f0fr,990-pf return of private...
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F0fr,990-PF Return of Private Foundation OMB ho 15454052
or Section 4947(a)(1) Nonexempt Charitable Trust 2@0 DeoerlmentofIMeT~un Treated as a Private Foundation _
Ft 1
IInternal Revenue SeMCe I Hots The Organization may be able (o use a copy or tn15 remm ro sansiy STere ro4W~i~ y uirvmenm i
For calendar ear 2007 or tan ear inning , 2007, and ending G Check ail that apply Initial return Final return Amended return Address change Name change
I Name of organization JA Employer Identification number
(d) Disbursements (c) Adjusted net for charitable
income purposes
7 Con~lu~r,y_na Check
praib etc ~ol+af~~w~l " 215. 486 . ~ ~ If the IouMatlm b not ~ulreG to L J attach Scn B
2 Distributions from splRanterest wets , ,
" Interest on savings and temporary own investments 819 .
1 Dividends and interest horn securities , , , 66 , 535 . 66
Sa Gross rents � � � � � � . .
d D (Not rental Income a (loss)
B a Net pain or (loss) horn seta of assets not on line 10 14 ,142 . v b Gloss sales prim for all d assets 229,628 .
7 Capital gain net income (from Pert IV, line 2) . 148
NM short-term capital gam . . . . . . .
8 Income modifications 10a Gloss sales less returns
and allowances b Less Wit of peach sold ,
c Gross profit a (lass) (attach schedule) , , ,
11 Other Income (attach schedule) . . . , ,
iEi4+o a 000 Far Paperwork Reduction Act Notice, sue, the Instructions N7737 1506 V01-6
F (2007)
1`l Form
31309
Use the IRS label 3LOSSVAG RAMILY CHARITABLE TRUST
Otherwise, Number end street (or P O box number A marl is not delivered to street address) print
r" SseSpxMc 10040 REGENCY CIRCLE instructions City or town, stele, and 21P code
6811 I Check type o nabn X SecLOn 501(cZL3) exempt private foundation
I Fair market value of all assets at end Accounting method U Cash U Accrual of year (from Pert ll, cot (c), line a Other (specify) _______________ 16) 10- 1 , 060 , 316 . (Pert 1, column (d) must be on cash basis )
Malyals of Revenue and Expenses a Revenue end (The total of amounts m columns (b), (c), and ( ~ (b) Net Investment (dg may n 1-1 1 --- ---- - ~ I ~ ot necessarily equal the amounts in expenses ~ Income
41-viyeyoa Telephone number pee papa 70 of the Instructions)
C II mmptim Wowed. b p .,a`ro era here . . .
p t Foreign ap~ cheelt here so
7 Far.lpn eqantrallmi mw1inp Me 05%talthW, her, anO~OW~ ~vUwo-, . . . . .
, . .
E u o~w~~ iauna.um am m iwm.vua unax sidlm 507NN1I(Al check here . 0. El
p u m . muoe .n. a r, . ~m ~�.mn under rcmn5o7(eXINe)~nan "r7
11 Compensation of offices directors Wsteas, stc
y 14 Other employee salaries and wages , . c 15 Pension plans, employee benefits , d . . . . .
78e Legal f N d D Accou ~ np fe
; ul~.
c= w t Other o1 Ssional few (attach srhedWe) 17 Interes P , ppiiY .q i) .gaoz ' /~I 1/IM 6 J
N e 18 Taxes ( sUieEUle)1ess Page 14 of )
79 Depre tl W
a zo orcuP ~ . OGD.~N . T . . . . . e 21 Travel, conterencrs and meetings . . .
�~ m 22 PnnLng and publications , , , , , , 2] Other expenses (attach schedule) $TM, 5 .
Z `u 24 Total operating and Administrative expenses
p Add tines 13 through 23 . . . . 23 Contributions, gifts, grants paid . . . .
9D n 38 real ~.. ..d diiia .rinnienni Add lines 24 and 25
27 Subtract line 26 from line 12 a raewwnn,nu.o..rcm.n.e .naei .eur..m.no b Net Investment Income (if negative, enter -D-)
Form 990-PF (2001) JSA tE14203000
JU7737 1506 VO1-6 31349
Farm 990-PF 2001 47-0798965 ?aoe2 Attached sUleGUles and amounts in the year End d r Balance Sheets Eescnpilon column snala be r« Beginning
and-ofsmr emwnts mN (see inavuWms ) (a) Book Value (b) Book Value (c) Fair Market Value 1f10 7flG
2 Savings end temporary cash investments
7 Accounts receivable 10 - ' <
Less allowance for doubtful accounts 1110
4 Pledges receivable " ,
Less allowance for doubtful accounts 1 S Grants receivable , , , , , , , , , ,, -----_-_,-_ 6 Receivables due from officers, directors. trustees, and olhc
disqualified persorw (attach Schedule) (see peps 15 of the instructions) 7 Other notes and loans receivable (attach schedule) ~
Less allowance for doubtful accounts 10, 8 Inventories for sale a use , , , , , .
°, 9 Prepaid euvenses and deferred charges , , , , , , , , , , , a 108 Investments - U 5 and state government obligations ( schedule) b Investments - corporate stale (attach schedule) , , , , , 918 , 300 * 918, 300 942 , 290 . c Investments - corporate bonds (attach schedule) , ,
11 Investments -IanE,bulplnps, 1110, anEequipment basis ------------------- Less accumulated depreciation 1 (attach schedule) _._________________
12 Investments - mortgage loam
11 Investments - other (mach schedule) $T= 6, , , , , , 401 * 117 , 918 . 117 , 918 14 Lane, buildings, and ,
equipment basis ___________________ Less accumulated depreciation 1, (attach schedule) ____________________
15 Other assets (doaibe 1____________________) 18 Total assets (to be completed by all filers - see page 18 01
17 Accounts payable end accrued eq~eenso , , , , , , , ,
1 B Grants payable .
19 Deferred revenue , , , , , , , , , , , , , , , , ,
20 Loans from ofllun, directors trustees, and other disqualified persons
21 Mortgages and other notes payable (attach schedule) , , , ,
22 Other liabilities (describe " ______ )
za ma iaouma lead a ea i th rough nun nuo Organizations that follow SFAS 117, check here " U and complete lines 24 through 26 and lines 30 and 31 .
