-
TIN:
Form
990-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.
Go to
www.irs.gov/Form990PF
for instructions and the latest information.
OMB No. 1545-0047
20
23
Open to Public Inspection
For calendar year 2023, or tax year beginning
01-01-2023
, and ending
12-31-2023
Name of foundation
The Jacquemin Family Foundation Inc
Number and street (or P.O. box number if mail is not delivered to street address)
45150 Russell Branch Pkwy Ste 102
Room/suite
City or town, state or province, country, and ZIP or foreign postal code
Ashburn
,
VA
20147
A Employer identification number
54-1887187
B
Telephone number (see instructions)
(703) 917-0707
C
If exemption application is pending, check here
G
Check all that apply:
Initial return
Initial return of a former public charity
Final return
Amended return
Address change
Name change
D 1.
Foreign organizations, check here.............
2
. Foreign organizations meeting the 85%
test, check here and attach computation ...
E
If private foundation status was terminated
under section 507(b)(1)(A), check here .......
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 .......
I
Fair market value of all assets at end
of year (from Part II, col. (c),
line 16)
$
15,733,313
J
Accounting method:
Cash
Accrual
Other (specify)
(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)
1
Contributions, gifts, grants, etc., received (attach schedule)
2
Check
.............
3
Interest on savings and temporary cash investments
5,116
5,116
5,116
4
Dividends and interest from securities
...
477,052
477,052
477,052
5a
Gross rents
............
b
Net rental income or (loss)
6a
Net gain or (loss) from sale of assets not on line 10
b
Gross sales price for all assets on line 6a
7
Capital gain net income (from Part IV, line 2)
...
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
........
482,168
482,168
482,168
13
Compensation of officers, directors, trustees, etc.
14
Other employee salaries and wages
......
15
Pension plans, employee benefits
.......
16a
Legal fees (attach schedule)
.........
b
Accounting fees (attach schedule)
.......
c
Other professional fees (attach schedule)
....
17
Interest
...............
18
Taxes (attach schedule) (see instructions)
...
19
Depreciation (attach schedule) and depletion
...
20
Occupancy
..............
21
Travel, conferences, and meetings
.......
22
Printing and publications
..........
23
Other expenses (attach schedule)
.......
List of Attached Documents:
// Content
105
105
24
Total operating and administrative expenses.
Add lines 13 through 23
..........
105
105
0
25
Contributions, gifts, grants paid
.......
1,200,000
1,200,000
26
Total expenses and disbursements.
Add lines 24 and 25
1,200,105
105
1,200,000
27
Subtract line 26 from line 12:
a
Excess of revenue over expenses and disbursements
-717,937
b
Net investment income
(if negative, enter -0-)
482,063
c
Adjusted net income
(if negative, enter -0-)
...
482,168
For Paperwork Reduction Act Notice, see instructions.
Cat. No. 11289X
Form
990-PF
(2023)
Form 990-PF (2023)
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
1
Cash—non-interest-bearing
.............
4,001,009
3,290,124
3,290,124
2
Savings and temporary cash investments
.........
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)
52,939
Less: allowance for doubtful accounts
49,990
List of Attached Documents:
// Content
52,939
52,939
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)
.......
10,831,555
12,378,770
12,378,770
c
Investments—corporate bonds (attach schedule)
.......
11
Investments—land, buildings, and equipment: basis
Less: accumulated depreciation (attach schedule)
12
Investments—mortgage loans
.............
13
Investments—other (attach schedule)
..........
11,480
11,480
11,480
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)
14,894,034
15,733,313
15,733,313
17
Accounts payable and accrued expenses
..........
1,000
11,000
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)
.........
1,000
11,000
Foundations that follow FASB ASC 958, check here
and complete lines 24, 25, 29 and 30.
24
Net assets without donor restrictions
...........
14,893,034
15,722,313
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)
.....
14,893,034
15,722,313
30
Total liabilities and net assets/fund balances
(see instructions)
.
14,894,034
15,733,313
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
14,893,034
2
Enter amount from Part I, line 27a
.....................
2
-717,937
3
Other increases not included in line 2 (itemize)
List of Attached Documents:
// Content
3
1,547,216
4
Add lines 1, 2, and 3
..........................
4
15,722,313
5
Decreases not included in line 2 (itemize)
5
6
Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 29
.
6
15,722,313
Form
990-PF
(2023)
Form 990-PF (2023)
Page
3
Part IV
Capital Gains and Losses for Tax on Investment Income
(a)
List and describe the kind(s) of property sold (e.g., real estate,
2-story brick warehouse; or common stock, 200 shs. MLC Co.)
(b)
How acquired
P—Purchase
D—Donation
(c)
Date acquired
(mo., day, yr.)
(d)
Date sold
(mo., day, yr.)
