** PUBLIC INSPECTION COPY ** EXTENDED TO NOVEMBER 15, 2018 Exempt Organization Business Income Tax Return
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1 Form Department of the Treasury Internal Revenue Service For calendar year 2017 or other tax year eginning, and ending. Go to for instructions and the latest information. Do not enter SSN numers on this form as it may e made pulic if your organization is a 501(c). OMB No Open to Pulic Inspection for 501(c) Organizations Only Employer identification numer A Check ox if Name of organization ( Check ox if name changed and see instructions.) D (Employees trust, see address changed instructions.) B Exempt under section Print FOUNDATION X 501( c )( 3 ) or E Unrelated usiness activity codes Numer, street, and room or suite no. If a P.O. ox, see instructions. (See instructions.) Type 408(e) 220(e) 324 3RD ST SE Book value of all assets C F Group exemption numer (See instructions.) at end of year 173,227,883. G Check organization type X 501(c) corporation 501(c) trust 401(a) trust Other trust H Descrie the organization s primary unrelated usiness activity. INVESTMENT IN PARTNERSHIP INTERESTS I During the tax year, was the corporation a susidiary in an affiliated group or a parent-susidiary controlled group? ~~~~~~ Yes X No If "Yes," enter the name and identifying numer of the parent corporation. J The ooks are in care of JEAN BRENNEMAN Telephone numer Part I Unrelated Trade or Business Income (A) Income (B) Expenses (C) Net c Less returns and allowances c Balance ~~~ 12 Other income (See instructions; attach schedule) ~~~~~~~~~~~~ Total. Comine lines 3 through , ,31. Part II Deductions Not Taken Elsewhere (See instructions for limitations on deductions.) (Except for contriutions, deductions must e directly connected with the unrelated usiness income.) T 408A 530(a) City or town, state or province, country, and ZIP or foreign postal code 52(a) CEDAR RAPIDS, IA a Gross receipts or sales Cost of goods sold (Schedule A, line 7) ~~~~~~~~~~~~~~~~~ Gross profit. Sutract line 2 from line 1c ~~~~~~~~~~~~~~~~ 4 a Capital gain net income (attach Schedule D) ~~~~~~~~~~~~~~~ Net gain (loss) (Form 477, Part II, line 17) (attach Form 477) ~~~~~~ Capital loss deduction for trusts ~~~~~~~~~~~~~~~~~~~~ Income (loss) from partnerships and S corporations (attach statement) ~~~ Rent income (Schedule C) ~~~~~~~~~~~~~~~~~~~~~~ Unrelated det-financed income (Schedule E) ~~~~~~~~~~~~~~ Interest, annuities, royalties, and rents from controlled organizations (Sch. F)~ Investment income of a section 501(c)(7), (), or (17) organization (Schedule G) Exploited exempt activity income (Schedule I) ~~~~~~~~~~~~~~ Advertising income (Schedule J) ~~~~~~~~~~~~~~~~~~~~ Compensation of officers, directors, and trustees (Schedule K) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Salaries and wages ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Repairs and maintenance Bad dets ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Interest ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Taxes and licenses ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Charitale contriutions (See instructions for limitation rules) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ STATEMENT 3 SEE STATEMENT 1 Depreciation (attach Form 4562) Less depreciation claimed on Schedule A and elsewhere on return Depletion Contriutions to deferred compensation plans ~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Total deductions. Add lines 14 through 28 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Unrelated usiness taxale income. Sutract line 33 from line 32. If line 33 is greater than line 32, enter the smaller of zero or line 32 For Paperwork Reduction Act Notice, see instructions. 