FEB Deprecl do and depletion E 20 Occupa cy a 21 Travel, onfere(pe

Transcription

1 I r e4.e ~1t ft~ Form 990-PF Return of Privte Foundtion Deprtment of the Tresury Internl Revenue Service OMB No or Section 4947()(1) Nonexempt Chritle Trust Treted s Privte Foundtion 2005 Note: The orgniztion my e le to use copy of this return to stisfy stte reporting requirements. For clendr yer 2005, or tx yer eginning --1, nd ending ~--t -- P Ph-L, oii fh,t o nhr l~ In,t,ol rehire I~ t,nol rnfi,r I I Am nrlrl return I I Arlrlrocc rhsnno F ] Mm rhnn Use the IRS Nme of orgniztion A Employer identifiction numer lel. Otherwise, OUTTS & CLARK FOUNDATION INC print Numer nd street (or P 0 ox numer if mil is not delivered to street ddress) Room /swte B Telephone numer ortype. 0 BOX See Specific City or town, stte, nd ZIP code C It exemption ppliction is pending, check here Instructions. EAST STROUDS BURG PA D 1. Foreign orgniztions, check here 0 H Check type of orgniztion: Section 501(c)(3) exempt privte foundtion. Foreign orniztions meeting test, ~ 2 check here nd ttch computtion 0 Section 4947()(1) nonexempt chritle trust L1 Other txle privte foundtion E If p rivte foundtion sttus ws terminted I Fir mrket vlue of ll ssets t end of yer J Accounting method: Csh 0 Accrul under section 507()(1)(A), check here 0 (from Prt 11, col (c), line 16) = Other (specify) F If the foundtion is in 60-month termintion No.$ (Prt 1, column (d) must e on csh sis) under section 507()(1 B check here lo~ 0 Prt I Anlysis of Revenue nd Expenses ( ) Revenue nd ( ) Net investment (c) Adjusted net ( d) Disursements 4 3 (The totl of mounts in columns (), (c), nd (d) my not necessrily equl the mounts in column ( )) expenses per ooks income Income 1 Contriutions, gifts, grnts, etc., received 89,000. N/A 2 Check Fl If the foundtion is not required to ttch Sc0 B for chritle purposes (csh sis only) Interest on svings nd temporry csh investments 4 Dividends nd interest from securities STATEMENT 1 5 Gross rents Net rentl income or (loss) d 6 Net gin or ( loss) from sle of ssets not on line 10 7 Gross sles price for ll ssets on line e N 7 Cpitl gin net income (from Prt IV, line 2) 0. 8 Net short-term cpitl gin 9 Income modifictions G.oss sles less returns 10 nd t ownces Less Cost of goods sold c Gross profit or (loss) 11 Other income 12 Totl. Add lines 1 through 11 89, Compenstion of officers, directors, trustees, etc Other employee slries nd wges 15 Pension plns, employee enefits 16 Legl fees Accou Ingofe eep, W c Other p ofes ;P 17 Interes C~ m 18 Txes W g FEB Deprecl do nd depletion E 20 Occup cy 21 Trvel, onfere(pe F ~ T C 22 Printing nd pulictions m 23 Other expenses STMT v 24 Totl operting nd dministrtive expenses. Add lines 13 through Contriutions, gifts, grnts pid 90, , e 26 Totl expenses nd disursements. Add lines 24 nd 25 90, , Sutrct line 26 from line 12: Excess of revenue over expenses nd disursements <900. Net investment income (if negtive, enter -0-) 181. c Adjusted net income (i f negtive, enter -0-) N/A LHA For Privcy Act nd Pperwork Reduction Act Notice, see the instructions. Form 990-PF (2005) 1 I

