6b	0
c	Tax paid with application for extension of time to file (Form 8868)...	6c	2,687
d	Backup withholding erroneously withheld ...........	6d

7	Total credits and payments. Add lines 6a through 6d..............		7	2,687
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
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 tax0	Refunded	11	0

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

$ (2) On foundation managers. bullet

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

on foundation managers. bullet

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

The books are in care of bullet

WELLS FARGO BANK Telephone no. bullet

(888) 730-4933

Located at bullet

100 N MAIN STWINSTON SALEMNC ZIP+4 bullet

27101

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)

Yes

(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
WELLS FARGO BANK N A	TRUSTEE 1	68,406
100 N MAIN ST MAC D4001-117 WINSTON SALEM,NC27101	TRUSTEE 1	68,406

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

5,665,058

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

165,104

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

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

5,830,162

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

5,830,162

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

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

87,452

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

5,742,710

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

287,136

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

287,136

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

2,687

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

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

2,687

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

284,449

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

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

284,449

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

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

284,449

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					284,449
2 Undistributed income, if any, as of the end of 2021:
a Enter amount for 2020 only.......				220,151
b Total for prior years:20, 20, 20			0
3 Excess distributions carryover, if any, to 2021:
a From 2016......	0
b From 2017......	0
c From 2018......	0
d From 2019......	0
e From 2020......	0
f Total of lines 3a through e ........		0
4Qualifying distributions for 2021 from Part
XI, line 4: $ 210,392
a Applied to 2020, but not more than line 2a				210,392
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.....					0
e Remaining amount distributed out of corpus		0
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		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 .............				9,759
f Undistributed income for 2021. Subtract lines 4d and 5 from line 1. This amount must be distributed in 2022 ..........					284,449
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) ...		0
9 Excess distributions carryover to 2022. Subtract lines 7 and 8 from line 6a ......		0
10 Analysis of line 9:
a Excess from 2017....	0
b Excess from 2018....	0
c Excess from 2019....	0
d Excess from 2020....	0
e Excess from 2021....	0

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).)

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
JEWISH FEDERATION PALM BCH CNTY 1 HARVARD CIRCLE SUITE 100 WEST PALM BEACH,FL33409	NONE	PC	GENERAL SUPPORT	65,000
KRAVIS CENTER FOR THE PERF ARTS 701 OKEECHOBEE BOULEVARD WEST PALM BEACH,FL33401	NONE	PC	GENERAL SUPPORT	65,000
DREYFOOS SCHOOL OF THE ARTS 501 S SAPODILLA AVE WEST PALM BEACH,FL33401	NONE	PC	GENERAL OPERATING	65,000
Total ................................. 3a				195,000

bApproved for future payment

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

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 ...........
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	167,317
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) ..				271,810

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

271,810

(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:

LEWIS CATHY K CHARITABLE FOUNDATION

EIN:

83-1872703

Category	Amount	Net Investment Income	Adjusted Net Income	Disbursements for Charitable Purposes
TAX PREPARATION FEE (NON-ALLOC	1,011			1,011

- TIN:

TY 2021 InvestmentsCorpBondsSchedule

Name:

LEWIS CATHY K CHARITABLE FOUNDATION

EIN:

83-1872703

Name of Bond	End of Year Book Value	End of Year Fair Market Value
912828U24 US TREASURY NOTE 2.0	10,389	11,379
912828S50 TREAS INFL IND BD		11,271
60636SFN9 MISSOURI ST DEV FIN	50,424	52,362
625847EU8 MUNCIE IN SANTN DIST	45,321	53,228
01179RTD5 ALASKA ST MUNI BOND	44,425	48,825
61074PSZ1 MONROE CNTY NY	48,245	53,645
107781JK3 BREWTON AL	47,112	53,656
34282CLF6 FLORIDA ST MUNI LOAN	46,133	53,176
836753LZ4 SOUTH BROWARD FL HOS	46,386	53,356
894435DV5 TRAVIS CNTY TX WC&ID	45,667	50,985
982674JU8 WYANDOTTE CNTY/KANSA	45,950	48,750
912828M80 US TREASURY NOTE	15,265	15,217