1c 2 3 4a 4 4c ~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Employee enefit programs ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Excess exempt expenses (Schedule I) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Excess readership costs (Schedule J) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Other deductions ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ SEE STATEMENT 2 Unrelated usiness taxale income efore net operating loss deduction. Sutract line 2 from line 13 ~~~~~~~~~~~~ Net operating loss deduction (limited to the amount on line 30) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ SEE STATEMENT 4 Unrelated usiness taxale income efore specific deduction. Sutract line 31 from line 30 ~~~~~~~~~~~~~~~~~ Specific deduction (Generally $1,000, ut see line 33 instructions for exceptions) ~~~~~~~~~~~~~~~~~~~~~ LHA EXTENDED TO NOVEMBER 15, 2018 Exempt Organization Business Income Tax Return (and proxy tax under section 6033(e)) 21 22a , ,31. 17, , , ,463. 1,00-231,463. Form 0-T (2017)
2 Form 0-T (2017) FOUNDATION Part III Tax Computation 35 Organizations Taxale as Corporations. See instructions for tax computation a c Controlled group memers (sections 1561 and 1563) check here See instructions and: $ $ $ Enter organization s share of: Additional 5 tax (not more than $11,750) $ Additional 3 tax (not more than $100,000) ~~~~~~~~~~~~~ $ Trusts Taxale at Trust Rates. See instructions for tax computation. Income tax on the amount on line 34 from: Proxy tax. See instructions ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 3 40 Tax on Non-Compliant Facility Income. See instructions ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Total. Add lines 37, 38 and 3 to line 35c or 36, whichever applies Part IV Tax and Payments 41a Foreign tax credit (corporations attach Form 1118; trusts attach Form 1116) ~~~~~~~~ 41a c d e Total credits. Add lines 41a through 41d ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Other taxes. Check if from: Form 4255 Form 8611 Form 867 Form 8866 Other Total tax. Add lines 42 and 43 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 45 a Payments: A 2016 overpayment credited to 2017 ~~~~~~~~~~~~~~~~~~~ estimated tax payments ~~~~~~~~~~~~~~~~~~~~~~~~~~~~ c Tax deposited with Form 8868 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~ d Foreign organizations: Tax paid or withheld at source (see instructions) ~~~~~~~~~~ f g Other credits and payments: Total payments. Add lines 45a through 45g ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 46 Tax due. If line 46 is less than the total of lines 44 and 47, enter amount owed ~~~~~~~~~~~~~~~~~~~ 4 Overpayment. If line 46 is larger than the total of lines 44 and 47, enter amount overpaid ~~~~~~~~~~~~~~ 50 Enter the amount of line 4 you want: Credited to 2018 estimated tax Refunded Part V Statements Regarding Certain Activities and Other Information (see instructions) 51 At any time during the 2017 calendar year, did the organization have an interest in or a signature or other authority Yes No Sign Here Enter your share of the $50,000, $25,000, and $,25,000 taxale income rackets (in that order): Income tax on the amount on line 34 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Tax rate schedule or Schedule D (Form 1041) ~~~~~~~~~~~~~~~~~~~~~~~~~~~ Alternative minimum tax Other credits (see instructions) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~ General usiness credit. Attach Form 3800 ~~~~~~~~~~~~~~~~~~~~~~ Credit for prior year minimum tax (attach Form 8801 or 8827) ~~~~~~~~~~~~~~ Sutract line 41e from line 40 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ e Backup withholding (see instructions) ~~~~~~~~~~~~~~~~~~~~~~~~ Credit for small employer health insurance premiums (Attach Form 841) Form 243 ~~~~~~~~ Form 4136 Other Total Estimated tax penalty (see instructions). Check if Form 2220 is attached ~~~~~~~~~~~~~~~~~~~ over a financial account (ank, securities, or other) in a foreign country? If YES, the organization may have