TY 2023 Form 990PF

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.........	17,964	124,689	124,689
	3	Accounts receivable
		Less: allowance for doubtful accounts
	4	Pledges receivable
		Less: allowance for doubtful accounts
	5	Grants receivable.................
	6	Receivables due from officers, directors, trustees, and other
		disqualified persons (attach schedule) (see instructions).....
	7	Other notes and loans receivable (attach schedule)
		Less: allowance for doubtful accounts
	8	Inventories for sale or use..............
	9	Prepaid expenses and deferred charges..........
	10a	Investments—U.S. and state government obligations (attach schedule)
	b	Investments—corporate stock (attach schedule).......
	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)..........
	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)	17,964	124,689	124,689
	17	Accounts payable and accrued expenses..........
	18	Grants payable.................
	19	Deferred revenue.................
	20	Loans from officers, directors, trustees, and other disqualified persons	700,000	700,000
	21	Mortgages and other notes payable (attach schedule)......
	22	Other liabilities (describe )
	23	Total liabilities (add lines 17 through 22).........	700,000	700,000
		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........	4,779,565	4,779,565
	27	Paid-in or capital surplus, or land, bldg., and equipment fund	0	0
	28	Retained earnings, accumulated income, endowment, or other funds	-5,461,601	-5,354,876
	29	Total net assets or fund balances (see instructions).....	-682,036	-575,311
	30	Total liabilities and net assets/fund balances (see instructions).	17,964	124,689

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

-682,036

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

627,357

Other increases not included in line 2 (itemize) right arrow

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

-54,679

Decreases not included in line 2 (itemize) right arrow

List of Attached Documents:

// Content

520,632

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

-575,311

(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	27,713 SHS AEVA TECHNOLOGIES	D	2022-08-11	2023-08-15
b	1,200 SHS AKAMAI TECHNOLOGIES	D	2017-09-25	2023-02-01
c	1,000 SHS AKAMAI TECHNOLOGIES	D	2017-09-25	2023-10-23
d	1,000 SHS AKAMAI TECHNOLOGIES	D	2017-09-25	2023-12-11
e	1,000 SHS AKAMAI TECHNOLOGIES	D	2017-09-25	2023-04-18
	8,292 SHS EVOLV TECHNOLOGIES	D	2023-05-22	2023-05-23
	10,815 SHS EVOLV TECHNOLOGIES	D	2022-08-30	2023-06-01
	8,328 SHS SCIENCE 37 HOLDINGS	D	2022-04-20	2023-09-22
	MZR TOPCO, LLC - PROCTORU	D	2013-01-01	2023-12-15

(e) Gross sales price		(g) Cost or other basis plus expense of sale	(h) Gain or (loss) (e) plus (f) minus (g)
a	28,967	4,254	24,713
b	108,672	483	108,189
c	103,926	403	103,523
d	114,493	403	114,090
e	82,800	403	82,397
	47,092	6,191	40,901
	66,466	11,150	55,316
	3,241	4,420	-1,179
	190		190

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			24,713
b			108,189
c			103,523
d			114,090
e			82,397
			40,901
			55,316
			-1,179
			190

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	528,140
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

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	7,311
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	7,311
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	7,311
6	Credits/Payments:

a	2023 estimated tax payments and 2022 overpayment credited to 2023	6a	10,484
b	Exempt foreign organizations—tax withheld at source......	6b	0
c	Tax paid with application for extension of time to file (Form 8868)...	6c	0
d	Backup withholding erroneously withheld ..........	6d	0

7	Total credits and payments. Add lines 6a through 6d..............		7	10,484
8	Enter any penalty for underpayment of estimated tax. Check here if Form 2220 is attached. List of Attached Documents: // Content		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	3,173
11	Enter the amount of line 10 to be: Credited to 2024 estimated tax3,173	Refunded	11	0

(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
ARTHUR BILGER	PRESIDENT 2.00	0	0	0
480 BEL AIR ROAD LOS ANGELES,CA90077

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

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

		(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.......				0
b Total for prior years:20 , 20, 20			0
3 Excess distributions carryover, if any, to 2022:
a From 2018......	762,443
b From 2019......	507,394
c From 2020......	469,959
d From 2021......	1,249,453
e From 2022......	911,441
f Total of lines 3a through e ........		3,900,690
4Qualifying distributions for 2023 from Part
XI, line 4: $ 447,201
a Applied to 2022, but not more than line 2a				0
b Applied to undistributed income of prior years (Election required—see instructions).....			0
c Treated as distributions out of corpus (Election required—see instructions)........		0
d Applied to 2023 distributable amount.....					0
e Remaining amount distributed out of corpus		447,201
5 Excess distributions carryover applied to 2023.		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		4,347,891
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 2022. Subtract line 4a from line 2a. Taxable amount—see instructions .............				0
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) .......		0
8 Excess distributions carryover from 2018 not applied on line 5 or line 7 (see instructions) ...		762,443
9 Excess distributions carryover to 2024. Subtract lines 7 and 8 from line 6a ......		3,585,448
10 Analysis of line 9:
a Excess from 2019....	507,394
b Excess from 2020....	469,959
c Excess from 2021....	1,249,453
d Excess from 2022....	911,441
e Excess from 2023....	447,201