2 Form 990-PF (2005) C(NTTTG A. (T.AR TC F OTTNT)ATT0W TNC Pe2 Blnce Sheets A~ched Schedules nd mounts inthedescnpon Beginning of yer End of yer P rt II column should e for end-ol-yer mounts only () Book Vlue () Book Vlue (c) Fir Mrket Vlue 1 Csh - non-interest-ering 2 Svings nd temporry csh investments 6,600. 5,700. 5, Accounts receivle Less: llownce for doutful ccounts 4 Pledges receivle Less: llownce for doutful ccounts 5 Grnts receivle 6 Receivles due from officers, directors, trustees, nd other disqulified persons 7 Other notes nd lons receivle Less: llownce for doutful ccounts 8 Inventories for sle or use 9 Prepid expenses nd deferred chrges 10 Investments - U.S. nd stte government oligtions Investments - corporte stock c Investments - corporte onds 11 Investments - lnd, uildings, nd equipment sis Less ccumulted deprecion 12 Investments - mortgge lons 13 Investments - other 14 Lnd, uildings, nd equipment sis Less ccumulted deprecition 15 Other ssets (descrie 16 Totl ssets to e completed y ll filers 6,600. 5,700. 5, Accounts pyle nd ccrued expenses 18 Grnts pyle 19 Deferred revenue 20 Lons from officers, directors, trustees, nd other disqulified persons 21 Mortgges nd other notes pyle J 22 Other liilities (descrie 23 Totl liilities (dd line s 17 throw h 22) Orgniztions tht follow SFAS 117, check here nd complete lines 24 through 26 nd lines 30 nd Unrestricted 6,600. 5,700. j 25 Temporrily restricted co 26 Permnently restricted r_ Orgniztions tht do not follow SFAS 117, check here LL nd complete lines 27 through 31 u) 27 Cpitl stock, trust principl, or current funds 28 Pid-in or cpitl surplus, or lnd, ldg., nd equipment fund < 29 Retined ernings, ccumulted income, endowment, or other funds 41 Z 30 Totl net ssets or fund lnces 6, , Totl liilities nd net ssets /fund lnces 6,600. 5,700.1 P rt III Anlysis of Chnges in Net Assets or Fund Blnces 1 Totl net ssets or fund lnces t eginning of yer - Prt II, column (), line 30 (must gree with end-of-yer figure reported on prior yer's return) 2 Enter mount from Prt I, line 27 3 Other increses not included in line 2 (itemize) 4 Add lines 1, 2, nd 3 5 Decreses not included in line 2 (itemize) 6 Totl net ssets or fund lnces t end of yer (line 4 minus line 5) - Prt II, column line 30 6,600. <900. > 0. 5, Form 990-PF (2005)

3 Form 990-PF 2005) COUTTS & CLARK FOUNDATION INC Pge 3 P rt IV Cpitl Gins nd Losses for Tx on Investment Income () List nd descrie the kind(s) of property sold (e.g., rel estte, 2-story rick wrehouse; or common stock, 200 shs. MLC Co.) (1 How cquired D - Dontion (c) Dte cquired (mo., dy, yr.) (d) Dte sold (mo., dy, yr.) l C d e c d e c d e (e) Gross sles price NONE (f) Deprecition llowed (or llowle) (g) Cost or other sis plus expense of sle (h) Gin or (loss) (e) plus (f) minus (g) Complete only for ssets showing gin in column (h) nd owned y the foundtion on 12/31/69 (I) Gins (Cl. (h) gin minus (j) Adjusted sis (k) Excess of col. (i) c ol. (k), ut not less thn -0-) or (i) F.M.V. s of 12/31/69 s of 12/31/69 over col. (1), if ny Losses (from col. (h)) f If in, lso enter in Prt I, line Cpitl gin net income or ( net cpitl loss ). ` If (llss), enter -0- in Prt I, line Net short-term cpitl gin or (loss) s defined in sections 1222(5) nd (6): If gin, lso enter in Prt I, line 8, column (c). If (lss), enter -0- in Prt I, line 8 3 Prt V I Qulifiction Under Section 4940(e) for Reduced Tx on Net Investment Income (For optionl use y domestic privte foundtions suject to the section 4940() tx on net investment income.) If section 4940(d)(2) pplies, leve this prt lnk. Ws the orgniztion lile for the section 4942 tx on the distriutle mount of ny yer in the se period? Yes No If 'Yes," the orgniztion does not qulify under section 4940( e). Do not complete this prt. 1 Enter the pp roprite mount in ech col umn for ech yer ; see instructions efore mking ny entries. Bse period yers Clendr yer (or tx yer eginning in) () Adjusted qulifying distriutions (c) Net vlue of nonchritle-use ssets Distriuttiion rtio (col. () divided y col. (c)) , , , ,500. 1, , Totl of line 1, column (d) Averge distriution rtio for the 5-yer se period - divide the totl on line 2 y 5, or y the numer of yers the foundtion hs een in existence if less thn 5 yers Enter the net vlue of nonchritle-use ssets for 2005 from Prt X, line , Multiply line 4 y line , Enter 1% of net investment income (1% of Prt I, line 27) Add lines 5 nd , Enter qulifying distriutions from Prt XI I, line ,026. If line 8 is equl to or greter thn line 7, check the ox in P rt VI, line 1, nd complete tht prt using 1% tx rte. See the Prt VI instructions / Form 990-PF (2005)

