Return of Private Foundation OMB No 1545 -0052 Fonn 990 -PFI or Section 4947( a)(1) Nonexempt Charitable Trust Treated as a Private Foundation 2012 Department of the Treasury Internal Revenue Sennce Note The foundation may be able to use a copy of this return to satisfy state reporting requirements For calendar year 2012 or tax year beginning 12/01 , 2012 , and endii 11/30. 2013 Name of foundation A Employer identification number JACK ADJMT FAMILY FOUNDATION. INC. 13-3202295 Number and street ( or P 0 box number If mail is not delivered to street address ) Room/suite B Telephone number ( see instructions) (212) 629-9600 463 SEVENTH AVENUE, 4TH FLOOR City or town, state , and ZIP code C If exemption application is , q pending , check here . NEW YORK, NY 10018 G Check all that apply: Initial return Initial return of a former public charity D 1 Foreign organ izations . check here El Final return Amended return 2 Foreign organizations meeting the 85% test, check here and attach Address change Name chang e computation . • • • • • • . H Check type of organization X Section 501 ( cJ 3 exempt private foundation E If private foundation status was terminated Section 4947 ( a )( 1 nonexem pt charitable trust Other taxable p rivate foundation under section 507(bxlXA ), check here . Ill. El I Fair market value of all assets at end J Accountin g method X Cash L_J Accrual F If the foundation is in a 60-month termination of year (from Part Il, col. (c), line 0 Other ( specify) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ under section 507(b )( 1)(B), check here 16) 10- $ 17 0 , 2 4 0 . (Part 1, column (d) must be on cash basis) (d) Disbursements Analysis of Revenue and Expenses (The (a ) Revenue and (b) Net investment (c) Adjusted net for charitable total of amounts in columns (b), (c), and (d) expenses per may not necessarily equal the amounts in income income purposes books column (a) (see instructions ( cash basis onl y) 1 Contributions Rts, grants , etc , received ( attach schedule ) 3,750, 608 . if the foundation is not required to 2 Check ► attach Sch B . 3 Interest on savings and temporary cash investments C cl^j 4 Dividends and interest from securities 5a Gross rents . b Net rental income or (loss) o 6a Net gain or ( loss) from sale of assets not on line 10 O 0 b Gross sales puce for all o assets on line 6a w 7 Capital gain net income (from Part IV , line 2) LIA 8 Net short -term capital gain . 9 Income modifications . 10 a Gross sales less returns and allowances b Less Cost of goods sold , c Gross profit or (loss ) ( attach schedule) , , , , 11 Other income ( attach schedule ) , , , , • • • 12 Total. Add lines 1 throu g h 11 3, 750, 608. 13 Compensation of officers, directors, trustees, etc 0 14 Other employee salps3 /Iti QvapesC D . E 15 Pension pla s, Iove^e-beeneCflt_sv X 16a Legal fees ( Oeh schedule ) • • . , W b Accounting Qi (att3E sEhQue)2a14 > c Other profe slonal fees ( attach schedule). 17 Interest . • .-. ^ p 18 Taxes (attach LS1I UT 19 Depreciation (attach schedule ) and depletion. 20 Occupancy . 21 Travel , conferences , and meetings . , 16 22 Printing and publications . , , . • 23 Other expenses ( attach schedule)A.TCH . L 2 , 497. 2 , 497 24 Total operating and administrative expenses. 2,497. 2,497. 1 Add lines 13 through 23 . • . • • • . • • . 25 Contributions , gifts, grants paid . 3 , 769, 863. 3,769,863 26 Total expenses and disbursements Add lines 24 and 25 3,772,360. 2,497. 3, 7 69, 863 27 Subtract line 26 from line 12 a Excess of revenue over expenses and disbursements -21,752 . b Net investment income ( if negative, enter -0-) 0 c Adjusted net income ( if negative , enter -0- ) . JSA For Paperwork Reduction Act Notice , see instructions . Form UUU-Pt- (2012) 2E1410 1 000 5847HS 3846 J17878 /1/^' V' V Form 990-PF (2012 ) JACK ADJMI FAMILY FOUNDATION, INC. 13-3202295 Page 2 Attached schedules and amounts in the Beginning of year End of year Balance Sheets description column should be for endof-year amounts only (See instructions ) ( a) Book Value ( b) Book Value (c) Fair Market Value 1 ' Cash - non-interest-bearing . 191, 992. 170,240. 17 0 , 2 4 0 2 Savings and temporary cash investments . Accounts receivable 3 ► ----------------------- 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 ( attach schedule ) ( see instructions) , , , , 7 Other notes and loans receivable ( attach schedule ) ► - - - _ _ Less- allowance for doubtful accounts ► ------- -- ---- 2 8 Inventories for sale or use 9 Prepaid expenses and deferred charges . 