Form 990-PF Return of Private Foundation or Section 4947(a)(1) Nonex

Caution: DRAFT FORM
This is an advance proof copy of an IRS tax form.
It is subject to change and OMB approval before it
is officially released. You can check the scheduled
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If you have any comments on this draft form, you can
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I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 990-PF, PAGE 1 of 16
MARGINS: TOP 13mm (1⁄ 2 "), CENTER SIDES.
PRINTS: HEAD to HEAD
PAPER: WHITE, WRITING, SUB. 20
INK: BLACK
DETACHED PAGE SIZE: 216mm (81⁄ 2 ") 3 279mm (11")
PERFORATE: ON FOLD FOR 216mm (81⁄ 2 ") 3 279mm (11") DETACHED PAGE SIZE

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form

990-PF

Department of the Treasury
Internal Revenue Service
(77)

Revised proofs
requested

OMB No. 1545-0052

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2009

Note. The foundation may be able to use a copy of this return to satisfy state reporting requirements.

Initial return
Amended return

Name of foundation

, 2009, and ending

Initial return of a former public charity
Address change
Name change

, 20

Final return

A Employer identification number

Number and street (or P.O. box number if mail is not delivered to street address)

Room/suite

B Telephone number (see page 10 of the instructions)

(

City or town, state, and ZIP code

H Check type of organization:
Section 501(c)(3) exempt private foundation
Section 4947(a)(1) nonexempt charitable trust
Other taxable private foundation
I Fair market value of all assets at end
of year (from Part II, col. (c),
line 16) © $

Signature

O.K. to print

Return of Private Foundation

G Check all that apply:

Part I

Date

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

For calendar year 2009, or tax year beginning

Use the IRS
label.
Otherwise,
print
or type.
See Specific
Instructions.

Action

J Accounting method:
Other (specify)

Cash

Accrual

Revenue

1 Contributions, gifts, grants, etc., received (attach schedule)
if the foundation is not required to attach Sch. B
2 Check ©
3 Interest on savings and temporary cash investments
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
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

Operating and Administrative Expenses

amounts in columns (b), (c), and (d) may not necessarily equal
the amounts in column (a) (see page 11 of the instructions).)

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 page 14 of the instructions)
19 Depreciation (attach schedule) and depletion
20 Occupancy
21 Travel, conferences, and meetings
22 Printing and publications
23 Other expenses (attach schedule)
24 Total operating and administrative expenses.
Add lines 13 through 23
25 Contributions, gifts, grants paid
26 Total expenses and disbursements. Add lines 24 and 25

(a) Revenue and
expenses per
books

C If exemption application is pending, check here

©

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

(Part I, column (d) must be on cash basis.)

Analysis of Revenue and Expenses (The total of

)

(b) Net investment
income

(c) Adjusted net
income

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

27 Subtract line 26 from line 12:
a Excess of revenue over expenses and disbursements
b Net investment income (if negative, enter -0-)
c Adjusted net income (if negative, enter -0-)
For Privacy Act and Paperwork Reduction Act Notice, see page 30 of the instructions.

Cat. No. 11289X

Form

990-PF

(2009)

5
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 990-PF, PAGE 2 of 16
MARGINS: TOP 13mm (1⁄ 2 "), CENTER SIDES.
PRINTS: HEAD to HEAD
PAPER: WHITE, WRITING, SUB. 20
INK: BLACK
DETACHED PAGE SIZE: 216mm (81⁄ 2 ") 3 279mm (11")
PERFORATE: ON FOLD FOR 216mm (81⁄ 2 ") 3 279mm (11") DETACHED PAGE SIZE

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 990-PF (2009)

Part II
1
2
3
4
5
6

Assets
Liabilities

Beginning of year

2

End of year

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(a) Book Value

(b) Book Value

(c) Fair Market Value

Cash—non-interest-bearing
Savings and temporary cash investments
Accounts receivable ©
Less: allowance for doubtful accounts ©
Pledges receivable ©
Less: allowance for doubtful accounts ©
Grants receivable

Receivables due from officers, directors, trustees, and other
disqualified persons (attach schedule) (see page 15 of the
instructions)

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)
7

Net Assets or Fund Balances

Balance Sheets

Page

Attached schedules and amounts in the description column
should be for end-of-year amounts only. (See instructions.)

