Professional Documents
Culture Documents
"
EXTENSION
GRANTED
Return of Private Foundation
Form990-PF
Department
ol theTreasury
or Section
LJ
Initial return
Amended return
Name of foundabon
DAVID
H.
E.
ST.
LJ
Final return
Name change
A Employer ldentlflcatlon number
KOCH CHARITABLE
37TH
Address chanae
FOUNDATION
48-0926946
20
en mg
~@09
.
rt1n re u1rements
2009 ,an
OMB No 1545-0052
Trust
Room/suite
If exemptJonappllcallon 1s
pending check here
N.
(316)
orthe tnstruetJons)
828 -5552
......
check here
D 1 Foreign organ1zat1ons,
WICHITA,
llS.J
Section
67220-3203
KS
501 (cfli
........
LJ Cash
J Accounting method
Other (specify)
(Part I, column (d) must be on cash basis)
1
3
Accrual
______________________
:o
....o
...on
undersecbon
507(b)(1)(A),
checkhere
F
If the foundation
1$
In 8 60-month terrmnatJon
undersecbon
507(b)(1
)(B) checkhere , ...
(d) Disbursements
for chantable
purposes
leash basis onlvl
10,000,000.
986
ATCH
986.
5a Gross rents
b Net rentalincomeor (loss)
QI
:::,
c:
QI
>
QI
~ 8
c:,
~
cc
~
>
l1!ei!'&e.
\VEO ... i
Net sh6rt-term
9
lncom~ mod1ficat1ons_!...-!-,-"--.-.--a
10 a GrosssaJesl~ss re1ums
and allowffis
,
b Less colltofboodsl~V.
1>.'),
101 or (loss)
(attach scheduleL
c Gross piofit
(:)
\ <;Q\
-.
11
a
UJ
12
Other in ;ome1aomm
Total. Aid lrnes
13
Compensationof officers,directors,trustees,etc
14
15
z:
z
CII
QI
() c: 16 a
LJ\ ....
:1'. t :
CII
QI
CJ;,Q,
)(
w
..
...
..
QI
>
C'CI
CII
7_01U\ '!.\
j 0:::
....
18
*
Taxes(attachschedule)(seepage14orthe,nstrucbons,*
-c 21
c:
C'CI 22
0.
0.
825
17
e
-c 20
9,695
1,245
20
Occupancy .
<(
.........
23
24
QI
Q,
11,770.
~
l!!
986.
0
19
Cl)
10,000,986.
..........
.......
1,033.
1,033
13,648.
0.
0.
11,
13,648.
0.
0.
11, 973
973
25
26
Totalexoensesanddisbursements
Add lines 24 and 25
27
9,987,338.
986.
-0-
* ATCH
3 JSA
85652
**
ATCH
48-0926946
Attachedschedulesand amounts111the
descnpt1oncolumnshould be for end--0f-year
amountsonly (See 1nstruct1ons
)
lilnlllBalance Sheets
..
Cash - non-1nterest-beanng
Accounts receivable
Page 2
End of year
Beginning of year
...
-----------------------...------------75,000,000
.
...-----------------------...-------------
3,697.
272,255.
5,224.
20,259,741.
5,224
20,259,741.
75,000,000.
75,000,000
Pledges receivable
85,000,000.
..
..
Grants receivable
...- - - - ...-------------
J!l
QI
Cl)
Cl)
<
.. . .
..
33.
53.
33
. . ..
...
-----------------...-------------------
13
14
15
16
17
18
Grants payable
...------------------
...____________________
)
..
..
-------
_____
Deferred revenue
; 20
'.g21
~ 22
Other hab1ht1es(describe
85,001,545.
85,003,200.
95,264,998
)
...___________________
..
23
95,264,998.
3,200.
85,000,000.
xi 19
85,276,005.
1,545.
85,000,000.
