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TO PROMOTE THE HEALTH OF PEOPLE WHO ARE AFFECTED BY POLLUTED DRINKING WATER BY FUNDING THE DEVELOPMENT OF A WATER MONITORING SYSTEM 7101 BIO-ACTIVES SYNERGIO LTD. - TO PROMOTE HEALTH BY FUNDING RESEARCH INTO DEVELOPING NON-HAZARDOUS, NATURAL PRODUCTS THAT DO NOT ENDANGER HUMAN HEALTH 100000 BARAK BALLET - TO DEVELOP AND PRODUCE A LIVE DANCE PERFORMANCE ENTITLED MEMORYHOUSE 200000 Jeff Polak * DAVID POLAK (DIRECTOR), JANET POLAK (DIRECTOR) AND JEFF POLAK PRESIDENT/DIRECTOR/EXECUTIVE DIRECTOR), OF DAVID & JANET POLAK FOUNDATION (THE "FOUNDATION"), ARE PRINCIPALS AT THE INVESTMENT MANAGEMENT FIRM POLAK INVESTORS, LLC, A DISQUALIFIED PERSON WHICH PROVIDES INVESTMENT MANAGEMENT SERVICES TO THE FOUNDATION. IN THE TAXABLE YEAR ENDING DECEMBER 31, 2021, THE FOUNDATION PAID $383,363 FOR INVESTMENT MANAGEMENT SERVICES RENDERED BY SUCH DISQUALIFIED PERSON, AS REPORTED IN PART I, LINE 16C. THE REASONABLENESS OF THE PROFESSIONAL FEES WAS ESTABLISHED BY AN OUTSIDE COMPENSATION COMMITTEE, WHICH REVIEWED THE RATES CHARGED BY COMPARABLE INVESTMENT MANAGEMENT FIRMS. NEUROVISION IMAGING LLC 1395 GARDEN HIGHWAY SUITE 250 SACRAMENTO CA 95833 2014-12-17 250000 PRI INVEST-SEE GEN EXPLAN FOR PURPOSE & ADDTL DETAILS RE AMT, AMT EXPENDED, & LACK OF DIVERSION NO SEE GENERAL EXPLANATION FOR REPORT DATES THE GRANTOR HAS NO REASON TO DOUBT THE ACCURACY OR RELIABILITY OF THE REPORTS FROM THE GRANTEE; THEREFORE, NO INDEPENDENT VERIFICATION OF THE REPORTS WERE MADE. BRUIN BIOMETRICS LLC 10960 WILSHIRE BLVD SUITE 950 LOS ANGELES CA 90024 2015-05-13 250000 PRI INVEST-SEE GENERAL EXPLANATION FOR PURPOSE & ADDTL DETAILS RE AMT EXPENDED & LACK OF DIVERSION NO SEE GENERAL EXPLANATION FOR REPORT DATES THE GRANTOR HAS NO REASON TO DOUBT THE ACCURACY OR RELIABILITY OF THE REPORTS FROM THE GRANTEE; THEREFORE, NO INDEPENDENT VERIFICATION OF THE REPORTS WERE MADE. BIOP MEDICAL LTD 10 HAELIAV ST RAMAT GAN IS 5252263 2017-04-21 250000 PRI INVEST-SEE GENERAL EXPLANATION FOR PURPOSE & ADDTL DETAILS RE AMT EXPENDED & LACK OF DIVERSION NO SEE GENERAL EXPLANATION FOR REPORT DATES THE GRANTOR HAS NO REASON TO DOUBT THE ACCURACY OR RELIABILITY OF THE REPORTS FROM THE GRANTEE; THEREFORE, NO INDEPENDENT VERIFICATION OF THE REPORTS WERE MADE. ONLINE DISRUPTIVE TECHNOLOGIES INC MATAM ADV TECH PK BLD 23 POBX 15050 HAIFA IS 3190501 2017-04-21 250000 PRI INVEST-SEE GENERAL EXPLANATION FOR PURPOSE & ADDTL DETAILS RE AMT EXPENDED & LACK OF DIVERSION NO SEE GENERAL EXPLANATION FOR REPORT DATES THE GRANTOR