Return of Private Foundation
F- 990-PF
Or Section 4947(a)(1) Nonexempt Charitable Trust Treated as a Private Foundation
Note : The organization ma be able to use a copy o/ this return to cabs state reporting requirements.
Department of the Treaury
Internal ~u. s.rwce
For calendar
o
Otherwise,
print
or type.
(n
Amended return
Number and street (or P .O . box number if mail is not delivered to street address)
Room/suite
(402) 536-5588
Z Section 501 (C~q exempt private foundation
H Check type of organization :
Section 4947( a )( 1 ) nonexem pt charitable trust
Other taxable private foundatic
I Fair market value of all assets at end
Accounting method :
Cash ~J Accra
~ Other (specify) ----------of year (from Part !l, col. (c), line
(Part l, column (d) must be on cash basis.)
16)00- $
1 , 597 , 853 .
1
Con Vrbutans
2
Check 1
3
Interest on savings and temporary cash investments
4
51, 806
Dividends and interest from securities
"'-
9
Income modifications
10 8 Gross sales less returns
" " " " " " " " "
b
ss Cos~~d Eo~,
c
ro
11
tort
c=
~n
A
~
-
Y'~~F ~~`"^
-_
~a X "
,bye
th
o~fBIS~T }I N.
.~. . .. .. .. .
T
13
C m
is
PeMIUM 151115-W-employee benefits
_Iher
o
.
1 D
E
It private foundation status was tertrdnated
under section 5o7(b)(1xA), check here . 1
F
If the foundation la in a6o-month termination
under section so7(b)(1)(B), check here , 1
I
(d) Disbursements
for charitable
purposes
_
___~ -.I- . UbL
, etc
-
~~
6.
`
- 1, -*;,
_-'~>
1 1.
_
_ ----r.~r_ .a
attac sc
12
2 . Foreign organizations meeting the
BS% test, check here and attach
computation . . . . . . . .
7 Foreign organizations, check here
(c) Adjusted net
income
--
52
Capital gam net income (from Part IV, line 2)
Net short-term capital gain . . , . . . . .
8
,I
I
I-J
"
51 .806
52,846
-
499, 414
assets on pine sa
7
"
"
k
-
6 e Net gam or (loss) horn sale of assets not on line 10
b Gross sales puce for all
.
o
_ .__ ._ .
"
"
.
I, . . .,Y
5 a Gross rents , . . . , , , , . . , , , , . .
m
I
b Net inves nent
income
its, Oronts, etc , received (attach schedule)
if the foundation is not required to
attach Sch B
b Netrental income or(loss)
47-6141512
B Telephone number (seepage 70 of
the instructions)
C If exemption application B
pending, check here " "
D
~a) Revenue and
expenses per
Name charn
A Employer IdsntHlcatlon number
M 68508
Analysis of Revenue and Expenses
(The iota! of amounts in columns (b), (c), and
(d) may not necessarily equal the amounts m
column a see page 1 f of the instructions .
05/31/Z005
Address change
I
1COMRnC CH11IlIT118LS TRUST 1573-25175000
LII~00
~oo
, 2004, and ending
06/01
Final return
s.. spe,m, 1fiI+LB lr]IRdO MM, 1Z48 0 BT ., 4TH FLOOR
Instructions . City or town, state, and ZIP code
d
Q
ear beginni ng
Initial return
Name of organization
C=)
W
Z
ear 2004 or tax
G Check all that a
Use the IRS
OMB No 1545-0052
10-1,652 .1
104
4.
6ff~waga
:sr
. . . . .
, , , , ,
16@ Legal lees (attach schedule) , , , , , , , ,
44 b Accounting fees (attach schedule) , , , , ,
c Other professional fees (attach schedule) . . ,
17
Interest , , , , , , , , , , , ,
1e
Taxes (attach schedule) (see gape 14 of tang")
19
49
, , , ,
20
Occupancy . . , ., .
21
Travel, conferences, and meetings , , , , , ,
4 22
Panting and publications
c 23
Other expenses (attach schedule)
Total operating and administrative expenises.
a
Add lines 13 through 23
X 25
Contributions, gifts, grants paid , , , , . .
27
, . . ,
. . .
Subtract line 26 from line 12:
Excess o1 nvenw over e3perissis and disbursements
b Net Investment Income (if negative, enter -0-)
JSA
10
. . .
all 24
I
4,2
Depreciation (attach schedule) and depletion
c walusua net woomi in negative, enter -u-) . . L. __ . . ~
566
23
77
100 566
4 .086
-
y
14,72
_ _}~0 89, 9 2
_ ..,~,~..,.. .. .
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions.
4E1.102000
I1C1535 7250 09/13/2005 09s14s17
4,674 .
77,000 .
81~674 .
14,72
1573-25175000
Form 990-PF (2ooa)
3
8 0
1
min of ear
Book Value
Hicacnea scneou~es ana amounts m me
1
2
3
Balance Sheets description column should be for
end-of-year amounts only (See instructions
Cash - non-interest-bearing , , , , , , , , , , , , , , , , ,
Savings and temporary cash investments , , , , , , , , , ,
5
Accounts receivable
Less : allowance for doubtful accounts
Pledges receivable
- Less : allowance for doubtful accounts 0Grants receivable ,
6
Recelvables due from officers, directors, trustees, and other
4
7
8
9
13
14
15
16
Less : allowance for doubtful accounts t
Inventories for sale or use , , , , , , , , , , , , , , , , ,
Prepaid expenses and deferred charges , , , , , , , , ,
c Investments - corporate bonds (attach schedule)
$~T ,6 ,
Investments-land, buildings,
---_- - - - r±
111111~___________
and equipment basis
Less accumulated depreciation Ill
___________________
(attach schedule)
Investments - mortgage loans , , , , , , , , , , , , , , ,
Total assets (to be completed by all filers - see page 16 of
the Instructions . Also see
N
X24
Deferred revenue
Mortgages and other notes payable (attach schedule)
Other liabilities (describe
,
,
,
7 "^'Jr~s
_
Y~ Y
n " O"7
a
7LC_
7
, '
, `7
1,455,188
)
NONE
Total liabilities add lines 17 throu g h 22 Organizations that follow SFAS 117, check here " "
NOIi
and complete lines 24 through 26 and lines 30 and 31 .
Unrestricted . . ., . . . . . ., . . . . . ., . . .,
. , . , . Organizations that do not follow SFAS 117,
check here and complete lines 27 through 31 .
t Fx
Capital stock, trust principal, or current funds . . . . . . . . .
1,449,507 .
1,455,188
1,449,507 .
1,455,188
1,449,507 .
1,455,188
Paid-in or capital surplus, or land, bldg , and equipment fund
h 29
Retained earnings, accumulated income, endowment, or other funds
Y 30
Total net assets or fund balances (see page 17 of the
31
J.
302,805 .
1,075,326 .
192,974 .
,
10-
Permanently restricted " " " " - " " " " . " " " -
z
298,869 .
946,367 .
183,204 .
, . Temporarily restricted
28
777-,7
Loans from officers, directors, trustees, and other disqualified persons
pip 26
0 27
7
coo 25
c
ii
d(° ~_
1 .449,507 .1
e 1 item I
Grants payable
23
148,436 .
885,573 .
235,693 .
FIMM71"M 111`1~"'
Investments - other (attach schedule) , , , , , , , , , , , ,
Land, buildings, and
,
equipment: basis
___________________
Less . accumulated depredation 0i,,
(attach schedule)
-------------------)
Other assets (describe "
18
~ 21
:3
22
77
Other notes and loans receivable (attach schedule)
Accounts payable and accrued expenses , , , , , , , , , ,
20
26,748 .
disqualified persons (attach schedule) (see page 15 of the instructions)
17
X19
26,748 .
+
b Investments - corporate stock (attach schedule) , 87W ,5,
12
Page 2
End of ear
b Book Value
c Fair Market Value
178,805 .
i( 108 Investments - U S. and state government obligations (attacOIM614
11
47-6141512
,
instructions) . . . . . . . . . . . . . . . . . , . . . . . .
Total liabilities and net assets/fund balances (see page 17 of
the instructions
Analysis of Changes in Net Assets or Fund Balances
1 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 prior year's return) , , , , , , , , , , , , , , , , , , , , , , , , ,
1
1,449,507 .
2 Enter amount from Part I, line 27a ,
2
41086 .
2,001 .
8 Other increases not included in line 2 (itemize) "_ S$E STA3
and
3~
-4~-.
5
406 .
5 Decreases not included in line 2 (itemize) t ____ $~ STAT~IQ'P 8
11 455,188 .
6 Total net assets or fund balances at end of ear line 4 minus line 5 - Part II column b line 30 . . . . . 6
Form 990-PF (2ooa)
J9A
" E 1420 2 000
I1C2535 F250 09/13/2005 09 :14 :17
1573-25175000
4
-
47-6141512
r
Form 990-PF
kol now
acquired
P-Purchase
D-Donation
(a) List and describe the kind(s) of property sold (e .g., real estate,
2-story brick warehouse ; or common stock, 200 shs. MLC Co.)
SEE PART N SCHSDULB
is
b
c
d
e
(e) Gross sales price
3
(g) Cost or other basis
plus expense of sale
(f) Depreciation allowed
(or allowable)
(c) Date
acquired
(mo. Qday, Yr.) ~
(d) Date sold
(mo., day. Yr.)
(h) Gain or (loss)
(e) plus (f) minus (g)
C
B
om lete onl y for assets showin g g ain in column h and owned b the foundation on 12/31/69
(k) Excess of col . (i)
U) Adjusted basis
(I) F .M .V . as of 12/31/69
as of 12/31/69
over col. Q), If any
(1) Gains (Col . (h) gain minus
col . (k), but not less man -0-) or
Losses (from col . (h))
If gain, also enter in Part I, line 7
If (loss), enter -0- in Part I, line 7
} 2
3 Net short-term capital gain or (loss) as defined in sections 1222(5) and (6) :
If gain, also enter in Part I, line 8, column (c) (see pages 13 and 17 of the instructions) .
If loss , enter -0- in Part I, line 8
~ 3
Qualification Under Section 4940 ( e ) for Reduced Tax on Net Investment Income
(For optional use by domestic private foundations subject to the section 4940(a) tax on net investment income )
2 Capital gain net income or (net capital loss) " " " " "
{
52,846 .
If section 4940(d)(2) applies, leave this part blank .
Was the organization liable for the section 4942 tax on the distributable amount of any year in the base period . . . .
I f " Y e s," th e orga nization d oes not q u a lify unde r sec tion 4 94 0(e) . Do not complet e thi s par t
1
F-]Yes F--A No
Enter the appropriate amount in each column for each year ; see page 18 of the instructions before making any entries.
a)
Base period years Calendar year
(or tax year beginning in)
2003
2002
2001
2000
1999
~b~
Adjusted qualifying distributions
77,062
89,623
96,688
93,582
86,600
(~)
Net value of noncharitable-use assets
.
.
.
.
.
1,559,173
1,454,368
1,738,013
1,967,069
1,991,732
col
.
.
.
.
.
Distribution
~
ratio
b divided b col
c
0 .04942491949
0 .06162333055
0 .05563134453
0 .04757433522
0 .04347974527
2
3
Total of line 1, column (d) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Average distribution ratio for the 5-year base period - divide the total on line 2 by 5, or by
the number of years the foundation has been m existence if less than 5 years , , , , , , , , ,
2
0 .25773367506
3
0 .05154673501
4
Enter the net value of noncharitable-use assets for 2004 from Part X, line 5
4
1,562,196 .
5
Multiply line 4 by line 3 . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
80,526 .
6
Enter 1% of net investment income (1% of Part 1, line 27b)
6
899 .
7
Addlines 5and6 , . . . . I 7 1
8
Enter qualifying distributions from Part XII, line 4, , , , , , , , , , , , , , , , , , , , , , , , , 1 8 1
81,674 .