17
18
19
20
21
22
23

Accounts payable and accrued expenses
Grants payable
Deferred revenue
Loans from officers, directors, trustees, and other disqualified persons
Mortgages and other notes payable (attach schedule)
Other liabilities (describe ©
Total liabilities (add lines 17 through 22)
Foundations that follow SFAS 117, check here

)

©

and complete lines 24 through 26 and lines 30 and 31.

24
25
26

Unrestricted
Temporarily restricted
Permanently restricted
Foundations that do not follow SFAS 117, check here
and complete lines 27 through 31.

©

27
28
29
30

Capital stock, trust principal, or current funds
Paid-in or capital surplus, or land, bldg., and equipment fund
Retained earnings, accumulated income, endowment, or other funds
Total net assets or fund balances (see page 17 of the
instructions)

31

Total liabilities and net assets/fund balances (see page 17
of the instructions)

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 30 (must agree with
end-of-year figure reported on prior year’s return)
2 Enter amount from Part I, line 27a
3 Other increases not included in line 2 (itemize) ©
4 Add lines 1, 2, and 3
5 Decreases not included in line 2 (itemize) ©
6 Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 30

1
2
3
4
5
6
Form

990-PF

(2009)

5
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 990-PF, PAGE 3 of 16
MARGINS: TOP 13mm (1⁄ 2 "), CENTER SIDES.
PRINTS: HEAD to HEAD
PAPER: WHITE, WRITING, SUB. 20
INK: BLACK
DETACHED PAGE SIZE: 216mm (81⁄ 2 ") 3 279mm (11")
PERFORATE: ON FOLD FOR 216mm (81⁄ 2 ") 3 279mm (11") DETACHED PAGE SIZE

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 990-PF (2009)

Part IV

Page

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(b) How acquired
P—Purchase
D—Donation

(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.)

1a
b
c
d
e
(e) Gross sales price

a
b
c
d
e

(f) Depreciation allowed
(or allowable)

(c) Date acquired
(mo., day, yr.)

(g) Cost or other basis
plus expense of sale

(i) F.M.V. as of 12/31/69

a
b
c
d
e

(j) Adjusted basis
as of 12/31/69

(l) Gains (Col. (h) gain minus
col. (k), but not less than -0-) or
Losses (from col. (h))

(k) Excess of col. (i)
over col. (j), if any

$

If gain, also enter in Part I, line 7
If (loss), enter -0- in Part I, line 7
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 pages 13 and 17 of the instructions).
If (loss), enter -0- in Part I, line 8
2 Capital gain net income or (net capital loss)

(d) Date sold
(mo., day, yr.)

(h) Gain or (loss)
(e) plus (f) minus (g)

Complete only for assets showing gain in column (h) and owned by the foundation on 12/31/69

Part V

3

Capital Gains and Losses for Tax on Investment Income

%
%

2

3

Qualification Under Section 4940(e) for Reduced Tax on Net Investment Income

(For optional use by domestic private foundations subject to the section 4940(a) tax on net investment income.)
If section 4940(d)(2) applies, leave this part blank.
Was the foundation liable for the section 4942 tax on the distributable amount of any year in the base period?
If “Yes,” the foundation does not qualify under section 4940(e). Do not complete this part.

Yes

No

1 Enter the appropriate amount in each column for each year; see page 18 of the instructions before making any entries.
(a)
Base period years
Calendar year (or tax year beginning in)

(b)
Adjusted qualifying distributions

(d)
Distribution ratio
(col. (b) divided by col. (c))

(c)
Net value of noncharitable-use assets

2008
2007
2006
2005
2004
2 Total of line 1, column (d)
3 Average distribution ratio for the 5-year base period—divide the total on line 2 by 5, or by the
number of years the foundation has been in existence if less than 5 years

2

4 Enter the net value of noncharitable-use assets for 2009 from Part X, line 5

4

5 Multiply line 4 by line 3

5

6 Enter 1% of net investment income (1% of Part I, line 27b)

6

7 Add lines 5 and 6

7

3

8
8 Enter qualifying distributions from Part XII, line 4
If line 8 is equal to or greater than line 7, check the box in Part VI, line 1b, and complete that part using a 1% tax rate. See
the Part VI instructions on page 18.
Form

990-PF

(2009)

