d I EXTENSION ATTACHED

Return of Private Foundation OMB No 1545-0052 Form 990-PF or Section 4947(a)(1) Nonexempt Charitable Trust Treated as a Private Foundation Department of the Treasury 2010 Internal Revenue Service Note . The foundation may be able to use a copy of this return to satisfy state reporting requirements. For calendar year 2010 , or tax year beginning DEC 1, 2010 and ending NOV 3 0, 2011 G Check all that apply. Initial return Initial return of a former public charity Ej Final return 0 Amended return ® Address chanae Name change Name of foundation A Employer identification number

JACK ADJMI FAMILY FOUNDATION INC 13-3202295 Number and street (or P O box number if mail is not delivered to street address) Room/swte B Telephone number 463 SEVENTH AVENUE , 4TH FLOOR 212-629-960 0 City or town, state, and ZIP code C If exemption application is pending, check here NEW YORK , NY 10 018 D 1- Foreign organizations, check here 2. Foreign organizations meeting the 85% test, H Check type of organization: Section 501(c)(3) exempt private foundation check here and attach computation charitable Other taxable foundation Section 4947(a )( 1 ) nonexem pt trust 0 private E If p rivate foundation status was terminated I Fair market value of all assets at end of year J Accounting method: ® Cash 0 Accrual under section 507(b)(1)(A), check here (from Part ll, col. (c), line 16) = Other (specify) F If the foundation is in a 60-month termination 111114 218 5 2 4 . (Part 1, column (d) must be on cash basis.) under section 507 b 1 B , check here Part I Analysis of Revenue and Expenses (a) Revenue and (b) Net investment (c) Adjusted net ( d) Disbursements (The total of amounts in columns (b) (c), and (d) may not for charitable purposes necessarily equal the amounts in column (a)) expenses per books income income (cash basis only) 1 Contributions, gifts, grants, etc., received 2 , 178 , 450. N / A

2 Check ► O If the foundation is not required to attach Sob B 3 Interest on savings and temporary cash investments 4 Dividends and interest from securities 5a Gross rents

b Net rental income or Qoss)

6a Net gain or (loss) from sale of assets not on line 10 Gross sales puce for all b assets on tine 6a 7 Capital gain net income (from Part IV, line 2) 0. 8 Net short-term capital gain 9 Income modifications Gross sales less returns 10a and allowances

b Less Cost of goods sold c Gross profit or (loss) 11 Other income r 12- 2 178 450. 0. 13 V 4r^PRlq;e ,Mffjn. erectors, rustees, etc 0. 0. 0. 44 Other emp oyee sa anes a d ges 115 Ja7n 01 el ee 101 is c 6a Legal fees a 6 c S rs^^r)ale sf > 17^teres 2 18 Taxes 19 Depreciation and depletion E 20 Occupancy < 21 Travel, conferences, and meetings J c 22 Printing and publications N 0 23 Other expenses STMT 1 204. 204. 0. M 24 Total operating and administrative expenses . Add lines 13 through 23 204. 204. 0. 0 25 Contributions, gifts, grants paid 2 , 115 , 709. 2 115 , 709. 26 Total expenses and disbursements. Add lines 24 and 25 2 , 115 , 913. 204. 2 , 115 , 709. 0 27 Subtract line 26 from line 12: LU a Excess of revenue over expenses and disbursements 62 , 537. b Net investment income of negative, enter -0-) 0. c Adjusted net income (if negative, enter -0-) N / A 023501 12-07-1 1-ini;il , V, +

It I Fnrm qqn-PF t2Rin1 . T7u('V /1Tl.TMT P11MTT.V 'nTTATfATTn7Q TAT(' 1 '2 _'t x!1') 7 a rz Pnno 9

Attached schedules and amounts in description Beginning of year End of year r r Part II Balance Sheets the column should betorend-ot-year amounts only (a) Book Value (b) Book Value (c) Fair Market Value 1 Cash - non-Interest-bearing 141 , 092. 204 , 524. 204 , 524. 2 Savings and temporary cash investments 895. 3 Accounts receivable ► Less: allowance for doubtful accounts ► 4 Pledges receivable ► Less: allowance for doubtful accounts ► 5 Grants receivable 6 Receivables due from officers, directors, trustees, and other disqualified persons

7 Other notes and loans receivable ► Less. allowance for doubtful accounts ► 8 Inventories for sale or use 9 Prepaid expenses and deferred charges a 10a Investments - U.S. and state government obligations b Investments - corporate stock c Investments - corporate bonds

11 Investments - land,buddings , and equipment basis ►

Less accumulated depreciation ► 12 Investments - mortgage loans 13 Investments - other 14 Land, buildings, and equipment basis ► Less accumulated depreciation ► 15 Other assets (describe ► ADVANCE TO CHARITY ) 14 , 000. 14 , 000. 14 , 000.

16 Total assets (to be completed by all filers ) 155 , 987. 218 , 524. 218 , 524. 17 Accounts payable and accrued expenses 18 Grants payable w 19 Deferred revenue

20 Loans from officers, directors, trustees, and other disqualified persons 21 Mortgages and other notes payable 16 , 500. 16 , 500. J 22 Other liabilities (describe ►

23 Total liabilities ( add lines 17 throu g h 22 ) 16,50 0. 16,50 0. Foundations that follow SFAS 117, check here ► 0 and complete lines 24 through 26 and lines 30 and 31. 24 Unrestricted 25 Temporarily restricted co 26 Permanently restricted Foundations that do not follow SFAS 117, check here Eil C ► LL and complete lines 27 through 31

N° 27 Capital stock, trust principal, or current funds 0. 0. N 28 Paid-in or capital surplus, or land, bldg., and equipment fund 0. in 0. 29 Retained earnings, accumulated income, endowment, or other funds 139 , 487. 202 , 024. Z 30 Total net assets or fund balances 139 , 487. 202 , 024.

31 Total liabilities and net assets/fund balances 155 , 987 . 218 , 524. Part III Analysis of Changes in Net Assets or Fund Balances

1 Total net assets or fund balances at beginning of year - Part II, column (a), line 30 (must agree with end-of-year figure reported on prior year's return) 1 139 , 487 2 Enter amount from Part I, line 27a 2 62 , 537 3 Other increases not included in line 2 (itemize) ► 3 0 4 Add lines 1, 2, and 3 4 202 , 024. 5 Decreases not included in line 2 (itemize) ► 5 0 6 Total net assets or fund balances at end of year (line 4 minus line 5) - Part II. column N. line 30 6 2 0 2 . 0 2 4 . Form 990-PF (2010) 023511 12-07-10

2 13061011 797 696 4CKJAF 2010.O F020 ,TAOK A fl ,TMT 'AMT T.V VnTMMA m Tn A( Tr -rA VI Form 1990-PF (2010) JACK ADJMI FAMILY FOUNDATION , INC 13-3202295 Page 3 Part IV Capital Gains and Losses for Tax on Investment Income How acquired (c) (a) List and describe the kind(s) of property sold (e.g.,., real estate, (P Date acquired (d) Date sold - Purchase yr.) 2-story brick warehouse; or common stock, 200 shs. MLC Co.) D - Donation (mo., day, (mo., day, yr.) is b NONE C d e Depreciation allowed or (e) Gross sales price (f) (g) Cost or other basis (h) Gain (loss) (or allowable) plus expense of sale (e) plus (f) minus (g) a b c d e Complete only for assets showing gain in column (h) and owned by the foundation on 12/31/69 (I) Gains (Col. (h) gain minus (j) Adjusted basis (k) Excess of col. (i) col. (k), but not less than -0-) or Losses (from col. (h)) (i) F.M.V. as of 12/31/69 as of 12/31/69 over col. (I), if any a b c d e If gain, also enter in Part I, line 7 2 Capital gain net income or (net capital loss) If (loss), enter -0- in Part I, line 7 2 3 Net short-term capital gain or (loss) as defined in sections 1222(5) and (6): If gain, also enter in Part I, line 8, column (c). If loss enter -0- in Part I line 8 3 Part V UualiTicatlon under Jectlon 45l4U(e) Tor Heaucea I ax on Net investment income (For optional use by domestic private foundations subject to the section 4940(a) tax on net investment income.)