- TIN:

TY 2021 InvestmentsCorpStockSchedule

Name:

LEWIS CATHY K CHARITABLE FOUNDATION

EIN:

83-1872703

Name of Stock	End of Year Book Value	End of Year Fair Market Value
G5960L103 MEDTRONIC PLC	4,383	5,793
15135B101 CENTENE CORP DEL	6,904	10,712
457187102 INGREDION INC	3,062	2,319
437076102 HOME DEPOT INC	66,882	151,064
46625H100 JPMORGAN CHASE & CO	7,480	10,926
14040H105 CAPITAL ONE FINANCIA	9,674	14,944
57772K101 MAXIM INTEGRATED PRO
126650100 CVS HEALTH CORPORATI	6,501	10,935
22160K105 COSTCO WHOLESALE COR	8,279	25,547
172967424 CITIGROUP INC.	10,508	9,360
031162100 AMGEN INC	3,673	4,949
67077M108 NUTRIEN LTD	6,592	10,678
110122108 BRISTOL MYERS SQUIBB	57,332	57,736
500754106 KRAFT HEINZ CO/THE	16,990	10,016
92556H206 VIACOMCBS INC	3,259	1,932
65339F101 NEXTERA ENERGY INC	24,593	56,389
M22465104 CHECK POINT SOFTWARE	6,140	7,227
742718109 PROCTER & GAMBLE CO	13,839	28,954
855244109 STARBUCKS CORP COM	38,348	79,306
594918104 MICROSOFT CORP	60,125	142,600
718172109 PHILIP MORRIS INTERN	57,902	55,765
87612E106 TARGET CORP	12,861	43,511
460146103 INTERNATIONAL PAPER
532457108 ELI LILLY & CO COM	38,788	140,320
931427108 WALGREENS BOOTS ALLI	3,646	2,973
17275R102 CISCO SYSTEMS INC	7,692	11,723
75513E101 RAYTHEON TECHNOLOGIE	31,029	39,157
084670702 BERKSHIRE HATHAWAY I	68,535	104,650
G7S00T104 PENTAIR PLC	4,865	7,887
92556V106 VIATRIS INC	431	392
254687106 WALT DISNEY CO	10,237	15,954
40434L105 HP INC
609207105 MONDELEZ INTERNATION	32,303	52,120
92343V104 VERIZON COMMUNICATIO	749	787
88579Y101 3M CO	8,350	6,928
14448C104 CARRIER GLOBAL CORP	10,512	24,679
02209S103 ALTRIA GROUP INC	714	528
747525103 QUALCOMM INC	6,282	21,213
478160104 JOHNSON & JOHNSON	54,935	74,929
037833100 APPLE INC	48,846	208,112
98956P102 ZIMMER BIOMET HOLDIN	6,751	8,004
68902V107 OTIS WORLDWIDE CORP	14,669	19,765
717081103 PFIZER INC	7,918	13,995
74834L100 QUEST DIAGNOSTICS IN	6,304	11,073
525ESC711 ESC LEHMAN BRTH HLD	1
59156R108 METLIFE INC
00206R102 AT & T INC	52,566	36,728
922908736 VANGUARD GROWTH VIPE	90,533	208,585
922908769 VANGUARD TOTAL STOCK	82,184	148,727
92204A702 VANGUARD INFORMATION	108,732	387,154
03027X100 AMERICAN TOWER CORP	402	871
78464A763 SPDR S&P DIVIDEND ET	123,965	178,056
46138E537 INVESCO NATIONAL AMT	24	26
78464A870 SPDR S & P BIOTECH E	44,447	58,331
464287507 ISHARES CORE S&P MID	214,133	495,390
92204A504 VANGUARD SECTOR INDE	33,344	58,879
81369Y605 FINANCIAL SELECT SEC	32,194	74,703
92206C870 VANGUARD INTERMEDIAT	15,857	17,346
872365713 TCW EMRG MRKTS INC-P	147,000	141,138
464287226 ISHARES CORE U.S. AG	238,444	244,588
464288414 ISHARES NATIONAL MUN	60	65
464287655 ISHARES RUSSELL 2000	136,507	211,328
92206C409 VANGUARD S/T CORP BO	35,706	37,055
77958B402 T ROWE PRICE INST FL	33,466	33,743
302544101 FPA NEW INCOME FUND	237,000	239,401
464287465 ISHARES MSCI EAFE ET	71,380	78,680
78462F103 SPDR S & P 500 ETF T	115,520	220,381
464287309 ISHARES S&P 500 GROW	53,342	59,824
81369Y209 HEALTH CARE SELECT S	32,420	107,358
81369Y407 AMEX CONSUMER DISCR	28,875	119,597
464287408 ISHARES S&P 500 VALU	17,568	18,639
921908844 VANGUARD DIVIDEND AP	83,127	143,755
921937835 VANGUARD TOTAL BOND	13,737	14,577
922042676 VANGUARD GLBL EX-US	20,950	18,721
032654105 ANALOG DEVICES INC	6,761	12,831
464287168 ISHARES SELECT DIVID	58,461	76,251
922908553 VANGUARD REAL ESTATE	111,462	172,855
922908744 VANGUARD VALUE VIPER	87,234	126,515
67065Q822 NUVEEN LIMITED TERM	50,000	49,912
81369Y704 AMEX INDUSTRIAL SPDR	22,190	57,032
46653M849 JOHCM INTERNATIONAL	125,000	124,727