If Nne 8 is equal to or greater than line 7, check the box in Part VI, line 1b, and complete that part using a 1% tax rate See the Part VI instructions on page 18
JSA
4E I430 2 000
I1C2535 F250 09t13/2005 09 :14117
, , , , , , , , , , , , , , , , , , ,
1573-25175000
81,425 .
Form 990-PF (2004)
5
Form
47-6141512
Excise Tax Based on Investment Income i
4
or 4948 - see oaae 18 of the
1 a Exempt operating foundations described in section 4940(d)(2), check here
1 u and enter 'N/A' on line 1
- -
Date of ruling letter : _ _ _ --- _ _ _ (attach copy of ruling letter if necessary - see Instructions)
b Domestic organizations that meet the section 4940(e) requirements in Part V, check
here " V and enter 1 % of Part 1, line 27b
_.r. -
899 .
1
c All other domestic organizations enter 2% of tine 27b Exempt foreign organizations enter 41/6 of Part 1, line 12, col (b)
Tax under section 511 (domestic section 4947(a)(1) trusts and taxable foundations only . Others enter -0-)
2
3
4
5
6
e
b
c
d
Add lines 1 and 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Subtitle A (income) tax (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter
Tax based on investment Income. Subtract line 4 from line 3 . If zero or less, enter -0- , , , , , , , ,
Credits/Payments:
2004 estimated tax payments and 2003 overpayment credited to 2004 , , ,
6a
Exempt foreign organizations - tax withheld at source , , , , , , , , , , , ,
61b
Tax paid with application for extension of time to file (Form 8868), ,
6c
Backup withholding erroneously withheld , , , , , , , , , , , , ,
6d
7
Total credits and payments . Add lines 6a through 6d " "
g
Enter any penalty for underpayment of estimated tax Check here " E] "if Form 2220 is attached
g
10
11
. . . . .
-0-) , , ,
, , , , ,
s
899 .
a
NONE
s
899 .
t~
3,396 .
NO
NONE
" " . . . . . . . . . . . . . . . . . . . . .
, , , , , , , , , , ,
Tax due . If the total of lines 5 and 8 is more than line 7, enter amount owed , , , , , , , , , , , , , , , , 1111.
Overpayment If line 7 is more than the total of lines 5 end 8, enter the amount overpaid , ,
, , , , , , 10,
Enter the amount of line 10 to be : Credited to 2005 estimated tax jp~
90 0 . Refunded 10,
Activities
7'
3,396 .
S
9
2,497 .
1,597 .
io
11
1 a During the tax year, did the organization attempt to influence any national, state, or local legislation or did
it participate or intervene in any political campaign? , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,
b Did it spend more than $100 during the year (either directly or indirecfly) for political purposes (see page
19 of the Instructions for definition)? , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,
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 organization in connection with the activities .
c Did the organization file Form 1120-POL for this year? , , , , , , , , , , , , , , . , . _ , . . . , . . . . . . . . . . . .
d Enter the amount (if any) of tax on political expenditures (section 4955) imposed during the year
(1) On the organization 00- $
e
.s
1a
Yes
-
No
X
1b
x
1c
X
2
X
3
X
(2) On organization managers 1 $
Enter the reimbursement (if any) paid by the organization during the year for political expenditure tax imposed
on organization managers
jo~ $
2
Has the organization engaged in any activities that have not previously been reported to the IRS
3
Has the organization made any changes, not previously reported to the IRS, in its governing instrument, articles
4a
Did the organization have unrelated business gross income of $1,000 or more during the year?
, . , , . , , . , , . . . .
If "Yes," attach a detailed description of the activities
of incorporation, or bylaws, or other similar instruments? I/ "Yes,"attach a conformed copy of the changes
, , , , , , , , , ,
, , , , , , , , , , , , , , ,
b If "Yes," has it filed a tax return on Form 990-T for this years , , , , , , , , , , , . , , , . . . . . . . . . . . . . . . . .
5
Was there a liquidation, termination, dissolution, or substantial contraction during the years , , , , , , , , , , , , , , , , .
6
Are the requirements of section 508(e) (relating to sections 4941 through 4945) satisfied either
X
4a
/A
4b
5
If 'Yes,' attach the statement required by General Instruction T
By language in the governing instrument, or
By state legislation that effectively amends the governing instrument so that no mandatory directions
7
8a
that conflict with the state law remain in the governing instruments
, , , , , , , , , , , , , , , , , , , , , , , , , ,
7
Enter the states to which the foundation reports or with which it is registered (see page 19 of the
instructions) jo. SEE STATEMENT 9
b If the answer is "Yes" to line 7, has the organization 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 , , , , , , , , , , , , ,
9
Is the organization claiming status as a private operating foundation within the meaning of section 49420(3)
or 49420(5) for calendar year 2004 or the taxable year beginning in 2004 (see instructions for Part XIV on
page 25)? If "Yes," complete Part XIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10
Did any persons become substantial contributors during the tax year? // 'Yes," attach a schedule listing rheirnames and addresses ,
11
Did the organization comply with the public inspection requirements for its annual returns and exemption application?
N/A
Web site address "
e books are n care o
_i __ . _________--______ e ep one no.
13
6
Did the organization have at least $5,000 m assets at any time during the years if "Yes,"complete Part Il, col (c), and Part XV
Located at lo. _ 1248 0 ST. ,_ 4TH FLOOR, LINCOWN13
ZIP+4 " _____ 68508
Section 4947(a)(1) nonexempt charitable trusts filing Form 990-PF in lieu of Form 1041 - Check here . . .
. .
and enter the amount of tax-exempt Interest received or accrued during the year .
. 001 1 13
JSA
4E1440 2 000
I1C2535 7250 09/13/2005 09s14 :17
1573-25175000
. . .
8b
-
fi-
}9
10
X
X
. . . . . . . .
Form 990-PF (2004)
6
-
'
Form X90-PF
Statements Regarding Activities for Which Form 4720
47-614151a
5
Be Required
File Form 4720 if any item Is checked in the "Yes" column, unless an exception applies.
.
1a During the year did the organization (either directly or Indirectly) :
(1) Engage in the sale or exchange, or teasing of property with a disqualified person? , , , , , , ,
(2) Borrow money from, lend money to, or otherwise extend credit to (or accept it from)
a disqualified person? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(3) Furnish goods, services, or facilities to (or accept them from) a disqualified person? . . . . . . .
(4) Pay compensation to, or pay or reimburse the expenses of, a disqualified person? . . , . . . , ,
Yes
R No
Yes
Yes
Yes
R No
X No
(5) Transfer any income or assets to a disqualified person (or make any of either available
Yes
for the benefit or use of a disqualified person)? . . . . . . . . , . . . . . . . . . . . . . . . .
Eg No
(6) Agree to pay money or property to a government official? (Exception. Check "No"
if the organization agreed to make a grant to or to employ the official for a period
Yes
a No
after termination of government service, if terminating within 90 days .) . . . . . . . . . . . . .
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 page 20 of the Instructions)? " " " " " a
Organizations relying on a current notice regarding disaster assistance check here , . , . . . . . . . . .
c Did the organization 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 2004? . . . . . , , . . , , , . , . . . . , . . . . .
2 Taxes on failure to distribute income (section 4942) (does not apply for years the organization was a private
operating foundation defined in section 4942(j)(3) or 49420(5)) :
a At the end of tax year 2004, did the organization have any undistributed income (lines 6d
Yes
a No
and 6e, Part XIII) for tax year(s) beginning before 2004? . . . . . . . . . . . . . . . . . . . . . .
If 'Yes.' list the years " ---------- ~--------- '--------- ~--------b 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 of assets) to the year's undistributed income? (If applying section 4942(a)(2)
to all years listed, answer 'No' and attach statement - see page 20 of the instructions.) . . . . . . . . . . . . . . . . . . . .
c If the provisions of section 4942(a)(2) are being applied to any of the years listed in 2a, list the years here .
3a
1
'---------'--------Did the organization hold more than a 2% direct or indirect interest in any business
.
Yes
enterprise at any time during the years , , , , , , , , , , , , , , , . . , , , . , , , , , , , , ,
b
~a;
I
No
~ `9
k
;:mt
16
.`
#'-1,fifX
1'
c
'7
X
1` n -s b
2b
H
r
N A
42
X No
If "Yes," did it have excess business holdings in 2004 as a result of (1) any purchase by the organization
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 periods (Use Schedule C, Form 4720, to determine
4a
b
if the organization had excess business holdings in 2004 )
. , . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . , .
Did the organization invest during the year any amount in a manner that would jeopardize it charitable purposes
3b
NIA
4a
Did the organization 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 2004?
5a
. . . . . . .
During the year did the organization pay or incur any amount to
(1) Carry on propaganda, or otherwise attempt to influence legislation (section 4945(e))9 , , , , , ,
(2) Influence the outcome of any specific public election (see section 4955), or to carry
on, directly or indirectly, any voter registration drives
(3) Provide a grant to an individual for travel, study, or other similar purposes . . . . . . . . . . . ,
(4) Provide a grant to an organization other than a charitable, etc , organization described
in section 509(a)(1), (2), or (3), or section 4940(d)(2)? , , , , , , , , , , , , , , , , , , , , ,
(5) Provide for any purpose other than religious, charitable, scientific, literary, or
educational purposes, or for the prevention of cruelty to children or animals?
, , , , , , , , , ,
X
. , , , , . . . , . .
~ Yes
IX No
Yes
X No
e Yes
e
X No
Yes
Ex No
~ Yes
X 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 m a current notice regarding disaster assistance (see page 20 of the instructions)? " ~ Organizations relying on a current nonce regarding disaster assistance check here , . . . . , . . . . , ,
c Ii the answer is `Yes" to question 5a(4), does the organization claim exemption from the
tax because it maintained expenditure responsibility for the grant? . . . , , . . . . , . . . . . . , a yes
El No
If "Yes," attach the statement required by Regulations section 53 .4945-5(d).
6 a Did the organization, during the year, receive any funds, directly or indirectly, to pay
Yes
premiums on a personal benefit contract? , , , , , , , , , , , ,
, , ,
, , , ,
, , , , , , ,
E~ No
mza"n
got,cruiingtar, pay premwms, erect y
in ikon a personal benefit cotrF
If you answered 'Yes' to 6b, also file Form 8870.
F
s
117
Form 990-PF (2004)
JSA
4E 1450 2 000
I1C2535 F250 09/13/2005 09 :14 :17
A
1573-25175000
7
47-614151a
Forth 990-PF (2004)
Page s
-Information About Officers, Directors, Trustees, Foundation Managers, Highly Paid Employees, and Contr actors
List all officers, directors, trustees, foundation managers and their compensation see page 20 of the Instructions).
1
Ca1 Name and address
(b) Title, and average
, hours .per week
8EE STATSI~NT 1- -------------------- ~
c) Compensation
(~f not paid, enter
~
(d) contributions to
employee benefit plans
18,697 . 1
-0-
(e) Expense account,
other allowances
-0-
1
-----------------------------------2
Compensation of five highest-paid employees (other than those included on line 1 - see page 21 of the instructions).
If none, enter "NONE."
(a) Name and address of each employee paid more then $50,000
Title and average
rohours per week
devoted to P
position
(c) Compensation
NONE
(~ Contributions to
employee benefit
plans and deferred
compensation
(e) Expense account,
other allowances
--------------------------------------------------------------------------------------------------------
Total number of other employees paid over $50,000
."
3
Five highest-paid independent contractors for professional services - (see page 21 of the instructions). If none, enter
"NONE ."
(a) Name and address of each person paid more than $50,000
NONE
(b) Type of service
---------------------------------------------------- 1
Total number of others receiving over $50,000 f or professional services
NONE
(c) Compensation
, ."
NONE
Summary of Direct Charitable Activities
List the foundation's four largest direct charitable activities during the tax year Include relevant statistical information such as the number
of organizations and other beneficiaries served, conferences convened, research papers produced, etc
1
2
3
menses
NONE
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Form 990-PF (2004)
JSA
" E 1480 2.000
I1C1535 7250 09/13/2005 09s14 :17
1573-25175000
8
-
Form 990-PF
mary
Describe the two Ian,
1
tQON$
a7-siaisia
see page
z
investments made by the foundation during the tax vear on lines 1 and 2 .
