990-PF Return of Private Foundation or Section 4947(a)(1) Trust

Form

990-PF

Department of the Treasury
Internal Revenue Service

Return of Private Foundation

OMB No. 1545-0047

2021

or Section 4947(a)(1) Trust Treated as Private Foundation
▶ Do

not enter social security numbers on this form as it may be made public.
▶ Go to www.irs.gov/Form990PF for instructions and the latest information.

For calendar year 2021 or tax year beginning

, 20

A Employer identification number

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

Open to Public Inspection

, 2021, and ending

Room/suite

B Telephone number (see instructions)

City or town, state or province, country, and ZIP or foreign postal code

C If exemption application is pending, check here ▶

G Check all that apply:

D 1. Foreign organizations, check here .

Initial return
Initial return of a former public charity
Amended return
Final return
Address change
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
J Accounting method:
I Fair market value of all assets at
Cash
Accrual
end of year (from Part II, col. (c),
Other (specify)
line 16) ▶ $
(Part I, column (d), must be on cash basis.)

Operating and Administrative Expenses

Revenue

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).)

(a) Revenue and
expenses per
books

.

.

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
. .

(b) Net investment
income

(c) Adjusted net
income

▶

(d) Disbursements
for charitable
purposes
(cash basis only)

1
2
3
4
5a
b
6a
b
7
8
9
10a
b
c
11
12
13
14
15
16a
b
c
17
18
19
20
21
22
23
24

Contributions, gifts, grants, etc., received (attach schedule)
Check ▶
if the foundation is not required to attach Sch. B
Interest on savings and temporary cash investments
Dividends and interest from securities . . . .
Gross rents . . . . . . . . . . . . .
Net rental income or (loss)
Net gain or (loss) from sale of assets not on line 10
Gross sales price for all assets on line 6a
Capital gain net income (from Part IV, line 2) . .
Net short-term capital gain . . . . . . . .
Income modifications
. . . . . . . . .
Gross sales less returns and allowances
Less: Cost of goods sold . . .
Gross profit or (loss) (attach schedule) . . . .
Other income (attach schedule) . . . . . .
Total. Add lines 1 through 11 . . . . . . .
Compensation of officers, directors, trustees, etc.
Other employee salaries and wages . . . . .
Pension plans, employee benefits
. . . . .
Legal fees (attach schedule) . . . . . . .
Accounting fees (attach schedule) . . . . .
Other professional fees (attach schedule) . . .
Interest . . . . . . . . . . . . . .
Taxes (attach schedule) (see instructions) . . .
Depreciation (attach schedule) and depletion . .
Occupancy . . . . . . . . . . . . .
Travel, conferences, and meetings . . . . .
Printing and publications . . . . . . . .
Other expenses (attach schedule)
. . . . .
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 (2021)

Page 2

Form 990-PF (2021)

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
(a) Book Value

End of year
(b) Book Value

(c) Fair Market Value

Net Assets or Fund Balances

Liabilities

Assets

1
2
3

Cash—non-interest-bearing . . . . . . . . . . .
Savings and temporary cash investments . . . . . . .
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) ▶
Other assets (describe ▶
15
)
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) . . .
Other liabilities (describe ▶
22
)
23
Total liabilities (add lines 17 through 22) . . . . . . .

24
25

26
27
28
29
30

Part III

Foundations that follow FASB ASC 958, check here ▶
and complete lines 24, 25, 29, and 30.
Net assets without donor restrictions . . . . . . . .
Net assets with donor restrictions
. . . . . . . . .
Foundations that do not follow FASB ASC 958, check here ▶
and complete lines 26 through 30.
Capital stock, trust principal, or current funds . . . . . .
Paid-in or capital surplus, or land, bldg., and equipment fund
Retained earnings, accumulated income, endowment, or other funds
Total net assets or fund balances (see instructions) . . .
Total liabilities and net assets/fund balances (see
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 29 (must agree
end-of-year figure reported on prior year’s return) . . . . . . . . . . . . . . . .
2 Enter amount from Part I, line 27a . . . . . . . . . . . . . . . . . . . . .
3 Other increases not included in line 2 (itemize) ▶
4 Add lines 1, 2, and 3 . . . . . . . . . . . . . . . . . . . . . . . . . .
5 Decreases not included in line 2 (itemize) ▶
6 Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 29 .

with
.
.
.
.