If section 4940( d)(2) applies, leave this part blank.

Was the foundation liable for the section 4942 tax on the distributable amount of any year in the base periods Yes ® No If 'Yes, the foundation does not quality under section 4940(e). Do not complete this part. 1 Enter the aooroonate amount in each column for each year: see instructions before makma any entries.

Base per iod years ) Distribution ratio Calendar year or tax year beginnin g m Adjusted qualifying(b) distributions Net value of noncharitable -use assets (col. (b) divided by col. (c)) 2009 1 , 888 , 162. 172 826. 10.925220 2008 1 , 894 , 454. 97 , 633. 19.403829 2007 2 , 716 , 315. 181 015. 15.006022 2006 3 , 935 , 442. 3 , 068 , 400. 1.282571 2005 3 , 650 , 653. 87 , 701. 41.626127

2 Total of line 1, column (d) 2 88.243769 3 Average distribution ratio for the 5-year base period - divide the total on line 2 by 5, or by the number of years the foundation has been in existence if less than 5 years 3 17 .648754

4 Enter the net value of noncharitable -use assets for 2010 from Part X, line 5 4 272 , 430.

5 Multiply line 4 by line 3 5 4 , 808 , 050.

6 Enter 1% of net investment income (1% of Part I, line 27b) 6 0.

7 Add lines 5 and 6 7 4 , 808 , 050.

8 Enter qualifying distributions from Part XII, line 4 8 2 , 115 , 709. If line 8 is equal to or greater than line 7, check the box in Part VI, line 1b, and complete that part using a 1% tax rate. See the Part VI instructions.

023521 12-07-10 Form 990-PF (2010) 3 13061011 797696 4CKJAF 201 n . nf;n2n .TA('K AT). TMT VAMTT .V 'nTT r mTn Arm -r c.1 Form 990-PF (2010) JACK ADJMI FAMILY FOUNDATION , INC 13-3202295 Page 4 Part VI Excise Tax Based on Investment Income (Section 4940(a), 4940(b), 4940(e), or 4948 - see instructions)

la Exempt operating foundations described in section 4940(d)(2), check here ► U and enter'N/A' on line 1. Date of ruling or determination letter: ( attach copy of letter if necessary-see instructions) b Domestic foundations that meet the section 4940(e) requirements in Part V, check here ► 0 and enter 1% of Part I, line 27b c All other domestic foundations enter 2% of line 27b. Exempt foreign organizations enter 4% of Part I, line 12, col. (b). 2 Tax under section 511 (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-) 3 Add lines 1 and 2 3 4 Subtitle A (income) tax (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-) 5 Tax based on investment income . Subtract line 4 from line 3. If zero or less, enter -0- 6 Credits/Payments: a 2010 estimated tax payments and 2009 overpayment credited to 2010 6a b Exempt foreign organizations - tax withheld at source 6b c Tax paid with application for extension of time to file (Form 8868) 6c d Backup withholding erroneously withheld 6d 7 Total credits and payments. Add lines 6a through 6d 8 Enter any penalty for underpayment of estimated tax Check here = if Form 2220 is attached 8 9 Tax due If the total of lines 5 and 8 is more than line 7, enter amount owed ► line 7 is more total of lines and enter the 10 Overpayment . If than the 5 8, amount overpaid ► 10 Pa rt VII-A I Statements Regarding Activities la During the tax year, did the foundation attempt to influence any national, state, or local legislation or did it participate or intervene in Yes No any political campaign? is X b Did it spend more than $100 during the year (either directly or indirectly) for political purposes (see instructions for definition)? If the answer is "Yes" to 1a or 1b, attach a detailed description of the activities and copies of any matenals published or distributed by the foundation in connection with the activities. c Did the foundation file Form 1120-POL for this year? d Enter the amount (if any) of tax on political expenditures (section 4955) imposed during the year: (1) On the foundation. ► $ 0. (2) On foundation managers. ► $ 0. e Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed on foundation managers. ► $ 0. 2 Has the foundation engaged in any activities that have not previously been reported to the IRS? 2 1 1 X If "Yes,' attach a detailed descnption of the activities. 3 Has the foundation made any changes, not previously reported to the IRS, in its governing instrument, articles of incorporation, or bylaws, or other similar instruments? If 'Yes," attach a conformed copy of the changes 3 X 4a Did the foundation have unrelated business gross income of $1,000 or more during the year? 4a X b If 'Yes,' has it filed a tax return on Form 990-T for this year? N/A 4b 5 Was there a liquidation, termination, dissolution, or substantial contraction during the year? 5 X If "Yes, " attach the statement required by General Instruction T 6 Are the requirements of section 508(e) (relating to sections 4941 through 4945) 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? 1 6 1 X I 7 Did the foundation have at least $5,000 in assets at any time during the year? If "Yes,' complete Part 11, col. (c), and Part XV 8a Enter the states to which the foundation reports or with which it is registered (see instructions) ►

b If the answer is 'Yes' to line 7, has the foundation furnished a copy of Form 990-PF to the Attorney General (or designate) of each state as required by General Instruction G9 If "No, " attach explanation g Is the foundation claiming status as a private operating foundation within the meaning of section 4942(I)(3) or 4942( I)(5) for calendar year 2010 or the taxable year beginning in 2010 (see instructions for Part XIV)? If "Yes,' complete Part XIV n no anv norcnnc harnmo ciihctnntin1 rnntnhntnrc rinnnn tho t2Y vear9 i. • -.. _.._ _ _ ^_ .. _ ._..__ .^_.. _____ a ------Form 990-PF (2010)

023531 12-07-10 4 13061011 797696 4CKJAF 2010.06020 ,-w"V ATI,TMT FAMTT,V FnrrmmAmTC Ar'tr.Tn'1 Form 990-PF (2010) JACK ADJMI FAMILY FOUNDATION , INC 13-3202295 Page 5 Part VII-A Statements Regarding Activities (continued) 11 At any time during the year, did the foundation, directly or indirectly, own a controlled entity within the meaning of section 512(b)(13)? It'Yes, attach schedule (see instructions) 11 X 12 Did the foundation acquire a direct or indirect interest in any applicable insurance contract before August 17, 2008? 12 X 13 Did the foundation comply with the public inspection requirements for its annual returns and exemption application? 13 X Website address ► N/A 14 The books are in care of ► ERIC ADJMI Telephone no. ► 212 - 6 2 9 - 9 6 0 0 Located at ► 4 6 3 SEVENTH AVENUE, 4TH FLOOR, NEW YORK, NY ZIP+4 ►10 018 15 Section 4947(a)(1) nonexempt charitable trusts filing Form 990-PF in lieu of Form 1041 - Check here ► El and enter the amount of tax-exempt interest received or accrued during the year ► 15 N/A 16 At any time during calendar year 2010, did the foundation have an interest in or a signature or other authority over a bank, Yes No securities, or other financial account in a foreign country? 16 X See page 20 of the instructions for exceptions and filing requirements for Form TD F 90-22.1. If 'Yes,' enter the name of the forei n countrylo^ Part VII- B Statements Regarding Activities for Which Form 4720 May Be Required File Form 4720 if any item is checked in the "Yes" column , unless an exception applies. Yes No la During the year did the foundation (either directly or indirectly): (1) Engage in the sale or exchange, or leasing of property with a disqualified person? El Yes No (2) Borrow money from, lend money to, or otherwise extend credit to (or accept it from) a disqualified person? 0 Yes ® No (3) Furnish goods, services, or facilities to (or accept them from) a disqualified person? El Yes No (4) Pay compensation to, or pay or reimburse the expenses of, a disqualified person? 0 Yes ® No (5) Transfer any income or assets to a disqualified person (or make any of either available for the benefit or use of a disqualified person)? L1 Yes ® No (6) Agree to pay money or property to a government official'? ( Exception . Check "No' 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 90 days.) El Yes ® No b If any answer is 'Yes' to la(1)-(6), did any of the acts fail to qualify under the exceptions described in Regulations section 53.4941(d)-3 or in a current notice regarding disaster assistance (see page 22 of the instructions)' 1b X Organizations relying on a current notice regarding disaster assistance check here ► El c Did the foundation engage in a prior year in any of the acts described in la, other than excepted acts, that were not corrected before the first day of the tax year beginning in 20109 is X 2 Taxes on failure to distribute income (section 4942) (does not apply for years the foundation was a private operating foundation defined in section 4942(l)(3) or 4942(I)(5)): a At the end of tax year 2010, did the foundation have any undistributed income (lines 6d and 6e, Part XIII) for tax year(s) beginning before 2010' El Yes ® No If 'Yes,' list the years ► b Are there any years listed in 2a for which the foundation is not applying the provisions of section 4942(a)(2) (relating to incorrect valuation of assets) to the year's undistributed income? (If applying section 4942(a)(2) to all years listed, answer "No' and attach statement - see instructions.) N/A 2b c If the provisions of section 4942(a)(2) are being applied to any of the years listed in 2a, list the years here.

