Form 990-PF

Department of the Treasury 

Internal Revenue Service 

Return of Private Foundation 

or Section 4947(a)(1) Nonexempt Charitable Trust 

Treated as a Private Foundation

Note. The foundation may be able to use a copy of this return to satisfy state reporting requirements.

OMB No. 1545-0052

2012

Open to Public Inspection

For calendar year 2012 or tax year beginning , 2012, and ending , 20

Name of foundation

Number and street (or P.O. box number if mail is not delivered to street address) Room/suite

City or town, state, and ZIP code

A Employer identification number

B Telephone number (see instructions)

C If exemption application is pending, check here ▶

D 1. Foreign organizations, check here . . . ▶

2. Foreign organizations meeting the 85% test, 

check here and attach computation . . ▶

E If private foundation status was terminated under 

section 507(b)(1)(A), check here . . . . ▶

F If the foundation is in a 60-month termination 

under section 507(b)(1)(B), check here . . ▶

G Check all that apply: Initial return

Final return

Address change

Initial return of a former public charity

Amended return

Name change

H Check type of organization: Section 501(c)(3) exempt private foundation

Section 4947(a)(1) nonexempt charitable trust Other taxable private foundation

I Fair market value of all assets at 

end of year (from Part II, col. (c),

line 16) ▶ $

J Accounting method: Cash Accrual

Other (specify)

(Part I, column (d) must be on cash basis.)

Part I Analysis of Revenue and Expenses (The total of

amounts in columns (b), (c), and (d) may not necessarily equal

the amounts in column (a) (see instructions).)

Revenue Operating and Administrative Expenses

(a) Revenue and

expenses per 

books

(b) Net investment

income

(c) Adjusted net

income

(d) Disbursements

for charitable

purposes 

(cash basis only)

1 Contributions, gifts, grants, etc., received (attach schedule)

2 Check ▶ if the foundation is not required to attach Sch. B

3 Interest on savings and temporary cash investments

4 Dividends and interest from securities . . . .

5a Gross rents . . . . . . . . . . . . .

b Net rental income or (loss)

6a Net gain or (loss) from sale of assets not on line 10

b Gross sales price for all assets on line 6a

7 Capital gain net income (from Part IV, line 2) . .

8 Net short-term capital gain . . . . . . . .

9 Income modifications . . . . . . . . .

10a Gross sales less returns and allowances

b Less: Cost of goods sold . . .

c Gross profit or (loss) (attach schedule) . . . .

11 Other income (attach schedule) . . . . . .

12 Total. Add lines 1 through 11 . . . . . . .

13 Compensation of officers, directors, trustees, etc.

14 Other employee salaries and wages . . . . .

15 Pension plans, employee benefits . . . . .

16a Legal fees (attach schedule) . . . . . . .

b Accounting fees (attach schedule) . . . . .

c Other professional fees (attach schedule) . . .

17 Interest . . . . . . . . . . . . . .

18 Taxes (attach schedule) (see instructions) . . . .

19 Depreciation (attach schedule) and depletion . .

20 Occupancy . . . . . . . . . . . . .

21 Travel, conferences, and meetings . . . . .

22 Printing and publications . . . . . . . .

23 Other expenses (attach schedule) . . . . .

24 Total operating and administrative expenses. 

Add lines 13 through 23 . . . . . . . . .

25 Contributions, gifts, grants paid . . . . . .

26 Total expenses and disbursements. Add lines 24 and 25

27 Subtract line 26 from line 12:

a Excess of revenue over expenses and disbursements

b Net investment income (if negative, enter -0-) .

c Adjusted net income (if negative, enter -0-) . .

For Paperwork Reduction Act Notice, see instructions. Cat. No. 11289X Form 990-PF (2012) 
Form 990-PF (2012) Page 2 

Part II Balance Sheets Attached schedules and amounts in the description column 

should be for end-of-year amounts only. (See instructions.)

Beginning of year End of year

Assets Liabilities Net Assets or Fund Balances (a) Book Value (b) Book Value (c) Fair Market Value

1 Cash—non-interest-bearing . . . . . . . . . . .

2 Savings and temporary cash investments . . . . . . .

3 Accounts receivable ▶

Less: allowance for doubtful accounts ▶

4 Pledges receivable ▶

Less: allowance for doubtful accounts ▶

5 Grants receivable . . . . . . . . . . . . . . .

6 Receivables due from officers, directors, trustees, and other 

disqualified persons (attach schedule) (see instructions) . .