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	(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

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:

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
BET TZEDEK 3250 WILSHIRE BLVD LOS ANGELES,CA90010	NONE	PUBLIC CHARITY	CHARITABLE CONTRIBUTION	50,000
FRIENDS OF ELNET 5215 OLD ORCHARD RD STE 880 SKOKIE,IL60077	NONE	PUBLIC CHARITY	CHARITABLE CONTRIBUTION	10,000
PROJECT ANGEL FOOD 922 VINE STREET LOS ANGELES,CA90038	NONE	PUBLIC CHARITY	CHARITABLE CONTRIBUTION	5,000
RETT SYNDROME RESEARCH TRUST 67 UNDER CLIFF ROAD TRUMBULL,CT06611	NONE	PUBLIC CHARITY	CHARITABLE CONTRIBUTION	10,000
SINAI TEMPLE 10400 WILSHIRE BLVD LOS ANGELES,CA90024	NONE	PUBLIC CHARITY	CHARITABLE CONTRIBUTION	43,000
SKIRBALL CULTURAL CENTER 2701 N SEPULVEDA BLVD LOS ANGELES,CA90049	NONE	PUBLIC CHARITY	CHARITABLE CONTRIBUTION	25,000
STAND WITH US PO BOX 341069 LOS ANGELES,CA90034	NONE	PUBLIC CHARITY	CHARITABLE CONTRIBUTION	150,000
THE JEWISH FEDERATION OF GREATER LOS ANGELES 6505 WILSHIRE BLVD LOS ANGELES,CA90048	NONE	PUBLIC CHARITY	CHARITABLE CONTRIBUTION	65,000
URBAN GATEWAYS 1000 WEST WASHINGTON BLVD UNIT 503 CHICAGO,IL60607	NONE	PUBLIC CHARITY	CHARITABLE CONTRIBUTION	15,000
AMERICAN FRIENDS OF SHALVA 441 LEXINGTON AVE 602 NEW YORK,NY10017	NONE	PUBLIC CHARITY	CHARITABLE CONTRIBUTION	10,000
ASPCA PO BOX 96929 WASHINGTON,DC200906929	NONE	PUBLIC CHARITY	CHARITABLE CONTRIBUTION	2,000
ISRAAID PO BOX 61227 PALO ALTO,CA94306	NONE	PUBLIC CHARITY	CHARITABLE CONTRIBUTION	25,000
JEWISH BIG BROTHERS BIG SISTERS OF LOS ANGELES 11150 W OLYMPIC BLVD STE 900 LOS ANGELES,CA90064	NONE	PUBLIC CHARITY	CHARITABLE CONTRIBUTION	5,000
LOS ANGELES POLICE RESERVE FOUNDATION 6350 W 80TH STREET LOS ANGELES,CA90045	NONE	PUBLIC CHARITY	CHARITABLE CONTRIBUTION	10,000
JEWISH FAMILY SERVICE 330 N FARIFAX AVENUE LOS ANGELES,CA90036	NONE	PUBLIC CHARITY	CHARITABLE CONTRIBUTION	1,000
TRIBE MEDIA CORP 3250 WILSHIRE BLVD STE 1250 LOS ANGELES,CA90010	NONE	PUBLIC CHARITY	CHARITABLE CONTRIBUTION	5,000
LOS ANGELES PRESS CLUB 6464 SUNSET BLVD 870 LOS ANGELES,CA90028	NONE	PUBLIC CHARITY	CHARITABLE CONTRIBUTION	3,600
Total ................................. 3a				434,600

	Analysis of Revenue and Expenses (The total of amounts in columns (b), (c), and (d) may not necessarily equal the amounts in column (a) (see instructions).)	(a) Revenue and expenses per books		(b) Net investment income	(d) Disbursements for charitable purposes (cash basis only)