1a
b
c
d
e
(e)
Gross sales price
(f)
Depreciation allowed
(or allowable)
(g)
Cost or other basis
plus expense of sale
(h)
Gain or (loss)
(e) plus (f) minus (g)
a
b
c
d
e
Complete only for assets showing gain in column (h) and owned by the foundation on 12/31/69
(l)
Gains (Col. (h) gain minus
col. (k), but not less than -0-)
or
Losses (from col.(h))
(i)
F.M.V. as of 12/31/69
(j)
Adjusted basis
as of 12/31/69
(k)
Excess of col. (i)
over col. (j), if any
a
b
c
d
e
2
Capital gain net income or (net capital loss)
If gain, also enter in Part I, line 7
If (loss), enter -0- in Part I, line 7
2
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
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)
1
6,701
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
3
Add lines 1 and 2
...........................
3
6,701
4
Subtitle A (income) tax (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-)
4
5
Tax based on investment income.
Subtract line 4 from line 3. If zero or less, enter -0-
.....
5
6,701
6
Credits/Payments:
a
2023 estimated tax payments and 2022 overpayment credited to 2023
6a
22,087
b
Exempt foreign organizations—tax withheld at source
......
6b
c
Tax paid with application for extension of time to file (Form 8868)
...
6c
d
Backup withholding erroneously withheld
..........
6d
7
Total credits and payments. Add lines 6a through 6d
..............
7
22,087
8
Enter any
penalty
for underpayment of estimated tax.
Check here
if Form 2220 is attached.
List of Attached Documents:
// Content
8
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
15,386
11
Enter the amount of line 10 to be:
Credited to 2024 estimated tax
15,386
Refunded
11
Form
990-PF
(2023)
Form 990-PF (2023)
Page
4
Part VI-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.
$
(2)
On foundation managers.
$
e
Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed
on foundation managers.
$
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 XIV.
.................................
7
Yes
8a
Enter the states to which the foundation reports or with which it is registered (see instructions)
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 2023 or the taxable year beginning in 2023? See the instructions for Part XIII.
If "Yes," complete Part XIII
.............................
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
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 address
N/A
14
The books are in care of
John M Jacquemin
Telephone no.
(703) 917-0289
Located at
8609 Westwood Center Drive Suite 45
Vienna
VA
ZIP+4
22182
15
Section 4947(a)(1) nonexempt charitable trusts filing Form 990-PF in lieu of
Form 1041
—check here
.........
and enter the amount of tax-exempt interest received or accrued during the year
........
15
16
At any time during calendar year 2023, did the foundation have an interest in or a signature or other authority over
Yes
No
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
Form
990-PF
(2023)
Form 990-PF (2023)
Page
5
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
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?
...........
1a(1)
No
(2)
Borrow money from, lend money to, or otherwise extend credit to (or accept it from)
a disqualified person?
..............................
1a(2)
No
(3)
Furnish goods, services, or facilities to (or accept them from) a disqualified person?
...........
1a(3)
No
(4)
Pay compensation to, or pay or reimburse the expenses of, a disqualified person?
............
1a(4)
No
(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)
No
(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)
No
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
c
Organizations relying on a current notice regarding disaster assistance check here
........
d
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 2023?
.............
1d
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 2023, did the foundation have any undistributed income (Part XII, lines 6d
and 6e) for tax year(s) beginning before 2023?
....................
2a
No
If "Yes," list the years
20
,
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.
20
,
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?
..............................
3a
No
b
If "Yes," did it have excess business holdings in 2023 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 2023.)
.....................
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 2023?
..
4b
No
Form
990-PF
(2023)
Form 990-PF (2023)
Page
6
Part VI-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))?
..........
5a(1)
No
(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)
No
(3)
Provide a grant to an individual for travel, study, or other similar purposes?
.............
5a(3)
No
(4)
Provide a grant to an organization other than a charitable, etc., organization described
in section 4945(d)(4)(A)? See instructions
........................
5a(4)
No
(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)
No
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
c
Organizations relying on a current notice regarding disaster assistance check
.........
d
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?
.................
5d
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?
.............................
6a
No
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?
7a
No
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?
.........................
8
No
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
John M Jacquemin
Manager
0.00
0
8609 Westwood Center Dr 450
Vienna
,
VA
22182
Tracie J Jaquemin
Secretary
1.00
0
8609 Westwood Center Dr 450
Vienna
,
VA
22182
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
...................
Form
990-PF
(2023)
Form 990-PF (2023)
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
.............
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
.........................
Form
990-PF
(2023)
Form 990-PF (2023)
Page
8
Part IX
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
0
b
Average of monthly cash balances
.......................
1b
0
c
Fair market value of all other assets (see instructions)
................
1c
0
d
Total
(add lines 1a, b, and c)
.........................