Foundations
that follow SFAS
and complete lines 24 through
...w
xi
24
u
Unrestricted
; 25
ia 26
Temporanly restricted
"ti
c:
::,
Foundations
that do not follow SFAS 117,
check here and complete lines 27 through
0 27
J!l 28
29
~ 30
274,460.
10,261,798.
274,460.
10,261,798.
Permanently restncted
u..
QI
...o
31.
::l
QI
..
mstrucllons)
Total liabilities and net assets/fund balances
31
(see page 17
.. . .
of the instructions)
.. ..
85,276,005.
95,264,998.
=
1 Total
end-of-year
2
3
4
5
6
at beginning
..
not included
of year - Part
II, column
(a), line
30 (must
agree with
.. . .
not included
..
in hne 2 (1tem1ze)
in hne 2 (1tem1ze)
...
....-----------------------------------..
.. ..
.
..
..
1
2
3
4
5
6
274,460
9,987,338
10,261,798
10,261,798
Form 990-PF
JSA
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85652
(2009)
,.
...
48-0926946
~lT.
Pagel
(a) List and descnbe the kind(s) of property sold (e g , real estate,
2-story bnck warehouse, or common stock, 200 shs MLC Co )
acquired
P-Purdlase
"-""""b~n
(c) Date
acquired
(mo, day, yr)
1a
c
d
e
(g) Cost or other basis
plus expense of sale
(f) Depreciationallowed
(or allowable)
a
b
c
d
e
Complete only for assets showing gain in column (h} and owned bv the foundation on 12/31/69
(k) Excess of col (1)
U) AdJustedbasis
(i) FM V as of 12/31/69
over col (J), 1fany
as of 12/31/69
a
b
c
d
e
If gain, also enter in Part I, line 7
If (loss). enter -0- in Part I, line 7
3 Net short-term capital gain or (loss) as defined 1nsections 1222(5) and (6)
If gain, also enter 1n Part I, line 8, column (c) (see pages 13 and 17 of the instructions)
.....
}
}
.....
::E:Ti- 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 )
If section 4940(d)(2) applies, leave this part blank
Was the foundation liable for the section 4942 tax on the distributable amount of any year in the base period?
If ''Yes," the foundation does not qualify under section 4940(e) Do not complete this part
Yes[K]
No
1 Enter the appropriate amount in each column for each year, see page 18 of the instructions before making any entries
(a)
Base penod years
Calendar year (or tax year beginning 1n)
(b)
AdJusted qualifying d1stnbut1ons
18,657,783.
10,106.
4,350,615.
11,518.
8,899.
2008
2007
2006
2005
2004
2
3
(d)
D1stnbut1onratio
(col (b) d1v1dedby col (cl)
(c)
Net value of nonchantable-use assets
12.178789
0.002704
1,531,990.
3,737,419.
982,416.
218,181.
13,600.
...................................
0.654338
..
17.317107
. . . ..
3.463421
4.428485
0.052791
..........
1,087,431.
. . . . . . . . . . . . . . . . . . ....................
3, 766,231.
....................
Enter the net value of noncharitable-use assets for 2009 from Part X, line 5
11,973.
Enter qualifying d1stribut1onsfrom Part XII, line 4
8
If line 8 1s 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
PartVI instructions on page 18
. . . . . . . . . . . . . . . . . .........................
10.
3,766,241.
.........................
JSA
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990-PF
(2009)
48-0926946
Form990-PF(2009)
Excise Tax Based on Investment
Page4
Income (Section 4940(a), 4940(b), 4940(e), or 4948 - see page 18 of the instructions)
LJ
2_0_.
t---1-t _________
Tax under section 511 (domestic section 4947(a)(1) trusts and taxable foundabons only Others enter -0-)
Subtitle A (income) tax (domestic section 4947(a)(1) trusts and taxable foundations only Others enter-0-)
Tax based on investment income. Subtract line 4 from hne 3 If zero or less, enter -O-
20.