HAS NO REASON TO DOUBT THE ACCURACY OR RELIABILITY OF THE REPORTS FROM THE GRANTEE; THEREFORE, NO INDEPENDENT VERIFICATION OF THE REPORTS WERE MADE. ORGENESIS LTD ARAD STREET 9 TEL AVIV IS 2017-04-21 305498 PRI INVEST-SEE GENERAL EXPLANATION FOR PURPOSE & ADDTL DETAILS RE AMT EXPENDED & LACK OF DIVERSION NO SEE GENERAL EXPLANATION FOR REPORT DATES THE GRANTOR HAS NO REASON TO DOUBT THE ACCURACY OR RELIABILITY OF THE REPORTS FROM THE GRANTEE; THEREFORE, NO INDEPENDENT VERIFICATION OF THE REPORTS WERE MADE. BRYN PHARMA LLC FKA EPI-NOW LLC 518 NORTH HILLCREST ROAD BEVERLY HILLS CA 90210 2018-07-13 250000 PRI INVEST-SEE GENERAL EXPLANATION FOR PURPOSE & ADDTL DETAILS RE AMT EXPENDED & LACK OF DIVERSION NO SEE GENERAL EXPLANATION FOR REPORT DATES THE GRANTOR HAS NO REASON TO DOUBT THE ACCURACY OR RELIABILITY OF THE REPORTS FROM THE GRANTEE; THEREFORE, NO INDEPENDENT VERIFICATION OF THE REPORTS WERE MADE. CYWAT TECHNOLOGIES LTD 168 JABOTINSKY ST BNEI BRAK IS 2018-11-26 250000 PRI INVEST-SEE GEN EXPLAN FOR PURPOSE & ADDTL DETAILS RE AMT, AMT EXPENDED, & LACK OF DIVERSION NO SEE GENERAL EXPLANATION FOR REPORT DATES THE GRANTOR HAS NO REASON TO DOUBT THE ACCURACY OR RELIABILITY OF THE REPORTS FROM THE GRANTEE; THEREFORE, NO INDEPENDENT VERIFICATION OF THE REPORTS WERE MADE. BIO-ACTIVES SYNERYGIO LTD FKA YB MO CHO HITECH VIL 4/9 GIVAT RAM POB 39231 JERUSALEM IS 9129102 2018-04-20 250000 PRI INVEST-SEE GENERAL EXPLANATION FOR PURPOSE & ADDTL DETAILS RE AMT EXPENDED & LACK OF DIVERSION NO SEE GENERAL EXPLANATION FOR REPORT DATES THE GRANTOR HAS NO REASON TO DOUBT THE ACCURACY OR RELIABILITY OF THE REPORTS FROM THE GRANTEE; THEREFORE, NO INDEPENDENT VERIFICATION OF THE REPORTS WERE MADE. BIO-ACTIVES SYNERYGIO LTD FKA YB MO CHO HITECH VIL 4/9 GIVAT RAM POB 39231 JERUSALEM IS 9129102 2018-07-19 250000 PRI INVEST-SEE GENERAL EXPLANATION FOR PURPOSE & ADDTL DETAILS RE AMT EXPENDED & LACK OF DIVERSION NO SEE GENERAL EXPLANATION FOR REPORT DATES THE GRANTOR HAS NO REASON TO DOUBT THE ACCURACY OR RELIABILITY OF THE REPORTS FROM THE GRANTEE; THEREFORE, NO INDEPENDENT VERIFICATION OF THE REPORTS WERE MADE. MAXQ AI LTD 96 YIGAL ALON STREET ENTRANCE A TEL AVIV IS 6789140 2019-03-19 250000 PRI INVEST-SEE GENERAL EXPLANATION FOR PURPOSE & ADDTL DETAILS RE AMT EXPENDED & LACK OF DIVERSION NO THE GRANTOR HAS NO REASON TO DOUBT THE ACCURACY OR RELIABILITY OF THE REPORTS FROM THE GRANTEE; THEREFORE, NO INDEPENDENT VERIFICATION OF THE REPORTS WERE MADE. EXTHERA MEDICAL CORPORATION 757 ARNOLD DRIVE SUITE B MARTINEZ CA 94553 