to file FinCEN Form 114, Report of Foreign Bank and Financial Accounts. If YES, enter the name of the foreign country here During the tax year, did the organization receive a distriution from, or was it the grantor of, or transferor to, a foreign trust? ~~~~~~~~~ If YES, see instructions for other forms the organization may have to file. Enter the amount of tax-exempt interest received or accrued during the tax year $ 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. = = PRESIDENT & CEO Signature of officer Date Title Print/Type preparer s name Preparer s signature Date Check 41 41c 41d 45a 45 45c 45d 45e 45f 45g 35c e Page 2 May the IRS discuss this return with the preparer shown elow (see instructions)? X Yes No self- employed Paid CARLEY UMSTEAD P Preparer Firm s name RSM US LLP Firm s EIN Use Only 201 FIRST ST SE, SUITE 800 Firm s address CEDAR RAPIDS, IA Phone no Form 0-T (2017) if PTIN X X
3 Form 0-T (2017) FOUNDATION Page 3 Schedule A - Cost of Goods Sold. Enter method of inventory valuation N/A 1 Inventory at eginning of year ~~~ 1 6 Inventory at end of year ~~~~~~~~~~~~ 6 2 Purchases ~~~~~~~~~~~ 2 7 Cost of goods sold. Sutract line 6 3 Cost of laor~~~~~~~~~~~ 3 from line 5. Enter here and in Part I, 4 a Additional section 263A costs line 2 ~~~~~~~~~~~~~~~~~~~~ 7 ~~~~~~~~ 4a 8 Do the rules of section 263A (with respect to Other costs ~~~ 4 property produced or acquired for resale) apply to 5 Total. Add lines 1 through 4 5 the organization? Schedule C - Rent Income (From Real Property and Personal Property Leased With Real Property) (see instructions) 1. Description of property Yes No (a) 2. From personal property (if the percentage of rent for personal property is more than 10 ut not more than 50) Rent received or accrued () From real and personal property (if the percentage of rent for personal property exceeds 50 or if the rent is ased on profit or income) 3(a) Deductions directly connected with the income in columns 2(a) and 2() Total Total (c) Total income. Add totals of columns 2(a) and 2(). Enter () Total deductions. here and on page 1, Part I, line 6, column (A) Part I, line 6, column (B) Schedule E - Unrelated Det-Financed Income (see instructions) 3. Deductions directly connected with or allocale 2. Gross income from to det-financed property 1. Description of det-financed property or allocale to detfinanced property (a) Straight line depreciation () Other deductions 4. Amount of average acquisition 5. Average adjusted asis 6. Column 4 divided 7. Gross income 8. Allocale deductions det on or allocale to det-financed of or allocale to y column 5 reportale (column (column 6 x total of columns property det-financed property 2 x column 6) 3(a) and 3()) Part I, line 7, column (A). Part I, line 7, column (B). Totals ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Total dividends-received deductions included in column 8 Form 0-T (2017)
4 Form 0-T (2017) FOUNDATION Schedule F - Interest, Annuities, Royalties, and Rents From Controlled Organizations (see instructions) Exempt Controlled Organizations 1. Name of controlled organization 2. Employer 3. Net unrelated income 4. Total of specified 5. Part of column 4 that is 6. Deductions directly identification (loss) (see instructions) payments made included in the controlling connected with income numer organization s gross income in column 5 Page 4 Nonexempt Controlled Organizations 7. Taxale Income 8. Net unrelated income (loss). Total of specified payments 1 Part of column that is included 11. Deductions directly connected (see instructions) made in the controlling organization s with income in column 10 gross income Totals J Schedule G - Investment Income of a Section 501(c)(7), (), or (17) Organization (see instructions) 1. Description of exploited activity 1. Description of income 2. Amount of income 2. Gross unrelated usiness income from trade or usiness Enter here and on page 1, Part I, line 10, col. (A). 