7 Other notes and loans receivable (attach schedule) ▶

Less: allowance for doubtful accounts ▶

8 Inventories for sale or use . . . . . . . . . . . .

9 Prepaid expenses and deferred charges . . . . . . .

10a Investments—U.S. and state government obligations (attach schedule)

b Investments—corporate stock (attach schedule) . . . . .

c Investments—corporate bonds (attach schedule) . . . .

11 Investments—land, buildings, and equipment: basis ▶

Less: accumulated depreciation (attach schedule) ▶

12 Investments—mortgage loans . . . . . . . . . . .

13 Investments—other (attach schedule) . . . . . . . .

14 Land, buildings, and equipment: basis ▶

Less: accumulated depreciation (attach schedule) ▶

15 Other assets (describe ▶ )

16 Total assets (to be completed by all filers—see the

instructions. Also, see page 1, item I) . . . . . . . .

17 Accounts payable and accrued expenses . . . . . . .

18 Grants payable . . . . . . . . . . . . . . . .

19 Deferred revenue . . . . . . . . . . . . . . .

20 Loans from officers, directors, trustees, and other disqualified persons

21 Mortgages and other notes payable (attach schedule) . . .

22 Other liabilities (describe ▶ )

23 Total liabilities (add lines 17 through 22) . . . . . . .

Foundations that follow SFAS 117, check here . . ▶

and complete lines 24 through 26 and lines 30 and 31.

24 Unrestricted . . . . . . . . . . . . . . . . .

25 Temporarily restricted . . . . . . . . . . . . .

26 Permanently restricted . . . . . . . . . . . . .

Foundations that do not follow SFAS 117, check here ▶

and complete lines 27 through 31.

27 Capital stock, trust principal, or current funds . . . . . .

28 Paid-in or capital surplus, or land, bldg., and equipment fund

29 Retained earnings, accumulated income, endowment, or other funds

30 Total net assets or fund balances (see instructions) . . .

31 Total liabilities and net assets/fund balances (see 

instructions) . . . . . . . . . . . . . . . . .

Part III Analysis of Changes in Net Assets or Fund Balances

1 Total net assets or fund balances at beginning of year—Part II, column (a), line 30 (must agree with

end-of-year figure reported on prior year’s return) . . . . . . . . . . . . . . . . . 1

2 Enter amount from Part I, line 27a . . . . . . . . . . . . . . . . . . . . . . 2

3 Other increases not included in line 2 (itemize) ▶ 3

4 Add lines 1, 2, and 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

5 Decreases not included in line 2 (itemize) ▶ 5

6 Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 30 . . 6

Form 990-PF (2012) 
Form 990-PF (2012) Page 3 

Part IV Capital Gains and Losses for Tax on Investment Income

(a) List and describe the kind(s) of property sold (e.g., real estate,

2-story brick warehouse; or common stock, 200 shs. MLC Co.)

(b) How acquired

P—Purchase

D—Donation

(c) Date acquired

(mo., day, yr.)

(d) Date sold

(mo., day, yr.)

1a

b

c

d

e

(e) Gross sales price (f) Depreciation allowed

(or allowable)

(g) Cost or other basis

plus expense of sale

(h) Gain or (loss)

(e) plus (f) minus (g)

a

b

c

d

e

Complete only for assets showing gain in column (h) and owned by the foundation on 12/31/69

(i) F.M.V. as of 12/31/69 (j) Adjusted basis

as of 12/31/69

(k) Excess of col. (i)

over col. (j), if any

 (l) Gains (Col. (h) gain minus 

col. (k), but not less than -0-) or 

Losses (from col. (h))

a

b

c

d

e

2 Capital gain net income or (net capital loss) { If gain, also enter in Part I, line 7 

If (loss), enter -0- in Part I, line 7 } 2

3 Net short-term capital gain or (loss) as defined in sections 1222(5) and (6): 

If gain, also enter in Part I, line 8, column (c) (see instructions). If (loss), enter -0- in

Part I, line 8 . . . . . . . . . . . . . . . . . . . . . . . . } 3

Part V Qualification Under Section 4940(e) for Reduced Tax on Net Investment Income

(For optional use by domestic private foundations subject to the section 4940(a) tax on net investment income.)

If section 4940(d)(2) applies, leave this part blank.

Was the foundation liable for the section 4942 tax on the distributable amount of any year in the base period? Yes No

If “Yes,” the foundation does not qualify under section 4940(e). Do not complete this part.