3a Did the foundation hold more than a 2% direct or indirect interest in any business enterprise at any time during the year? 0 Yes ® No b If'Yes," did it have excess business holdings in 2010 as a result of (1) any purchase by the foundation or disqualified persons after May 26, 1969; (2) the lapse of the 5-year period (or longer period approved by the Commissioner under section 4943(c)(7)) to dispose of holdings acquired by gift or bequest; or (3) the lapse of the 10-, 15-, or 20-year first phase holding periods (Use Schedule C, Form 4720, to determine if the foundation had excess business holdings in 2010) N/A 3b 4a Did the foundation invest during the year any amount in a manner that would jeopardize its charitable purposes 4a X b Did the foundation make any investment in a prior year (but after December 31, 1969) that could jeopardize its charitable purpose that had not been removed from eo and before the first day of the tax year beginning in 2010' 4b X Form 990-PF (2010)

023541 12-07-10 5 13061011 797696 4CKLTAF 201 n . n6n20 TArW AT),TMT FAMTT.V WflT1 TnamT C dr v.-raW1 ruIInoau-rr [ uiu UtIL\.A rjjurl-L r Z%L-11LZ PVIJlVLlillVlV 11V%- 1J-., u667J va es Part VII - B Statements Regarding Activities for Which Form 4720 May Be Required (continued) 5a During the year did the foundation pay or incur any amount to: (1) Carry on propaganda, or otherwise attempt to influence legislation (section 4945(e))? Yes No (2) Influence the outcome of any specific public election ( see section 4955); or to carry on, directly or indirectly, any voter registration drive' Yes No (3) Provide a grant to an individual for travel, study, or other similar purposes ? Yes ® No (4) Provide a grant to an organization other than a charitable , etc., organization described in section 509(a )( 1), (2), or (3 ), or section 4940 (d)(2)9 Yes No (5) Provide for any purpose other than religious , charitable, scientific , literary, or educational purposes, or for the prevention of cruelty to children or animals? Yes No b If any answer is 'Yes' to 5a(1)-(5 ), did any of the transactions fail to qualify under the exceptions described in Regulations section 53.4945 or in a current notice regarding disaster assistance (see instructions)? 5b X Organizations relying on current notice regarding a disaster assistance check here ► c If the answer is 'Yes' to question 5a(4), does the foundation claim exemption from the tax because it maintained expenditure responsibility for the grant? N/A Yes No If 'Yes, " attach the statement required by Regulations section 53 4945-5(d) 6a Did the foundation , during the year , receive any funds, directly or indirectly, to pay premiums on a personal benefit contract? Yes No b Did the foundation , during the year, pay premiums , directly or indirectly, on a personal benefit contract? 6b X If "Yes ' to 6b , file Form 8870. 7a At any time during the tax year, was the foundation a party to a prohibited tax shelter transaction? Yes ® No b If 'Yes' did the foundation receive any proceeds or have any net income attributable to the transaction? N/A 7b Information About Officers, Directors, Trustees, Foundation Managers, Highly 0Part VIII Paid Employees, and Contractors 1 List all officers, directors, trustees, foundation managers and their compensation. Title, and average (c) Compensation (d) Contributlonsto (e) (b) emp anddedbenefitt plans Expense (a) Name and address hours per week devoted ( If not paid, eferTed account, other to position enter -0-) compensation allowances RACHEL ADJMI DIRECTOR 463 SEVENTH AVENUE , 4TH FLOOR NEW YORK , NY 10018 2.00 0. 0. 0. ERIC ADJMI DIRECTOR 463 SEVENTH AVENUE , 4TH FLOOR NEW YORK , NY 10018 2.00 0. 0. 0.

Z e, ompensauon of Ttve nianest-oaio emoiovees (other than those included on line 11. If none. enter "NONE." Title, and average (b) (d)Coebenefiotoye stns (e) Expense (a) Name and address of each employee paid more than $50,000 hours per week (c) Compensation a nd deferred account, other devoted to position compensation allowances NONE

Total number of other employees paid over $50,000 ► 1 0 Form 990-PF (2010)

023551 12-07-10 6 TBOV Form 990-PF (2010) JACK ADJMI FAMILY FOUNDATION, INC 13-3202295 Page 7 Information About Officers, Directors, Trustees , Foundation Managers, Highly 0Part VIII Paid Employees, and Contractors (continued) 3 Five highest-paid independent contractors for pr ofessional services. If none, enter "NONE." (a) Name and address of each person paid more than $50,000 (b) Type of service (c) Compensation NONE

number Total of others receivin over $50,000 for professional services ► 0 Part IX-A Summary of Direct Charitable Activities List the foundation's four largest direct charitable activities during the tax year. Include relevant statistical information such as the number of organizations and other beneficiaries served, conferences convened, research papers produced, etc. Expenses N/A

2

3

4

I Part IX-B I Summary of Program-Related Investmen ts Describe the two largest program-related investments made by the foundation during the tax year on lines 1 and 2. Amount 1 N / A

2

All other program-related investments. See instructions. 3

Total. Add lines 1 throu g h 3 ► 0 Form 990-PF (2010)

023561 12-07-10 7 9 l n r w n w 4 rl Ante, / w Form 990-PF (2010) JACK ADJMI FAMILY FOUNDATION, INC 13- 3202295 Page 8

Part X Minimum Investment Return (A l domestic foundations must complete this part Foreign foundations , see instructions.)