1	Contributions, gifts, grants, etc., received (attach schedule)	558,941
2	Check .............
3	Interest on savings and temporary cash investments	21		21
4	Dividends and interest from securities...
5a	Gross rents............
b	Net rental income or (loss)
6a	Net gain or (loss) from sale of assets not on line 10		528,140
b	Gross sales price for all assets on line 6a 555,847
7	Capital gain net income (from Part IV, line 2)...			528,140
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........	1,087,102		528,161
13	Compensation of officers, directors, trustees, etc.	0		0	0
14	Other employee salaries and wages......
15	Pension plans, employee benefits.......
16a	Legal fees (attach schedule).........
b	Accounting fees (attach schedule).......	List of Attached Documents: // Content	14,825	2,224	12,601
c	Other professional fees (attach schedule)....
17	Interest...............
18	Taxes (attach schedule) (see instructions)...	List of Attached Documents: // Content	10,200	0	0
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	120	0	0
24	Total operating and administrative expenses.
	Add lines 13 through 23..........	25,145		2,224	12,601
25	Contributions, gifts, grants paid.......	434,600			434,600
26	Total expenses and disbursements. Add lines 24 and 25	459,745		2,224	447,201
27	Subtract line 26 from line 12:
a	Excess of revenue over expenses and disbursements	627,357
b	Net investment income (if negative, enter -0-)			525,937
c	Adjusted net income (if negative, enter -0-)...

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

Enter gross amounts unless otherwise indicated.	Unrelated business income		Excluded by section 512, 513, or 514		(e) Related or exempt function income (See instructions.)
1Program service revenue:	(a) Business code	(b) Amount	(c) Exclusion code	(d) Amount	(e) Related or exempt function income (See instructions.)
a
b
c
d
e
f
gFees and contracts from government agencies
2 Membership dues and assessments ....
3 Interest on savings and temporary cash investments ...........			14	21
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	528,140
9 Net income or (loss) from special events:
10 Gross profit or (loss) from sales of inventory
11 Other revenue: a
b
c
d
e
12 Subtotal. Add columns (b), (d), and (e) ..		0		528,161	0

(a) Line No.	(b) Amount involved	(c) Name of noncharitable exempt organization	(d) Description of transfers, transactions, and sharing arrangements

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.


(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

bApproved for future payment

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

Name of organization THE BILGER FOUNDATION			Employer identification number 22-6524956

Part I Contributors	Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions		(d) Type of contribution
1	ADASE PARTNERS LP 480 BEL AIR ROAD LOS ANGELES, CA90077	$ 28,392		Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions		(d) Type of contribution
2	DAHLIA BILGER 480 BEL AIR ROAD LOS ANGELES, CA90077	$ 106,704		Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions		(d) Type of contribution
3	DAHLIA BILGER 480 BEL AIR ROAD LOS ANGELES, CA90077	$ 103,860		Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions		(d) Type of contribution
4	DAHLIA BILGER 480 BEL AIR ROAD LOS ANGELES, CA90077	$ 114,590		Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions		(d) Type of contribution
5	ART BILGER 480 BEL AIR ROAD LOS ANGELES, CA90077	$ 82,875		Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions		(d) Type of contribution
6	ADASE PARTNERS LP 480 BEL AIR ROAD LOS ANGELES, CA90077	$ 47,306		Person Payroll Noncash (Complete Part II for noncash contributions.)
Schedule B (Form 990) (2023)

Name of organization THE BILGER FOUNDATION			Employer identification number 22-6524956
Part I Contributors	Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions		(d) Type of contribution
7	ADASE PARTNERS LP 480 BEL AIR ROAD LOS ANGELES, CA90077	$ 65,214		Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions		(d) Type of contribution
8	ART BILGER 480 BEL AIR ROAD LOS ANGELES, CA90077	$ 10,000		Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions		(d) Type of contribution
		$		Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions		(d) Type of contribution
		$		Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions		(d) Type of contribution
		$		Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions		(d) Type of contribution
		$		Person Payroll Noncash (Complete Part II for noncash contributions.)
Schedule B (Form 990) (2023)

Name of organization THE BILGER FOUNDATION		Employer identification number 22-6524956

Part II	Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
1	27,713 SHS AEVA TECHNOLOGIES	$ 28,392	2023-08-15
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
2	1,200 SHS AKAMAI TECHNOLOGIES	$ 106,704	2023-02-01
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
3	1,000 SHS AKAMAI TECHNOLOGIES	$ 103,860	2023-10-23
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
4	1,000 SHS AKAMAI	$ 114,590	2023-12-11
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
5	1,000 SHS AKAMAI TECHNOLOGIES	$ 82,875	2023-04-18
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
6	8,292 SHS EVOLV TECHNOLOGIES	$ 47,306	2023-05-23
Schedule B (Form 990) (2023)

Name of organization THE BILGER FOUNDATION		Employer identification number 22-6524956
Part II	Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
7	10,815 SHS EVOLV TECHNOLOGIES	$ 65,214	2023-06-01
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
Schedule B (Form 990) (2023)


Name of organization THE BILGER FOUNDATION			Employer identification number 22-6524956
Part III Exclusively religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10) that total more than $1,000 for the year from any one contributor. Complete columns (a) through (e) and the following line entry. For organizations completing Part III, enter the total of exclusively religious, charitable, etc., contributions of $1,000 or less for the year. (Enter this information once. See instructions.) $ Use duplicate copies of Part III if additional space is needed.

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