Fillable Printable Form 990-PF
Fillable Printable Form 990-PF
Form 990-PF
Form 990-PF
Department of the Treasury
Internal Revenue Service
Return of Private Foundation
or Section 4947(a)(1) Trust Treated as Private Foundation
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Do not enter social security numbers on this form as it may be made public.
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Information about Form 990-PF and its separate instructions is at www.irs.gov/form990pf.
OMB No. 1545-0052
2016
Open to Public Inspection
For calendar year 2016 or tax year beginning , 2016, and ending , 20
Name of foundation
Number and street (or P.O. box number if mail is not delivered to street address) Room/suite
City or town, state or province, country, and ZIP or foreign postal code
A Employer identification number
B Telephone number (see instructions)
C
If exemption application is pending, check here
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D 1. Foreign organizations, check here . . .
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2. Foreign organizations meeting the 85% test,
check here and attach computation
. .
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E
If private foundation status was terminated under
section 507(b)(1)(A), check here . . . .
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F
If the foundation is in a 60-month termination
under section 507(b)(1)(B), check here . .
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G Check all that apply: Initial return
Final return
Address change
Initial return of a former public charity
Amended return
Name change
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)
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$
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).)
Revenue
Operating and Administrative Expenses
(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
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if the foundation is not required to attach Sch. B
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 . . . . . . .
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) . . . . .
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
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 Paperwork Reduction Act Notice, see instructions.
Cat. No. 11289X
Form 990-PF (2016)
Form 990-PF (2016)
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
AssetsLiabilitiesNet Assets or Fund Balances
(a) Book Value (b) Book Value (c) Fair Market Value
1 Cash—non-interest-bearing . . . . . . . . . . .
2 Savings and temporary cash investments . . . . . . .
3
Accounts receivable
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Less: allowance for doubtful accounts
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4
Pledges receivable
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Less: allowance for doubtful accounts
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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)
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Less: allowance for doubtful accounts
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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
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Less: accumulated depreciation (attach schedule)
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12 Investments—mortgage loans . . . . . . . . . . .
13 Investments—other (attach schedule) . . . . . . . .
14
Land, buildings, and equipment: basis
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Less: accumulated depreciation (attach schedule)
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15
Other assets (describe
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)
16 Total assets (to be completed by all filers—see the
instructions. Also, see page 1, item I) . . . . . . . .
17 Accounts payable and accrued expenses . . . . . . .
18 Grants payable . . . . . . . . . . . . . . . .
19 Deferred revenue . . . . . . . . . . . . . . .
20
Loans from officers, directors, trustees, and other disqualified persons
21 Mortgages and other notes payable (attach schedule) . . .
22
Other liabilities (describe
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)
23
Total liabilities (add lines 17 through 22) . . . . . . .
Foundations that follow SFAS 117, check here . .
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and complete lines 24 through 26 and lines 30 and 31.
24 Unrestricted . . . . . . . . . . . . . . . . .
25 Temporarily restricted . . . . . . . . . . . . .
26 Permanently restricted . . . . . . . . . . . . .
Foundations that do not follow SFAS 117, check here
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and complete lines 27 through 31.
27 Capital stock, trust principal, or current funds . . . . . .
28 Paid-in or capital surplus, or land, bldg., and equipment fund
29
Retained earnings, accumulated income, endowment, or other funds
30 Total net assets or fund balances (see instructions) . . .
31 Total liabilities and net assets/fund balances (see
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) . . . . . . . . . . . . . . . . .
1
2 Enter amount from Part I, line 27a . . . . . . . . . . . . . . . . . . . . . . 2
3
Other increases not included in line 2 (itemize)
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3
4 Add lines 1, 2, and 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
5
Decreases not included in line 2 (itemize)
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5
6 Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 30 . .
6
Form 990-PF (2016)
Form 990-PF (2016)
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
(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
(l) Gains (Col. (h) gain minus
col. (k), but not less than -0-) or
Losses (from col. (h))
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 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?
Yes No
If “Yes,” the foundation does not qualify under section 4940(e). Do not complete this part.
1 Enter the appropriate amount in each column for each year; see the instructions before making any entries.
(a)
Base period years
Calendar year (or tax year beginning in)
(b)
Adjusted qualifying distributions
(c)
Net value of noncharitable-use assets
(d)
Distribution ratio
(col. (b) divided by col. (c))
2015
2014
2013
2012
2011
2 Total of line 1, column (d) . . . . . . . . . . . . . . . . . . . . . . 2
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 . . . . . .
3
4 Enter the net value of noncharitable-use assets for 2016 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
8 Enter qualifying distributions from Part XII, line 4 . . . . . . . . . . . . . . .
8
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.