1 Fair market value of assets not used (or held for use) directly in carrying out charitable, etc., purposes: a Average monthly fair market value of securities 0. b Average of monthly cash balances c Fair market value of all other assets d Total (add lines la, b, and c) e Reduction claimed for blockage or other factors reported on lines la and 1c (attach detailed explanation) le 0. 2 Acquisition indebtedness applicable to line 1 assets 3 Subtract line 2 from line 1d 2 4 Cash deemed held for charitable activities. Enter 1 1/2% of line 3 (for greater amount, see instructions) 5 Net value of noncharitable - use assets . Subtract line 4 from line 3. Enter here and on Part V, line 4

Distributable Amount (see instructions) (Section 4942(l)(3) and (I)(5) private operating foundations and certain Part XI foreign organizations check here ► = and do not complete this part.) 1 Minimum investment return from Part X, line 6 2a Tax on investment income for 2010 from Part VI, line 5 b Income tax for 2010. (This does not include the tax from Part VI.) c Add lines 2a and 2b 3 Distributable amount before adjustments. Subtract line 2c from line 1 4 Recoveries of amounts treated as qualifying distributions 5 Add lines 3 and 4 2. 6 Deduction from distributable amount (see instructions) XIII. line 1 PartXII Qualifying Distributions (see instructions)

1 Amounts paid (including administrative expenses) to accomplish charitable, etc., purposes: a Expenses, contributions, gifts, etc. - total from Part I, column (d), line 26 la 2 , 115 , 709. b Program-related investments - total from Part IX-B 1b 0. 2 Amounts paid to acquire assets used (or held for use) directly in carrying out charitable, etc., purposes 2 3 Amounts set aside for specific charitable projects that satisfy the: a Suitability test (prior IRS approval required) 3a b Cash distribution test (attach the required schedule) 3b 4 Qualifying distributions . Add lines la through 3b. Enter here and on Part V, line 8, and Part XIII, line 4 4 2 , 115 , 709. 5 Foundations that qualify under section 4940(e) for the reduced rate of tax on net investment income. Enter 1% of Part I, line 27b 5 0. 6 Adjusted qualifying distributions . Subtract line 5 from line 4 6 2 , 115 , 709. Note . The amount on line 6 will be used in Part V, column (b), in subsequent years when calculating whether the fo undation qualifies for the section 4940(e) reduction of tax in those years. Form 990-P F (2010)

023571 12-07-10 8 1'4091 ni 1 707909 At-W.7h"M )fI n ncn ")n 7 7% Tr 1 .IT "WT1u-T V V^TT1.TT- m -r % AnTr,wTn9 Form 990-PF (2010) JACK ADJMI FAMILY FOUNDATION, INC 13-3202295 Page 9 Part XIII Undistributed Income (see instructions)

(a) (b) (c) (d) Corpus Years prior to 2009 2009 2010 1 Distributable amount for 2010 from Part XI, line? 13 , 622. 2 Undistributed income, if any , as of the end of 2010 a Enter amount for 2009 only 0. b Total for prior years: 0. 3 Excess distributions ca rryover, if any, to 2010: aFrom2005 3 646 268. b From 2006 3 , 822 307. c From 2007 2 707 264. dFrom2008 1 889 586. e From 2009 1 879 521. f Total of lines 3a throug h e 13 , 944 , 946 4 Qualifying distributions for 2010 from Part Xll, line 4: ► $ 2 , 115 , 709. a Applied to 2009, but not more than line 2a 0. b Applied to undistributed income of prior years (Election required - see instructions) 0. c Treated as distributions out of corpus (Election required - see instructions) 0. d Applied to 2010 distributable amount 13 , 622. e Remaining amount distributed out of corpus 2 , 102 , 087.

5 Excess distributions carryover applied to 2010 0. 0. (If an amount appears in column (d), the same amount must be shown in column (a) ) 6 Enter the net total of each column as indicated below:

a Corpus Add lines 3f, 4c, and 4e Subtract line 5 16 , 047 , 033. b Prior years' undistributed income. Subtract line 4b from line 2b 0. c Enter the amount of prior years' undistributed income for which a notice of deficiency has been issued, or on which the section 4942(a) tax has been previously assessed 0 d Subtract line 6c from line 6b. Taxable amount - see instructions 0 . e Undistributed income for 2009. Subtract line 4a from line 2a. Taxable amount - see instr. 0 f Undistributed income for 2010. Subtract lines 4d and 5 from line 1. This amount must be distributed in 2011 0 7 Amounts treated as distributions out of corpus to satisfy requirements imposed by section 170(b)(1)(F) or 4942(g)(3) 0 . 8 Excess distributions carryover from 2005 not applied on line 5 or line 7 3 6 4 6 2 6 8. 9 Excess distributions carryover to 2011. Subtract lines 7 and 8 from line 6a 12 , 400 , 765. 10 Analysis of line 9: a Excess from 2006 3 , 822 , 307. b Excess from 2007 2 , 707 , 264. c Excess from 2008 1 8 8 9 5 8 6. d Excess from 2009 1 8 7 9 5 21 . e Excess from 2010 2 , 102 , 087. Form 990-PF (2010) 023581 12-07-10 9 1 ZIrC1 /111 '707000 AP1VTT'M '1119 /1 r%Cr1'1!1 TwnTP ''' " rw^rrre ,• •....^,...w Form 990-PF 2010 JACK ADJMI FAMILY FOUNDATION , INC 13-3202295 Page 10 Part XIV Private Operating Foundations (see instructions and Part VII-A, question 9) N/A a If the foundation has received a ruling or determination letter that it is a private operating foundation, and the ruling is effective for 2010, enter the date of the ruling ► b Check box to indicate whether the foun dation is a p rivate o eratm foundation described in section LJ 4y4L or LJ 4Y4L 5 2 a Enter the lesser of the adjusted net Tax year Prior 3 years income from Part I or the minimum (a) 2010 (b) 2009 (c) 2008 (d) 2007 (e) Total investment return from Part X for each year listed b 85% of line 2a c Qualifying distributions from Part XII, line 4 for each year listed d Amounts included in line 2c not used directly for active conduct of exempt activities e Qualifying distributions made directly for active conduct of exempt activities. Subtract line 2d from line 2c 3 Complete 3a, b, or c for the alternative test relied upon: a 'Assets' alternative test - enter: (1) Value of all assets (2) Value of assets qualifying under section 4942(I)(3)(B)(i) b 'Endowment' alternative test - enter 2/3 of minimum investment return shown in Part X, line 6 for each year listed c 'Support° alternative test - enter: (1) Total support other than gross investment income (interest, dividends, rents, payments on securities loans (section 512(a)(5)), or royalties) (2) Support from general public and 5 or more exempt organizations as provided in section 4942(I)(3)(B)(ui) (3) Largest amount of support from an exempt organization ( 4 ) Gross investment income Part XV Supplementary Informationrmation (CompleteCom plete this part only if the foundation had 95. 000 or more in assets at any time during the year-see the instructions.) 1 Information Regarding Foundation Managers- a List any managers of the foundation who have contributed more than 2% of the total contributions received by the foundation before the close of any tax year (but only if they have contributed more than $5,000). (See section 507(d)(2).) ERIC ADJMI b List any managers of the foundation who own 10% or more of the stock of a corporation (or an equally large portion of the ownership of a partnership or other entity) of which the foundation has a 10% or greater interest NONE 2 Information Regarding Contribution, Grant, Gift, Loan , Scholarship, etc., Programs: Check here ► ® if the foundation only makes contributions to preselected charitable 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 2a, b, c, and d. a The name, address, and telephone number of the person to whom applications should be addressed:

TATEMENT 2 b The form in which applications should be submitted and information and materials they should include:

c Any submission deadlines:

d Any restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other factors:

023601 12-07-10 Form 990-PF (2010) 10 1 r)11 '7Q'79. 0 r A ov .m Ti ') n1 n n1Z nIn TT ('Tp TT>T7.xT C'7 UTTv LT/1TTTTT-%AM-r % /I riT) TT 'MI Form 990-PF (2010) on 3 Grants and Contributions Paid Durina the Year or Anoroved for Future Payment Recipient If recipient is an individual, show any relationship to Foundation Purpose of grant or Amount Name and address (home or business) any foundation manager status of contribution or substantial contributor recipient a Paid dung the year SEE ATTACHED 2,115,709.

