Return of Private Foundation

Transcription

1 Form Department of the Treasury Internal Revenue Service For calendar year 01 or tax year eginning Name of foundation Numer and street (or P.O. ox numer if mail is not delivered to street address) Room/suite OMB Open to Pulic Inspection City or town, state or province, country, and ZIP or foreign postal code C If exemption application is pending, check here ~ Net rental income or (loss) a Net gain or (loss) from sale of assets not on line 10 ~~ Gross sales price for all assets on line a ~~ Capital gain net income (from Part IV, line ) ~~~~~ 8 Net short-term capital gain ~~~~~~~~~ Income modifications~~~~~~~~~~~~ Gross sales less returns 10a and allowances ~~~~ Less: Cost of goods sold ~ or Section (a)(1) Trust Treated as Private Foundation Do not enter social security numers on this form as it may e made pulic. Information aout Form 0-PF and its separate instructions is at Compensation of officers, directors, trustees, etc. ~~~, and ending A Employer identification numer B Telephone numer G Check all that apply: Initial return Initial return of a former pulic charity D 1. Foreign organizations, check here ~~ Final return Amended return. Foreign organizations meeting the 8% test, Address change Name change check here and attach computation ~~~~ H Check type of organization: Section 01(c)() exempt private foundation E If private foundation status was terminated Section (a)(1) nonexempt charitale trust Other taxale private foundation under section 0()(1)(A), check here ~ I Fair market value of all assets at end of year J Accounting method: Cash Accrual F If the foundation is in a 0-month termination (from Part II, col. (c), line 1) Other (specify) under section 0()(1)(B), check here ~ $ 11,. (Part I, column (d) must e on cash asis.) Part I Analysis of Revenue and Expenses (d) Disursements (The total of amounts in columns (), (c), and (d) may not (a) Revenue and () Net investment (c) Adjusted net for charitale purposes necessarily equal the amounts in column (a).) expenses per ooks income income (cash asis only) 1 Contriutions, gifts, grants, etc., received ~~~ N/A Check if the foundation is not required to attach Sch. B Interest on savings and temporary cash investments ~~~~~~~~~~~~~~ Revenue Operating and Administrative Expenses a Gross rents ~~~~~~~~~~~~~~~~ 11 c Gross profit or (loss) ~~~~~~~~~~~~ 1 Total. Add lines 1 through a Legal fees~~~~~~~~~~~~~~~~~ Accounting fees ~~~~~~~~~~~~~~ STMT PF SOUTHSHORE FOUNDATION P.O. BO 0 FLIPPIN, AR Dividends and interest from securities~~~~~ Other income ~~~~~~~~~~~~~~~ Other employee salaries and wages ~~~~~~ Pension plans, employee enefits c Other professional fees ~~~~~~~~~~~ Total operating and administrative expenses. Add lines 1 through ~~~~~ Total expenses and disursements. ~~~~~~ Interest ~~~~~~~~~~~~~~~~~~ Taxes~~~~~~~~~~~~~~~~~~~ Depreciation and depletion ~~~~~~~~~ Occupancy Travel, conferences, and meetings Printing and pulications ~~~~~~~~~~ Other expenses ~~~~~~~~~~~~~~~~ ~~~~~~ ~~~~~~~~~~~~~~ Contriutions, gifts, grants paid ~~~~~~~ Add lines and Return of Private Foundation 01 Sutract line from line 1: a Excess of revenue over expenses and disursements ~ -8,01. Net investment income (if negative, enter -0-) ~~~ c Adjusted net income (if negative, enter -0-) N/A LHA For Paperwork Reduction Act tice, see instructions SOUTHSHORE FOUNDATION 1_1 1,8. 1,8. 1,8. 1,8.,1,1 8,01. 8,01.