4 Form 990-PF (2005) COUTTS & CLARK FOUNDATION INC Pge 4 Prt VI Excise Tx Bsed on Investment Income (Section 4940 (), 4940 (), 4940 (e), or see instructions) Is Exempt operting foundtions descried in section 4940(d)(2), check here 0 nd enter N/A" on line 1. Dte of ruling letter: ( ttch copy of ruling le tter if necess ry -see instructions) Domestic orgniztions tht meet the section 4940(e) requirements in Prt V, check here 0 nd enter 1% 1 4. of Prt I, line 27 c All other domestic orgniztions enter 2% of line 27. Exempt foreign orgniztions enter 4% of Prt I, line 12, col. () 2 Tx under section 511 (domestic section 4947()(1) trusts nd txle foundtions only. Others enter -0-) Add lines 1 nd Sutitle A (income) tx (domestic section 4947()(1) trusts nd txle foundtions only. Others enter -0-) Tx sed on investment income. Sutrct line 4 from line 3. If zero or less, enter Credits/Pyments: 2005 estimted tx pyments nd 2004 overpyment credited to Exempt foreign orgniztions - tx withheld t source 6 c Tx pid with ppliction for extension of time to file (Form 8868) 6c d Bckup withholding erroneously withheld 6d 7 Totl credits nd pyments. Add lines 6 through 6d Enter ny penlty for underpyment of estimted tx. Check here 0 if Form 2220 is ttched 8 9 Tx due. If the totl of lines 5 nd 8 is more thn line 7, enter mount owed Overpyment. If line 7 is more thn the totl of lines 5 nd 8, enter the mount overpid Enter the mount of line 10 to e: Credited to 2006 estimted tx 00, Refunded lp~ 11 Prt VII-A Sttements Regrding Activities 1 During the tx yer, did the orgniztion ttempt to influence ny ntionl, stte, or locl legisltion or did it prticipte or intervene in Yes No ny politicl cmpign? Is X Did it spend more thn $100 during the yer (either directly or indirectly) for politicl purposes (see instructions for definition)? l X If the nswer is "Yes" to to or 1, ttch detiled descnption of the ctivities nd copies of ny mterils pulished or distriuted y the orgniztion in connection with the ctivities. c Did the orgniztion file Form POL for this yer? 1c X d Enter the mount (if ny) of tx on politicl expenditures (section 4955) imposed during the yer: (1) On the orgniztion. Jo- $ 0. (2) On orgniztion mngers. No- $ 0. e Enter the reimursement (if ny) pid y the orgniztion during the yer for politicl expenditure tx imposed on orgniztion mngers. $ 0. 2 Hs the orgniztion engged in ny ctivities tht hve not previously een reported to the IRS9 2 X If "Yes," ttch detiled description of the ctivities 3 Hs the orgniztion mde ny chnges, not previously reported to the IRS, in its governing instrument, rticles of incorportion, or ylws, or other similr instruments? If "Yes," ttch conformed copy of the chnges 3 X 4 Did the orgniztion hve unrelted usiness gross income of $1,000 or more during the yer? 4 X If "Yes, hs it filed tx return on Form 990 -T for this yer? N/A 4 5 Ws there liquidtion, termintion, dissolution, or sustntil contrction during the yer? 5 X If "Yes, " ttch the sttement required y Generl Instruction T. 6 Are the requirements of section 508(e) (relting to sections 4941 through 4945) stisfied either: By lnguge in the governing instrument, or By stte legisltion tht effectively mends the governing instrument so tht no mndtory directions tht conflict with the stte lw remin in the governing instrument9 6 X 7 Did the orgniztion hve t lest $5,000 in ssets t ny time during the yers 7 X If "Yes, " complete Prt II, col. (c), nd Prt XV 8 Enter the sttes to which the foundtion reports or with which it is registered (see instructions) NEY JERSEY If the nswer is "Yes" to line 7, hs the orgniztion furnished copy of Form 990-PF to the Attorney Generl (or designte) of ech stte s required y Generl Instruction G9 If "No, " ttch explntion 8 X 9 Is the orgniztion climing sttus s privte operting foundtion within the mening of section 4942(j)(3) or 4942(I)(5) for clendr yer 2005 or the txle yer eginning in 2005 (see instructions for Prt XIV)? If "Yes," complete Prt XIV 9 X 10 Did ny persons ecome sustntil contriutors during the tx yer? If "Yes," ttch schedule listing their nmes nd ddresses 10 X 11 Did the orgniztion comply with the pulic inspection requirements for its nnul returns nd exemption ppliction? 11 X We site ddress N/A 12 The ooks re in cre of WILLIAM CARSON Telephone no. ' Locted t DOVE ISLAND ROAD, NEWTON, NJ ZIP Section 4947( )(1) nonexempt chritle trusts filing Form 990-PF in lieu of Form Check here 0 nd enter the mount of tx-exempt interest received or ccrued during the yer 1 13 I N/A of os 06 Form 990-PF (2005) 4

