990-PF Return of Private Foundation 2004990s.foundationcenter.org/990pf_pdf_archive/566/566046767/... · City or town, state, and ZIP code C it exemption application is (] pending

" Form 990-PF Return of Private Foundation Department oftheTreasury Of Section 4947(a)(1) Nonexempt Charitable Trust Treated as a Private Foundation Internal Revenue Service Note : The organization ma be able to use a co of this return to sags/ state reporting re uvemeni For calendar ear 2004, or tax ear beginning , 2004, and ending

OMB No 1545-0052

2004 G Check all that app ly: Initial return Final return Amended return Address change Name change

Name of organization A Employer identification number

Use the IRS S HKMY FOUNDATION label C/O T.E . FIEMBY JR . TRUSTEE 56-6046767

Otherwise, Number and street (or P O box number if mad is not delivered to street address) Room/suite e Telephone number (see page 10 of print the instructions)

or type. See specific 2633 RICHARDSON DRIVE 704 365-5675

Instructions . City or town, state, and ZIP code C it exemption application is (]� pending check here

D 7 Foreign organizations check here

0

111,

CHARLOT E NC 28211 2 Foreign organizations meeting the

H Check type of organization S Section 501(c 3 exempt private foundation asi test check here and attach . , computation

section 494 7a 1 nonexem t charitable trust Other taxable private foundation E Ii private foundation status was terminated

I Fair market value of all assets at end J Accounting method U Cash U Accrual under section 507(b)(7)(A) check here . 11~ EJ

of year (from Part ll, COI. (C), line 1:1 Other (specify) ----____-__________ F If the foundation is m a60-month termination 16 " $ 5 , 612 , 469 . (Part l, column (d) must be on cash basis ) under section so7(b)(i)(s) check here , t

Analysis of Revenue and Expenses (d) Disbursements (The total of amounts m columns (b)- (c) (a) Revenue and (b) Net investment (c) Adjusted net .- and I I I I . for charitable (d) may not necessarily equal the amounts in expenses per income income _ , , , -.~ . . books purposes

Contributions rfts, grants etc rccerved (attxh schedule)

2 Check ~ if the foundation is not required to attach Sch B

3 Interest on savings and temporary cash investments

4 Dividends and interest from securities 210 , 550 . 2

5a Gross rents � �� , . . . � ,

b Net rental income or (loss)

63 Net gain or (loss) from sale of assets riot on line 10 -771 , 532 . b Gross sales price for all

assets on line sa 932 , 848 ,

7 Capital gain net income (from Part IV, line 2) ,

8 Net short-term capital gam . . . . . . , , ,

9 Income modifications " 0 a Gross sales less returns

and allowances

b Less Cost of goods sold

c Gross profit or (loss) (attach schedule)

1 Other income (attach schedule) . . . . . . . -11 . 496 .

o r ..*~~i AAA i.- I rti . ..-ti 11 _977 d72 7

210 .550 .

- YI

dl ZIX

Z m v

N

-11 .496

13 Compensation of officers, directors, trustees, etc

14 Other employee salaries and wages , , , , .

15 Pension plans, employee benefits , , , , , ,

16a Legal fees (attach schedule)

~b~ Accountin fees (attach scheduls)STMT . 3

c ~ ~~~I~~~fees (a ch schedule) , , , ~.v~...~ v rv

1 .V . . . . . . . . .

~T~ycp$ (3~tec~ SC,~1gCQlf~) 1 ~ of the instructions) r ~ ~~

ge

De~ecl~tan ~tlbl.+h ~e ule and de pletion

27 Subtract line 26 from line 12

3 Excess ofrevenue over expenses anddisbursements -804 , 042 .

b Net investment income (if negative, enter -0-)

c Adjusted net income if ne alive enter -0-). .

For Privacy Act and Paperwork Reduction Act Notice, see the instructions JSA 4E14102000

TM4946 599D 04/08/2005 11 :49 :34 V04-5 .1 0962 3

c 23 Other expenses (attach schedule) $'1'=, 4 ,

24 Total operating and administrative expenses .

C. Add lines 13 through 23 , , . , , , , , , ,

25 Contributions, gifts, grants paid , , , , , , ,

Form 990-PF (2ooa)

End

Book Value I (c) Fair Market Value

1 Cash - non-interest-bearing , , , , , , , , , , , , , , , , , ,

2 Savings and temporary cash investments , , , , , , , , , , ,

3 Accounts receivable t _____---___---_-41993_

Less allowance for doubtful accounts

4 Pledges receivable

Less allowance for doubtful accounts

5 Grants receivable

6 Recervables due from officers, directors, trustees, and other

disqualified persons (attach schedule) (see page 15 of the instructions)

7 Other notes and loans receivable (attach schedule) 10 .

Less allowance for doubtful accounts 1

8 Inventories for sale or use , , , , , , , , , , , , , , , , , ,

9 Prepaid expenses and deferred charges , , , , , $';'= ,5, ,

10 8 Investments-US and state government obligations (attach schedule)*

b Investments -corporate stock (attach schedule) , $'J.'D¢'~ ,7, , 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) , , , , , , $TW 14 Land, buildings, and ,

equipment basis ___________________ Less accumulated depreciation p . (attach schedule) _______________..___

15 Other assets (describe 101 _____--------STMT 10 )

16 Total assets (to be completed by all filers - see page 16 of

the instructions Also, see pals 1, item I)

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 (attach schedule) , , , ,

22 Other liabilities (describe 1 -___-_____-________ )

1 .057 .036 .

JSA 4E 1420 2 000

TM4946 599D 04/08/2005 11 :49 :34 V04-5 .1 0962 4

Attached schedules and amounts in the Beginnin g of e. Baiance Sheets description column should be for

end-of-year amounts only (See instructions 1 (e) Book Value

co via aoHa au i uirou n [t Organizations that follow SFAS 117, check here " U and complete lines 24 through 28 and lines 30 and 31 .

N X 24 Unrestricted , . . . . . . . . , . . . . . . . . . . . , , , .

X 25 Temporarily restricted . . , . . . . , . . . . . . , , , , , .

p~°p 26 Permanently restricted " " " " " " " " "

Organizations that do not follow SFAS 117, check here and complete lines 27 through 31 . lip.

0 27 Capital stock, trust principal, or current funds . . . . . . . . .

m 28 Paid-in or capital surplus, or land, bldg , and equipment fund

H 29 Retained earnings, accumulated income, endowment or other funds . . 6 , 853, 214. 5 , 204, 376 .

a 30 Total net assets or fund balances (see page 17 of the

z instructions) � � � � � . � � , . � � � � 6,853,214. 5 , 204,376 .

31 Total liabilities and net assets/fund balances (see page 17 of

the instructions 6, 853, 214. 1 5 , 204,376 . 1

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 vwth

end-of-year figure reported on prior year's return) , , , , , , , , , , , , , , , , , , , , , , , , 1 6 , 853 , 214 . 2 Enter amount from Part I, line 27a , , , , . , , , , , , , 2 -804 , 042 . 3 Other increases not included in line 2 (itemize) t________________________---__-3

4 Add lines 1, 2, and 3 , , , , , , , , , , , 4 6 , 049 , 172 . 5 Decreases not included in line 2 (itemize) "_____ SEE STATEMENT 11____-______________ 5 844 796 .

e Total net assets or fund balances at end of ear line 4 minus line 5 - Part II column b line 30 . . 8 5 , 204 , 376 .