2 Part II Assets Liailities Net Assets or Fund Balances 1 8 Other notes and loans receivale ~~~~~~~~ Investments - land, uildings, and equipment: asis Less: accumulated depreciation Less: accumulated depreciation Attached schedules and amounts in the description column should e for end-of-year amounts only. Prepaid expenses and deferred charges ~~~~~~~~~~~~~ 10a Investments - U.S. and state government oligations ~~~~~~~ Investments - corporate stock c Investments - corporate onds ~~~~~~~~~~~~~~~~~ Total assets (to e completed y all filers - see the Loans from officers, directors, trustees, and other disqualified persons Total liailities (add lines 1 through ) Foundations that follow SFAS 11, check here ~~~~ 8 0 Balance Sheets Cash - non-interest-earing Savings and temporary cash investments Accounts receivale Less: allowance for doutful accounts Pledges receivale Less: allowance for doutful accounts and complete lines through and lines 0 and 1. Foundations that do not follow SFAS 11, check here and complete lines through 1. ~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~ Grants receivale ~~~~~~~~~~~~~~~~~~~~~~~ Receivales due from officers, directors, trustees, and other disqualified persons ~~~~~~~~~~~~~~~~~~~~~~ Less: allowance for doutful accounts Inventories for sale or use Investments - mortgage loans ~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~ ~~ ~~~~~~~~ Investments - other ~~~~~~~~~~~~~~~~~~~~~~ Land, uildings, and equipment: asis ~~~~~~~~ ~~~~~~~~~~~~~~~~~ Other assets (descrie ) instructions. Also, see page 1, item I) Accounts payale and accrued expenses ~~~~~~~~~~~~~ Grants payale ~~~~~~~~~~~~~~~~~~~~~~~~ Deferred revenue ~~~~~~~~~~~~~~~~~~~~~~~ Mortgages and other notes payale Other liailities (descrie Unrestricted SOUTHSHORE FOUNDATION ~~~~ ~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~ Temporarily restricted ~~~~~~~~~~~~~~~~~~~~~ Permanently restricted~~~~~~~~~~~~~~~~~~~~~ Capital stock, trust principal, or current funds ~~~~~~~~~~~ Paid-in or capital surplus, or land, ldg., and equipment fund ~~~~ Retained earnings, accumulated income, endowment, or other funds ~ Total net assets or fund alances~~~~~~~~~~~~~~~~ ~ ) Page Beginning of year End of year (a) Book Value () Book Value (c) Fair Market Value 1, 11,. 11,. 1, 11,. 11,.,00,00,00,00 1,,. 1,,. 1 Total liailities and net assets/fund alances Part III Analysis of Changes in Net Assets or Fund Balances 1, 11,. 1 Total net assets or fund alances at eginning of year - Part II, column (a), line 0 (must agree with end-of-year figure reported on prior year's return) ~~~~~~~~~~~~~~~~~~~~~~~~~~~ Enter amount from Part I, line a ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Other increases not included in line (itemize) Add lines 1,, and ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Decreases not included in line (itemize) Total net assets or fund alances at end of year (line minus line ) - Part II, column (), line , -8,01.,., SOUTHSHORE FOUNDATION 1_1

3 SOUTHSHORE FOUNDATION Page Part IV Capital Gains and Losses for Tax on Investment Income (a) List and descrie the kind(s) of property sold (e.g., real estate, () How acquired (c) Date acquired (d) Date sold P - Purchase -story rick warehouse; or common stock, 00 shs. MLC Co.) D - Donation (mo., day, yr.) (mo., day, yr.) 1a c d e a c d e a c d e (e) Gross sales price (f) Depreciation allowed (g) Cost or other asis (h) Gain or (loss) (or allowale) plus expense of sale (e) plus (f) minus (g) Complete only for assets showing gain in column (h) and owned y the foundation on 1/1/ (l) Gains (Col. (h) gain minus (j) Adjusted asis (k) Excess of col. (i) col. (k), ut not less than -0-) or (i) F.M.V. as of 1/1/ Losses (from col. (h)) as of 1/1/ over col. (j), if any If gain, also enter in Part I, line Capital gain net income or (net capital loss) If (loss), enter -0- in Part I, line ~~~~~~ Net short-term capital gain or (loss) as defined in sections 1() and (): If gain, also enter in Part I, line 8, column (c). If (loss), enter -0- in Part I, line 8 Part V Qualification Under Section 0(e) for Reduced Tax on Net Investment Income (For optional use y domestic private foundations suject to the section 0(a) tax on net investment income.) If section 0(d)() applies, leave this part lank. Was the foundation liale for the section tax on the distriutale amount of any year in the ase period? If "," the foundation does not qualify under section 0(e). Do not complete this part. 1 Enter the appropriate amount in each column for each year; see the instructions efore making any entries. (a) () (c) Base period years Calendar year (or tax year eginning in) Adjusted qualifying distriutions Net value of noncharitale-use assets NONE rqs pmo pmo ~~~~~~~~~~~~~~~~ (d) Distriution ratio (col. () divided y col. (c)) 10,. 8, ,1. 1,..00 1,., ,1, ,.,1. 1. Total of line 1, column (d) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Average distriution ratio for the -year ase period - divide the total on line y, or y the numer of years the foundation has een in existence if less than years ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Enter the net value of noncharitale-use assets for 01 from Part, line ~~~~~~~~~~~~~~~~~~~~~,. Multiply line y line ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 10,. Enter 1% of net investment income (1% of Part I, line ) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Add lines and ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 10,. 8 Enter qualifying distriutions from Part II, line ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If line 8 is equal to or greater than line, check the ox in Part VI, line 1, and complete that part using a 1% tax rate. See the Part VI instructions SOUTHSHORE FOUNDATION 1_1 8 8,01.