1d
0
e
Reduction claimed for blockage or other factors reported on lines 1a and
1c (attach detailed explanation)
.............
1e
0
2
Acquisition indebtedness applicable to line 1 assets
..................
2
3
Subtract line 2 from line 1d
.........................
3
0
4
Cash deemed held for charitable activities. Enter 1.5% (0.015) of line 3 (for greater amount, see
instructions)
.............................
4
0
5
Net value of noncharitable-use assets.
Subtract line 4 from line 3.
............
5
0
6
Minimum investment return.
Enter 5% (0.05) of line 5
................
6
0
Part X
Distributable Amount
(see instructions) (Section 4942(j)(3) and (j)(5) private operating foundations and certain foreign organizations check here
and do not complete this part.)
1
Minimum investment return from Part IX, line 6
..................
1
2a
Tax on investment income for 2022 from Part V, line 5
.......
2a
6,701
b
Income tax for 2022. (This does not include the tax from Part V.)
...
2b
c
Add lines 2a and 2b
............................
2c
6,701
3
Distributable amount before adjustments. Subtract line 2c from line 1
............
3
6,701
4
Recoveries of amounts treated as qualifying distributions
................
4
5
Add lines 3 and 4
............................
5
6,701
6
Deduction from distributable amount (see instructions)
.................
6
7
Distributable amount
as adjusted. Subtract line 6 from line 5. Enter here and on Part XII, line 1
...
7
0
Part XI
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
1,200,000
b
Program-related investments—total from Part VIII-B
..................
1b
2
Amounts paid to acquire assets used (or held for use) directly in carrying out charitable, etc.,
purposes
...............................
2
3
Amounts set aside for specific charitable projects that satisfy the:
a
Suitability test (prior IRS approval required)
....................
3a
b
Cash distribution test (attach the required schedule)
.................
3b
4
Qualifying distributions.
Add lines 1a through 3b. Enter here and on Part XII, line 4.
.......
4
1,200,000
Form
990-PF
(2023)
Form 990-PF (2023)
Page
9
Part XII
Undistributed Income
(see instructions)
(a)
Corpus
(b)
Years prior to 2022
(c)
2022
(d)
2023
1
Distributable amount for 2023 from Part X, line 7
0
2
Undistributed income, if any, as of the end of 2022:
a
Enter amount for 2022 only
.......
b
Total for prior years:
20
,
20
,
20
3
Excess distributions carryover, if any, to 2022:
a
From 2018
......
b
From 2019
......
46,833
c
From 2020
......
d
From 2021
......
81,414
e
From 2022
......
1,223,000
f
Total
of lines 3a through e
........
1,351,247
4
Qualifying distributions for 2023 from Part
XI, line 4:
$
1,200,000
a
Applied to 2022, but not more than line 2a
b
Applied to undistributed income of prior years
(Election required—see instructions)
.....
c
Treated as distributions out of corpus (Election
required—see instructions)
........
0
d
Applied to 2023 distributable amount
.....
e
Remaining amount distributed out of corpus
1,200,000
5
Excess distributions carryover applied to 2023.
(If an amount appears in column (d), the
same amount must be shown in column (a).)
6
Enter the net total of each column as
indicated below:
a
Corpus. Add lines 3f, 4c, and 4e. Subtract line 5
2,551,247
b
Prior years’ undistributed income. Subtract
line 4b from line 2b
..........
c
Enter the amount of prior years’ undistributed
income for which a notice of deficiency has
been issued, or on which the section 4942(a)
tax has been previously assessed
......
d
Subtract line 6c from line 6b. Taxable amount
—see instructions
...........
e
Undistributed income for 2022. Subtract line
4a from line 2a. Taxable amount—see
instructions
.............
f
Undistributed income for 2023. Subtract
lines 4d and 5 from line 1. This amount must
be distributed in 2024
..........
0
7
Amounts treated as distributions out of
corpus to satisfy requirements imposed by
section 170(b)(1)(F) or 4942(g)(3) (Election may
be required - see instructions)
.......
8
Excess distributions carryover from 2018 not
applied on line 5 or line 7 (see instructions)
...
9
Excess distributions carryover to 2024.
Subtract lines 7 and 8 from line 6a
......
2,551,247
10
Analysis of line 9:
a
Excess from 2019
....
46,833
b
Excess from 2020
....
c
Excess from 2021
....
81,414
d
Excess from 2022
....
1,223,000
e
Excess from 2023
....
1,200,000
Form
990-PF
(2023)
Form 990-PF (2023)
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 2023, enter the date of the ruling
......
b
Check box to indicate whether the organization is a private operating foundation described in section
4942(j)(3)
or
4942(j)(5)
2a
Enter the lesser of the adjusted net
income from Part I or the minimum
investment return from Part IX for each
year listed
..........
