Return of Private Foundation OMB No. 1545-0052

Form 990-PF or Section 4947(a)(1) Nonexempt Charitable Trust

Treated as a Private Foundation

Department of the Treasury

Internal Revenue Service Note: The organization may be able to use a copy of this return to satisfy state reporting requirements.

For calendar year 2004, or tax year beginning , 2004, and ending , 20

Name of organization A Use the IRS

label.

Otherwise,

print

or type.

See Specific

Instructions.

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

City or town, state, and ZIP code C If exemption application is pending, check here 

D 1. Foreign organizations, check here 

H Check type of organization:

E If private foundation status was terminated

under section 507(b)(1)(A), check here 

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

I Fair market value of all assets at end J Accounting method: Cash Accrual

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

line 16)  $ F If the foundation is in a 60-month termination

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

Other (specify)

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

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 page 11 of the instructions).)

(d) Disbursements

for charitable

purposes

(cash basis only)

(a) Revenue and

expenses per

books

(c) Adjusted net

income

(b) Net investment

income

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

2

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

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

Revenue

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 page 14 of the instructions)

19 Depreciation (attach schedule) and depletion

20 Occupancy

21 Travel, conferences, and meetings

22 Printing and publications

23 Other expenses (attach schedule)

Total operating and administrative expenses.

Add lines 13 through 23

24

25 Contributions, gifts, grants paid

Operating and Administrative Expenses

26 Total expenses and disbursements. Add lines 24 and 25

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 Privacy Act and Paperwork Reduction Act Notice, see the instructions. Cat. No. 11289X

Employer identification number

Telephone number (see page 10 of the instructions)

Part I

Form 990-PF (2004)

2. Foreign organizations meeting the 85% test,

check here and attach computation 

Room/suite

27 Subtract line 26 from line 12:

( )

Section 501(c)(3) exempt private foundation

G Check all that apply: Initial return Final return Amended return Address change Name change

b Gross sales price for all assets on line 6a

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

2004
Form 990-PF (2004) Page 2

Attached schedules and amounts in the description column Beginning of year End of year Balance Sheets should be for end-of-year amounts only. (See instructions.) (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 page 15 of the

instructions)

7 Other notes and loans receivable (attach schedule) 

Less: allowance for doubtful accounts 

8 Inventories for sale or use

Assets

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  )

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

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

16

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)

Liabilities

22 Other liabilities (describe  )

23 Total liabilities (add lines 17 through 22)

Organizations that follow SFAS 117, check here 

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

24 Unrestricted

Temporarily restricted

Permanently restricted

25

26

27

Organizations that do not follow SFAS 117, check here 

and complete lines 27 through 31.

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

Net Assets or Fund Balances

Total net assets or fund balances (see page 17 of the

instructions)

31 Total liabilities and net assets/fund balances (see page 17 of

the instructions)

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

Part III

Part II

Form 990-PF (2004)
Form 990-PF (2004) 

Capital Gains and Losses for Tax on Investment Income

(b) How acquired

P—Purchase

D—Donation

(c) Date acquired

(mo., day, yr.)

(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.)

1a

(h) Gain 

(e) plus (f) 

(f) Depreciation allowed

(or allowable) (e) Gross sales price (g) Cost or other basisplus expense of sale

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

col. (k), but not le

Losses (fro

(k) Excess of col. (i)

over col. (j), if any

(j) Adjusted basis

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

If gain, also enter in Part I, line 7 2 Capital gain net income or (net capital loss) 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 pages 13 and 17 of the instructions).

If (loss), enter -0- in Part I, line 8 3

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 organization liable for the section 4942 tax on the distributable amount of any year in the base period? 

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

1 Enter the appropriate amount in each column for each year; see page 18 of the instructions before making 

(a)

Base period years

Calendar year (or tax year beginning in)

Distri

(col. (b) div

(b)

Adjusted qualifying distributions

(c)

Net value of noncharitable-use assets

2003

2002

2001

2000

1999

2 Total of line 1, column (d) 2

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

3

4 Enter the net value of noncharitable-use assets for 2004 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% 

Part VI instructions on page 18.

Part V

Part IV

 



b

c

d

e

a

b

c

d

e

a

b

c

d

e
Part VII-A

Form 990-PF (2004) Page 4

Excise Tax Based on Investment Income (Section 4940(a), 4940(b), 4940(e), or 4948—see page 18 of the instructions)

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

Date of ruling letter: (attach copy of ruling letter if necessary–see instructions)

Domestic organizations that meet the section 4940(e) requirements in Part V, check 1

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

b

c All other domestic organizations enter 2% of line 27b. Exempt foreign organizations enter 4% of Part I, line 12, col. (b)

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 2004 estimated tax payments and 2003 overpayment credited to 2004 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 2005 estimated tax  Refunded  11

Statements Regarding Activities

No During the tax year, did the organization attempt to influence any national, state, or local legislation or did

it participate or intervene in any political campaign?

1a

1a

1b

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

19 of the instructions for definition)?

b

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 organization in connection with the activities.