h X 24 Unrestricted � � � � � � � � � � m ZS Temporarily restricted , , , , , , , , , , , , , , m 28 Permanently restricted
°c Organizations that do not follow SFAS 177, check here and complete lines 27 through 31 . lo. X
`0 27 Capital stock, trust principal, a current funds . . . . . r 28 Paid-in or cepllel surplus w lend, DIUp , end equipment fund H 29 Retained earnings, accumulated Income, enEwment, w other funds , 918 752 . 1 036 32 E a 70 Total net ass. u or fund balances (see page 17 d the u z Instructions) , , , , , , , , 918 , 752 1 036 32E
71 Total liabilities and not ssneLYNnd balances (see page 17 of the lnstrucUOne 918 , 752 1 036 32E
Analysis of Changes in Net Assets or Fund Balances
t Total net assets or fund balances at beginning of year- Part II, column (a), line 30 (must agree with end-of-year figure reported on pnor years return) , , , , , , , ,
x Enter amount from Part I, line 27a , , , , , , , , , , , , , , , , , , , , , , , , 2 7 Other Increases not included in line 2 (itemize) " 3 a Add lines 7, 2, and 3 4 5 Decreases not included in line 2 (item¢e) " _______ 5 6 Total net assets or fund balances at end of veer (line 4 minus line 5) Part II . column lbl line 30 6
capital mains ant! posses ror i ax on investment income ~.~ i .~ enA Ang~nA~ Ihn WnAI"1 OI nlw~7y add (e g real estate ... 2-story brick warehouse a common stock, 200 slu MLC Cc )
a SEE PART N SCHEDULE b c d e
(s) Grass sales price (1) Depreciation allowed (p) Cost a other bays (or allowable) plus expense of sale
(p lE¢esa of cd (p over cd Q), 7 any (1) F M V as of 12/31/69 I U) Adjusted basis
as of 12/31189
Was the organization liable (or the section 4942 tax on we distnbuteble amount of any year in the base period? , a Yes X No If "Yes,' the organization does not qualify under section 4940(e) Do not complete this part
7 Enter the appropriate amount in each column for each year, see page 18 of the Instructions before making any entries
(c) Not value of mncharttablsuse assets
radio
2000 1999 7
8 Enter qualifying distributions from Part XII, line 4 . . . " " " . . . . . . . . " " I 8 I 178 , 042 II line B Is equal to or greater roan line 7 Deck the box in Part Vl, one 7D, and complete that pert using a 1% to role See the Pert VI instructions on page 18
JSA ,e,uoaooo Form 990-PF (2001 )
JV7737 1506 vol-6 31349
ecQUl~d I (e) Date (d) Date sold ..G,. . . ,.,. ~I (mo day . n ) I I= . day . K )
(h) Gain « (lass) (e) plus (f) minus (g)
(I) Gams (Col (h) gain minus cd (k), but not less than -0-) or
Wastes (from cd (h))
r If gam, also enter in Part I, line 7 2 Capital gain net income or (net capital loss) " " " " ~ Ii (loss), enter ~ u~ Part I, Ivie 7 } T 7 Net short-term capital gain or (loss) as defined N sections 1222(5) and (6) H gain, also enter in Part I, line 8, column (c) (see pages 73 and 17 of the uLStructwns) If (loss) . enter ~ In Part I . line 8 . . . . . . . . . . . . . . . . . . . . . . ~ 3
/uggym HU811TIG81100 UIIOBf .76CL100 4`J4U(B) for KBOIlGBO i ax on met investment income
(For optional use by domestic private foundations subject to the section 4940(a) tax on net investment Income
If section 4940(d)(2) applies, leave thus part blank
Base period yeere Calendar year (b) Adjusted qualifying distributions
-12 .10 1997 121 , 45 4 . -6 707 . - 1996 66 .301 . SB .636 .
2 Total of line ), column (d) . . . . . . . . . . . . . . . . . . 3 Average distribution ratio for the 5-year bas--' e penod-divide the total on line 2 by 5, or by
the number of years the foundation has been In ewstence A less than 5 years 7 -5 .
4 Enter the net value of nonchantable-use assets for 2001 from Part X line 5 4
5 Multiply line 4 by line 3 , . , , , , . . . , , , , .
8 Enter 1% of net investment income (1% of Part I, lute 27b) . . . . . . . . . . . .
7 Add lines 5 and 6 . . . . . . . . . . . . . . . . . . . . . . . . .
Excise Tax Based on Investment Income (Section 4940(a), 4940(b), 4940(e), or 3948 - see page 78
1 a Exempt operating foundations described in section 4940(4)(2), check here ~ w ~ .~
_- and enter *N/A' on line 1
vaie vi .u ~ ~ _yr~_c.u._c~ . i_ .._ Vl .. . ~ . ...n .~ iiuii u ..----- 7 . ~ ~ P~w~.n ..~+r~ I
b Domestic or anizaLOns that meet the section 4940(e) requirements in Part V, check . . y 1 here " X and enter 79G of Part I, line 27b , , , . , . . , , , . . , . . , , ,
e All other domestic organizations enter 2°/, of line 27b Exempt foreign organizations enter 4% d Part I, line 12, ed (b) J 2 Tax under section 511 (domestic section 4947(a)(1) trust and taxable foundations only Others enter -0-) , , , , , , , 2 3 Add lines 1 and 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Subtitle A (income) tax (domestic section 4947(a)(1 ) trusts and taxable foundations mly Others enter -0-), , , , , , , 4 5 Tax based on Investment Income Subtract line 4 from line 3 Ii zero a less, inter-0- , , , , , , , , , , , , , , S 8 Credits/Payments a 2001 estimated tax payments and 2000 Overpayment credited to 2001 , , , , , , 68 756 . b Exempt foreign organizations - tax withheld at source , , , , Bb NONE c Tax paid with application for extension of time to file (Form 8868) , , , , , , , 8e NONE d Backup withholding erroneously withheld , , , , , , , , , , , , , , , 6d
7 Total credits and payments Add lines 6a through 6d , , , , , , , , , , , , . . . . 7 B Enter any penalty for underpayment of estimated tax Check hue O if Form 2220 is attached , , , , , , , , , , 8 9 Tax duo If the total of lines 5 and 8 Is more than line 7, eirter amount owed , , , , , , , , , , , , , , , , , , " 9
10 Overpayment If line 7 is more than the total of lines 5 and 8, enter the amount overpaid , , , , , , , , , " 10
JU7737 1506 V01-6 31349
7 a During the tax year, did the organization attempt to influence any national, state, or local legislation or did - Yes No it participate or intervene in any political campaigns , , , , , , , , , , , , , , , , , , , , , , , , 1 e X
b Did it spend more than $100 during the year (ether directly or indirectly) far political purposes (see page 19 W the instructions to definition)? , , , , , . , , , 1 b X
11 the answer is 'Yes' to f a or 76, attach a defected description of the adrvHles and copies of any materials published or distributed by the organization in connection with the activities
e Did the organization file Form 1120 "POL for this year? , , , , , , , , , , , , , , , , , , , , , , 1 e N A d Enter the amount (d any) of tax on political expenditures (section 4955) imposed during the year -
(1) On the organization go. $ (2) On organization managers " $ a Enter the reimbursement (if any) paid by the organization during the year for polNcal expenditure tax imposed
on organization managers 1 $ 2 Has the organization engaged in any activities that have not previously been reported to the IRS? , , , , , , , , , , , 2 X
If *Yes,' attach a detected description of the activities 3 Has the organization made any changes, not previously reported to the IRS, in its governing instrument, articles
of incorporation, or bylaws, a other similar instruments? II 'Yes,' attach a conformed copy of the changes , , , , , , , , , , , , , ] X 4 e Did the organization have unrelated business grow income of $1,000 a more during the yeah , , , , , , , , , , , , , , , , , , 4a X b If 'Yes,' has It flied a tax return m Form 990 "7 for this year? , , . . . . . . . . . . . . . . . . . . . . . . . . . 4b N A
5 Was were a liquidation, termination, dissolution, or substantial contraction dunngthe yeah , 5 X M'Yes,' attach the statement required by General Inshuctlon 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 that conflict with the state law remain in the governing instrument? , , , , , , , , , . . . , , , , , 6 X
7 Did the organization have at least $5,000 In assets at any time during the year If 'Yes,' complete Part ll, cd /cf, end Part XV , , 7 X
B a Enter the states to which the foundation reports or with which it is registered (see page 19 of the instructions) jo, NEEA_7~aRA
b If the answer is -Yes* to line 7, has the organization furnished a copy d Form 990-PF to the Attorney General (or designate) of each state as required by General Instruction G1 11 'No ' attach explanation , , , , , , . , . 8 b X
9 Is the organization claiming status as a private operating foundation within the meaning d section 49420(3) or 49420(5) for calendar year 2001 or the taxable year beginning In 2001 (see instructions for Part XIV on page 25)1 h'Yas,' complete Part XN , , , . . . 9 X
10 Did any persons become substantial contributors during the tax year? If 'Yes,' attach e schedule listing their names end addresses 7 0 X 17 Did the organization comply with the public inspection requirements for its annual returns and exemption application? .