5 Form 990-PF (2005) COUTTS & CLARK FOUNDATION INC Pge 5 P rt VII-B Sttements Regrding Activities for Which Form 4720 My Be Required File Form 4720 if ny item is checked in the "Yes" column, unless n exception pplies. Yes No Is During the yer did the orgniztion (either directly or indirectly): (1) Engge in the sle or exchnge, or lesing of property with disqulified persons Yes No (2) Borrow money from, lend money to, or otherwise extend credit to (or ccept it from) disqulified persons Yes No (3) Furnish goods, services, or fcilities to (or ccept them from) disqulified person? Yes No (4) Py compenstion to, or py or reimurse the expenses of, disqulified person? Yes No (5) Trnsfer ny income or ssets to disqulified person (or mke ny of either ville for the enefit or use of disqulified person)? Yes No (6) Agree to py money or proper ty to government officil? ( Exception. Check "No' if the orgniztion greed to mke grnt to or to employ the officil for period fter termintion of government service, if terminting within 90 dys.) Yes No If ny nswer is "Yes ' to l(1)-(6), did ny of the cts fil to qulify under the exceptions descried in Regultions section (d)-3 or in current notice regrding disster ssistnce (see pge 20 of the instructions) Orgniztions relying on current notice regrding disster ssistnce check here c Did the orgniztion engge in prior yer in ny of the cts descried in l, other thn excepted cts, tht were not corrected efore the first dy of the tx yer eginning in Txes on f il ure to distriute income (section 4942 ) ( does not pply for yers the orgniztion ws privte operting foundtion defined in section 4942 ( j)(3) or 4942(1)(5)): At the end of tx yer 2005, did the orgniztion hve ny undistriuted income ( lines 6d nd 6e, Prt XIII) for tx yer ( s) eginning efore 2005? Yes No If "Yes," list the yers Are there ny yers listed in 2 for which the orgniztion is not pplying the provisions of section 4942 ( )(2) (relting to incorrect vlution of ssets ) to the yer's undistriuted income? ( If pplying section 4942 ()(2) to ll yers listed, nswer "No " nd ttch sttement - see instructions.) N/A c If the provisions of section 4942 ( )(2) re eing pplied to ny of the yers listed in 2, list the yers here Did the orgniztion hold more thn 2% direct or indirect interest in ny usiness enterprise t ny time during the yer? 0 Yes No If "Yes," did it hve excess usiness holdings in 2005 s result of ( 1) ny purchse y the orgniztion or disqulified persons fter My 26, 1969; (2 ) the lpse of the 5-yer period ( or longer period pproved y the Commissioner under section 4943( c)(7)) to dispose of holdings cquired y gift or equest ; or (3) the lpse of the 10-, 15-, or 20-yer first phse holding period? (Use Schedule C, Form 4720, to determine if the orgniztion hd excess usiness holdings in 2005.) 4 Did the orgniztion invest during the yer ny mount in mnner tht would jeoprdize its chritle purposes? Did the orgniztion mke ny investment in prior yer ( ut fter Decemer 31, 1969) tht could jeoprdize its chritle purpose tht hd not een removed from jeoprdy efore the first dy of the tx yer eginning in During the yer did the orgniztion py or incur ny mount to: (1) Crry on propgnd, or otherwise ttempt to influence legisltion ( section 4945 (e))? Yes No (2) Influence the outcome of ny specific pulic election ( see section 4955); or to crry on, directly or indirectly, ny voter registrtion drive? E::]Yes No (3) Provide grnt to n individul for trvel, study, or other similr purposes? Yes No (4) Provide grnt to n orgniztion other thn chritle, etc., orgniztion descried in section 509( )( 1), (2), or (3 ), or section 4940 (d)(2)? Yes No (5) Provide for ny purpose other thn religious, chritle, scientific, literry, or eductionl purposes, or for the prevention of cruelty to ch ildren or nimls? Yes No If ny nswer is "Yes" to 5 ( 1)-(5), did ny of the trnsctions fil to qulify under the exceptions descried in Regultions section or in current notice regrding disster ssistnce (see instructions)'? Orgniztions relying on current notice regrding disster ssistnce check here c If the nswer is "Yes' to question 5 ( 4), does the orgniztion clim exemption from the tx ecuse it mintined expenditure responsiility for the grnt? N/A Yes No If "Yes, " ttch the sttement required y Regultions section (d). 6 Did the orgniztion, during the yer, receive ny funds, directly or indirectly, to py premiums on personl enefit contrcts Yes No Did the orgniztion, during the yer, py premiums, directly or indirectly, on personl enefit contrct? If you nswered " Yes" to 6, lso file Form N/A N/A N/A 1c X X 4 I I X Form 990-PF (2005)