Form 990-PF (2016)
Form 990-PF (2016)
Page 4
Part VI 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
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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
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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).
}
1
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
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 Credits/Payments:
a
2016 estimated tax payments and 2015 overpayment credited to 2016
6a
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
8 Enter any penalty for underpayment of estimated tax. Check here if Form 2220 is attached 8
9 Tax due. If the total of lines 5 and 8 is more than line 7, enter amount owed
. . . . . .
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9
10 Overpayment. If line 7 is more than the total of lines 5 and 8, enter the amount overpaid . .
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10
11
Enter the amount of line 10 to be: Credited to 2017 estimated tax
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Refunded
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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? . . . . . . . . . . . . . . . . . . .
Yes No
1a
b
Did it spend more than $100 during the year (either directly or indirectly) for political purposes (see
Instructions for the definition)? . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
If the answer is “Yes” to 1a or 1b, attach a detailed description of the activities and copies of any materials
published or distributed by the foundation in connection with the activities.
c Did the foundation file Form 1120-POL for this year? . . . . . . . . . . . . . . . . . . 1c
d Enter the amount (if any) of tax on political expenditures (section 4955) imposed during the year:
(1) On the foundation.
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$ (2) On foundation managers.
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$
e
Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed
on foundation managers.
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$
2 Has the foundation engaged in any activities that have not previously been reported to the IRS? . . . . 2
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
4a Did the foundation have unrelated business gross income of $1,000 or more during the year? . . . . . 4a
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
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
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
7
8a
Enter the states to which the foundation reports or with which it is registered (see instructions)
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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
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 2016 or the taxable year beginning in 2016 (see instructions for Part XIV)? If “Yes,”
complete Part XIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
10
Did any persons become substantial contributors during the tax year? If “Yes,” attach a schedule listing their
names and addresses . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10
Form 990-PF (2016)
Form 990-PF (2016)
Page 5
Part VII-A Statements Regarding Activities (continued)
Yes 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
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
13
Did the foundation comply with the public inspection requirements for its annual returns and exemption application?
13
Website address
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14
The books are in care of
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Telephone no.
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Located at
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ZIP+4
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15 Section 4947(a)(1) nonexempt charitable trusts filing Form 990-PF in lieu of Form 1041—Check here. . . . . . .
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and enter the amount of tax-exempt interest received or accrued during the year . . . . .
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15
16
At any time during calendar year 2016, did the foundation have an interest in or a signature or other authority
over a bank, securities, or other financial account in a foreign country?. . . . . . . . . . . . .
Yes No
16
See the instructions for exceptions and filing requirements for FinCEN Form 114. If "Yes," enter the name of
the foreign country
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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.
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? . .
Yes No
(2)
Borrow money from, lend money to, or otherwise extend credit to (or accept it from) a
disqualified person? . . . . . . . . . . . . . . . . . . . . . . .
Yes No
(3) Furnish goods, services, or facilities to (or accept them from) a disqualified person? . .
Yes No
(4) Pay compensation to, or pay or reimburse the expenses of, a disqualified person? . .
Yes 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)? . . . . . . . . . . . . . . .
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 instructions)? . . . . . . .
1b
Organizations relying on a current notice regarding disaster assistance check here . . . . . .
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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 2016? . . . . . . . . . . .
1c
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 2016, did the foundation have any undistributed income (lines 6d and
6e, Part XIII) for tax year(s) beginning before 2016? . . . . . . . . . . . . . .
Yes No
If “Yes,” list the years
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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.
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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 2016 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 2016.) . . . . . . . . . . . . . . . . . . .
3b
4a
Did the foundation invest during the year any amount in a manner that would jeopardize its charitable purposes?
4a
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 2016?
4b
Form 990-PF (2016)
Form 990-PF (2016)
Page 6
Part VII-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:
(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 4945(d)(4)(A)? (see 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 instructions)? . . . .
5b
Organizations relying on a current notice regarding disaster assistance check here . . . . . .
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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 No
b Did the foundation, during the year, pay premiums, directly or indirectly, on a personal benefit contract? . 6b
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 No
b If “Yes,” did the foundation receive any proceeds or have any net income attributable to the transaction? .
7b
Part VIII
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
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
Total number of other employees paid over $50,000
. . . . . . . . . . . . . . . . . . . .
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Form 990-PF (2016)
Form 990-PF (2016)
Page 7
Part VIII
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
Total number of others receiving over $50,000 for professional services . . . . . . . . . . . . .
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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.