Total ► 3a 2 115 709 . b Approved for future payment

NONE

Total ► 3b 1 0 . 023811 12-07-10 Form 990-PF (2010) 11 Form 990-PF (2010) JACK ADJMI FAMILY FOUNDATION, INC 13-320229 5 Paoe 12 Part XVI-A Analysis of Income-Producing Activities

Enter boss amounts unless otherwise indicated. Unrelate d business income Exclu ded b y section 512, 513, or 514 (e) (a) (b) Ei^^„_ (d ) Related or exempt Business Amount Sion function I Program service revenue: code code Amount income a b c d e f 9 Fees and contracts from government agencies 2 Me mbershlp dues and assessments 3 IntBrest on savings and temporary cash Investments 4 Div idends and interest from securities 5 Net rental income or (loss) from real estate: a Debt-financed property b Not debt-financed property 6 Net rental income or (loss) from personal property 7 0th er investment income 8 Gal n or (loss) from sales of assets other tha n inventory 9 Net income or (loss) from special events 10 Gross profit or (loss) from sales of inventory 11 Oth er revenue: a b c d e 12 Subtotal. Add columns (b), (d), and (e) 0. 1 0. 1 0 . Total. Add line 12, columns (b), (d), and (e) 13 0. (See worksheet in line 13 instructions to verify calculations.) Part XVI-B Relationship of Activities to the Accomplishment of Exempt Purposes

0212312121 io Form 990-PF (2010) Form 990-PF 2010 JACK ADJMI FAMILY FOUNDATION , INC 13-3202295 Pa a 13 Part XVII Information Regarding Transfers To and Transactions and Relationships With Noncharitable Exempt Organizations 1 Did the organization directly or indirectly engage in any of the following with any other organization described in section 501(c) of Yes No the Code (other than section 501(c)(3) organizations) or in section 527, relating to political organizations? a Transfers from the reporting foundation to a noncharitable exempt organization of (1) Cash la( l ) X (2) Other assets la ( 2 ) X b Other transactions: (1) Sales of assets to a noncharltable exempt organization lb ( l ) X (2) Purchases of assets from a noncharitable exempt organization lb ( 2 ) X (3) Rental of facilities, equipment, or other assets lb ( 3) X (4) Reimbursement arrangements 1b( 4) X (5) Loans or loan guarantees lb ( 5 ) X (6) Performance of services or membership or fundraising solicitations lb( 6 ) X c Sharing of facilities, equipment, mailing lists, other assets, or paid employees 1c X d If the answer to any of the above is 'Yes,' complete the following schedule. Column (b) should always show the fair market value of the goods, other assets, or services given by the reporting foundation. If the foundation received less than fair market value in any transaction or sharing arrangement, show in

2a Is the foundation directly or indirectly affiliated with, or related to, one or more tax-exempt organizations described in section 501 ( c) of the Code ( other than section 501(c)(3 )) or in section 5279 Yes ® No h if 'Yec ' rmmnlete the fnllnwmn crhoriiila (a) Name of organization (b) Type of organization (c) Description of relationship N / A

Under penalties of perjury, I declare that I have examined this return, i ncluding and complete Declarati of pr parer (other than taxpayer or fiduciary) n Here

prr ure o 0 r or trustee Print/Ty eparer's name Pre r s,gnatur

Paid BENJAMIN GADON Preparer Firm's name MHM, LLC Use Only Firm's address 6 5 AVENUE OF THE NEW YORK , NY 10 018

023622 04-26-11 Schedule B Schedule of Contributors OMB No 1545-0047 (Form 990, 990- EZ, or 990-PF ) ► Attach to Form 990, 990-EZ, or 990-PF. Department of the Treasury 2010 Internal Revenue Service Name of the organization Employer identification number

.TAOV AT).TMT FAMTT.V F(1TTATT12,mT r1TT TWO 1 Z_^7(177QR Organization type (check one)

Filers of: Section:

Form 990 or 990-EZ 0 501 (c)( ) (enter number) organization

El 4947(a)(1) nonexempt charitable trust not treated as a private foundation

527 political organization

Form 990-PF ® 501 (c)(3) exempt private foundation

0 4947(a)(1) nonexempt charitable trust treated as a private foundation

0 501 (c)(3) taxable private foundation

Check if your organization is covered by the General Rule or a Special Rule. Note . Only a section 501 (c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See Instructions.

General Rule

® For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, $5,000 or more (in money or property) from any one contributor. Complete Parts I and II

Special Rules

For a section 501 (c)(3) organization filing Form 990 or 990-EZ that met the 33 1/3% support test of the regulations under sections 509(a)(1) and 170(b)(1)(A)(vi), and received from any one contributor, during the year, a contribution of the greater of (1) $5,000 or (2) 2% of the amount on () Form 990, Part VIII, line 1h or (I) Form 990-EZ , line 1 Complete Parts land II.

0 For a section 501(c)(7), (8), or (10) organization filing Form 990 or 990-EZ that received from any one contributor , dunng the year, aggregate contributions of more than $1,000 for use exclusively for religious , charitable, scientific, literary , or educational purposes, or the prevention of cruelty to children or animals Complete Parts I, II, and III

For a section 501(c)(7), (8), or (10) organization filing Form 990 or 990- EZ that received from any one contributor, during the year, contributions for use exclusively for religious , charitable , etc , purposes , but these contributions did not aggregate to more than $1,000 If this box is checked , enter here the total contributions that were received during the year for an exclusively religious , charitable, etc., purpose Do not complete any of the parts unless the General Rule applies to this organization because it received nonexcluslvely religious, charitable, etc., contributions of $5,000 or more during the year 1111. $

Caution. An organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990, 990-EZ, or 990-PF), but it must answer "No" on Part IV, line 2 of its Form 990, or check the box on line H of Its Form 990-EZ, or on line 2 of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990, 990-EZ, or 990-PF)

LHA For Paperwork Reduction Act Notice, see the Instructions for Form 990, 990- EZ, or 990-PF. Schedule B (Form 990 , 990-EZ , or 990-PF ) ( 2010)

023451 12-23-10 Schedule B (Form 990, 99 Page L of L of Part Name of organization Employer identification number

Part I Contributors (see instructions)

(a) (b) (c) (d) No. Name, address , and ZIP + 4 Aggregate contributions Type of contribution

1 BELUGA, INC Person Payroll 463 7TH AVENUE, 4TH FLOOR $ 120,000. Noncash (Complete Part II if there NEW YORK, NY 10 018 is a noncash contribution.)

(a) (b) (c) (d) No. Name , address, and ZIP + 4 Aggregate contributions Type of contribution

2 CONSOLIDATED CHILDRENS APPAREL Person EK] Payroll 0 463 7TH AVENUE, 4TH FLOOR $ 369 ,000. Noncash (Complete Part II If there NEW YORK, NY 10 018 is a noncash contribution )

(a) (b) (c) (d) No. Name , address , and ZIP + 4 Aggregate contributions Type of contribution

3 ERIC ADJMI Person ERI Payroll 463 7TH AVENUE, 4TH FLOOR $ 28,100. Noncash (Complete Part II if there NEW YORK, NY 10 018 is a noncash contribution.)