6 ' COUTTS & CLARK FOUNDATION INC Informtion Aout Officers Prt VIII, Directors, Trustees, Foundtion Mngers, Highly Pge 6 Pid Employees, nd Contrctors 1 List ll officers, directors, trustees, foundtion mngers nd their compenstion. () Nme nd ddress () Title, nd verge hours per week devoted to position (c) Compenstion ( If not pid, enter -O ( d)contnuonsto emp nddelerfitins compenstion (e) Expense ccount, other llownces SEE STATEMENT Comoenstion of five hihest-pid em olovees (other thn those included on line 1). If none. enter "NONE." () Nme nd ddress of ech employee pid more thn $50,000 NONE () Title nd verge 'hours per week devoted to position (c) Compenstion (d Contriutlonsto enefit plns employee deferred compenstion (e) Exp ense ccount, other llownces Totl numer of other employees pid over $50, Five highest - pid independent contrctors for professionl services. If none, enter "NONE." List the foundtion's four lrgest direct chritle ctivities during the tx yer. Include relevnt sttisticl informtion such s the numer of orgniztions nd other eneficiries served, conferences convened, reserch ppers produced, etc. N/A Expenses oe Form 990-PF (2005)

7 Form 990-PF (2005) COUTTS & CLARK FOUNDATION INC Pge 7 P rt IX - B Summ ry of Progrm - Relted Investments Descrie the two lrgest progrm-relted investments mde y the foundtion during the tx yer on lines 1 nd 2. Amount 1 N A 2 All other progrm-relted investments. See instructions. 3 Totl. Add lines 1 through 3 0. Prt X Minimum Investment Return (All domestic foundtions must complete this prt Foreign foundtions, see instructions.) 1 Fir mrket vlue of ssets not used (or held for use) directly in crrying out chritle, etc., purposes: Averge monthly fir mrket vlue of securities l Averge of monthly csh lnces 1 10, 352. c Fir mrket vlue of ll other ssets 1c d Totl (dd lines l,, nd c) 1d 10, 352. e Reduction climed for lockge or other fctors reported on lines l nd 1c (ttch detiled explntion) le 0. 2 Acquisition indetedness pplicle to line 1 ssets Sutrct line 2 from line 1d 3 10, Csh deemed held for chritle ctivities. Enter 1 1/2% of line 3 (for greter mount, see instructions) Net vlue of nonchritle - use ssets Sutrct line 4 from line 3. Enter here nd on Prt V, line , Minimum investment return Enter 5% of line P rt XI Distriutle Amount (see instructions) (Section 4942(l)(3) nd (j)(5) privte operting foundtions nd certin foreign orgniztions check here 0 nd do not complete this prt.) 1 Minimum investment return from Prt X, line Tx on investment income for 2005 from Prt VI, line Income tx for (This does not include the tx from Prt VI.) 2 c Add lines 2 nd 2 2c 4. 3 Distriutle mount efore djustments. Sutrct line 2c from line Recoveries of mounts treted s qulifying distriutions 0. 5 Add lines 3 nd Deduction from distriutle mount (see instructions) Distriutle mount s djusted. Sutrct line 6 from line 5. Enter here nd on Prt XIII, line P rt XII Qulifying Distriutions (see instructions) 1 Amounts pid (including dministrtive expenses) to ccomplish chritle, etc., purposes: Expenses, contriutions, gifts, etc. - totl from Prt I, column (d), line ,026. Progrm-relted investments - totl from Prt IX-B Amounts pid to cquire ssets used (or held for use) directly in crrying out chritle, etc., purposes 2 3 Amounts set side for specific chritle projects tht stisfy the: Suitility test (prior IRS pprovl required) 3 Csh distriution test (ttch the required schedule) 3 4 Qulifying distriutions. Add lines l through 3. Enter here nd on Prt V, line 8, nd Prt XIII, line , Orgniztions tht qulify under section 4940(e) for the reduced rte of tx on net investment income. Enter 1% of Prt I, line Adjusted qulifying distriutions Sutrct line 5 from line ,026. Note: The mount on line 6 will e used in Prt V, column (), in susequent yers when clculting whether the foundtion qulifies for the section 4940(e) reduction of tx in those yers Form 990-PF (2005)

8 Form 990-PF (2005) COUTTS & CLARK FOUNDATION INC Pge 8 Prt XIII Undistriuted Income (see instructions) () () (c) (d) Corpus Yers prior to Distriutle mount for 2005 from Prt XI, line Undistriuted income, if ny, s of the end of 2004 Enter mount for 2004 only 0. Totl for prior yers: 0. 3 Excess distriutions c rryover, if ny, to 2005: From 2000 From cfrom ,433. d From , 000. efrom ,252. f Totl of lines 3 throug h e 188, Qulifying distriutions for 2005 from Prt Xll, line 4:0, $ 90,026. Applied to 2004, ut not more thn line 2 0. Applied to undistriuted income of prior yers (Election required - see instructions) 0. c Treted s distriutions out of corpus (Election required - see instructions) 0. d Applied to 2005 distriutle mount 506. e Remining mount distriuted out of corpus 89, Excess distriutions crryover pplied to (if n mount ppers in column ( d), the sme mount must e shown in column () ) 6 Enter the net totl of ech column s indicted elow: Corpus Add lines 3f, 4c, nd 4e Sutrct line 5 278,251. Prior yers' undistriuted income. Sutrct line 4 from line 2 0. c Enter the mount of prior yers' undistriuted income for which notice of deficiency hs een issued, or on which the section 4942() tx hs een previously ssessed 0 d Sutrct line 6c from line 6. Txle mount - see instructions 0 e Undistriuted income for Sutrct line 4 from line 2. Txle mount - see Instr. 0 f Undistriuted income for Sutrct lines 4d nd 5 from line 1. This mount must e distriuted in Amounts treted s distriutions out of corpus to stisfy requirements imposed y section 170()(1)(E) or 4942(g)(3) 0. 8 Excess distriutions crryover from 2000 not pplied on line 5 or line Excess distriutions crryover to Sutrct lines 7 nd 8 from line 6 278, Anlysis of line 9: Excess from ,046. Excess from ,433. c Excess from ,000. d Excess from ,252 e Excess from Form 990-PF (2005)