1 Enter the appropriate amount in each column for each year; see the instructions before making any entries.

(a) 

Base period years 

Calendar year (or tax year beginning in)

(b) 

Adjusted qualifying distributions

(c) 

Net value of noncharitable-use assets

(d) 

Distribution ratio 

(col. (b) divided by col. (c))

2011

2010

2009

2008

2007

2 Total of line 1, column (d) . . . . . . . . . . . . . . . . . . . . . . 2

3 Average distribution ratio for the 5-year base period—divide the total on line 2 by 5, or by the

number of years the foundation has been in existence if less than 5 years . . . . . . 3

4 Enter the net value of noncharitable-use assets for 2012 from Part X, line 5 . . . . . . 4

5 Multiply line 4 by line 3 . . . . . . . . . . . . . . . . . . . . . . . 5

6 Enter 1% of net investment income (1% of Part I, line 27b) . . . . . . . . . . . 6

7 Add lines 5 and 6 . . . . . . . . . . . . . . . . . . . . . . . . . 7

8 Enter qualifying distributions from Part XII, line 4 . . . . . . . . . . . . . . . 8

If line 8 is equal to or greater than line 7, check the box in Part VI, line 1b, and complete that part using a 1% tax rate. See the

Part VI instructions.

Form 990-PF (2012) 
Form 990-PF (2012) Page 4 

Part VI Excise Tax Based on Investment Income (Section 4940(a), 4940(b), 4940(e), or 4948—see instructions)

1a Exempt operating foundations described in section 4940(d)(2), check here ▶ and enter “N/A” on line 1.

Date of ruling or determination letter: (attach copy of letter if necessary—see instructions)

b Domestic foundations that meet the section 4940(e) requirements in Part V, check

here ▶ and enter 1% of Part I, line 27b . . . . . . . . . . . . . . . . .

c All other domestic foundations enter 2% of line 27b. Exempt foreign organizations enter 4% of

Part I, line 12, col. (b).

} 1

2 Tax under section 511 (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-) 2

3 Add lines 1 and 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

4 Subtitle A (income) tax (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-) 4

5 Tax based on investment income. Subtract line 4 from line 3. If zero or less, enter -0- . . . . 5

6 Credits/Payments:

a 2012 estimated tax payments and 2011 overpayment credited to 2012 6a

b Exempt foreign organizations—tax withheld at source . . . . . 6b

c Tax paid with application for extension of time to file (Form 8868) . 6c

d Backup withholding erroneously withheld . . . . . . . . . 6d

7 Total credits and payments. Add lines 6a through 6d . . . . . . . . . . . . . . . 7

8 Enter any penalty for underpayment of estimated tax. Check here if Form 2220 is attached 8

9 Tax due. If the total of lines 5 and 8 is more than line 7, enter amount owed . . . . . . ▶ 9

10 Overpayment. If line 7 is more than the total of lines 5 and 8, enter the amount overpaid . . ▶ 10

11 Enter the amount of line 10 to be: Credited to 2013 estimated tax ▶ Refunded ▶ 11

Part VII-A Statements Regarding Activities

1a During the tax year, did the foundation attempt to influence any national, state, or local legislation or did it 

participate or intervene in any political campaign? . . . . . . . . . . . . . . . . . . .

Yes No

1a

b Did it spend more than $100 during the year (either directly or indirectly) for political purposes (see 

Instructions for the definition)? . . . . . . . . . . . . . . . . . . . . . . . . . . 1b

If the answer is “Yes” to 1a or 1b, attach a detailed description of the activities and copies of any materials

published or distributed by the foundation in connection with the activities.

c Did the foundation file Form 1120-POL for this year? . . . . . . . . . . . . . . . . . . 1c

d Enter the amount (if any) of tax on political expenditures (section 4955) imposed during the year:

(1) On the foundation. ▶ $ (2) On foundation managers. ▶ $

e Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed 

on foundation managers. ▶ $

2 Has the foundation engaged in any activities that have not previously been reported to the IRS? . . . . 2

If “Yes,” attach a detailed description of the activities.

3 Has the foundation made any changes, not previously reported to the IRS, in its governing instrument, articles of 

incorporation, or bylaws, or other similar instruments? If “Yes,” attach a conformed copy of the changes . . . 3

4a Did the foundation have unrelated business gross income of $1,000 or more during the year? . . . . . 4a

b If “Yes,” has it filed a tax return on Form 990-T for this year? . . . . . . . . . . . . . . . . 4b

5 Was there a liquidation, termination, dissolution, or substantial contraction during the year? . . . . . 5

If “Yes,” attach the statement required by General Instruction T.

