Document 6423233

ORIGIN/5.
xu
Return
of Private
OMBNO
Form
- or Section
4947(a)(1) Foundation
Nonexempt Charitable
Trust
1555-0052
Tr Treated as a Private Foundation
Department ofthe easury
intemai Revenue serviee 77 Note. The foundation may be able to use a copy of this retum to satisfy state reporting requirements
For calendar year 2009, or tax year beginning , and ending
G Check all that apply. El Initial return El Initial return of a former public charity Cl Final return
lj Amended return CI Address change (II Name change
Use the IRS Name of foundatlon A Employer ldentlflcatlon number
label- RBSL BERGMAN FOUNDATION 95-4522669
. t Number and street (or P O box number if mail is not delivered to street address) Room/suite B Telephone number (see page 10 of the instructions)
offxe.
175 s BARRINGTON PLACE 1 (310) 440-0500
See Specific CIW of town- 51319- and ZIP 0055 C lf exemption application is pending, check here D E1
Otherwise,
ll1StrUcti0I1$- LOS ANGELES CA 90049-3305 D 1. Foreign organizations, check here D El
H Check type of organization: Section 501 (c)(3) exempt private foundation 2, Foreign erganrzations meeting the 05% test,
CI Section 4947(a)(1) nonexempt charitable trust III Other taxable private foundation check here and attach eomputailon v E
. E If pnvate foundation status was terminated
I Fair market value of all assets at end J Accounting method Cash lj Accrual under section 5o7(b)(1)(A), check here
Of year (ffOm P811 //, CO/. (C), lj other (SpeCify) ----------------------- N F If the foundation is in a 60-month termination
line 16) L $ 587,752 (Part /, column (d) must be on cash basis ) under section 507(b)(1)(B), check here
Analysis of Revenue and Expenses (The tote/of
amounts in columns (b), (c), and (d) may not necessan/y equal
the amounts in column (a) (see page 11 ofthe instn/ct/ons) )
-E1
-Ei
(8)
Revenue and (d) Disbursements
expenses per (b) Net investment (c) Adjusted net for charitable
books income income purposes
(cash basis only)
Contributions, gifts, grants, etc, received (attach schedule)
Check P il the foundation is not required to attach Sch B
Interest on savmgs and temporary cash investments
Q 4 Dividends and interest from securities
5 a Gross rents . . .
0
O
10,857
10,857
0
b Net rental income or (loss) 0
6 a Net gain or (loss) from sale of assets not on line 10
b Gross sales price for all assets on line 6a 159,263
7 Capital gain net income (from Part IV, line 2)
8,929
8.929
8 Net short-term capital gain . . .
9 Income modifications .
10 a Gross sales less retums and allowances
b Less Cost of goods sold
c Gross profit or (loss) (attach schedule)
11 Other income (attach schedule)
Toiai. Add iin s. , 1
13 Compensatioril of ofti ,-,ii-ei:Tors,trustees
14 Other employee s%l.arigs,and waies
15 Pension plans,x@Hiployt,9eLb@ngfit"7
16 a Legal fees (attach schedule) WF--55,3
1:2f::r"""g
7 Interest .U11
.
-- professio al fee a sc edul
O
0
0
19,786
19,786
0
0
0
0
1.000
1,000
O
0
O
O
0
.- 1 8 Taxes (attach schedule) (see page 14 of the instructions)
0
O
-- 19 Depreciation (attach schedule) and depletion
O
0
0
0
0
1,000
45,300
46,300
1,000
0
1,000
45,300
45,300
20 Occupancy .
21 Travel, conferences, and meetings
22 Printing and publications .
Other expenses (attach schedule)
.- 24 Total operating and administrative expenses.
Add lines 13 through 23 .
Contributions, gifts, grants paid
Total expenses and disbursements. Add lines 24 and 25
27 Subtract line 26 from line 12
3 Excess of revenue over expenses and disbursements
b Net investment Income (if negative, enter -O-)
c Adjusted net income (if negative, enter -O-) .
-26,514
18,786
0
For Privacy Act and Paperwork Reduction Act Notice, see page 30 of the instructions. Form 990-PF (2009)
(HTA)
Q* (X
S
-IForlm 990-PF (2009) RBSL BERGMAN FOUNDATION 95-4522669 P296 2
Attached schedules and amounts in the descnption column Be9"1fllfl9 Of Veal" End Of Veal
Balance Sheets should be for endaol-year amounts only. (See instnictions) (a) Book value (b) Book value (c) Fair Market Value
4 ..... -­
1 Cash-non-interest-bearing .
2 Savings and temporary cash investments .
3 Accounts receivable P -------------------------- - ­
Less" allowance for doubtful accounts V ---------- U
Pledges receivable P -------------------------- -­
Less. allowance for doubtful accounts P ---------- - ­
56 Receivables
Grants
receivable . . .
due from officers, directors, trustees, and other
704,651 105,847 105,847
.e,,-. "LO, ,,i-,.6,- L ­
N77* "o*7" Ao
00
7 - - - --­
disqualified persons (attach schedule) (see page 15 of the
instructions)
Other notes and loans receivable (attach schedule) P ------- - - Q
Less allowance for doubtful accounts 5 ----------------------- - -Q
0
0
0
0
0
O.