4 SOUTHSHORE FOUNDATION Page Part VI Excise Tax Based on Investment Income (Section 0(a), 0(), 0(e), or 8 - see instructions) 1a Exempt operating foundations descried in section 0(d)(), check here and enter "N/A" on line 1. 8 Domestic foundations that meet the section 0(e) requirements in Part V, check here (attach copy of letter if necessary-see instructions) c All other domestic foundations enter % of line. Exempt foreign organizations enter % of Part I, line 1, col. (). Tax ased on investment income. Sutract line from line. If zero or less, enter -0- ~~~~~~~~~~~~~~~~~ a 01 estimated tax payments and 01 overpayment credited to 01 ~~~~~~~~ Exempt foreign organizations - tax withheld at source ~~~~~~~~~~~~~~~~ c Tax paid with application for extension of time to file (Form 888) d Backup withholding erroneously withheld ~~~~~~~~~~~~~~~~~~~~~ Enter any penalty for underpayment of estimated tax. Check here if Form 0 is attached ~~~~~~~~~~~~~ 8 Tax due. If the total of lines and 8 is more than line, enter amount owed ~~~~~~~~~~~~~~~~~~~~ 10 Overpayment. If line is more than the total of lines and 8, enter the amount overpaid Enter the amount of line 10 to e: Credited to 01 estimated tax. Refunded 11 Part VII-A Statements Regarding Activities 1a During the tax year, did the foundation attempt to influence any national, state, or local legislation or did it participate or intervene in Did it spend more than $100 during the year (either directly or indirectly) for political purposes (see instructions for the definition)? ~~~~ If the answer is "" to 1a or 1, attach a detailed description of the activities and copies of any materials pulished or distriuted y the foundation in connection with the activities. c Did the foundation file Form 110-POL for this year? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ d Enter the amount (if any) of tax on political expenditures (section ) imposed during the year: (1) On the foundation. $ () On foundation managers. $ e Enter the reimursement (if any) paid y the foundation during the year for political expenditure tax imposed on foundation managers. $ a Did the foundation have unrelated usiness gross income of $1,000 or more during the year? ~~~~~~~~~~~~~~~~~~~~~ If "," has it filed a tax return on Form 0-T for this year? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ N/A Date of ruling or determination letter: of Part I, line ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "," attach a detailed description of the activities. ylaws, or other similar instruments? If "," attach a conformed copy of the changes ~~~~~~~~~~~~~~~~~~~~~ If "," attach the statement required y General Instruction T. Did the foundation have at least $,000 in assets at any time during the year? If "," complete Part II, col. (c), and Part V ~~~~~ 8a Enter the states to which the foundation reports or with which it is registered (see instructions) AR and enter 1% Tax under section 11 (domestic section (a)(1) trusts and taxale foundations only. Others enter -0-) ~~~~~~~~~ Add lines 1 and ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Sutitle A (income) tax (domestic section (a)(1) trusts and taxale foundations only. Others enter -0-) ~~~~~~~~ Credits/Payments: ~~~~~~~~~~ Total credits and payments. Add lines a through d ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ any political campaign? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Has the foundation engaged in any activities that have not previously een reported to the IRS? ~~~~~~~~~~~~~~~~~~~~ Has the foundation made any changes, not previously reported to the IRS, in its governing instrument, articles of incorporation, or Was there a liquidation, termination, dissolution, or sustantial contraction during the year? ~~~~~~~~~~~~~~~~~~~~~~ Are the requirements of section 08(e) (relating to sections 1 through ) satisfied either: By language in the governing instrument, or By state legislation that effectively amends the governing instrument so that no mandatory directions that conflict with the state law remain in the governing instrument? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If the answer is "" to line, has the foundation furnished a copy of Form 0-PF to the Attorney General (or designate) of each state as required y General Instruction G? If "," attach explanation ~~~~~~~~~~~~~~~~~~~~~~~~~ Is the foundation claiming status as a private operating foundation within the meaning of section (j)() or (j)() for calendar year 01 or the taxale year eginning in 01 (see instructions for Part IV)? If "," complete Part IV ~~~~~~~~~~~~~~ 10 Did any persons ecome sustantial contriutors during the tax year? If "," attach a schedule listing their names and addresses 10 a c d pnmno. 1 1a 1 1c a SOUTHSHORE FOUNDATION 1_1