1
2
3
4
5
6
Form 990-PF (2021)

Page 3

Form 990-PF (2021)

Part IV

Capital Gains and Losses for Tax on Investment Income
(a) List and describe the kind(s) of property sold (for example, 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) FMV as of 12/31/69

(j) Adjusted basis
as of 12/31/69

a
b
c
d
e

{

(l) Gains (Col. (h) gain minus
col. (k), but not less than -0-) or
Losses (from col. (h))

(k) Excess of col. (i)
over col. (j), if any

If gain, also enter in Part I, line 7
If (loss), enter -0- in Part I, line 7

}

2

Capital gain net income or (net capital loss)

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 . . . . . . . . . . . . . . . . . . . . . . . .

}

Part V
1a

2

3

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

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 All other domestic foundations enter 1.39% (0.0139) of line 27b. Exempt foreign organizations,
enter 4% (0.04) of Part I, line 12, col. (b) . . . . . . . . . . . . . . . . . . .

2
3
4
5
6

}

Tax under section 511 (domestic section 4947(a)(1) trusts and taxable foundations only; others, enter -0-)
Add lines 1 and 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Subtitle A (income) tax (domestic section 4947(a)(1) trusts and taxable foundations only; others, enter -0-)
Tax based on investment income. Subtract line 4 from line 3. If zero or less, enter -0- . . . . .
Credits/Payments:
a 2021 estimated tax payments and 2020 overpayment credited to 2021 . .
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 . . . . . . . . . . . . . . . .
8
Enter any penalty for underpayment of estimated tax. Check here
if Form 2220 is attached
9
Tax due. If the total of lines 5 and 8 is more than line 7, enter amount owed . . . . . . . ▶
10
Overpayment. If line 7 is more than the total of lines 5 and 8, enter the amount overpaid . . . ▶
11
Enter the amount of line 10 to be: Credited to 2022 estimated tax ▶
Refunded ▶

1

2
3
4
5

7
8
9
10
11
Form 990-PF (2021)

Page 4

Form 990-PF (2021)

Part VI-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? . . . . . . . . . . . . . . . . . . .
b Did it spend more than $100 during the year (either directly or indirectly) for political purposes? See the
instructions for the definition . . . . . . . . . . . . . . . . . . . . . . . . . .
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? . . . . . . . . . . . . . . . . . .
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? . . . .
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 .
4a Did the foundation have unrelated business gross income of $1,000 or more during the year? . . . .
b If “Yes,” has it filed a tax return on Form 990-T for this year? . . . . . . . . . . . . . . .
5
Was there a liquidation, termination, dissolution, or substantial contraction during the year? . . . .
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
conflict with the state law remain in the governing instrument? . . . . . . . . . . . . . .
7
8a

.
.
.

10
11
12
13
14
15
16

1b

1c

2

3
4a
4b
5

that
.

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 XIV
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 . . . . .
9

Yes No
1a

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 2021 or the tax year beginning in 2021? See the instructions for Part XIII. If “Yes,”
complete Part XIII . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Did any persons become substantial contributors during the tax year? If “Yes,” attach a schedule listing their
names and addresses . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
At any time during the year, did the foundation, directly or indirectly, own a
meaning of section 512(b)(13)? If “Yes,” attach schedule. See instructions . .
Did the foundation make a distribution to a donor advised fund over which the
person had advisory privileges? If “Yes,” attach statement. See instructions . .

controlled entity within the
. . . . . . . . .
foundation or a disqualified
. . . . . . . . .

Did the foundation comply with the public inspection requirements for its annual returns and exemption application?
Website address ▶
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 . . . . . ▶ 15
At any time during calendar year 2021, 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?. . . . . . . . . . . . .
See the instructions for exceptions and filing requirements for FinCEN Form 114. If “Yes,” enter the name of
the foreign country ▶

8b

9
10
11
12
13

.

.