Web site address " X402=391-7900 _________ 12 The books are in =a of t_D,_DAVID_SIA_SHURG_____-___________________ Telephone no
Located at ~ 10040 REGENCY CIRCLE,- SUITE 200 _ ZIP"4 68114 ________ 1 J Section 4947(a)(1) nonexempt charitable casts filing Form 990-PF in lieu o! Form 1011 -Check here
and enter the amount of tax-exempt interest received a accrued during the year
JsA Form 990-PF (2001)
t E 1 4A0 t 000
S
File Form 4720 If any Item Is chacked In the "Yes" column, unless an exception applies
1 s bunng the veer did the nraemzaunn l.rther Nnnlv nr mdironti)
(1) Engage in the sale or exchange, or leasing of property with a disqualified person? ~ Yap ~X No
(7) Borrow money (ran, lend money to, or otherwise extend credit to (a accept it from) a disqualified Person? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : Yes X No
(1) Furnish goods, services, or facilities to (a accept them from) a disqualified person? . . . . Yap X No
(4) Pay compensation to, or pay or reimburse the expenses of, s disqualified person? . . . . . Yon X No
(S) Transfer any Income a assets to a disqualified person (or make any of either available for the benefit a use of e disqualified person)? . . . . . . . , a yes ER No
(8) Agree to pay money or property to a government offidal? (Exception Check "No' N the organization agreed to make a grant to or to empty the official for a period after termination of government service . n terminating within 90 days) . . . . . . . . . Yes ~X No
D I( any answer Is 'Ya+' m 1e(1){6), did any of the acts fail to quality under the exceptions described in Regulations section 53 4941(d)-3 or In a current nonce regarding disaster assistance (sea page 19 of we Ins4uc4ons)T . . . Organizations relying on a current notice regarding disaster assistance check here . . . . . . . . " ~ U
c Did the organization engage in a prior year in any of the acts described in 7a, other then excepted acts, that were not corrected before the first day of the tax year beginning In 2001 ? . . . . . . . . . . . . . . . . .
2 Taxes on failure to distribute income (section 4942) (does not apply for years the organization was a private operating foundation defined in section 49420(3) a 49420j(5))
a At the end of tax year 2001, did tie organization have any undistributed Income (line 8d and Be, Part XI II) for tax year(s) beginning betas 2007 . . . . . . . . . . . ~ Yes OX No It"Yes,'list Neyears " __________ . _________ . ________ . ________
6 Are there any years listed In 2a for which the organization Is not applying the provisions of section 4942(a)(2) (relating to Incorrect valuation M assets) to the year's undistributed incomes (If applying section 4942(a)(2) to ell years listed, answer 'No' and attach statement - see page 19 of the Instructions ) . . . . . . . . . . . .
e If the provisions of section 4942(x)(2) ere being applied to any of the years listed m 2a, list the years here
7 a Did the organization hold more than a 2% direct a indirect interest in any business enterprise at any time during the yea( , , , , , , . . , , , , , , , , , , , , , , , , , 1:1 Yes ~X No
b If 'Yes,' did it have excess business holdings in 2001 as a result of (1) any purchase by the organization or disqualified persons after May 28 1989, (2) the lapse of the 5-year period (a longer period approved by the Commissioner under season 4943(c)(7)) to dispose of holifinps acquired by gift or bequest or (3) the lapse of the 10-, 15-, a 20-year first phase holding period? (Use Schedule C, Form 4720, to determine I! the organization had excess business holdings m 2001 ) . . . . . . . . . . . . . . . . . . . . . . . .
4 a Did the organization Invest during the year any amount In a manner Met would leoperdiae its charitable purposais? . . D Did the organization make any investment in a prior year (but after December 37, 1989) Mat could jeopardize ft charitable
purpose that had not been removed from jeopardy before the first day of me tae year beginning In 2007? . . . . . . . . . . S a During the year did the organization pay a incur any amount to
(7) Carry on propaganda, or otherwise attempt to influence legislation (section 4945(e))? , , , , , El Yes a No (Z) Influence the outcome of any specific public election (see section 4955), or to wry
on, directly or indirectly, any voter registration drive? , , , , , , , , , , , , , : B Yes X No (7) Provide a grant to an Individual for travel, study. ar other similar purposes , , , , , , , yen X No (4) Provide a grant to en organization other then a charitable, etc , organization described
in section 509(a)l1l . (Z) . a (3) . a section 4940(d)(2)? . . . . . . . . . . . . . a Yes ~X No (5) Provide for any purpose other than religious, charitable . scientific, literary, a
educational purposes, or for the prevention of cruelty to children a animals? Yes No b If any answer is 'Vrs'to 5a(1)-(5), did any of the transactions (ail to qualify under the rxxptlau descnDed in
Regulations section 53 4945 or in e current notice regarding d,sastrs assistance (see page 20 of the instructions)? Organizations relying on a current notice regarding disaster assistance check here . . . .
c If the answer is -Yes* to question Se(4), does the organization dam exemption hors the tax because it maintained expenditure responsabihly for the grant? . . . . . . . . PI/A [:] Yes ONo
If "Yes .' attach the statement required by Regulations section 53 494b5(d) 6 a Did the organization, during the year, receive any funds, directly a indirectly, to pay
premiums on a personal benefit contract? , . , . , , , , , , , , , Yes ~X No b Did the organization, during the year, pay premiums, directly a Indirectly, m a personal benefit contract?
1/ you answered 'Yes'to 66, also file Form 8870
Form 990-PF (2001)
JSA 1 E1450 4 000
JU7737 1506 V01-6 31349
Farm 990.PF
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Total number of others receiving over $50 . 000 /or professional services , , . " NONE
MIRR MM Summary of Direct Charitable Activities
List the foundation's bur largest direct charitable eclMllm during the tax year Include releranl statistic al information such as the number Dgenwes of organizations and agar beneficiaries served. conMncm mnwnw, research papers produced, ate
7 NONE
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Form 990-PF(2001)
JSA 1E1460 7 000
JU7737 1506 V01-6 31349
Fdrm990-pF(2001) 47-0798965 Page 6 Information About Officers, Directors, Trustees, Foundation Managers, Highly Paid Employees, and Contractors
1 test all officers directors trustees foundation manaaara and than eomewnaafien (it" eaan ?n of f M nufn_r_tin.Ml (b) Title, and ewrpe c Compensatio n (e) canineuoau b
p) Name and address fours per week (II n~ paid, enter emo~o,+ewnn o~ru ~~~ ~enss account Q_ naa other allohanCm devoted to po5lUo nUon rind aete ~~wiWOn
-------------------------------------- SEE STATEMENT 7 NONE NONE NONE
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I 2 Compensation o1 five highest paid employees (other than those Included on line 1 - see page 21 of the instructions).
If none, enter "NONE " (h) Title and average (a) contneamns m (a) Expense atocount, (2) Name end address of each employee paid mss then $50,000 hours psweek (c) Compensation amol other ellarisnces devoted to position Ma a~~ena ~rmn
NONE
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I Total number of other employees paid over $50,000 3 Five highest-paid Independent contractors for professional services " lace page 21 of the Instructions) K none,
"NONE." a Name and address of each arson aid more than $50 .000 (b) Tvite of service (C
NONE -----------------------------------------------'1
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Amount
MWM Qualifying Distributions (see page 23 of the instructions) Amounts paid (including administrative expenses) to accomplish charitable, etc , purposes
a Expenses, contributions, gifts, etc - total from Part I, column (d), line 26 . . . . . , , , , . 7 a 178 , 042 . b Program-related investments -Total from Part UC-B 7 b NONE
Amounts paid to acquire assets used (or held for use) directly in carrying out charitable', etc,* purposes 2 NONE Amounts set aside for specific chantable projects that satisfy the
a Suitability test (prior IRS approval required) . , . . . , , , , , . , , . . . 3a NONE b Cash distribution test (attach the required schedule) , , 3b NONE
Qualifying distributions Add lines 1a through 3b Enter here and on Part V, line 8 and Part Xlll, .luie 4 4 178 , 042 . Organizations that quality under section 4940(e) for the reduced rate of tax on net investment income Enter 1% of Part I, line 27b (see page 24 of the instructions) . , , . . . , . , . . . S 870 . Adjusted qualifying distributions . Subtract line 5 from line 4 . . . . . 6 177 , 232 Note : The amount online 6 will be used in Part V, column (b), in subsequent years when calculating whether the foundation
qualities for the section 4940(e) reduction o/ fax in those years
2
3
4 5
6
JSA tEt/70000
Form 990 "PF(2007)
JU7737 1506 VO1-6 31349
DescriDe'the two largest program-related investment made by the foundation dunnq the tax vow m lines 7 aM 2 I
7 NONE
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All other Program-related InvasVnmh See peps 22 d the InsWNms
NONE
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Total . Add lines 1 through 3 , , , , , , , , , , , , , , , , , , , , , , , . , . . , , , . . , , , , 11. Minimum Investment Return (All domestic foundations must complete this part . Fore see page 22 of the instructions .)