0
0
8 Inventories for sale or use .
9 Prepaid expenses and deferred charges .
14 Q
O
10 8 Investments-U S and state government obligations (attach schedule)
572,290 581,90 5
b Investments-corporate stock (attach schedule) . . .
O
c Investments-corporate bonds (attach schedule) . .
O
0
0
O
0
6
O
0
0
11 Investments-land, buildings, and equipment basis P ---------- - -Q
Less accumulated depreciation (attach schedule) P - - - - - . -- ­
12
13
0
Investments-mortgage loans . .
Investments-other (attach schedule)
Land, buildings, and equipment basis P ---------- -­
15
Less accumulated depreciation (attach schedule) P ------------- - ­ Q
E
0
6
Other assets (describe P ------------------------------ - - )
O
0
O
16 Total assets (to be completed by all filers-see the
instructions Also, see page 1, item l) .
in
an
E
IE
.E
.J
17
18
19
20
Accounts payable and accrued expenses
21
Mortgages and other notes payable (attach schedule)
22
23
Total liabilities (add lines 17 through 22) . . .
704,651
678,137 687,752
i
Grants payable . . . . .
i
Deferred revenue . . . .
i
Loans from officers, directors, trustees, and other disqualified persons
i
Other liabilities (describe P ------------------------------ - - )
Foundations that foiiow SFAS 117, check here P D
and complete lines 24 through 26 and lines 30 and 31.
24
25
26
Unrestricted . . . . .
l
i
Temporarily restricted . .
Permanently restricted .
Foundations that do not follow SFAS 117, check here P Ill
and complete lines 27 through 31.
27
28
29
30
Capital stock, trust principal, or current funds
Paid-in or capital surplus, or land, bldg , and equipment fund
Retained earnings, accumulated income, endowment, or other funds
31
Total liabilities and net assetslfund balances (see page 17
704,651
678,137
instructions) . . .
704,651
678.137
of the instructions) . .
704,651
678,137
Total net assets or fund balances (see page 17 of the
Analysis of Changes in Net Assets or Fund Balances
1
Total net assets or fund balances at beginning of year-Part ll, column (a), line 30 (must agree with
end-of-year figure reported on prior years return) .
2 Enter amount from Part l, line 27a
3
4
Other increases not included in line 2 (itemize) P ------------------- -­
Add lines 1, 2, and 3 . . . .
5 Decreases not included in line 2 (itemize) V ------------------------- - ­
6 Total net assets or fund balances at end of year (line 4 minus line 5)-Part ll, column (b), line 30 .
704 651
-26 51 4
0
678 137
O
678,137
Form 990­ PF (zoo 9)
II
- Form 990-PF (2009) RBSL BERGMAN FOUNDATION 95-4522669 P292 3
X
Part IV Capital Gains and Losses for Tax on Investment Income
(b) How acquired
(a) List and describe the kind(s) of property sold (e g . real estate, P-purchase (c) Date acquired (d) Date sold
2-story bnck warehouse, or common stock, 200 shs MLC Co) D-Donation (mo , day, yr) (mo , day, yr)
7/24/2009
9/14/2009
9/28/2009
10/20/2009
12/22/2009
1a 332.005 VANGUARD 500 INDEX FUND
b 360.268 VANGUARD 500 INDEX FUND
c 3.406 VANGUARD 500 INDEX FUND
d 347.705 VANGUARD 500 INDEX FUND P
e 482.998 VANGUARD 500 INDEX FUND P
12/24/2009
1 2/24/2009
1 2/24/2009
1 2/24/2009
1 2/24/2009
(f) Depreciation allowed (g) Cost or other basis (h) Gain or (loss)
Ie) Gross sales pnce (or allowable) plus expense of sale (e) plus (I) minus (g)
30,000
4,642
35,000
2.590
334
21
1,280
35,000
0
396
50,000
Complete only for assets show ing gain in column (h) and owned by the foundation on 12/31/69 (I) Gam (C0) (h) gam mms
34,642
37,590
355
36,280
50,396
(i) F M V as of 12/31/69
(1) Adjusted basis (k) Excess ofcui (I) GOI (K). but not less than -0-) Or
as of 12/31/69 over col (1), if any Losses (from col (h))
4,642
2,590
21
1,280
396
If gain, also enter in Part I, line 7
2 Capital gain net income or (net capital loss) I If (loss), enter -0- in Part I, line 7
3 Net short-term capital gain or (loss) as detined in sections 1222(5) and (6)
If gain, also enter in Part I, line 8, column (c) (see pages 13 and 17 of the
8,929
instructions). If (loss), enter -0- in Part I, line 8 . . . . . . . . . . . .
Qualification Under Section 4940(g) for Reduced Tax on Net Investment Income
8,929
(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
"I iw ici Id)
Was the foundation liable for the section 4942 tax on the distributable amount of any year in the base period? III Yes No
If "Yes," the foundation does not qualify under section 4940(e). Do not complete this part.
