Form 990-AR (1971)

Page 4

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

Recipient

Name and address (home or business)

Paid during year

If recipient is an in-
dividual, show any rela
tionship fo any foundation
manager or substantial
contributor

Concise statement of
Purpose of grant or
‘contribution

‘Amount

Approved for future payment

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 of each State entitled to receive reports and listed on Form 990.

(Date) ~ (Signature of officer) ~ (Title)
(Date) (Signature of individual or firm preparing return) 7 “(address) 7 oO
Instructions eral circulation in the county in which the a holder of property devoted to a charitable

A. Annual Report.—The foundation man-
agers (as defined in: section 4946(b)) of every
organization which is a private foundation
having at least $5,000 of assets at any time
during a taxable year shall file an annual re-
port. A private foundation may use this form
for its annual reporting requirements.

The annual report required to be filed is in
addition to and not in lieu of submitting the
information required on Form 990 under sec-
tion 6033.

The report may be prepared in printed, type-
written or any other form the foundation
chooses; provided that it readily and legibly
discloses the information required by section
6056 and the regulations thereunder.

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

€. Public Inspection of Private Foundation’s
Annual Reports.—The annual report required
to be filed under section 6056 shall be made
available by the foundation managers for in-
spection at the principal office of the founda-
tion during regular business hours by any citi-
zen on request made within 180 days after the
publication of notice of its availability; or if the
foundation manager chooses, he may furnish
a copy free of charge to such persons request-
ing inspection, provided such persons do so at
the time and manner prescribed in section
6104(d) and the regulations thereunder.

The notice shall be published not later than
the day prescribed for filing such annual re-
port (determined with regard to any extensions
of time for filing), in a newspaper having gen-

principal office of the private foundation is lo-
cated. The notice shall state that the annual
report of the private foundation is available
at its principal office for inspection during
regular business hours by any citizen who re-
quests it within 180 days after the date of such
publication, and shall state the address of the
private foundation's principal office and the
name of its principal manager. A private
foundation may designate in addition to its
principal office, or (if the foundation has no
principal office or none other than the resi-
dence of a substantial contributor or founda-
tion manager) in lieu of such office, any other
location at which its annual report shall be
made available.

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

A copy of such notice as published and a
statement signed by a foundation manager
stating that such notice was published, setting
forth the date of publication and the publica-
tion in which it appears shall be sufficient proof
of publication.

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 a list of
all States:

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

(>) 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,

purpose.

F, Furnishing of Copies to State Officers;
Listing of States.—The foundation managers
shall furnish a copy of the annual report (re-
quired by section 6056) to the Attorney Gen-
eral of (1) each State which they are required
to list above, (2) the State in which is located
the principal office of the foundation, and (3)
the State in which the foundation’ was in-
corporated or organized. Such report shall 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 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
“C” 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 such
failure continues, not to exceed $5,000. See
section 6652(d)(3). If such failure to file the
annual report or comply with “C” is willful,
there shall be imposed in addition to the
amount mentioned above a penalty of $1,000
with respect to 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
shall not be subject to the requirements of
C and F above.

US. GOVERNMENT PRINTING OFFICE:1971——O-418-029 36-2249473


Form 990-AR

1971
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 is available for
public inspection. Consult an
Internal Revenue Service office for
further information.

Department
of the
Treasury

AN

Internal
Revenue
Service


Form 990-AR (1971) Page 2

Annual report for calendar year 1971, or fiscal year beginning .

1971, and ending , 19.

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

Revenues

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

3 Total, . 6 ee
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
peter i al before the close of any taxable year (but only if they have contributed more than $5,000). (See
section B

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 (1971)

Page 3

Balance Sheet Per Books

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

Liabilities
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

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

Asset

Book value

Market value

Total -