0.
20.
Cred1ts/Payments
53.
Sa
53.
Sb
0.
0.
c Tax paid with application for extension of time to file (Form 8868)
Sc
Sd
7
8
Tax due. If the total of Imes 5 and 8 1smore than hne 7, enter
amount owed
Overpayment. If hne 7 1smore than the total of Imes 5 and 8, enter the amount overpaid
Enter the amount of hne 10 to be Credited to 2010 estimated tax ~
10
11
10
Refunded ~
11
33.
33.
1a Dunng the tax year, did the foundation attempt to influence any national, state, or local leg1slat1onor did 11
1a
. . . . . . !----+----<,.--b Did 11spend more than $100 during the year (either directly or indirectly) for political purposes (see page 19
part1e1pateor intervene m any political campaign?
. .
. .
No
1b
1c
e Enter the reimbursement (1f any) paid by the foundation during the year for poht1cal expenditure tax imposed
on foundation managers ~ $ ___________
_
2
. . . . . . . . . . . . . . . . f--'2=---+---+--x-
Has the foundation made any changes, not previously reported to the IRS, 1n its governing instrument, articles of
4a
3
incorporation, or bylaws, or other s1m1larinstruments? If "Yes,'' attach a conformed copy of the changes . . . . . . . . -~+-----,l--4a
Did the foundation have unrelated business gross income of $1,000 or more during the year?
b If "Yes," has 11filed a tax return on Form 990-T for this year?
4b
Are the requirements of section 508(e) (relating to sections 4941 through 4945) satisfied either
the foundabon
reports or with
which
x
x
Sb
Did the foundation have at least $5,000 m assets at any time during the year?
. . . . .
Is the foundation da1mmg status as a private operating foundabon w1th1n the meaning of secbon 4942(1)(3) or
4942(1)(5) for calendar year 2009 or the taxable year beginning m 2009 (see mstrucbons for Part XIV on page
27)? If "Yes, "complete Part XIV.
10
10
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Form990.PF(2009)
~-41...-,
....Statements
Page5
Rei:1ardini:1Activities (continued)
11 At any time during the year, did the foundation, directly or indirectly, own a controlled entity w1th1nthe
. .............
11
. . . . . . . . ..
12
....
meai<11ng
of section 512(b)(13)? If "Yes," attach schedule (see page 20 of the instrucllons)
12 Did the foundation acquire a direct or indirect interest in any applicable insurance contract before
August 17, 2008? ..
13
13 Did the foundation comply with the public inspection requirements for its annual returns and exemption application?
Website address ... ____ ~~~~ ___________________________________________________________________
______________________
Telephone no ... _____
14 The books are in care of ""-'~:C2~~~-li.~1=_1=_I_M_A_N
Locatedat ...jlll_E._37TH_ST._N.
WICHITA, KS _______________________
ZIP+ 4 ...
x
x
x
_
~~~-=-~~~-=._5_~5-~
_____ _
67220-3203
____
11
15 Section 4947(a)(1) nonexempt chantable 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
. "" 15
I I
""L..J
::r.111.4111!1:
Statements Regarding Activities for Which Form 4720 May Be Required
Yes
File Form 4720 if any item is checked in the "Yes" column, unless an exception applies.
1a Dunng the year did the foundation (either directly or indirectly)
.......
(1) Engage in the sale or exchange, or leasing of property with a disqualified person?
G]
0Yes
(2) Borrow money from, lend money to, or otherwise extend credit to (or accept 11from) a
disqualified person? . . . .
(3) Furnish goods, services, or facilities to (or accept them from) a disqualified person?
Yes
~No No
Yes
No
(5) Transfer any income or assets to a disqualified person (or make any of either available for
GJNo
0Yes
No
~y~
(4) Pay compensation to, or pay or reimburse the expenses of, a disqualified person?