9 Form 990-PF (see instructions nd Prt VII-A, 1 If the foundtion hs received ruling or determintion letter tht it is privte operting foundtion, nd the ruling is effective for 2005, enter the dte of the ruling I Check ox to indicte whether the orgniztion is privte oper in foundtion descried in section 4942(j)(3) or 4 426)(5) 2 Enter the lesser of the djusted net income from Prt or the minimum Tx yer () 2005 () 2004 Prior 3 yers (c) 2003 (d) 2002 ( e) Totl investment return from Prt X for ech yer listed 85% of line 2 c Qulifying distriutions from Prt XII, line 4 for ech yer listed d Amounts included in line 2c not used directly for ctive conduct of exempt ctivities e Qulifying distriutions mde directly for ctive conduct of exempt ctivities. Sutrct line 2d from line 2c Complete 3,, or c for the lterntive test relied upon: 'Assets* lterntive test - enter: (1) Vlue of ll ssets (2) Vlue of ssets qulifying under section 4942(I)(3)(B)(i) "Endowment" lterntive test - enter 2/3 of minimum investment return shown in Prt X, line 6 for ech yer listed c "Support lterntive test - enter: (1) Totl support other thn gross investment income (interest, dividends, rents, pyments on securities lons (section 512()(5)), or roylties) (2) Support from generl pulic nd 5 or more exempt orgniztions s provided in section 4942(I)(3)(B)(ui) (3) Lrgest mount of support from n exempt orgniztion (4) Gross investment income P rt XV Supplement ry Informtion (Complete this p rt only if the orgniztion hd $5,000 or more in ssets t ny time during the yer-see pge 26 of the instructions.) 1 Informtion Regrding Foundtion Mngers: List ny mngers of the foundtion who hve contriuted more thn 2% of the totl contriutions received y the foundtion efore the close of ny tx yer (ut only if they hve contriuted more thn $5,000). (See section 507(d)(2).) List ny mngers of the foundtion who own 10% or more of the stock of corportion (or n eqully lrge portion of the ownership of prtnership or other entity) of which the foundtion hs 10% or greter interest. NONE 2 Informtion Regrding Contriution, Grnt, Gift, Lon, Scholrship, etc., Progrms: Check here 0 if the orgniztion only mkes contriutions to preselected chritle orgniztions nd does not ccept unsolicited requests for funds. If the orgniztion mkes gifts, grnts, etc. (see instructions) to individuls or orgniztions under other conditions, complete items 2,, c, nd d. The nme, ddress, nd telephone numer of the person to whom pplictions should e ddressed: WILLIAM CARSON CIO COUTTS & CLARK FOUNDATION INC The form in which pplictions should e sumitted nd informtion nd mterils they should include: NO SPECIFIC FORM - HOWEVER AN APPLICATION FORM MAY BE REQUESTED c Any sumission dedlines: d Any restrictions or limittions on wrds, such s y geogrphicl res, chritle fields, kinds of institutions, or other fctors: NONE / Form 990-PF (2005) 9

10 Form 990-PF (2005) COUTTS & CLARK FOUNDATION INC P rt XV Supplement ry Informtion (continued) 3 Grnts nd Contriutions Pid During the Yer or ADoroved for Future Pyment Recipient If recipient is n individul, show ny reltionship to Foundtion Purpose of grnt or Nme nd ddress (home or usiness) ny foundtion mnger sttus of contriution or sustntil contriutor recipient Pid dung the yer Amount PUBLIC BLAIR ACADEMY ONE HARITY ANNUAL CAMPAIGN 15,000. PROJECT SELF-SUFFICIENCY PUBLIC OF SUSSEX COUNTY ONE CHARITY ANNUAL CAMPAIGN 55,026. UNITED WAY OF MONROE PUBLIC COUNTY ONE CHARITY ANNUAL CAMPAIGN 20,000. Totl 3 90,026. Approved for future pyment NONE Totl / Form 990-PF (2005) 10

