Form 990-AR (1974)

Page 4

Grants and Contributions Paid or Approved for Future Payment During the Year
Recipient Concise statement of
. 7 _ _ purpose of grant or Amount
contribution

Name and address (home or business)

contributor

Paid during year

Total. 2... ee ee eee

Approved for future payment

Total 2. 1. ee ee ee ee

A notice has been published that tl

‘Annual Report is available for public inspection at the principal offices of the foundation, and copies of

this Annual Report have been furnished to the Attorney of each State entitled to receive reports as required by instruction “F.””

Date

Date

Signature of

dividual or

Signature of foundation manager

irm preparing the report

Preparer’s address

ident. or Soc. Sec. No.

Emp.

Instructions

A. Annual Report.—An annual report is re-
quired from the foundation managers (as de-
fined in section 4946(b)) of every organiza-
tion which is a private foundation, including
a trust described in section 4947(a)(1) which
is treated as a private foundation, having at
least $5,000 of assets at any time during a
taxable year. A private foundation may use this
form for its annual reporting requirements.

If you prefer not to use this form, you may
prepare the report in printed, typewritten or
any other form you choose, provided it readily
and legibly discloses the information required
by section 6056 and the regulations there
under.

The annual report is in addition to and not
in lieu of submitting the information required
on Form 990-PF under section 6033.

B. Where and When to File—The annual
report must be filed at the time and place
specified for filing Form 990-PF.

C. Public Inspection of Private Foundation’s
Annual Reports.—As a foundation manager,
you must make the annual report required by
section 6056 available at the principal office of
the foundation for inspection during regular
business hours by any citizen who so requests
within 180 days after publication of notice of
its availability; or, if you choose, you may
furnish a copy free of charge to such persons
requesting inspection, provided these persons
do so at the time and manner prescribed in
section 6104(d) and the regulations there-
under.

The notice must be published not later than
the day prescribed for filing the annual re-
port (determined with regard to any extensions
of time for filing), in a newspaper having gen-
eral circulation. in the county in which the
Principal office of the private foundation is lo-
cated. The notice must state that the annual
report of the private foundation is available
at its principal office during regular business
hours for inspection by any citizen who so re-
quests within 180 days after the date of the

publication. It must also show the address of
the private toundation’s principal office and the
name of its principal manager. A private foun-
dation may designate in addition to its princi-
pal office, or (if the foundation has no principal
office or none other than the residence of a
substantial contributor or foundation manager)
instead of such office, any other location where
its annual report is available.

The term ‘‘newspaper having general circu-
lation” shall include any newspaper or journal
which is permitted to publish statements in
satisfaction of State statutory requirements
relating to transfer of title to real estate or
other similar legal notices.

A copy of the notice must be attached to the
annual report filed with the Internal Revenue
Service.

A private foundation which has terminated
its status as such under section 507(b)(1)(A),
by distributing all its net assets to one or
more public charities without retaining any
right, title or interest in such assets, does
not have to publish notice of availability of its
annual report or furnish such report to the
public for the taxable year in which it so ter-
minates (Reg. 1.507-2(a)(6)).

D. Signature and Verification.—The report
must be signed by the foundation manager.

E. List of States.—A private. foundation is
required to attach to its Form 990-PF a list of
all States:

(a) to which the organization reports in any
fashion concerning its organization, assets, or
activities, and

(b) with which the organization has regis-
tered (or which it has otherwise notified in any
manner) that it intends to be, or is a charitable
organization or that it is, or intends to be,
a holder of property devoted to a charitable
Purpose.