No
(6) Agree to pay money or property to a government official? ( Exception. Check "No" 1f
the foundation agreed to make a grant to or to employ the official for a period after
term1nat1onof government service, 1fterminating within 90 days )
Yes
GJNo
b If any answer 1s"Yes" to 1a(1)-(6), did any of the acts fail to qualify under the exceptions described 1nRegulations
section 53 4941(d)-3 or 1na current notice regarding disaster assistance (see page 20 of the 1nstruct1ons)?
Organizations relying on a current notice regarding disaster assistance check here
1b
1c
c Did the foundation engage in a pnor year 1nany of the acts described 1n 1a, other than excepted acts, that
were not corrected before the first day of the tax year beginning 1n2009?
Taxes on failure to d1stnbute income (section 4942) (does not apply for years the foundation was a pnvate
a At the end of tax year 2009, did the foundation have any undistributed income (lines 6d and
6e, Part XIII) for tax year(s) beginning before 2009? . . .
If "Yes," list the years ... __________
. _________
. ________
, _______
_
Yes
b Are there any years listed in 2a for which the foundation 1s not applying the prov1s1onsof section 4942(a)(2)
(relating to incorrect valuation of assets) to the year's undistributed income? (If applying section 4942(a)(2)
2b
to all years listed, answer "No" and attach statement see page 20 of the instructions )
c
---------
""---------3a
--------
--------
Did the foundation hold more than a 2% direct or indirect interest in any business
enterprise at any time dunng the year? . . . .
Yes
GJNo
b If "Yes," did 1t have excess business holdings in 2009 as a result of (1) any purchase by the foundation or
disqualified persons after May 26, 1969, (2) the lapse of the 5-year period (or longer period approved by the
Comm1ss1oner under section 4943(c)(7)) to dispose of holdings acquired by gift or bequest, or (3) the lapse
of the 10-, 15-, or 20-year first phase holding period? (Use Schedule C, Form 4720, to determine if the
. . . . . . . . .
Did the foundation invest during the year any amount in a manner that would Jeopardize its charitable purposes?
b Did the foundation make any investment in a pnor 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 2009?
3b
4a
4b
JSA
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~l"I=
Statements
Page6
5 a Dunng the y;ar did the foundabon pay or incur any amount to
(1) Carry on propaganda, or otherwise attempt to influence leg1slat1on(secbon 4945(e))?
Yes
[fil No
Yes
tili
Yes
[fil No
(2) Influence the outcome of any specific public electJon (see sechon 4955), or to carry on,
. ....
....
...
(4) Provide a grant to an orgamzabon other than a charitable, etc , orgamzahon described in
section 509(a)(1), (2), or (3), or section 4940(d)(2)? (see page 22 of the instructJons)
BYes
..... D
No
No
(5) Provide for any purpose other than religious, charitable, sc1ent1fic,literary, or educational
.....
[fil No
0Yes
b If any answer 1s "Yes" to 5a(1)-(5), did any of the transactions fall to qualify under the excephons described in
Regulations section 53 4945 or in a current notice regarding disaster assistance (see page 22 of the instructions)?
Orgamzat1ons relying on a current nobce regarding disaster assistance check here
. . ....
Sb
c If the answer 1s"Yes" to question 5a(4), does the foundation claim exemption from the tax
for the grant?
because 11maintained expenditure respons1b11ity
0Yes
0No
0Yes
6b
. . . . . . . I-'-~+--+---
7 a At any time during the tax year, was the foundation a party to a proh1b1tedtax shelter transaction?
b If yes, did the foundation receive any proceeds or have any net income attributable to the transaction?
~ .-.,.,,.
[fil
No
0Yes
.
7b
Information About Officers, Directors, Trustees, Foundation Managers, Highly Paid Employees,
and Contractors
List all officers, directors, trustees, foundation managers and their compensation (see page 22 of the instructions).