5
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 990-PF, PAGE 4 of 16
MARGINS: TOP 13mm (1⁄ 2 "), CENTER SIDES.
PRINTS: HEAD to HEAD
PAPER: WHITE, WRITING, SUB. 20
INK: BLACK
DETACHED PAGE SIZE: 216mm (81⁄ 2 ") 3 279mm (11")
PERFORATE: ON FOLD FOR 216mm (81⁄ 2 ") 3 279mm (11") DETACHED PAGE SIZE

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Page 4
Excise Tax Based on Investment Income (Section 4940(a), 4940(b), 4940(e), or 4948—see page 18 of the instructions)

Form 990-PF (2009)

Part VI

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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 Domestic foundations that meet the section 4940(e) requirements in Part V, check
here ©
and enter 1% of Part I, line 27b
c All other domestic foundations enter 2% of line 27b. Exempt foreign organizations enter 4%
of Part I, line 12, col. (b)
2 Tax under section 511 (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-)
3 Add lines 1 and 2
4 Subtitle A (income) tax (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-)
5 Tax based on investment income. Subtract line 4 from line 3. If zero or less, enter -06 Credits/Payments:
6a
a 2009 estimated tax payments and 2008 overpayment credited to 2009
6b
b Exempt foreign organizations—tax withheld at source
6c
c Tax paid with application for extension of time to file (Form 8868)
6d
d Backup withholding erroneously withheld
7
8
9
10
11

Total credits and payments. Add lines 6a through 6d
Enter any penalty for underpayment of estimated tax. Check here
if Form 2220 is attached
©
Tax due. If the total of lines 5 and 8 is more than line 7, enter amount owed
©
Overpayment. If line 7 is more than the total of lines 5 and 8, enter the amount overpaid
©
Enter the amount of line 10 to be: Credited to 2010 estimated tax ©
Refunded

1

2
3
4
5

7
8
9
10
11

Part VII-A Statements Regarding Activities

1a During the tax year, did the foundation attempt to influence any national, state, or local legislation or did it
participate or intervene in any political campaign?
b Did it spend more than $100 during the year (either directly or indirectly) for political purposes (see page 19
of the instructions for 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.
c Did the foundation file Form 1120-POL for this year?
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?
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
4a Did the foundation have unrelated business gross income of $1,000 or more during the year?
b If “Yes,” has it filed a tax return on Form 990-T for this year?
5 Was there a liquidation, termination, dissolution, or substantial contraction during the year?
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?
7 Did the foundation have at least $5,000 in assets at any time during the year? If “Yes,” complete Part II, col. (c), and Part XV
8a Enter the states to which the foundation reports or with which it is registered (see page 19 of the
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
9

10

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 2009 or the taxable year beginning in 2009 (see instructions for Part XIV on
page 27)? If “Yes,” complete Part XIV
Did any persons become substantial contributors during the tax year? If “Yes,” attach a schedule listing their
names and addresses

Yes No
1a
1b

1c

2

3
4a
4b
5

6
7

8b

9
10

Form

990-PF

(2009)

5
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 990-PF, PAGE 5 of 16
MARGINS: TOP 13mm (1⁄ 2 "), CENTER SIDES.
PRINTS: HEAD to HEAD
PAPER: WHITE, WRITING, SUB. 20
INK: BLACK
DETACHED PAGE SIZE: 216mm (81⁄ 2 ") 3 279mm (11")
PERFORATE: ON FOLD FOR 216mm (81⁄ 2 ") 3 279mm (11") DETACHED PAGE SIZE

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 990-PF (2009)

Page

5

Part VII-A Statements Regarding Activities (continued)
11
12
13
14
15

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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 page 20 of the instructions)
Did the foundation acquire a direct or indirect interest in any applicable insurance contract before
August 17, 2008?
Did the foundation comply with the public inspection requirements for its annual returns and exemption application?