1 Enter the appropriate amount in each column for each yearg see page 18 ofthe instructions before making any entries.
Base period years Distnbution ratio
Calendar year (or tax year beginning In Adjusted qualifying distnbutions Net value of nonchantable-use assets (col Q) divided by col (ED
2008
2007
2006
2005
2004
26,272
0
0
79,819
36,503
726,932
737,707
668,175
606,034
563,797
0.036146
0.000000
0 000000
0.131707
0.065961
2 Total of line 1, column (d)
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 .
2
0.233814
3
0.046763
4 Enter the net value of noncharitable-use assets for 2009 from Part X, line 5 .
4
694,611
5 Multiply line 4 by line 3 .
5
32,482
6 Enter 1% of net investment income (1% of Part I, line 27b) .
6
188
7 Add lines 5 and 6
7
32,670
8 Enter qualifying distributions from Part XII, line 4 . . . . . . . . . .
8
45,300
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 on page 18
Form 990-PF (2009)
F9rIf1 990-PF (2009) RBSL BERGMAN FOUNDATION 95-4522669 Page 4
Part VI Excise Tax Based on Investment Income (Section 4940(a), 4940(b), 4940(e), or 4948-see page 18 of the instructions)
1 a Exempt operating foundations described in section 4940(d)(2), check here P lj and enter "N/A" on line 1
Date of ruling or determination letter" ---------------- -.(attach copy of Ietterlf necessary-see Instnictlons) A 7 g W 7 i gg W A i
b Domestic foundations that meet the section 4940(e) requirements in Part V, check
here D 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)
Tax under section 511 (domestic section 4947(a)(1) trusts and taxable foundations only Others enter -0-)
Add lines 1 and 2 . . . .
Credits/Payments" "
Subtitle A (income) tax (domestic section 4947(a)( 1) trusts and taxable foundations only Others enter -0-) .
Tax based on investment income. Subtract line 4 from line 3 If zero or less, enter -0- .
a 2009 estimated tax payments and 2008 overpayment credited to 2009 6a 545
b Exempt foreign organizations-tax withheld at source . 6b
c Tax paid with application for extension of time to file (Form 8868) 6c 0
d Backup withholding erroneously withheld . 6d
Total credits and payments Add lines 6a through 6d . - .
Enter any penalty for underpayment of estimated tax Check here E) if Form 2220 is attached
9 Tax due. lfthe total of lines 5 and 8 is more than line 7, enter amount owed . . . . .
10 Overpayment. If line 7 is more than the total of lines 5 and 8, enter the amount overpald
11 Enter the amount of line 10 to be Credited to 2010 estimated tax P 357I Refunded P 0
Part Vll-A Statements Regarding Activities
1 a During the tax year, did the foundation attempt to influence any national, state, or local legislation or did it Yes N0
participate or intervene in any political campaign? . . .
instructions for definition)? . . .
b Did it spend more than $100 during the year (either directly or indirectly) for political purposes (see page 19 of the
1a X
1b X
lf the answer is "Yes" to 1a or 1b, attach a detailed descnption of the activities and copies of any matenals
published or distnbuted by the foundation in connection with the activities
c Did the foundation file Form 1120-POL for this year? 1c X
d Enter the amount (if any) of tax on political expenditures (section 4955) imposed during the year ­
(1) On the foundation P $ (2) On foundation managers P $
on foundation managers P $ M- k k g
e Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed
2 Has the foundation engaged in any activities that have not previously been reported to the IRS? 2 X
/f "Yes," attach a detailed descnption of the activities i
3 Has the foundation made any changes, not previously reported to the IRS, in its governing instrument, articles W
of incorporation, or bylaws, or other similar instruments? If "Yes, " attach a confomied copy of the changes 3 X
4 a 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? . 4b N/A
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
0 By language in the governing instrument, or
0 By state legislation that effectively amends the governing instrument so that no mandatory directions - l g w
that conflict with the state law remain in the governing instrument? . 6 X
7 Did the foundation have at least $5,000 in assets at any time during the year? If "Yes," complete Part /I, col (c), and Part XV 7 X
8 a Enter the states to which the foundation reports or with which it is registered (see page 19 of the
instructions) P -QA - - - - - - - . . . - - - - . - - - - - - - - . - - - - - - - - - . - . - - - - - . - - - . Q . - - - - - - - - - - - - - - - - - - - - - - U - - - - - - - - - - - - - -- - I
b lf the answer is "Yes" to line 7, has the foundation furnished a copy of Form 990-PF to the Attorney J - Y
General (or designate) of each state as required by General Instruction G? lf "No," attach explanation . . . 8b X
9 ls the foundation claiming status as a private operating foundation within the meaning of section 4942())(3) i
If "Yes, " complete Part X/ V . 9 X
or 4942())(5) for calendar year 2009 or the taxable year beginning in 2009 (see instructions for Part XIV on page 27)?
their names and addresses 10 X
10 Did any persons become substantial contributors during the tax year? /f "Yes," attach a schedule listing
Femi 990-PF (zoos)
).