6 Are the requirements of section 508(e) (relating to sections 4941 through 4945) satisfied either:

⦁ By language in the governing instrument, or

⦁ By state legislation that effectively amends the governing instrument so that no mandatory directions that 

conflict with the state law remain in the governing instrument? . . . . . . . . . . . . . . . 6

7 Did the foundation have at least $5,000 in assets at any time during the year? If “Yes,” complete Part II, col. (c), and Part XV 7

8a Enter the states to which the foundation reports or with which it is registered (see instructions) ▶

b If the answer is “Yes” to line 7, has the foundation furnished a copy of Form 990-PF to the Attorney General 

(or designate) of each state as required by General Instruction G? If “No,” attach explanation . . . . . 8b

9 Is the foundation claiming status as a private operating foundation within the meaning of section 4942(j)(3) or 

4942(j)(5) for calendar year 2012 or the taxable year beginning in 2012 (see instructions for Part XIV)? If “Yes,”

complete Part XIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

10 Did any persons become substantial contributors during the tax year? If “Yes,” attach a schedule listing their

names and addresses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Form 990-PF (2012) 
Form 990-PF (2012) Page 5 

Part VII-A Statements Regarding Activities (continued)

11 At any time during the year, did the foundation, directly or indirectly, own a controlled entity within the

meaning of section 512(b)(13)? If “Yes,” attach schedule (see instructions) . . . . . . . . . . . 11

12 Did the foundation make a distribution to a donor advised fund over which the foundation or a disqualified

person had advisory privileges? If “Yes,” attach statement (see instructions) . . . . . . . . . . . 12

13 Did the foundation comply with the public inspection requirements for its annual returns and exemption application? 13

Website address ▶

14 The books are in care of ▶ Telephone no. ▶

Located at ▶ ZIP+4 ▶

15 Section 4947(a)(1) nonexempt charitable trusts filing Form 990-PF in lieu of Form 1041—Check here. . . . . . . ▶

and enter the amount of tax-exempt interest received or accrued during the year . . . . . ▶ 15

16 At any time during calendar year 2012, did the foundation have an interest in or a signature or other authority 

over a bank, securities, or other financial account in a foreign country?. . . . . . . . . . . . .

Yes No

16

See the instructions for exceptions and filing requirements for Form TD F 90-22.1. If "Yes," enter the name of 

the foreign country ▶

Part VII-B Statements Regarding Activities for Which Form 4720 May Be Required

File Form 4720 if any item is checked in the “Yes” column, unless an exception applies. Yes No

1a During the year did the foundation (either directly or indirectly):

(1) Engage in the sale or exchange, or leasing of property with a disqualified person? . . Yes No

(2) Borrow money from, lend money to, or otherwise extend credit to (or accept it from) a 

disqualified person? . . . . . . . . . . . . . . . . . . . . . . . Yes No

(3) Furnish goods, services, or facilities to (or accept them from) a disqualified person? . . Yes No

(4) Pay compensation to, or pay or reimburse the expenses of, a disqualified person? . . Yes No

(5) Transfer any income or assets to a disqualified person (or make any of either available for 

the benefit or use of a disqualified person)? . . . . . . . . . . . . . . . Yes No

(6) Agree to pay money or property to a government official? (Exception. Check “No” if the

foundation agreed to make a grant to or to employ the official for a period after 

termination of government service, if terminating within 90 days.) . . . . . . . . Yes No

b If any answer is “Yes” to 1a(1)–(6), did any of the acts fail to qualify under the exceptions described in Regulations 

section 53.4941(d)-3 or in a current notice regarding disaster assistance (see instructions)? . . . . . . . 1b

Organizations relying on a current notice regarding disaster assistance check here . . . . . . ▶

c Did the foundation engage in a prior year in any of the acts described in 1a, other than excepted acts, that 

were not corrected before the first day of the tax year beginning in 2012? . . . . . . . . . . . 1c

2 Taxes on failure to distribute income (section 4942) (does not apply for years the foundation was a private 

operating foundation defined in section 4942(j)(3) or 4942(j)(5)):

a At the end of tax year 2012, did the foundation have any undistributed income (lines 6d and 

6e, Part XIII) for tax year(s) beginning before 2012? . . . . . . . . . . . . . . Yes No

If “Yes,” list the years ▶ 20 , 20 , 20 , 20

b Are there any years listed in 2a for which the foundation is not applying the provisions of section 4942(a)(2) 

(relating to incorrect valuation of assets) to the year’s undistributed income? (If applying section 4942(a)(2) to 

all years listed, answer “No” and attach statement—see instructions.) . . . . . . . . . . . . . 2b

c If the provisions of section 4942(a)(2) are being applied to any of the years listed in 2a, list the years here.