(a) (b) (c) (d) No. Name , address , and ZIP + 4 Aggregate contributions Type of contribution

4 IFG CORP Person Payroll 463 7TH AVENUE, 4TH FLOOR $ 900,000. Noncash 0 (Complete Part II if there NEW YORK, NY 10018 is a noncash contnbutlon )

(a) (b) (c) (d) No. Name , address, and ZIP + 4 Aggregate contributions Type of contribution

5 MARK ADJMI Person Payroll 463 7TH AVENUE, 4TH FLOOR $ 141 ,600. Noncash (Complete Part II if there NEW YORK, NY 10 018 is a noncash contribution )

(a) (b) (c) (d) No. Name, address, and ZIP + 4 Aggregate contributions Type of contribution

6 RACHEL ADJMI Person EK] Payroll 463 7TH AVENUE, 4TH FLOOR $ 33 ,000. Noncash (Complete Part II if there NEW YORK, NY 10 018 is a noncash contnbution.) 023452 12-23-10 Schedule B (Form 990, 990-EZ, or 990-PF) (2010) Schedule B (Form 990, 990-EZ, or of Part I Name of organization Employer identification number

Part I Contributors (see instructions)

(a) (b) (c) (d) No. Name, address, and ZIP + 4 Aggregate contributions Type of contribution

7 RONALD ADJMI Person Payroll 463 7TH AVENUE, 4TH FLOOR $ 526,750. Noncash (Complete Part II if there NEW YORK, NY 10 018 is a noncash contribution )

(a) (b) (c) (d) No. Name, address, and ZIP + 4 Aggregate contributions Type of contribution

8 SOLOMON & KIM DABAH Person I-XI Payroll 463 7TH AVENUE, 4TH FLOOR $ 60,000. Noncash (Complete Part II if there NEW YORK, NY 10 018 is a noncash contribution )

(a) (b) (c) (d) No. Name, address , and ZIP + 4 Aggregate contributions Type of contribution

Person Payroll $ Noncash (Complete Part II if there is a noncash contribution )

(a) (b) (c) (d) No. Name , address , and ZIP + 4 Aggregate contributions Type of contribution

Person Payroll $ Noncash (Complete Part II if there is a noncash contribution )

(a) (b) (c) (d) No. Name , address, and ZIP + 4 Aggregate contributions Type of contribution

Person Payroll $ Noncash (Complete Part II if there is a noncash contnbution.)

(a) (b) (c) (d) No. Name , address , and ZIP + 4 Aggregate contributions Type of contribution

Person Payroll $ Noncash (Complete Part II if there is a noncash contnbution ) 023452 12-23- 10 Schedule B (Form 9 90 . 990-EZ . or 990-PF1120101 Schedule B (Form 990, 990-EZ, or of of Part U Name of organization Employer identification number

Part 11 Noncash Property (see instructions)

(a) (c) No. (b) FMV (or estimate) (d) from Description of noncash property given Date received (see instructions) Part I

(a) (c) No. (b) FMV (or estimate) (d) from Description of noncash property given Date received (see instructions) Part I

(a) (c) No. (b) FMV (or estimate) (d) from Description of noncash property given Date received (see instructions) Part I

(a) No. (b) FMV (or(estimate) (d) from Description of noncash property given Date received (see instructions) Part I

(a) (c) No. (b) FMV (or estimate) (d) from Description of noncash property given Date received (see instructions) Part l

(a) (c) No. (b) FMV (or estimate) (d) from Description of noncash property given Date received (see instructions) Part I

023453 12-23-10 Schedule B (Form 990 , 990-EZ, or 990 -PF) (2010) 1 '7 Schedule 8 (Form 990, 990-EZ, or Page of of Part III Name of organization Employer identification number

UJ L1. L-1LUML rtu•11L1 rLULVLH-11ViN, 11'1. I 1J-J4U6677 Part III Exclusively religious, charitable , etc., individual contributions to section 501(c)(7), (8), or ( 10) organizations aggregating more than $ 1,000 for the year. Complete columns (a) through (e) and the following line entry. For organizations completing Part III, enter the total of exclusively religious , charitable, etc., contributions of C1 AAA , r Ives fnr the vemr (Pntor the infnrmnfinn nnro q-a -+n irfinne 1 P (a) No. from (b) Purpose of gift (c) Use of gift (d) Description of how gift is held Part I

(e) Transfer of gift

Transferee's name, address , and ZIP + 4 Relationshi p of transferor to transferee

(a) No. from (b) Purpose of gift (c) Use of gift (d) Description of how gift is held Part I

(e) Transfer of gift

Transferee's name, address , and ZIP + 4 Relationshi p of transferor to transferee

(a) No. from (b) Purpose of gift (c) Use of gift (d) Description of how gift is held Part I

(e) Transfer of gift

Transferee's name, address , and ZIP + 4 Relationship of transferor to transferee

(a) No. from (b) Purpose of gift (c) Use of gift (d) Description of how gift is held Part I

(e) Transfer of gift

Transferee's name, address, and ZIP + 4 Relationshi p of transferor to transferee

023454 12-23-10 Schedule B (Form 990 , 990-EZ, or 990- PF) (2010) 10 JAFF 4 2-3 Contributions 12/1/2010 through 11/30/2011

AFIKIM 36.00 B Allenhurst Fire Dept. & First Aid Squad 100.00 C American Cancer Society 100.00 C American Cancer Society 100.00 C American Cancer Society 100.00 C American Friends Of Hazon Yeshaya 1000.00 B American Friends of Yad-Shlomo 101.00 B Ateret Torah 200.00 B Ateret Torah 200.00 8 Beit Yaacov Inc. 955.00 B Bet Yaakov Of The Jersey Shore 1000.00 B Bet Yaakov Of The Jersey Shore 100.00 B Bet Yaakov Of The Jersey Shore 1000.00 B Bnei Aram Soba 1000.00 B BneiYacov 500.00 B Chabad Jewish Center 72.00 B Chabad Vocational Schools 300.00 A Chabad Vocational Schools 500.00 A Chai Lifeline 218.00 B Chai Lifeline 100.00 B Chai Lifeline 100.00 8 Chai Lifeline 300.00 B Chai Lifeline 1000.00 B Chai Lifeline 100.00 B Chai Lifeline 100.00 B Chaverim 500.00 B Children's Wish Foundation 26.00 B Children's Wish Foundation 26.00 B Cong. Shaare Rahamim 1000.00 B Congregation Benei Yakov 300.00 B Congregation Beth Torah 301.00 B Congregation Beth Torah 1354.00 B Congregation Beth Torah 2559.00 B Congregation Beth Torah 1512.00 8 Congregation Edmond J. Safra 252.00 B Congregation Edmond J. Safra 252.00 B Congregation Edmond J. Safra 0.00 B Congregation Edmond J. Safra 360.00 B Congregation Edmond J. Safra 1600.00 B Congregation Edmond J. Safra 250.00 B Congregation Edmond J. Safra 500.00 B Congregation Magen David Of Beverly Hills 501.00 B Congregation Shaare Rahamim 400.00 B Congregation Shaare Rahamim 400.00 B Congregation Shaare Rahamim 200.00 B Congregation Shaare Rahamim 300.00 B Darkei Noam 18.00 a Deal Fire Company No. 2 52.00 C Deal First Aid & Emergency Squad 100.00 C Deal Sephardic Network 252.00 B Edmond J. Safra Synagogue Of Deal, NJ. 1001.00 8 Edmond J. Safra Synagogue Of Deal, NJ. 600.00 B Emunah Of America 18.00 B Ezer Mizion 100.00 B Ezer Mizion 400.00 B Friends Of Ahavat Shalom 1350.00 B Friends Of Ahavat Shalom 1350.00 B Friends Of Ahavat Shalom 1350.00 B Friends Of Ahavat Shalom 1350.00 B Friends Of Ahavat Shalom 1350.00 B Friends Of Ahavat Shalom 1350.00 B Friends Of Ahavat Shalom 1350.00 B Friends Of Ahavat Shalom 1350.00 B Friends Of Ahavat Shalom 1350.00 B Friends Of Ahavat Shalom 1450.00 B Friends Of Ahavat Shalom 1450.00 B Friends Of Ahavat Shalom 1450.00 B Friends Of The IDF 500.00 8 Gesher Yehuda 500.00 B Gesher Yehuda 500.00 B Gesher Yehuda 1000.00 B GIOH 18.00 B GIOH 18.00 B Hatzalah Volunteer EMS 252.00 B Ilan High School 250.00 A Ilan High School 250.00 A Imagine Academy 520.00 A Imagine Academy 401.00 A Imagine Foundation Inc. 200.00 B Israel Purim Fund 500.00 B Jerusalem Center For Research 500.00 B Keren Hayeled 36.00 B Keren Mazkeres Yosef 18.00 B K'hal Bnei Torah 252.00 B Mary Tawil Foundation 500.00 B Mary Tawil Foundation 500.00 B Mazkeret Halphone 252.00 B Mazkeret Halphone 252.00 B Mikdash Melech 301.00 B Mirrer Yeshiva Central Institute 101.00 A Mitzvah Man Foundation Corp. 250.00 B Multiple Sclerosis Association Of America 36.00 C Nefesh Academy 1300.00 A New York Cancer Center 250.00 C Ohel Simha Superfund Honor Of Menahem 1000.00 B Ohr Joseph Institutions 2500.00 B Ohr Joseph Institutions 500.00 B Ohr Joseph Institutions 1000.00 B Or Hatorah 300.00 B Or Hatorah 400.00 B Or Hatorah 50.00 B Rabbi Meir Baal Maness 18.00 B Rochel Leah Chesed Fund 500.00 B Sarah Dabah Elementary School 1000.00 A Sderot Media Center 101.00 B Sephardic Bikur Holim 750.00 B Sephardic Community Center 1400,00 B Sephardic Community Center 1400.00 B Sephardic Food Fund 90.00 B Sephardic Food Fund 360.00 B Sephardic Press 36.00 B Shaare Rahamim 400.00 B Shaare Rahamirn 600.00 B Shaare Rahamim 400.00 B Shaare Rahamim 300.00 B Shaare Torah 300.00 B Sh'or Yoshuv Institute 18.00 B Stella Liniado Rainbow Foundation 252.00 B Susan G. Komen For The Cure 100.00 C Susan G. Komen For The Cure 36.00 C Susan G. Komen For The Cure 100.00 C Susan G. Komen For The Cure 52.00 C The Davis Memorial Fund 36.00 c The Leukemia & Lymphoma Society 25.00 C Tzedakah Vachesed 501.00 B Tzedakah Vachesed 301.00 B Yad Yosef 700.00 B Yad Yosef 4000.00 B Yad Yosef 700.00 B Yad Yosef 700.00 B Yad Yosef 700.00 B Yad Yosef 5000.00 B Yad Yosef 700.00 B Yad Yosef 700.00 B Yad Yosef 3000.00 B Yad Yosef 2600.00 B Yad Yosef 700.00 B Yad Yosef 1500.00 8 Yad Yosef 1000.00 B Yad Yosef 3600.00 B Yad Yosef 1000.00 B Yad Yosef Kollel 26.00 B Yad Yosef KoIlel 252.00 B Yad Yosef Torah Center 26.00 B Yad Yosef Torah Center 78.00 B Yad Yosef Torah Center 353.00 B Yad Yosef Torah Center 250.00 B Yehuda Habshush 100.00 B Yeshiva Gedolah Bais Yisroel 250.00 A Yeshiva Gedolah Of Bayonne 1000.00 A Yeshiva Zichron Meilech 18.00 A Yeshivah Ateret Torah 1000.00 A Yeshivah Magen Abraham 2600.00 A Yeshivah Of Flatbush 52.00 A Yeshivah Of Flatbush 500.00 A Yeshivah Of Flatbush 52.00 A Yeshivah Of Flatbush 250.00 A Yeshivah Of Flatbush 100.00 A Yeshivat Ateret Torah 250.00 A Yeshivat Ateret Torah 200.00 A Yeshivat Lev Aharon 15500.00 A Yeshivat Lev Aharon 500.00 A Yeshivat Mikdash Melech 500.00 A Zaka-Rescue & Recovery 36.00 B Total: :.1^5fi9,200 Jaff 1,4,5- Given on July 9,2012