11 Form 990-PF (2005) COUTTS & CLARK FOUNDATION INC Pge 11 P rt XVI -A Anlysis of Income - Producing Activities Enter gross mounts unless otherwise indicted. 1 Pro grm se rvice revenue: c d e f 9 Fees nd contrcts from government gencies 2 Memership dues nd ssessments 3 Int Brest on svings nd temporry csh investments Dividends nd interest from securities 5 Net rentl income or (loss) from rel estte: Det-finnced property Not det-finnced property 6 Net rentl income or (loss) from personl pro perry 7 0th er investment income 8 Gt n or (loss) from sles of ssets other th n inventory 9 Net income or (loss) from specil events 10 Gr o ss profit or (loss) from sles of inventory 11 0th er revenue: d e 12 Sutotl. Add columns (), (d), nd (e) Totl Add line 12, columns (), (d), nd (e) (See worksheet in line 13 instructions to verify clcultions.) Prt XVI- B Unrelte d usiness income Excluded section or514 1 () () ExcL (d) Business Amount Sion code code Amount Reltionship of Activities to the Accomplishment of Exempt Purposes (e) Relted or exempt function income 11

12 Form 990-PF (2005) COUTTS & CLARK FOUNDATION INC P Qt 12 P rt XVII Informtion Regrding Trnsfers To nd Trnsctions nd Reltionships With Nonchritle Exempt Orgniztions Did the orgniztion directly or indirectly engge in ny of the following with ny other orgniztion descried in section 501(c) of Yes No the Code (other thn section 501(c)(3) orgniztions) or in section 527, relting to politicl orgniztions? Trnsfers from the reporting orgniztion to nonchritle exempt orgniztion of: (1) Csh l(l) X (2) Other ssets l(2) X Other trnsctions: (1) Sles of ssets to nonchritle exempt orgniztion (2) Purchses of ssets from nonchritle exempt orgniztion (3) Rentl of fcilities, equipment, or other ssets l(3)1 X (4) Reimursement rrngements l(4) X (5) Lons or lon gurntees l(5) X (6) Performnce of services or memership or fundrising solicittions l(6) X Shring of fcilities, equipment, miling lists, other ssets, or pid employees 1c X If the nswer to ny of the ove is "Yes," complete the following schedule. Column () should lwys show the fir mrket vlue of the goods, other ssets, or services given y the reporting orgniztion. If the orgniztion received less thn fir mrket vlue in ny trnsction or shring rrngement, show in 11:10)l l(2)1 X X 2 Is the orgniztion directly or indirectly ffilited with, or relted to, one or more tx -exempt orgniztions descried in section 501 ( c) of the Code ( other thn section 501(c)(3 )) or in section 5279 E] Yes EXI No If "Yes. complete the followin schedule. () Nme of orgniztion () Type of orgniztion (c) Description of reltionship N/A y Under penlties of perjury, I d lne tht I hve exms this return, including ccompnying schedules nd sttements, nd to the est of my knowledge nd elief, it is true, correct, nd complete Decl rtion o sp r er loth t n t er or fiduciry) is sed on ll informtion of which oreorer hs ny knowledge I 1A 11 ' Signture of o er or trustee Dl Preprer's signture 2L ) Arm ' snme ( oryours THOMAS M. GILL & CO. W If self employed), ' 838 SHOEMAKER AVENUE ddress, ndzipcode WEST WYOMING, PA

