Form 990-Pf - Return Of Private Foundation - 2012 Page 5

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5
Form 990-PF (2012)
Page
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)
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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) .
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12
13
Did the foundation comply with the public inspection requirements for its annual returns and exemption application?
13
Website address
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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.
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and enter the amount of tax-exempt interest received or accrued during the year .
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15
At any time during calendar year 2012, did the foundation have an interest in or a signature or other authority
16
Yes
No
over a bank, securities, or other financial account in a foreign country?.
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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
Yes
No
File Form 4720 if any item is checked in the “Yes” column, unless an exception applies.
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?
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Yes
No
(2) Borrow money from, lend money to, or otherwise extend credit to (or accept it from) a
disqualified person? .
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Yes
No
(3) Furnish goods, services, or facilities to (or accept them from) a disqualified person? .
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Yes
No
(4) Pay compensation to, or pay or reimburse the expenses of, a disqualified person?
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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)?
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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.) .
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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)? .
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1b
Organizations relying on a current notice regarding disaster assistance check here
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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?
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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? .
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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.) .
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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? .
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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.)
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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
990-PF
Form
(2012)

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