7 Fair market value of assets not used (or held for use) directly in carrying out charitable, etc , purposes
a Average monthly fair market value of securities . . . , , , . . , , , , . . . , , , . . . . . . . . t o b Average of monthly cash balances . . , , , , , , , , , , , , , t D e Fair market value of all other assets (see page 22 of the Instructions) . , , , , , , , , , , , , 7 e d Total (add lines t a, b, and c) . . . . , . , , , , , , , , , , , , t d- o Reduction claimed for blockage or other factors reported on lines to and
tc (attach detailed explanation) , . . . . . . Is 2 Acquisition indebtedness applicable to line 1 assets 2 3 Subtract line 2 from line 1d 3 4 Cash deemed held for charitable ectlwhes Enter 1 1 /2% of line 3 (for greater amount, see page 23
of the instructions) . , ~
4 5 Net value of noneharitable-use assets Subtract line 4 from line 3 Enter here and on Part V, line 4 S 6 Minimum Investment return Enter 5% of line 5 , ,
Distributable Amount (see page 23 of the instructions) (Section 49420(3) and Q)(5) private foundations and certain foreign organizations check here to F1 and do not complete this par
1 Minimum investment return from Part X, line 6 . . , . , . . . , , , . , , , , . . . . . . . . . 7 2 a Tax on investment income for 2001 from Part VI, lute 5 2a 810 . b Income tax for 2001 (This does not include the tax from Part VI ), , , 2b e Add lines 2a and 2b
3 Distnbutable amount before adjustments SubVact line 2c from line 1 , .
. . . . . . . . . . . . 4 a Recoveries of amounts treated as qualifying distributions , , , , , 4a NONE b Income distributions from section 4947(a)(2) trusts , , . , , . . , , 4b C Add lines 4a and 4b 4c
5 Add lines 3 and 4c 6 Deduction from distnbutable amount (see page 23 of the instructions) . . , , 7 Olatrihutahle amount as adwsteA Subtract line 6 from line 5 Fitter here and on Part XIII . line 1 . .
isA ieueo 4 000
VO1-6 31349 JU7737 1506
47-0798965 Form 880 PF (2001) Pqe 8
Undistributed Income (see page 24 of the Instructions)
(a) (b) (c) (d)
1 Dlstributa6le amount for 2001 from Pert XI, Corpus Years prior to 2000 2000 2001
line ? � � � � , � � � 45 , 578
," 2 Undistributed Income, Ilmy, a of the end o(2000 s Enter amount for 2000 my , , , , , , , NONE
b Toui mr prior years 1999 NONE
7 Excess distributions car rywer, A any, to 2001
a From 1998 , , , , ~ 63 , 398 .
b From 1997 , , , , 121 . 670
e From 1998 , , , , , 174 042 .
d From 1999 , , , , , 39 , 413 . ,
a From 2000 55 , 887 .
1 Total W Tines 3a through e , , , , , . , 454 , 410 .
4 Qualifying distributions for 2001 hen Part
XII, line 4 . 178 .042 .
a Applied to 2000, but not more than line 2a , NONE
G Applied to undistributed income of poor yeas (Election required " see page 24 of the instructicru ;) NONE
e Treated as distributions an of corpus (F1ecUOn . required - see page 24 of the Instructions) NONE
d Applied to 2001 distributable amount, , , , , 45 , 578 .
e Remaining amount distributed out of corpus 132 , 464 5 Excess distributions carryover applied W 2001 HO NONE
(If en amount appears In column (d), the same amount must be shown in column (a)
e Enter the net total of each column as indicated below.
a Corpus Add lines 7f, 4c, and 4e Subtract line 5 586 , 874 .
b Prior years' undistributed income Subtract line 4b from line 2b NONE
c Enter the amount of prior years' undlstnbuted Income for which a notice of cleflaency hate been issued, a on which the section 4942(a) tax has been previously assessed , , , , , NONE
d Subtract line 8c from line 6b Taxable amount " see page 25 of the instructions , NONE
8 Undistributed Income for 2000 Subtract line 4e from line 2e Taxable amount " see papa 25 of the instructions NONE
f Undistributed income for 2001 Subtract lines 4d end 5 from line 1 This amount must be distributed in 2002 " " - NONE
7 Amounts treated as distributions, C ;U;
corpus to satisfy requirements imposed by section 170(b)(1)(E) a 4942(p)(3) (sea page 25 of the Instructions) , NO
8 Excess distributions carryover from 1998 not applied on line 5 a line 7 (see page 25 of the instructions) . . . . . . . . . . 63 , 398 .
9 Excess EIStrIbullonseerryovartn2002 Subtract lines 7 and B from line 8e . . 523 476.
110 Analysis of line 9
a Excess from 1997 . 121 670 .
b Excess from 1998 . . 174 042
c Excess from 1999 . 39 413
e Excess trap 2001
132 , 464 .
d Excess from 2000 . 55 887
- ' Form 990-PF (2001 )
9
2a Enter the assiar of this adjusted not income from Pen I or the minimum investment return from Part x for each ym listed . . .
b 85% al line 2e . . . . .
C QuoIMy1n0 OhtrEUCau hvn Pan %1I line 4 for each Year, listed .
a Aureumu Mama.a n m. a not Used directly lo- scIve conduct al exempt rJAW , , ,
e Quelifiring distributions Made atrealy for s" mbuq d exaniDI acRAYs 9uDhd iM .xairor, One 2C
3 Complete yC or efnMe .Ilwn.tM tat r" 1~0 upon
a "~...rr r~rw. w .,ter, (1) vrwarie.d . . (2) value aaun.wrN~+v
under aecdort 4B42(j)(3)(1t)(1)
D 'EnaawmmrWwnNwtest Enter 213 0l mMlmum invnimitnl Mnn Cu~ n Pan x ~�" a ra ue, ya.. laded . .
e "s~oooTr~.n.~w .mr (1) Total suppoia other Man
pro., lnwash n.11 miw (Interest, dividends nints Payments m rorrMe la.ro (sectiort S72(a)(51) ., ., no), ,
(Z) support horn pwir" public and S u mui inum01 vYeniallvu as, DroNOW H section, 4W ION7IIelIo1 .
(J) Largest anwnt a .oDort from an abannitt orpain4ihn . . . . .
JSA IE7490 7 000 Form 990-PF (2001 )
JU7737 1506 V01-6 31349
Fomn sso-t4
Is If the foundation has received a ruling or determination letter that it is a private operating ' foundation, and the ruling is effective for 2001, enter the data of the ruling
b Check box to indicate whether the organization is a private operating foundation described in sect= F
Supplementary Information (Complete this part only If the organization had 13,000 or more in assets at any time during the year - see page 26 01 the Irmtnutiwks.)
t 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 A they have contributed more than $5.000) (See section 507(d)(2) ~
N/A
b List any managers of the foundation who own 10% or more of the stock of e corporation (a an equally large portion of the ownership of a partnership a older entity) of which we foundation has a 10% a greater Interest
N/A
2 Information Re arding Contribution, Grant, Oft Loan, Scholarship, eta, Programs : Check oars 1 d ins organization only makes contributions to pr6teletleE charitable agen17911ons and does not accept unsolicited requissts for funds If the organization makes gifts, grants , etc (see page 28 of the Instructions) to Individuals G orOaniZellOrts under other mn0111ons, Complete items 2a, It, c, and d
a The name, address, and telephone number of the person to wham applications should be addressed
SEE STATEMENT 8 b The form in which applications should be submitted end information end matenals they should Include
VERBAL OR WRITTEN REQUESTS
e My submission deadlines NONE
d Any restrictions or limitations on awards, such as by geographical areas charitable fields, kinds of InstRUhms, a other tetras NONE
Fog 990-PF (2001 )
ieusi a 000 JV7737 1506 VO1-6 31349
Fog sso-ar' croon e7-
Grants and Contributions Paid Durin the Year or roved for Future Payment
Recipient If recipient is en inaMeusl, FounaNOn slaw any rolellonshlp a status al Purpose of pram a
Name and address (home or business) I e; y rounaeuon Manager I ~a ient I w~tnouuo~
a Peed dunng the year SEE STATEMENT 19
b Approved for future payment NONE
178,042
47-0798965
eitempt income I 1M
Business I '-' IAI
1 Program service revenue e b
e
d s
f
g Fees and comets from government agencles 2 Membership duev and a9sessments , , , 7 Interest on aaNnps and temporary cash Inwstrnents "
4 Dividends and interest it= securNrs
5 Net rental income a (loss) from real estate a Debt-financed property b Not debt-financed property , , , , , ,
" 8 Nat rental Income or (loss) hom personal property , 7 Other investment Income
8 Gain or (loss) from sales of riots other than Inwntory 9 Net income or (loss) from special events 10 Grass profit or (loss) from sales of Inventory 17 Other revenue a
b c a
12 Subtotal Add columns (b), (d), and (e) , , 13 Total Add line 12, columns (b), (d), and (e) , , . . . . . . . . . . . . . . "ta 81 .496 .
