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Form 990-PF Return of Private Foundation OMB No 1545-0052 Form 990-PF Return of Private Foundation or Section 4947(a)(1) Nonexempt Charitable Trust ^oo^ Department of the Treasury Treated as a' Private Foundation Internal Revenue Service Note: The organization may be able to use a copy of this return to satisfy state reporting requirements. For calendar year 2004 , or tax year beginning DEC 1, 2004 , and ending NOV 3 0, 2005 G Check all that aDDly El Initial ret urn n Final return n Amended return n Address channe n Name. chnnna Use the IRS Name of organization A Employer identification number label. Otherwise , JACK ADJMI FAMILY FOUNDATION, INC 13-3202295 print Number and street (or P 0 box number If mall is not delivered to street address) Room/sulte B Telephone number ortype . 500 SEVENTH AVENUE 16TH FLOOR 212-629-9600 See Specific City or town, state, and ZIP code If exemption Instructions . C application Is pending, check here ► EW YORK , NY 10 018 0 1. Foreign organizations , check here . ► 2. cheeckh' and a mecommpueting too 85%test, ► H Check type of org anization 0X Section 501 (c)( 3 ) exem pt p rivate foundation c ckheerreand attach pu tation [] Section 4947(a)(1) nonexempt charitable trust El Other taxable private foundation E If private foundation status was terminated I Fair market value of all assets at end of year J Accounting method OX Cash El Accrual under section 507 (b)(1)(A), check here (from Part ll, co!. (c), line 16) El Other (specify) F If the foundation is in a 60-month termination $ 64 , 735 . (Part 1, column (d) must be on cash basis.) under section here ► 507 (b )( 1 ( 8 ) , check ► El of P (I Analysis 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 chantable purposes necessarily equal the amounts In column (a) expenaR s es per books income income (cash basis only) 1 Contributions , gifts, grants , etc , received 4,723,422 . 2 Check ► El lithe foundation is not required to attach Sch B and temporary 3. 3. ^. 7t . NP 1 3 cash investmenntss 4 Dividends and interest from securities 5a Gross rents b Net rental income or (loss) Net galn or (loss) from sale of assets not on ) 6a line 10 7 Gross sales price for all b assets on I1 ne6a 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 12 Total . Add lines 1 throug h 11 0 . 13 Compensation of officers , dinectors, trustees , etc 0. 0. 14 Other employee sal 15 slo ign , ^^refits N C 16a Lega a b cc writing fees 0 18 xes. (^^ 9 U 19 preciatt^ 20 Occupancy 21 Travel, conferences , and meetings co 22 Printing and publications 0 0 23 Other expenses STMT 2 130. 0. 0. 130. cl^j 0 24 Total operating and administrative c1' Add 13 130. 0. 0. 130. C\t Q, expenses . lines through 23 0 25 Contributions , gifts, grants paid 4, 609,666. 4,609,666. 26 Total expenses and disbursements. Add lines 24 and 25 4 , 609 , 796 . 0. 0. 4 , 609 , 796. 0 27 Subtract line 26 from line 12 w a Excess of revenue over expenses and disbursements 113,629. Z Z b Net Investment Income (If negawe, enter-0-) 3 . c Adjusted net income (if negative, enter -0-) 0 . C) LHA For Privacy Act and Paperwork Reduction Act Notice , see the instructions. Form 990-PF (2004) M 423501 01-03-05 1 12120619 797696 4CKJAF 2004.09000 JACK ADJMI FAMILY FOUNDATIO 4CKJAF_1 Form 990-PE (2004 ) JACK ADJMI FAMILY FOUNDATION. INC 13-3202295 Pane2 schedules and amounts in the description Beginning of year End of year Pitt Balance Sheets A"" column should beforend-ot-yearamounts only (a) Book Value (b) Book Value (c) Fair Market Value 1 Cash - non-Interest-bearing 5 r 432. 63,848. 63 848. 2 Savings and temporary cash investments 884. 8 8 7. 887. 3 Accounts receivable ► Less allowance for doubtful accounts ► 4 Pledges receivable ► Less allowance for doubtful accounts ► 5 Grants receivable 5 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 as 9 Prepaid expenses and deferred charges 10a Investments - U.S and state government obligations b Investments - corporate stock c Investments - corporate bonds Investments- 11 land, buildings, 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 ► ) 16 Total assets to be completed by all filers 6 , 316. 1 - 64 1 735. 64 , 735 . 17 Accounts payable and accrued expenses 18 Grants payable 19 Deferred revenue 20 Loans from officers, directors, trustees , and other disqualified persons 21 Mortgages and other notes payable CASH OVERDRAFT 22 Other liabilities (describe ► 67 , 850. 12 , 640. 23 Total liabilities (add lines 17 throu gh 22 ) 67 , 850. 1 12 r 640. Organizations that follow SFAS 117, check here ► and complete lines 24 through 26 and lines 30 and 31. 24 Unrestricted co 25 Temporarily restricted m 26 Permanently restricted Organizations that follow do not SFAS 117, check here ► LL and complete lines 27 through 31. 0 27 Capital stock, trust principal, or current funds 0. 0. 28 Paid-in or capital surplus, or land, bldg , and equipment fund 0. 0. 29 Retained earnings, accumulated income, endowment, or other funds <6 1 5 3 4 . 52,095. Z 30 Total net assets or fund balances . <61, 534 . 52 , 0 9 5 . 31 Total liabilities and net assets and balances 6 , 316. 1 64 7 35 . p ii} 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 <61,534.> 2 Enter amount from Part I, line 27a 2 113,629. Other 3 increases not included in line 2 (itemize) ► 3 0. 4 Add lines 1, 2, and 3 4 52,095. 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 (b), line 30 52,095. Form 990-PF (2004) 423511 01-03-05 2 12120619 797696 4CKJAF 2004.09000 JACK ADJMI FAMILY FOUNDATIO 4CKJAF 1 Foim990-P (2004) JACK ADJMI FAMILY FOUNDATION , INC 13-3202295 Page 3 Pert IV I Capital Gains and Losses for Tax on Investment Income (a) List and describe the kind(s) of property sold (e g , real estate, (b How acquired (c) Date acquired (d) Date sold D - (mo , day, yr) (mo., day, yr.) 2-story brick warehouse, or common stock, 200 shs MLC Co D - PuDonationrchase 1a b NONE C d e Depreciation allowed (g) Cost or other basis (h) Gain or (loss) (e) Gross sales price (f) (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 (I) F M V. as of 12/31/69 as of 12/31/69 over col (j), it any col (h)) a b c d e If ain, also enter in Part I, line 7 2 Capital gain net income or ( net capital loss)) l 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 " .V I 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 organization liable for the section 4942 tax on the distributable amount of any year in the base period? Yes EXI No If Yes, the organization does not qualify under section 4940(e) Do not complete this part 1 Enter the appropriate amount in each column for each year, see instructions before making any entries Di divdedn y co Base peray years (b) Calendar year ( or taxx year beg inning m Adjusted qualifying distributions Net value of noncha)ntable-use assets (col ) divided by col. (c)) 2003 3,509,829. <93 339. .0000000 _ 2002 2 , 761 , 648. <103,321. > .0000000 _ 2001 2,813,394. 39 , 250. 71.6788280 2000 2 , 296 , 495. 18 , 584. 123.5737731 1999 1 , 908 , 240. 1 33 , 830. 56.4067396 2 Total of line 1 , column (d) 2 251.6593407 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 50 .3318681 4 Enter the net value of noncharitable -use assets for 2004 fro m Part X , line 5 4 <4 r 649 . 5 Multiply line 4 by line 3 5 <233,993.
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