- TIN:

TY 2021 InvestmentsOtherSchedule2

Name:

LEWIS CATHY K CHARITABLE FOUNDATION

EIN:

83-1872703

Category/ Item	Listed at Cost or FMV	Book Value	End of Year Fair Market Value
65339F101 NEXTERA ENERGY INC
464287168 ISHARES SELECT DIVID
172967424 CITIGROUP INC
03027X100 AMERICAN TOWER CORP
457187102 INGREDION INC
437076102 HOME DEPOT INC
81369Y506 AMEX ENERGY SELECT S
532457108 ELI LILLY & CO COM
81369Y605 FINANCIAL SELECT SEC
G7S00T104 PENTAIR PLC
92343V104 VERIZON COMMUNICATIO
982674JU8 WYANDOTTE CNTY/KANSA
34282CLF6 FLORIDA ST MUNI LOAN
922042858 VANGUARD EMERGING MA
922908736 VANGUARD GROWTH VIPE
00206R102 AT & T INC
92204A702 VANGUARD INFORMATION
464288414 ISHARES NATIONAL MUN
464287655 ISHARES RUSSELL 2000
500754106 KRAFT HEINZ CO/THE
92204A504 VANGUARD SECTOR INDE
17275R102 CISCO SYSTEMS INC
254687106 WALT DISNEY CO
747525103 QUALCOMM INC
78462F103 SPDR S & P 500 ETF T
836753LZ4 SOUTH BROWARD FL HOS
625847EU8 MUNCIE IN SANTN DIST
464287499 ISHARES RUSSELL MID-
88579Y101 3M CO
40434L105 HP INC
92206C409 VANGUARD S/T CORP BO
02209S103 ALTRIA GROUP INC
78464A763 SPDR S&P DIVIDEND ET
031162100 AMGEN INC
57772K101 MAXIM INTEGRATED PRO
74834L100 QUEST DIAGNOSTICS IN
107781JK3 BREWTON AL
464287507 ISHARES CORE S&P MID
931427108 WALGREENS BOOTS ALLI
81369Y209 HEALTH CARE SELECT S
464287226 ISHARES CORE U.S. AG
922908744 VANGUARD VALUE VIPER
247361702 DELTA AIR LINES INC
78464A870 SPDR S & P BIOTECH E
921908844 VANGUARD DIVIDEND AP
14040H105 CAPITAL ONE FINANCIA
855244109 STARBUCKS CORP COM
59156R108 METLIFE INC
464286806 ISHARES MSCI GERMANY
46138E537 INVESCO NATIONAL AMT
G5960L103 MEDTRONIC PLC
98956P102 ZIMMER HOLDINGS INC
912828S50 TREAS INFL IND BD
922042866 VANGUARD PACIFIC ETF
464288513 ISHARES TRI BOXX $ H
921943858 VANGUARD EUROPE PACI
037833100 APPLE COMPUTER INC C
110122108 BRISTOL MYERS SQUIBB
922042676 VANGUARD GLBL EX-US