Pane 990-PF (2001 )
JSA tE1497 t 000
JV7737 1506 VO1-6 31349
Form 990-PF
Entef gross amounts unless otherwise indicated
71
Explain below how each activity for which Income is reported m column (e) of Part XVFA contributed Importantly to aria No the accomplishment of the organization's exempt purposes (other than by providing funds for such purposes) (See V ~ page 27 of the instructions
(2) Purchases o1 assets from a nmdiarrtaDle exempt organization , , , , , , , , , , , , , , , (S) Rental of facilities, equipment, a other assets , , , , , , , , , , , , , , , , , , , , , , , (4) Reimbursement arrangemmb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (S) Loans or loan guarantees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (6) Performance of sernces or membership a fundraeslng solicitations , , , , , , , , , , , , , , , , , , , , , , , ,
c Sharing of facilities, equipment, malting lists, other assets, a paid employees , , , , , , , , , , , , , , , , , , , , , 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 goads other assets, or services given by the reporting organization K the organization received less than fair market value In any transaction or sharing arrangement, shoe in column (A) the value of the goods, other ewers, or services
2 a Is the organization directly or indirectly affiliated with, or related to, one or more tax-exempt organizations described in section 501(c) of the Code (other than section 501(c)(3)) a in section 5277 , , , , , , , , , , , , , a Yea a No
--
statements, and to the best of my knowledge and ballet, A Is Under penalties of per/uy, 1 declare that I haw examined this return, InUUGI true, co ct, e 4 complete Dxlera n of pnpanr (other than laxilprym a
Signeturo of oRlmr or Wri v d Z
m N
i _ Preparefs
q C
am 0 signature �
a a j Firm's name (or yours if self-employed), address, and ZIP code
JSA tEi4B7 7 000
JU7737 1506 VO1-6
Form sso- 'r zoos d7-0798965 wee 1 2 Information Regarding Transfers To and Transactions and Relationships Wit Noncharitable
t ' Did the organization directly or indirectly engage in any o1 the following with any other organization described in section 501(c) of the Code (other than section 501(c)(3) organizations) or In serum 527 relatlna to odwcal uganizahona?
a Transfers from the reporting organization to a noncharXa6le exempt organobabon of
(2) Other assets
b Other Transactions
(1 ) Sales of assets to e noncharltsble exempt organization
233 SOUTH 13TH ST
Schedule B (Form 990,990-EZ, or 990-PF) vepenmem of me Trecsuy
~)nn~ 1"vv e Succlementary Information for line 1 of Form 890, 990 "EZ and 990 "PF (see Instructions)
Form 990-PF
501(c)(3) taxable private foundation
JSA
t E1357 t 000
.7U7737 1506 VO1-6 31349
Schedule of Contributors OMB No 1515.00<7
Organization type (check one)
Filers of :
Forth 990 or 990-EZ
Section:
501 (c)( ) (enter number) organization
4947(a)(1) nonexempt charitable trust not treated as a private foundation
527 political organization
501(c)(3) exempt private foundation
D 4947(a)(1) nonexempt charitable trust treated as a private foundation
Check d your organization is covered by the General rule a a Special rule. (Note. Only e section 501(c)(7), (8), or (10) organization can check boxes) for both the General rule end a Special rule - see instructions )
General Rule
For organizations filing Forth 990, 990-EZ, or 990-PF that received, during the year, $5,000 or more (N money or property) from any one contributor (Complete Parts I and II )
Special Rules
0 For a section 501(c)(3) organization filing Forth 990, or Form 990-EZ, that met the 33 1/3% support test of the regulations under sections 509(a)(1)/170(b)(1)(A)(vi) and received from anyone contributor, during the year, a contribution of the greater of $5.000 or 2% of the amount on line 1 of these forms (Complete Parts I and II )
0 For a section 501(c)(7), (8), or (10) organization filing Form 990, or Forth 990-EZ, that received from anyone contributor, during the year, aggregate contributions or bequests of more wan $1,000 for use exclusively for religious, charitable, scientific, literary, or educational purposes, or the prevention of cruelty to children or animals (Complete Parts I, II, and III )
0 For a section 501(c)(7), (8), or (10) organization filing Form 990, or Form 990-EZ, that received from any one contributor, during the year, some contributions for use exclusively for religious, charitable, etc , purposes, but these contributions did not aggregate to more than $1,000 (If this box is checked, enter here the total contributions that were received during the year for an exclusively religious, charitable, etc , purpose Do not complete any of the Parts unless the General rule applies to this organization because it received nonexclusively religious, charitable, etc , contributions of $5,000 or more during the year ) . . . . . . . . . . . . . . . . . . . . . . . . . " $
Caution. Organizations that ere not covered by the General rule end/or the Special rules do not file Schedule 8 (Form 990, 990-EZ, or 990-PF) but they must check the box in the heading of their Form 990, Form 990-EZ, or on line 1 of them Form 990-PF, to certify that they do not meet the filing requirements of Schedule B (Form 990, 990.EZ, or 990.PF)
Schedule B (Farm 880, BBOfZ or 990-0F) (4001)
VO1-6 31349 JU7737 1506
Schedule B (Form 990 cr99PE2J(pppt)
If 'a section 501(c)(7), (8), or (10) organization received contributions or bequests for use exclusively ,-or religious, uurnaoie, ecc , purposes tsecuorts 170(c)(4), 2055(a)(3), or 2522(a)(3))-
List in Part I each contributor whose contributions total more than $1,000 during the year that were for a religious, charitable, etc , purpose To determine the 51,000, aggregate all of a contributors grits for the year (regardless of amount) For a rwncash contribution, complete Part II
All section 501(c)(7), (8), or (10) organizations that received any charitable contributions and listed any charitable contributors on Part I must also complete Part III
If a section 501(c)(7), (8), or (70) organization received charitable gifts, but is not required to list any charitable contributors on Part I, check the box on tine A at the top of Schedule B (Forth 990 or 99o-EZ) end enter we amount of charitable contributions received m the space provided The organization need cwt complete and attach Part III
Specific Instructions Note : You may duplicate Parts 1, 11, and /it If more copies ere needed Number each page of each Part Part 1 In column (a), identify the first contributor listed as no 1 and we second contributor as no 2, etc Number consecutively Show the contributor's name, address, aggregate contributions for the year, and the type of contribution (e g , whether an individual, payroll, or nonwsh contribution) Report payroll contributions by listing we employers name, address, and total amount given (unless an employee gave enough to be listed individually)