**STMT 6 Form 990-PF (zooa)

" F

(a) List and describe the kind(s) of property sold (e g , real estate, 2-story brick warehouse, or common stock, 200 sins MLC Co

1a SEE PART IV SCHEDULE

c

d

e

(e) Gross sales price

e b c

(f) Depreciation allowed (g) Cost or other basis (or allowable) ` plus expense of sale

Comp lete only for assets shown gain in column h and owned b the foundation on 12/31/69

(i) F M V as of 12/31/69 (1) Adjusted basis (k) Excess of col (i) as of 12131169 over col Q), if any

(I) Gams (Col (h) gain minus col (k), but not less than -0-) or

Losses (from col (h))

8 Enter qualifying distributions from Part XII, line 4 , , , , , , , , , , , , , , , , , , , , , , , , , 1 8 1 228 , 500 . 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 t% tax rate Seethe Part VI instructions on page 18

Js^ 4E 1430 2 000 Form 990-PF (2004) TM4946 599D 04/08/2005 11 :49:34 V04-5 .1 0962 5

3

to~ now I (c) Date I acquired acquired

n_n~~ar ~ , ., ~ ~d) Date s~ j

Purchase Imo , day, yr ) ~ mo , da

~, .,

(h) Gain or (loss) (e) plus (f) minus (g)

If gain, also enter in Part I, line 7 2 Capital gain net income or (net capital loss) ~ ~ ~ ~

f If (loss), enter -0- m Part I, line 7 } 2 -771 , 532 . 3 Net short-term capital gain or (loss) as defined in sections 1222(5) and (6) :

If gam, also enter in Part I, line 8, column (c) (see pages 13 and 17 of the instructions) If loss , enter -0- in Part I, line 8 ~ 3 -3 , 667 .

FMMM 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 distnbutable amount of any year in the base period? . . . , a Yes a% 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 page 18 of the instructions before making any entries

(a) (b) 10 (d) Base period years Calendar year Distribution ratio

(or tax year beginning

in) Adjusted qualifying distributions Net value of noncharitable-use assets col b divided b col c

2003 133 250 . 5 , 894 , 101 . 0 .02260734928 2002 289 000 . 6 , 143 , 892o 0 .04703858727 2001 509 609 . 5 , 752 , 373 . 0 .08859109102 2000 509 409 . 6 374 221 . 0 .07991705967 1999 522 .939 . 6,641 .256 . 0 .07874097912

2 Total of line 1, column (d) . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . 2 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

4 Enter the net value of nonchantable-use assets for 2004 from Part X, line 5 . . . . . . . . . . ~ 4

5 Multiply line 4 by line 3 5

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

7 Add lines 5 and 6

56-6046767 4 m

18 of the instructions excise Tax Based on Investment Income Section 4940 (a~, 4940 (b), 4940 (e), or 4948 - see

18 Exempt operating foundations described in section 4940(d)(2), check here 10. and enter N/A' on line 1

Date of ruling letter - _ - _ _ _ _ _ _ (attach copy of ruling letter if necessary -see instructions) b Domestic organizations that meet the section 4940(x) requirements in Part V, check .

here " Fland enter 1 % of Part I, line 27b . , . . . , . . . . . . . . . . . . . . , . . . . . . ,

C All other domestic organizations enter 2°l0 of line 27b Exempt foreign organizations enter 4% of Part I, line 12, cot (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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . q 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 2004 estimated tax payments and 2003 overpayment credited to 2004 6a 4 , 264 .

b Exempt foreign organizations - tax withheld at source , , , , , , , 6b NONE

c Tax paid with application for extension of lime to file (Form 8868). . . . . . . 6c NONE

d Backup withholding erroneously withheld , , , , , , , , , , , , , , , 6d

7 Total credits and payments Add lines 6a through 6d ~ ~

" "

" ~ . . " " " " " " ~ ~

$ Enter any penalty for underpayment of estimated tax Check here 0 if Form 2220 is attached ,

g Tax due . If the 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 overpaid , , , , , , , , , , 11 Enter the amount of line 10 to be Credited to 2005 estimated tax jo. 344 . Refunded 1111,

2

4

4,264 .

344 .

Activities Statements Re

TM4946 599D 04/08/2005 11 :49 :34 V04-5 .1 0962 6

1 a During the tax year, did the organization attempt to influence any national, state, or local legislation or did Yes No

it participate or intervene m any political campaigns , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 1 a $

b Did it spend more than $100 during the year (either directly or indirectly) for political purposes (see page

19 of the instructions for definition)? , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 1 b %

I/ the answer is "Yes" to 1 a or 16, attach a detailed description of the activities and copes o/ any materials

published or distributed by the organization m connection with the activities c Did the organization file Form 1120-POL for this years . , , , . . . . . . , , , . . . , . , . . . . , , . . . . . . , . . . 1 c B

d Enter the amount (if any) of tax on political expenditures (section 4955) imposed during the year

(7) On the organization jl~ $ (2) On organization managers 1 $

e Enter the reimbursement (if any) paid by the organization during the year for political expenditure tax imposed

on organization managers III. $

y Has the organization engaged m any activities that have not previously been reported to the IRS? . . , , , . . . . . , . . . 2 %

If "Yes," attach a detailed description of the activities

3 Has the organization made any changes, not previously reported to the IRS, m its governing instrument, articles

of incorporation, or bylaws, or other similar instruments? 1( "Yes,"attach a conformed copy of the changes , , , , , , , , , , 3 S

4a Did the organization have unrelated business gross income of $1,000 or more during the years , , , , , , , , , , , , , , . 4a %

b If "Yes," has it filed a tax return on Form 990-T for this year? , , , . . . , , , , , , . , , , , , . . , , , , . . . . , , , . 4b A

5 Was there a liquidation, termination, dissolution, or substantial contraction during the years , , , , , , , , , , , , , , , , , 5 X

I( "Yes,"attach the statement required by General Instruction T

6 Are the requirements of section 508(x) (relating to sections 4941 through 4945) satisfied ether

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 m the governing instrument? , , , , , , , , , , , , , , , , , , , , , , , , , , 6 %

7 Did the organization have at least $5,000 in assets at any time during the years H "Yes,"canplete Part fl, cd (c), and Part XV 7 S

8a Enter the states to which the foundation reports or with which it is registered (see page 19 of the

instructions) jj~ NORTH CAROLINA

b If the answer is "Yes" to line 7, has the organization furnished a copy of Form 990-PF to the Attorney

General (or designate) of each state as required by General Instruction G? If "No,"attach explanation . . . , , , , . . , , , , 8b X

9 Is the organization claiming status as a private operating foundation within the meaning of section 4942x3)

or 4942(j)(5) for calendar year 2004 or the taxable year beginning in 2004 (see instructions for Part XIV on

page 25)? H "Yes," complete Part XIV , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 9 %

10 Did any persons become substantial contributors during the tax years if "Yes," attach a schedule listing their names and addresses 10 X

11 Did the organization comply with the public inspection requirements for its annual returns and exemption application? , , , , , 11 S

Website address "_____N1A

12 The books are in care of 1 _ T_ E__ HEMSYI_ JR_ ________________Telephone no No-704-365-5675 _ _-______ Located at po._2633_RICHARDSON_DRIVEs_CHARLOTTE,_ NC ___ ZIP+4 1 28211___

13 Section 4947(a)(1) nonexempt charitable trusts filing Form 990-PF m lieu of Form 1041 -Check here . . . "

. . . . N/8 . .

and enter the amount of tax-exempt interest received or accrued during the year . . "" ̀̀ 13 "I JSA Form 990-PF (2004) 4 E 1440 2 000

5 Form 990-PF

fired Statements Reqardinq Activities for Which Form 4720 Mav Be

JSA 4E1450 2 000

7

File Form 4720 if any item is checked in the "Yes" column, unless an exception applies