2019-12-19 250000 PRI INVEST-SEE GENERAL EXPLANATION FOR PURPOSE & ADDTL DETAILS RE AMT EXPENDED & LACK OF DIVERSION NO SEE GENERAL EXPLANATION FOR REPORT DATES THE GRANTOR HAS NO REASON TO DOUBT THE ACCURACY OR RELIABILITY OF THE REPORT FROM THE GRANTEE; THEREFORE, NO INDEPENDENT VERIFICATION OF THE REPORT WAS MADE. YONALINK LTD HADASSAH EIN KEREM HOSP POB 12000 JERUSALEM IS 9112001 2019-11-12 250000 PRI INVEST-SEE GENERAL EXPLANATION FOR PURPOSE & ADDTL DETAILS RE AMT EXPENDED & LACK OF DIVERSION NO SEE GENERAL EXPLANATION FOR REPORT DATES THE GRANTOR HAS NO REASON TO DOUBT THE ACCURACY OR RELIABILITY OF THE REPORT FROM THE GRANTEE; THEREFORE, NO INDEPENDENT VERIFICATION OF THE REPORT WAS MADE. AMICROBE INC 3142 TIGER RUN COURT 103 CARLSBAD CA 92010 2019-10-31 250000 PRI INVEST-SEE GENERAL EXPLANATION FOR PURPOSE & ADDTL DETAILS RE AMT EXPENDED & LACK OF DIVERSION NO SEE GENERAL EXPLANATION FOR REPORT DATES THE GRANTOR HAS NO REASON TO DOUBT THE ACCURACY OR RELIABILITY OF THE REPORT FROM THE GRANTEE; THEREFORE, NO INDEPENDENT VERIFICATION OF THE REPORT WAS MADE. OCTHEALTH LLC 1395 GARDEN HIGHWAY SUITE 250 SACRAMENTO CA 95833 2021-06-08 250000 PRI INVEST-SEE GENERAL EXPLANATION FOR PURPOSE & ADDTL DETAILS RE AMT EXPENDED & LACK OF DIVERSION NO SEE GENERAL EXPLANATION FOR REPORT DATES NONE NECESSARY BIO-ACTIVES SYNERGIO LTD HI-TECH VILLAGE UNIT 4/9 POB39231 GIVAT RAM IS 9129102 2021-10-12 100000 PRI INVEST-SEE GENERAL EXPLANATION FOR PURPOSE & ADDTL DETAILS RE AMT EXPENDED & LACK OF DIVERSION NO SEE GENERAL EXPLANATION FOR REPORT DATES NONE NECESSARY CYWAT TECHNOLOGIES LTD 168 JABOTINSKY ST BNEI BRAK IS 2021-06-15 100000 PRI INVEST-SEE GENERAL EXPLANATION FOR PURPOSE & ADDTL DETAILS RE AMT EXPENDED & LACK OF DIVERSION NO SEE GENERAL EXPLANATION FOR REPORT DATES THE GRANTOR HAS NO REASON TO DOUBT THE ACCURACY OR RELIABILITY OF THE REPORTS FROM THE GRANTEE; THEREFORE, NO INDEPENDENT VERIFICATION OF THE REPORTS WERE MADE. part I line 6A (990-PF) PART I LINE 6A (990-PF) RECONCILIATION OF NET GAIN/(LOSS) FROM SALES OF ASSETS NOT INCLUDED IN PART IV TOTAL INCLUDED IN PART IV: (DETAILS BELOW) NET GAIN/(LOSS): $1,268,140 TOTAL NOT INCLUDED IN PART IV: PASSTHROUGH K-1 CAPITAL GAIN/(LOSS) - UBI NET GAIN/(LOSS): $496,644 TOTAL PART I, LINE 6A: $1,764,784 DETAILS OF ASSETS INCLUDED IN PART IV: PUBLICLY-TRAIDED SECURITIES GROSS SALES PRICE: $61,461,953 BOOK BASIS: $61,303,288 NET GAIN/(LOSS): $158,665 PASSTHROUGH K-1 CAPITAL GAIN/(LOSS) - NON UBI NET GAIN/(LOSS): $1,028,632 SALES OF OTHER ITEMIZED ASSETS