3. Expenses directly connected with production of unrelated usiness income Enter here and on page 1, Part I, line 10, col. (B). Part I, line, column (A). 4. Net income (loss) from unrelated trade or usiness (column 2 minus column 3). If a gain, compute cols. 5 through 7. Add columns 5 and 1 Part I, line 8, column (A). Add columns 6 and 11. Part I, line 8, column (B). 3. Deductions Total deductions directly connected 4. Set-asides 5. and set-asides (col. 3 plus col. 4) 5. Gross income 6. Expenses from activity that attriutale to is not unrelated column 5 usiness income Part I, line, column (B). Totals Schedule I - Exploited Exempt Activity Income, Other Than Advertising Income (see instructions) 7. Excess exempt expenses (column 6 minus column 5, ut not more than column 4). Enter here and on page 1, Part II, line 26. Totals Schedule J - Advertising Income (see instructions) Part I Income From Periodicals Reported on a Consolidated Basis 1. Name of periodical 2. Gross 3. Direct advertising advertising costs income 4. Advertising gain or (loss) (col. 2 minus col. 3). If a gain, compute cols. 5 through Circulation 6. Readership income costs 7. Excess readership costs (column 6 minus column 5, ut not more than column 4). Totals (carry to Part II, line (5)) Form 0-T (2017)
5 Form 0-T (2017) FOUNDATION Part II Income From Periodicals Reported on a Separate Basis (For each periodical listed in Part II, fill in columns 2 through 7 on a line-y-line asis.) Totals from Part I 1. Name of periodical 2. Gross 3. Direct advertising advertising costs income Enter here and on page 1, Part I, line 11, col. (A). Enter here and on page 1, Part I, line 11, col. (B). 4. Advertising gain or (loss) (col. 2 minus col. 3). If a gain, compute cols. 5 through Circulation 6. Readership income costs 7. Excess readership costs (column 6 minus column 5, ut not more than column 4). Enter here and on page 1, Part II, line 27. Totals, Part II (lines 1-5) Schedule K - Compensation of Officers, Directors, and Trustees (see instructions) 3. Percent of 4. Compensation attriutale Title time devoted to 1. Name 2. to unrelated usiness usiness Total. Part II, line 14 Page 5 Form 0-T (2017)
6 FOUND }}}}}}}}}}}} }}}}}}}}}} FORM 0-T CONTRIBUTIONS STATEMENT 1 DESCRIPTION/KIND OF PROPERTY METHOD USED TO DETERMINE FMV AMOUNT CHARITABLE CONTRIBUTIONS N/A 7,0,805. TOTAL TO FORM 0-T, PAGE 1, LINE 20 7,0,805. ~~~~~~~~~~~~~~ FORM 0-T OTHER DEDUCTIONS STATEMENT 2 DESCRIPTION AMOUNT }}}}}}}}}}} INVESTMENT MANAGEMENT FEES 17,532. TOTAL TO FORM 0-T, PAGE 1, LINE 28 17,532. ~~~~~~~~~~~~~~ STATEMENT(S) 1, 2
7 FOUND }}}}}}}}}}}} }}}}}}}}}} FORM 0-T CONTRIBUTIONS SUMMARY STATEMENT 3 QUALIFIED CONTRIBUTIONS SUBJECT TO 100 LIMIT CARRYOVER OF PRIOR YEARS UNUSED CONTRIBUTIONS FOR TAX YEAR 2012 FOR TAX YEAR ,076,022 FOR TAX YEAR ,736,267 FOR TAX YEAR ,236,887 FOR TAX YEAR ,650,317 TOTAL CARRYOVER TOTAL CURRENT YEAR 10 CONTRIBUTIONS TOTAL CONTRIBUTIONS AVAILABLE TAXABLE INCOME LIMITATION AS ADJUSTED EXCESS 10 CONTRIBUTIONS EXCESS 100 CONTRIBUTIONS TOTAL EXCESS CONTRIBUTIONS 25,6,43 7,0,805 33,60, ,60, ,60,28 ALLOWABLE CONTRIBUTIONS DEDUCTION 0 TOTAL CONTRIBUTION DEDUCTION 0 ~~~~~~~~~~~~~~ ~~ STATEMENT(S) 3
8 FOUND }}}}}}}}}}}} }}}}}}}}}} FORM 0-T NET OPERATING LOSS DEDUCTION STATEMENT 4 LOSS PREVIOUSLY LOSS AVAILABLE TAX YEAR LOSS SUSTAINED APPLIED REMAINING THIS YEAR }}}}}}}} 12/31/13 6, ,714. 6, /31/15 35, , , /31/16 43,88. 43,88. 43,88. NOL CARRYOVER AVAILABLE THIS YEAR 86, ,255. ~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~ FORM 0-T INCOME (LOSS) FROM PARTNERSHIPS STATEMENT 5 NET INCOME PARTNERSHIP NAME GROSS INCOME DEDUCTIONS OR (LOSS) }} }}}}}}}}}}}} }}}}}}}}}}}} MERCER PRIVATE INVESTMENT PARTNERS LP -1, ,072. MONTAUK TRIGUARD FUND V LP -17, ,342. FEG PRIVATE OPPORTUNITIES FUND II LP -3,5. -3,5. FEG PRIVATE OPPORTUNITIES FUND III LP -156, ,333. PARK STREET CAPITAL PRIVATE EQUITY FUND VII, LP -1, ,003. NEWBURY EQUITY PARTNERS LP NORTHGATE IV LP 1,44 1,44 PORTFOLIO ADVISORS PRIVATE EQUITY FUND II, LP -77. }}}}}}}}}}}} TOTAL TO FORM 0-T, PAGE 1, LINE }}}}}}}}}}}} -213, ,31. ~~~~~~~~~~~~ ~~~~~~~~~~~~ ~~~~~~~~~~~~~~ STATEMENT(S) 4, 5