Amount
---------------------------------------------------------
-----------------------
----------------------------------------------------------
-----------------------
2
All other program-related investments See page 22 of the instructions
3
NONE
------------------------------------
---------------------------------------------------------------------
lines 1 through 3
Minimum Investment Return (All domestic ~foundations must complete this part. Foreign fo
see page 22 of the instructions .)
1
a
b
c
d
e
2
S
4
5
6
Fair market value of assets not used (or held for use) directly in carrying out charitable, etc.,
purposes :
Average monthly fair market value of securities . . . . , . . . . . . . . . . . . . . . . . . . . .
Average of monthly cash balances, .
, , , . , . . . , . , , , . . , , , , , . , , , , , , , ,
Fair market value of all other assets (;~e page 22 of the instructions) , . , , , , , , , , , , , , ,
Total (add lines 1 a, b, and c) . . , .
. . . . . . . . .
. . . . . .
. , , . . . . . , . , .
Reduction claimed for blockage or other factors reported on lines 1a and
1 c (attach detailed explanation)
. . . , . . . . . . 1e
Acquisition indebtedness applicable ~to line 1 assets . . . . , . . . . . , . . _ . . . . , . . . . ,
Subtract line 2 from line 1 d
Cash deemed held for charitable activities . Enter 1 1 l2 *%'of Ime 3 (for greater amount, see page
of the instructions) .
. . . . . .
. . .
.
,
,
.
.
,
,
,
,
,
,
,
1,532,920 .
la
1b
1c
1d
.
,
,
.
53,066 .
NONE
1,585,986 .
:a= ;
r ~4a
. . . .
2
3
23
. . .
4
NOVA
1,585,986 .
23,790 .
1,562,196 .
Net value of noncharitable-use assets.~Subtract cline 4 from line 3 . Enter here and on Part V, line 4
5 Minimum investment return . Enter 5% of line 5
.
6
Distributable Amount (see page 23 of .the instructions) (Section 4942(j)(3) and (j)(5) private operating
78,110 .
fo unda tions and certai n foreig n org anizations chec k here pp. n and do not comp lete this part )
1
2a
b
c
3
4
5
6
7
Minimum investment return from Part X line 6 . . . .
. . . . .
. .
Tax on investment income for 2004 from Part VI, line 5 . . . . . . . . I 2a ~
Income tax for 2004 . (This does not include the tax from Part VI )
2b
Add fines 2a and 2b
Distnbutable amount before adjustments Subtract line 2c from line 1 . . . .. .
Recoveries of amounts treated as qualifying distributions , , , , , , , , , , ,
Add fines 3 and 4
Deduction from distnbutableamount (see page 23 of the instructions)
Distributable amount as adjusted . Subtract line 6 from line 5 Enter here and
. . . . . . . . . . . . .
899 .1
. . . . . .. .. . . . . . . . .
, , , , , , , , . , , , , ,
on Part X111,
78,110 .
1
899 .
77,211 .
NONE
2c
3
4
', 5
6
77,211 .
NONE
77,211 .
line 1
Qualifying Distributions (see page 23 of the instructions)
1
a
2
3
4
5
b
a
b
Amounts paid (including administrative expenses) to accomplish charitable, etc , purposes
Expenses, contributions, gifts, etc . - total from Part I, column (d), line 26 . . . . . . .
81,674 .
Program-related investments - total from Part IX-B
Amounts paid to acquire assets used (or held for use) directly in carrying out chardable, etc.,
purposes . . . .
. . .
. . . . . . . . . . . . . . . . . . . . .
Amounts set aside for specific charitable projects that satisfy the:
Suitability test (prior IRS approval required)
. . . , . . . . . . . . . . . . .
Cash distribution test (attach the required schedule) ~ . . . . . . . . . . . . . . . , . . . . . ,
NaneE
NONE
NONE
NONE
81,674 .
Qualifying distributions . Add lines 1 a through 3b. Enter here and on Part V, line 8, and Part XIII, line 4 . , , ,
Organizations that qualify under section 4940(e) for the reduced rate of tax on net investment
income . Enter 1 % of Part t, line 27b (see page 24 of the instructions)
899 .
Note : The amount on line 6 will be used in Part V, column (b), in subsequent years when calculating whether the foundation
qualifies for the section 4940(e) reduction of tax in those years.
Form 990-PF (2004)
J9A
4E7470 2 000
I1C2535 F250 09/13/2005 09 :14 :17
1573-25175000
9
-
47-6141512
Form 990-PF (2004)
Page 8
Undistributed Income (see page 24 of the instructions)
1
2
- -
Years prior to 2003
Corpus
2004
77,aii .
a Enter amount for 2003 only , , , , , , , , ,
2002
Excess distributions car
,
ver, if any, to 2004NONE
NONE
NONE
13,191 .
1,364 .
a From 1999 , , , , ,
b From 2000 , , , , ,
c From 2001 , , , , ,
d From 2002 , , , , ,
e From 2003 , , , , , ,
f Total of lines 3a through e , , , , , , , , , ,
Qualifying distributions for 2004 from Part
x1 I, line a: t $
81,674 .
^;
3
1
-
~
N
~_
~~
-_-
d Applied to 2004 distnbutable amount, , , , ,
e Remaining amount distributed out of corpus , ,
5
Excess distributions carryover applied to 2004
(If an amount appears in column (d), the
same amount must be shown m column (a) )
6
Enter the net total of each column as
indicated below :
a Corpus Add lines 3f, 4c, and 4e Subtract line 5
77,211 .
NONE
"IT'
19,018 .
NOW
line 4b from line 2b
NO
d Subtract line 6c from line 6b Taxable
NONE
amount - see page 25 of the instructions
Undistributed income for 2003 Subtract line
4a from line 2a Taxable amount - see page
25 of the instructions
7
8
of the instructions) . . . . . . . . . . . . . . .
9
a
b
c
d
e
Excess distributions carryover to 2005 .
Subtract lines 7 and S from line 6a . . . . . . .
Analysis of line 9 :
NONE
Excess from 2000 . .
NONE
.
.
Excess from 2001
13
,191
.
Excess from 2002 . .
1
,
364
.
Excess from 2003 . .
Excess from 2004 . . .
4 .463 .
rsa,
4E1480 2 000
I1C2535 F250 09/13/2005 09 :14s17
~. '- ;,-
NO
c Enter the amount of prior years' undistributed . .
income for which a notice of deficiency has
been issued, or on which the section 4942(a)
tax has been previously assessed , , , , , , , ,
Undistributed income for 2004 Subtract
lines 4d and 5 from line 1 This amount must
be distributed in 2005
Amounts treated as distributions out of
" . .
corpus to satisfy requirements imposed by
section 170(b)(1)(E) or 4942(8)(3) (see page
25 of the instructions) . . ,
. , , .
Excess distributions carryover from 1999
not applied on line 5 or line 7 (see page 25
~5; x~~," 3t.,g
--,
HUM
b Prior years' undistributed income Subtract
f
.,
{"
b Applied to undistributed income of prior years
(Election required - see page 24 of the instructions)
c Treated as distributions out of corpus (Election
required - see page 24 of the instructions)
iA
wyt
14,, 555 . __,
s Applied to 2003, but not more than line 2a
10
2003
Undistributed income, if any, as of the end of 2003
b Total for prior years
3
4
Distributable amount for 2004 from Part XI,
line 7 . . . . . . . . . . . . . . . . . . . .
NO
NONE
NO
NO
19 .018 . .
__
~-
~-
rah-
Z
p
iA
;
.~
1573-25175000
10
-
980-PF
47-6141512
id Part VII-A, q
e
If the foundation has received a ruling or determination letter that it is a private operating
foundation, and the ruling Is effective for 2004 . enter the date of the ruling . . . . . . . . . . . .
b Check box to indicate whether the organization is a
operating foundation described in section
Tax year
Prior 3 years
1a
2"
Enter the lesser of the
adjusted net Income from
Part I or the minimum
investment return from Part
X for each year Wed . .
b
85% of line 2a
C
Qualifying distributions from Part
(a) 2004
2003
(c) 2002
9
01.1
or
2001
(e) Total
I
. , . . .
Xll, line 4 for each year listed
d
3
O
b
C
Amounts included in line 2c not
used directly for active conduct
of exempt acmies ,
Qualifying distributions made
directly for active conduct of
exempt activities Subtract
line 2d from line 2c . . . . .
Complete 3a, b, or c for we
alternative test relied upon
'Assets' alternative test - enter
(11 ) Value o1 all assets . . .
(2) Value of assets qualifying
under section
4942U)(9)(Bxi) . . . . .
'Endowment' alternative testenter Z3 of minimum
Investment return shown In
Part X, line 8 for each year
listed . . . . . . . . . .
*Support* alternative test - enter
(1) Total support other than
prose 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(I)(3)(B)(u0
Largest amount of support
from an exempt
organization
Supplementary Information (Complete this part only if the organization had $5,000 or more in
assets at any time during the year - see page 26 of the 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 $5,000) (See section 507(d)(2) )
NONE
b
List any managers of the foundation who own 10% or more of the stock of a corporation (or an equally large portion of the
ownership of a partnership or other entity) of which the foundation has a 10% or greater interest
NONE
2
Information Regarding Contribution, Grant, Gin, Loan, Scholarship, etc ., Programs :
Check here
a
1 0 if the organization only makes contributions to preselected charitable organizations and does not accept unsolicited requests fog funds
If the organization makes gifts, grants, etc (see page 26 of the instructions) to individuals or organizations under other conditions, complete items 2a, b, c, and d
The name, address, and telephone number of the person to whom applications should be addressed :
SEE STATEMENT 11
b The form in which applications should be submitted and information and materials they should include:
SEE ATTACKED STATSNMNT 8
c
Any submission deadlines :
e
asp
ir~Y
d Any restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other
factors: 8$S ATTACHED STATMU1'P 8
JSA
4E14902000
=1C2535 F250 09/13/2005 09 :14 :17
1573-25175000
Form
990-PF (2004)
11
-
47-614151a
Form 990-PF (2004)
Page 1 0
3
Supplementary Information (continued)
Grants and Contributions Paid During the Year or Approved for Future Payment
Recipient
Name and address (home Of bUSIneSS~
a Paid during the year
If recipient is an individual,
snow any relationship to
any foundation manager
or substantial contributor
Foundation
status
reci Ppient
purpose of grant or
Amount
contribution
SEE sTArrr 12
t 3a
Total
b Approved for future payment
77,000 .
i./ G,i E
" 3b
Total .
JSA
4E 1491 2 000
I1Ca535 F250 09/13/2005 09s14 :17
1573-25175000
Form 990-PF (2004)
12
-
a7-siaisia
Form 990-PF
Analysis of Income-Pra
Enter gross amounts unless otherwise indicated.
Unrelated business income
Business
code
1 Program service revenue :
a
b
c
d
e
t
g
Activities
Amount
Page 1 1
Excluded b section 512, 513, or 514
(c)
(d)
Exclu ion
Amount
code
Related or
function i
See page
t e instructions .
Fees and contracts from government agencies
2 Membership dues and assessments , , , , ,
3 Interest on savings and temporary cash investments
4 Dividends and interest from securities
5 Net rental income or (loss) from real estate :
a
Debt-financed property , , , , , , , , ,
b
Not debt-financed property
51,806 .
14
~
.-
Y
, , , , , , ,
6 Net rental income or (loss) from personal property
7
8
9
10
11
Other investment income , , , , , , , , , ,
Gain or (loss) from saes of assets other than Inventory
Net income or (loss) from special events , , ,
18
Gross profit or (loss) from sales of inventory . .
Other revenue : a
b
c
d
e
12 Subtotal . Add columns (b), (d), and (e) , , , ,
52,846 .
~
104, 652 .