.
Yes

▶

No

16

Form 990-PF (2021)

Page 5

Form 990-PF (2021)

Part VI-B

Statements Regarding Activities for Which Form 4720 May Be Required

Yes
File Form 4720 if any item is checked in the “Yes” column, unless an exception applies.
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?
. . . . . . .
1a(1)
(2) Borrow money from, lend money to, or otherwise extend credit to (or accept it from) a disqualified
person? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1a(2)
(3) Furnish goods, services, or facilities to (or accept them from) a disqualified person? . . . . . . .
1a(3)
(4) Pay compensation to, or pay or reimburse the expenses of, a disqualified person? . . . . . . .
1a(4)
(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)? . . . . . . . . . . . . . . . . . . . . . . . . .
1a(5)
(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.)
. . . . . . . . . . . . . . . . . . . . . . . . .
1a(6)
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
▶
c Organizations relying on a current notice regarding disaster assistance, check here . . . . . .
d 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 2021?
. . . . . . . . . . .
1d
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 2021, did the foundation have any undistributed income (Part XII, lines 6d and 6e) for
tax year(s) beginning before 2021? . . . . . . . . . . . . . . . . . . . . . . . .
2a
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?
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3a

No

1a

b If “Yes,” did it have excess business holdings in 2021 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 Form 4720, Schedule C, to determine if the
foundation had excess business holdings in 2021.) . . . . . . . . . . . . . . . . . . .
4a Did the foundation invest during the year any amount in a manner that would jeopardize its charitable purposes?
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 2021?

3b
4a
4b

Form 990-PF (2021)

Page 6

Form 990-PF (2021)

Part VI-B
5a

b
c
d

6a
b
7a
b
8

Yes
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))? . . . . . .
5a(1)
(2) Influence the outcome of any specific public election (see section 4955); or to carry on, directly or
indirectly, any voter registration drive? . . . . . . . . . . . . . . . . . . . . . .
5a(2)
(3) Provide a grant to an individual for travel, study, or other similar purposes? . . . . . . . . . .
5a(3)
(4) Provide a grant to an organization other than a charitable, etc., organization described in section 4945(d)
(4)(A)? See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . .
5a(4)
(5) Provide for any purpose other than religious, charitable, scientific, literary, or educational purposes, or for
the prevention of cruelty to children or animals? . . . . . . . . . . . . . . . . . . .
5a(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 instructions . .
5b
▶
Organizations relying on a current notice regarding disaster assistance, check here . . . . . .
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? . . . . . . . . . . . . . . . . . . .
5d
If “Yes,” attach the statement required by Regulations section 53.4945-5(d).
Did the foundation, during the year, receive any funds, directly or indirectly, to pay premiums on a personal
benefit contract? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6a
Did the foundation, during the year, pay premiums, directly or indirectly, on a personal benefit contract? .
6b
If “Yes” to 6b, file Form 8870.
At any time during the tax year, was the foundation a party to a prohibited tax shelter transaction?
7a
If “Yes,” did the foundation receive any proceeds or have any net income attributable to the transaction? .
7b
Is the foundation subject to the section 4960 tax on payment(s) of more than $1,000,000 in remuneration or
excess parachute payment(s) during the year? . . . . . . . . . . . . . . . . . . . . .
8

Part VII
1

Statements Regarding Activities for Which Form 4720 May Be Required (continued)

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

List all officers, directors, trustees, and foundation managers and their compensation. See instructions.
(a) Name and address

2

No

(b) Title, and average
hours per week
devoted to position

(c) Compensation
(If not paid,
enter -0-)

(d) Contributions to
(e) Expense account,
employee benefit plans
other allowances
and deferred compensation

Compensation of five highest-paid employees (other than those included on line 1—see instructions). If none, enter
“NONE.”
(b) Title, and average
hours per week
devoted to position

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

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

.

.

.

.

.

.

.

.

.

(d) Contributions to
employee benefit (e) Expense account,
plans and deferred
other allowances
compensation

(c) Compensation

.

.

.

.

.

.

.

.

.

.

▶
Form 990-PF (2021)

Page 7

Form 990-PF (2021)

Part VII
3

Information About Officers, Directors, Trustees, Foundation Managers, Highly Paid Employees,
and Contractors (continued)

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

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

Part VIII-A

.