5 SOUTHSHORE FOUNDATION Part VII-A Statements Regarding Activities (continued) Section (a)(1) nonexempt charitale trusts filing Form 0-PF in lieu of Form Check here ~~~~~~~~~~~~~~~~~~~~~~~ and enter the amount of tax-exempt interest received or accrued during the year ~~~~~~~~~~~~~~~~~~~ 1 N/A At any time during calendar year 01, did the foundation have an interest in or a signature or other authority over a ank, securities, or other financial account in a foreign country? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 1 1a During the year did the foundation (either directly or indirectly): (1) () () () () () Agree to pay money or property to a government official? ( Exception. Check "" c Did the foundation engage in a prior year in any of the acts descried in 1a, other than excepted acts, that were not corrected a At the end of tax year 01, did the foundation have any undistriuted income (lines d and e, Part III) for tax year(s) eginning Are there any years listed in a for which the foundation is not applying the provisions of section (a)() (relating to incorrect c If the provisions of section (a)() are eing applied to any of the years listed in a, list the years here. a At any time during the year, did the foundation, directly or indirectly, own a controlled entity within the meaning of section 1()(1)? If "," attach schedule (see instructions) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the foundation make a distriution to a donor advised fund over which the foundation or a disqualified person had advisory privileges? If "," attach statement (see instructions) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 1 Did the foundation comply with the pulic inspection requirements for its annual returns and exemption application? ~~~~~~~~~~~ 1 Wesite address The ooks are in care of DEANNA SULLIVAN, TRUSTEE Telephone no Located at P.O. BO 0, FLIPPIN, AR ZIP+ See the instructions for exceptions and filing requirements for FinCEN Form 11. If "," enter the name of the foreign country Part VII-B Statements Regarding Activities for Which Form 0 May Be Required File Form 0 if any item is checked in the "" column, unless an exception applies. Engage in the sale or exchange, or leasing of property with a disqualified person? Borrow money from, lend money to, or otherwise extend credit to (or accept it from) a disqualified person? ~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Furnish goods, services, or facilities to (or accept them from) a disqualified person? Pay compensation to, or pay or reimurse the expenses of, a disqualified person? Transfer any income or assets to a disqualified person (or make any of either availale ~~~~~~~~~~~~~ ~~~~~~~~~~~~~~ for the enefit or use of a disqualified person)?~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ if the foundation agreed to make a grant to or to employ the official for a period after termination of government service, if terminating within 0 days.) ~~~~~~~~~~~~~~~~~~~~~ If any answer is "" to 1a(1)-(), did any of the acts fail to qualify under the exceptions descried in Regulations section.1(d)- or in a current notice regarding disaster assistance (see instructions)? ~~~~~~~~~~~~~~~~~~~~~ N/A Organizations relying on a current notice regarding disaster assistance check here ~~~~~~~~~~~~~~~~~~~~~ efore the first day of the tax year eginning in 01?~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Taxes on failure to distriute income (section ) (does not apply for years the foundation was a private operating foundation defined in section (j)() or (j)()): efore 01? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "," list the years,,, valuation of assets) to the year's undistriuted income? (If applying section (a)() to all years listed, answer "" and attach statement - see instructions.) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ N/A,,, Did the foundation hold more than a % direct or indirect interest in any usiness enterprise at any time during the year? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "," did it have excess usiness holdings in 01 as a result of (1) any purchase y the foundation or disqualified persons after May, 1; () the lapse of the -year period (or longer period approved y the Commissioner under section (c)()) to dispose of holdings acquired y gift or equest; or () the lapse of the 10-, 1-, or 0-year first phase holding period? (Use Schedule C, Form 0, to determine if the foundation had excess usiness holdings in 01.) ~~~~~~~~~~~~~~~~~~~~~~ N/A a Did the foundation invest during the year any amount in a manner that would jeopardize its charitale purposes? ~~~~~~~~~~~~~ Did the foundation make any investment in a prior year (ut after Decemer 1, 1) that could jeopardize its charitale purpose that had not een removed from jeopardy efore the first day of the tax year eginning in 01? c a Page SOUTHSHORE FOUNDATION 1_1

6 SOUTHSHORE FOUNDATION Part VII-B Statements Regarding Activities for Which Form 0 May Be Required a During the year did the foundation pay or incur any amount to: (1) () () () () Carry on propaganda, or otherwise attempt to influence legislation (section (e))? ~~~~~~~~~~~~~ Influence the outcome of any specific pulic election (see section ); or to carry on, directly or indirectly, any voter registration drive? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Provide a grant to an individual for travel, study, or other similar purposes? Provide a grant to an organization other than a charitale, etc., organization descried in section (d)()(a)? (see instructions) c If the answer is "" to question a(), does the foundation claim exemption from the tax ecause it maintained expenditure responsiility for the grant?~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ N/A If "," attach the statement required y Regulations section.-(d). a Did the foundation, during the year, receive any funds, directly or indirectly, to pay premiums on ~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Provide for any purpose other than religious, charitale, scientific, literary, or educational purposes, or for the prevention of cruelty to children or animals? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ (continued) If any answer is "" to a(1)-(), did any of the transactions fail to qualify under the exceptions descried in Regulations section. or in a current notice regarding disaster assistance (see instructions)? ~~~~~~~~~~~~~~~~~~~~~~~~ N/A Organizations relying on a current notice regarding disaster assistance check here ~~~~~~~~~~~~~~~~~~~~~ a personal enefit contract? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the foundation, during the year, pay premiums, directly or indirectly, on a personal enefit contract? ~~~~~~~~~~~~~~~~ If "" to, file Form 88 a At any time during the tax year, was the foundation a party to a prohiited tax shelter transaction? ~~~~~~~~~ If "," did the foundation receive any proceeds or have any net income attriutale to the transaction? N/A Part VIII Information Aout Officers, Directors, Trustees, Foundation Managers, Highly Paid Employees, and Contractors 1 List all officers, directors, trustees, foundation managers and their compensation. (a) Name and address () Title, and average (c) Compensation (d) Contriutions to (e) Expense employee enefit plans hours per week devoted (If not paid, and deferred account, other to position enter -0-) compensation allowances DEANNA SULLIVAN MEMBER, BOARD OF TRUSTEES P.O BO 0 FLIPPIN, AR 1.00 STEVE SMITH MEMBER, BOARD OF TRUSTEES P.O BO 0 FLIPPIN, AR 1.00 Page Compensation of five highest-paid employees (other than those included on line 1). If none, enter "NONE." (a) Name and address of each employee paid more than $0,000 () Title, and average hours per week devoted to position (c) Compensation NONE (d) Contriutions to employee enefit plans and deferred compensation (e) Expense account, other allowances Total numer of other employees paid over $0, SOUTHSHORE FOUNDATION 1_1