1a During the year did the organization (either directly or indirectly) $ No (1) Engage in the sale or exchange, or leasing of property with a disqualified persons , , , , , , , , 0 Yes D

(2) Borrow money from, lend money to, or otherwise extend credit to (or accept it from)

a disqualified persons . . . . . . . . . . . . . . . . . . , . . . . , . . , . . . . . . . . . . Yes $ No

(3) Furnish goods, services, or facilities to (or accept them from) a disqualified persons , . . , , . , Yes $ No

(4) Pay compensation to, or pay or reimburse the expenses of, a disqualified persons , , . . , , , , 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) . . . . . . , . . . . . . . , . . . . . . , . . , a yes 1Z No

(6) Agree to pay money or property to a government official? (Exception . Check "No"

if the organization agreed to make a grant to or to employ the official for a period

after termination of government service, if terminating within 90 days ) . . . . . . . . . . . . . a yes a No

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 of the instructions)

Organizations relying on a current notice regarding disaster assistance check here , , , . , , , , , , . , . 1

c Did the organization 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 2004 , , , , , , . , , , , . . , . . , , . , , , , ,

2 Taxes on failure to distribute income (section 4942) (does not apply for years the organization was a private

operating foundation defined m section 4942Qx3) or 4942(jx5))

a At the end of tax year 2004, did the organization have any undistributed income (lines 6d

and 6e, Part XIII) for tax year(s) beginning before 20047 . . . . . . . . . . . . . . . . . . . . . . Yes EZNo If "Yes," list the years ON - _ _ _ _ _ _ _ _ _ _ ,

b Are there any years listed m 2a for which the organization 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 page 20 of the instructions ) , . . . , . . . , . . . , . . . . . . ,

c If the provisions of section 4942(a)(2) are being applied to any of the years listed m 2a, list the years here

3a Did the organization hold more than a 2% direct or indirect interest in any business

enterprise at any time during the years , , , , , , , , , , . , , , , , , , , , , , , , , , , , , , , Yes ~$ No

b If "Yes," did it have excess business holdings in 2004 as a result of (1) any purchase by the organization

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 determine

ii the organization had excess business holdings in 2004 ) , , . . . . . , . . . . . , . . . . . . . . . . , . . . , . . . . .

4a Did the organization invest during the year any amount m a manner that would jeopardize its charitable purposes . . . . , . .

b Did the organization make any investment m a prior year (but after December 31, 1969) that could jeopardize its charitable

purpose that had not been removed from jeopardy before the fist day of the tax year beginning in 2004? . , . . . , . . . , .

5a During the year did the organization pay or incur any amount to (1) Carry on propaganda, or otherwise attempt to influence legislation (section 4945(e))? , , , , , , 0 Yes a$ No

(2) Influence the outcome of any specific public election (see section 4955), or to carry

on, directly or indirectly, any voter registration drive? . . . . . . . . , . . . . . e yes BS 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)? , , , , , , , , , , , , , , , , , , , , , Yes rX] 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 fad to qualify under the exceptions described in

Regulations section 53 4945 or in a current notice regarding disaster assistance (see page 20 of the instructions)? "

Organizations relying on a current notice regarding disaster assistance check here , . . , , , , , , , , , , ,

~

c If the answer is "Yes" to question 5a(4), does the organization claim exemption from the

tax because it maintained expenditure responsibility for the grant? , . . . , , . , , , , , , . NBA E]Yes E ] No

If "Yes," attach the statement required by Regulations section 53 4945-5(d)

6a Did the organization, during the year, receive any funds, directly or indirectly, to pay premiums on a personal benefit contracts , , , , , , , , , , , , , , , , , , , , , , , , , , , . , a yes $ No

b Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract? , _ , . . _ , , . , , If you answered "Yes" to Bb, also file Form 8870

Form 990-PF (2004)

Tbt4946 599D 04/08/2005 11 :49 :34 V04-5 .1 0962

Tbt4946 599D 04/08/2005 11 :49 :34 V04-5 .1 0962 8

56-6046767 Form 990-PF(2Q04) ' Page

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 20 of the instructions ).

(b) Title, and average (c) Compensation (d) Ca

ntnbutwns to (e) Expense account, (a) Name and address hours per week (If not paid, enter employee benein plans other allowances devoted to position -0-1 and dete..ed comoensation

--------------------------

--------------------------

------------------------------

2 Compensation of five highest-paid employees (other than those included on line 1 - see page 21 of the instructions) . If none, enter "NONE:"

b Title and average (d) Contributions to

(a) Name and address of each employee paid more than $50,000 ( hours per week (c) Compensation employee benefit (e) Expense account,

devoted to position Plcomo nsahon deferred other allowances

NONE

-------------------------------------

-------------------------------------

-------------------------------------

------------------------------------- 1 Total number of other employees paid over $50,000 3 Five highest-paid independent contractors for professional services - (see page 21 of the instructions) . If none, enter

"NONE ." (a) Name and address of each person paid more than $50,000 (b) Type of service (c) Compe

NONE

--------------------------- -------------------------- ----------------------------

----------------------------------------------------I

Total number of others receiving over $50,000 for professional services . . " NO1ZE

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 Expenses

of organizations and other beneficiaries served, conferences convened, research papers produced, efc

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2

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3

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4

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Form 990-PF (2004) JSA 4E 1460 2 000

Form 990-PF (2004), Page 7

nEM Summary of Program-Related Investments (see page 1z of the Describe the two largest program-related investments made by the foundation during the tax Amount on lines 1 and 2

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Total . Add lines 1 through 3 ~ Minimum Investment Return (All domestic foundations must complete this part . Foreign foundations,

see page 22 of the 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 . . _ , , . _ , . . , , _ , _ , , _ . _ _ . . _ . , b Average of monthly cash balances . c Fair market value of all other assets (see page 22 of the instructions) . . . . . . d Total (add lines 1a, b, and c) . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . , e Reduction claimed for blockage or other factors reported on lines 1a and

1c (attach detailed explanation) . . . . . . . . . . . . . . I 1e 2 Acquisition indebtedness applicable to line 1 assets 3 Subtract line 2 from line 1d 4 Cash deemed held for charitable activities Enter 1 "111'2 °/a of line 3 (for greater amount, see page 23

of the instructions) . . . . . . . ~ ~ 5 Net value of noncharitable-use assets.Subtract line 4 from line 3 Enter here and on Part V, line 4

e Minimum investment return . Enter 5% of line 5 . . , . , , , . . . . . . . . . . . . . . _ . , _ . .

1 a 1b

. . . 1c

. . . 1d

36,773 .

5 . L-

Distributable Amount (see page 23 of the instructions) (Section asa20)(3) and (j)(5) private operating foundations and certain foreign organiza tions check here 10. M and do not comple te this part)

1 Minimum investment return from Part X, line 6 . . . , . . . . , . . . . . . . . . . . , . . , . . . . . 2a Tax on investment income for 2004 from Part VI, line 5 . ~ 2a ~ 3 , 920 . b Income tax for 2004 (This does not include the taxfrom ~Part VI .) . . . 2b 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 e Deduction from distnbutable amount (see page 23 of the instructions) . . ,

~ . . ,

7 Distributable amount as adjusted . Subtract line 6 from line 5 . Enter here and on Part XIII,

Qualifying Distributions (see page 23 of the instructions)

- _NJp'-----------------------------------------------------------------------

2

All other program-related investments See page 22 of the instructions

3 NONZ

2 3

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1 Amounts paid (including administrative expenses) to accomplish charitable, etc , purposes a Expenses, contributions, gifts, etc . - total from Part I, column (d), line 26 . . . . . . . . . . . . . . . . . 1 a 228 , 500 . b Program-related investments - total from Part IX-13 1 b NONE

2 Amounts paid to acquire assets used (or held for use) directly in carrying out charitable, etc , purposes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 NONE

3 Amounts set aside for specific charitable projects that satisfy the' a Suitability test (prior IRS approval required) . . , . . . . . . . . . . . . . . . . . . . . . . . , . . 3a NONE b Cash distribution test (attach the required schedule) , . , . . , . . , . . . . , . . . . . . . . . . . . 3b NONE

4 Qualifying distributions. Add lines 1a through 3b Enter here and on Part V, line 8, and Part X111, line 4 . . . 4 228 , 500 . 5 Organizations that qualify under section 4940(e) for the reduced rate of tax on net investment

income Enter 1 % of Part I, line 27b (see page 24 of the instructions) . . . . . . . _ . . . . . . . . . . 5 N/A 8 Adjusted qualifying distributions . Subtract line 5 from line 4 8 2 28 , 500 .