Tax year
Prior 3 years
(e) Total
(a)
2023
(b)
2022
(c)
2021
(d)
2020
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.)
1
Information Regarding Foundation Managers:
a
List 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).)
John M Jacquemin
b
List 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.
2
Information Regarding Contribution, Grant, Gift, Loan, Scholarship, etc., Programs:
Check here
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
a
The name, address, and telephone number or e-mail address of the person to whom applications should be addressed:
John M Jacquemin
8609 Westwood Center Drive Suite 45
Vienna
,
VA
22182
(703) 917-0707
b
The form in which applications should be submitted and information and materials they should include:
No form required
c
Any submission deadlines:
None
d
Any restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other
factors:
no
Form
990-PF
(2023)
Form 990-PF (2023)
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)
a
Paid during the year
Levine School of Music
2801 Upton Street NW
Washington
,
DC
20008
None
501(c)(3)
Non-for-profit community music school.
10,000
Main Street Child Development Cente
4401 Sideburn Road
Fairfax
,
VA
22030
None
501(c)(3)
Main Street provides 3,000 hours of nationally-accredited educational instruction and enrichment for at-risk children (ages 2 to 5) each year.
10,000
Wolf Trap Foundation
1645 Trap Road
Vienna
,
VA
22182
None
501(c)(3)
SUPPORT THE FOUNDATION'S EARLY LEARNING THROUGHTHE ARTS
5,000
Kenya Education Fund KEF
PO Box 7015
Mclean
,
VA
22106
None
501(c)(3)
Funds the high school education of 40 needy and nomadic students in Kenya.
30,000
Kid Pan Alley
PO Box 38
Washington
,
VA
22747
None
501(c)(3)
Funds the process of inspiring and empowering children to work together to become creators of their own music and rekindles creativity as a core value in education.
25,000
University at Buffalo BNAC
PO Box 730
Buffalo
,
NY
14226
None
501(c)(3)
Supports the Buffalo Neuroimaging Analysis Center Fund in the School of Medicine and Biomedical Sciences in particular research in multiple sclerosis. This research allows clinicians, researchers and medical students from around the world to advance their understanding of multiple sclerosis and other diseases of the brain, spinal cord and optic nerve .
35,000
Second Story
PO Box 694
Dun Loring
,
VA
22027
None
501(c)(3)
Funds shelter for runaway, abused and homeless teens by offering safe and accessible places where teens can get help, development important life skills, and improve family relationships.
15,000
Homestretch
303 South Maple Ave Suite 400
Falls Church
,
VA
22046
None
501(c)(3)
Empowers homeless families to return to stable housing and self-sufficiency by providing them with the skills to become productive participants in Northern Virginia.
15,000
Hopecam
12100 Sunset Hills Rd C10
Reston
,
VA
20190
None
501(c)(3)
Hopecam connects children undergoing treatment for cancer with their friends at school usingtablet computers, high speed internet connections and web cameras.
5,000
ARC NOVA
2755 Hartland Rd Suite 200
Falls Chruch
,
VA
22043
None
501(c)(3)
Supporting thousands of people and families living with cognitive, intellectual, and developmental disabilities.
10,000
Rappahannock Pantry
602 Mt Salem Ave
Washington
,
VA
22747
None
501(c)(3)
distributes food to residents in need.
10,000
ArtStream
8401 Connecticut Ave 1230
Chevy Chase
,
MD
20815
None
501(c)(3)
To creates artistic opportunities for communities underserved by the arts, mainly individuals with disabilities.
10,000
Headwaters
12018 Lee Hwy
Sperryville
,
VA
22740
None
PF
To foster educational excellence in Rappahannock County by cultivating the cooperative spirit and resources of the whole community to benefit all students.
10,000
Inova Kellar
11204 Waples Mill Rd
Fairfax
,
VA
22030
None
501(c)(3)
Inova Kellar Center has provided behavioral health services for children, adolescents and their families for twenty years. Our comprehensive mental health and substance abuse treatment programs and an innovative special education school support families throughout Northern Virginia and continue to expand to meet future needs.
10,000
RAAC
PO Box 24
Washington
,
VA
22747
None
501(c)(3)
RAAC is an organization in Rappahannock country that focuses on enhancing the lives of the community through exposure to and participation in the arts.
10,000
SAGWA Suzuki Association
2349 Belleview Ave
Cheverly
,
MD
20785
None
501(c)(3)
To improving childrens lives through music education. Our mission is to inspire an appreciation for the untapped possibilities of children through promoting the understanding and use of the music teaching approach and educational philosophy of Dr. Shinichi Suzuki for the greater happiness of all children.
5,000
Child Care Learning Center of Rappa
12763 Lee Highway PO Box 520
Washington
,
VA
22747
None
501(c)(3)
To provide early childhood programs.