▶ 20 , 20 , 20 , 20

3a Did the foundation hold more than a 2% direct or indirect interest in any business enterprise 

at any time during the year? . . . . . . . . . . . . . . . . . . . . . . Yes No

b If “Yes,” did it have excess business holdings in 2012 as a result of (1) any purchase by the foundation or 

disqualified persons after May 26, 1969; (2) the lapse of the 5-year period (or longer period approved by the

Commissioner under section 4943(c)(7)) to dispose of holdings acquired by gift or bequest; or (3) the lapse of

the 10-, 15-, or 20-year first phase holding period? (Use Schedule C, Form 4720, to determine if the

foundation had excess business holdings in 2012.) . . . . . . . . . . . . . . . . . . . 3b

4a Did the foundation invest during the year any amount in a manner that would jeopardize its charitable purposes? 4a

b Did the foundation make any investment in a prior year (but after December 31, 1969) that could jeopardize its 

charitable purpose that had not been removed from jeopardy before the first day of the tax year beginning in 2012? 4b

Form 990-PF (2012) 
Form 990-PF (2012) Page 6 

Part VII-B Statements Regarding Activities for Which Form 4720 May Be Required (continued)

5a During the year did the foundation pay or incur any amount to:

(1) Carry on propaganda, or otherwise attempt to influence legislation (section 4945(e))? . Yes No

(2) Influence the outcome of any specific public election (see section 4955); or to carry on, 

directly or indirectly, any voter registration drive? . . . . . . . . . . . . . Yes No

(3) Provide a grant to an individual for travel, study, or other similar purposes? . . . . . Yes No

(4) Provide a grant to an organization other than a charitable, etc., organization described in

section 509(a)(1), (2), or (3), or section 4940(d)(2)? (see instructions) . . . . . . . Yes No

(5) Provide for any purpose other than religious, charitable, scientific, literary, or educational

purposes, or for the prevention of cruelty to children or animals? . . . . . . . . Yes No

b If any answer is “Yes” to 5a(1)–(5), did any of the transactions fail to qualify under the exceptions described in 

Regulations section 53.4945 or in a current notice regarding disaster assistance (see instructions)? . . . . 5b

Organizations relying on a current notice regarding disaster assistance check here . . . . . . ▶

c If the answer is “Yes” to question 5a(4), does the foundation claim exemption from the tax 

because it maintained expenditure responsibility for the grant? . . . . . . . . . . Yes No

If “Yes,” attach the statement required by Regulations section 53.4945–5(d).

6a Did the foundation, during the year, receive any funds, directly or indirectly, to pay premiums

on a personal benefit contract? . . . . . . . . . . . . . . . . . . . . Yes No

b Did the foundation, during the year, pay premiums, directly or indirectly, on a personal benefit contract? . 6b

If “Yes” to 6b, file Form 8870.

7a At any time during the tax year, was the foundation a party to a prohibited tax shelter transaction? Yes No

b If "Yes," did the foundation receive any proceeds or have any net income attributable to the transaction? . 7b

Part VIII Information About Officers, Directors, Trustees, Foundation Managers, Highly Paid Employees, 

and Contractors

1 List all officers, directors, trustees, foundation managers and their compensation (see instructions).

(a) Name and address

(b) Title, and average

hours per week 

devoted to position

(c) Compensation

(If not paid, 

enter -0-)

(d) Contributions to

employee benefit plans 

and deferred compensation

(e) Expense account,

other allowances

2 Compensation of five highest-paid employees (other than those included on line 1—see instructions). If none, enter 

“NONE.”

(a) Name and address of each employee paid more than $50,000

(b) Title, and average

hours per week devoted to position(c) Compensation

(d) Contributions to

employee benefit

plans and deferred

compensation

(e) Expense account,

other allowances

Total number of other employees paid over $50,000 . . . . . . . . . . . . . . . . . . . . ▶

Form 990-PF (2012) 
Form 990-PF (2012) Page 7 

Part VIII Information About Officers, Directors, Trustees, Foundation Managers, Highly Paid Employees, 

and Contractors (continued)

3 Five highest-paid independent contractors for professional services (see instructions). If none, enter “NONE.”

(a) Name and address of each person paid more than $50,000 (b) Type of service (c) Compensation

Total number of others receiving over $50,000 for professional services . . . . . . . . . . . . . ▶

Part IX-A Summary of Direct Charitable Activities

List the foundation’s four largest direct charitable activities during the tax year. Include relevant statistical information such as the number of 

organizations and other beneficiaries served, conferences convened, research papers produced, etc. Expenses

1

2

3

4

Part IX-B Summary of Program-Related Investments (see instructions)

Describe the two largest program-related investments made by the foundation during the tax year on lines 1 and 2. Amount

1

2

All other program-related investments. See instructions.