11
12
13

Website address ©
The books are in care of ©
Telephone no. ©
©
Located at
ZIP+4 ©
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

©

Part VII-B Statements Regarding Activities for Which Form 4720 May Be Required

File Form 4720 if any item is checked in the “Yes” column, unless an exception applies.
1a During the year did the foundation (either directly or indirectly):
(1) Engage in the sale or exchange, or leasing of property with a disqualified person?
(2) Borrow money from, lend money to, or otherwise extend credit to (or accept it from) a
disqualified person?
(3) Furnish goods, services, or facilities to (or accept them from) a disqualified person?
(4) Pay compensation to, or pay or reimburse the expenses of, a disqualified person?
(5) Transfer any income or assets to a disqualified person (or make any of either available for
the benefit or use of a disqualified person)?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

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.)
Yes
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 page 20 of the instructions)?
©
Organizations relying on a current notice regarding disaster assistance check here
c Did the foundation engage in a prior year in any of the acts described in 1a, other than excepted acts, that
were not corrected before the first day of the tax year beginning in 2009?
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 2009, did the foundation have any undistributed income (lines 6d and
6e, Part XIII) for tax year(s) beginning before 2009?
Yes
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 page 20 of the instructions.)
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?
Yes
No
b If “Yes,” did it have excess business holdings in 2009 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 2009.)
4a Did the foundation invest during the year any amount in a manner that would jeopardize its charitable purposes?
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 2009?

Yes

No

1b

1c

2b

3b
4a
4b

Form

990-PF

(2009)

5
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 990-PF, PAGE 6 of 16
MARGINS: TOP 13mm (1⁄ 2 "), CENTER SIDES.
PRINTS: HEAD to HEAD
PAPER: WHITE, WRITING, SUB. 20
INK: BLACK
DETACHED PAGE SIZE: 216mm (81⁄ 2 ") 3 279mm (11")
PERFORATE: ON FOLD FOR 216mm (81⁄ 2 ") 3 279mm (11") DETACHED PAGE SIZE

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 990-PF (2009)

Page

6

Part VII-B Statements Regarding Activities for Which Form 4720 May Be Required (continued)

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5a During the year did the foundation pay or incur any amount to:
(1) Carry on propaganda, or otherwise attempt to influence legislation (section 4945(e))?
Yes
No
(2) Influence the outcome of any specific public election (see section 4955); or to carry on,
directly or indirectly, any voter registration drive?
Yes
No
(3) Provide a grant to an individual for travel, study, or other similar purposes?
Yes
No
(4) Provide a grant to an organization other than a charitable, etc., organization described in
section 509(a)(1), (2), or (3), or section 4940(d)(2)? (see page 22 of the instructions)
Yes
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?
Yes
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 page 22 of the instructions)?
©
Organizations relying on a current notice regarding disaster assistance check here
c If the answer is “Yes” to question 5a(4), does the foundation claim exemption from the tax
because it maintained expenditure responsibility for the grant?
Yes
No
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?
Yes
b Did the foundation, during the year, pay premiums, directly or indirectly, on a personal benefit contract?
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?
Yes
b If yes, did the foundation receive any proceeds or have any net income attributable to the transaction?

Part VIII

5b

No

6b

No

7b

Information About Officers, Directors, Trustees, Foundation Managers, Highly Paid Employees,
and Contractors

1 List all officers, directors, trustees, foundation managers and their compensation (see page 22 of the 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
(e) Expense account,
employee benefit plans
other allowances
and deferred compensation

2 Compensation of five highest-paid employees (other than those included on line 1—see page 23 of the 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 (e) Expense account,
plans and deferred
other allowances
compensation

©

Total number of other employees paid over $50,000
Form

990-PF

(2009)

5
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 990-PF, PAGE 7 OF 16
MARGINS; TOP 13mm (1/2"), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 990-PF (2009)

Part VIII

Page

7

Information About Officers, Directors, Trustees, Foundation Managers, Highly Paid Employees,
and Contractors (continued)

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3 Five highest-paid independent contractors for professional services (see page 23 of the instructions). If none, enter “NONE.”
(a) Name and address of each person paid more than $50,000

(b) Type of service

(c) Compensation

Total number of others receiving over $50,000 for professional services

Part IX-A

©

Summary of Direct Charitable Activities

List the foundation’s four largest direct charitable activities during the tax year. Include relevant statistical information such as the number
of organizations and other beneficiaries served, conferences convened, research papers produced, etc.

1

Expenses

2

3

4

Part IX-B

Summary of Program-Related Investments (see page 23 of the 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 page 24 of the instructions.