JSA
1Eit57 1 000
Part II In column (a), show the number that corresponds to we contributors number in Part I Describe the noncash contribution fully Report on property with readily determinable market value (I e , market quotations for securities) by listing its fair market value (FMS For marketable securities registered and listed on a recognized securities exchange, measure market value by the average of the highest and lowest quoted selling prices (or the average between we bona fide bid and asked prices) on the contribution date See Regulations section 20 2031-2 to determine the value of contributed stocks and bonds When market value cannot be readily determined, use an appraised or estimated value To determine we amount of a noncash contribution that is subject to an outstanding debt, subtract the debt from the propertys fair market value Part III . Section 501(c)(7), (8), or (70) organizations that received contributions or bequests for use exclusively for religious, charitable, etc , purposes must complete Parts I through III for those persons whose gifts totaled more than $1,000 during we year Straw also, in the heading of Part III, total gifts that were $1,000 or less and were for a religious, charitable, etc , purpose Complete this information only on the first Part 111 page
If an amount Is set aside for a religious, charitable, etc, purpose, show m column (d) how the amount is held (e g , whether It is mingled with amounts held for other purposes) If the organization transferred the get to another organization, show we name and address of the transferee organisation in column (e) and explain the relationship between the two organizations
Schedule B (Form 990 a 99o-EZ) (2001)
Contributors (See Specific Instructions )
(a) (b) No Name, address and LP+4
1 D DAVID SIASHURG
(d) be of contribution
(e)
Person Payroll
50 .685 . Noncash NX (Complete Part II R there is a noncash contribution )
(c) (d) Aggregate contributions Type of contribution
Person x Payroll
50,685 . Noncash NX (Complete Part II if there is a nonwsh contribution )
(a) (b) No Name, address and ZIP +4
2 RICHARD H . SIASSUAG
(c) (d) contributions Type of contribution
Person Payroll
114,116 . Noneash NX (Complete Part II d there is a noncash contribution )
(c) (d) Aggregate contributions I Type of contribution
(a) I lbl No Name, address and DP + 4
(a) (b) (e) (d) No Name, address and DP+4 Aggregate contributions Type of contribution
Person Payroll Noncaah (Complete Part II rf there is a noncash contribution )
(a) (b) (e) (d) No Name, address and ZIP+4 Aggregate contributions Type of contribution
Person Payroll Noneash (Complete Part II A there is a noncash contribution )
Scntui.e(Fonnooo ON-eZ or 9W7F) (7W1)
JSA
t E1257 3 000
JU7737 1506 VO1-6 31349
(a) (b) No Name, address and LP+4
3 AD INVESTMENT COMPANY
Parson Payroll Honwah (Complete Part II d there is a noncash contribution )
Schedule B~(Fartn 990, 990-EZ to o: Pert II
Noncash Property (See Specific InsUvc6ons )
(a)
(b) FMV (or estimate) (d) from Description of noncash property given Date received Part I (see Instructions)
189 SH SPDA FUND 1 323 SH NA3D0 FUND
223 3B DIAMONDS FUND 50 .685 10/03/2001
No. y from Description of noneaah property given
FMV (or estimate) Date received Part I (see Instructions)
189 SH SPDR FUND 2 323 SH NASDO FUND
223 SH DIAMONDS FUND 50 .685 . 10/03/2001
No,. b (C) from Description of noncash property given
FMV (or estimate) Data received
Part 1 (see instructions)
4000 SH COMFED 3
114 .116 08/21/2001
No from Description of noncash property given
FMV (or estimate) Data reserved
Part I (see Instructions)
No) b (C) d from Description of noncash property green
FMV (or estimate) Date received
Part I (see instructions)
No) b (C) d from Description of noneaah property green
FMV (or estimate) Date received
Part I (see instructions)
Schedule B (Forth 990, 990£Z or 990PF) (2007)
JSA 1E77U 2 000
JU7737 1506 VO1-6 31349
" FORM 990-PF - PART IV CAPITAL GAINS AND LOSSES FOR TAX ON INVESTMENT INCOME
qnd of Property DescrIpUm Date Date add n acquired
ixass saie ueprectaJm Cost or F al u n price less allowed/ other as of as of MV over or e of sale allowable hmqm 12111/69 12131169 adl basm flossi
4000 SB COMMERCIAL FEDERAL GROUP 08/21/2001 08/21/2001 PROPERTY TYPE : SECURITIES
113,909 . 114,117 . -208 .
189 SH SPDA TRUST UNIT SERIES 1 10/03/2001 10/03/2001 PROPERTY TYPE : SECURITIES
20,279 . 20,312 . -33 .
323 SH NASDQ 100 TRUST UNITS SERIES 1 10/03/2001 10/03/2001 PROPERTY TYPE SECURITIES
10,005 . 10,09 . -44 .
223 SB DIAMONDS SERIES TRUST SERIES 1 10/03/2001 10/03/2001 PROPERTY TYPE : SECURITIES
20,288 . 20,324 . -36 .
223 SH DIAMONDS TRUST SERIES 1 10/03/2001 10/03/2001 PROPERTY TYPE : SECURITIES
20,288 . 20,324 . -36 .
323 SH 2a1SDQ 100 TRUST SERIES 1 10/03/2001 10/03/2001 PROPERTY TYPE : SECURITIES
10,005 10,049 . -44
189 S8 SPDR TRUST UNITS SERIES 1 10/03/2001 10/03/2001 PROPERTY TYPE : SECURITIES
20,279 . 20,312 . -33 .
----------
TOTAL GAIN(LOSS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14,142 .
a, I E77701000 ~.~ .~~ .~ ~ cn~ vM _G 71 Owl
---------------TOTAL CONTRIBUTION AMOUNTS 215,486
STATEMENT 2 JU7737 1506 Vol-6 31349
SIASBURG FAMILY CHARITABLE TRUST 47-0798965
FORM 990PF, PART Z - CONTRIBUTIONS, GIFTS AND GRANTS RECEIVED
DIRECT PUBLIC
NAME AND ADDRESS DATE SUPPORT ---------------- ---- -------
D . DAVID SLOSBURG 10/03/2001 50,685 .
RICHARD H . SLOSBURG 10/03/2001 50,685 .
RD INVESTMENT COMPANY 08/21/2001 114,116 .
FORM 990PF, PART I - INTEREST ON TEMPORARY CASH INVESTMENTS
819 .
STATEMENT 2 JU7737 1506 VO1-6 31349
SLOSBURG FAMILY CHARITABLE TRUST
DESCRIPTION
NORWEST INTEREST JOINT 100 INVESTMENT INTEREST
REVENUE AND
EXPENSES PER BOOKS
33 . 786 .
------------ TOTAL 819 .
47-0798965
NET INVESTMENT
INCOME
33 . 786 .
65,512 . 1,023 .
------------66,535 .
STATEMENT 3 ,7U7737 1506 V01-6 31349
SLOSBURG FAMILY CHARITABLE TRUST
FORM 990PF, PART I - DIVIDENDS AND INTEREST FROM SECURITIES
REVENUE AND
EXPENSES DESCRIPTION PER BOOKS ----------- ---------
IRT DIVIDENDS 65,512 . SBC DIVIDENDS 1,023 .
------------ TOTAL 66,535 .
47-0798965
NET INVESTMENT
INCOME
882 . ------------
TOTALS 882 .
STATEMENT 4
VO1-6 31349 JII7737 1506
SLOSBIIRG FAMILY CHARITABLE TRUST
FORM 990PF, PART I - TAXES
DESCRIPTION
INCOME TAX EXPENSE
REVENUE AND
EXPENSES PER BOORS
47-0798965
18 . 18 . --- ------------ 18 . 18 .
BANK CHARGES
STATEMENT 5 31349 JU7737 1506 V01-6
SIASBURG FAMILY CHARITABLE TRUST
FORM 990PF, PART I - OTHER EXPENSES
DESCRIPTION
TOTALS
REVENUE AND
EXPENSES PER HOOKS
47-0798965
NET INVESTMENT
INCOME
117,918 . ---------------
117,918 . TOTALS
VO1-6 31349 STATEMENT 6 JU7737 1506
SLOSBURG FAMILY CHARITABLE TRUST
FORM 990PF, PART II - OTHER INVESTMENTS
DESCRIPTION
JOINT 100 INVESTMENT
47-0798965
ENDING BOOK VALUE
ENDING FMV
117,918 . ---------------
117,918 .