3

Total. Add lines 1 through 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . ▶

Form 990-PF (2012) 
Form 990-PF (2012) Page 8 

Part X Minimum Investment Return (All domestic foundations must complete this part. Foreign foundations, 

see instructions.)

1 Fair market value of assets not used (or held for use) directly in carrying out charitable, etc., 

purposes:

a Average monthly fair market value of securities . . . . . . . . . . . . . . . . . 1a

b Average of monthly cash balances . . . . . . . . . . . . . . . . . . . . . 1b

c Fair market value of all other assets (see instructions) . . . . . . . . . . . . . . . 1c

d Total (add lines 1a, b, and c) . . . . . . . . . . . . . . . . . . . . . . . 1d

e Reduction claimed for blockage or other factors reported on lines 1a and 

1c (attach detailed explanation) . . . . . . . . . . . . . . . 1e

2 Acquisition indebtedness applicable to line 1 assets . . . . . . . . . . . . . . . . 2

3 Subtract line 2 from line 1d . . . . . . . . . . . . . . . . . . . . . . . . 3

4 Cash deemed held for charitable activities. Enter 1 1

/2 % of line 3 (for greater amount, see 

instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

5 Net value of noncharitable-use assets. Subtract line 4 from line 3. Enter here and on Part V, line 4 5

6 Minimum investment return. Enter 5% of line 5 . . . . . . . . . . . . . . . . . 6

Part XI Distributable Amount (see instructions) (Section 4942(j)(3) and (j)(5) private operating

foundations and certain foreign organizations check here ▶ and do not complete this part.)

1 Minimum investment return from Part X, line 6 . . . . . . . . . . . . . . . . . . 1

2a Tax on investment income for 2012 from Part VI, line 5 . . . . . . . 2a

b Income tax for 2012. (This does not include the tax from Part VI.) . . . 2b

c Add lines 2a and 2b . . . . . . . . . . . . . . . . . . . . . . . . . . 2c

3 Distributable amount before adjustments. Subtract line 2c from line 1 . . . . . . . . . . 3

4 Recoveries of amounts treated as qualifying distributions . . . . . . . . . . . . . . 4

5 Add lines 3 and 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

6 Deduction from distributable amount (see instructions) . . . . . . . . . . . . . . . 6

7 Distributable amount as adjusted. Subtract line 6 from line 5. Enter here and on Part XIII,

line 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Part XII Qualifying Distributions (see instructions)

1 Amounts paid (including administrative expenses) to accomplish charitable, etc., purposes:

a Expenses, contributions, gifts, etc.—total from Part I, column (d), line 26 . . . . . . . . . 1a

b Program-related investments—total from Part IX-B . . . . . . . . . . . . . . . . 1b

2 Amounts paid to acquire assets used (or held for use) directly in carrying out charitable, etc., 

purposes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

3 Amounts set aside for specific charitable projects that satisfy the:

a Suitability test (prior IRS approval required) . . . . . . . . . . . . . . . . . . . 3a

b Cash distribution test (attach the required schedule) . . . . . . . . . . . . . . . . 3b

4 Qualifying distributions. Add lines 1a through 3b. Enter here and on Part V, line 8, and Part XIII, line 4 4

5 Foundations that qualify under section 4940(e) for the reduced rate of tax on net investment income. 

Enter 1% of Part I, line 27b (see instructions) . . . . . . . . . . . . . . . . . . 5

6 Adjusted qualifying distributions. Subtract line 5 from line 4 . . . . . . . . . . . . 6

Note. The amount on line 6 will be used in Part V, column (b), in subsequent years when calculating whether the foundation

qualifies for the section 4940(e) reduction of tax in those years.

Form 990-PF (2012) 
Form 990-PF (2012) Page 9 

Part XIII Undistributed Income (see instructions)

(a) 

Corpus

(b) 

Years prior to 2011

(c) 

2011

(d) 

2012 1 Distributable amount for 2012 from Part XI, 

line 7 . . . . . . . . . . . . .