13 Total. Add line 12, columns (b), (d), and (e) , , , , , , , , , , , , , , , , , , , , , , . , , . , . . . , , , . . 13
(See worksheet in lire 13 instructions on page 26 to verify calculations )
104,652 .
Relationship of Activities to the Accomplishment of Exempt Purposes
Line No.
Explain below how each activity for which income is reported in column (e) of Part XVI-A contributed importantly to
the accomplishment of the organization's exempt purposes (other than by providing funds for such purposes) (See
page 27 of the instructions )
NOT APPLICABLE
JSA
4E1492 2 000
Form 990-PF (2004)
I1C3535 F250 09/13/2005 09 :14 :17
1573-25175000
13
Form 990-PF 2004
1
47 -6141512
Page 1 2
Information Regarding Transfers To and Transactions and Relationships With Noncharitable
Exempt Organizations
Did the organization directly or indirectly engage in any of the following with any other organization described in section
501(c) of the Code (other than section 501(c)(3) organizations) or in section 527, relating to political organizations?
a Transfers from the reporting organization to a noncharitable exempt organization of:
(1)Cash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(2) Other assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b Other transactions :
(1) Sales of assets to a nonchantable exempt organization , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,
(2) Purchases of assets from a noncharitable exempt organization , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,
(3) Rental of facilities, equipment, or other assets , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,
(4) Reimbursement arrangements , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,
(5) Loans or loan guarantees , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,
(B) Performance of services or membership or fundraising solicitations , , , , , , , , , , , , , , , , , , , , , , , , , , ,
c Sharing of facilities, equipment, mailing lists, other assets, or 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 goods, other assets, or services given by the reporting organization . If the organization received less than fair
market value m any transaction or sharing arrangement, show fn column (d) the value of the goods, other assets, or services
1
Yes No
777-~
1a1
. 18 (2)
,
x
A
1 b(1)
, 1 b ( 2)
1 b ( 3)
1b 4
1b 5
, 1b 6
,
1c
x
Y
X
X
X
X
X
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)) or in section 527
b If "Yes," complete the followin g schedule
(a) Name of organization
(b) Type of organization
, , , , , , , , , , , , , , , , , ,
D Yes EX No
(c) Description of relationship
Under penalties of penury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and
belief, U true^rrect, and comyLete Qeclaratiop of preparer (other than taxpayer or fiduciary) is based on all information of which preparer has any knowledge
G1
Z
C
Si
azure of officer or trustee
>~ Preparer's
~
'o W O signature ' (! " 1
u°r Firm's name (or yours if
self-employed), address,
and ZIP code
JSA
XT811 1000
VICE PRESIDENT &
' 1CPMG LLP
O1QE 1CAISSR PLAZA,
IlC2535 F250 09/13/2005 09 :14 :17
FORM 990-PF - PART IV
CAPITAL GAINS AND LOSSES FOR TAX ON INVESTMENT INCOME
Kind of Property
roes sale
price less
Depreciation
allowed/
Date
acquired
Gain
or
Description
Cost or
other
FMV
as of
Adj . basis
as of
Ewcess o
FMV over
TOTAL LONG-TERM CAPITAL GAIN DIVIDENDS
11
350 . ANADARKO PETROLEUM CORD
24,601 .
15,014 .
13,125 .
07/10/a00a
PROPERTY TYPE : SECURITIES
16,026 .
300 . CARDINAL MIAIrTB INC COM
PROPERTY TYPE: SECURITIES
PROPERTY TYPE : SECURITIES
50,000 .
4E 1730 1 000
07/07/1993
9,400 .
01/12/1990
2,227 .
07/07/2004
6,777 .
PROPERTY TYPE : SECURITIES
01/12/1990
3,341 .
09/22/2004
11,272 .
4 .125
05/21/2004
50,558 .
12/01/2004
-558 .
50000 . FEDL NATL MTG ASSN NOTES 6 .5
PROPERTY TYPE : SECURITIES
49,827 .
IK2535 F250 09/13/2005 09 :14 :17
07/07/2004
7,692 .
PROPERTY TYPE : SECURITIES
PROPERTY TYPE : SECURITIES
09/27/2004
-2,606 .
PROPERTY TYPE : SECURITIES
50000 . FED HOME LN BR
50,000 .
08/26/2004 02/22/2005
07!23/1999
PROPERTY TYPE : SECURITIES
18,811 .
300 . EXXON MOBIL CORPORATION
14,613 .
1
7,493 .
200 . EXXON MOBIL CORPORATION
9,004 .
07/27/2009
axes .
13,754 .
400 . DU PONT (S .I .) DS NEMOURS &
17,092 .
11/01/1999
8,842 .
700 . DISNEY (WALT) CO
16,205 .
07/06/2009
4,128 .
aoo . CONSTELLATION sins INC
21,247 .
10/x5/2009
9,587 .
600 . BARNES & NOBLE INC
20,154 .
6,638 .
08/27/x003
PROPERTY TYPE : SECURITIES
Date sold
09/18/2000
1573-25175000
08/15/2004
173 .
15
-
FORM 990-PF - PART IV
CAPITAL GAINS AND LOSSES FOR TAX ON INVESTMENT INCOME
Date
Date sold
Kind of Property
Description
acquired
roes sale
Depreciation
Cost or
FMV
Adj . basis
Excess of
Gain
price less
allowed/
FMV over
or
other
as of
as of
ens of ale
w ible
hagis
12/31/69
12/31/69
ad' basis
(loss)
04/17/1995
531 .
530 .96 (GOVT NATL XTG 7188N POOL #3
PROPERTY TYPE : SECURITIES
532 .
04/17/1995
534 .
533 .67 GOVT NATL XTG ASSN POOL #3
PROPERTY TYPE : SECURITIES
535 .
04/17/1995
164 .
164 .26 GOVT NATL XTG ASSN POOL #3
PROPERTY TYPE : SECURITIES
165 .
04/17/1995
09/15/200
166 .
165 .59 GOVT NATL MG ASSN POOL #3
PROPERTY TYPE : SECURITIES
166 .
04/17/1995
10/15/200
166 .
166 .46 GOVT NATL XTG ASSN POOL #3
PROPERTY TYPE : SECURITIES
167 .
04/17/1995
11/15/200
168 .
167 .57 GOVT NATL XTG ASSN POOL #3
PROPERTY TYPE : SECURITIES
168 .
04/17/1995
12/15/200
169 .
168 .68 GOVT NATL MTG ASSN POOL #3
PROPERTY TYPE : SECURITIES
169 .
04/17/1995
01/15/200'.
170 .
169 .81 GOVT NATL XTG ASSN POOL #3
PROPERTY TYPE : SECURITIES
170 .
04/17/1995
02/15/200 .
774 .
774 .14 GOVT NATL MTG ASSN POOL #3
PROPERTY TYPE : SECURITIES
775 .
04/17/1995
03/15/200 .
144 .
143 .5 GOVT NATL MTG ASSN POOL #37
PROPERTY TYPE : SECURITIES
144 .
04/17/1995
04/15/200!
144 .
144 .46 GOVT NATL XTG ASSN POOL #3
PROPERTY TYPE : SECURITIES
145 .
,.ooo
I1C2535 F250 09/13/2005 09 :14 :17
1573-25175000
06/15/200
-1 .
07/15/200
-1.
08/15/x00
-1 .
-1 .
-1 .
-1 .
16
-
FORM 990-PF - PART IV
=0R TAX ON INVESTMENT INCOME
r
Kind of Property
roes sale
price less
Dep~
all
_
Description
;ost or
other
I
FMV
as of
I
Adj. basis
as of
I
Excess OT
FMV over
I I
_ Date
-
Date sold
Gal
or
191 .41 GOVT NATL MG ASSN POOL #3
PROPERTY TYPES SECURITIES
192 .
04/17/1995
300 . GENERAL BLEC CO
PROPERTY TYPE : SECURITIES
1,825 .
04/23/1991
400 . MERCK & CO INC
PROPERTY TYPE : SECURITIES
29,625 .
02/27/x001
.0606 NEENAH PAPER INC
PROPERTY TYPE : SECURITIES
06/07/2002
12/21/2004
6 . NEENAH PAPER INC
PROPERTY TYPE : SECURITIES
06/0712002
01/18/2005
07/07/2004
4,523 .
200 . PEPCO HOLDINGS INC
PROPERTY TYPE : SECURITIES
3,675 .
03/11/2004
18,091 .
800 . P$PCO HOLDINGS INC
PROPERTY TYPE : SECURITIES
15,940 .
191 .
9,918 .
18,500 .
a.
iss .
100,000 .
10,280 .
10,326 .
10,336 .
,730, o00
-1 .
-ao .
03/16/2005
2,151 .
DUE 0
01/29/1998
06/07/2002
400 . SUNGARD DATA SYSTEMS INC
PROPERTY TYPE : SECURITIES
05/10/2004
15,654 .
02/01/2005
454 .
400 . SBC CONIIKJNICATIONS INC
PROPERTY TYPE : SECURITIES
1573-25175000
03/16/2005
848 .
02/27/2001
Ilt2535 F250 09/13/2005 09 :14 :17
07/07/2004
-11,125 .
400 . SBC COMIIKUNICATIONS INC
PROPERTY TYPE : SECURITIES
20,156 .
10,404 .
09/27/2004
8,093 .
aoa .
100000 . PITNEY BOWES INC 5 .95
PROPERTY TYPE : SECURITIES
99,546 .
05/15/200!
08/26/2004
-9,876 .
09/27/2004
-5,328 .
02/22/2005
-68 .
17
FORM 990-PF - PART IV
CAPITAL GAINS AND LOSSES FOR TAX ON INVESTMENT INCOME
Kind of Property
roes sale
price less
menses of sale -
Description
Depreciation
allowed/
a ll owable
Cost or
other
hams
FMV
as of
/69
Adj . basis
as of
12131LE9
Excess of
FMV over
ad' basis
p
Date
acquired
Gain
or
(loss)
200 . TARGET CORP
PROPERTY TYPE : SECURITIES
6,846 .
04/14/2000
110 . VERIZON COMMUNICATIONS
PROPERTY TYPE : SECURITIES
4,210 .
03/19/1997
05/07/2004
26,471 .
600 . WAiGREEN CO
PROPERTY TYPE : SECURITIES
19,652 .
20,333 .
500 . WASHINGTON MUTUAL INC
PROPERTY TYPE : SECURITIES
19,771 .
10,096 .
4,368 .
150 . WEYERHAEUSER CO
PROPERTY TYPES SECURITIES
7,98 .
9,982 .
TAL GAIN(LOSS)
. . . . .
. . . . ... . . . ... . . .... . . .. . . .. . . .. . . ... . .. .
7301000
I1C2535 F250 09/13/2005 09 :14s17
1573-25175000
Date sold
02/18/200
3,250 .
09/x7/200
158 .
05/13/200
6,819 .
1 12/12/2003
02/01/200
562 .
07/22/2002
01/13/200
2,054 .
52,846 .
18
-
1COK71RZ1C
FORD 990PF~
TRUST 1573-25175000
47-6141Sia
PART I - DIVIDENDS AND INTEREST FROM SECURITIES
saa:s~~mm~~a~aea~m-ax==ee~==e======_.... . .... .====_=====ae~~
REVENUE
AND
EXPENSES
PER HOOAB
---------
DLSCRIPTIO
FOREIGN D
DOMESTIC
CORPORATE
U .S . QOVZ
U .S . GOVE
804 .
MIT INTEREST ( FEDERAL TAXABLE
M'1' INTEREST - FEDERAL & STA
DOMESTIC DIVIDENDS
TOTAL
XD577 2 000
NET
INVESTME19T
INCOME
------
IR25~5 Fa50 09/13/2005 09 :14 :17
804 .
22,856 .
22,856 .
2,373 .
2,373 .
14,325 .
9,871 .
1,577 .
-------------51,806 .
----===saxm~xa
1573-25175000
14,325 .
9,871 .
1,577 .