FORM 990PF, PART VIII - LIST OF OFFICERS, DIRECTORS, AND TRUSTEES ------- - -- --
VO1-6 31349 STATEMENT 7 JU7737 1506
SLOSBURG FAMILY CHARITABLE TRUST 47-0798965
NAME AND ADDRESS ----------------
D . DAVID SLOSBURG 10040 REGENCY CIRCLE, SUITE 200 OMAHA, NEBRASKA 68114
RICHARD H . SIASBURG 10040 REGENCY CIRCLE, SUITE 200 OMAHA, NE 68114
CONTRIBUTIONS EXPENSE; ACCT TITLE AND TIME TO EMPLOYEE AND OTHER
DEVOTED TO POSITION COMPENSATION BENEFIT PLANS ALLOWANCES ------------------- ------------ ------------- -----------
TRUSTEE NONE NONE NONE
TRUSTEE NONE NONE NONE
---------- ---------- ----------- GRAND TOTALS NONE NONE LiONE
SI.OS13IIRG FAMILY CHARITABLE TRUST ,47-0798965
D . DAVID SLOSBIIRG 10040 REGENCY CIRCLE SUITE 200 OMAHA, NE 68114 (402) 391-7900
STATEMENT 8
Vol-6 31349 JU7737 1506
FORM 990PF, PART XV - MANE, ADDRESS AND PHONE FOR APPLICATIONS
+nm1 Ttimugn 13r31101
Date Aect Num Description Amount Memo
. . .- .,
SLp5f3Q R6 FAM1L`I G ae.Q~ip.g~.E ~-RUST-
Fo9m' ~9b P~" ZOO l LEON A ~ ~Opl.̀>
y -7 -a`r 9T 4,65
129/01 SFC 1081 Donation- Memorial Dr Jay P Jewish Com CV(YouM Sports Program) -10000 2/1107 SFC 1082 DONATION In Honor of M8M Gerald Kahn -2500 2/14101 SFC 1083 DONATION Anti-Defamation League -85000 2Q1/01 SFC 1085 Donation Pa1n Springs Desert Museum -1,05000 282/01 SFC 1088 Donation U S Holocaust Memorial Museum -40000 222/01 SFC 1087 Donation United Jewish Appeal -15500 228/07 SFC 1088 Donation Stanley PassedMarty Lehi -2000 228/01 SFC 1089 Donation Un of No Foundation -0CSMAC -7 .00000 3BI01 SFC 1090 Donation Omaha Hearing School for Children Inc -2.50000 3I8I01 SFC 1081 Donation Omaha Symphony Ass -5.00000 320/01 SFC 1094 Donation Pale Springs Deaers Museum Dues -1,00000 327/01 SFC 1095 Donation JuvenBe Diabetes Research Foundation -25000 323107 SFC 1098 Donation Memorial Sam Strum -10000 3!30/01 SFC 1097 Donation Rose Blumkn Jewish Home-Art GoIdsL -10000 3!30/01 SFC 1098 Donation-Memorol Kazua Take Downtown Omaha Rorary Scholarship -10000 4/10/01 SFC 1100 Donation Husker Athb6csFund 30000 4/16101 SFC 1101 Donation Memorial Laurie CeDmn -20000 4!28/01 SFC 1102 Donation NCJW Eleanor -2500 5/1/01 SFC 1103 Donation College World Series -30000 511101 SFC 1104 Donation Glesby Foundation Jew Fed Houston -5000 5/7/01 SFC 1105 Donation Big Brothers/Big Sisters -5000 5/7/01 SFC 1108 Donation Council of Jewish Women -50 00 5/21/01 SFC 1110 Donation DDS/RHSDONATION -2,50000 5/31101 SFC 1111 Donation Abort Vaequez -20000 8/5/01 SFC 1112 Donation Caribbean Cabaret Pledge-Child Savm -2,000 JO 615/01 SFC 1113 Donation The Benjamin Franklin Society -5,00000 8/5/01 SFC 1114 DonaUOn Jewish Family Services -25000 617101 SFC 1117 Donation Eisenhower Medical Center SJS -1 .00000 8/12101 SFC 1118 Donation Jewish Fed of P SSDeaert Area SJS/EI -7,50000 7/10/01 SFC 1120 Donation Jewish Federation of Omaha-Awards E -50000 724/01 SFC 1121 Donation- William Chapman BoysBGefs Club of Omaha -10000 7/25/01 SFC 1122 Donation Easter Seals Nebraska -25000 822/01 SFC 1123 Donation Make-A-Wish Foundation -10000 8/28/01 SFC 1125 Donation NCCJ-Humandaren Awards -5.00000 829101 SFC 1128 Donation The Pro : ~a Foundation -50000 8f31/01 SFC 1127 Donation Aksarben Scholarship Fund -81000 9/5/01 SFC 1128 Donation Stroke Jesuit College Prepatory-Parsley -10000 9/5/01 SFC 1129 Donation 2001-2002 -16,50000 9/5/01 SFC 1131 Donation 2001-2002 JDS -500 00 9/13101 SFC 1133 Donation Open Door Mission 2001 Thanksgiving -2500 9R5I07 SFC 1134 Donation Memorial Harvey Ferer -10000 9/28101 SFC 1135 Donation Archduxese d Omaha -64000 928/01 SFC 1138 Donation Twos Towers Fund New York -10,00000 928/01 SFC 1137 Donation 2001 Untied Way of the Midlands Else -6000 9R8I01 SFC 1738 Donation Memorial lorBernard White -2000 102/01 SFC 1139 Donation David Olson Memorial -5000 10/8/01 SFC 1140 Donation Opera Omaha -1,00000 10/10101 SFC 1117 Donation No Chpt Nat] MS Society -10000 10HBI01 SFC 1142 Donation Jewish Comm Center Youth Athletics -20000 1022/01 SFC 1143 Donation Palm Springs Friends of Philharmonic -1,20000 11N8/01 SFC 1144 Donation World Herald Goodfebws -1,00000 11!27/01 SFC 1145 Donation Nat'I Aphasia Association -10000 12/3/01 SFC 1148 Donation Josyn Art Museum Contributor Mambo -40000 12/d/01 SFC 1147 Donation Nebraskane for Public Television -10000 12/5/01 SFC 1150 Donation The Jewish Braille Institute of America -5000 12/14/01 SFC 1151 Donation Swanson Elementary -3,00000 12/18/01 SFC 1153 Donation Muscular Dystrophy Assoc -10000 12/78101 SFC 1154 Donation Mid-Amenca Council -25000 12/18N1 SFC 1155 Donation United Way of the Midlands -1,25000 12/18101 SFC 1181 Donation Sacred Heart Cues -25000
5~r5R0 ;~- C, F= A+~~% ~.Y C- NAR ;Tcag\- IE, TRUsr
Date Acct Num
12/78101 SFC 7784 Donation 12/18101 SFC 7185 Donation 12A8/01 SFC 1185 Donation 12/18/07 SFC 1185 Donation 12/18101 SFC 1185 Donation 12/18101 SFC 1185 Donation 12/19101 SFC 1185 Donation 12/18101 SFC 1185 Donation 1228/01 SFC 1188 Donation
TOTAL 1NI01 -12/31/01
Description Memo
JCC 2002 Maecabi Games Jewish Federation of Omaha Eleanor Jewish Federation of Omaha Marthal Jewel Federation of Omaha Elgin Jewish Federation of Omaha JCC Campus Project 3 of 5 JCC Omaha,Richard family JCC Omaha Davd Slosburg family Unmted Jewish Community of Palm Sp
' ~tT 1.1 ti i
-F- 00.~ Q\ gOPF -zoo ~C., N a7-1D1~ s 1/1/01 Through 12f31101
-o~g1~g65
Page 2
Amount
-5,00000 5,000 00 -2 .25000 -2 .26000
-59,00000 -20,00000
-75800 -1,10600 -35000
-778,042.00
, . SCHEDULE D (Form 1041) Capital Gains and Losses . , j
I OMB No 75X5.0092
Y Short-term capital gain or (loss) from Forms 4684, 6252, 6781, and 8824 , , , , , , , , 3 Net short-term gam or (loss) from partnerships, S Corporations. and other
estates or trusts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Short-term capital loss carryover Enter the amount, d any, from late 9 of the
2000 Capital Loss Carryover Worksheet , , , , , , , , , , , 5 Not short-term gain or (loss) . Combine lines 1 through 4 In column (f) Enter
here and on line 14 below
Long-Term Capital Gains and Losses -Assets Held More Than One Year
(Q Gain or (lun) I - or (Loss)
6
7 Long-term capital gain or (loss) from Forms 2439, 4684, 6252, 6781, and 8824 , , , , 8 Net long-term gain or (loss) from partnerships, S corporations, and other estates or trusts 9 Capital gain distributions , , , ,
10 Gain from Form 4797, Part I , , , , , , , , , , . ~ . . 17 Long-term capital loss carryover Enter m bow columns (f) and (g) the amount.