3

Total. Add lines 1 through 3

©
Form

990-PF

(2009)

5
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 990-PF, PAGE 8 of 16
MARGINS: TOP 13mm (1⁄ 2 "), CENTER SIDES.
PRINTS: HEAD to HEAD
PAPER: WHITE, WRITING, SUB. 20
INK: BLACK
DETACHED PAGE SIZE: 216mm (81⁄ 2 ") 3 279mm (11")
PERFORATE: ON FOLD FOR 216mm (81⁄ 2 ") 3 279mm (11") DETACHED PAGE SIZE

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Page

Form 990-PF (2009)

Part X
1

8

Minimum Investment Return (All domestic foundations must complete this part. Foreign foundations,
see page 24 of the instructions.)

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Fair market value of assets not used (or held for use) directly in carrying out charitable, etc.,
purposes:
1a
a Average monthly fair market value of securities
1b
b Average of monthly cash balances
1c
c Fair market value of all other assets (see page 24 of the instructions)
1d
d Total (add lines 1a, b, and c)
e Reduction claimed for blockage or other factors reported on lines 1a and
1e
1c (attach detailed explanation)
2
2 Acquisition indebtedness applicable to line 1 assets
3
3 Subtract line 2 from line 1d
4 Cash deemed held for charitable activities. Enter 11⁄ 2 % of line 3 (for greater amount, see page 25
4
of the instructions)
5
5 Net value of noncharitable-use assets. Subtract line 4 from line 3. Enter here and on Part V, line 4
6 Minimum investment return. Enter 5% of line 5
6
Part XI Distributable Amount (see page 25 of the instructions) (Section 4942(j)(3) and (j)(5) private operating
foundations and certain foreign organizations check here ©
and do not complete this part.)
1
1 Minimum investment return from Part X, line 6
2a
2a Tax on investment income for 2009 from Part VI, line 5
2b
b Income tax for 2009. (This does not include the tax from Part VI.)
2c
c Add lines 2a and 2b
3
3 Distributable amount before adjustments. Subtract line 2c from line 1
4
4 Recoveries of amounts treated as qualifying distributions
5
5 Add lines 3 and 4
6
6 Deduction from distributable amount (see page 25 of the instructions)
7

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

Part XII

7

Qualifying Distributions (see page 25 of the instructions)

1

Amounts paid (including administrative expenses) to accomplish charitable, etc., purposes:
1a
a Expenses, contributions, gifts, etc.—total from Part I, column (d), line 26
1b
b Program-related investments—total from Part IX-B
2 Amounts paid to acquire assets used (or held for use) directly in carrying out charitable, etc.,
2
purposes
3 Amounts set aside for specific charitable projects that satisfy the:
3a
a Suitability test (prior IRS approval required)
3b
b Cash distribution test (attach the required schedule)
4
4 Qualifying distributions. Add lines 1a through 3b. Enter here and on Part V, line 8, and Part XIII, line 4
5 Foundations that qualify under section 4940(e) for the reduced rate of tax on net investment income.
5
Enter 1% of Part I, line 27b (see page 26 of the instructions)
6
6 Adjusted qualifying distributions. Subtract line 5 from line 4
Note. The amount on line 6 will be used in Part V, column (b), in subsequent years when calculating whether the foundation
qualifies for the section 4940(e) reduction of tax in those years.
Form

990-PF

(2009)

5
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 990-PF, PAGE 9 of 16
MARGINS: TOP 13mm (1⁄ 2 "), CENTER SIDES.
PRINTS: HEAD to HEAD
PAPER: WHITE, WRITING, SUB. 20
INK: BLACK
DETACHED PAGE SIZE: 216mm (81⁄ 2 ") 3 279mm (11")
PERFORATE: ON FOLD FOR 216mm (81⁄ 2 ") 3 279mm (11") DETACHED PAGE SIZE

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 990-PF (2009)

Part XIII
1
2
a
b
3
a
b
c
d
e
f
4
a
b
c
d
e
5

6
a
b

Page

9

Undistributed Income (see page 26 of the instructions)