Note : The amount on line e 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 (2004) JSA 4E 1470 2 000

TM4946 599D 04/08/2005 11 :49 :34 V04-5 .1 0962 9

Form 990-PF (2604) 56-6046767 Page 8

Undistributed Income (see page 24 of the instructions)

Corpus Years prior to 2003 2003 2004 1 Distnbutable amount for 2004 from Part XI, line 7

2 Undistributed income, if any, as of the end of 2003

a Enter amount for 2003 only , , , , , , ,

b Total for prior years 2002 ,

3 Excess distributions carr over, if any, to 2004 a From 1999 , , , 197 , 180 b From 2000 195, 748 c From 2001 227,572 d From 2002 NON e From 2003 NON f Total of lines 3a through e , , , , , , , , , , ,

4 Qualifying distributions for 2004 from Part XI I, line 4 " $ 228 , 500 .

a Applied to 2003, but not more than line 2a , , ,

b Applied to undistributed income of prior years (Election required - see page 24 of the instructions)

c Treated as distributions out of corpus (Election required - see page 24 of the instructions) , , ,

d Applied to 2004 distnbutable amount, , , , , , e Remaining amount distributed out of corpus , ,

5 Excess distributions carryover applied to 2004 (ff an amount appears m column (d), the same amount must be shown m column (a)

s Enter the net total of each column as indicated below:

a Corpus Add lines 3f, 4c, and 4e Subtract line 5

b Prior years' undistributed income Subtract line 4b from line 2b

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 , , , , , , , ,

d Subtract line 6c from line 6b Taxable amount - see page 25 of the instructions , , Undistributed income for 2003 Subtract line 4a from line 2a Taxable amount - see page 25 of the instructions

0 .

f Undistributed income for 2004 Subtract lines 4d and 5 from line 1 This amount must be distributed m 2005

7 Amounts treated as distributions out of " " . " corpus to satisfy requirements imposed by section 170(b)(1)(E) or 4942(8)(3) (see page 25 of the instructions) , , , , , , ,

8 Excess distributions carryover from 1999 not applied on line 5 or line 7 (see page 25 of the instructions) . . . . . , , , , , . , , , ,

9 Excess distributions carryover to 2005. Subtract lines 7 and 8 from line 8a . . . . . . .

10 Analysis of line 9 a Excess from 2000 . , . 195 , 748 b Excess from 2001 , . 227 , 572 c Excess from 2002 . . . NON

d Excess from 2003 . . . NON

JSA 4E 1480 2 000

TbI4946 599D 04/08/2005 11 :49 :34 V04-5 .1 0962 10

Form 990-PF (2ooa)

JSA 4E1480 2 000 Form 990-PF (2004)

TM4946 599D 04/08/2005 11 :49 :34 V04-5 .1 0962 11

Form,990-PF (2004) 56-6046767 Pie 9 f3r, M, -Private Operating Foundations see pag e 25 of the instructions and Part VII -A, question 9 NOT APPLICABLJ 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 2004, enter the date of the ruling

b Check box to indicate whether the organization is a private operating foundation described m section 4942(j)(3) or 4942(j)(5)

2 a E rifer the lesser of the Tax year Prior 3 years

adjusted net income from (a) 2004 (b) 2003 (c) 2002 (d) 2001 (e) Total Part I or the minimum 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 ,

8 Qualifying distributions made directly for active conduct of exempt activities Subtract line 2d from line 2c ,

3 Complete 3a b or c (or the

alternative test relied upon a 'Assets alternative test -enter

1) Value o! all assets (2) Value of assets qualifying

u rider section

4842OH3)(B)(i) . Endowment aRematrvetesl- enter 2/3 of minimum investment return shown m 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(e)(5)), or royalties) .

(2) Support from general public and 5 or more exempt organ¢atrons as provided in section 4842U)(3)(B)(m)

(3) Largest amount of support from an exempt organization

FOEM Supplementary Information (Complete this part only if the organization 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) )

NONE

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 10' a if the organization only makes contributions to preselected charitable organizations and does not accept unsolicited requests for funds

If the organization makes gifts, grants, etc (see page 26 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

T.E . HMMY, JR . 2633 RICIiARDSON DRIVE CHARLOTTE, NC 28211 b The form in which applications should be submitted and information and materials they should include

LETTER REQUEST

c Any submission deadlines

NONE

d Any restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other factors NONE

56-6046767 Form 990-PF (2004) Page 10

Mra M. Supplementary Information (continued)

JSA 4E 1 491 2 000

12 TM4946 599D 04/08/2005 11 :49:34 V04-5.1 0962

Form 990-PF (2ooa)

Form 990-PF (2004) JSA 4E 1492 2 000

TM4946 599D 04/08/2005 11 :49 :34 V04-5 .1 0962 13

Form "990-PF (2004) 56-6046767 Page 1 1

Analysis of Income-Producin Activities

Enter gross amounts unless otherwise indicated Unrelated business income Excluded b section 512, 513, or 514 Related or exempt

Business (b) (C) (d) function income

Exclusion (See page 26 of 1 Program service revenue code Amount code Amount the instructions a

b

c

d

e

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 , , , , 210 , 550 . 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 -771 , 532 .

9 Net income or (loss) from special events , , ,

10 Gross profit or (loss) from sales of inventory . , 11 Other revenue a

b BEVERLY CREST -11 , 496 . c d

e

12 Subtotal Add columns (b), (d), and (e) , , , , -572,478 . 13 Total. Add line 12, columns (b), (d), and (e) , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , . , 13 -572 ,478 . (See worksheet in line 13 instructions on page 26 to verify calculations )

Relationship of Activities to the Accomplishment of Exempt Purposes Explain below how each activity for which income is reported in column (e) of Part XVI-A contributed importantly to Line No. the accomplishment of the organization's exempt purposes (other than by providing funds for such purposes) . (See page 27 of the instructions .)

Did the organization directly or indirectly engage in any of the following with any other organization described m section 501(c) of the Code (other than section 501(c)(3) organizations) or in section 527, relating to political organizations?

a Transfers from the reporting organization to a nonchantable exempt organization of

(1)Cash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (2) Other assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

b Other transactions

(1) Sales of assets to a nonchantable exempt organization , , , , , , , , , , , , , , , , , , , , . , . .

(2) Purchases of assets from a noncharitable exempt organization , , , , , , , , , , , , , , , , , , , , , . ,

(3) Rental of facilities, equipment, or other assets , , , , , , , , , , , , , , , , , , , , , , , , , , . ,

(4) Reimbursement arrangements , , , , , , , , , , , , , , , , , , , , , , , , . , . , . . . . . . . .

(5) Loans or loan guarantees , , , , , , , , , , , , , , , , , , , , , , . . . . . . . . . . . . . . . .