(b) Trtle, and average
dehv~~~~~~r
~:~i~n
0
(c) Compensation
(II not
enter
ATTACHMENT 7
(d) Contnbu~onsto
an~":i~:~:db:~:~~~;;on
P]'.1
0.
0.
0.
Compensation of five highest-paid employees (other than those included on line 1 - see page 23 of the instructions).
If none, enter "NONE."
(b) Trtle, and average
hours per week
devoted to posrt1on
(a) Name and address of each employee paid more than $50,000
(c) Compensation
(d) Contnbut1onsto
employee benefrt
plans and deferred
compensation
........ I
NONE
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iffC,)01and
Information About Officers, Directors,
Contractors (continued)
4 8-092 694 6
Trustees, Foundation Managers, Highly Paid Employees,
Page7
3 Five highest-paid independent contractors for professional services (see page 23 of the instructions). If none, enter "NONE."
(a) Name and address of each person paid more than $50,000
(c) Compensation
NONE
..............................
iffii
NONE
List the foundation's four largest direct chantable act1vrt1esdunng the tax year Include relevant stallst1cal information such as the number
of organizations and other benefic1anes served, conferences convened, research papers produced, etc
Expenses
1 N/A
~,.e:
Descnbe the two largest program-related investments made by the foundation dunng the tax year on Imes 1 and 2
Amount
NONE
NONE
....
Form
JSA
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85652
990-PF
(2009)
4 8-092 694 6
UiflQ
1
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 ..........
.
b Average of monthly cash balances . . . . . . . . . . . . . . . . . . .
c Fair market value of all other assets (see page 24 of the instructions)
1a
1b
1c
1d
2
3
4
Page8
Minimum Investment Return (All domestic foundations must complete this part. Foreign foundations,
se~ page 24 of the 1nstruct1ons)
~~~~~~~~~~~--1
2
3
0
~r
1
2a
b
c
3
4
.. . .
line 1
a
b
2
a
b
4
o.
16, 5 6
4 31 .
54, 372.
o8 7,
..
..
..
54,372.
2c
3
4
20.
54,352.
5
6
54,352.
54,352.
1a
1b
11,973.
20.
..
..
..
. . ..
..
..
..
......
.. . .
..
..
#1311Qualifying
1
1,
.. . . . .
5
6
0.
1,103,991.
4
of the instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1--~1--~~~~~~......;.~~
Net value of noncharitable-use assets. Subtract line 4 from line 3 Enter here and on Part V, line 4
5
1--~1--~~~~-'-~---'-~~
Minimum investment return. Enter 5% of line 5 . . . . . . . . . . . . . . . . . . . . . . . . . .
6
Distributable Amount (see page 25 of the 1nstruct1ons)(Section 4942(!)(3) and (J)(5) private operating
foundations and certain foreign organizations check here ..,..
and do not complete this part )
5
6
0.
1,103,991.
I 1e I
. .........
1,103,991.
.
.
..
........................
. . . . . . . . . . ..........
.....
....
. .........
.. ......
. . ...
0.
0.
3a
3b
4
0.
0.
11,973.
N/A
5
6
11,973.
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 1nthose years
...............
.....
Form
JSA
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85652
990-PF
(2009)
48-0926946
Page9
amount
for 2009
from
Part XI,
(b)
Years pnor to 2008
(a)
Corpus
.....................
(c)
2008
(d)
2009
54,352.
..........
20 __
,20 __
,20 __
4,165,825.
From 2006
d From 2007
18,582,189.
e From 2008
f
Qualifying
line 4
22,748,014.
..........
11,973.
...
......
..
11,973.
0.
42,379.
42,379.
of
each
column
as
22,705,635.
income
Subtract
b Prior years' und1\,tributed
line 4b from line 2b
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. . .
...
. . . . . . .....
line 6b
Taxable
line 6c from
d Subtract
amount - see page 27 of the 1nstruct1ons
e Undistributed income for 2008 Subtract lme
4a from line 2a Taxable amount - see page
27 of the 1nstruct1ons
....