277432100 EASTMAN CHEM CO COM
460146103 INTERNATIONAL PAPER
478160104 JOHNSON & JOHNSON
46625H100 JPMORGAN CHASE & CO
01179RTD5 ALASKA ST MUNI BOND
9707012Y3 WILLISTON ND
922908553 VANGUARD REAL ESTATE
609207105 MONDELEZ INTERNATION
921937835 VANGUARD TOTAL BOND
M22465104 CHECK POINT SOFTWARE
126650100 CVS/CAREMARK CORPORA
717081103 PFIZER INC
742718109 PROCTER & GAMBLE CO
894435DV5 TRAVIS CNTY TX WC&ID
81369Y704 AMEX INDUSTRIAL SPDR
084670702 BERSHIRE HATHAWAY IN
92206C870 VANGUARD INTERMEDIAT
21870Q105 CORESITE REALTY CORP
912828U24 US TREASURY NOTE
525ESC711 ESCROW LEINER HEALTH
718172109 PHILIP MORRIS INTERN
594918104 MICROSOFT CORP
913017109 UNITED TECHNOLOGIES
22160K105 COSTCO WHOLESALE COR
67077M108 NUTRIEN LTD
87612E106 TARGET CORP
60636SFN9 MISSOURI ST DEV FIN
61074PSZ1 MONROE CNTY NY
464287200 ISHARES CORE S & P 5
15135B101 CENTENE CORP DEL
81369Y407 AMEX CONSUMER DISCR
922908769 VANGUARD TOTAL STOCK
92556H206 VIACOMCBS INC
302544101 FPA NEW INCOME FUND
87234N765 TCW EMRG MKTS INCM-I
46140H403 INVESCO DB OIL FUND
00770G847 JOHCM INTERNATIONAL
464287465 ISHARES MSCI EAFE ET
67065Q822 NUVEEN LIMITED TERM
77958B402 T ROWE PRICE INST FL

- TIN:

TY 2021 LegalFeesSchedule

Name:

LEWIS CATHY K CHARITABLE FOUNDATION

EIN:

83-1872703

Category	Amount	Net Investment Income	Adjusted Net Income	Disbursements for Charitable Purposes
LEGAL FEES - PRINCIPAL (ALLOCA	7,540			7,540

- TIN:

TY 2021 OtherDecreasesSchedule

Name:

LEWIS CATHY K CHARITABLE FOUNDATION

EIN:

83-1872703

Description	Amount
PY RETURN OF CAPITAL ADJ	2,202
MUTUAL FUND TIMING ADJ	144
COST BASIS ADJUSTMENT	124

- TIN:

TY 2021 TaxesSchedule

Name:

LEWIS CATHY K CHARITABLE FOUNDATION

EIN:

83-1872703

Category	Amount	Net Investment Income	Adjusted Net Income	Disbursements for Charitable Purposes
FOREIGN TAXES	242	242		0
FOREIGN TAXES ON NONQUALIFIED	46	46		0