Form 990-AR (1976)

Page 4

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

Recipient

If recipient is an
individual, show any
relationship to any

foundation manager

Concise statement of
Purpose of grant or

Amount

‘or substantial contribution
Name and address (home or business) r_ Substantia
Paid during year
Total... woot eee : . o>

Approved for future payment

Total. 2 ee ee eee ee

Te

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 “F.”

Bate

Signature of foundation manager

Signature of individual or firm preparing the report

ireparer's a

Instructions

A. Annual Report.—An annual report is re-
quired from the foundation managers (as defined
in section 4946(b)) of every organization which
is a private foundation, including a nonexempt
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 pre-
pare the report in printed, typewritten or any
other form you choose, provided it readily and
legibly discloses the information required by sec-
tion 6056 and the regulations thereunder.

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

(1) Tax-exempt private foundation.—File the
report at the time and place specified for filing
Form 990-PF, Return of Private Foundation
Exempt from Income Tax.

(2) Nonexempt trust described in section 4947
(a)(1) and treated as a private foundation.—
File the report at the time and place specified
for filing Form 5227, Return of Nonexempt
Charitable or Split-Interest Trust Treated as a
Private Foundation under section 4947(a) of the
Internal Revenue Code.

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 foun-
dation 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 thereunder.

The notice must be published not later than
the day prescribed for filing the annual report
(determined with regard to any extensions of
time for filing), in a newspaper having general
circulation in the county in which the principal

office of the private foundation is located. The
notice must state that the annual report of the
private foundation is available at its principal
office during regular business hours for inspec-
tion by any citizen who so requests within 180
days after the date of the publication. It must
also show the address of the private foundation’s
principal office and the name of its principal man-
ager. A private foundation may designate in addi-
tion to its principal office, or (if the foundation
has no principal office or none other than the
residence of a substantial contributor or founda-
tion manager) instead of such office, any other
location where its annual report is available,

The term “newspaper having general circula-
tion” shall include any newspaper or journal
which is permitted to publish statements in satis-
faction 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 pub-
lic charities without retaining any right, title or
interest in such assets, does not have to publish
notice of availability of its annual report or fur-
nish such report to the public for the taxable
year in which it so terminates (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 re-
quired to attach to its Form 990-PF a list of all
States:

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

(2) with which the organization has registered
(or which it has otherwise notified in any man-
ner) 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; List-
ing of States.—The foundation managers must

furnish a copy of the annual report (required by
section 6056) to the Attorney General (or his/
her designate) of (1) each State listed for Form
990-PF above, (2) the State in which the prin-
cipal office of the foundation is located, and (3)
the State in which the foundation was incor-
porated or organized. Such report must be fur-
nished at the same time it is sent to the Internal
Revenue Service. In addition, the foundation
managers shall provide upon request _a copy of
the annual report to the Attorney General or
other appropriate State officer of any other
State. The foundation manager shall also attach
to the report a copy of the Form 990-PF (or
Form 5227 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 No-
tice 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 person (any-
one under a duty to perform the act), a $10
penalty for each day during which the failure con
tinues, not to exceed $5,000. (See section 6652
(d)@).) 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 section 508(b) as to
their status and have not received a letter from
the Internal Revenue Service containing a deter-
mination as to such status—refer to Revenue
Procedure 72-31, 1972-1 C.B. 759, or later re-
visions, 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 organi-
zation which has received substantially all of its
support (other than gross investment income)
from sources outside the United States will not
be subject to the requirements of instructions
“C" and “F’” above.

‘Ye U.S. GOVERNMENT PRINTING OFFICE : 1976—O-218-045

218-045-1


Form 990-AR

1976
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.

Service 218-045-1


Form 990-AR (1976) Page 2

1 19.

+ 1976, and ending ..

Annual report for calendar year 1976, or fiscal year beginning .

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 >
(c) Check here > ["], if you have attached a copy of the newspaper notice as required by instruction “C.

attached, the report will be considered incomplete.)
Check box for type of annual return P ("] Form 990-PF ( Form 5227

(If the notice is not

Revenues
1 Amount of gifts, grants, bequests, and contributions received forthe year . . . . . . «

2 Gross income forthe year . 6 6 1 ew ee ee ee ee

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) forthe year . . 2... . ee ee ee

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.

218-045-1


Form 990-AR (1976)

Page 3

Balance Sheet

Per Books at the Beginning of the Year

Assets

Cash ww wwe
Accounts and notes receivable
Inventories . .

Securities
Government obligations .

Corporatebonds . . . .

Corporate stocks .
Mortgage loans .
Realestate . .
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. . se eee

Net Worth

Principalfund. . . .

Income fund . . . 2. ©

Total net worth . .

Total liabilities and net worth

Ttemized ‘Statement “of Securities and All Other Assets Held at the Close of the ‘Taxable Year

Asset

Book value

Market value

Total . . - -

218-045-1