Achdus Foundation {Gan Israel 1666) $ (52.00) B Achdus Foundation (pHUS100) $ (52.00) B Acheinu (Acheinu The Holy Yeshiva ) $ ( 201.00) B Afula Education Center { Derech Emmet 16471 $ (250.00) B Agudat Ahaba Ve Achva $ (100.00) 8 Agudat Israel Of Borough Park { }{Dina Abuzaglo} $ (500.00) 8 Agudat Israel Of Long island ( Hadrat Kodesh) $ (250.00) B Agudat Refuah Vechaim(Ezra Nisuin Chasdei Shalom} $ ( 150.00) B Agudath Masei Chesed $ (201.00) B Ahavas Chesed {p)jTamar Sadykova } $ ( 101.00) B Ahavas Chesed Love Of Kindness Inc. {p}(Ilana Admon) $ (101.00) B Ahavat Mordechai $ (450.00} 8 AhavatTorah $ ( 101.00) B Ahavat Yerushalayim { }{ R Binyamin Apple) $ ( 101.001 B AN Ezer Yeshiva {US108} $ (10,000.00) A Aish Center $ (5,000.00) B Aishel Shabbat (K.B. Cheese Inc) $ (250.00) B Aliyat Bet Chanania (1110) $ (1,000.00) B American Friends lmrel Noam {Yeshivas Imrei NoamAF805 } $ ( 201.00) B American Friends Of Agudat Ahava Veahva (p} $ (300.00) B American Friends Of Agudat Ahava Veahva {p}{Joe Esses ) $ ( 300.00) B American Friends Of Ahavat Israel {p}(Moshe Habusha) $ (101.00) B American Friends Of Aram Soba (AF1.5 Kollel Aram Soba} $ ( 2,000.00 B American Friends Of Ayelet Hashachar (AF20S) $ ( 1,000.00 B American Friends of Beer Chaim Yitzhak{Mosdot Limudey Zion1782 } $ (300.00) B American Friends Of Beis Maoz $ ( 250.00) B American Friends Of Bet Shemaya (Bet Shemaya 1803} $ (500.00) B American Friends Of Bet Yosef Maron $ (300.00) B American Friends of Binyan Av {AF120} $ ( 2,000.00) B American Friends Of Birkat Efraim (AF121 ) $ ( 5,000.00) B American Friends Of Birkat Efraim {AF121 } $ ( 5,000.00) B American Friends Of Birkat Israel {AF122} $ (500.00) B American Friends Of Carmei Ha'ir {Mitzadei Gaver} $ (300.00) B American Friends Of Darchei Avot {Yeshivat Aish HatalmudI 804} $ (126.00) B American Friends Of Darchei Noam (AF125 ) $ (1,200.00) B American Friends Of Dvar Avraham (AF216) $ (700.00) B American Friends Of Eperlon Shlomo {AF128) $ (5,000.00) B American Friends Of Hazon Yeshaya Soup Kitchen (AF338) $ (6,000.00) 8 American Friends Of Hebron Yeshiva {1812} $ (3,000.00) B American Friends Of Hechal Ezra {AF129} $ (3,600.00) B American Friends Of Imrei Da'at {AF130} $ ( 2,600.00) B American Friends Of Kavey TTET (AF133) $ (500,00) B American Friends of Kindness & Charity Inc{Chesed Umarpehl858} $ (900.00) B American Friends Of Kol Itzhak {AF134 } $ (600.00) B American Friends Of Kol Torah Jerusalem {AF824} $ (1,200.00) B American Friends Of K01 Yehuda (AF135 ) $ (800.00) B American Friends Of Kolel Tiferes Yisroel(Givat Rokack Torah C) $ ( 201,00 . 8 American Friends Of Kolel Tiferes Yisroel (Givat RokackTorahCtr ) $ ( 300.00 8 American Friends Of Kollei Ohr L'Halacha { }{R Shaul Buskila) $ (150.00) B American Friends Of Kollel Zlchron Yosef (AF137 ) $ (1,200.00) B American Friends Of Lev Aharon {AF138,Lev Aharon Camp Program) $ (1,000.00) 8 American Friends Of Lev Aharon {AF138} $ (6,000.00) B American Friends Of Lev Aharon {AF138} $ (6,000.00) B American Friends Of Lev Aharon {p}{R Yitzhak Akiva) $ (76.00) B American Friends Of Levush Maichus $ (201.00) B American Friends Of Levush Malchus {AF140) $ (200.00) B American Friends Of Ulmod Ulelamed $ (250.00) B American Friends Of Ulmod Ulelamed {p} $ (101.00) B American Friends Of L'Maan Daat {L'Maan Daat} $ (400.00) B American Friends Of M,C.Y. (US831) $ (3,600.00) 8 American Friends Of Maayanel Torah L'Moshe(Ateret Chaim) $ (201.00) B American Friends Of Mateh Aharon (AF178) $ (400.00) 8 American Friends Of Meoros Avraham{Debei Eliyahou Yeshivah} $ (201.00) 8 American Friends Of Meorot Avraham {Ner L'Shimon} $ (201.00) B American Friends Of Merkaz Hatorah {FR801} $ (2.000.00) B American Friends Of Michkane Meir {Armon Hatorah} $ (36.00) B American Friends Of Michkane Meir {Druftiki D'Orayta 1771) $ (126.00) B American Friends Of Michkane Meir (Koliei Rinat Yiitzchakl778) $ (126.00) 8 American Friends Of Michkane Meir {Mishkan Rafael} $ (200.00) B American Friends Of Michkane Meir {Mishkan Yosef} S (201.00) 8 American Friends Of Michkane Meir {Nahal Abraham 17771 $ (126.00) B American Friends Of Michkane Meir (p}{Dina Gabay) $ (101.00) B American Friends Of Michkane Meir (p}{R Aharon Soudry} $ (101.00) B American Friends Of Michkane Meir (p){R Avner Zadok} $ (101.00) B American Friends Of Michkane Meir {p}{R Avraham Marshal} $ (101.00) B American Friends Of Michkane Meir (p){R Eyai Levy) $ (252.00) B American Friends Of Michkane Meir (pXR Gabriel Swisa} $ (101.00) B American Friends Of Michkane Meir {p}{R Meir Dori) $ (52.00) B American Friends Of Michkane Meir {p}{R Sasson Dill $ (52.00) B American Friends Of Michkane Meir (p}{R Yaakov Cohen) $ (36.00) B American Friends Of Michkane Meir (Shaare Haim 1803) $ (300.00) B American Friends Of Michkane Meir {Shaare Torah Modiin llit} $ (126.00) B American Friends Of Michkane Meir {Shay Lamora} $ (150.00) B American Friends Of Michkane Meir {Shemesh Tzdaka Vehayim} $ (101.00) B American Friends Of Michkane Meir {Yeshivas Kiryat Yehuda} $ (400.00) B American Friends Of Michkane Meir Inc (Bet David Kolel) $ (52.00) B American Friends Of Michkane Meir Inc (Bet Perez Yeshiva/Kollel} $ (101.00 ' s American Friends Of Michkane Meir Inc {Mishkan Aharon} $ (101.00) B American Friends Of Michkane Meir Inc {Or Harambam} $ (126.00) 8 American Friends Of Michkane Meir Inc {Orah VeSimcha1847} $ (1,200.00) 8 American Friends Of Michkane Meir Inc {Oros Memizrahl656} $ (150.00) 8 American Friends Of Michkane Meir Inc { }{Ariyeh Pinto) $ (101.00) 8 American Friends Of Michkane Meir Inc {p}(Ner Rafael Sadka) $ (101.00) B American Friends Of Mlchkane Meir Inc {pXR Abraham Lankry} $ (72.00) B American Friends Of Mlchkane Meir Inc {p}{R Avraham Benisti} $ (150.00) B American Friends of Michkane Meir Inc {p}{R Daniel Bracha) $ (101.00 , 3 American Friends Of Michkane Meir Inc (p){R Ishay Mazuz} $ (1,000.00) B American Friends Of Michkane Meir Inc { }{R Mordechai Ovadya} $ (126.00) B American Friends Of Michkane Meir Inc {p}(R Yair Elkrief) $ (72.00) B American Friends Of Michkane Meir Inc (p){R Yehoshua Elharar) $ (200.00) B American Friends Of Michkane Meir Inc { }{R Yitzhak Tourgian} $ (201.00) B American Friends Of Mlchkane Meir Inc { }(Yosef Kehati) $ (101.00) 1 8 American Friends Of Michkane Meir Inc (Peer HatalmudI817) $ (500.00) B American Friends Of Michkane Meir Inc {Peer Yosef} $ (252.00) B American Friends of Michkane Meir Inc (Shaare Torah Institution) $ (201.00) B American Friends Of Michkane Meir Inc {Shaare Torah Modiin Ilit) $ (126.00) 8 American Friends Of Michkane Meir Inc (Shay tamora} $ (101.00) B American Friends Of Michkane Meir Inc (Tachlit) $ (126.00) B American Friends Of Michkane Meir Inc {Techelet Mordechal Kfar G $ (101.00) B American friends Of Michkane Meir Inc (Torat Besalel 1792) $ (250.00) B American Friends Of Michkane Meir Inc(ShaareTevounalnstAF823) $ (1,200.00) B American Friends Of Michkane Meir{KollSimchaMosheOhel$araht795} $ (101.00 . 8 American Friends Of Midrash Eliahu {Midrash Eliahu} $ (250.00) B American Friends Of Midrash Shmuel $ (201.00) B American Friends of Mifal Chesed $ (150.00) 8 American Friends Of Mishkan Meir (p) $ (52.00) B American Friends Of Mishkan Meir (Yeshivat Malan Ganim} $ (126.00) B American Friends Of Mosdot Ner David $ (300.00) B American Friends Of Mosdot Zera Yitzhak 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Enter the Return code for the return that this application is for (file a separate application for each return) 0 4-