(6) Performance of services or membership or fundraising solicitations , , , , , , , , , , , , , , , , , , , , c Sharing of facilities, equipment, mailing lists, other assets, or paid employees , , , , , , , , , , , , , , . 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 organization If the organization received less than fair market value m any transaction or sharing arrangement, show in column (d) the value of the goods, other assets, or services received

2 a Is the organization 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 527 , , , , , . , , , , , , ,A[/j~, . , a Yes [::] No

b If "Yes ," complete the following schedule (a) Name of organization (b) Type of organization (c) Description of relationship

Under penalties of penury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belt is true, correct, and complete Declaration of preparer (other than taxpayer or fiduciary) is based on all information of~ preparer has any knowledge

V Signature of officer or trustee

C

N

a 2' Preparer's ' / p signature

m H Firm's name (dCxgyWi self-employed), address, and ZIP code

' VANCE FLOIIHOIISE 6 2115 RE7FORD ROAD,

JSA 4E 1483 2 000

TM4946 599D 04/08/2005 11 :49 :34 V04-5 .1

Form .990-PF 2004 56-6046767 Pace 12 Information Regarding Transfers To and Transactions and Relationships With Noncharitable Exempt Organizations

FORM 990-PF - PART IV CAPITAL GAINS AND LOSSES FOR TAX ON INVESTMENT INCOME

P Kind of Property Description Date Date sold

acquired Gross sale Deprecation Cost or FMV Add basis Excess of Gain pace less allowed/ other as of as of FMV over or

ex enses o s a le hnqm 12/31/M 69 ad basis loss

TOTAL SHORT-TLRM CAPITAL GAIN DIVIDENDS 923 .

TOTAL LONG-TERM CAPITAL GAIN DIVIDENDS 450 .

DOMINION RES INC VA NEW 04/02/2004 09/17/2004 PROPERTY TYPE : SECURITIES

32,489 . 32,301 . 188 .

MARSH AND MCLENNAN COMPANIES, INC . 10/04/2004 10/18/2004 PROPERTY TYPE : SECURITIES

5,810 . 10,582 . -4,772 .

POLARIS INDS, INC . 10/04/2004 10/15/2004 PROPERTY TYPE : SECURITIES

904 . 910 . -6 .

BNP RESIDENTIAL PPTY3, INC . 10/27/1998 09/17/2004 PROPERTY TYPE : SECURITIES

66,692 . 44,677 . 22,015 .

JANUS TWENTY FUND 03/29/1999 09/17/2004 PROPERTY TYPE : SECURITIES

30,481 . 50,000 . -19,519 .


1,558 . 3,150 . -1,592 .


72 . 146 . -74 .


929 . 1,424 . -495 .


702 . 609 . 93 .

SUMMIT PROPERTIES, INC . 10/27/1998 10/05/2004 PROPERTY TYPE : SECURITIES

91,824 . 56,271 . 35,553 .

JSA 4E1730 1 000

TM4946 599D 04/08/2005 11 :49 :34 V04-5 .1 0962 15

FORM 990-PF - PART IV CAPITAL GAINS AND LOSSES FOR TAX ON INVESTMENT INCOME

P Kind of Property Description Date Date sold

acquired Gross sale Deprecation Cost or FMV Add basis Excess of Gain price less allowed/ other as of as of FMV over or

expenses of sale ad basis loss

WORLDCOM, INC . 03/29/1999 06/10/2004 PROPERTY TYPE : SECURITIES

44,351 . -44,351 .

WORLDCObi, INC . 03/29/1999 06/10/2004 PROPERTY TYPE : SECURITIES

1,795 . -1,795 .

FEDERAL SOS LOAN BANK BONDS 10/16/2003 10/29/2004 PROPERTY TYPE : OTHER

300,000 . 300,000 .

FEDERAL HOB LOAN BANK BONDS 02/06/2001 05/06/2004 PROPERTY TYPE : OTHER

200,000 . 203,865 . -3,865 .

US TREASURY NOTES 08/30/1997 11/15/2004 PROPERTY TYPE : OTHER

200,000 . 198,842 . 1,158 .

NORTH FOLK BANCORP CASH IN LIEU PROPERTY TYPE : OTHER

14 . 14 .

BEVERLY CREST DISPOSAL

755,457 . -755,457 .

TOTAL GAIN (LOSS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -771,532 .

JSA 4E 1730 1 000

TM4946 599D 04/08/2005 11 :49 :34 V04-5 .1 0962 1 6

56-6046767

FORM 990PF, PART I - DIVIDENDS AND INTEREST FROM SECURITIES

DIVIDEND INCOME-CAP ACCOUNT 49,553 . 49,553 . 49,553 . INTEREST INCOME- CAP ACCOUNT 160,997 . 160,997 . 160,997 .

-------------- -------------- -------------- TOTAL 210,550 . 210,550 . 210,550 .

TM4946 599D 04/08/2005 11 :49 :34 V04-5 .1 0962 17 STATEMENT 1

ALEX HEMBY FOUNDATION

REVENUE AND NET ADJUSTED

EXPENSES INVESTMENT NET DESCRIPTION PER BOOKS INCOME INCOME ----------- --------- ------ ------

NET INVESTMENT

INCOME

-11,496 . --------------

-11,496 .

BEVERLY CREST INCOME

TOTALS

TM4946 599D 04/08/2005 11 :49 :34 V04-5 .1 0962 18 STATEMENT 2


FORM 990PF, PART I - OTHER INCOME

DESCRIPTION

REVENUE AND

EXPENSES PER BOOKS

56-6046767

-11,496 . --------------

-11,496 .

ADJUSTED NET INCOME

-11,496 . --------------

-11,496 .

56-6046767

REVENUE AND NET

EXPENSES INVESTMENT PER BOOKS INCOME --------- ------

ADJUSTED NET CHARITABLE INCOME PURPOSES ------ --------

188 . 188 . 188 . NONE 2,775 . 2,775 . 2,775 . NONE

-------------- -------------- -------------- --------------2,963 . 2,963 . 2,963 . NONE TOTALS

TM4946 599D 04/08/2005 11 :49 :34 V04-5 .1 0962 19 STATEMENT 3


FORM 990PF, PART I - ACCOUNTING FEES

DESCRIPTION

BOOKKEEPING SERVICES ACCOUNTING SERVICES

REVENUE AND NET ADJUSTED

EXPENSES INVESTMENT NET CHARITABLE DESCRIPTION PER BOOKS INCOME INCOME PURPOSES ----------- --------- ------ ------ --------

MISCELLANEOUS 101 . 101 . 101 . NONE -------------- -------------- -------------- --------------

TOTALS 101 . 101 . 101 . NONE

TM4946 599D 04/08/2005 11 :49 :34 V04-5 .1 0962 STATEMENT 4 20

ALEX HEMBY FOUNDATION 56-6046767

FORM 990PF, PART I - OTHER EXPENSES

56-6046767

FORM 990PF, PART II - PREPAID EXPENSES AND DEFERRED CHARGES

PREPAID EXPENSES

TM4946 599D 04/08/2005 11 :49 :34 V04-5 .1 0962 21 STATEMENT 5


DESCRIPTION

TOTALS

ENDING ENDING BOOK VALUE E'MV ---------- ---

348 . 348 . --------------- ---------------

348 . 348 .

TM4946 599D 04/08/2005 11 :49 :34 V04-5 .1 0962 22 STATEMENT 6


FORM 990PF, PART II - U .S . AND STATE OBLIGATIONS

ENDING ENDING DESCRIPTION BOOK VALUE F'MV ----------- ---------- ---

INVESTMENTS- U .S . OBLIGATIONS 1,870,574 . 1,851,412 . --------------- ---------------

TOTALS 1,870,574 . 1,851,412 .