GROSS SALES PRICE: $505,843 BOOK BASIS: $425,000 NET GAIN/(LOSS): $80,843 Form 8865 Form 8865 The Foundation has prepared this form to the best of its ability based on the limited information provided to it by the investment on which the Foundation is reporting and on the basis of having received no information to the contrary. Any missing or incomplete information is due to the Foundation's inability to obtain such information and is not a willful attempt to withhold such information. Form 990-PF Form 990-PF One or more partnerships have provided a Schedule K-3 for the tax year in which they have checked one or more of the boxes in Part I but not provided sufficient back-up information to allow the Foundation to verify why such boxes were checked or the extent to which the checking of such boxes affects any item on this return. The Foundation has prepared this return to the best of its ability and without any foreign filings for such partnerships based on the information provided to it by these partnerships and on the basis of having received no information to the contrary. Any missing or incomplete information is due to the Foundation's inability to obtain such information and is not a willful attempt to withhold such information. EDISON INTL BOND PERPETUAL - 5 1000149 1047600 AMERICAN AXLE & MFG HOLDINGS I 251018 205260 ARCH COAL, INC 84323 91320 B2 GOLD CORP COM NPV 150587 165846 BANK OF AMERICA CORP 113640 533880 BARRICK GOLD CORPORATION 757502 475000 BAYER A G SPONSORED ADR 198370 106080 BERRY PLASTICS GROUP INC 220739 368900 BP PLC SPONSORED ADR 102249 79890 CAMECO CORPORATION 19784 21810 CENTURY ALUMINUM COMPANY 150170 198720 CHENIERE ENERGY INC 200948 304260 CITIGROUP INC 248049 301950 CLIFFS NATURAL RESOURCES INC. 122035 174160 COMPASS MINERALS INTERNATIONAL 202745 204320 COMSTOCK RES INC 82955 121350 CONSOL ENERGY, INC 73339 68130 CONSTELLIUM NV 136767 107460 COPPER MOUNTAIN MINI NG CORP 78225 379052 COTERRA ENERGY INC 312903 361266 CROWN HOLDINGS INC 185100 553100 CVS CAREMARK CORP 466000 1031600 DANA HOLDING CP 68217 114100 ELDORADO GOLD CORP COM NPV 218701 168300 ENDEAVOUR MINING CORP 206264 218696 FIDELITY CONSERV INC BD FD 8589 8586 FIRST QUANTUM MINERALS LTD 17953 48000 FLUTTER ENTERTAINMENT ORD SHS 59804 70875 FTS INTERNATIONAL INC 321080 378473 GENERAL MOTORS 361740 586300 GOLD FIELDS LTD ADS 140581 285740 GOLDEN STAR RESOURCES LTD 13940 15320 GRAFTECH INTERNATIONAL LTD 294224 295750 GRAPHIC PACKAGING CORP COM STK 41828 58500 HALLIBURTON COMPANY 226736 137220 HOLCIM LTD