7 SOUTHSHORE FOUNDATION Page Part VIII Information Aout Officers, Directors, Trustees, Foundation Managers, Highly Paid Employees, and Contractors (continued) Five highest-paid independent contractors for professional services. If none, enter "NONE." (a) Name and address of each person paid more than $0,000 () Type of service (c) Compensation NONE Total numer of others receiving over $0,000 for professional services Part I-A Summary of Direct Charitale Activities 0 List the foundation's four largest direct charitale activities during the tax year. Include relevant statistical information such as the numer of organizations and other eneficiaries served, conferences convened, research papers produced, etc. 1 N/A Expenses Part I-B Summary of Program-Related Investments Descrie the two largest program-related investments made y the foundation during the tax year on lines 1 and. 1 N/A Amount All other program-related investments. See instructions. Total. Add lines 1 through J SOUTHSHORE FOUNDATION 1_1

8 SOUTHSHORE FOUNDATION Part Minimum Investment Return (All domestic foundations must complete this part. Foreign foundations, see instructions.) Page 8 1 Fair market value of assets not used (or held for use) directly in carrying out charitale, etc., purposes: a Average monthly fair market value of securities ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 1a c Average of monthly cash alances Fair market value of all other assets ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 1 1c d e Total (add lines 1a,, and c) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Reduction claimed for lockage or other factors reported on lines 1a and 1d 1c (attach detailed explanation) ~~~~~~~~~~~~~~~~~~~~~~ 1e Acquisition indetedness applicale to line 1 assets ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Sutract line from line 1d~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Cash deemed held for charitale activities. Enter 1 1/% of line (for greater amount, see instructions) ~~~~~~~~ STMT Net value of noncharitale-use assets. Sutract line from line. Enter here and on Part V, line ~~~~~~~~~~ Minimum investment return. Enter % of line Part I Distriutale Amount (see instructions) (Section (j)() and (j)() private operating foundations and certain foreign organizations check here and do not complete this part.) 1 Minimum investment return from Part, line a Tax on investment income for 01 from Part VI, line ~~~~~~~~~~~ a Income tax for 01. (This does not include the tax from Part VI.) ~~~~~~~ c Add lines a and ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Distriutale amount efore adjustments. Sutract line c from line 1 ~~~~~~~~~~~~~~~~~~~~~~~ Recoveries of amounts treated as qualifying distriutions ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Add lines and ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Deduction from distriutale amount (see instructions) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Distriutale amount as adjusted. Sutract line from line. Enter here and on Part III, line 1 Part II Qualifying Distriutions (see instructions) 1 c 1,. 1,. 1,.,0., a a Amounts paid (including administrative expenses) to accomplish charitale, etc., purposes: Expenses, contriutions, gifts, etc. - total from Part I, column (d), line ~~~~~~~~~~~~~~~~~~~~~~ Program-related investments - total from Part I-B ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Amounts paid to acquire assets used (or held for use) directly in carrying out charitale, etc., purposes ~~~~~~~~~ Amounts set aside for specific charitale projects that satisfy the: Suitaility test (prior IRS approval required) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Cash distriution test (attach the required schedule) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Qualifying distriutions. Add lines 1a through. Enter here and on Part V, line 8, and Part III, line ~~~~~~~~~ Foundations that qualify under section 0(e) for the reduced rate of tax on net investment income. Enter 1% of Part I, line ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Adjusted qualifying distriutions. Sutract line from line ~~~~~~~~~~~~~~~~~~~~~~~~~~~ te: The amount on line will e used in Part V, column (), in susequent years when calculating whether the foundation qualifies for the section 0(e) reduction of tax in those years. 1a 1 a 8,01. 8,01. 8, SOUTHSHORE FOUNDATION 1_1