Fqfm 990-PF (2009) RBSL BERGMAN FOUNDATION 95-4522669 P298 5
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)? If "Yes," attach schedule (see page 20 of the instructions)
12 Did the foundation acquire a direct or indirect interest in any applicable insurance contract before
13
14
(1)-­­
(2)
August 17, 2008? . . . . .
Did the foundation comply with the public inspection requirements for its annual returns and exemption application?
Website address P ------------------------------------------------------------------------------ - ­
11 x
BIHX
The books are in care of P .DlRfE-S-SL-E.R-iQ-AS-SQ-QLAI-E-SiN-Q ------------- - - Telephone no P .(3-1-O)-Sf:-1--1-2-2-Q ---------- - ­
Located at P 10390 SANTA MONICA BLVD #360 LOS ANGELES CA ZlP+4 P 90025
lu-­Cl
15 Section 4947(a)(1) nonexempt charitable trusts filing Form 990-PF in lieu of Form 1041-Check here . .
and enter the amount of tax-exempt interest received or accrued during the year P I 15 I
Part Vll-B Statements Regarding Activities for Which Form 4720 May Be Required
File Fomi 4720 if any item is checked in the "Yes" column, unless an exception applies.
1a
Yes No
During the year did the foundation (either directly or indirectly) u- ­
Engage in the sale or exchange, or leasing of property with a disqualified person? Yes L No
a disqualified person? . . .
Borrow money from, lend money to, or otherwise extend credit to (or accept it from)
(3)
Q Yes LNO
Furnish goods, services, or facilities to (or accept them from) a disqualified person? Q Yes LNO
Pay compensation to, or pay or reimburse the expenses of, a disqualified person? Yes LNO
(4)
(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)?
Yes i 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 )
Yes
LNo
b If any answer is "Yes" to 1a(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 20 ofthe instructions)? ­
1b N/A
Organizations relying on a current notice regarding disaster assistance check here . P X
1c X
c Did the foundation engage in a prior year in any of the acts described in 1a, other than excepted acts,
that were not corrected before the first day of the tax year beginning in 2009? . .
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(i)(3) or 4942(i)(5))
a At the end of tax year 2009, did the foundation have any undistributed income (lines 6d
and 6e, Part Xlll) for tax year(s) beginning before 2009? El yes
lf "Yes," list the years 5 20 ---- U , 20 ---- - - , 20 ---- U , 20 ---- - ­
No
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? (lf applying section 4942(a)(2)
to all years listed, answer "No" and attach statement-see page 20 of the instructions ) . . .
2b X
c lf the provisions of section 4942(a)(2) are being applied to any of the years listed in 2a, list the years here
3a
P zo ----- zo ------ -.,2o ---- .-.zo ,,,, H
Did the foundation hold more than a 2% direct or indirect interest in any business
enterprise at any time during the year? EI yes No
b lf "Yes," did it have excess business holdings in 2009 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 period? (Use Schedule C, Form 4720, to detemiine
if the foundation had excess business holdings in 2009 ) . . . .
4a Did the foundation invest during the year any amount in a manner that would jeopardize its charitable purposes?
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 jeopardy before the first day of the tax year beginning in 2009?
sb N/A
4a X
4bH x
Fomi 990-PF (zoos)
*.
Fqrm 990-PF (2009) RBSL BERGMAN FOUNDATION 95-4522669 Page 6
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
(1) Carry on propaganda, or otherwise attempt to influence legislation (section 4945(e))? D Yes L No
(2) Influence the outcome of any specific public election (see section 4955), or to carry 1
on, directly or indirectly, any voter registration drive? lj yes X No
(3) Provide a grant to an individual for travel, study, or other similar purposes? . I:-I Yes X No
(4) Provide a grant to an organization other than a charitable, etc , organization described 1
in section 509(a)(1), (2), or (3), or section 4940(d)(2)? (see page 22 of the instructions) . EI Yes X No
(5) Provide for any purpose other than religious, charitable, scientific, literary, or 1
educational purposes, or for the prevention of cruelty to children or animals? lj yes X No
b If any answer is "Yes" to 5a(t)-(5), did any of the transactions fail to qualify under the exceptions described in 1 1 1 1 7 I
Regulations section 53 4945 or in a current notice regarding disaster assistance (see page 22 of the instructions)? . 1 5b N/A
Organizations relying on a current notice regarding disaster assistance check here . P 1
c If the answer is "Yes" to question 5a(4), does the foundation claim exemption from the 1
tax because it maintained expenditure responsibility for the grant? . . III Yes 1 No
lf "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 1
premiums on a personal benefit contract? . . . EI yes X No
b Did the foundation, during the year, pay premiums, directly or indirectly, on a personal benefit contract? . .