-------------51,806 .
aaex~asmms~e~e
19
STABM
1
K01f71Rl1C
TRUST 1573-25175000
47-614151a
FORD 990PPART I - TAXES
a=aa~cmams~ ==_===========
REVENUE
AND
EXPENSES
PER BOORS
---------
FOREIGN
FEDERAL
FEDERAL
S
PAYMENT - PRIOR YEqP-HATES - PRINCIPAL
TOTALS
xDsn z 000
- =R25
F250 09/13/2005 09 :14 :17
100 .
773 .
3,396 .
-------------4,269 .
NET
INVESTMENT
INCOME
------
100 .
-------------100 .
1573-25175000
20
STA'M
2
KOKhRZX
FORD 99
=xmQm=a
TRUST 1573-25175000
PART I - OTHER EXPENSES
eamoaaa================
REVENUE
AND
EXPENSES
PER BOOKS
---------
----CHAPEL MAX
TOTALS
xosn z 000
47-6141512
- IK25~5 F250 09/13/2005 09 :14 :17
600 .
-------------600 .
NET
Il'QVBSTMEl"
INCOME
-----600 .
-------------600 .
1573-25175000
21
STA'M
3
1tOK11RElC
IT11HIA TRUST 1573-25175000
FORK 9 9
msomssmi
PART II - U .S . AND STATE OBLIGATIONS
aas~a :eexam=======_============_====
47-6141512
DING
Fw
MID=NG
BOOR VALUE
88L ATTIC
STATEMENT A
TOTALS
XD577 2 000
IK25~5 Fa50 09/13/2005 09 :14 :17
298,869 .
---------------
asa,ss9 .
==om=asm=-sm=ez
1573-25175000
as
302,805 .
--------------302,805 .
STATEMENT
4
47-6141512
ar0mR31C CS~RITAHLE TRUST 1573-25175000
FORK 990P~I
PART II - CORPORATE STOCK
ENDING
HOOK VALUE
----------
----------
SEA
STATEMENT A
TOTALS
xDsn z aoo
- IKa5~5 F250 09/13/2005 09 :14 :17
ENDING
PTV
1,075,326 .
---------------
946,367 .
--------------946,367 .
1573-25175000
1,075,326 .
as
STATSNEN'P
5
KOIVlRg1C
ITAHLE TRUST 1573-25175000
47-6141512
FORK 990P , BART II - CORPORATE BONDS
$NDING
HOOK VALUE
SEE ATTA
D STATEMENT A
TOTALS
XD577 2 000
- IiC25~5 FZ50 09/13/2005 09 :14 :17
ENDING
I+xV
183,204 .
---------------
192,974 .
---------------
=sa=ssxamx=mmm :
=~==a=x==as-e=m
is3,ao4 .
1573-25175000
24
isa,s7a .
STATM
6
XOMAKEK CHARITABLE TRUST 1573-25175000
47-6141512
FORM 990PF, PART III - OTHER INCREASES IN NET WORTH OR FUND BALANCES
~:~e~mmom~eQ=aseo====°==x=aaes=====°a===°===°=s=====~=~eoc====sms===
DESCRIPTION
AMOUNT
FOND BALANCE ADJUSTMENT
ROUNDING ADJUSTMENT
2,000 .
TOTAL
xo578
20 0
1.
-------------2,001 .
eeme======ommo
STATEMENT
=R2535 F250 09/13/2005 09 :14s17
1573-25175000
25
7
-
47-6141512
"KOKAREK CHARITABLE TRUST 1573-25175000
FORM 990PF,
PART III - OTHER DECREASES IN NET FORTH OR FEND BALANCES
e~aeQ~=xaemm=c==~m~~am~~e~~CCCC~~~Cam~C~~CC'r.~S~m~~C7~~~OSmms~~secede
DESCRIPTION
-----------
AMOUNT
TAXABLE AMOUNT & INC CASH DIFF
TOTAL
xu576 2 ooo
406 .
-------------406 .
s=eea=amen==mx
STATEMENT
=82535 10'250 09/13/2005 09 :14 :17
1573-25175000
26
8
-
'KOMAREK CHARITABLE TRUST 1573-25175000
47-6141512
-m-mm --- mmmmm --- mmmmmmm-m ----- mmmm ----- m-mmm ---
OTHER STATES
SERE THE FOUNDATION I8 REGISTERED
o~~os~m~o=m===xma~mooe====emaoommeem=mmo~ee=~=a
STATEMENT
XD578 2000
=R2535 1250 09/13/2005 09 :14 :17
1573-25175000
27
9
WOIIUtSX C~71RITABLE TRUST 1573-25175000
FORD 990pl,,
47-6141512
PART VIII - LIST OF OFFICERS, DIRECTORS, AND '1'RU8'1'S=S
NAME AND - J~DDRESS
-----WELLS F1i1R
HANK, IQ . A .
1248 O ST ., 4T8 FLOOR
LINCOLN, ICE 68508,
TITLE AND TIME
DEVOTED TO POSITION
------------------TRUSTEE
PART-TIME
GRAND TOTALS
xDsn z 000
IK25~5 F250 09/13/2005 09 :14 :17
COMPENSATION
-----------18,697 .
18,697 .
me=~acosna
1573-25175000
as
STATEMENT
10
47-6141512
'KOMAR' EK CHARITABLE TRUST 1573-25175000
FOAL 990PF, PART XV - NAB, ADDRESS AND PHONE FOR APPLICATIONS
game :m======°°=~==_====__==_===========x=ms=nem~e~~esa~~===°==
WELLS FARGO HANK, N .A .
1248 O ST ., 4TH FLOOR
LINCOLN
xo576 2.000
NE 68508
=R2535 F250 09/13/2005 09 :14 :17
1573-25175000
STATEMENT
11
29
-
13
1573-25175000
47-6141512
PM 9909, PEA! Iil - MM 1!1D CONTRIBUTIONS PAID DURING THE YEAR
~I~PP 101
m
MI
S
C
RELATIONSHIP TO SUBSTANTIAL CONTRIBUTM
AND
FOUNDATION STATUS OF RICIPIENT
NONE
E7mn
PMtPOBR OF MW OR COMMMM
Man
MARITABLZ
77,000 .
TM (70MR1BUTI088 PAID
XD577 2 000
- 92535
09/13/2005 09:14 :17
1573-25175000
30
8'AMM 12
------------
77,000 .
~~a:saxeee.
a
SCHEDULED
(Form
,04,)
Department ortneTreasury
Internal Revenue service
Name of estate or trust
OMB No isas-oos2
Capital Gains and Losses
00, Attach to Form 1041, Form 5227, or Form 990-T. See the separate
Instructions for Form 1041 (also for Form 5227 or Form 990-T, if applicable).
Employer Identification number
ROIt11RF1C CHARITABLE TRUST 1573-25175000
47-614151a
Short-Term Capital Gains and Losses - Assets Held One Year or Less
(a) Description of property
(b) Date
(c) Date sold
(Example, 100 shares 7%
acquired
(d) Sales price
(mo , day, yr )
preferred of "Z" Co )
(mo, day, yr )
1
S$S STATEMENT 1 -
2
3
4
5
200
1
1
86 106 .1
1
(0 Gain or (Loss)
for the entire year
(col (d) less col (e1'.
(e) Cost or other basis
(see page 33)
78,391 .1
Short-term capital gain or (loss) from Forms 4684, 6252, 6781, and 8824 , , , , , , , , , , , , , , , , , , ,
Net short-term gain or (loss) from partnerships, S corporations, and other estates or trusts , , , , , , , , ,
Short-term capital loss carryover . Enter the amount, if any, from line 9 of the 2003 Capital Loss
Carryover Worksheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Net short-term gain or (loss) . Combine lines 1 through 4 in column (f) . Enter here and on line 13,
column 3 below
"
7,715 .
2
3
5
7,715 .
(e) Cost or other basis
(see page 33)
(f) Gain or (Loss)
for the entire year
(col (d) less col (e))
6,638 .
38,493 .
Long-Term Capital Gains and Losses - Assets Held More Than One Year
6
(a) Description of property
(b) Date
(Example, 100 shares 7%
acquired
referred of 'Z" Co
mo , ay ,
LONG-TERM CAPITAL GAIN DIVIDE WS
SEE STATEMENT 3
7
(c) Date sold
(mo , day, yr )
(d) Sales price
S'PmT 4
406,670 .
368,177 .
Long-term capital gam or (loss) from Forms 2439, 4684, 6252, 6781, and 8824 . .
. . . . . . . .
Net long-term gain or (loss) from partnerships, S corporations, and other estates or trusts
Capital gain distributions , . , . . . . _ _ . .
Gain from Form 4797,Part l
. . . . .
Long-term capital loss carryover . Enter the amount, if any, from line 14 of the 2003 Capital Loss
Carryover Worksheet . . . . . . . . . . . . . . . .
Net long-term gain or (loss) . Combine lines 6 through
. . .11. in. .column
. . . . (f). .. Enter
***'**'*'**
here and on line. 14a,
. . .
column (3) below
8
9
10
11
12
Summary of Parts I and II
Caution : Read the Instructions before completing this part.
13
14
Net short-term gain or (loss) . . . .
Net long-term gain or (loss) :
a Total for year . . . . . . . . . . . . .
b Unrecaptured section 1250 gain (see
the worksheet on page 34) . . . . .
. . . . . . . . . . . . . . . . .
15
Total net gain or (loss) . Combine lines 13 and 14a
. . . . . . .
7
. . . . .
. . . .,
10
. . .
8
g
.
>>
"
12
(2) Estate's
or trust's
)
45,131 .
I
(3) Total
13
7,715 .
14a
. . . . . . . . . . . . . . . .
line 18 of
. . . . . . . . . . . . . . . .
c 28% rate gain or (loss) . . . . . . . . . . . . . . . . . . . . . . . .
I (1) Beneficiaries'
(see page 34)
. . . . .
45,131 .
14b
X14
No. 1 15 1
1
1
52,846 .
Note : If line 15, column (3), is a net gain, enter the gain on Form 1041, line 4. If lines 14a and 15, column (2), are net gains, go to
Part V, and do not complete Part IV. If line 15, column (3), is a net loss, complete Part !V and the Capital Loos Carryover Worksheet,
ac naceesnni
For Paperwork Reduction Act Notice, see the Instructions for Form 1041 .
JSA
4F 1210 d 000
IK2535 F250 09/13/2005 09 :14s17
Schedule D (Form 1041) 2004
1573-25175000
31
-
" Schedule'D (Form 1047) 2004
Pag e 2
Capital Loss Limitation
16
Enter here and enter as a (loss) on Form 1041, line 4, the smaller of :
a The loss on line 15, column (3) or
b $3,000 . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . 16
If the loss on line 15, column (3), is more than $3,000, or if Form 1041, page 1, line 22, is a loss, complete the Capihal Loss
(:m7yiover Worksheet on page 36 of the instructions to determine your capital loss carryover.
Tax Computation Using Maximum Capital Gains Rates (Complete this part only if both lines 14a and
15 in column (2) are gains, or an amount is entered in Part I or Part II and there is an entry on Form 1041,
line 2b(2), and Form 1041, line 22 is more than zero.)
Note: If line 14b, column (2) or line 14c, column (2) is more than zero, complete the worksheet on page 37 of the instructions
and skip Part V. Otherwise, go to line 17.
17
18
19
Enter taxable income from Form 1041, line 22
, , , , , . , . . . . . . . .
Enter the smaller of line 14a or 15 in column (2)
but not less than zero 18
Enter the estate's or trusts qualified dividends
from Form 1041, line 2b(2) , , , , , , , , , , , , 19
17
°'
~
20
21
Add lines 18 and 19 . . . . . . . . . . , , , . .
If the estate or trust is filing Form 4952, enter the
22
Subtract line 21 from line 20 . If zero or less, enter -0-
. . . . . . . . . . . . .
22
23
Subtract line 22 from line 17 . If zero or less, enter -0-
. . . . . . . . . . . . .
23
24
25
Enter the smaller of the amount on line 17 or $1,950 , , , , , , , , , , , , ,
Is the amount on line 23 equal to or more than the amount on line 24?