.............
...............
....
Excess
distributions
carryover
2010.
... . . . .
to
22,705,635.
Analysis of line 9
4,123,446.
18,582,189.
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48-0926946
!-.,~-Private
1a
If the
Operating Foundations
found'abon
has received
a ruling
or determmabon
letter
that
found.abon, and the ruling 1seffecbve for 2009, enter the date of the ruling
b
2a
Page 10
operabng
....
I I
Check box to indicate whether the foundabon 1sa pnvate operallng foundation descnbed in section
Enter the lesser of the adJustednet income from Part
I or the minimum investment
return from Part X for each
year listed
85% of line 2a
(a) 2009
4942@3) or
Pnor 3 years
Tax year
(b) 2008
NOT APPLICABLE
I I
4942~)(5)
(e) Total
(c) 2007
(d) 2006
1n line
Amounts 1nduded
2c not
of exempt acllv1tJes
d1stnbutJons made
Quahfy1ng
directly
for
act.Jve conduct
exempt actMlles
2d from line 2c
of
Subtract line
......
(1)
(2)
...
under section
4942~)(3)(8)!1).
,
alternative
"Endowmenr
test-
Part X,
in
..
(1)
(2)
Support
from
general
public
and 5 or more
exempt organizations
as
provided 1n section 4942
@3)(8)(111) ,
(3)
Largest amount
port
from
an
organrzation
(4)
:r.
of supexempt
had $5,000
or more in assets
H.
KOCH
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
N/A
2
c Any subm1ss1ondeadlines
d Any restrictions or hm1tat1ons on awards, such as by geographical areas, charitable fields, kinds of mst1tut1ons, or other
factors
JSA
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4 8-092 694 6
lnfonnation (continued)
3 Grants and Contributions Paid During the Year or Approved for Future Payment
Page
1:idf:\*j
Supplementary
Rec1p1ent
Name and address (home or business)
If rec:1p:1ent
as an ind1Y1dual,
show any relatJonsh1pto
any foundation manager
or substantJal contnbutor
Foundation
status of
recipient
Purpose of grant or
contnbut1on
11
Amount
Total.
b Approved for future payment
Total.
3a
3b
Form
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990-PF
(2009)
48-0926946
Form990-PF(2009)
Page 12
'!.t-:
(a)
(b)
(c)
Businesscode
Amount
E.xdusJOn
code
(d)
Amount
(e)
Related or exempt
function income
~ee page 28 of
e instructions )
a
b
c
d
e
f
....
14
..
986.
.......
.....
Debt-financed property
........
....
986.
13
986.
:1:1--'f.U'
Line No.
foundation's
exempt
purposes
(other
than
by
importantly
to
purposes)
(See
NOT APPLICABLE
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HffiNII
1
Page13
Did the organization directly or indirectly engage 1n any of the following with any other organization descnbed
in section 501(c) of the Code (other than secbon 501(c)(3) organizations) or 1n secbon 527, relabng to polibcal
orgam..zat1ons?
a Transfers from the reporting foundation to a nonchantable exempt organization ot
Yes
(1) Cash
1al1l
1al21
No
x
x
b Other transactions
(1) Sales of assets to a noncharitable exempt organization
1bl1l
1bl2l
1bl31
1bl41
1b(5)
1b(6)
any of the
or sharing
(b) Amountinvolved
arrangement,
the
by the
show
1c
following
schedule
reporting
foundation
1n column
(d) the
N/A
2a
x
x
x
x
x
x
x
Column
(b) should
If the foundation
always
received
show
the
less than
fair
market
fair market
(d) Descnpt1on
of transfers.transactions,and sharingarrangements
N/A
Is the foundation directly or indirectly affiliated with, or related to, one or more tax-exempt organizations descnbed 1n
section 501 (c) of the Code (other than section 501 (c)(3)) or in section 527? .