25,000
SafeSpot Children's Advocacy Center
PO Box 148
Fairfax
,
VA
22038
None
501(c)(3)
To provide direct services to child victims of sexual abuse and severe physical abuse.
10,000
Assistance League of Northern Virgi
PO Box 209
Herdon
,
VA
20172
None
501(c)(3)
To feed, cloth and educate children in need in our community.
5,000
Crossways Community
3015 Upton Dr
Kensington
,
MD
20895
None
501(c)(3)
Crossway Community is a prepared environment, intentionally designed and maintained to be conducive to healthy family interaction healthy development for all ages.
5,000
Friend of Guest House
1 E Luray Ave
Alexandria
,
VA
22301
None
501(c)(3)
Guest House helps Northern Virginia women make successful transitions from incarceration back into the community. The program focuses on issues ranging from trauma and addiction to housing and employment, in order to prevent the women from reoffending in the future. Fewer than 10% of Guest House graduates re-offend.
25,000
Piedmont Environmental Council
45 Horner St
Warrenton
,
VA
20186
None
501(c)(3)
To promote and protect the Piedmont area's rural economy, natural resources, history, and beauty. The organization was founded in 1972.
10,000
Castleton Community Volunteer Fire
593 Castleton View Road
Castleton
,
VA
22716
None
501(c)(3)
Castleton Community Volunteer Fire Company was established in 1956 as a Fire Company and later added EMS Transport capabilities and continues today as a Fire and Rescue Company.
5,000
Common Good City Farm
PO Box 26030
Washington
,
DC
20001
None
501(c)(3)
Common Good City Farm (CGCF) is a place where community members can source fresh food, see sustainable urban agriculture in action, and gain exposure to concepts and skills to lead healthy lives. Their mission is to create a vibrant, informed, and well-nourished community through urban farming.
7,500
Rapp at Home
PO Box 193
Washington
,
VA
22747
None
501(c)(3)
Rapp at Homes mission is to sustain and enrich Rappahannock County residents who are members of Rapp at Home to age in the community comfortably, safely, independently and with peace of mind by fostering the community supports and services needed to do so.
10,000
Safe Shores
429 O Street NW
Washington
,
DC
20001
None
501(c)(3)
Safe Shores is dedicated to working with and advocating for children and adolescents affected by trauma and violence.
5,000
Belle Meade Montessory School
353 FT Valley Rd
Sperryville
,
VA
22740
None
501(c)(3)
Belle Meade Montessori School provides an exceptional education that emphasizes individual responsibility as well as social and environmental consciousness through experiential learning.
20,000
Boston Home
2049 Dorchester Ave
Boston
,
MA
02124
None
501(c)(3)
The Boston Home is a national model for the care of adults with advanced progressive neurological diseases, primarily Multiple Sclerosis. It provides the highest level of care in a specialized residential facility and is one of few in the nation that does so.
10,000
Foothills Forum
311 Gay St PO Box 153
Washington
,
VA
22747
None
501(c)(3)
Foothills Forum is an independent, nonpartisan civic news organization, a 501(c)3 nonprofit, serving Rappahannock County, Va. Foothills raises community support for local news.
25,000
Mental Health Association of Fauqui
321 Walker Dr
Warrenton
,
VA
20186
None
501(c)(3)
Mental Health Assocation of Fauquier County provides mental health and addiction and substance use resources in Fauquier, Rappahannock, and nearby areas. They promote and facilitate mental wellness in the communities they serve primarily Fauquier and Rappahannock counties in Virginia.
5,000
Chaska USA
844 Summerfield Dr
Roselle
,
IL
60172
None
501(c)(3)
Chaska, USA provides disaster relief.
25,000
First Nations Development Institute
2432 Main St 2nd Floor
Longmont
,
CO
80501
None
501(c)(3)
First Nations mission is to strengthen American Indian economies to support healthy Native communities. We invest in and create innovative institutions and models that strengthen asset control and support economic development for American Indian people and their communities.
10,000
Raap Center for Education
11669 Lee Highway
Sperrryville
,
VA
22740
None
501(c)(3)
RappU Lifelong Learning organization committed to lifelong learning and workforce training in Rappahannock County, Virginia.
25,000
Scrabble School
PO Box 356
Sperryville
,
VA
22740
None
501(c)(3)
The Scrabble School Preservation Foundation's mission is to preserve the school's history and to share its legacy through public outreach and educational programs.
5,000
Insight Memory Care Center
3953 Pender Dr Ste 100
Fairfax
,
VA
22030
None
501(c)(3)
Insight Memory Care Center (IMCC) is a nonprofit adult day health and resource center providing specialized care, support, and education for individuals with Alzheimers.