Application Return Application Return Is For Code Is For Code Form 990 01 Form 990-BL 02 Form 1041-A 08 Form 990-EZ 01 Form 4720 09 Form 990-PF 04 Form 5227 10 Form 990-T sec 401 a or 408(a) trust) 05 Form 6069 11 Form 990-T (trust other than above) 06 Form 8870 12 STOP! Do not complete Part II if you were not already granted an automatic 3-month extension on a previously filed Form 8868. ERIC ADJMI • The books are in the care of ► 4 6 3 SEVENTH AVENUE, 4TH FLOOR - NEW YORK, NY 10 018 212-629-9600 FAX No ► • If the organization does not have an office or place of business in the United States, check this box ► • If this is for a Group Return, enter the organization's four digit Group Exemption Number (GEN) . If this is for the whole group, check this box ► 0 If it is for part of the group, check this box ► 0 and attach a list with the names and EINs of all members the extension is for 4 I request an additional 3-month extension of time until OCTOBER 15, 2012 . 5 For calendar year , or other tax year beginning DEC 1, 2010 , and ending NOV 30 , 2011 6 If the tax year entered in line 5 is for less than 12 months, check reason 0 Initial return Final return = Change in accounting period 7 State in detail why you need the extension ADDITIONAL TIME IS NEEDED TO GATHER ALL INFORMATION NECESSARY FROM THIRD PARTY TO PREPARE A COMPLETE AND ACCURATE TAX RETURN.

8a If this application is for Form 990-BL, 990-PF, 990-T, 4720, or 6069, enter the tentative tax, less any nonrefundable credits See Instructions If this application is for Form 990-PF, 990-T, 4720, or 6069, enter any refundable credits and estimated tax payments made Include any prior year overpayment allowed as a credit and any amount paid 8868. c Balance due . Subtract line 8b from line 8a Include your payment with this form, if required, by using EFTPS (Electronic Federal Tax Payment System) See Instructions Signature and Verification Under penalties of perjury, I declare that I have examined this form, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete, and that I am authorized to prepare this form.

Sianature ► Title ► CPA Date ► Form 8868 (Rev. 1.2011)

023842 01-16-12

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