/f "Yes" to 6b, file Fonri 8870
6b X
7a At any time during the tax year, was the foundation a party to a prohibited tax shelter transaction? VI Yes X No I
b If yes, did the foundation receive any proceeds or have any net income attributable to the transaction? . . 7b ,
Part VIII Information About Officers, Directors, Trustees, Foundation Managers, Highly Paid Employees,
and Contractors
1 List all officers, directors, trustees, foundation managers and their compensation (see page 22 of the instructions).
(b) Title, and average (c) Compensation (d) Contributions to
(a) Name and address hours per week (If not paid, enter employee benefit plans
devoted to position -0-) and deterred compensation
(e) Expense account,
other allowances
-RI-QI-I-AR-D -QERQ-MA-N ---------------------- - I PRESIDENT
11995 BRENTRIDGE DR LOS ANGELES CA 9 6 O0 0 O O
11995 BRENTRIDGE DR LOS ANGELES CA 9 6.00 0 O O
.5/5RBAI?B.I3.E.BQM/SN ...................... -. SECRETARY
00 O 0 O
" I b ft
------------------------------------------- " .oo 0 o o
2 Compensation of five highest-paid employees (other than those included on line 1-see page 23 of the instructions).
If none, enter "NONE."
(b) Title and average Id) Conmbutlons Io
devoted to position p
(a) Name and address of each employee paid more than $50,000 hours per week (c) Compensation $312 Zizedeigseld
.N999 .......................................... -.
(e) Expense account,
other allowances
compensation
Total number of other employees paid over $50,000 . . Form
. P990-PF
I (zoos)
i
*­
Fqfm 990-PF (2009) RBSL BERGMAN FOUNDATION 95-4522669 Page 7
Part VIII Information About Officers, Directors, Trustees, Foundation Managers, Highly Paid Employees,
and Contractors (continued)
3 Five highest-paid independent contractors for professional services (see Ego 23 of the instructions). If none, enter "NONE."
(a) Name and address of each person paid more than $50,000 (b) Type of sen/ice (c) Compensation
.NQNE ......................................................... -.
0
0
0
0
Total number of others receiving over $50,000 for professional services .
...I
0
Part IX-A Summary of Direct Charitable Activities
List the foundation"s four largest direct chantable activities during the tax year Include relevant statistical information such as
the number of organizations and other benehciaries served, conferences convened, research papers produced, etc
Expenses
1 NONE
2 --------------------------------------------------------------------------------------- -­
3 --------------------------------------------------------------------------------------- U
4 --------------------------------------------------------------------------------------- U
Part IX-B Summary of Program-Related Investments (see page 24 of the instructions)
Describe the two largest program-related investments made by the foundation dunng the tax year on lines 1 and 2
Amount
1 N/A
2 --------------------------------------------------------------------------------------- U
All other program-related investments See page 24 of the instructions
3
.P0
0
Total. Add lines 1 through 3 .
Form 990-PF (2009)
6 6­
*.
Fqfm 990-PF (2009) RBSL BERGMAN FOUNDATION 95-4522669 P892 8
Minimum Investment Return (All domestic foundations must complete this part. Foreign foundations,
see page 24 of the instructions )
Fair market value of assets not used (or held for use) directly in carrying out charitable, etc
purposes
1
Average monthly fair market value of securities 1a 196,195
Average of monthly cash balances . . . . . 1b 508,994
1c
Total (add lines 1a, b, and c) . . . 1d 705,189
Fair market value of all other assets (see page 24 of the instructions)
Reduction claimed for blockage or other factors reported on lines 1a and
1c (attach detailed explanation) . . . .
I1eI
Acquisition indebtedness applicable to line 1 assets . . . . . . 2
Subtract line 2 from line 1d . . . 3 705,189
2
3
of the instructions) . . . . 4 10,578
4
Cash deemed held for charitable activities Enter 1*/2 % of line 3 (for greater amount, see page 25
5
Net value of noncharitable-use assets. Subtract line 4 from line 3 Enter here and on Part V, line 4 5 694,611
Minimum
investment return. Enter 5% of line 5 . 34,731
Part XI Distributable Amount (see page 25 of the instructions) (Section 4942(j)(3) and (j)(5) private opera ting
foundations and certain foreign organizations check here P U and do not complete this part.)
1
2a
b
c
@ -.-Li
Minimum investment return from Part X, line 6 . . . . 1 34,731
Tax on investment income for 2009 from Part VI, line 5 . .
Income tax for 2009 (This does not include the tax from Part VI )
Add lines 2a and 2b . . . . .
Distributable amount before adjustments Subtract line 2c from line 1
Recoveries of amounts treated as qualifying distributions
Add lines 3 and 4 . . . . . .
line 1 .
,zal 188 2c 188
Deduction from distributable amount (see page 25 of the instructions)
Distributable amount as adjusted Subtract line 6 from line 5 Enter here and on Part Xlll,
Part XII Qualifying Distributions (see page 25 of the instructions)
1
a
b
2
3
a
b
4
5
Amounts paid (including administrative expenses) to accomplish charitable, etc , purposes
Expenses, contributions, gifts, etc -total from Part I, column (d), line 26 .
Program-related investments-total from Part IX-B
Amounts paid to acquire assets used (or held for use) directly in carrying out charitable, etc ,
purposes . . . . .
Amounts set aside for speciic charitable projects that satisfy the"
Suitability test (prior IRS approval required)
Cash distribution test (attach the required schedule)
Qualifying distributions. Add lines 1a through 3b Enter here and on Part V, line 8, and Part XIII, line 4
Foundations that qualify under section 4940(e) for the reduced rate of tax on net investmen t
income Enter 1% of Part I, line 27b (see page 26 of the instructions) .