10,000
Cheyenne River Youth Project
PO Box 410 702 4th Street
Eagle Butte
,
SD
57625
None
501(c)(3)
The mission of the Cheyenne River Youth Project is to give the Lakota youth of the Cheyenne River Sioux reservation access to a vibrant and secure future through our culturally sensitive programs, projects, and facilities ensuring strong, self-sufficient families and communities.
35,000
Norcal Resist Fund
PO Box 188331
Sacramento
,
CA
95818
None
501(c)(3)
Norcal Resist is community members organizing for a better world, and we invite you to join us. We believe that as activists and organizers, we must not only stand in opposition to policies, politicians, and systems that harm our communities, but also begin building the better world we want to live in. That's why it's our mission to fight injustice through making a positive impact in our communities. We host educational events and trainings, organize actions, and maintain a variety of resources and programs that provide support to those in need.
15,000
Gender Health Center
2020 29th St Ste 201
Sacramento
,
CA
95817
None
501(c)(3)
The Gender Health Center is committed to creating access to healthcare for all as an act of social justice. To affect change that alleviates the systematic oppression of transgender people- especially those at the intersection of identities- through advocacy and direct services, while using a mental health-centered model and social justice lens.
15,000
Sogorea Te Land Trust
2501 Harrison St
Oakland
,
CA
94612
None
501(c)(3)
Sogorea Te Land Trust is an urban Indigenous women-led land trust based in the San Francisco Bay Area that facilitates the return of Indigenous land to Indigenous people. Through the practices of rematriation, cultural revitalization, and land restoration, Sogorea Te calls on native and non-native peoples to heal and transform the legacies of colonization, genocide, and patriarchy and to do the work our ancestors and future generations are calling us to do.
5,000
Serendipity Equine Inc
162 Rollins Ford Rd
Amissville
,
VA
20106
None
501(c)(3)
Serendipity Equine strives to develop Educational and Equine-Assisted Learning programs and to meet a growing need for rescue and rehabilitation services, which partners youth and their families, veterans, first-responders and their families with rehabilitated equines. To create programs in which each participant and horse will be treated as an individual and they themselves will determine how quickly or slowly their training takes place. Serendipitys goal is to provide these programs to the community at large regardless of social or economic standing and create an inclusive community equestrian center where integration, not segregation, of individuals at-risk or those with disabilities is the rule.
5,000
Sango-Kenya Inc
196 Walnut Grove Ln
Washington
,
VA
22747
None
501(c)(3)
SANGO-Kenya partners with the most vulnerable communities to help them become resilient to the acute and long-term effects of climate and other shocks on farming and nutrition.
10,000
Neighborhood Health
6677 Richmond Highway
Alexandria
,
VA
22306
None
501(c)(3)
Neighbor Healths mission is to improve health and advance health equity in Alexandria, Arlington, and Fairfax by providing high quality primary care regardless of ability to pay.
10,000
Arlington Free Clinic Inc
2921 11th Street South
Arlington
,
VA
22204
None
501(c)(3)
Arlington Free Clinic provides free, high-quality medical care to low-income, uninsured Arlington County adults through the generosity of donors and volunteers.
10,000
Greater DC Diaper Bank
1532 A Street NE
Washington
,
DC
20002
None
501(c)(3)
Greater DC Diaper Bank empowers families and individuals in need throughout DC, Maryland, and Virginia by providing an adequate and reliable source for basic baby needs and personal hygiene products.
5,000
Miriam's Kitchen
2401 Virginia Avenue NW
Washington
,
DC
20037
None
501(c)(3)
Miriam's Kitchen works to end chronic (long-term) homelessness in Washington DC. From meals to housing, we provide a variety of services to honor the dignity of people experiencing homelessness, create a place of belonging and achieve long term change. Unlike most organizations that provide services directly to people experiencing homelessness in DC, we work at the system level to address root causes and to bring about change. We are pleased to be part of a cross-sector partnership that has brought down veteran homelessness 40% and chronic homelessness 22% since 2013. Our mission is to collaborate across sectors to end all chronic homelessness in our nation's capital.
5,000
PathForward Inc A-SPAN
PO Box 10073
Arlington
,
VA
22210
None
501(c)(3)
PathForward's mission is to secure permanent housing and provide life-sustaining services for Arlingtons most vulnerable individuals through outreach and relationships built on trust and respect.
10,000
ALIVE
2723 King Street
Alexandria
,
VA
22302
None
501(c)(3)
ALIVE!s mission is to help Alexandrians faced with emergency situations or long-term needs become capable of assuming self-reliant roles in the community. ALIVE!s programmatic work focuses on the following service areas: Food, Shelter, and Emergency Help.
10,000
Arlington Food Assistance Center AF
PO Box 6261
Arlington
,
VA
22206
None
501(c)(3)
AFAC is an independent, community-based non-profit food pantry that provides dignified access to nutritious supplemental groceries to all our Arlington neighbors in need. In doing so, AFAC makes it possible for vulnerable families in our community to devote their limited resources to financial obligations such as housing, utilities, and other basic needs.
