Form 990-Pf - Return Of Private Foundation - 2012 Page 4
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134
Form 990-PF (2012)
Page
Part VI
Excise Tax Based on Investment Income (Section 4940(a), 4940(b), 4940(e), or 4948—see instructions)
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1a Exempt operating foundations described in section 4940(d)(2), check here
and enter “N/A” on line 1.
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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
1
here
and enter 1% of Part I, line 27b
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c All other domestic foundations enter 2% of line 27b. Exempt foreign organizations enter 4% of
Part I, line 12, col. (b).
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2
Tax under section 511 (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-)
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Add lines 1 and 2 .
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3
4
Subtitle A (income) tax (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-)
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5
Tax based on investment income. Subtract line 4 from line 3. If zero or less, enter -0- .
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Credits/Payments:
a 2012 estimated tax payments and 2011 overpayment credited to 2012
6a
b Exempt foreign organizations—tax withheld at source .
6b
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c Tax paid with application for extension of time to file (Form 8868)
6c
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d Backup withholding erroneously withheld
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6d
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Total credits and payments. Add lines 6a through 6d
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7
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Enter any penalty for underpayment of estimated tax. Check here
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if Form 2220 is attached
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Tax due. If the total of lines 5 and 8 is more than line 7, enter amount owed
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9
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Overpayment. If line 7 is more than the total of lines 5 and 8, enter the amount overpaid .
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Enter the amount of line 10 to be: Credited to 2013 estimated tax
Refunded
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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
Yes No
participate or intervene in any political campaign?
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1a
b Did it spend more than $100 during the year (either directly or indirectly) for political purposes (see
Instructions for the definition)? .
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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?
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1c
d Enter the amount (if any) of tax on political expenditures (section 4955) imposed during the year:
(1) On the foundation.
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(2) On foundation managers.
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e Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed
on foundation managers.
$
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Has the foundation engaged in any activities that have not previously been reported to the IRS? .
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If “Yes,” attach a detailed description of the activities.
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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 .
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4a Did the foundation have unrelated business gross income of $1,000 or more during the year? .
4a
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b If “Yes,” has it filed a tax return on Form 990-T for this year? .
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4b
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Was there a liquidation, termination, dissolution, or substantial contraction during the year?
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If “Yes,” attach the statement required by General Instruction T.
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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?
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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
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8a Enter the states to which the foundation reports or with which it is registered (see instructions)
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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
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8b
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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 .
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Did any persons become substantial contributors during the tax year? If “Yes,” attach a schedule listing their
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names and addresses .
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10
990-PF
Form
(2012)
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