Form 990-AR (1972)

Page 4

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

Recipient

If recipient is an
indivi show any
relationship to any’

ge

Name and address (home or business)

foundation manager
or substantial
contributor

Concise statement of
purpose of grant or

Amount
contribution

Paid during year

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-PF.

ignature of individual or firm preparing the return

Signature of foundation manager

Preparer’s a

Instructions

A. Annual Report.—The foundation man-
agers (as defined in section 4946(b)) of every
organization which is a private foundation, in-
cluding 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 shall file an annual report. 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-PF under
section 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
report must be filed at the
specified for filing Form 990-PF.

€. Public Inspection of Private Foundati
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 found
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-
eral circulation in the county in which the
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
fame 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-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
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-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
“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 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
(IRB 1972-23, dated June 5, 1972) for rules
relating to relief from the penalty provision of
Section 6652. 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.

‘x US. GOVERNMENT PRINTING OFFICE:1972—O-458-041 48-0627165


Form 990-AR

1972
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
Treasury

a

Internal
Revenue
Service


Form 990-AR (1972) Page 2

Annual report for calendar year 1972, or fiscal year beginning ... eevey 1972, aNd ONGING ooo cceeeeceeeeeeeeeeeeeeeeeneeey Qe

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, 2. 6 eee ee 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 norma! 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 (1972)

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 -