9 SOUTHSHORE FOUNDATION Part III Undistriuted Income (see instructions) Page 1 Undistriuted income, if any, as of the end of 01: a Enter amount for 01 only ~~~~~~~ Total for prior years: a From 011 From 01 c From 01 d From 01 e From 01 f Total of lines a through e ~~~~~~~~ Qualifying distriutions for 01 from Part II, line : $ 8,01. a Applied to 01, ut not more than line a ~ Applied to undistriuted income of prior c Treated as distriutions out of corpus e Remaining amount distriuted out of corpus Excess distriutions carryover applied to 01 ~~ (If an amount appears in column (d), the same amount must e shown in column (a).) Enter the net total of each column as indicated elow: 8 10 Distriutale amount for 01 from Part I, line ~~~~~~~~~~~~~~~~~,, Excess distriutions carryover, if any, to 01: ~~~ ~~~ ~~~ ~~~ ~~~ years (Election required - see instructions) ~ (Election required - see instructions) Prior years' undistriuted income. Sutract c Enter the amount of prior years' undistriuted income for which a notice of deficiency has een issued, or on which the section (a) tax has een previously assessed ~~~~~~~~~~~~~~~ d Sutract line c from line. Taxale e Undistriuted income for 01. Sutract line f Undistriuted income for 01. Sutract Excess distriutions carryover to 01. a Excess from 01 ~ Excess from 01 ~ c Excess from 01 ~ d Excess from 01 ~ e Excess from 01 ~~~ d Applied to 01 distriutale amount ~~~ a Corpus. Add lines f, c, and e. Sutract line ~~ line from line ~~~~~~~~~~~ amount - see instructions ~~~~~~~~ a from line a. Taxale amount - see instr.~ lines d and from line 1. This amount must e distriuted in 01 ~~~~~~~~~~ Amounts treated as distriutions out of corpus to satisfy requirements imposed y section 10()(1)(F) or (g)() (Election may e required - see instructions) ~~~~ Excess distriutions carryover from 011 not applied on line or line ~~~~~~~ Sutract lines and 8 from line a ~~~~ Analysis of line : 8,1. 0,. 1,8. 8,0. 10,. 0,. 1,8. 8,0. 10,.,. (a) () (c) (d) Corpus Years prior to ,...,. 100,1. 8,1. 1, SOUTHSHORE FOUNDATION 1_1

10 SOUTHSHORE FOUNDATION Part IV Private Operating Foundations (see instructions and Part VII-A, question ) 1 a If the foundation has received a ruling or determination letter that it is a private operating foundation, and the ruling is effective for 01, enter the date of the ruling ~~~~~~~~~~~ Check ox to indicate whether the foundation is a private operating foundation descried in section ~~~ (j)() or (j)() a Enter the lesser of the adjusted net Tax year Prior years income from Part I or the minimum (a) 01 () 01 (c) 01 (d) 01 (e) Total 8% of line a ~~~~~~~~~~ c Qualifying distriutions from Part II, d Amounts included in line c not e Qualifying distriutions made directly Sutract line d from line c~~~~ Complete a,, or c for the alternative test relied upon: a "Assets" alternative test - enter: (1) Value of all assets ~~~~~~ c "Support" alternative test - enter: (1) () () () Gross investment income Part V Supplementary Information (Complete this part only if the foundation had $,000 or more in assets at any time during the year-see instructions.) 1 investment return from Part for each year listed ~~~~~~~~~ line for each year listed ~~~~~ used directly for active conduct of exempt activities ~~~~~~~~~ for active conduct of exempt activities. () Value of assets qualifying under section (j)()(b)(i) ~ "Endowment" alternative test - enter / of minimum investment return shown in Part, line for each year listed ~~~~~~~~~~~~~~ Total support other than gross investment income (interest, dividends, rents, payments on securities loans (section 1(a)()), or royalties) ~~~~ Support from general pulic and or more exempt organizations as provided in section (j)()(b)(iii) ~~~ Largest amount of support from an exempt organization ~~~~ Information Regarding Foundation Managers: a List any managers of the foundation who have contriuted more than % of the total contriutions received y the foundation efore the close of any tax year (ut only if they have contriuted more than $,000). (See section 0(d)().) NONE 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 Information Regarding Contriution, Grant, Gift, Loan, Scholarship, etc., Programs: Check here if the foundation only makes contriutions to preselected charitale organizations and does not accept unsolicited requests for funds. If the foundation makes gifts, grants, etc. (see instructions) to individuals or organizations under other conditions, complete items a,, c, and d. a The name, address, and telephone numer or address of the person to whom applications should e addressed: SEE STATEMENT The form in which applications should e sumitted and information and materials they should include: N/A Page 10 c Any sumission deadlines: d Any restrictions or limitations on awards, such as y geographical areas, charitale fields, kinds of institutions, or other factors: SOUTHSHORE FOUNDATION 1_1

11 SOUTHSHORE FOUNDATION Part V Supplementary Information (continued) a Grants and Contriutions Paid During the Year or Approved for Future Payment Recipient If recipient is an individual, show any relationship to Foundation any foundation manager status of Name and address (home or usiness) or sustantial contriutor recipient Paid during the year Purpose of grant or contriution Amount Page 11 ARKANSAS STATE UNIVERSITY - MOUNTAIN HOME 100 SOUTH COLLEGE DRIVE MOUNTAIN HOME, AR PC STUDENT SCHOLARSHIP 1,00 UNIVERSITY OF ARKANSAS 11 SILAS HUNT HALL FAYETTEVILLE, AR 01 PC STUDENT SCHOLARSHIP 1,00 ARKANSAS TECH UNIVERSITY 10 WEST O STREET RUSSELLVILLE, AR 801 PC STUDENT SCHOLARSHIP 1,00 UNIVERSITY OF CENTRAL ARKANSAS 01 DONAGHEY AVENUE CONWAY, AR 0 PC STUDENT SCHOLARSHIP 1,00 NORTH ARKANSAS COLLEGE PC STUDENT SCHOLARSHIP 11 PIONEER DRIVE HARRISON, AR 01 Total SEE CONTINUATION SHEET(S) Approved for future payment a 1,00,1 NONE Total SOUTHSHORE FOUNDATION 1_1