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Distributable amount for 2009 from Part XI,
line 7
Undistributed income, if any, as of the end of 2009:
Enter amount for 2008 only
, 20
, 20
Total for prior years: 20
Excess distributions carryover, if any, to 2009:
From 2004
From 2005
From 2006
From 2007
From 2008
Total of lines 3a through e
Qualifying distributions for 2009 from Part XII,
line 4: © $
Applied to 2008, but not more than line 2a
Applied to undistributed income of prior years (Election
required—see page 26 of the instructions)
Treated as distributions out of corpus (Election
required—see page 26 of the instructions)
Applied to 2009 distributable amount
Remaining amount distributed out of corpus
Excess distributions carryover applied to 2009
(If an amount appears in column (d), the same
amount must be shown in column (a).)
Enter the net total of each column as
indicated below:
Corpus. Add lines 3f, 4c, and 4e. Subtract line 5
Prior years’ undistributed income. Subtract
line 4b from line 2b

(a)
Corpus

(b)
Years prior to 2008

(c)
2008

(d)
2009

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 page 27 of the instructions
e Undistributed income for 2008. Subtract line
4a from line 2a. Taxable amount—see page
27 of the instructions
f Undistributed income for 2009. Subtract lines
4d and 5 from line 1. This amount must be
distributed in 2010
7

Amounts treated as distributions out of corpus
to satisfy requirements imposed by section
170(b)(1)(F) or 4942(g)(3) (see page 27 of the
instructions)

8

Excess distributions carryover from 2004 not
applied on line 5 or line 7 (see page 27 of the
instructions)
Excess distributions carryover to 2010.
Subtract lines 7 and 8 from line 6a
Analysis of line 9:
Excess from 2005
Excess from 2006
Excess from 2007
Excess from 2008
Excess from 2009

9
10
a
b
c
d
e

Form

990-PF

(2009)

5
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 990-PF, PAGE 10 of 16
MARGINS: TOP 13mm (1⁄ 2 "), CENTER SIDES.
PRINTS: HEAD to HEAD
PAPER: WHITE, WRITING, SUB. 20
INK: BLACK
DETACHED PAGE SIZE: 216mm (81⁄ 2 ") 3 279mm (11")
PERFORATE: ON FOLD FOR 216mm (81⁄ 2 ") 3 279mm (11") DETACHED PAGE SIZE

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 990-PF (2009)

Page

10

Private Operating Foundations (see page 27 of the instructions and Part VII-A, question 9)

Part XIV

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1a If the foundation has received a ruling or determination letter that it is a private operating
©

foundation, and the ruling is effective for 2009, enter the date of the ruling

b Check box to indicate whether the foundation is a private operating foundation described in section

2a Enter the lesser of the adjusted net
income from Part I or the minimum
investment return from Part X for
each year listed
b 85% of line 2a
c Qualifying distributions from Part XII,

line 4 for each year listed
d Amounts included in line 2c not used directly

for active conduct of exempt activities
e Qualifying distributions made directly

for active conduct of exempt activities.
Subtract line 2d from line 2c

3

Complete 3a, b, or c for the
alternative test relied upon:
a “Assets” alternative test—enter:
(1) Value of all assets
(2) Value of assets qualifying
under section 4942(j)(3)(B)(i)
b “Endowment” alternative test—enter 2⁄ 3 of
minimum investment return shown in Part
X, line 6 for each year listed
c “Support” alternative test—enter:

Tax year
(a) 2009

4942(j)(3) or

Prior 3 years

(b) 2008

(c) 2007

4942(j)(5)
(e) Total

(d) 2006

(1) Total support other than gross
investment income (interest,
dividends, rents, payments on
securities loans (section
512(a)(5)), or royalties)
(2) Support from general public
and 5 or more exempt
organizations as provided in
section 4942(j)(3)(B)(iii)
(3) Largest amount of support from
an exempt organization
(4) Gross investment income

Part XV

Supplementary Information (Complete this part only if the foundation had $5,000 or more in assets
at any time during the year—see page 27 of the 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).)

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. (see page 28 of the instructions) to individuals or
organizations under other conditions, complete items 2a, b, c, and d.

a The name, address, and telephone number of the person to whom applications should be addressed:

b The form in which applications should be submitted and information and materials they should include:

c Any submission deadlines:
d Any restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other

factors:
Form

990-PF

(2009)

5
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 990-PF, PAGE 11 of 16
MARGINS: TOP 13mm (1⁄ 2 "), CENTER SIDES.
PRINTS: HEAD to HEAD
PAPER: WHITE, WRITING, SUB. 20
INK: BLACK
DETACHED PAGE SIZE: 216mm (81⁄ 2 ") 3 279mm (11")
PERFORATE: ON FOLD FOR 216mm (81⁄ 2 ") 3 279mm (11") DETACHED PAGE SIZE