5,000
Acclerated Cure Project
460 Totten Pond Rd STE 140
Waltham
,
MA
02451
None
501(c)(3)
The Accelerated Cure Project for MS believes that research is the only way to greatly improve the outlook for people with MS. The organization promotes scientific collaboration and accelerates research by rapidly and cost-effectively providing researchers with data and biospecimens they need to explore novel research ideas that can lead to better care for people with MS.
20,000
Allegheny Mountain Institute
PO Box 542
Staunton
,
VA
24402
None
501(c)(3)
Allegheny Mountain Institute (AMI) is an educational non-profit organization with the mission to cultivate healthy communities through food and education. The vision of AMI is a thriving network of collaborative, vibrant communities who value the connection between food and health.
5,000
District Alliance for Safe Housing
PO Box 91730
Washington
,
DC
20090
None
501(c)(3)
The District Alliance for Safe Housing (DASH) is an innovator in providing access to safe housing and services for survivors of domestic and sexual violence and their families as they rebuild their lives on their own terms. We envision a culture where safe housing is a human right shared by everyone.
10,000
Dreaming Out Loud
3015 Upton Dr
Kensington
,
MD
20895
None
501(c)(3)
Crossway Community is a prepared environment, intentionally designed and maintained to be conducive to healthy family interaction healthy development for all ages. Practical Life Skills Coordinators work with FLA mothers to set up and maintain their apartments according to Montessori principles of order, independence, and respect, and reduced stress for the mothers. A robust parent education initiative (including a partnership agreement) is a cornerstone of our Montessori school. Parents and children work together in the on-site garden, learning about healthy eating and nutrition while planting and harvesting vegetables, and celebrating the community through regular social gatherings and celebrations.
5,000
Family Futures
PO Box 570
Sperryville
,
VA
22740
None
501(c)(3)
Family Futures mission is to provide financial education, access and tools to residents of Rappahannock County
10,000
Free Clinic of Culpeper
610 Laurel St Ste 3
Culpeper
,
VA
22701
None
501(c)(3)
Free Clinic of Culpepers mission is to provide out-patient medical care.
10,000
George Mason University
4400 University Drive
Fairfax
,
VA
22030
None
501(c)(3)
George Mason University is a Virginia public higher-education institution. It is the largest public research institution in the state.
175,000
Health Tree Foundation
1525 Newton St NW
Washington
,
DC
20010
None
501(c)(3)
The Homeless Children's Playtime Project cultivates resilience in children experiencing family homelessness by providing and expanding access to transformative play experiences. They partner with transitional housing and emergency shelters across the city, where we create safe and fun play spaces in the shelters where the children live.
25,000
International Myeloma Foundation
12650 Riverside Dr Ste 206
North Hollywood
,
CA
91607
None
501(c)(3)
The Mission of the International Myeloma Foundation (IMF) is to improve the quality of life of myeloma patients while working toward prevention and a cure.
20,000
Kids in Distress
819 NW 26th Street
Wilton Manors
,
FL
33305
None
501(c)(3)
Kids in Distress mission is to prevent child abuse, preserve the family and treat children who have been abused and neglected.
10,000
Public Education Foundation Penn Di
4350 South Maryland Parkway
Las Vegas
,
NV
89119
None
501(c)(3)
The Public Education Foundation partners with the community and the Clark County School District to meet immediate, critical education needs that will strengthen our public schools.
100,000
Smithsonian Institute
PO Box 418320
Boston
,
MA
02241
None
501(c)(3)
The Smithsonian Conservation Biology Institute (SCBI) plays a leading role in the Smithsonians global efforts to save wildlife species from extinction and train future generations of conservationists. SCBI spearheads research programs at its headquarters in Front Royal, Virginia, the Smithsonians National Zoo in Washington, D.C., and at field research stations and training sites worldwide. SCBI scientists tackle some of todays most complex conservation challenges by applying and sharing what they learn about animal behavior and reproduction, ecology, genetics, migration and conservation sustainability.
10,000
Sexual Minority Youth Assistance Le
410 7th Street SE
Washington
,
DC
20003
None
501(c)(3)
SMYAL supports and empowers lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth in the Washington, DC metropolitan region. Through youth leadership, SMYAL creates opportunities for LGBTQ youth to build self-confidence, develop critical life skills, and engage their peers and community through service and advocacy. Committed to social change, SMYAL builds, sustains, and advocates for programs, policies, and services that LGBTQ youth need as they grow into adulthood.
7,500
Wesley Housing Development Corp of
5515 Cherokee Ave Ste 200
Alexandria
,
VA
22312
None
501(c)(3)
Wesley Housing builds up the lives of our most vulnerable community members by creating and operating healthy, supportive, stable, affordable housing communities.