12 SOUTHSHORE FOUNDATION Page 1 Part VI-A Analysis of Income-Producing Activities Enter gross amounts unless otherwise indicated. 1 Program service revenue: a c d e f g Interest on savings and temporary cash Dividends and interest from securities ~~~~~~~~ Net rental income or (loss) from real estate: a Net rental income or (loss) from personal Other investment income ~~~~~~~~~~~~~~ 8 Gain or (loss) from sales of assets other 10 Gross profit or (loss) from sales of inventory 11 Other revenue: a c d Fees and contracts from government agencies ~~~ Memership dues and assessments ~~~~~~~~~ investments ~~~~~~~~~~~~~~~~~~~~ Det-financed property ~~~~~~~~~~~~~ t det-financed property ~~~~~~~~~~~~ property ~~~~~~~~~~~~~~~~~~~~~ than inventory ~~~~~~~~~~~~~~~~~~~ Net income or (loss) from special events ~~~~~~~ ~~~~~ (See worksheet in line 1 instructions to verify calculations.) Part VI-B Unrelated usiness income Excluded y section 1, 1, or 1 (a) (c) () Exclusion (d) Business code Amount code Amount Relationship of Activities to the Accomplishment of Exempt Purposes (e) Related or exempt function income e 1 Sutotal. Add columns (), (d), and (e) ~~~~~~~~ 1 Total. Add line 1, columns (), (d), and (e) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 1 Line. < Explain elow how each activity for which income is reported in column (e) of Part VI-A contriuted importantly to the accomplishment of the foundation's exempt purposes (other than y providing funds for such purposes) SOUTHSHORE FOUNDATION 1_1

13 SOUTHSHORE FOUNDATION Page 1 Part VII Information Regarding Transfers To and Transactions and Relationships With ncharitale Exempt Organizations 1 Did the organization directly or indirectly engage in any of the following with any other organization descried in section 01(c) of a c the Code (other than section 01(c)() organizations) or in section, relating to political organizations? Transfers from the reporting foundation to a noncharitale exempt organization of: (1) () (1) () () () () () Cash ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Other assets~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Other transactions: Sales of assets to a noncharitale exempt organization ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Purchases of assets from a noncharitale exempt organization ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Rental of facilities, equipment, or other assets ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Reimursement arrangements ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Loans or loan guarantees ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Performance of services or memership or fundraising solicitations ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Sharing of facilities, equipment, mailing lists, other assets, or paid employees ~~~~~~~~~~~~~~~~~~~~~~~~~~~~ d If the answer to any of the aove is "," complete the following schedule. Column () should always show the fair market value of the goods, other assets, or services given y the reporting foundation. If the foundation received less than fair market value in any transaction or sharing arrangement, show in column (d) the value of the goods, other assets, or services received. (a) Line no. () Amount involved (c) Name of noncharitale exempt organization (d) Description of transfers, transactions, and sharing arrangements C NORTHERN ARKANSAS TELEPHONE COMPANY SEE STATEMENT 1a(1) 1a() 1(1) 1() 1() 1() 1() 1() 1c a Is the foundation directly or indirectly affiliated with, or related to, one or more tax-exempt organizations descried in section 01(c) of the Code (other than section 01(c)()) or in section? ~~~~~~~~~~~~~~~~~~~~~~~~~~ If "," complete the following schedule. (a) Name of organization () Type of organization (c) Description of relationship N/A Sign Here Paid Preparer Use Only Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the est of my knowledge and elief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is ased on all information of which preparer has any knowledge. = = May the IRS discuss this return with the preparer shown elow (see instr.)? TRUSTEE Signature of officer or trustee Date Title Print/Type preparer's name Preparer's signature Date Check if PTIN self- employed LEO TOLKACHEV, CPA LEO TOLKACHEV, CP 0/01/1 P0101 Firm's name MOSS ADAMS LLP Firm's EIN **-***18 Firm's address 01 W RIVERSIDE AVENUE STE 1800 SPOKANE, WA 01 Phone no SOUTHSHORE FOUNDATION 1_1

14 Part V SOUTHSHORE FOUNDATION Supplementary Information Grants and Contriutions Paid During the Year (Continuation) Recipient Name and address (home or usiness) If recipient is an individual, show any relationship to any foundation manager or sustantial contriutor Foundation status of recipient Purpose of grant or contriution Amount ARKANSAS NONPROFIT ALLIANCE 01 PRESIDENT CLINTON AVE LITTLE ROCK, AR 01 PC DONATION 1 NORTH ARKANSAS COLLEGE 11 PIONEER DRIVE HARRISON, AR 01 PC STUDENT SCHOLARSHIP 1,00 Total from continuation sheets 1, SOUTHSHORE FOUNDATION 1_1