TM4946 599D 04/08/2005 11 :49 :34 V04-5 .1 0962 23 STATEMENT 7


FORM 990PF, PART II - CORPORATE STOCK -------- -------

ENDING ENDING DESCRIPTION BOOK VALUE E'MV ----------- ---------- ---

INVESTMENTS-COPORATE STOCK 846,918 . 1,217,216 . --------------- ---------------

TOTALS 846,918 . 1,217,216 .

TM4946 599D 04/08/2005 11 :49 :34 V04-5 .1 0962 24 STATEMENT 8


FORM 990PF, PART II - CORPORATE BONDS

ENDING ENDING DESCRIPTION BOOK VALUE FMV ----------- ---------- ---

INVESTMENT-CORPORATE BONDS 1,057,036 . 1,113,993 . --------------- ---------------

TOTALS 1,057,036 . 1,113,993 .

TM4946 599D 04/08/2005 11 :49 :34 V04-5 .1 0962 25 STATEMENT 9


FORM 990PF, PART II - OTHER INVESTMENTS

DESCRIPTION

MONEY MARKET

TOTALS

56-6046767

ENDING ENDING BOOK VALUE FMV ---------- ---

1,001,255 . 1,001,255 . --------------- ---------------

1,001,255 . 1,001,255 .

TM4946 599D 04/08/2005 11 :49 :34 V04-5 .1 0962 26 STATEMENT 10


FORM 990PF, PART II - OTHER ASSETS

ENDING ENDING DESCRIPTION BOOK VALUE FMV ----------- ---------- ---

LAND 386,252, 386,252 . --------------- ---------------

TOTALS 386,252 . 386,252 .


FORM 990PF, PART III - OTHER DECREASES IN NET WORTH OR FUND BALANCES

EXCISE TAXES PRIOR PERIOD ADJUSTMENT

STATEMENT 11

TM4946 599D 04/08/2005 11 :49 :34 V04-5 .1 0962 27

DESCRIPTION AMOUNT

8,180 . 836,616 .

-------------- TOTAL 844,796 .


FORM 990PF, PART VIII - LIST OF OFFICERS, DIRECTORS, AND TRUSTEES

BEVERLY H . SHEAFF

ALEXA H . AMICK

GRAND TOTALS

TM4946 599D 04/08/2005 11 :49 :34 V04-5 .1 0962 28 STATEMENT 12

NAME AND ADDRESS ----------------

T .E . HEMBY, JR .

BEVERLY LEAHY

SANDY D . BURNETT

TITLE AND TIME DEVOTED TO POSITION -------------------

TRUSTEE

TRUSTEE

TRUSTEE

TRUSTEE

TRUSTEE

SCHEDULE D OMB No 1545-0092

(Form 1041) Capital Gains and Losses Department orineTreasury " Attach to Form 1041, Form 5227, or Form 990-T . See the separate ~00 Internal Revenue Service instructions for Form 1041 (also for Form 5227 or Form 990-T, if applicable) . Name of estate or trust Employer identification number

ALEX HENBY FOUNDATION

Short-Term Capital Gains and Losses - Assets Held One Year or Less (a) Description of property (b) Date (Example, 100 shares 7% acquired (c) Dale sold (d) Sales price

referred of "Z" Co mo, da y, r (mo day, yr )

TERM CAPITAL GAIN DIVIDENDS STMT 3

I Gain or (Loss) (f) (s) Cost or other basis for the entire year (see page 33) (col (d) less col (e)'

8

(3) Total

-3,667 .

-767 .865 .

13 Net short-term gain or (loss) . . . . . . . . . . . . . . . . . . . . . . 13 14 Net long-term gain or (loss) :

a Total for year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14a

b Unrecaptured section 1250 gain (see line 18 of the worksheet on page 34) . . . . . . . . . . . . . . . . . . . . . . 14b

c 28% rate gain or (loss) . . . . . . . . . . . . . . . . . . . . . . . . . 14c

JSA 4F12104000

TM4946 599D 04/08/2005 11 :49 :34 V04-5 .1 0962 29

1

2 Short-term capital gain or (loss) from Forms 4684, 6252, 6781, and 8824 , , , , , , , , , , , , , , , , , , , 2 3 Net short-term gam or (loss) from partnerships, S corporations, and other estates or trusts , , , , , , , , , , 3 4 Short-term capital loss carryover Enter the amount, if any, from line 9 of the 2003 Capital Loss

Carryover Worksheet �� , . �� 4 5 Net short-term gain or (loss) . Combine lines 1 through 4 in column (f) Enter here and on line 13,

column 3 below " 5

Long-Term Capital Gains and Losses - Assets Held More Than One Year

(a) Description of property (b) Date (Example, 100 shares 7% acquired (c) Date sold (e) Cost or other basis

preferred of "Z" Co 1 (mo , dav. yr ) (mo, day, yr ) (d) Sales pace (sae page 33)

7 Long-term capital gain or (loss) from Forms 2439, 4684, 8252, 8781, and 8824 . . . . . . . . . . . . . . . 7 8 Net bong-term gain or (loss) from partnerships, S corporations, and other estates or trusts 8 9 Capital gain distributions � , . �� _ �� , 9

10 Gam from Form 4797,Part l �� 1l 11 Long-term capital loss carryover . Enter the amount, if any, from line 14 of the 2003 Capital Loss

Carryover Worksheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Net long-term gain or (loss) . Combine lines 6 through 11 m column (f) Enter here and on line 14a,

column (3) below t Summary of Parts I and II (1) Beneficiaries' (2) Estate's Caution: Read the instructions before completing this part I (see page 34) I or trust's

M Gain or (Loss) for the entire year 'col (d) less col (e)

15 Total net gain or (loss) . Combine lines 13 and 14a . . . . . . . 0- 1 15 1 1 1 -771,532 .

Note : If line 15, column (3), is a net gain, enter the gam on Form 1041, line 4 . If lines 14a and 15, column (2), are net gains, go to Part V, and do not complete Part IV. If line 15, column (3), is a net lass, complete Part IV and the Capita! Loss Carryover Worksheet; as necessary. For Paperwork Reduction Act Notice, see the Instructions for Form 1041 . Schedule D (Form 1041) 2004

Schedule D (Form.1041) 2004 Page

Capital Loss Limitation

18 Enter here and enter as a (loss) on Form 1041, line 4, the smaller of a The loss on line 15, column (3) or b $3,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1e 3 , 000 . :

If the loss on line 15, column (3), is more than $3,000, or if Form 1041, page 1, line 22, is a lass, complete the Capital Loss Carryover Worksheet on page 36 of the instructions to determine your capital loss carryover

'/ Tax Computation Using Maximum Capital Gains Rates (Complete this part only if both lines 14a and 15 in column (2) are gains, or an amount is entered in Part I or Part II and there is an entry on Form 1041, line 2b(2), and Form 1041, line 22 is more than zero )

Note : If line 14b, column (2) or line 14c, column (2) is more than zero, complete the worksheet on page 37 of the instructions and skip Part V Otherwise, go to line 17.