10,000
Wild Virginia Incorporated
PO Box 1065
Charlottesville
,
VA
22903
None
501(c)(3)
Wild Virginia Incorporateds mission is protecting and connecting Virginia's wild lands and waters.
5,000
Sylvester Comprehensive Cancer Cent
1475 NW 12th Avenue
Miami
,
FL
33136
None
501(c)(3)
At Sylvester Comprehensive Cancer Center, our endeavors in developing and researching new cancer therapies are more promising than ever. Advancements in precision oncology, immunotherapy, innovative supportive-care, and prevention are already benefiting our patients today.
50,000
Culmore Clinic
6165 Leesburg Pike
Falls Church
,
VA
22044
None
501(c)(3)
Culmore Clinic is an interfaith 501(c)(3) healthcare clinic serving low-income adults in the Baileys Crossroads community at little to no cost. Its mission is to provide excellent medical care, counseling, and specialty referrals to all, no matter economic or language barriers. With particular interest in effectively serving the communitys diverse population, Culmore Clinic offers interpretation services by native speakers and trained medical interpreters in order to provide culturally-sensitive and compassionate care. The Clinic is committed to maintaining a significantly volunteer staff allowing more resources to go toward patient care. The Clinic was founded by the community, for the community and strives to be a safe-haven for all those who wish to give and receive care.
10,000
Building Bridges Across the River
1901 Mississippi Avenue SE
Washington
,
DC
20020
501(c)(3)
Building Bridges Across the River (Building Bridges) envisions a future in which the residents East of the Anacostia River experience vital, thriving communities characterized by social, cultural, economic and racial equity.
10,000
Multiple Sclerosis Association of A
375 Kings Highway North Suite B
Cherry Hill
,
NJ
08034
None
501(c)(3)
MSAA is a national, nonprofit organization founded in 1970. Our organization is dedicated to improving lives today through ongoing support and direct services to individuals with MS, their families, and their care partners.
20,000
The Arrt Legue Inc
105 N Union Street
Alexandria
,
VA
22314
501(c)(3)
The Art League develops the artist through education, exhibition and a stimulating, supportive environment, while sharing the experience of the visual arts with the community
50,000
Solar Community Housing Association
7 Baggins End
Davis
,
CA
95616
501(c)(3)
SCHA is committed to providing low-income cooperative housing that works to confront and critique systems of oppression through ecological awareness, inclusive self-governance and alternative economic models.
25,000
Arcadia Food Inc
90002 Richmond Hwy
Alexandria
,
VA
22309
501(c)(3)
The Arcadia Center for Sustainable Food and Agriculture is dedicated to cultivating vibrant food systems that prioritize health, equity, and sustainability from the farm forward. Arcadia is on a mission to ensure everyone has access to high quality, affordable, nourishing food, the building blocks of human health.
15,000
Total
.................................
3a
1,200,000
b
Approved for future payment
Total
.................................
3b
Form
990-PF
(2023)
Form 990-PF (2023)
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.)
1
Program service revenue:
(a)
Business code
(b)
Amount
(c)
Exclusion code
(d)
Amount
a
b
c
d
e
f
g
Fees and contracts from government agencies
2
Membership dues and assessments
....
3
Interest on savings and temporary cash
investments
...........
14
5,116
4
Dividends and interest from securities
....
14
477,052
5
Net rental income or (loss) from real estate:
a
Debt-financed property
......
b
Not 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
............
9
Net income or (loss) from special events:
10
Gross profit or (loss) from sales of inventory
11
Other revenue:
a
Inv fee reimbursement
b
c
d
e
12
Subtotal. Add columns (b), (d), and (e)
..
482,168
13
Total.
Add line 12, columns (b), (d), and (e)
..................
13
482,168
(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.)
4
Safe investments of assets
Form
990-PF
(2023)
Form 990-PF (2023)
Page
13
Part XVI
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?
...........
Yes
No
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.
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
(2023)
Additional Data
Software ID:
23017517
Software Version:
2023v5.1
Form 990PF - Special Condition Description:
Special Condition Description
-
TIN:
TY 2023 OtherExpensesSchedule
Name:
The Jacquemin Family Foundation Inc
EIN:
54-1887187
Software ID:
23017517
Software Version:
2023v5.1
Description
Revenue and Expenses per Books
Net Investment Income
Adjusted Net Income
Disbursements for Charitable Purposes
Bank Service Charges
30
30
Filing Fees
75
75
-
TIN:
TY 2023 OtherIncreasesSchedule
Name:
The Jacquemin Family Foundation Inc
EIN:
54-1887187
Software ID:
23017517
Software Version:
2023v5.1
Description
Amount
Unrealized gains on investment
1,547,216