15 SOUTHSHORE FOUNDATION }}}}}}}}}}}}}}}}}}}}} }}}}}}}}}} ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ FORM 0-PF ACCOUNTING FEES STATEMENT 1 }}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}} (A) (B) (C) (D) EPENSES NET INVEST- ADJUSTED CHARITABLE DESCRIPTION PER BOOKS MENT INCOME NET INCOME PURPOSES }}}}}}}}}}} }}}}}}}}}}}} }}}}}}}}}}}} }}}}}}}}}}}} }}}}}}}}}}} FORM 0-PF PREPARATION FEES 1,8. 1,8. }}}}}}}}}}}} }}}}}}}}}}}} }}}}}}}}}}}} }}}}}}}}}}} TO FORM 0-PF, PG 1, LN 1B 1,8. 1,8. ~~~~~~~~~~~~ ~~~~~~~~~~~~ ~~~~~~~~~~~~ ~~~~~~~~~~~ 1 STATEMENT(S) SOUTHSHORE FOUNDATION 1_1

16 SOUTHSHORE FOUNDATION }}}}}}}}}}}}}}}}}}}}} }}}}}}}}}} ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ FORM 0-PF CASH DEEMED CHARITABLE EPLANATION STATEMENT STATEMENT PART, LINE }}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}} IN ACCORDANCE WITH REG..(A)-(C)()(IV), THE ABOVE-REFERENCED FOUNDATION IS ECLUDING FROM ITS MINIMUM INVESTMENT RETURN (MIR) CALCULATION A TOTAL OF $,0 IN CASH THAT IT DEEMS HELD FOR CHARITABLE ACTIVITIES. THIS AMOUNT IS IN ECESS OF 1.% OF THE FAIR MARKET VALUE OF THE FOUNDATION'S NONCHARITABLE ASSETS. THE FOLLOWING INFORMATION IS SUBMITTED IN SUPPORT OF THE ECLUSION FROM MIR OF THIS AMOUNT. 1. FAIR MARKET VALUE OF FOUNDATION'S NONCHARITABLE ASSETS: $1,. 1.% OF LINE 1: $. FACTS AND CIRCUMSTANCES JUSTIFYING THE ECLUSION OF AN AMOUNT IN ECESS OF THE AMOUNT ON LINE : SOUTHSHORE FOUNDATION RECEIVES 100% OF ITS FUNDING FROM NORTHERN ARKANSAS COMPANY (NATCO). THE AMOUNT OF CONTRIBUTIONS THAT SOUTHSHORE FOUNDATION RECEIVES FROM NATCO VARIES FROM YEAR TO YEAR AND THERE IS NO ASSURANCE THAT ANY SPECIFIC LEVEL OF FUNDING WILL BE MAINTAINED IN THE FUTURE. IN ADDITION, CONTRIBUTIONS FROM NATCO ARE UNCERTAIN IN TIMING. CASH MAKES UP ALL ASSETS. 1 STATEMENT(S) SOUTHSHORE FOUNDATION 1_1

17 SOUTHSHORE FOUNDATION }}}}}}}}}}}}}}}}}}}}} }}}}}}}}}} ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ FORM 0-PF GRANT APPLICATION SUBMISSION INFORMATION PART V, LINES A THROUGH D STATEMENT }}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}} NAME AND ADDRESS OF PERSON TO WHOM APPLICATIONS SHOULD BE SUBMITTED }}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}} DEANNA SULLIVAN, TRUSTEE P.O. BO 0 FLIPPIN, AR TELEPHONE NUMBER }}}}}}}}}}}}}}}} FORM AND CONTENT OF APPLICATIONS }}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}} ORGANIZATION HAS AN APPLICATION WHICH REQUESTS INFORMATION ANY SUBMISSION DEADLINES }}}}}}}}}}}}}}}}}}}}}}}} N/A RESTRICTIONS AND LIMITATIONS ON AWARDS }}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}} RESTRICTED TO NONPROFIT ORGANIZATIONS, INCLUDING EDUCATONAL, MUSEUM, OR GOVERNMENTAL AGENCIES BASED IN, OR SERVING, THE AREA ON THE SOUTH SHORE OF BULL SHOALS LAKE IN ARKANSAS. }}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}} 1 STATEMENT(S) SOUTHSHORE FOUNDATION 1_1

18 SOUTHSHORE FOUNDATION }}}}}}}}}}}}}}}}}}}}} }}}}}}}}}} ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 0-PF INVOLVEMENT WITH NONCHARITABLE ORGANIZATIONS PART VII, LINE 1, COLUMN (D) STATEMENT }}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}} NAME OF NONCHARITABLE EEMPT ORGANIZATION }}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}} NORTHERN ARKANSAS TELEPHONE COMPANY DESCRIPTION OF TRANSFERS, TRANSACTIONS, AND SHARING ARRANGEMENTS }}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}} THE TELEPHONE COMPANY EMPLOYEES MAINTAIN THE FOUNDATION'S BOOKS AND RECORDS AT NO CHARGE. 18 STATEMENT(S) SOUTHSHORE FOUNDATION 1_1