Expenses
1
2
3
4
Part IX-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 . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Form 990-PF (2016)
Form 990-PF (2016)
Page 8
Part X
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
b Average of monthly cash balances . . . . . . . . . . . . . . . . . . . . . 1b
c Fair market value of all other assets (see instructions) . . . . . . . . . . . . . . . 1c
d Total (add lines 1a, b, and c) . . . . . . . . . . . . . . . . . . . . . . . 1d
e
Reduction claimed for blockage or other factors reported on lines 1a and
1c (attach detailed explanation) . . . . . . . . . . . . . . .
1e
2 Acquisition indebtedness applicable to line 1 assets . . . . . . . . . . . . . . . . 2
3 Subtract line 2 from line 1d . . . . . . . . . . . . . . . . . . . . . . . . 3
4 Cash deemed held for charitable activities. Enter 1
1
/2% of line 3 (for greater amount, see
instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
5 Net value of noncharitable-use assets. Subtract line 4 from line 3. Enter here and on Part V, line 4 5
6 Minimum investment return. Enter 5% of line 5 . . . . . . . . . . . . . . . . .
6
Part XI Distributable Amount (see instructions) (Section 4942(j)(3) and (j)(5) private operating foundations
and certain foreign organizations check here
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and do not complete this part.)
1 Minimum investment return from Part X, line 6 . . . . . . . . . . . . . . . . . . 1
2a Tax on investment income for 2016 from Part VI, line 5 . . . . . . . 2a
b Income tax for 2016. (This does not include the tax from Part VI.) . . . 2b
c Add lines 2a and 2b . . . . . . . . . . . . . . . . . . . . . . . . . . 2c
3 Distributable amount before adjustments. Subtract line 2c from line 1 . . . . . . . . . . 3
4 Recoveries of amounts treated as qualifying distributions . . . . . . . . . . . . . . 4
5 Add lines 3 and 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
6 Deduction from distributable amount (see instructions) . . . . . . . . . . . . . . . 6
7 Distributable amount as adjusted. Subtract line 6 from line 5. Enter here and on Part XIII,
line 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
Part XII
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
b Program-related investments—total from Part IX-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 V, line 8, and Part XIII, line 4
4
5
Foundations that qualify under section 4940(e) for the reduced rate of tax on net investment income.
Enter 1% of Part I, line 27b (see instructions) . . . . . . . . . . . . . . . . . .
5
6 Adjusted qualifying distributions. Subtract line 5 from line 4 . . . . . . . . . . . . 6
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 (2016)
Form 990-PF (2016)
Page 9
Part XIII Undistributed Income (see instructions)
(a)
Corpus
(b)
Years prior to 2015
(c)
2015
(d)
2016
1 Distributable amount for 2016 from Part XI,
line 7 . . . . . . . . . . . . .
2
Undistributed income, if any, as of the end of 2016:
a Enter amount for 2015 only . . . . . .
b
Total for prior years:
20 ,20 ,20
3 Excess distributions carryover, if any, to 2016:
a From 2011 . . . . . .
b From 2012 . . . . . .
c From 2013 . . . . . .
d From 2014 . . . . . .
e From 2015 . . . . . .
f Total of lines 3a through e . . . . . .
4 Qualifying distributions for 2016 from Part XII,
line 4:
▶
$
a Applied to 2015, 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) . . . . . .
d Applied to 2016 distributable amount . .
e Remaining amount distributed out of corpus
5 Excess distributions carryover applied to 2016
(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
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 2015. Subtract line
4a from line 2a. Taxable amount—see
instructions . . . . . . . . . . .
f
Undistributed income for 2016. Subtract lines
4d and 5 from line 1. This amount must be
distributed in 2017 . . . . . . . . .
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 2011 not
applied on line 5 or line 7 (see instructions) .
9 Excess distributions carryover to 2017.
Subtract lines 7 and 8 from line 6a . . .
10
Analysis of line 9:
a Excess from 2012 . . . .
b Excess from 2013 . . . .
c Excess from 2014 . . . .
d Excess from 2015 . . . .
e
Excess from 2016 . . . .
Form 990-PF (2016)
Form 990-PF (2016)
Page 10
Part XIV Private Operating Foundations (see instructions and Part VII-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 2016, enter the date of the ruling . . . . . .
▶
b
Check box to indicate whether the foundation is a private operating foundation described in section
4942(j)(3) or 4942(j)(5)
Tax year Prior 3 years
(a) 2016 (b) 2015 (c) 2014 (d) 2013
(e) Total
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:
(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 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 instructions) to individuals or organizations under
other conditions, complete items 2a, b, c, and d.
a
The name, address, and telephone number or e-mail address 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 (2016)
Form 990-PF (2016)
Page 11
Part XV Supplementary Information (continued)
3 Grants and Contributions Paid During the Year or Approved for Future Payment
Recipient
Name and address (home or business)
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
a Paid during the year
Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
▶
3a
b Approved for future payment
Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
▶
3b
Form 990-PF (2016)
