IRS Form 990-PF for 2009 - Blue Shield of California Foundation

Form 990-PF (2009)
1a
b
c
d
e
a
b
c
d
e
a
b
c
d
e
(e) Gross sales price
(a) List and describe the kind(s) of property sold (e.g., real estate,
(b) How acquired (c) Date acquired (d) Date sold
P - Purchase
2-story brick warehouse; or common stock, 200 shs. MLC Co.)
D - Donation
(mo., day, yr.) (mo., day, yr.)
(f) Depreciation allowed
(g) Cost or other basis
(h) Gain or (loss)
(or allowable)
plus expense of sale
(e) plus (f) minus (g)
Complete only for assets showing gain in column (h) and owned by the foundation on 12/31/69 (l) Gains (Col. (h) gain minus
(j) Adjusted basis
(k) Excess of col. (i)
col. (k), but not less than -0-) or
(i) F.M.V. as of 12/31/69
Losses (from col. (h))
as of 12/31/69
over col. (j), if any
If gain, also enter in Part I, line 7
2 Capital gain net income or (net capital loss) If (loss), enter -0- in Part I, line 7 ~~~~~~ 2
3
Part IV
CALIFORNIA PHYSICIANS' SERVICE FDN
(DBA BLUE SHIELD OF CALIFORNIA FDN) 94-2822302
Capital Gains and Losses for Tax on Investment Income
PUBLICLY TRADED SECURITIES - NORTHERN TRUST
GOV'T BONDS AND S&P 500 INDEX FUND -
NORTHERN TRUST
PUBLICLY TRADED SECURITIES - NORTHERN TRUST
Net short-term capital gain or (loss) as defined in sections 1222(5) and (6):
If gain, also enter in Part I, line 8, column (c).
If (loss), enter -0- in Part I, line 8
Part V
(For optional use by domestic private foundations subject to the section 4940(a) tax on net investment income.)
If section 4940(d)(2) applies, leave this part blank.
Was the foundation liable for the section 4942 tax on the distributable amount of any year in the base period?
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 year; see instructions before making any entries.
(a) (b) (c)
Base period years
Calendar year (or tax year beginning in) Adjusted qualifying distributions Net value of noncharitable-use assets
2008
2007
2006
2005
2004
3
Page 3
25,086,807. 15,566,208. 9,520,599.
5,114,669. 9,486,840. -4,372,171.
864,193. 691,029. 173,164.
rqs
Qualification Under Section 4940(e) for Reduced Tax on Net Investment Income
pmo
pmo
D
P
P
N/A
9,520,599.
-4,372,171.
173,164.
5,321,592.
X
~~~~~~~~~~~~~~~~ Yes No
(d)
Distribution ratio
(col. (b) divided by col. (c))
34,986,979. 58,021,425. .603001
34,119,855. 51,493,578. .662604
25,326,819. 48,742,986. .519599
22,657,753. 45,778,405. .494944
14,535,907. 29,546,362. .491969
2
3
Total of line 1, column (d) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 2
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
2.772117
.554423
4
Enter the net value of noncharitable-use assets for 2009 from Part X, line 5
~~~~~~~~~~~~~~~~~~~~~
4
50,303,453.
5
Multiply line 4 by line 3 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
5
27,889,391.
6
Enter 1% of net investment income (1% of Part I, line 27b) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~
6
55,800.
7
Add lines 5 and 6 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
7
27,945,191.
8 Enter qualifying distributions from Part XII, line 4~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
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.
8
38,887,152.
923521 02-02-10
990-PF
3
09011109 794095 155930.0 2009.04050 CALIFORNIA PHYSICIANS' SERV 15593001
Form (2009)