24
amount from line 4g ; otherwise, enter-0-
. .
"
20
21
_-
e Yes . Skip lines 25 through 27, go to line 28 and check the "No" box
No. Enter the amount from line 23
25
26
Subtract line 25 from line 24
26
27
28
Multiply line 26by5%(05) . . . ,
Are the amounts on lines 22 and 26 the same?
Yes . Skip lines 28 through 31 ; go to line 32 : . . . . . . . . . . . . . . .
H No . Enter the smaller of line 17 or line 22
28
29
Enter the amount from line 26 (If line 26 is blank, enter -0-) , , , , _ , , , , ,
29
30
Subtract line 29 from line 28
30
31
32
Multiply line 30by15%( .15) , . _ . . . .,_ _ . . . . . . . .,
Figure the tax on the amount on line 23 . Use the 2004 Tax Rate Schedule on page 22 of the
instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
33
34
35
. . . , . , _ ,
Add lines 27, 31, and 32, , , , , , , , , , , , , , , , , , , , , , , ,
, , , , . , , , ,
Figure the tax on the amount on line 17 . Use the 2004 Tax Rate Schedule on page 22 of the
instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tax on all taxable income. Enter the smaller of line 33 or line 34 here and on line 1 a of
Schedule G Form 1041
27
31
32
33
34
35
Schedule D (Form 1041) 2004
JSA
4F 1220 2 000
I1C2535 7250 09/13/2005 09 :14 :17
1573-25175000
32
-
X0NARR1t
47-614151a
~18LE TRUST 1573-25175000
Schedule D Detail of Short-term Capital Gains and Losses
F_
Date
Ac cared
Description
ITAL GKINS
LOSSES
OLD FOR INVES'
400 . CONSTELLATION BRANDS INC
50000 . FED HOME LN BR
4 .1259s 12/01/06
2001. PZPCO HOLDINGS INC
400 . SDNQARD DATA SYSTEMS INC
AL CAPITAL QrAINB
( LOSSES )
Date
Sold
Grams Sales
Price
Cost or Other
Basis
Short-term
Gain/Loss
PURPOSES
08/26/2004
02/22/2005
21 , 247 .
13 , 754 .
7 , 493
05/21/2004
07/07/2004
05!10/2004
12/01/2004
03/16/2005
02/22/2005
50 , 000 .
4 , 523 .
10 , 336 .
50 , 558 .
3 , 675 .
10 , 404 .
-558
848
-68
86,106 .
78,391 .
7,715
86,106 .1
78 391 .1
7 .715
HELD FOR
Totals
JSA
4F0971 2 000
- IA25I5 F250 09/13/2005 09 :14 :17
1573-25175000
33
STATEMENT
1
1GOILARM
Schedule D
~19L= TRUST 1573-25175000
etail of Long-term Capital Gains and Losses
47-6141512
Date
Ac wired
Date
Sold
Gross Sales
I
Cost or Other
I
Long-term
PURPOSES
08 / 27 / 2003
07 / 10 / 2002
.I .)
DE
. E][XON MOBIL CORPORATION
. F"aDL NATL MTG ASSN NOTES
6 .50% DUE 08/15/2004
53 .96 GOVT NATL MTG ASSN POOL
#379005
DTD 04/01/94
53~ .67 GOVT NATL MTG ASSN POOL
30
00
16
#379005
DTD 04/01/94
.a6 GOVT NATL MTG ASSN POOL
#379005
DTD 04/01/94
.59 GQVT NATL MTG ASSN POOL
#379005
DTD 04/01/94
16 .46 (30'V'P NATL MTG ASSN POOL
#379005
DTD 04/01/94
161 .57 f30VT NATL MTG ASSN POOL
DTD 04/01/94
#379005
16 .68 GOVT NATL MTG ASSN POOL
#379005
DTD 04/01/94
16 .81 GOVT NATL MTG ASSN POOL
DTD 04/01/94
#379005
77 : .14 (3QV'P NATL MTG ASSN POOL
#379005
DTD 04/01/94
14$ .5 GOVT NATL MTG ASSN POOL
X379005
DTD 04/01/94
GOVT
NATL
MTG
ASSN POOL
144 .46
DTD
04/01/94
#379005
16
11 / 01 / 1999
07/23/1999
10 /25 / 20
07 /06 / 20
07 / 27 / 20
09/27/20
154 .
125 .
205 .
16 , 026 .
8 , 842 .
18,811 .
4 , 128 .
4 , 283 .
-2 .606 .
9 1 400 .
2 , 227 .
3 , 341 .
7 , 692 .
6 , 777 .
11 , 272 .
01/12/1990
09/22 / 2004
17 . 092 .
9 1 004 .
14 , 613 .
09/18/2000
08/15/2004
50 , 000 .
49 , 827 .
173 .
04/17/1995
06/15/2004
531 .
532 .
-1 .
04/17/1995
07/15/2004
534 .
535 .
-1 .
04/17/1995
08/15/2004
164 .
165 .
-1 .
04/17/1995
09/15/2004
166 .
166 .
04/17/1995
10 / 15/2004
166 .
167 .
04/17/1995
11/15/2004
168 .
168 .
04/17/1995
12/15/2004
169 .
169 .
04/17/1995
01/15/2005
170 .
170 .
04/17/1995
02/15/2005
774 .
775 .
04/17/1995
03/15/2005
144 .
144 .
04/17/1995
04/15/2005
144 .
145 .
-1 .
-1 .
-1 .
JSA
4F0970 2 000
- IR25 5 F250 09/13/2005 09 :14 :17
1573-25175000
34
STATEINEM
2
KOIa=
Schedule D
a7-siaisia
ITl18Z.a TRUST 1573 - 25175000
etail of Long-term Capital Gains and Losses
Descri ption
VT NATL MTG ASSN POOL
#379005
DTD 04 / 01 / 94
ItAL ELEC CO
K & CO INC
NEENAH PAPER INC
AR PAPER INC
O HOLDINGS INC
8Y HOSES INC 5 .95
DUE
02 / 01 / 2005
COMWUNICATIOIQS INC
COMINUNICATION3 INC
ET CORP
ZON CONKONICATIONS
RLEN CO
Date
Ac quired
Date
Sold
04 / 17 / 1995
04 / 23 / 1991
02 / 27 / 2001
06 / 0 7 2002
06 / 07 / 2002
03 / 11 / 2004
05 / 15 /
09 / 27 / :
07/07/ :
12 / 21 / ;
01 / 18 /
03 / 16 / :
01 / 2 9 1998
02 / 27 /2001
06/07/2002
04/14/2000
~ 03/19/1997
05/07/2004
02 / 01 / :
08 /26 /
09 / 27 /:
02/18 ;
09/Z7/ :
05/13/ :
Gross Sales
I
Cost or Other
Long-term
Gain/Loss
-1 .
8,093 .
-11,125 .
18,5
2 .
-ao .
1
18,0
10,326
20,333
9,982
HELD FOR
2,151 .
15,654 .
6,846 .
4,210 .
454 .
-9,876 .
_r% a11a
..,. .
819 .
19 .652 .
17
38,493 .
JSA
4F0970 2 000
1K25 5 F250 09/13/2005 09 :14 :17
1573-25175000
35
STATEMENT
3
47-6141512
R0M4RLaA CHARITABLE TRUST 1573-25175000
FEDERAL CAPITAL GAIN DIVIDENDS
em~es~-~=~x=m~~mem=sem=mesa=xe
LONG-TERM CAPITAL GAIN DIVIDENDS
-------------------------------15916 RATE CAPITAL GAIN DIVIDENDS
LONG-TERM 156 CAPITAL GAIN DIVIDENDS
TOTAL 1516 RATE CAPITAL GAIN DIVIDENDS
6,638 .
------------
TOTAL LONG-TERM CAPITAL GAIN DIVIDENDS
xD57e
20 0
=R2535 F250 09/13/2005 09 :14 :17
1573-25175000
6,638 .
-----------6,638 .
__m_=====am=
STATEMENT
4
36
8
PAGE
3
TRUST
INVESTMENT DETAIL
MARKET VALUE/
CASH
26,747 .75
WELLS FARGO ADVANTAGE
(~/ ESTMENT MONEY MARKET SERVICE
#250
TOTAL MP1EY MARKET
0 .41
2 OF
cxRRIEKr
0.00
0.41
26,747 .75 100 .00
1 .000
26,747 .75
0.00
686
2 .56
26,748 .16
26,748 .16
0.00
686
2 .56
I I un4
50,000
FED FARM CREDIT BK
DTD 09/10/04 4 .490 03/10/2010
CUSIP 31331T6P1
50,015 .50
100 .031
16.52
50,000 .00
15 .50
2,245
4.49
50,000
FED HOME LN BK
DTD 03/23/05 5 .440 03/23/2015
CUSIP 3133XB2E4
50,203 .00
100 .406
16.58
49,950 .00
253 .00
2,720
5 .42
50,000
FED HOME LN BK
TRANCHE # TR 00400
DTD 07/12/04 5 .370 07/12/2011
CUSIP 3133X7SR6
50,109 .50
100 .219
16 .55
50,484 .00
374 .50-
2,685
5 .36
INVESTMENT OBJECTIVE : This account is being managed with an objective that places emphasis on potential
capital appreciation with sane consideration for current insane. If you feel that circumstances
warrant a change in this investment, please contact your account officer or portfolio manager .
!bICATES THAT THE ASSET IS HELD IN THE
INVESTED INCOME PORTFOLIO
-CONTINUED ON NEXT PAGE-
~~-~t
PAGE
INVESTMENT DETAIL
AS WMAY 31 . 2005
KOMAREK CHARITABLE TRUST
eccrbeur uiwecQ %n7eewn
--
INVESTMENT DETAIL
Lv
~~n16
~-~i17
MARKET VALUE/
X OF
UNIT PRICE
GATE
Y
COST VALUE
UNREALIZED
GAIN OSS
ESTIMATED CtAtREN
A"AL INCOME YIELD
rv~vvv
~
50,000
U S TREASURY NOTES DTD 02/15/97
6.2500 02/15/2007
CUSIP 9128272J0
52,242 .00
104 .484
17 .25
48,835 .94
3,406 .06
3,125
5 .98
50,000
t1 S TREASURY NOTES DTD 08/15/95
6.5000 08/15/2005
CUSIP 9128271.183
50,359 .50
100 .719
16 .63
49,773 .44
586 .06
3,250
6.45
1
302,804 .50 7W=
298,_969M
.
3,9n7ff
7,812 .71 100 .00
104 .634
7,478 .39
334.32
nJJ~~
DTD 12/15/03 4.000 12/15/2008
CUSIP 31359M7T0
L GOVERNMENT OBLIGATIONS
ASSN POOL #379005
OTD 04/O1/94G
7.5000 04/15/2009
CUSIP 36204TAE4
MORTGAGE BACKED SECURITIES
99 .750
"
.