F. Furnishing of Copies to State Officers;
Listing of States.—The foundation managers
must furnish a copy of the annual report (re-
quired by section 6056) to the Attorney Gen-

‘US. GOVERNMENT PRINTING OFFICE : 1971—-0-548-038

eral of (1) each State listed for Form 990—
PF above, (2) the State in which the princi-
pal office of the foundation is located, and (3)
the State in which the foundation was in-
corporated or organized. Such report must be
furnished at the same time it is sent to the
Internal Revenue Service. In addition, the
foundation managers shall provide upon re-
quest a copy of the annual report to the
Attorney General or other appropriate State
officer of any other State. The foundation man-
ager shall also attach to the report a copy of
the Form 990-PF (or Schedule PF (Form 1041)
for a 4947(a)(1) trust) and a copy of the Form
4720 (if any) filed by the foundation with the
Internal Revenue Service for the year.

G. Penalty for Failure to File Report and
Notice on Time.—if a private foundation fails
to file the annual report on or before the due
date, or to comply with the requirements under
above, there will be imposed on the per-
son (anyone under a duty to perform the act),
a $10 penalty for each day during which the
failure continues, not to exceed $5,000. (See
section 6652(d)(3).) If more than one person
is liable, all such persons shall be jointly and
severally liable with respect to such failure.
Organizations that have given notice under sec-
tion 508(b) as to their status and have not
received a letter from the Internal Revenue
Service containing a determination as to such
status—refer to Revenue Procedure 72-31,
1972-1 C.B. 759, or later revisions, for rules
relating to relief from the penalty provision of
Section 6652. If the failure to file the annual
report or comply with “C” is willful, there
will be imposed, in addition to the amount
mentioned above, a penalty of $1,000 for
each such report or notice. (See section 6685.)

H. Foreign Organizations.—A foreign or-
ganization which has received substantially all
of its support (other than gross investment in-
come) from sources outside the United States
will not be subject to the requirements of in-
structions “C” and "F” above.



Form 990—AR

1074
Annual Report

of Private
Foundation

Name

Under Section 6056 of the Internal Revenue Code

In addition to this Annual Report,
the annual return of the Foundation
filed on Form 990-PF is available for
public inspection. Consult an
Internal.Revenue Service office for
further information.

of the

Internal
Revenue
Service


Form 990-AR (1974) Page 2

Annual report for calendar year 1974, or fiscal year beginning .. . cecesseneennp 1974, and ending ...... ceccscccecescsseceenceeceett 1Qecceeeee

Name of organization Employer identification number

Address of principal office

If books and records are not at above address, specify where they are kept Name of principal officer of foundation

Public Inspection (See Instruction C):
(a) Enter date the notice of availability of annual report appeared in newspaper .

(b) Enter name of newspaper .____ _ ween
(c) Check [_] if you have attached a copy of the newspaper notice as req

the report will be considered incomplete.)

Revenues

1 Amount of gifts, grants, bequests, and contributions received for the year .
2 Gross income for the year

Bo Total. we
Disbursements and Expenses

4 Disbursements for the year for the purposes for which exempt (including administrative expenses) .

5 Expenses attributable to gross income (item 2 above) for the year

Foundation Managers
6 List all managers of the foundation (see section 4946(b) IRC):

Address where manager may be contacted

Name and title during normal business hours

6a List here any managers of the foundation (see section 4946(b) IRC) who have contributed 2 percent of the total contributions
received by the foundation before the close of any taxable year (but only if they have contributed more than $5,000). (See
section 507(d)(2).)

6b List here any managers of the foundation (see section 4946(b) IRC) who own 10 percent 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 percent or
greater interest.



Form 990-AR (1974)

Page 3

Balance Sheet Per Books at at the Beginning of the Year

Assets
Cash

Accounts and notes receivable
Inventories

Securities
Government obligations .

Corporate bonds
Corporate stocks .

Mortgage loans

Real estate .

Less: Depreciation
Other assets _
|

Less: Depreciation

Total_assets

|

~ Liabi

Accounts payable
Contributions, gifts, grants,
etc. payable :
Bonds and notes payable .
Mortgages payable

Other liabilities .

Total liabilities

Net Worth

Principal fund

Income fund .

Total net worth .

Total liabilities and net_worth

Temized Statement of Securities and All Other Assets Held at the Close of the Taxable Year

Asset

Book value

| Market value

Total -