Form 990-AR (1980)

Page 4

Grants and Contributions Paid During the Year or Approved for Future Payment

Recipient

relationship to any

Name and address (home or business)

foundation manager
‘or substantial
contributor

Concise statement of
Purpose of grant or
‘contribution

Amount

Paid during year

Total... , 7 ee
Approved for future payment
Total... Te To

A notice has been published that this 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 General (or his/her designate) of each State entitled to receive reports as required by instruction E.

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Dts

Dsscsereers

ress

Instructions

A. Who Must File.—An annual report is
required from the foundation managers (as
defined in section 4946(b)) of every orga-
nization that is a private foundation, in-
cluding a nonexempt charitable trust de-
scribed in section 4947(a)(1) that is
treated as a private foundation, and that
has at least $5,000 of assets at any time
during a tax year. A private foundation may
file this form as its annual report.

Foundation managers who prefer not to
use this form may prepare the report in
printed, typewritten, or other form as long
as it readily and legibly discloses the in-
formation required by section 6056 and the
related regulations.

The annual report is required in addition
to, and not in place of, the information re-
quired on Form 990-PF under section

B. Where and When to File.—File the an-
nual report by the due date of the orga-
nization’s annual information return, Form
990-PF or Form 5227, with the same serv-
ice center where the return is filed. See
the instructions for Form 990-PF and Form
5227 for more information.

C, Public Inspection of Private Founda-
tion's Annual Report—Foundation man-
agers must make the annual report avail-
able for inspection during regular business
hours at the principal office of the founda-
tion, or may furnish a free copy to any per-
son requesting inspection, provided the re-
quest is made at the time and in the man-
ner prescribed in section 6104(d) and the
related regulations.

A notice that the private foundation's an-
nual report is available for inspection must
be published by the due date for filing the
annual report, including any extensions of
time for filing. The notice must be pub-
lished in a newspaper with general circula-
tion in the county in which the principal of-
fice of the private foundation is located. (A
newspaper or journal that publishes real

estate title transfers or other similar legal
notices to satisfy State statutory require-
ments is also considered to have general
circulation.) The notice must state that the
annual report of the private foundation is
available for inspection at its principal of-
fice during regular business hours by any
citizen who requests inspection within 180
days after the date the notice is published.
It must also show the address of the pri-
vate foundation's principal office and the
name of its principal manager. A private
foundation may designate, in addition to
its principal office, any other location at
which its annual report will be made avail-
able. Another location may also be desig-
nated if the foundation has no principal
office, or none other than the residence of
a substantial contributor or foundation
manager.

A copy of the notice must be attached
to the annual report filed with the Internal
Revenue Service. Because IRS makes the
annual report available for public inspec-
tion under section 6104(d), the report and
any attachments should be of such quality
that they can be reproduced photographi-
cally.

A private foundation that has termi-
nated its status as such under section 507
(b)(1)(A), by distributing all its net assets
to one or more public charities without re-
taining any right, title, or interest in those
assets, should check the box on page 2
indicating termination. It does not have to
publish notice of availability of its annual
report or furnish the report to the public
for the tax year in which it terminates
(Reg. 1.507—2(a)(6)).

D. Signature and Verification.—The re-
port must be signed by the foundation
manager.

E. Furnishing of Copies to State Officers;
Listing of States.—Section 6056 requires
foundation managers to furnish a copy of
the annual report to the Attorney General
(or his or her designate) of (1) each State
required to be listed in Part V of Form

990-PF or Part III of Form 5227, (2) the
State in which the principal office of the
foundation is located, (3) the State in
which the foundation was incorporated or
organized, and (4) any other State if re-
quested. The report must be furnished at
the same time it is sent to IRS. The foun-
dation manager must attach to the report
a copy of the Form 990-PF (or Form 5227)
and a copy of any Form 4720 filed by the
foundation with IRS for the year.

F. Penalty for Not Filing the Annual Re-
port and Notice on Time.—lf a private
foundation does not file the annual report
by the due date or does not comply with
the requirements under instruction C, the
person required to file will be charged a
$10 penalty under section 6652 for each
day the report and notice are late, up toa
maximum of $5,000. If more than one per-
son is required to file, all such persons will
be jointly and separately liable for the
penalty.

The penalty of $10 a day may also be
charged if a report is filed with information
omitted. An entry should be made in each
part of the form. If a part or line item does
not apply, “N/A” (not applicable) should
be entered in that space. (See Rev. Rul.
77-162, 1977-1 C.B. 400, for details.)

If the failure to file the annual report or
comply with instruction C is willful, a pen-
alty of $1,000 for each such report or no-
tice will be charged in addition to the above
amount. (See section 6685.)

Organizations that have given notice
under section 508(b) regarding their foun-
dation status and have not received a de-
termination letter from IRS on their status
should refer to Rev. Proc. 79-8, 1979-1
C.B. 487, or later revisions for rules relat-
ing to relief from the penalty provision of
section 6652.

G. Foreign Organizations.—A foreign
organization which received substantially
all of its support (other than gross invest-
ment income) from sources outside the
United States will not be subject to the re-
quirements of instructions C and E above.

‘$e US. GOVERNMENT PRINTING OFFICE : 1980—O-313-054

'313-054—1


Form 990-AR

1980
Annual Report

of Private
Foundation

Name

Under Section 6056 of the Internal Revenue Code

This Annual Report and

the annual return of the foundation
filed on Form 990-PF are available for
public inspection. Consult an

Internal Revenue Service office for
further information.

Department
ot the
‘Treasury
Internal
levenue
Service 313-054~1


Form 990-AR (1980) Page 2

Annual report for calendar year 1980, or fiscal year beginning , 1980, and ending 119
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 D>

(b) Enter name of newspaper p> en . _
(c) Check here }> [] if you have attached a copy of the newspaper notice as required by instruction C. (If the notice is not
attached, the report will be considered incomplete.)

Check this box if your private foundation status
terminated under section 507(b)(1)(A) > o

Check box for type of annual return B [] Form 990-PF [_] Form 5227

Revenues
1 Amount of gifts, grants, bequests, and contributions received forthe year . 2. . 1. 1 ee ew ee

2 Gross income forthe year 2 6 1 we ee ee

3 Total 2. ee
Disbursements and Expenses

4 Disbursements for the year tor exempt (charitable) purposes (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)):

Address where manager may be contacted

Name and title during normal business hours

6a List here any managers of the foundation who have contributed more than 2% of the total contributions received by the foun-
dation before the close of any tax year (but only if they have contributed more than $5,000). (See section 507(d)(2).)

6b List here 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.

313-054-1


Form 990-AR (1980)

Page 3

Balance Sheet Per Books at the Beginning of the Year

Assets

Cash .

Accounts and notes receivable

Inventories . 2. 1 we

Securities:
Government obligations .

Corporatebonds . . .

Corporate stocks . . .

Mortgage loans . . .

Real estate

Less: Depreciation .

Other assets. . . |__.

Less: Depreciation .

Total assets

Liabilities
Accounts payable. . .
Contributions, gifts, Brants,
etc., payable . . woe
Bonds and notes payable . .
Mortgages payable . . .

Other liabilities. . . . .

Total liabilities. . . 2. 2.

Net Worth

Principal fund. . . 2. we

Income fund . . . .

Total net worth . . .

Total liabilities and net worth

Ttemized Statement of ‘Securities and All Other Assets Held at the Close of of the Ta

x Year

Asset

Book value

Market value

Total...

313-054-1