1 ou-00
lb,02S -9.-N
560
.-'T'G0
~T.1'7
50,000
BANK OF AMERICA CORP
DTD 01/23/03 4.875 01/15/2013
CUSIP 060505AX2
50,893 .00
101 .786
27 .49
50,383 .00
510 .00
2,438
4.79
75,000
CHASE MANHATTAN CORP NEW
DTD 01/25/94
6 .5000 01/15/2009
CUSIP 16161ABK3
80,434 .50
107 .246
43 .44
76,353 .00
4,081 .50
4,875
6 .06
50,000
MERRILL LYNCH & CO INC
DTD 04-27-93
7 .0000 04/27/2008
CUSIP 590188ES3
53,834 .00
107 .668
29.07
48,989 .50
4,844 .50
3,500
6.50
CORPORATE OBLIGATIONS
"
TBB.0d'
-CONTINUED ON NEXT PAGE-
7
.
x;$13' "5:84
u
r
e
e
w
7.17
TRS 26064 (3-02-51856)
ff 248
5
PAGE
INVESTFIENT DETAIL
AS OF IMY 31 . 200
CHARITABLE TRUST
INVESTMENT DETAIL
V
HARES
DESCRIPTION
MARKET VALUE/
% OF
UNIT PRICE
CATEGORY
495,778 .71
TOTAL FIXED INCOME
T VALUE
482,073 .27
UNREALIZED
GAIN/LOSS
ESTIMATED CURRENT
ANNUAL INCOME YIELD
13,705 .44
27,39
5.53
IALS
600
ALCOA INC
COM
CUSIP 013817101
250
INTERNATIONAL FLAVORS & FRAGRANCES
CUSIP 459506101
16,260 .00
27 .100
63 .68
16,808 .00
548.00-
360
2 .21
9,272.50
37 .090
36 .32
9,454 .50
182 .00-
185
2 .00
TW_
.8'6
MATERIALS
-345 -~T~
AL
GENERAL ELECTRIC CO
CUS I P 369604103
43,776 .00
36 .480
55 .87
7,300.00
36,476 .00
1,056
2 .41
440
HONEYWELL INTERNATIONAL INC
CUSIP 438516106
14,492 .00
36 .230
18 .50
13,224.00
1,268 .00
330
2 .28
300
UNION PACIFIC CORP
CUSIP 907818108
20,088 .00
66.960
25 .64
17,346 .00
2,742 .00
360
1 .79
iki,ssb.oo TM-.W
3-1,rm-.W
40'aM
.
17,690 .00 100 .00
35 .380
19,137 .30
1,7 .30-
810
TM.M
XgM
.
19, TM0
11,447 . .W~
810
1,200
_ INDUSTRIALS
1, _14b
ICATIDN SERVICES
500
VERIZON COMMUNICATIONS
CUSIP 92343V104
L TELECOMMUNICATION SERVICES
-CONTINUED ON NEXT PAGE-
3l8
4 .58
'
\I
PAGE
lMIES'~I !~NT DETAIL
AS QEIMAY 31, 200
INVESTMENT DETAIL
MARKET VALUE/
..
I
X OF
500
BLOCK H & R INC
CUSIP 093671105
24,960 .00
49 .920
18 .31
25,013 .50
700
COMCAST CORP-SPECIAL CL A
CUSIP 20030N200
22,148 .00
31 .640
16.24
21,017 .60
200
HARLEY DAVIDSON INC
CUSIP 412822108
9,806 .00
49.030
7 .19
500
KONINKLIJKE PHILIPS ELECTRONIC - ADR
SPONSORED ADR
CUSIP 500472303
12,810 .00
25 .620
300
REEBOK INTL LTD
CUSIP 758110100
400
1,200
53 .50-
440
1 .76
1,130.40
0
0.00
9,120 .00
686 .00
128
1 .31
9.40
14,310 .00
1,500 .00-
219
1 .71
12,213 .00
40 .710
8.96
9,647 .70
2,565 .30
90
0.74
TARGET CORP
CUSIP 87612E106
21,480 .00
53 .700
15 .75
8,953 .00
12,527.00
128
0.60
WALT DISNEY CO
CUSlP 254687106
32,928 .00
27 .440
24.15
24,779 .25
8,148 .75
288
0.87
L CONSUMER DISCRETIONARY
300
AVON PRODS INC
CUSIP 054303102
11,922.00
39.740
16.40
11,630 .25
291 .75
198
1 .66
200
KIMBERLY CLARK CORP COM
CUSIP 494368103
12,866 .00
64.330
17 .69
12,772 .01
93 .99
360
2 .80
600
PEPSICO INC
CUSIP 713448108
33,756 .00
56 .260
46 .42
10,018 .06
23,737 .94
624
1 .85
-CONTINUED ON NEXT PAGE-
TRS 26084 (3{02-51856}
%F
PAGE
K0PAREK CHARITABLE TRUST
NT DETAIL
Y 31, 2005
ACCOUNT MR'IBER 25175000
INVESTMENT DETAIL
LIIE/SHARES
?
MARKET VALUE/
% OF
UNIT PRICE
CATEGORY
DESCRIPTION
CUS f P 9313142103
-
-
' 47 . 230
~
COST VALUE
~
~
UNREALIZED
GA 1 N/LOSS
ESTIMATED CURRENT
AffUAL INCOME YIELD
.~27
TM-.W
CONSUMER STAPLES
~f,~6'~ 'T.'S7
300
CHEVRON CORP
CUSIP 166764100
16,134.00
53 .780
29 .87
10,803 .00
5,331 .00
540
3 .35
300
EXXON MOBIL CORPORATION
CUSIP 302316102
16,860.00
56.200
31 .21
3,341 .03
13,518 .97
348
2 .06
400
WEATHERFORD INTERNATIONAL INC
CIfSfP 695089101
21,028 .00
52 .570
38.92
17,036 .00
3,992.00
0
0.00
54, Mr.W Tom.M
IM.03
L ENERGY
r-31,
22,90M
.
~ T.
500
AFLAC INC
CUSIP 001055102
20,775'.00
41 .550
10.56
19,485 .56
1,289.44
220
1 .06
350
AMERICAN INTL GROUP INC
CllS I P 026874107
19,442 .50
55 .550
9.88
25,359 .00
5,916 .50-
175
0 .90
733
CITIGROUP INC
CUSIP 172967101
34,531 .63
47 .110
17 .55
33,412 .97
1,118.66
1,290
3 .74
400
FED HOME LN MTG CORP
CUSIP 313400301
26,016 .00
65 .040
13 .22
20,554 .52
5,461 .48
560
2 .15
700
JPMORGAN CHASE & CO
CUSIP 46625H100
25,025 .00
35 .750
12 .72
29,066 .45
4,041 .45-
952
3 .80
350
MORGAN STANLEY
COM
CUSIP 617446448
17,136 .00
48.960
8.71
18,697 .18
1,561 .18-
378
2 .21
-CONTINUED ON NEXT PAGE-
1
PAGE
DETAIL
KOMAREK
ACtMlNT
INVESTMENT DETAIL
ii~~
Yw
nnu~nn unvur
a& . vv
400
THE ST. PAUL TRAVELERS COMPANIES,INC
CUSIP 792860108
15,152 .00
37 .880
400
WACHdVIA CORD 2ND NEW
CURRENT
YIELD
,avv
~c
7.70
12,720 .00
2,432 .00
368
2 .43
20,300 .00
50 .750
10.32
18,260 .00
2,040.00
736
3 .63
iso. is
TW.M
197 , 51b . 80
s
F INANCIAL$
l
Boo "cv~ . ~A
45 .880
CQM
CUSIP 750236101
CUaSm IP 929903102
I
MARKET VALUE/
X OF
UNIT PRICE
CATEGORY
,
600
BRISTOL MYERS SQUIBB CO
CUSIP 110122108
15,216.00
25 .360
10.16
26,344 .00
11,128 .00-
672
4 .42
600
JOHNSON & JOHNSON
CUS P 478160104
40,260 .00
67.100
26.87
13,943 .25
26,316 .75
792
1 .97
500
MEDTRONIC INC
CUSIP 585055106
26,875 .00
53.750
17.94
21,951 .35
4,923 .65
168
0 .63
700
PFIZER INC
CUSIP 717081103
19,530 .00
27 .900
13.04
22,367 .68
2,837 .68-
532
2,72
250
QUEST DIAGNOSTICS INC
CUSIP 74834L100
26,250 .00
105 .000
17.52
14,797 .50
11,452 .50
180
0.69
500
~CJY~ETH
21,685 .00
43 .370
14 .47
5,270 .31
16,414 .69
460
2.12
149,Mr-M TOM
104,67W.'N
45, MEN
GUSIP 983024100
HEALTH CARE
-CONTINUED ON NEXT PAGE-
TRS 26084
i1
,I/e
PAGE
9
115--OF ~M~31ET200
INVESTMENT DETAIL
MARKET VALUE/
UNIT PRICE
300
ZED
I
AFFILIATED COMPUTER SVCS INC CL A
CUSIP 008190100
15,519 .00
51 .730
9.10
15,778 .98
1,000
EMC CORP MASS
CUSIP 268648102
14,060 .00
14 .060
8.24
7,320.00
400
FIRST DATA CORP
CUSIP 319963104
15,132 .00
37 .830
8 .87
HEWLETT PACKARD CO
CUSIP 428236103
22,510 .00
22 .510
COEL CORP
1,000
500
350
2,000
700
ESTI
0
0 .00
6,740 .00
0
0 .00
14,412 .00
720 .00
96
0.63
13 .20
16,857 .75
5,652 .25
320
1 .42
13,480 .00
26 .960
7 .90
15,568 .75
2,088.75-
160
1 .19
INTERNATIONAL BUSINESS MACHS CORP
COM
CUSIP 459200101
26,442 .50
75 .550
15 .50
37,748 .70
11,306 .20-
280
1 .06
MICROSOFT CORP
CUSIP 594918104
51,600 .00
25 .800
30.26
83,300 .00
31,700 .00-
640
1 .24
NOKIA CORPORATION - ADR
SPONSORED ADR
CUSIP 654902204
11,802 .00
16.860
6.92
9,7 .00
1,995 .00
CUSIP 458140100
L INFORMATION TECHNOLOGY
I
% OF
CATEGORY
I -i o, 9WM
.
lW.W
259.98-
.
254 2.15
1, 750 T.m
L -FORDS : EOI)iTIES
1,483 .538
MERIDIAN VALUE FUND
CUSfP 589619204
55,054 .10
37 .110
31 .72
56,992 .56
1,938.46-
420
-CONTINUED ON NEXT PAGE-
7l
0 .76
_~
FAR GO ,
10
1 NVE I NT DETAIL
AS ~ lU1Y 31, 2005
KOMAREK CHARITABLE IRUSI
ACCOW NUMBER ?5175000
INVESTMENT DETAIL
L~7G/ " L~~
I 2,858 .254
500
'~
.
f
IIIYV
NVI " -~VVI t
1
1Ln61\Llvl\1\
FUND - CLASS D 377
CUSIP 722005550
J1~n1a.~7
MARKET VALUE/
Y OF
UNIT PRICE
CATEGORY
COST VALUE
~45,255
'' :7a'-Zb .uT4'S;58V. TZ
15 .460
UWAL I ZED
GA I N/LpS.S
ESTf FATED ttMRENI
ORQ& IBM YI ELD
3,333.%.
2,242
5
THOftNBUR INTERNATIONAL VALUE FUND
CLASS A 139
CUSIP 885215657
58,251 .22
20 .380
33.56
50,201 .32
8,049 .90
203
0 .35
UTILITIES SELECT SECTOR SPDR
CUSIP 81369Y886
15,015 .00
30.030
8 .65
14,740.00
275 .00
444
2.96
IT I MUTUAL FUNDS: EQUITIES
rdrm- 3,4v-
US
C?Oy'-r 019L .
C aR-P_ 8 0,^LPS
¢ 3oL, 20s
~ l, o il-l; 326
192f 9 711
. . ..
__~ . 2q
f
~
.
--3;301 'T:9'T
9y6, 3` ;t
18 3, 2 oy
,I
'*
KCiXAPLEK CHA.QITABLE TRUST
Application for scholarship grant-in-aid to further the education
of
a deserving student who-wishes to pursue a career in the
ministry of
the Presbyterian or Methodist faiths .
A.
Faith (check) :
Presbyterian
Methodist
Name of nominating delegate :
Position of delegate within the denomination :
B . ~Nar-e of Student :
Address :
Name of educational institution (to be) attended by student :
Address :
Is the educational institution exempt under Section 501 (c)(3)
of the I .R .C .?
C.
Amount requested :
D.
'ne tryst instrument scales that, "In utakino its choice as to the
persons to be benefited, the Trustee shall be guided by the following
criteria :
(1) The character of the individual ; (2) the accual need
of the individual ; and (3) the scholastic record of the individual ."
Please attach a statement about the proposed recipient with respect
to the three criteria, providing supporting documentation such as
financial statements, tax returns, transcripts of grades, recommendations .
_
No restrictions shall be placed on the eligible
respect. to age, sex, race or national origin .
