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

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Corporation/Organization Name Address City 928941 12-31-09 Calendar Year 2009 or fiscal year beginning month day year , and ending month day year . A First Return Filed? Yes B Type of organization Exempt under Section 23701 d (insert letter) CORP # X No IRC Section 4947(a)(1) trust 1091748 E F Amended Return? Yes No Accounting method used (1) Cash (2) Accrual (3) Other Are you a subordinate/affiliate in a group exemption? Yes No (a) Is this a group filing for affiliates? See General Instruction L ~~~~ ¥ Yes No I If exempt under R&TC Section 23701d, has the organization during the year: (1) participated in any political campaign or (b) If "Yes," enter the number of affiliates ~~~~~~~~~~~~ (2) attempted to influence legislation or any ballot measure, (c) Are all affiliates included? ~~~~~~~~~~~~~~~~ Yes No or (3) made an election under R&TC Section 23704.5 (relating to lobbying by public charities)? If "Yes," complete (If "No," attach a list. See instructions.) and attach form FTB 3509, Political or Legislative Activities (d) Yes No Is this a separate return filed by an organization covered by a group ruling? ~~~~ by Section 23701d Organizations ~~~~~~~ ¥ Yes X No (e) Federal Group Exemption Number ~~~~~~~~~~~~~ J Did the organization have any changes in its activities, governing instrument, articles of incorporation, or bylaws that have not been reported to the (f) Is a roster of subordinates attached? ~~~~~~~~~~~~ Yes No Franchise Tax Board? If "Yes," complete an explanation Final return? and attach copies of revised documents Yes X No Merged/Reorganized (attach explanation) If "Yes," enter amount of gross receipts from nonmember sources $ If a box is checked, enter date ¥ L Is the organization under audit by the IRS or has the IRS Check the box if the organization filed the following federal forms or schedule: audited in a prior year? ~~~~~~~~~~~ ¥ Yes X No (1) ¥ 990T (2) ¥ X 990PF (3) ¥ (Schedule H) 990 M Is the organization a Limited Liability Company? ~~ ¥ Yes X No If organization is exempt under R&TC Section 23701d and is exclusively religious, N Did the organization file Form 100 or Form 109 to report educational, or charitable, and is supported primarily (50% or more) by public contributions, check box. See General Instruction F. No filing fee is required. taxable income? Yes X No FEIN State ZIP Code Dissolved Surrendered (Withdrawn) Is the organization exempt under R&TC Section 23701g? Yes No Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge. Signature of officer Preparer's signature ~~~~~~~~~~~~~~~~~~~~~ ¥ H ~~~~~~~~ X ~~~~~ ¥ ¥ ¥ K ¥ ¥ G ¥ ¥ Part I Complete Part I unless not required to file this form. See General Instructions B and C. 1 Gross sales or receipts from other sources. From Side 2, Part II, line 8 ~~~~~~~~~~~~~~~~ ¥ 1 2 Gross dues and assessments from members and affiliates ~~~~~~~~~~~~~~~~~~~~~ ¥ 2 3 Gross contributions, gifts, grants, and similar amounts received ~~~~~~~~~~~~~~~~~~ STMT 1 ¥ 3 Receipts 4 Total gross receipts for filing requirement test. Add line 1 through line 3. and This line must be completed. If the result is less than $25,000, see General Instruction C ¥ 4 Revenues 5 Cost of goods sold ~~~~~~~~~~~~~~~~~~~~~~ ¥ 5 00 6 Cost or other basis, and sales expenses of assets sold ~~~~~~~ ¥ 6 35,042,592. 00 7 Total costs. Add line 5 and line 6 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 7 8 Total gross income. Subtract line 7 from line 4 ¥ 8 Expenses 9 Total expenses and disbursements. From Side 2, Part II, line 18 ~~~~~~~~~~~~~~~~~~ ¥ 9 10 Excess of receipts over expenses and disbursements. Subtract line 9 from line 8 ¥ 10 11 Filing fee $10 or $25. See General Instruction F ~~~~~~~~~~~~~~~~~~~~~~~~~~~ 11 12 Total payments ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 12 Filing 13 Penalties and Interest. See General Instruction J ~~~~~~~~~~~~~~~~~~~~~~~~~~ 13 Fee 14 Use tax. See General Instruction K ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ¥ 14 15 Balance due. Add line 11, line 13, and line 14. Then subtract line 12 from the result 15 Sign Here TAXABLE YEAR Paid Preparer's Use Only California Exempt Organization FORM 2009 Annual Information Return 199 CALIFORNIA PHYSICIANS' SERVICE FDN (DBA BLUE SHIELD OF CALIFORNIA FDN) 94-2822302 50 BEALE STREET, FOURTEENTH FLOOR SAN FRANCISCO CA 94105 C X X D X | Firm's name (or yours, if selfemployed) | and address CAROLYN R. AMSTER Title Date Telephone Date Check if self-employed | | May the FTB discuss this return with the preparer shown above? See instructions ¥ 022 3651094 PRESIDENT AND Preparer's SSN/PTIN For Privacy Notice, get form FTB 1131. Form 199 C1 2009 Side 1 ¥ ¥ P00189994 BURR PILGER MAYER, INC. 26-3839190 2000 UNIVERSITY AVE, SUITE 201 ¥ Telephone E. PALO ALTO, CA 94303 (650) 855-6800 X Yes No ¥ 31,349,563. 24,864,623. 56,214,186. 35,042,592. 21,171,594. 33,327,007. -12155413. 10. FEIN 10. 00 00 00 00 00 00 00 00 00 00 00 00 00