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

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

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

Has the organization 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

3

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

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

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

Enter the states to which the foundation reports or with which it is registered (see page 19 of the

instructions) 

8a

If the answer is “Yes” to line 7, has the organization 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

b

8b

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

or 4942(j)(5) for calendar year 2004 or the taxable year beginning in 2004 (see instructions for Part XIV on

page 25)? 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.

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

Yes

Part VI



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

The books are in care of  Telephone no. 

Located at  ZIP+4 

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 

11

12

13

13

10

11

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

(1) On the organization.  $ (2) On organization managers.  $

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

on organization managers.  $

e

Form 990-PF (2004)

Web site address 
Form 990-PF (2004) Page 5

Statements Regarding Activities for Which Form 4720 May Be Required

Yes No

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 page 20 of the instructions)?

b

1b

Did the organization 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 2004?

c

1c

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

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

At the end of tax year 2004, did the organization have any undistributed income (lines 6d

and 6e, Part XIII) for tax year(s) beginning before 2004?

a

Are there any years listed in 2a for which the organization 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 page 20 of the instructions.)

b

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.

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

enterprise at any time during the year?

If “Yes,” did it have excess business holdings in 2004 as a result of (1) any purchase by the organization

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 organization had excess business holdings in 2004.)

b

3b

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

b Did the organization 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 2004? 4b

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

(1) Carry on propaganda, or otherwise attempt to influence legislation (section 4945(e))?

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

on, directly or indirectly, any voter registration drive?

(2)

(3) Provide a grant to an individual for travel, study, or other similar purposes?

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)?

(4)

Provide for any purpose other than religious, charitable, scientific, literary, or

educational purposes, or for the prevention of cruelty to children or animals?

(5)

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 page 20 of the instructions)?

b

5b

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

tax because it maintained expenditure responsibility for the grant?

c

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

Part VII-B



1a

File Form 4720 if any item is checked in the “Yes” column, unless an exception applies.

(1)

(2)

(3)

(4)

(5)

(6)

Engage in the sale or exchange, or leasing of property with a disqualified person?

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

a disqualified person?

Furnish goods, services, or facilities to (or accept them from) a disqualified person?

Pay compensation to, or pay or reimburse the expenses of, a disqualified person?

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

for the benefit or use of a disqualified person)?

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

if the organization agreed to make a grant to or to employ the official for a period

after termination of government service, if terminating within 90 days.)

During the year did the organization (either directly or indirectly):

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

If “Yes,” list the years 

Organizations relying on a current notice regarding disaster assistance check here 

Organizations relying on a current notice regarding disaster assistance check here 

20 , 20 , 20 , 20

20 , 20 , 20 , 20

Form 990-PF (2004)

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

premiums on a personal benefit contract? Yes No

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

If you answered “Yes” to 6b, also file Form 8870.
Form 990-PF (2004) Page 6

Compensation of five highest-paid employees (other than those included on line 1—see page 21 of the instructions).

If none, enter “NONE.”

2

(d) Contributions to

employee benefit

plans and deferred

compensation

(e) Expense account,

other allowances

(b) Title and average

hours per week

devoted to position

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

Total number of other employees paid over $50,000 

Five highest-paid independent contractors for professional services—(see page 21 of the instructions). If none, enter

“NONE.”

3

(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

Expenses 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.

1

2

3

4

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

and Contractors

1 List all officers, directors, trustees, foundation managers and their compensation (see page 20 of the instructions).

(c) Compensation 

(If not paid, enter 

-0-)

(d) Contributions to

employee benefit plans

and deferred compensation

(b) Title, and average

hours per week

devoted to position

(e) Expense account,

other allowances (a) Name and address

Part VIII

Form 990-PF (2004)
Form 990-PF (2004) Page 7

Qualifying Distributions (see page 23 of the 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 4

5

5

6

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

6

Organizations that qualify under section 4940(e) for the reduced rate of tax on net investment

income. Enter 1% of Part I, line 27b (see page 24 of the instructions)

Adjusted qualifying distributions. Subtract line 5 from line 4

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.

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

see page 22 of the instructions.)

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

purposes:

1

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 page 22 of the instructions) 1c

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

1e

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

1c (attach detailed explanation)

e

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 11⁄2% of line 3 (for greater amount, see page 23

of the 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

Distributable Amount (see page 23 of the 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 2004 from Part VI, line 5 2a

b Income tax for 2004. (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 page 23 of the instructions) 6

7

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

line 1

7

Part X

Part XI

Part XII

Part IX-B Summary of Program-Related Investments (see page 22 of the instructions)

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

1

2

3

Form 990-PF (2004)

All other program-related investments. See page 22 of the instructions.