2 Undistributed income, if any, as of the end of 2012:

a Enter amount for 2011 only . . . . . .

b Total for prior years: 20 ,20 ,20

3 Excess distributions carryover, if any, to 2012:

a From 2007 . . . . . .

b From 2008 . . . . . .

c From 2009 . . . . . .

d From 2010 . . . . . .

e From 2011 . . . . . .

f Total of lines 3a through e . . . . . .

4 Qualifying distributions for 2012 from Part XII, 

line 4: ▶ $

a Applied to 2011, but not more than line 2a .

b Applied to undistributed income of prior years 

(Election required—see instructions) . . .

c Treated as distributions out of corpus (Election 

required—see instructions) . . . . . .

d Applied to 2012 distributable amount . .

e Remaining amount distributed out of corpus 

5 Excess distributions carryover applied to 2012

(If an amount appears in column (d), the same 

amount must be shown in column (a).)

6 Enter the net total of each column as 

indicated below:

a Corpus. Add lines 3f, 4c, and 4e. Subtract line 5

b Prior years’ undistributed income. Subtract 

line 4b from line 2b . . . . . . . .

c Enter the amount of prior years’ undistributed 

income for which a notice of deficiency has 

been issued, or on which the section 4942(a) 

tax has been previously assessed . . . .

d Subtract line 6c from line 6b. Taxable 

amount—see instructions . . . . . .

e Undistributed income for 2011. Subtract line 

4a from line 2a. Taxable amount—see 

instructions . . . . . . . . . . .

f Undistributed income for 2012. Subtract lines 

4d and 5 from line 1. This amount must be 

distributed in 2013 . . . . . . . . .

7 Amounts treated as distributions out of corpus 

to satisfy requirements imposed by section 

170(b)(1)(F) or 4942(g)(3) (see instructions) .

8 Excess distributions carryover from 2007 not 

applied on line 5 or line 7 (see instructions) .

9 Excess distributions carryover to 2013. 

Subtract lines 7 and 8 from line 6a . . .

10 Analysis of line 9:

a Excess from 2008 . . . .

b Excess from 2009 . . . .

c Excess from 2010 . . . .

d Excess from 2011 . . . .

e Excess from 2012 . . . .

Form 990-PF (2012) 
Form 990-PF (2012) Page 10 

Part XIV Private Operating Foundations (see instructions and Part VII-A, question 9)

1a If the foundation has received a ruling or determination letter that it is a private operating 

foundation, and the ruling is effective for 2012, enter the date of the ruling . . . . . . ▶

b Check box to indicate whether the foundation is a private operating foundation described in section 4942(j)(3) or 4942(j)(5)

Tax year Prior 3 years

(a) 2012 (b) 2011 (c) 2010 (d) 2009

(e) Total 2a Enter the lesser of the adjusted net 

income from Part I or the minimum 

investment return from Part X for 

each year listed . . . . . . .

b 85% of line 2a . . . . . . .

c Qualifying distributions from Part XII, 

line 4 for each year listed . . . .

d Amounts included in line 2c not used directly 

for active conduct of exempt activities . .

e Qualifying distributions made directly 

for active conduct of exempt activities. 

Subtract line 2d from line 2c . . .

3 Complete 3a, b, or c for the 

alternative test relied upon:

a “Assets” alternative test—enter:

(1) Value of all assets . . . . .

(2) Value of assets qualifying under 

section 4942(j)(3)(B)(i) . . . .

b “Endowment” alternative test—enter 2/3

of minimum investment return shown in 

Part X, line 6 for each year listed . . .

c “Support” alternative test—enter:

(1) Total support other than gross 

investment income (interest, 

dividends, rents, payments on 

securities loans (section 

512(a)(5)), or royalties) . . . .

(2) Support from general public 

and 5 or more exempt 

organizations as provided in 

section 4942(j)(3)(B)(iii) . . . .

(3) Largest amount of support from 

an exempt organization . . .

(4) Gross investment income . . .

Part XV Supplementary Information (Complete this part only if the foundation had $5,000 or more in assets at 

any time during the year—see instructions.)

1 Information Regarding Foundation Managers:

a List any managers of the foundation who have contributed more than 2% of the total contributions received by the foundation

before the close of any tax year (but only if they have contributed more than $5,000). (See section 507(d)(2).)

b List 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.