Part II CALIFORNIA PHYSICIANS' SERVICE FDN (DBA BLUE SHIELD OF CALIFORNIA FDN) 94-2822302 Organizations with gross receipts of more than $25,000 and private foundations regardless of amount of gross receipts - complete Part II or furnish substitute information. See Specific Line Instructions. 1 Gross sales or receipts from all business activities. See instructions ~~~~~~~~~~~~~~~~~~~ ¥ 1 2 Interest ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ¥ 2 3 Dividends ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ¥ 3 Receipts 4 Gross rents ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ¥ 4 from 5 Gross royalties ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ¥ 5 Other 6 Gross amount received from sale of assets (See instructions) ~~~~~~~~~~~~~~~~~~~~~ ¥ 6 Sources 7 Other income ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ¥ 7 8 Total gross sales or receipts from other sources. Add line 1 through line 7. Enter here and on Side 1, Part I, line 1 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 8 9 Contributions, gifts, grants, and similar amounts paid ~~~~~~~~~~~~~~~~~~~~~~~~~ ¥ 9 10 Disbursements to or for members~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ¥ 10 11 Compensation of officers, directors, and trustees ~~~~~~~~~~~~~~~~~~~~~~~~~~~ ¥ 11 Expenses 12 Other salaries and wages~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ¥ 12 and 13 Interest ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ¥ 13 Disbursements 14 Taxes ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ See Attached 990-PF ¥ 14 15 16 Rents ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ¥ Depreciation and depletion (See instructions) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ¥ 15 16 17 Other ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ¥ 17 18 Total expenses and disbursements. Add line 9 through line 17. Enter here and on Side 1, Part I, line 9 18 Schedule L Balance Sheets Beginning of taxable year End of taxable year Assets (a) (b) (c) (d) 1 Cash ~~~~~~~~~~~~~~~~ ¥ 2 Net accounts receivable ~~~~~~~~ ¥ 3 4 5 Net notes receivable ~~~~~~~~~~ Inventories~~~~~~~~~~~~~~ Federal and state government obligations ¥ ¥ ¥ 6 Investments in other bonds ~~~~~~ ¥ 7 Investments in stock ~~~~~~~~~ ¥ 8 Mortgage loans (number of loans ) ¥ 9 Other investments ~~~~~~~~~~ ¥ 10 a Depreciable assets ~~~~~~~~~ b Less accumulated depreciation ~~~~ ( ) ( ) 11 Land ~~~~~~~~~~~~~~~~ See Attached 990-PF ¥ 12 Other assets ~~~~~~~~~~~~~ ¥ 13 Total assets ~~~~~~~~~~~~~ Liabilities and net worth 14 15 Accounts payable ~~~~~~~~~~~ Contributions, gifts, or grants payable ~~ ¥ ¥ 16 Bonds and notes payable ~~~~~~~ ¥ 17 Mortgages payable ~~~~~~~~~~ ¥ 18 Other liabilities ~~~~~~~~~~~~ 19 Capital stock or principle fund ~~~~~ ¥ 20 Paid-in or capital surplus. Attach reconciliation ~ ¥ 21 22 Retained earnings or income fund ~~~~ Total liabilities and net worth ¥ Schedule M-1 Reconciliation of income per books with income per return Do not complete this schedule if the amount on Schedule L, line 13, column (d), is less than $25,000 1 Net income per books ~~~~~~~~~~~~ ¥ 2 Federal income tax ~~~~~~~~~~~~~ ¥ 7 Income recorded on books this year 3 4 Excess of capital losses over capital gains Income not recorded on books this ~~~ ¥ not included in this return ~~~~~~~~~ ¥ year~~~~~~~~~~~~~~~~~~~~ ¥ 8 Deductions in this return not charged 5 Expenses recorded on books this year not against book income this year ~~~~~~~ ¥ deducted in this return ~~~~~~~~~~~ ¥ 9 Total. Add line 7 and line 8 ~~~~~~~~ 6 Total. 10 Net income per return. Add line 1 through line 5 Subtract line 9 from line 6 928951 11-19-09 SEE PART II SUBSTITUTE ATTACHMENT 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 Side 2 Form 199 C1 2009 022 3652094
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November 9, 2010 California Physici
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TAX RETURN FILING INSTRUCTIONS FORM
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Form 990-PF (2009) Assets Liabiliti
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Form 990-PF (2009) Part VI CALIFORN
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Form 990-PF (2009) Part VII-B CALIF
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Form 990-PF (2009) Part X CALIFORNI
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Schedule B (Form 990, 990-EZ, or 99
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IRS Form 990-PF for 2009 - Blue Shield of California Foundation

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