.

.

.

.

.

.

.

.

.

.

(c) Compensation

.

.

▶

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 VIII-B

Summary of Program-Related Investments (see instructions)
Amount

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

1

2

All other program-related investments. See instructions.

3

Total. Add lines 1 through 3 .

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▶
Form 990-PF (2021)

Page 8

Form 990-PF (2021)

Part IX
1

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

Fair market value of assets not used (or held for use) directly in carrying out charitable, etc.,
purposes:
a
b
c
d
e

2
3
4
5
6

Average monthly fair market value of securities . . . . . . . . . . . . .
Average of monthly cash balances . . . . . . . . . . . . . . . . .
Fair market value of all other assets (see instructions) . . . . . . . . . . .
Total (add lines 1a, b, and c) . . . . . . . . . . . . . . . . . . .
Reduction claimed for blockage or other factors reported on lines 1a and
1c (attach detailed explanation) . . . . . . . . . . . . . . .
1e
Acquisition indebtedness applicable to line 1 assets . . . . . . . . . . . .
Subtract line 2 from line 1d . . . . . . . . . . . . . . . . . . . .
Cash deemed held for charitable activities. Enter 1.5% (0.015) of line 3 (for greater
instructions) . . . . . . . . . . . . . . . . . . . . . . . . .
Net value of noncharitable-use assets. Subtract line 4 from line 3 . . . . . .
Minimum investment return. Enter 5% (0.05) of line 5 . . . . . . . . . . .

Part X
1
2a
b
c
3
4
5
6
7

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.
.
.

.
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.
.

. . .
. . .
amount,
. . .
. . .
. . .

.
.
.
.

.
.
see
.
.
.

1a
1b
1c
1d

2
3
4
5
6

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.)

Minimum investment return from Part IX, line 6 . . . . . . .
Tax on investment income for 2021 from Part V, line 5 . . . . .
Income tax for 2021. (This does not include the tax from Part V.)
.
Add lines 2a and 2b . . . . . . . . . . . . . . . .
Distributable amount before adjustments. Subtract line 2c from line 1
Recoveries of amounts treated as qualifying distributions . . . .
Add lines 3 and 4 . . . . . . . . . . . . . . . . .
Deduction from distributable amount (see instructions) . . . . .
Distributable amount as adjusted. Subtract line 6 from line 5.
line 1 . . . . . . . . . . . . . . . . . . . . .

Part XI

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Enter
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2a
2b
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here
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and
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on
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Part
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1

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XII,
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2c
3
4
5
6
7

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 . . . . . . . . .
b Program-related investments—total from Part VIII-B . . . . . . . . . . . . . . . .
2
Amounts paid to acquire assets used (or held for use) directly in carrying out charitable, etc.,
purposes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1a
1b
2

3

Amounts set aside for specific charitable projects that satisfy the:
a Suitability test (prior IRS approval required) . . . . . . . . . . . . . .
b Cash distribution test (attach the required schedule) . . . . . . . . . . .
4
Qualifying distributions. Add lines 1a through 3b. Enter here and on Part XII, line 4 .

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3a
3b
4
Form 990-PF (2021)

Page 9

Form 990-PF (2021)

Part XII

Undistributed Income (see instructions)
(a)
Corpus

1
2
a
b
3
a
b
c
d
e
f
4
a
b
c

(b)
Years prior to 2020

(c)
2020

(d)
2021

Distributable amount for 2021 from Part X, line 7
Undistributed income, if any, as of the end of 2021:
Enter amount for 2020 only . . . . . .
Total for prior years: 20
, 20
, 20
Excess distributions carryover, if any, to 2021:
From 2016 . . . . . .
From 2017 . . . . . .
From 2018 . . . . . .
From 2019 . . . . . .
From 2020 . . . . . .
Total of lines 3a through e . . . . . .
Qualifying distributions for 2021 from Part XI,
line 4: ▶ $
Applied to 2020, but not more than line 2a .
Applied to undistributed income of prior years
(Election required—see instructions) . . .
Treated as distributions out of corpus (Election
required—see instructions) . . . . . .

d Applied to 2021 distributable amount
. .
e Remaining amount distributed out of corpus
5
Excess distributions carryover applied to 2021
(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
amount—see instructions . .
e Undistributed income for 2020.
4a from line 2a. Taxable
instructions . . . . . . .
f

6b. Taxable
. . . .
Subtract line
amount—see
. . . .