13 Schedule B Schedule of Contriutors OMB No (Form 990, 990-EZ, or 990-PF) Supplementry Informtion for 2005 Deprtment of the Tresury Internl Revenue Service line 1 of Form 990, EZ, nd PF (see instructions) Nme of orgniztion Employer identifiction numer Orgniztion type (check one)- OnTTMMO f- /'T. AVY T+r1TTATT1PTr1AT TAT/C ZR) r, r, Filers of: Section: Form 990 or 990-EZ E] 501 (c)( ) (enter numer) orgniztion ( )(1) nonexempt chritle trust not treted s privte foundtion 527 politicl orgniztion Form 990-PF 501 (c)(3) exempt privte foundtion 4947()(1) nonexempt chritle trust treted s privte foundtion (c)(3) txle privte foundtion Check if your orgniztion is covered y the Generl Rule or Specil Rule. (Note : Only section 501(c)(7), (8), or (10) orgniztion cn check oxes for oth the Generl Rule nd Specil Rule-see instructions) Generl Rule- For orgniztions filing Form 990, 990-EZ, or 990-PF tht received, during the yer, $5,000 or more (in money or property) from ny one contriutor (Complete Prts I nd II.) Specil Rules- For section 501(c )(3) orgniztion filing Form 990, or Form EZ, tht met the 33 1/3% suppo rt test of the regultions under sections 509 ()(1)/170()(1)(A)(vl) nd received from ny one contriutor, during the yer, contriution of the greter of $5,000 or 2% of the mount on line 1 of these forms (Complete P rt s I nd II.) For section 501 (c)(7), (8), or ( 10) orgniztion f iling Form 990, or Form 990-EZ, tht received from ny one contriutor, during the yer, ggregte contriutions or equests of more thn $1,000 for use exclusively for religious, chritle, scientific, literry, or eductionl purposes, or the prevention of cruelty to children or nimls (Complete P rt s I, II, nd III.) For section 501 (c)(7), (8), or (10) orgniztion filing Form 990, or Form 990-EZ, tht received from ny one contriutor, during the yer, some contriutions for use exclusively for religious, chritle, etc., purposes, ut these contriutions did not ggregte to more thn $1,000 (If this ox is checked, enter here the totl contriutions tht were received during the yer for n exclusively religious, chritle, etc., purpose. Do not complete ny of the Prts unless the Generl Rule pplies to this orgniztion ecuse it received nonexclusively religious, chritle, etc, contriutions of $5,000 or more during the yer) $ Cution : Orgniztions tht re not covered y the Generl Rule nd/or the Specil Rules do not file Schedule B (Form 990, 990-EZ, or 990-PF), ut they must check the ox in the heding of their Form 990, Form 990-EZ, or on line 2 of their Form 990-PF, to certify tht they do not meet the filing requirements of Schedule B (Form 990, 990-EZ, or 990-PF) LHA For Pperwork Reduction Act Notice, see the Ins tructions Schedule B (Form 990, 990-EZ, or 990-PF) (2005) for Form 990, Form 990-EZ, nd Form 990-PF P

14 Schedule B (Form 990, 991 Nme of orgniztion Employer identifiction numer of Prt I Prt I Contriutors (See Specific Instructions) () No. () Nme, ddress, nd ZIP + 4 (c) Aggregte con tr iutions (d) Type of contriution 1 WILLIAM CARSON Person I-XI Pyroll 936 DOVE ISLAND ROAD $ 89,000. Noncsh (Complete Prt II if there NEWTON, NJ is noncsh contriution) () No. () Nme, ddress, nd ZIP + 4 (c) Aggregte contriutions (d) Type of contriution $ Person Pyroll Noncsh (Complete Prt II if there is noncsh contriution.) () No. () Nme, ddress, nd ZIP + 4 (c) Aggregte contriutions (d) Type of contriution $ Person Pyroll Noncsh (Complete Prt II if there is noncsh contriution.) () No. () Nme, ddress, nd ZIP + 4 (c) Aggregte contriutions (d) Type of contriution $ Person Pyroll Noncsh (Complete Prt II if there is noncsh contriution) () No. () Nme, ddress, nd ZIP + 4 (c) Aggregte contriutions (d) Type of contriution $ Person Pyroll Noncsh (Complete Prt II if there is noncsh contriution) () No. () Nme, ddress, nd ZIP + 4 (c) Aggregte contriutions (d) Type of contriution $ Person Pyroll Noncsh (Complete Prt II if there is noncsh contriution o_o5_05 Schedule B (Form EZ. or 990-PF) (

15 COUT''S &CLARK FOUNDATION INC FORM 990-PF INTEREST ON SAVINGS AND TEMPORARY CASH INVESTMENTS STATEMENT 1 SOURCE AMOUNT WACHOVIA TOTAL TO FORM 990-PF, PART I, LINE 3, COLUMN A FORM 990-PF OTHER EXPENSES STATEMENT 2 DESCRIPTION STATE FILING FEE BANK FEES TO FORM 990-PF, PG 1, LN 23 (A) (B) (C) EXPENSES NET INVEST- ADJUSTED PER BOOKS MENT INCOME NET INCOME (D) CHARITABLE PURPOSES STATEMENT(S) 1, 2

16 } COUTTS &0CLARK FOUNDATION INC FORM 990-PF PART VIII - LIST OF OFFICERS, DIRECTORS STATEMENT 3 TRUSTEES AND FOUNDATION MANAGERS EMPLOYEE TITLE AND COMPEN- BEN PLAN EXPENSE NAME AND ADDRESS AVRG HRS/WK SATION CONTRIB ACCOUNT WILLIAM C CARSON PRESIDENT 936 DOVE ISLAND ROAD NEWTON NJ MARTHA H CARSON TREASURER / SECRETARY 936 DOVE ISLAND ROAD NEWTON NJ WILLIAM H CARSON V PRESIDENT 3822 VISTA AZUL SAN CLEMENTE CA ROBERT C CARSON ASST SECRETARY 1635 MUSEUM ROAD WYOMISSING PA DANIEL B CARSON ASST TREASURER 67 LANNING ROAD BLAIRSTOWN NJ TOTALS INCLUDED ON 990-PF, PAGE 6, PART VIII STATEMENT(S) 3