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 990-PF (2009)

Page

11

Part XV Supplementary Information (continued)
3
Grants and Contributions Paid During the Year or Approved for Future Payment
Recipient

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Name and address (home or business)
a Paid during the year

Total

If recipient is an individual,
show any relationship to Foundation
status of
any foundation manager
recipient
or substantial contributor

Purpose of grant or
contribution

©

Amount

3a

b Approved for future payment

Total

©

3b
Form

990-PF

(2009)

5
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 990-PF, PAGE 12 of 16
MARGINS: TOP 13mm (1⁄ 2 "), CENTER SIDES.
PRINTS: HEAD to HEAD
PAPER: WHITE, WRITING, SUB. 20
INK: BLACK
DETACHED PAGE SIZE: 216mm (81⁄ 2 ") 3 279mm (11")
PERFORATE: ON FOLD FOR 216mm (81⁄ 2 ") 3 279mm (11") DETACHED PAGE SIZE

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 990-PF (2009)

Part XVI-A

Page

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Enter gross amounts unless otherwise indicated.

Unrelated business income

(a)
Business code

(b)
Amount

Excluded by section 512, 513, or 514
(c)
Exclusion code

1 Program service revenue:
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
4 Dividends and interest from securities
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
b
c
d
e
12 Subtotal. Add columns (b), (d), and (e)
13 Total. Add line 12, columns (b), (d), and (e)
(See worksheet in line 13 instructions on page 28 to verify calculations.)

Part XVI-B
Line No.
Ä

12

Analysis of Income-Producing Activities

(d)
Amount

(e)
Related or exempt
function income
(See page 28 of
the instructions.)

13

Relationship of Activities to the Accomplishment of Exempt Purposes
Explain below how each activity for which income is reported in column (e) of Part XVI-A contributed importantly to
the accomplishment of the foundation’s exempt purposes (other than by providing funds for such purposes). (See
page 28 of the instructions.)

Form

990-PF

(2009)

5
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 990-PF, PAGE 13 of 16 (Pages 14, 15, and 16 are blank)
MARGINS: TOP 13mm (1⁄ 2 "), CENTER SIDES.
PRINTS: HEAD to HEAD
PAPER: WHITE, WRITING, SUB. 20
INK: BLACK
DETACHED PAGE SIZE: 216mm (81⁄ 2 ") 3 279mm (11")
PERFORATE: ON FOLD FOR 216mm (81⁄ 2 ") 3 279mm (11") DETACHED PAGE SIZE

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Page 13
Information Regarding Transfers To and Transactions and Relationships With Noncharitable
Exempt Organizations

Form 990-PF (2009)

Part XVII
1

a

b

c
d

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Yes No
Did the organization directly or indirectly engage in any of the following with any other organization described
in section 501(c) of the Code (other than section 501(c)(3) organizations) or in section 527, relating to political
organizations?
Transfers from the reporting foundation to a noncharitable exempt organization of:
1a(1)
(1) Cash
1a(2)
(2) Other assets
Other transactions:
1b(1)
(1) Sales of assets to a noncharitable exempt organization
1b(2)
(2) Purchases of assets from a noncharitable exempt organization
1b(3)
(3) Rental of facilities, equipment, or other assets
1b(4)
(4) Reimbursement arrangements
1b(5)
(5) Loans or loan guarantees
1b(6)
(6) Performance of services or membership or fundraising solicitations
1c
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

2a Is the foundation directly or indirectly affiliated with, or related to, one or more tax-exempt organizations
described in section 501(c) of the Code (other than section 501(c)(3)) or in section 527?
b If “Yes,” complete the following schedule.
(a) Name of organization

(b) Type of organization

Yes

No

(c) Description of relationship

©

Signature of officer or trustee

Date

©

Title

Date
Paid
Preparer’s
Use Only

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 or fiduciary) is based on all information of which preparer has any knowledge.

Preparer’s
signature

©

Firm’s name (or yours if
self-employed), address,
and ZIP code

Check if
self-employed

©

©

EIN ©
Phone no. (

Preparer’s identifying
number (see Signature on
page 30 of the instructions)

)
Form

Printed on Recycled Paper

990-PF

(2009)