10
Form 990-PF (2015)
Page
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 2015, enter the date of the ruling .
.
.
.
.
.
▶
April 14, 2013 Exemption letter
b Check box to indicate whether the foundation is a private operating foundation described in section
4942(j)(3) or
4942(j)(5)
2a
Enter the lesser of the adjusted net
Tax year
Prior 3 years
(e) Total
income from Part I or the minimum
(a) 2015
(b) 2014
(c) 2013
(d) 2012
investment return from Part X for
each year listed .
.
.
.
.
.
.
0
0
0
0
0
b
85% of line 2a
.
.
.
.
.
.
.
0
0
0
0
0
c
Qualifying distributions from Part XII,
line 4 for each year listed .
.
.
.
207838
231664
216747
276318
932567
d
Amounts included in line 2c not used directly
for active conduct of exempt activities .
.
0
0
0
0
0
e
Qualifying distributions made directly
for active conduct of exempt activities.
Subtract line 2d from line 2c
.
.
.
207838
231664
216747
276318
932567
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) .
.
.
.
207838
231664
216747
276318
932567
(3)
Largest amount of support from
an exempt organization
.
.
.
0
0
0
0
0
(4)
Gross investment income .
.
.
207838
231664
216747
276318
932567
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).)
NONE
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.
NONE
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 address of the person to whom applications should be addressed:
Accounting Department, 2009 Gillionville Road, Albany, GA 31707
b The form in which applications should be submitted and information and materials they should include:
Request giving name and reason for support, EIN or SS# or recipient, name address, email, phone
c Any submission deadlines:
Open submissions
d Any restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other
factors:
Only as needs assessment and funds available for chariatable purpose, usually education and healthcare medical benefits.
990-PF
Form
(2015)