Undistributed income for 2021. Subtract lines
4d and 5 from line 1. This amount must be
distributed in 2022 . . . . . . . . .

7

Amounts treated as distributions out of corpus
to satisfy requirements imposed by section
170(b)(1)(F) or 4942(g)(3) (Election may be
required—see instructions) . . . . . .

8

Excess distributions carryover from 2016 not
applied on line 5 or line 7 (see instructions) .
Excess distributions carryover to 2022.
Subtract lines 7 and 8 from line 6a . . .

9
10
a
b
c
d
e

Analysis of line 9:
Excess from 2017
Excess from 2018
Excess from 2019
Excess from 2020
Excess from 2021

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Form 990-PF (2021)

Page 10

Form 990-PF (2021)

Part XIII
1a

Private Operating Foundations (see instructions and Part VI-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 2021, enter the date of the ruling . . . . . . ▶

b Check box to indicate whether the foundation is a private operating foundation described in section
Tax year
Prior 3 years
2a Enter the lesser of the adjusted net

b
c

income from Part I or the minimum
investment return from Part IX for
each year listed . . . . . . .
85% (0.85) of line 2a
. . . . .
Qualifying distributions from Part XI,
line 4, for each year listed . . . .

(a) 2021

(b) 2020

(c) 2019

4942(j)(3) or
(d) 2018

4942(j)(5)
(e) Total

d Amounts included in line 2c not used directly
for active conduct of exempt activities .

e

3

Qualifying distributions made directly
for active conduct of exempt activities.
Subtract line 2d from line 2c . . .
Complete 3a, b, or c
alternative test relied upon:

a

.

for

the

“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 IX, 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 XIV
1
a

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Supplementary Information (Complete this part only if the foundation had $5,000 or more in assets at
any time during the year—see instructions.)

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).)

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:
if the foundation only makes contributions to preselected charitable organizations and does not accept
Check here ▶
unsolicited requests for funds. If the foundation makes gifts, grants, etc., to individuals or organizations under other conditions,
complete items 2a, b, c, and d. See instructions.
a

The name, address, and telephone number or email address 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 (2021)

Page 11

Form 990-PF (2021)

Part XIV
Supplementary Information (continued)
3 Grants and Contributions Paid During the Year or Approved for Future Payment
If recipient is an individual, Foundation
Recipient
Purpose of grant or
show any relationship to
a

status of
recipient

any foundation manager
or substantial contributor

Name and address (home or business)

Amount

contribution

Paid during the year

Total . . . . . . . .
b Approved for future payment

Total

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3a

3b
Form 990-PF (2021)

Page 12

Form 990-PF (2021)

Part XV-A

Analysis of Income-Producing Activities

Enter gross amounts unless otherwise indicated.

Unrelated business income
(a)
Business code

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

Part XV-B
Line No.
▼

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Excluded by section 512, 513, or 514

(b)
Amount

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(c)
Exclusion code

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(d)
Amount

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(e)
Related or exempt
function income
(See instructions.)

13

Relationship of Activities to the Accomplishment of Exempt Purposes
Explain below how each activity for which income is reported in column (e) of Part XV-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 (2021)

Form 990-PF (2021)

Part XVI
1

Page 13
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) (other than section 501(c)(3) organizations) or in section 527, relating to political
organizations?
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) (other than section 501(c)(3)) or in section 527? . . . . . . . . . . .
b If “Yes,” complete the following schedule.
(a) Name of organization

No

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

Signature of officer or trustee

Paid
Preparer
Use Only

May the IRS discuss this return
with the preparer shown below?
See instructions.
Yes No

▲

▲

Sign
Here

(b) Type of organization

Yes

Print/Type preparer’s name

Date
Preparer’s signature

Title
Date

Check
if
self-employed

Firm’s name

▶

Firm’s EIN

Firm’s address

▶

Phone no.

PTIN

▶

Form 990-PF (2021)