2 Information Regarding Contribution, Grant, Gift, Loan, Scholarship, etc., Programs:

Check here ▶ if the foundation only makes contributions to preselected charitable organizations and does not accept 

unsolicited requests for funds. If the foundation makes gifts, grants, etc. (see instructions) to individuals or organizations under 

other conditions, complete items 2a, b, c, and d.

a The name, address, and telephone number or e-mail of the person to whom applications should be addressed:

b The form in which applications should be submitted and information and materials they should include:

c Any submission deadlines:

d Any restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other 

factors:

Form 990-PF (2012) 
Form 990-PF (2012) Page 11 

Part XV Supplementary Information (continued)

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

Recipient

Name and address (home or business)

If recipient is an individual, 

show any relationship to 

any foundation manager 

or substantial contributor

Foundation 

status of 

recipient

Purpose of grant or 

contribution Amount

a Paid during the year 

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ▶ 3a

b Approved for future payment

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ▶ 3b

Form 990-PF (2012) 
Form 990-PF (2012) Page 12 

Part XVI-A Analysis of Income-Producing Activities

Enter gross amounts unless otherwise indicated. Unrelated business income Excluded by section 512, 513, or 514

(a) 

Business code

(b) 

Amount

(c) 

Exclusion code

(d) 

Amount

(e) 

Related or exempt

function income

(See instructions.) 1 Program service revenue:

a

b

c

d

e

f

g Fees and contracts from government agencies

2 Membership dues and assessments . . . .

3 Interest on savings and temporary cash investments

4 Dividends and interest from securities . . . .

5 Net rental income or (loss) from real estate:

a Debt-financed property . . . . . . .

b Not debt-financed property . . . . . .

6 Net rental income or (loss) from personal property

7 Other investment income . . . . . . . .

8 Gain or (loss) from sales of assets other than inventory

9 Net income or (loss) from special events . . .

10 Gross profit or (loss) from sales of inventory . .

11 Other revenue: a

b

c

d

e

12 Subtotal. Add columns (b), (d), and (e) . . . .

13 Total. Add line 12, columns (b), (d), and (e) . . . . . . . . . . . . . . . . . . 13

(See worksheet in line 13 instructions to verify calculations.)

Part XVI-B Relationship of Activities to the Accomplishment of Exempt Purposes

Line No. 

▼

Explain below how each activity for which income is reported in column (e) of Part XVI-A contributed importantly to the 

accomplishment of the foundation’s exempt purposes (other than by providing funds for such purposes). (See instructions.)

Form 990-PF (2012) 
Form 990-PF (2012) Page 13 

Part XVII Information Regarding Transfers To and Transactions and Relationships With Noncharitable 

Exempt Organizations

1 Did the organization directly or indirectly engage in any of the following with any other organization described 

in section 501(c) of the Code (other than section 501(c)(3) organizations) or in section 527, relating to political 

organizations? 

Yes No

a Transfers from the reporting foundation to a noncharitable exempt organization of:

(1) Cash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1a(1)

(2) Other assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1a(2)

b Other transactions:

(1) Sales of assets to a noncharitable exempt organization . . . . . . . . . . . . . . . . 1b(1)

(2) Purchases of assets from a noncharitable exempt organization . . . . . . . . . . . . . . 1b(2)

(3) Rental of facilities, equipment, or other assets . . . . . . . . . . . . . . . . . . . 1b(3)

(4) Reimbursement arrangements . . . . . . . . . . . . . . . . . . . . . . . . . 1b(4)

(5) Loans or loan guarantees . . . . . . . . . . . . . . . . . . . . . . . . . . 1b(5)

(6) Performance of services or membership or fundraising solicitations . . . . . . . . . . . . 1b(6)

c Sharing of facilities, equipment, mailing lists, other assets, or paid employees . . . . . . . . . . 1c

d If the answer to any of the above is “Yes,” complete the following schedule. Column (b) should always show the fair market 

value of the goods, other assets, or services given by the reporting foundation. If the foundation received less than fair market 

value in any transaction or sharing arrangement, show in column (d) the value of the goods, other assets, or services received.

(a) Line no. (b) Amount involved (c) Name of noncharitable exempt organization (d) Description of transfers, transactions, and sharing arrangements

2a Is the foundation directly or indirectly affiliated with, or related to, one or more tax-exempt organizations

described in section 501(c) of the Code (other than section 501(c)(3)) or in section 527? . . . . . . . Yes No

b If “Yes,” complete the following schedule.

(a) Name of organization (b) Type of organization (c) Description of relationship

Sign 

Here

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, 

▲

correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

Signature of officer or trustee Date

▲

Title

May the IRS discuss this return 

with the preparer shown below 

(see instructions)? Yes No 

Paid 

Preparer 

Use Only

Print/Type preparer’s name Preparer's signature Date Check if 

self-employed

PTIN

Firm’s name ▶

Firm's address ▶

Firm's EIN ▶

Phone no.

Form 990-PF (2012)