Yes
[29 No
(c) Descnpt1on
of relat1onsh1p
'1/~
e~
I J/-/5-~0/..Q
Date
I r~q_ J
Cl)
Date
:I:
Cl
-~~ Preparer's
Q>
signature
en;:;a. 0c
,:,
D..
Q>
Ill
D..::::,
~~A,
u/12.Ju;10
JSA
9E1493 1 000
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Preparer's identifying
number (SeeSignature on
page 30 of the instructions)
Check1f
self-employed ....
~BKD, LLP
1551 N WATERFRONT PKWY, STE 300
WICHITA,
KS
67206-6601
85652
':!.C.e_r'
Trtle
EIN ....
P00770702
44-0160260
Phone no
316-265-2811
Form 990-PF
(2009)
Schedule B'
Schedule of Contributors
(Form 990,.990-EZ,
or 990-PF)
OMB No 1545-0047
~@09
InternalRevenueService
Section:
Form 990-PF
D
D
D
D
D
501(c)(
For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, $5,000 or more (1nmoney or
property) from any one contributor Complete Parts I and II
Special Rules
D
D
For a section 501 (c)(3) organization filing Form 990 or 990-EZ that met the 33
113 % support test of the regulations under
sections 509(a)(1) and 170(b)(1 )(A)(v1), and received from any one contributor, during the year, a contnbut1on of the greater
of (1) $5,000 or (2) 2% of the amount on (1)Form 990, Part VIII, line 1h or (11)Form 990-EZ, line 1 Complete Parts I and
II
For a section 501(c)(7), (8), or (10) organization filing Form 990 or 990-EZ that received from any one contributor, during
the year, aggregate contributions of more than $1,000 for use
exclus,vely for rel1g1ous,charitable, sc1ent1fic,literary, or
educational purposes, or the prevention of cruelty to children or animals Complete Parts I, II, and Ill
For a section 501(c)(7), (8), or (10) organization filing Form 990 or 990-EZ that received from any one contributor, during
the year, contributions for use exclus1velyfor religious, charitable, etc, purposes, but these contnbut1ons did not
aggregate to more than $1,000 If this box 1schecked, enter here the total contributions that were received during the
year for an exclus,vely religious, charitable, etc , purpose Do not complete any of the parts unless the General Rule
applies to this organization because 11received nonexclus1vely religious, charitable, etc , contributions of $5,000 or more
during the year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..,. $ ________
Caution. An organization that 1snot covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but 1t must answer "No" on Part IV, line 2 of its Form 990, or check the box on line H of its Fonn 990-EZ,
or on line 2 of its Form 990-PF, to certify that 1tdoes not meet the filing requirements of Schedule B (Form 990, 990-EZ, or
990-PF)
For Privacy Act and Paperwork ReducUon Act NoUce, see the lnstrucUons
for Form 990, 990-EZ, or 990-PF
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Page__
Name of organization
of __
of Part I
48-0926946
lmll
(a)
No.
--- 1
(c)
Aggregate contributions
DAVID H. KOCH
667 MADISON AVENUE
NEW YORK, NY
Person
Payroll
Noncash
10021
(b)
Name, address, and ZIP+ 4
(a)
No.
10,000,000.
(d)
Type of contribution
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash
---
(a)
No.
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash
--$
(a)
No.
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash
---
(b)
Name, address, and ZIP + 4
(a)
No.
(d)
Type of contribution
Person
Payroll
Noncash
---
(b)
Name, address, and ZIP + 4
(a)
No.
(d)
Type of contribution
Person
Payroll
Noncash
---
JSA
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ATTACHMENT 1
FORM 990PF,
DESCRIPTION
GOLDMANSACHS FUNDS
TOTAL
NET
INVESTMENT
INCOME
986.
986.
986.
986.