E.
recipients with
'
Is the student an employee or relative of an employee of Trustee?
Is the student a relative of the nominating delegate?
(Relative is
defined as spouse ; parent, descendant of parent, or descendant of parent's
sibling ; spouse's parent, descendant of spouse's parent, or descendant of
spouse's parent's sibling .)
Date proposal. submitted :
Delegate (signature)
S7TTEK~""fT 8
~
KOMA .REK CHARITABLE TRUST
Application for scholarship grant-in--aid to further the education of a
medical student enrolled in or accepted by the College of Medicine of
the University of Nebraska .
A.
Name of Student :
Address :
B.
Amount requested :
C.
The trust instrument states [hat, "In making its choice as to the
persons to be benefited, the Trustee shall be guided by the following
criteria :
(1) The character of the individual ; (2) the actual need
of the individual ; and (3) the scholastic record of the individual ."
Please attach a statement about the proposed recipient with respect
to the three criteria, providing supporting documentation such as
financial statements, tax returns, transcripts of grades, recommendations .
No restrictions shall be placed on the eligible recipients with repect to age, sex, race, national origin or religion .
D.
I= the student an employee or relative of an eopioyee of tru=tee?
Is the student a relative of a member of the Scholarship Committee of
the Co?leoe of Medicine of the University of Nebraska?
(Relat_ve
is defined as spouse ; parent, descendant of parent, or descendant of
parent's sibling ; spouse's parent, descendant of spouse's parent, or
descendant of spouse's parent's siblings .)
E.
Please list members of
the Scholarship Cocmittee .
Date proposal submitted :
Submitted by :
Title :
Signature
. ,
KOMAREK CHARITABLE TRUST
Application for grant-in-aid to charitable activity of the Omaha
Chapter of The Rebekah Assembly of the Independent Order of Odd
Fellows .
A.
Name of charitable organization :
Address :
B.
Amount Requested :
Purpose of grant-in-aid :
C.
Is the charitable organization exempt under Section 501 (c)(3)
of the I .R .C .?
If so, attach verification oL' tax-exempt
status .
Date proposal submic.ted :
(signature)
Submitted by :
Title/position within the Rebekah Assembly of The
Independent Order of Odd Fellows :
I
t
7
I ~
" ~
Komerek Charitable Trust
Application for grant-in-aid to provide for the temporal needs
of s church of the Presbyterian or Methodist faith in Western
.Iowa or Eastern Nebraska .
A.
Faith (check) :
Presbyterian
Methodist
Name of nominating delegate :
Position of delegate within the demonination :
B.
Name of Church :
Address :
C.
Amount requested :
Purpose of grant-in-aid :
D.
Are the funds requested for an actual need beyond that which
can be supplied by the church's parishioners?
c.
Is the delegate a member of the above church'
Dace proposal submitted :
Delegate
(signature)
.
,
.
SI~IICIC~~
KONAREK
CHARITABLE TRUST
~
~/
Scholarship grants-in-aid are made to further the
education of deserving students who wish to pursue a career in
the ministry of the Presbyterian and Methodist faiths and
medical students enrolled in or accepted by the College of
In making its choice
Medicine of the University of Nebraska .
the
Trustee
is guided by the
as to persons to* be benefited,
character
of
the individual ; (2)
(1)
the
following criteria :
the scholastic
the actual need of the individual ; and (3)
Prospective recipients are nominated
record of the individual .
annually by delegates of the Presbyterian and Methodist ninistries of Omaha and by the scholarship committee of the College
The Trustee's Discretionary Distriof Medicine, respectively .
butions Committee selects the recipients on the basis of the
Grants-in-aid are payable to the educanominations received .
tional institution for credit to the account of the individual
recipient .
The q,rants are gifts to the students, not loans .
At least one-fourth of net trust income is distributes as
The Trustee advises the r.onir.atinq
scholarship grants-in-aid .
individuals or coru,ittee of the respective amounts available for
distribution, and the nominating party reconr..er.ds the app ortior.ment .
Attached are copies of the application forms required by
the Trustee .
One is to request aid for further ecucat :on in the
T-e other is
ministrv of the Presb-vterian or Methodist faiths .
to request aid for further education or medical stude- :s .
No restrictions are placed on the eli ;ible recioien :.s
wish respect to sae, sex, race, national origin or re?_ :.-on_
(Excepc [or ministerlal students tno must be of the '!e .^edi_st
itecinLents mav not be a re? 3tive o£
or Presbyterian iai~_!:s .)
the no^_natina c'.zr.oni,atio :~al C'zlecste, an
any of the L:011o~ :i .^.c :
er.^lovee of the co~ :,-ora~:e trustee, or ne^.t-er of t`.e =c :~elsr5hio
corunittee of the College o . r?edicir.e of the (. ;.~~. ESN сР_ .o=
`:ebrasla .
Recipie .^.ts :-,ay ^ot be an enolo~~ee of t'-e corporate
trustee .
The selection committee is the Trustee's Discretionarv
Distributions Comrittee which consists of a minimum of four +
officers of the corporate trustee, .Lnclucir.g the sianaqer of
Relatives of members of the
the personal services department .
cor=unittee may not be recipients of grants-in-aid .
Because
membership on the -,ruszee's Discretionary Distributions
Committee chances every year, the names and addresses of members have not been ListeC .
Fter_orts and transcripts are su ::-ittecl uith t::e rec-uests .
At the ti.-..e funds ire sent to an educational institution, the
institution is rer.u:esced to return un ;:sed :unds to t ::e 1_-=ustee,
is the stucent s . e~.:J.d wit` ;draF: fro .m t ::-_ prcy'ram .
A substantial part of the annual income will be
distributed to churches of the Presbyterian and :lethoCU'st
.
fihancial aid
faiths which are in need of
W~ ;tCvn
So~eti
or
fnTtIYM
~v RbYatkr- "
Funds .will also be made available to the Omaha chapter
of The Rebekah Assembly of the Independent Order of Odd Fellows
Attached is
for use in promoting their charitable purposes .
the application required by the Trustees to request grants-iRaid by the Omaha Chapter .
NAME :
TAX ID :
RETUR TYPE:
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
25175000
KOMAREK CHARITABLE TRUST
47-6141512
990-PF
ZHEIMER'S ASSOCIATION
AERICA DIABETES ASSOCIATION
iTHRITIS FOUNDATION
>BURY THEOLOGICAL SEMINARY / MICHAEL AGNEW
-fHANY PRESBYTERIAN CHURCH
kRTER LAKE PRESBYTERIAN CHURCH
kRTER LAKE UMC
\SS COUNTY FOOD PANTRY
ASS COUNTY HISTORICAL SOCIETY MUSEUM
SIN UMC
ETZ UMC
JKE UNIVERSITY / JOEY SHERRARD
F. 11TH PRESBYTERIAN CHURCH
4RRETT EVANGELICAL THEOLOGICAL SEM . / JANICE JAC
kRRETT EVANGELICAL THEOLOGICAL SEM. / NATHAN CF
RACE UMC
)UISVILLE UMC
)UISVILLE UMC / KERI SHELTON
CHIDREN'S HOME SOCIETY
.1N LIFE PRESBYTERIAN CHURCH
1AAHA FOOD BANK
VIAHA FOOD BANK
=ARL MEMORIAL UMC
ATfSMOUTH SR CITIZEN NUTRITION CENTER
31NCETON THEOLOGICAL SEMINARY / JESSICA W IETZKE
R _BEKAH /ODD FELLOW LOW VISION
R =BEKAH /ODD FELLOW LOW VISION
R VERTON UMC
~LVATION ARMY
DNEY PRESBYTERIAN CHURCH
B TOTAL (STATEMENT C, PAGE 1)
770 .00
1,200.00
1,200.00
1,283.34
3,000.00
1,000.00
1,000.00
1,950.00
1,900.00
4,000.00
1,000.00
925 .00
2,500.00
1,283.33
1,283.33
700 .00
2,000.00
2,000.00
770 .00
1,500.00
1,200 .00
770.00
2,000.00
1,950.00
925 .00
1,700.00
3,850.00
700 .00
1,200.00
1,500.00
47,060.00
7101 Newport Ave., Ste 305, Omaha, NE 68152
7101 Newport Ave., Ste 207, Omaha, NE 68152
10946 Old Mill Rd ., Omaha, NE 68154
204 N . Lexington Ave ., Wilmore, KY 40390
Carter Lake, IA
614 Chicago Ave ., Plattsmouth, NE
646 Main St., Plattsmouth, NE
7402 Weeping Willow Dr, Sarasota, FL 34241
114 S. Buchanan Blvd., Durham, NC 27701
2121 Sheridan, Evanston, IL 60201
2121 Sheridan, Evanston, IL 60201
PO Box 540968, Omaha, NE 68154
1044 Alta Vista Rd, Louisville, KY 40205
1044 Alta Vista Rd, Louisville, KY 40205
3549 Fontelnelle Blvd., Omaha, NE 68104
6824 J St ., Omaha, NE 68117
6824 J St., Omaha, NE 68117
625 Ave A, Plattsmouth, NE 68048
P .O. Box 821, Princeton, NJ 08540
3925 Dewey Ave ., Omaha, NE 68105
3925 Dewey Ave ., Omaha, NE 68105
3118 S. 140th St ., Tukwila, WA 98168
3612 Cuming St., Omaha, NE 68131
1345Linden St., Sidney, NE 69162
STATEMENT
w
ACCOUNT #:
ACCOUNT NAME:
TAX ID ~:
RETUR TYPE:
25175000
KOMAREK CHARITABLE TRUST
47-6141512
990-PF
AM
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
S . PAUL SCHOOL OF THEOLOGY / JACK HOFMOCKEL
S . PAUL SCHOOL OF THEOLOGY / ROBERT PERKY
S . PAUL'S PAPILLION UMC
S DANESE/AMERICAN PRESBYTERIAN FELLOWSHIP
TOGETHER, INC
U DERWOOD HILLS PRESBYTERIAN CHURCH
U ION THEOLOGICAL SEMINARY 1 DAEHO KIM
U ITED FAITH CHURCH
U IV. OF DUBUQOE THEOLOGY SEMINARY l CARYN PEDEF
U IV. OF DUBUQOE THEOLOGY SEMINARY/ JASON PRINCI
U IV. OF DUBUQOE THEOLOGY SEMINARY /JEFFREY MCC
U IV. OF NE MEDICAL CENTER / BRIAN BUTLER
U IV. OF NE MEDICAL CENTER / CARRIE STUDSDAHL
U IV. OF NE MEDICAL CENTER / LAUREN BUTTERFIELD
V SITING NURSE ASSOCIATION
OODBINE FUMC
PI~ATTSMOUTH FIRE DEPT & RESCUE SQUADS
ATEMENT C, PAGE 2)
1,200.00
1,283.33
1,283.33
2,000.00
3,400.00
770 .00
1,500.00
2,000.00
1,000.00
925 .00
1,283.34
925 .00
2,700.00
2,700.00
2,300.00
770 .00
2,000.40
1702
5123
5123
5123
N
Truman Rd ., Kansas City, MO 64127
Truman Rd., Kansas City, MO 64127
Truman Rd., Kansas City, MO 64127
1616 Cass St., Omaha, NE 68102
3401 Brook Rd., Richmond, VA 23227
2000 University Ave ., Dubuque, IA 52001
2000 University Ave ., Dubuque, IA 52001
2000 University Ave ., Dubuque, !A 52001
Nebraska Medical Center, Omaha, NE 68198
Nebraska Medical Center, Omaha, NE 68198
Nebraska Medical Center, Omaha, NE 68198
1941 S. 42nd St., Suite 225, Omaha, NE 68105
5200 Woodbine Rd., Pace, FL 32571
1,900.00 136 No. 5th, Plattsmouth, NE
29,940 .00
SUMMARY
SUB TOTAL FROM STATEMENT C, PAGE 1
SUB TOTAL FROM STATEMENT C, PAGE 2
GRAND TOTAL
47,060.00
29,940.00
77,000.00
STATEMENT C