10 a Investments - U S and state government obligations (attach schedule), b Investments - corporate stock ( attach schedule ) , , , , . c Investments - corporate bonds ( attach schedule ), , , , , , , , 11 Investments - land, buildings, ► and equipment basis __________________ Less accumulated depreciation ► (attach schedule ) ----- - - --- - ---- ---- 12 Investments - mortgage loans . 13 Investments - other ( attach schedule ) . 14 Land , buildings, and ► equipment basis __________________ Less accumulated depreciation ► (attach schedule ) ------------ -------- 15 Other assets ( describe ► ________________ ____ ) 16 Total assets ( to be completed by all filers - see the instructions Also, see page 1, item I) . 191, 992. 170, 240. 170,240 17 Accounts payable and accrued expenses , , , , , , , , , , , 18 Grants payable ,,,,,,,,, ,,,,,,,,,,,,,, 0 19 Deferred revenue . 20 Loans from officers , directors , trustees, and other disqualified persons m_ 21 Mortgages and other notes payable ( attach schedule) . J 22 Other liabilities ( describe ► ___________________ ) 23 Total liabilities ( add lines 17 through 22) . 0 Foundations that follow SFAS 117 , check here ► U) and complete lines 24 through 26 and lines 30 and 31. d co 24 Unrestricted . R 25 Temporarily restricted . 26 Permanently restricted . n Foundations that do not follow SFAS 117, check here and complete lines 27 through 31. ► N 27 Capital stock , trust principal , or current funds , , , , , , , , , 28 Paid - in or capital surplus, or land, bldg , and equipment fund . Q 29 Retained earnings, accumulated income , endowment , or other funds , 191, 992. 170,240. m 30 Total net assets or fund balances (see instructions ), , , , , , 191,992. 170,240. Z 31 Total liabilities and net assets/fund balances (see instructions ) . ............. .... ...... 191, 9 92 . 170,240. Analysis of Chan ges 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 pnor year's return) , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 1 191, 992 2 Enter amount from Part I , line 27a ...................................... 2 -21,752 3 Other increases not included in line 2 ( Itemize) 3 ►------------------------------------- 4 Add lines 1 , 2, and 3 4 170,240 5 Decreases not included in line 2 ( itemize )Ill. _ 5 6 Total net assets or fund balances at end ofearline 4 minus line 5 - Part II, column ( b) , line 30 . 6 170,240 Form 990-PF (2012) JSA 2E1420 1 000 5847HS 3846 J17878 JACK ADJMI FAMILY FOUNDATION, INC. 13-3202295 Form 990-PF(2012) Page 3 Capital Gains and Losses for Tax on Investment Income (c) Date (a) List and describe the kind(s) of property sold (e g real estate, acquired acquired (d) Date sold , day, yr ) 2-story brick warehouse, or common stock, 200 shs MLC Co) D - Don on (mo , day, yr) (mo 1a b c d e (g) Cost or other basis (e) Gross sales price (f) Depreciation allowed (h) Gain or (loss) (or allowable) plus expense of sale (e) plus (f) minus (g) a b c d e Com p lete onl y for assets showin g g ain in column ( h ) and owned by the foundation on 12/31/69 (I) Gains (Col (h) gain minus Adjusted basis (k) Excess of col (i) col (k), but not less than -0-) or (I) F M V as of 12/31/69 (l) as of 12/31/69 over col 0), if any Losses (from col (h)) 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) (see instructions). If (loss), enter -0- in Part I, line 8 J 3 IMM Qualification Under Section 4940 ( e) for Reduced Tax on Net Investment Income (For optional use by domestic private foundations subject to the section 4940(a) tax on net investment income.) If section 4940(d)(2) applies, leave this part blank. Was the foundation liable for the section 4942 tax on the distributable amount of any year in the base period? q Yes No If "Yes," the foundation does not qualify under section 4940(e). Do not complete this part. i enter the appropriate amount in eacn column Tor eacn ear ; see the instructions Derore maKln any entries. Base period years Distribution ratio Calendar year ( or tax year beginning in) Adjusted qualifying distributions Net value of noncharrtable use assets (col (b ) divided by col (c)) 2011 2,569,371. 126,484. 20.313803 2010 2,115,709. 272,430. 7.766065 2009 1,888,162. 172,826. 10.925220 2008 1,894,454. 97,633. 19.403829 2007 2,716,315. 181,015. 15.006022 2 Total of line 1, column (d) 2 73. 414939 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 .