Sample Form 990-Pf - Return Of Private Foundation - 2015 Page 6
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Form 990-PF (2015)
Page
Part VII-B
Statements Regarding Activities for Which Form 4720 May Be Required (continued)
5a 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))?
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Yes
No
(2) Influence the outcome of any specific public election (see section 4955); or to carry on,
directly or indirectly, any voter registration drive?
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Yes
No
(3) Provide a grant to an individual for travel, study, or other similar purposes? .
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Yes
No
(4) Provide a grant to an organization other than a charitable, etc., organization described in
section 4945(d)(4)(A)? (see instructions) .
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Yes
No
(5) Provide for any purpose other than religious, charitable, scientific, literary, or educational
purposes, or for the prevention of cruelty to children or animals?
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Yes
No
b 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)?
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5b
Organizations relying on a current notice regarding disaster assistance check here
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c 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? .
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Yes
No
If “Yes,” attach the statement required by Regulations section 53.4945–5(d).
6a Did the foundation, during the year, receive any funds, directly or indirectly, to pay premiums
on a personal benefit contract?
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Yes
No
b Did the foundation, during the year, pay premiums, directly or indirectly, on a personal benefit contract?
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6b
If “Yes” to 6b, file Form 8870.
7a At any time during the tax year, was the foundation a party to a prohibited tax shelter transaction?
Yes
No
b If “Yes,” did the foundation receive any proceeds or have any net income attributable to the transaction? .
7b
Part VIII
Information About Officers, Directors, Trustees, Foundation Managers, Highly Paid Employees,
and Contractors
1
List all officers, directors, trustees, foundation managers and their compensation (see instructions).
(b) Title, and average
(c) Compensation
(d) Contributions to
(e) Expense account,
(a) Name and address
hours per week
(If not paid,
employee benefit plans
other allowances
devoted to position
enter -0-)
and deferred compensation
David Palardy,
President,
111 Marlow Dr., Albany, GA 31721
5 hrs
Andy Pejko
Vice-President,
1211 N McKinly St, Albany, GA 31701
5 hrs
Lee Johnson
Secretary,
1328 Philema Rd S, Leesburg, GA 31763
1 hrs
Vacant - due to deceased.
Treasurer
Compensation of five highest-paid employees (other than those included on line 1—see instructions). If none, enter
2
“NONE.”
(d) Contributions to
(b) Title, and average
employee benefit
(e) Expense account,
(a) Name and address of each employee paid more than $50,000
hours per week
(c) Compensation
plans and deferred
other allowances
devoted to position
compensation
NONE
Total number of other employees paid over $50,000 .
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NONE
990-PF
Form
(2015)
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