3 3 Add lines 27, 31, and 3 2 � � � � � � � � � � � � � � � � � � � � � � 3 3 NONE

34 Figure the tax on the amount on line 17 . Use the 2004 Tax Rate Schedule on page 22 of the

instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

35 Tax on all taxable income . Enter the smaller of line 33 or line 34 here and on line 1a of

Schedule G Form 1041 35

Schedule D (Form 1041) 2004

JSA

4F 1220 2 000

TbI4946 599D 04/08/2005 11 :49:34 V04-5.1 0962 30

17 Enter taxable income from Form 1041, line 22 18 Enter the smaller of line 14a or 15 in column (2) . . . . . . . ~ . . . . . . .

but not less than zero , , , , , , , , , , , , , , , 18 19 Enter the estate's or trusts qualified dividends

from Form 1041, line 2b(2) . , . . . . . . , . . . 19

20 Add lines 18 and 19 . . . . . . . . . . . . . . . . 21 If the estate or trust is filing Form 4952, enter the

amount from line 4g ; otherwise, enter -0- . .

22 Subtract line 21 from line 20 If zero or less, enter -0- . . . . . . . . . . . . . 22

23 Subtract line 22 from line 17 If zero or less, enter -0- . . . . . . . . . . . . . 23

24 Enter the smaller of the amount on line 17 or $1,950 , , , , , , , , , , , , , 25 Is the amount on !me 23 equal to or more than the amount on line 24?

S Yes . Skip lines 25 through 27 ; go to line 28 and check the "No" box 8 No. Enter the amount from line 23 , , , , , , , , , , , , , , , , , , , ,

28 Subtract line 25 from line 24 , . . � . � , . � . . � , . � � � . ,

27 Multiply line 26 by 5% (.05) , . . , , , , , . . , , , , , , . , , , , . , , , , , , . , , , , , . , 27 28 Are the amounts on lines 22 and 26 the same e yes. Skip lines 28 through 31 ; go to line 32

No. Enter the smaller of line 17 or line 22 . . . . . . . . . . . . . . .

, 28

29 Enter the amount from line 28 (If line 26 is blank, enter -0-) , . , , , , , , . , 20

30 Subtract line 29 from line 28 � � � � � � � � � � � � � 30

31 Multiply line 30 by 15% (15) , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 31 32 Figure the tax on the amount on line 23 Use the 2004 Tax Rate Schedule on page 22 of the

instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 NONE

TM4946 599D 04/08/2005 11 :49 :34 V04-5 .1 0962 31 STATEMENT

ALEX HEMBY FOUNDATION 56-6046767 Schedule D Detail of Short-term Capital Gains and Losses

Date Date Gross Sales Cost or Other Short-term Description Acq uired Sold Price Basis Gain/Loss

CAPITAL GAINS LOSSES HELD FOR INVESTMENT PURPOSES

DOMINION RES INC VA NEW 04 /02 /2004 09/17 /2004 32 , 489 . 32 , 301 . 188 . MARSH AND MCLENNAN COMPANIES INC . 10/04 /2004 10 /18 /2004 5 , 810 . 10 , 582 . -4 , 772 . POLARIS INDS INC . 10/04 /2004 10 /15 /2004 904 . 910 . -6 .

TOTAL CAPITAL GAINS LOSSES HELD FOR INVE STMENT PURPOSES 39 , 203 . 43 , 793 . -4 ,590 .

Totals 39 203 . 43 793 . -4 , 590 .

JSA

4F0971 2 000

4F0870 2 000

TM4946 599D 04/08/2005 11 :49 :34 V04-5 .1 0962 32 STATEMENT 2

ALEX HEMBY FOUNDATION 56-6046767 Schedule D Detail of Long-term Capital Gains and Losses

Date Date Gross Sales Cost or Other Long-term Description Acquired Sold Price Basis Gain/Loss

CAPITAL GAINS LOSSES HELD FOR INVESTMENT PURPOSES

BNP RESIDENTIAL PPTYS INC . 10 /27 /1998 09 /17 /2004 66 , 692 . 44 677 . 22 , 015 . JANUS TWENTY FUND 03 /29 /1999 09 /17 /2004 30 , 481 . 50 ,000 . -19 , 519 . JANUS TWENTY FUND 12 /14 /1999 09 /17 /2004 1 , 558 . 3 , 150 . -1 , 592 . JANUS TWENTY FUND 12 /14 /1999 09 /17 /2004 72 . 146 . -74 . JANUS TWENTY FUND 12 /22 /2000 09 /17 /2004 929 . 1 , 424 . -495 . JANUS TWENTY FUND 12 /22 /2000 09 /17 /2004 702 . 609 . 93 . SUMMIT PROPERTIES INC . 10 /27 /1998 10 /05 /2004 91 , 824 . 56 , 271 . 35 , 553 . WORLDCOM INC . 03/29 /1999 06 /10 /2004 44 , 351 . -44 , 351 . WORLDCOM INC . 03/29 /1999 06 /10 /2004 1 , 795 . -1 , 795 . FEDERAL HOME LOAN BANK BONDS 10 /16 /2003 10 /29 Z2004 300 000 . 300 000 . FEDERAL HOME LOAN BANK BONDS 02 /06 /2001 05 /06 /2004 200 000 . 203 865 . -3 , 865 . US TREASURY NOTES 08 /30 /1997 11 /15 /2004 200 000 . 198 842 . 1 , 158 . NORTH FOLK BANCORP CASH IN LIEU 14 . 14 . BEVERLY CREST DISPOSAL 755 457 . -755 , 457 .

TOTAL CAPITAL GAINS LOSSES HELD FOR INVESTMENT PURPOSES 892 272 . 1 , 660 ,587 . -768 , 315 .

Totals 892 272 . 1 , 660 ,587 . 1 -768 , 315 .

JSA

TM4946 599D 04/08/2005 11 :49 :34 V04-5 .1 0962 33


FEDERAL CAPITAL GAIN DIVIDENDS

SHORT-TERM CAPITAL GAIN DIVIDENDS ---------------------------------

BEDFORD PPTY INVS INC 910 . WEINGARTEN RLTY INVS SBI 13 .

------------ TOTAL SHORT-TERM CAPITAL GAIN DIVIDENDS 923 .

LONG-TERM CAPITAL GAIN DIVIDENDS --------------------------------

15$ RATE CAPITAL GAIN DIVIDENDS

SUMMIT PROPERTIES 450 . ------------

TOTAL 15$ RATE CAPITAL GAIN DIVIDENDS 450 . ------------

TOTAL LONG-TERM CAPITAL GAIN DIVIDENDS 450 .

STATEMENT 3

" Alex Hemby Foundation Alex Hembry Foundation Workpapers 12/31/04 Contributions

1 of 1 Contributions

Date Description Amount

per prior year late entry - planned parenthood 500

1115/2004 Make-A-Wish 250 1/15/2004 The Family Center 15,000 4/212004 Pres . Hospital Golf 10,000 8/3/2004 the Rams Club 5,000 12/1/2004 Art and Science Council 1,000 12/1/2004 YMCA 50,000 12/1/2004 Levine Chddrens Hospital 50,000 12/1/2004 UNCC 49ers Athletics 1,000 12/1/2004 Union PSCE 10,000 12/1/2004 Jacobs Ladder 500 12/1/2004 United Way 250 12/1/2004 Queens University 15,000 12/1/2004 Darlington School 2,000 12/1/2004 Independent College Fund 1,000 12/1/2004 Children's Miracle Network 1,000 12/1/2004 Crossnore School 1,000 12/1/2004 Alexander Children's Center 2,500 12/1/2004 Empty Stocking Fund 1,000 1211/2004 Foundation for the Carolinas 1,000 12/1/2004 Linvdle Foundation 1,500 1211/2004 Hospitality House 500 1211/2004 the Fletcher School 2,500 12/1/2004 Mitey Riders 500 12/1/2004 MPPC Endowment Fund 50,000 12/1/2004 Close to a Cure 250 12/1/2004 Elon Homes for children 5,000 12/2/2004 Healthcare Realty (171) 12/13/2004 Good Friends 250 12/31/2004 uncategonzed 171

228,500

None of the above contributions were made to an individual .