6
Adjusted qualifying distributions. Subtract line 5 from line 4 . . .
34 543
34 543
ii
7
34,543
1a 45,300
1b
o
3b 0
i1-.
Sa
45 300
. 65 188
45112
Note. The amount on line 6 will be used in Part V, column (b), in subsequent years when calculating whether the foundation
qualifies for the section 4940(e) reduction of tax in those years
Form 990-PF (2009)
*.
95-4522669 Page 9
Form 990-PF (2009) RBSL BERGMAN FOUNDATION
(8) (b)
Undistributed Income (see page 26 of the instructions)
line 7 . . . . .
1
Distributable amount for 2009 from Part Xl, Corpus Years prior to 2008
2
Undistributed income, if any, as of the end of 2009
ld)
2009
(C)
zoos
34,543
Enter amount for 2008 only . .
4,527
Total for prior years 20 , 20 , 20
3
Excess distributions carryover, if any, to 2009
From 2004
0
From 2005 .
From 2006
From 2007
From 2008
4
0
O
O
Total of lines 3a through e . .
0
Qualifying distributions for 2009 from Part
xii, line 4 P $ 45,300
4,527
Applied to 2008, but not more than line 2a
Applied to undistributed income of prior years
(Election required-see page 26 of the instructions)
Treated as distributions out of corpus (Election
0
required-see page 26 of the instructions) .
5
6
I
34,543
Applied to 2009 distributable amount .
Remaining amount distributed out of corpus
Excess distributions carryover applied to 2009 .
(If an amount appears in column (d), the
same amount must be shown in column (a) )
6,230
0
0
I
Enter the net total of each column as
indicated below:
6,230
Corpus Add lines 3f, 4c, and 4e Subtract line 5
Prior years" undistributed income Subtract
line 4b from line 2b . . .
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
Subtract line 6c from line 6b. Taxable
amount-see page 27 of the instructions .
Undistributed income for 2008 Subtract line
instructions . . .
4a from line 2a Taxable amount-see page 27 ofthe
7
O
Undistributed income for 2009 Subtract
lines 4d and 5 from line 1 This amount must
be distributed in 2010
Amounts treated as distributions out of
8
corpus to satisfy requirements imposed by
section 170(b)(1)(F) or 4942(g)(3) (see page 27 of
the instructions)
Excess distributions carryover from 2004
not applied on line 5 or line 7 (see page 27 of the
instructions)
9
Excess distributions carryover to 2010.
0
0
Subtract lines 7 and 8 from line 6a
10
6,230
Analysis of line 9
Excess from 2005
Excess from 2006 .
Excess from 2007
Excess from 2008
O
Excess from 2009 6,230
Form 990-PF (zoos)
Fqfmeso-PFi20o9) RBSL BERGMAN FOUNDATION 95-4522669 page 10
N71
Part XIV Private Operating Foundations (see page 27 of the instructions and Part Vll-A, question 9)
1 a If the foundation has received a ruling or determination letter that it is a private operating
foundation, and the ruling is effective for 2009, enter the date of the ruling . P
b Check box to indicate whether the foundation is a private operating foundation described in section (3 4942())(3) or (3 4942())(5)
2 a Enter the lesser of the ad)usted net
income from Part I or the minimum
Tax year Prior 3 years
listed
byear
85% of
line 2a. .. .. .O
O
investment return from Part X for each (3) 2009
c Qualifying distributions from Part XII,
line 4 for each year listed 0
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 . 0
3 Complete 3a, b, or c for the
alternative test relied upon
00O
(ii) zoos (C) 2oo7 (iii) zoos
(e) Total
O
O
0
000
a "Assets" alternative test-enter
(1) Value of all assets
O
0
0
(2) Value of assets qualifying
under section 4942())(3)(B)(i)
O
b "Endowment" alternative test-enter 2/3
of minimum investment return shown in
Part X, line 6 for each year listed . 0
O
c "Support" alternative test-enter
(1) Total support other than gross
investment income (interest,
dividends, rents, payments
on securities loans (section
5l2(a)(5)), or royalties)
(2) Support from general public
and 5 or more exempt
organizations as provided in
O
section 4942(1)(3)(B)(iii)
O
(3) Largest amount of support
from an exempt organization
O
(4) Gross investment income . .