ATTACHMENT 1
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ATTACHMENT 2
FORM 990PF,
DESCRIPTION
REVENUE
AND
EXPENSES
PER BOOKS
ACCOUNTING
11,770.
TOTALS
lL
NET
INVESTMENT
INCOME
ADJUSTED
NET
INCOME
CHARITABLE
PURPOSES
9,695.
770.
_O_.
O_.
9.695.
ATTACHMENT 2
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ATTACHMENT 3
FORM 990PF,
DESCRIPTION
GRANT ADMINISTRATION FEES
TOTALS
CHARITABLE
PURPOSES
825.
1,245.
_8_2_5~
1.245.
ATTACHMENT 3
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ATTACHMENT 4
FORM 990PF,
PART I - TAXES
REVENUE
AND
EXPENSES
PER BOOKS
DESCRIPTION
20.
EXCISE TAX
20.
TOTALS
ATTACHMENT 4
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-48-0926946
ATTACHMENT 5
FORM 990PF,
DESCRIPTION
INSURANCE
BANK FEES
CORPORATION REGISTRATION FEES
REVENUE
AND
EXPENSES
PER BOOKS
875.
69.
89.
CHARITABLE
PURPOSES
875.
69.
89.
L 033.
1. 033.
TOTALS
ATTACHMENT 5
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PART II
48-0926946
DESCRIPTION
PREPAID EXPENSES
TOTALS
ENDING
FMV
33.
33.
33.
3_3
__
.
ATTACHMENT 6
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PART VIII
- LIST OF OFFICERS,
ATTACHMENT 7
COMPENSATION
CONTRIBUTIONS
TO EMPLOYEE
BENEFIT PLANS
EXPENSE ACCT
AND OTHER
ALLOWANCES
DAVID H. KOCH
667 MADISON AVE
NEW YORK, NY 10021
PRESIDENT/DIRECTOR
1. 00
0.
0.
0.
RUTHE. WILLIAMS
PO BOX 2256
WICHITA, KS 67201
SECRETARY
1. 00
0.
0.
0.
VONDA HOLLIMAN
PO BOX 2256
WICHITA, KS 67201
TREASURER
1. 00
0.
0.
0.
0.
0.
GRAND TOTALS
__Q.
ATTACHMENT 7
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If you are filin!J for an Additional (Not Automatic) 3-Month Extension, complete only Part II and check this box , , .
Note. Only complete Part II if you have already been granted an automatic 3-month extension on a previously filed Form 8868.
If you are fihnQ for an Automatic 3-Month Extension, complete only Part I (on DaQe 1).
~u-Additional
Type or
print
Filebythe
extended
due detefor
filingthe
return. See
{Not Automatic) 3-Month Extension of Time. Onlv file the oriainal {no copies needed).
Employer Identificationnumber
48-0926946
inatrucbona WICHITA, KS
67220-3203
Check type of return to be filed (File a separate application for each return)
Form 6069
Form 1041-A
Form 990
X
Form 990-PF
Form 4720
Form 8870
Form 990-BL
Form 990- T (sec. 401 (a) or 408(a) trust)
Form 990-EZ
Form 990- T trust other than above
Form 5227
STOPI Do not complete Part II if you were not already granted an automatic 3-month extension on a previously flled Form 8868.
The books are in the care of .,. _v_o_N_D_A_H_O_L_L_I_MA_N
_____________________
_
O
D
D.
-r--.------~-
5
6
Initial return
and ending
F mal return
0
-r-~----------
Sa If this application is for Form 990-BL, 990-PF. 990-T, 4 720, or 6069, enter the tentative tax. less any
b
Ba $
Sb $
Be $
S111netura...
C.P.A.
Form8868 (Rev 42009)
BKD,LLP
1551N.'INIJlataJIIDrfroirfnmtnl
PllklllJlull 800
Wk:hlla.
KSe72DlMIIDI
44-01801:80
JSA
9FBOS5 3 000