All of the above contributions are to public charities as defined under Sec 509(a)(1) .

All of the above contributions are charitable m nature .

4/6/2005 5 :22 PM

[Or Comnraie Bond First UNOO Senior Ni 7 700% 05 21178000 100 000 100 016 10001633 100 567 10056700 Gngroup Inc 5 5000"0 06 81l7/2001 100 000 100 465 100,465 22 103 440 10344000 1P Morgan Chafe 5 625% 06 8/17/2001 100 000 100 585 100,585 19 103 654 103,654 00 Coratates Capital Corp 6 7506/6 06 21612001 100 000 102 435 102.43500 105 902 )0590200 Chase Manhanan 6 375% 08 219/1998 100 000 99 823 99,823 00 107 683 107,683 00 Fast Union Sub Nt 6 400% 08 8/6/1998 200,000 99 875 199,750 00 108 038 216,076 00 Wells Fargo 5 875% 08 8/172001 100,000 100 715 100,714 88 107 803 107,803 00 First Union Bank 5 800 08 6/12!?002 100000 102 577 102,577 22 106 559 10655900 General Electric 5 975% 12 5/92002 150,000 100 446 150,668 75 108 206 162,309 00

1,057,035 59 1,113,993 00

386,252 00 386,252 00

386,252 00 386,252 00

2,255,485 08 65839949

1,057,035 59 3,970,920 16

add stock purchases m 2004 ;N s ocA ~ur.l asm ,tua~l tr,^i " ~ 4 ~- -1 . _,v= IS- 1-;.m isp A1-1= ' I 1 ~,a' ")4 subtract cost o(stocksold (948,923 31 )

total return of capital (4,755 43) 3,774,882 51 3,774,527 67

difference 35484 nod reconcile diffQence, pass as immaterial to total assess stock assess from current year spreadsheet

Alex Hcmbv Foundation Anachmrnt id Form 990PF' 12/il/Oa

Part 11, Line 10

Bass Market Value Security Date Shares Pa Share Total Basis Pa Share Total original bass - return on capital= actual cost bags

1Da .ov mrnc Cep unnec Fed }lm Ln Bnk 5 83% 06 613/1999 400000 97 725 390 901 .9 103 540 914 16000 Fed] Farm Cr Ban}. 5 690% 08 2, 1/2001 100 000 100 555 100554 92 106 048 106 048 00 Freddie Mac Noes 4 250% 10 11/1712003 150000 100 000 150 000 00 99 199 148 798 50 Fed Nail Mpg Assn 5 000% 11 11117/2003 200000 100 725 201 44920 100 047 200 094 00 Fed Farm Cr Bnk 5 100io 12 11/17,2003 200000 100 709 201 41720 100 056 200 11200 Fed Rot Ln Bnk 4 750% 13 2/192004 100 000 100 006 101 431 00 98 125 98 125 00 basis plus accrued interest paid wpA2-4 Fed Nat] Mfg Assn 4 020% 08 12/17/2004 100 000 100 250 101 442 17 100 182 100 18200 bass plus accrued mtaest paid wpA2-5 US Treasury Note 3 375 % 08 121 172004 100 000 100 250 100 263 54 99 687 9968700 basis plus accrued interest paid wpA2-6 Goldman Sachs 6/62003 49 158 10 130 50765803 9 810 484 205 34 508,455 75 .797 72=507,658 03 wpA2-3 Goldman Saths various dividend ran Z 304 9 945 15 .451 27 9810 2259734

1 870,573 62 1,851 411 84

10A nmorarc S1ntk AOac Inc 10,1212004 225 40 650 9 146 18 39 840 896400 Abbott Laboratories 101122004 250 42 170 10,542 50 46 650 11 66250 Allstate Corp 12113/2004 124 50 363 624499 51 720 6,413 28 Amsouth Bantorporauou 101122004 420 25 000 10.500 00 25 900 1087800 Bank of America 10/12/2004 240 44 550 1069200 46 990 1I 27760 Bank of America 82011998 . 000 19 820 39.640 78 46 990 9399000 Bedford Ppry Invs Inc 10/122004 240 31 010 7,44240 28 410 681840 Bemis Co Inc 10/1212004 395 26550 1048725 29 090 11,490 55 Berkshire Hathaway Inc 6i18/1998 20 2,640 113 52 802 25 2936000 58 72000 Chubb Corp 3252004 500 68 794 34,396 95 76 900 3845000 Coca-Cola Company 6124/1998 1,000 29 141 29,14060 41 640 41,64000 Conagra Foods Inc 10/1212004 405 26 100 1057050 29 450 11 .927 25 Duke Energy Corp 2/1 1/2003 3,000 1B 208 5462500 25 330 7599000 Fannie Mae Assn 101122004 185 65 150 12 052 75 71 210 13 173 85 Fomme Brands IOC 10/12/2004 120 75 270 9,03240 77 180 9,261 60 General Electric Co 10/122004 310 34 040 1055240 36 500 11 31500 Gillette Company 3/29/1999 500 63 667 31 .833 50 44 780 2239000 Nancy Davidson Inc 10/1212004 100 60 760 607600 60 750 607500 Harrahs Entmt Inc 10/12/2004 140 53 040 7,42560 66 890 9,36460 Hdthcare Realty Tr Inc 10/12/2004 265 40 000 10.560 31 40 700 10 785 50 10 600 00-39 69=10 560 31 wpA2-3 Hershey Foods Corp 10/122004 190 47 640 9 051 60 55 540 1055260 Jefferson Plot Co 8/20/1998 1687 17 571 29641 55 51 960 87,656 52 Jefferson Pilot Co 10/122004 235 50 840 11 94740 51 960 12,210 60 Johnson Controls Inc 10122004 155 57 350 8,88925 63 440 983320 Johnson and Johnson 10/12/2004 710 52 025 36 .937 65 63 420 4502820 ICimco Realty Corp 10/132004 265 51 375 13,614 45 57 990 15367 35 McCormick and Co Inc 10/13/2004 260 34 920 9,07920 38 600 10,036 00 tVLaowft Corp 10/13/2009 320 28 130 9 001 60 26 720 8,55040 Wachovia Corp 6/18/1999 7,000 26 144 183,00762 52 600 36820000 North Fork Bancorp Inc 10/13/2004 352 29 896 1052330 28 850 10,155 20 Pfizer Inc 10/132009 885 34 108 30,18534 26 890 23 79765 Poles ands Inc 10/132004 169 56 892 9,61482 68 020 11 495 38 Prazav Inc 10/122004 105 42 745 4 488 18 44 150 4 635 75 Roger and Gamble Co 10/13/2004 165 54 750 9,03375 55 080 908820 Progress Energy Inc 3852004 500 47 494 2374720 45 240 2262000 Sysco Corporation 10/1812004 291 30 703 8,93459 38 170 11 10747 UST Inc 8/102001 1 000 30 972 30,972 20 48 110 48,11000 US Baucorp 1011212004 360 29 120 10.483 20 31 320 11 275 20 Washington Mutual Inc 10/12/2004 300 39 840 11 95200 42 280 1268400 Wemganrn Realty 10/122004 355 33 971 12,049 19 40 100 14,235 50 12,059 71-10 52=12,049 19 wpA2-3

846,91846 1217,216 35

134ths~ Evergreen Money Market

IS Other Asset Land

begriming hock assets from poor year spreadsheet

1,001,'.55 28 1,001,255 28

1,001,255 28 1,001,255 28

Documents

990-PF Return of Private Foundation 2004990s.foundationcenter.org/990pf_pdf_archive/566/566046767/... · City or town, state, and ZIP code C it exemption application is (] pending