9 Form (Rev. January 2017) Department of the Treasury Internal Revenue Service Type or print File y the due date for filing your return. See instructions. Application Is For 2 3a c File a separate application for each return. Information aout Form 8868 and its instructions is at Electronic filing (e-file). You can electronically file Form 8868 to request a 6-month automatic extension of time to file any of the forms listed elow with the exception of Form 8870, Information Return for Transfers Associated With Certain Personal Benefit Contracts, for which an extension request must e sent to the IRS in paper format (see instructions). For more details on the electronic filing of this form, visit click on Charities & Non-Profits, and click on e-file for Charities and Non-Profits. All corporations required to file an income tax return other than Form 0-T (including 1120-C filers), partnerships, REMICs, and trusts must use Form 7004 to request an extension of time to file income tax returns. Return Code Application Is For Balance due. Sutract line 3 from line 3a. Include your payment with this form, if required, Enter filer s identifying numer Caution: If you are going to make an electronic funds withdrawal (direct deit) with this Form 8868, see Form 8453-EO and Form 887-EO for payment instructions. LHA For Privacy Act and Paperwork Reduction Act Notice, see instructions. Form 8868 (Rev ) 3a 3 3c $ $ $ OMB No Name of exempt organization or other filer, see instructions. Employer identification numer (EIN) or FOUNDATION Numer, street, and room or suite no. If a P.O. ox, see instructions RD ST SE City, town or post office, state, and ZIP code. For a foreign address, see instructions. CEDAR RAPIDS, IA Social security numer (SSN) Enter the Return Code for the return that this application is for (file a separate application for each return) Form 0 or Form 0-EZ Form 0-BL Form 4720 (individual) Form 0-PF 8868 Application for Automatic Extension of Time To File an Exempt Organization Return Automatic 6-Month Extension of Time. Only sumit original (no copies needed). Form 0-T (sec. 401(a) or 408(a) trust) Form 0-T (trust other than aove) 06 Form 8870 JEAN BRENNEMAN The ooks are in the care of 324 3RD ST SE - CEDAR RAPIDS, IA Telephone No Fax No Return Code Form 0-T (corporation) 07 Form 1041-A Form 4720 (other than individual) Form 5227 Form 606 If the organization does not have an office or place of usiness in the United States, check this ox~~~~~~~~~~~~~~~~~ If this is for a Group Return, enter the organization s four digit Group Exemption Numer (GEN). If this is for the whole group, check this ox. If it is for part of the group, check this ox and attach a list with the names and EINs of all memers the extension is for. 1 I request an automatic 6-month extension of time until NOVEMBER 15, 2018, to file the exempt organization return for the organization named aove. The extension is for the organization s return for: X calendar year2017 or tax year eginning, and ending. If the tax year entered in line 1 is for less than 12 months, check reason: Initial return Final return Change in accounting period If this application is for Forms 0-BL, 0-PF, 0-T, 4720, or 606, enter the tentative tax, less any nonrefundale credits. See instructions. If this application is for Forms 0-PF, 0-T, 4720, or 606, enter any refundale credits and estimated tax payments made. Include any prior year overpayment allowed as a credit. y using EFTPS (Electronic Federal Tax Payment System). See instructions
Exempt Organization Business Income Tax Return
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