O
Supplementary information (Complete this part only if the foundation had $5,000 or more in
assets at any time during the year-see page 28 of 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) )
RICHARD BERGMAN BARBARA BERGMAN
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 P 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 page 28 of the 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
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
Form 990-PF (2009)
F0.m1.990-PF (2009) RBSL BERGMAN FOUNDATION 95-4522669 Page 11
Supplementary Information (continued)
3 Grants and Contributions Paid During the Year or Approved for Future Payment
Reci
jent
hreafoundation
Iions
t hipt oFoundation
Pgran
f t or Amount
P s ow
any
status
of urposeo
, any
manager
contnbution
If recipient is an individual,
Narne and address (hofne or bus"-less) 0( substantial cgnfnbutof recipient
a Paid dunng the year
HEREDITARY DISEASE FOUNDATION
3960 BROADWAY 6TH FLOOR NEW YORK NY 10021
THE ORANGE GIRAFFE PROJECT INC
444 W 49TH STREET #1AG NEW YORK NY 10012
AFTER SCHOOL ALL STARS
9255 SUNSET BLVD #500 LOS ANGELES CA 90069
PS ARTS
11965 VENICE BOULEVARD LOS ANGELES CA 900
THE FIRST TEE
425 S LEGACY TRAIL ST AUGUSTINE FL 32092
SANTA MONICA RAPE TREATMENT CENTER
1250 16TH STREET SANTA MONICA CA 90404
AMERICAN CANCER SOCIETY
PO BOX 22718 OKLAHOMA CITY OK 73123
MAKE A WISH FOUNDATION OF GREATER LA
1875 CENTURY PARK EAST LOS ANGELES CA 900
501C3
501 C3
501C3
501C3
501 C3
501 C3
501 C3
501 C3
RESEARCH AND CURE
OF DISEASES
HELPING PEOPLE
WITH CANCER
PROVIDES AFTER
SCHOOL PGMS FOR
RESTORING ARTS
PROGRAMS IN
CHILDREN
EDUCATION
TREATMENT AND
PREVENTION
RESEARCH AND CURE
BENEFITING ILL
CHILDREN
10,000
1,500
6,000
10,000
10,000
5,000
1,000
1,800
Total . . . . . . . . P 3a 45,300
b Approved for future payment
Total . . P 3b
0
Form 990-PF (zoos)
iVT
,F0l*m 990-PF (2009) RBSL BERGMAN FOUNDATION 95-4522669 Page 12
Part XVI-A Analysis of Income-Producing Activities
Enter gross amounts unless otherwise indicated
(2) (bl (C) ld)
Unrelated business income Excluded by section 512, 513, or 514 (9)
Related or exempt
function income
Business code Amount Exclusion code Amount (See page 25 of
1 Program service revenue
the instructions )
b
f
g Fees and contracts from government agencies
2 Membership dues and assessments .
3 Interest on savings and temporary cash investments .
4 Dividends and interest from securities . .
14 10,857
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 Other investment income .
8 Gain or (loss) from sales of assets other than inventory
9 Net income or (loss) from special events
10 Gross profit or (loss) from sales of inventory .
O
11 Other revenue a
b
c
d
e
0
12 subtotal Add columns (bi, (ti), and (ei I .
10,857 O
13 Total. Add line 12, columns (b), (d), and (e) . . 13 10,857
(See worksheet in line 13 instructions on page 28 to verify calculations )
Part XVI-B Relationship of Activities to the Accomplishment of Exempt Purposes
Line No. Explain below how each activity for which income is reported in column (e) of Part XVI-A contributed importantly to
1 the accomplishment of the foundation*s exempt purposes (other than by providing funds for such purposes) (See
page 28 of the instructions )
THE PURPOSE OF THIS FOUNDATION IS TO INVEST CONTRIBUTIONS AND DISTRIBUTE INCOME TO VARIOUS
ORGANIZATIONS DESCRIBED IN IRC SECTION 501(Q)3. THIS ORGANIZATION WILL NOT BE INVOLVED
IN FORMAL FUNDRAISING PROGRAMS OR ACTIVITIES THE ONLY EXPECTED SOURCE OF FINANCIAL
SUPPORT IS CONTRIBUTIONS MADE BY THE ORGANIZATION"S FOUNDERS.
Form 990-PF (zoos)
I
*1
.F0"" 990-PF (2009) RBSL BERGMAN FOUNDATION 95-4522669 Page 13
Part XVII Information Regarding Transfers To and Transactions and Relationships With Noncharitable
Exempt Organizations
Did the organization directly or indirectly engage in any of the following with any other organization described Yes No
1
in section 501(c) of the Code (other than section 501(c)(3) organizations) or in section 527, relating to political
organizations?
a
b
(1)casn.....
.1a(1)
fx
(2)
Otherassets
.
.
.
.
.
.
.
.
.
.
.
.
.
1a(2)
Other transactions" 4 X
Transfers from the reporting foundation to a noncharitable exempt organization of I
...Eli
(1) Sales of assets to a noncharitable exempt organization . . . . . 1b
(2) Purchases of assets from a noncharitable exempt organization . . .
(3) Rental of facilities, equipment, or other assets . . . .
1b(2)
1b(3)
(4) Reimbursement arrangements . . . . . . . . . . . . . . 1b(4)
(5) Loans or loan guarantees . . . . . . . . . . . . . . . 1b(5)
(6) Performance of services or membership or fundraising solicitations . . . . . . . . . 1b(6)
c Sharing of facilities, equipment, mailing lists, other assets, or paid employees . . . . . . . . .
d lfthe 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 column (d) the value ofthe goods, other assets, or services received
(a) Line no (b) Amount involved
(c) Name of noncharitable exempt organization (d) Description ot transfers, transactions, and shanng arrangements
0
0
2a ls the foundation directly or indirectly aftiliated 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 527? . . . . . . . III Yes No
b lf "Yes," complete the following schedule.