Total. Add lines 1 through 3 
Form 990-PF (2004) Page 8

Undistributed Income (see page 24 of the instructions)

(d)

2004

(c)

2003

(b)

Years prior to 2003

(a)

Corpus 1 Distributable amount for 2004 from Part XI,

line 7

2 Undistributed income, if any, as of the end of 2003:

a Enter amount for 2003 only

b Total for prior years: 20 ,20 ,20

3 Excess distributions carryover, if any, to 2004:

a From 1999

b

c

From 2000

From 2001

d

e

From 2002

f Total of lines 3a through e

4 Qualifying distributions for 2004 from Part

XII, line 4:  $

a Applied to 2003, but not more than line 2a

Applied to undistributed income of prior years

(Election required—see page 24 of the instructions)

b

Treated as distributions out of corpus (Election

required—see page 24 of the instructions)

c

d Applied to 2004 distributable amount

e Remaining amount distributed out of corpus

5 Excess distributions carryover applied to 2004

6 Enter the net total of each column as

indicated below:

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

Prior years’ undistributed income. Subtract

line 4b from line 2b

b

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

c

Subtract line 6c from line 6b. Taxable

amount—see page 25 of the instructions

d

Undistributed income for 2003. Subtract line

4a from line 2a. Taxable amount—see page

25 of the instructions

e

Undistributed income for 2004. Subtract

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

be distributed in 2005

f

7 Amounts treated as distributions out of

corpus to satisfy requirements imposed by

section 170(b)(1)(E) or 4942(g)(3) (see page

25 of the instructions)

8 Excess distributions carryover from 1999 not

applied on line 5 or line 7 (see page 25 of

the instructions)

9 Excess distributions carryover to 2005.

Subtract lines 7 and 8 from line 6a

10 Analysis of line 9:

Excess from 2004

a Excess from 2000

b Excess from 2001

c

d

Excess from 2002

Excess from 2003

e

From 2003

Part XIII

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

same amount must be shown in column (a). )

Form 990-PF (2004)
Form 990-PF (2004) Page 9

Private Operating Foundations (see page 25 of the instructions and Part VII-A, question 9)

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

foundation, and the ruling is effective for 2004, enter the date of the ruling 

1a

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

Enter the lesser of the adjusted net

income from Part I or the minimum

investment return from Part X for each

year listed

2a Tax year Prior 3 years (e) Total

(a) 2004 (b) 2003 (c) 2002 (d) 2001

b 85% of line 2a

Qualifying distributions from Part XII,

line 4 for each year listed

c

d Amounts included in line 2c not used directly

for active conduct of exempt activities

e

Complete 3a, b, or c for the

alternative test relied upon:

3

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)

(4) Gross investment income

Supplementary Information (Complete this part only if the organization had $5,000 or more in

assets at any time during the year—see page 26 of the instructions.)

1 Information Regarding Foundation Managers:

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).)

a

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.

b

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

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

unsolicited requests for funds. If the organization makes gifts, grants, etc. (see page 26 of the instructions) to individuals or

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

a The name, address, and telephone number 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:

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

factors:

d

Qualifying distributions made directly

for active conduct of exempt activities.

Subtract line 2d from line 2c

Largest amount of support

from an exempt organization

Part XIV

Part XV

Form 990-PF (2004)
Form 990-PF (2004) Page 10

Supplementary Information (continued)

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

If recipient is an individual,

show any relationship to

any foundation manager 

or substantial contributor

Foundation

status of

recipient

Recipient Purpose of grant or

contribution Amount

Name and address (home or business)

a Paid during the year

Total  3a

b Approved for future payment

3b

Total 

Part XV

Form 990-PF (2004)
Form 990-PF (2004) Page 11

Unrelated business income Excluded by section 512, 513, or 514 (e) Enter gross amounts unless otherwise indicated. Related or exempt

function income

(See page 26 of

the instructions.)

(a) (b) (c) (d)

Business code Amount Exclusion code Amount

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:

Debt-financed property

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

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

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

(See worksheet in line 13 instructions on page 26 to verify calculations.)

Relationship of Activities to the Accomplishment of Exempt Purposes

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

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

page 27 of the instructions.)

Line No.



Part XVI-A

Part XVI-B

a

b

c

d

e

b

13

Analysis of Income-Producing Activities

Form 990-PF (2004)
Form 990-PF (2004) Page 12

Information Regarding Transfers To and Transactions and Relationships With Noncharitable

Exempt Organizations

Yes No 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?

1

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

Cash 1a(1) (1)

Other assets 1a(2) (2)

b Other transactions:

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

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

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

Reimbursement arrangements 1b(4) (4)

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

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

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

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 organization. If the organization 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.

d

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

Is the organization 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?

2a

Yes No

b If “Yes,” complete the following schedule.

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

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 or fiduciary) is based on all information of which preparer has any knowledge.

Signature of officer or trustee Date  Title

Date Preparer’s SSN or PTIN

Preparer’s

signature

Check if

self-employed 

Firm’s name (or yours if

self-employed), address,

and ZIP code

Paid

Preparer’s

Use Only

EIN 

Sign Here

Phone no. ( )

Part XVII







(1)

(2)

Form 990-PF (2004)

(See Signature on page 28

of the instructions.)