d any, from line 14, of the 2000 Capital Loss Carryover Worksheet , , , , , , , , , 72 Combine lines 6 through 11 in column (g) , , , , , , , , , , , , , , , , 7 3 Net long-term gain or (loss) Combine lines 6 through 11 in column (f) Enter
"28°h rate gain or loss includes all collectibles gains and losses' (as defined on page 30 of the instructions) and up to 50% of the eligible gam on qualified small business stock (see page 28 of the instructions)
(7) Beneficiaries' I (2) Estate's I (3) Total (see page 30) or Wst's Summary of Parts I and II
J5A
1F1710I000
JII7737 1506 VO1-6 31349
Department mN. r~ry ~ Attach to Form 1041 (or Form 5227) See the separate instructions for 200 1 iminternal I Form 1041 (or Form 5227) .
Name of estate a trust Employer Identification number
SIASHURG FAMILY CHARITABLE TRUST I 47-0798965 Note: Form 5227 filers need to complete only Parts I and 11
Short-Term Capital Gales and Losses -Assets Held One Year or Less
700 shares 7% ecputreE (c) Date sold (6) Cast a Other basis (q Why Or (Lws) . (~ Sees prim I . . . . . . . .
100 shares 7% ecQulreG I imp I
(c) Date sold I (A) Sales prim
(a) Cost a other basis n M -r r_ i nw uI (MO . day Yr ) I (see page 29)
7 4 Net short-term gain or (loss) (from line 5 above) , , , 14 15 Net long-term gain or (lose) : a 28% rate gain or (loss) (from line 12 above) I se b Unrecaptured section 1250 gain (see line 17 of the worksheet on page 37), , , , , , , , 15b 8 , 489
c Total for year (from line 13 above) , , 15C 14 , 142 . 18 Total not gam or (loss) Combine lines 14 and 15c "" 16 14 , 142 Note II Irne 16 column (3) is a net gam, enter the gain on Fwm 1017, line 4 Illlnes 75c and 16, column (2), ere net gains, go to Pert V end dD rot complete Part N M line 76 column (3). is a net loss . complete Part N end the Capital lo= Canrover Worksheet as necessary For Paperwork Reduction Act Notice, spa the instructions 1a Form 1047 Schedule D (Form 1041) 2001
Tax Computation Using Maximum Capital Gains Rates (Complete this part only if both lines 15c and 16 in column (2) are gams, and Form 1041, line 22 is more than zero )
Note : 1l line 15s, column (2) or line 156, column (2) is more than zero, complete the worksheet on pegs 34 to figure the instructions to figure the amount to enter on lines 20, 27, end 38 below end skip all other lines below Otherw7se, go to line 18
Enter taxable income from Forth 1041, line 22 Enter the smaller of line 15c or 16 In column (2) 1 9 If the estate or trust is filing Form 4952, enter the amount from line 4e, otherwise, enter-0- " 20 Subtract line 20 from line 19 If zero or less, enter- , . . , , , , , 21 Subtract line 21 from line 18 If zero or less, enter -0- 22 Figure the tax on the amount on line 22 Use the 2001 Tax Pat; Schedule on pogo 20 of the instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Enter the smaller of the amount on line 18 or $1,800 . . . . . , , , . . ~ 24
Enter the amount from line 22 . . . . . . . . . . . . . . . . . Subtract line 25 from line 24 If zero or less, enter -0- and go to line 32 . Enter the estate's or trust's allocable portion of qualified 5-year gam, if any, from line 7c of the
12 worksheet on page 33 . . . . . . . . Enter the smaller of line 26 or line 27, , , . , , . . . . . . . . . . . . . Multiply line 28 by 89'0 ( 08) ~ ~ ~ " " " Subtract line 28 from line 26 . . . . . . . . . . . . . . . . . . M Iti I line 30 b 10% ( 10)
28 29 30 37
30
PY Y . . . . . . . . . . . . . .
36 Add lines 23, 29, 31, and 35 ~~x
, , , , , , , , 37 Figure the tax on the amount on line 18 Use the 2001 Rate Schedule on page 20 of the
instructions 38 Tax on all taxable Income (Inc ludirg cap ital gains) . Enter the smaller of line 36 or Ilne 37 here
and on line 1 a of Schedule G, Forth 1041 , . . . , , , , . . , , ,
Schedule D (Form 7041) 2001
voi-s 31349 JU7737 1506
. , . Schedule D (Form 104 1) 2001 .~ v Page 2
Capital Loss Limitation
77 Enter here and enter as a (loss) on Forth 1041, line 4, the smaller of a The loss online 16, column(3)or O YJ~UUU . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 I C I
11 the loss on line 16, column (3), is mare than $3,000, d i/ Form 1041, page 1, line 22, is e loss, complete the Caplml Low Carryover Worksheet on page 32 of the Instructions to determine your capital loss carryover
18 79 20
21 22 23
24
25 26 27
If line 24 is greater than line 22, go to line 25 Otherwise, skip lines 25 through 31 and go to line 32
, , . . 25 1
H the amounts on lines Zt and 26 era the same, skip lines 32 through 35 and go to line 36
32 Enter the smaller of line 18 or line 21 , , , , . , . , . . , , , , . . . 32
33 Enter we amount, d any, from line 26 . . . . . . . . . . . . . . . . 33 34 Subtract line 33 from line 32 . . . . . . . . . . . . . . . , . , . , 34
35 Multiply line 34 by 20% ( 20) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
J5A t F 7770 7 000
Duplicate Affidavits of this Publication have been filed in the office of PROOF OF PUBLICATION County Court El Clerk otDist Court . County C lerk L I Sec S t ate`.
ss
R+meni to paragraph 6107(A) of the Internal Revenue ('.ode o(1986. an amended, noi,ce a hereby given that the return of lh Slmburg Family Chan-uble Trvst, 0 pnvue foundation, for the fiscal year coded December 31, 2001 u mflhble for inspection n KPMG has Manvuc4 LIP, Two Central Put PLua. Suite 1501, Omaha, Nebnaka, during miler business hours from 9 W a m 11 4 00 p m by any rnven -ho quest. a W npm 180 days filer the fine of the publication
The Foundation 's registered address is IUU40 Regency circle, Suite 200, Omaha, Nebraska 68114, and ire rtgmered gem n such address is D David Slmdup Phone number (102) 391 7900
Published In the Douglm County PaetC.-ulte Tuesday, May 7, 2002
Publishers Fee R 11 .78
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LegaF-Notice NOTICE OF AVAIIABI WTY OF ANNUAL REIURN
STATF_ (1F KIFRGACVA
COUNTY OF DOUGLAS
Penny Overmann , being duly sworn, deposes and says that he/she is P� t,t i shPr of DOUGLAS COUNTY POST-GAZETTE, a legal weekly newspaper published in the City of Elkhorn, Douglas County, Nebraska, printed in the English language, having a bona fide circulation in Douglas County in excess of 300 copies for more than 52 weeks last past, that the printed notice attached hereto was published in said DOUGLAS COUNTY POST-GAZETTE for one week, on May 7 , 2002
and said newspaper was during that time and has since been in general circulation in said County and State, and that said newspaper was
panted in whole or in part in the office maintained at place of publication
V Subscribed in my presence, and sworn to before me
this 7th day of May ,2002
NOTARY-SW of Nebraska BARBAAAJ.KRUSE
Ity famta E~. IW~78r7A