(a) Name of organization (b) Type of organization (c) Description of relationship
Under penaltie of pequry, I declare that I ave examined this return, including accompanying schedules and statements, and to the best of my knowledge and
belief, it is tru . corr t, and mplete laration of preparer (other than taxpayer or fiduciary) i ibased on all information of which preparer has any knowledge
, ign
%re fof -9
oflicer
, orPREsioENT
trustee Date Title
Date Preparers identifying
- Check if number (see Signature on
- Preparefs
* selpemplgyed
DEI page 30 of the instructions)
5I9nature
7/28/2010
F""*"$"a"*el0fY0"fS *f DRESSLER & AssociATEs iNc Ein P 954198016
self-employed),
and ZIP codeaddress,
10390, SANTA
MONICA BLVD #360 LA CA 90025
Phone no (310) 551-1220
Form 990-PF (zoos)
- it
8863 Appiioerion for Extension of Time To Fiie an
(Rev Aon oooei Exempt Organization Return
OMB N0 1545-1709
Department ofthe Treasury , . . .
Internal Revenue Semce File a separate application for each return.
o lf you are tiling for an Automatic 3-Month Extension, complete only Part I and check this box . . . . . . . D
0 If you are filing for an Additional (Not Automatic) 3-Month Extension, complete only Part ll (on page 2 of this form).
Do not complete Part ll unless you have already been granted an automatic 3-month extension on a previously filed Form 8868.
Pai1lonIy.................. ..
m Automatic 3-Month Extension of Time. Only submit original (no copies needed).
P D
A corporation required to tile Form 990-T and requesting an automatic 6-month extension-check this box and complete
All other corporations (including 1 120-C filers), partnerships, REMICS, and trusts must use Fomv 7004 to request an extension of
time to file income tax retums
Electronic Filing (e-file). Generally, you can electronically tile Form 8868 if you want a 3-month automatic extension of time to file one
of the returns noted below (6 months for a corporation required to tile Form 990-T) However, you cannot nie Form 8868
electronically if (1) you want the additional (not automatic) 3-month extension or (2) you file Fomris 990-BL, 6069, or 8870, group
returns, or a composite or consolidated Form 990-T. Instead, you must submit the fully completed and signed page 2 (Part ll) of
Form 8868. For more details on the electronic filing of this form, visit www.irs.gov/efi/e and click on e-li/e for Charities & Nonprofits
Type or Name of Exempt Organization
1 Employer identiication number
print RBSL BERGMAN FOUNDATION 95-4522669
F", by the Number, street, and room or suite no lf a P O box, see instructions
due dam" 175 S BARRINGTON PLACE
*"S""C"0"s LOS ANGELES CA
rim?-nyoslee City, town or post office, state, and ZIP code For a foreign address, see instructions.
90049-3305
Check type of return to be tiled (tile a separate application for each return):
lj Form 990 lj Form 990-T (corporation)
ll-I Form 4720
lj Form 990-Bi. III Fonn 990-T (seo. 4o1(a) or4oa(e) mist)
lj Form 990-Ez III Form 990-T (tniei other than above)
lj Form 5227
lj Form 6069
Form 990-PF lj Form 1041-A
CI Form 8870
* The DOOKS are in the Cafe Of P DB.E.S.S.L.EB.i3-.A$$Q9.tN.C. J9.32Q.SANT8.MQNl.QA.BLMD.LAQA.QQQ?f5.-- -­
Telephone No. P (3-1-Qi 5,51--1-2-go ------------------ U FAX No v,(s1-913351-gig -1 --------------- U
* lf the organization does not have an office or place of business in the United States, check this box . . .
0 If this is for a Group Return, enter the organization"s four digit Group Exemption Number (GEN)
. . . .Qi
.Ifthis
is for the whole group, check this box . . . . . .. . PE . If it is for part ofthe group, check this box . . . .P EI and attach a
list with the names and ElNs of all members the extension will cover.
b.
1 l request an automatic 3-month (6 months for a corporation required to file Form 990-T) extension of time
until -------- - -8115120-10 ------- to tile the exempt organization return for the organization named above. The extension
is for the organizations return for
P calendar year 2-QQ9" or
P EI tax year beginning ------------------------------------ U , and ending ---------------- U
2 lf this tax year is for less than 12 months, check reason* E Initial retum lj Final return EI Change in accounting period
3 a lf this application is for Form 990-BL, 990-PF, 990-T, 4720, or 6069, enter the tentative tax,
less any nonrefundable credits See instructions. 3a $ 450
lf this application is for Form 990-PF or 990-T enter any refundable credits and estimated tax
-payments made Include any-prior year overpayment allowed as a credit 3b S 545
c Balance Due. Subtract line 3b from line 3a Include your payment with this form, or, if required, f)i3$3*jhi
3c $ 0
deposit with FTD coupon or, if required, by using EFTPS (Electronic Federal Tax Payment
System) See instructions.
Caution. If you are going to make an electronic fund withdrawal with this Form 8868, see Form 8453-EO and Form 8879-EO
for payment instructions.
For Privacy Act and Paperwork Reduction Act Notice, see Instructions.
(HTA)
Form 8868 (Rev 4-zoos)