SPON ADS 57245 100900 HOLCIM N 513587 495500 HUDBAY MINERALS INC 186121 217500 IVANHOE MINES LTD 60260 246000 JAPAN SMALLER CAPITALIZATION F 365092 360446 JET2 PLC 78926 151021 JOHNSON & JOHNSON 231728 427675 KAZATOMPROM JSC NAC GDR 147503 367500 KIRKLAND LAKE GOLD LTD 289047 365426 MARKET VECTORS VIETNAM ETF 40705 42480 MERCK & CO INC 362950 613120 MICRON TECHNOLOGY 325144 1117801 MICROSOFT CORP 28785 336320 NEWMONT GOLDCORP CORPORATION 574088 983389 NEXGEN ENERGY LTD 83653 117990 NOVAGOLD RESOURCES 108485 137200 NUVEEN MLT STR I&G 9760 9760 OCEANAGOLD CORPORATION COM 142250 103800 ORGANON & CO 18170 24360 PEABODY ENERGY CORP 60905 50350 PFIZER INC 441678 1062900 PHILIP MORRIS INTL 8916 9500 PRETIUM RESOURCES INC 109012 169080 TEVA PHARMACEUTICAL INDUSTRIES 36513 8010 THE MOSAIC CO 261023 275030 TOREX GOLD RESOURCES 181332 155700 TPG RE FINANCE TRUST INC 2013 1232 TRUIST FINANCIAL CORPORATION 30848 58550 TURQUOISE HILL RESOURCES LTD 98774 98700 UNITED STATES STEEL CORP 23905 23810 VALARIS LTD WTS EXP 04/29/2028 220170 314 VALARIS PLC COM CL A 161969 VIATRIS ORD SHS 90189 87688 23334689 23402860 2621558 2816618 AIR U.S. LIFE FUND III, LP 2074320 2073099 AIR US LIFE FUND IV, LP 2069383 2133872 ALPHA WAVE (F/K/A FALCON EDGE) 557691 1487359 ALTAIR - PACIFIC COAST CPTL PT 714364 942515 ALTAIR DIRECT LENDING FUND, LL 171854 156702 ALTAIR EUROPEAN R E OPPORTUNIT 659098 308408 ALTAIR SENIOR HOUSING FUND (AE 188269 618063 ANAGENESIS CAPITAL PARTNERS SB 1120878 1783921 ASM CONNAUGHT HOUSE FUND III L 1000000 1289574 AVANTE CAPITAL PARTNERS SBIC I 146430 142105 BROAD ST REAL ESTATE CREDIT PT 60000 244636 BW GAS & CONVENIENCE ONSHORE F 249192 3082224 DORCHESTER CAPITAL SECONDARIES 461887 581433 ENLIGHTENMENT CAPITAL SOLUTION 1256641 2640217 FIRST EAGLE CLO EQUITY FUND I, 643264 612135 FOURTHSTONE SMALL-CAP FINANCIA 315314 404796 GOLDMAN SACHS VINTAGE FUND V L 302066 134705 GRANITE CREEK FLEXCAP II, L.P 795402 1232897 GS DISTRESSED OPPORTUNITIES FU 133187 203944 GSO CAPITAL SOLUTIONS FUND II 6436 5737 GSO CAPITAL SOLUTIONS FUND II 77877 51753 GSO CAPITAL SOLUTIONS FUND II 287881 153222 GSO ENERGY SELECT OPPORTUNITIE 321560 303953 GSO ENERGY SELECT OPPORTUNITIE 58054 51753 GSO ENERGY SELECT OPPORTUNITIE 1409 1256 GSO ENERGY SELECT OPPORTUNITIE 41371 36346 LATITUDE MGMT REAL ESTATE CAPI 75000 65274 LATITUDE MGMT REAL ESTATE CAPI 2000000 2011389 PCCP EQUITY VII, LP 1883263 3243232 PCCP EQUITY VIII, LP 665012 794793 QS CAPITAL STRATEGIES II, L.P 281655 264946 SILVERVIEW CREDIT OPPORTUNITES 172223 179901 SILVERVIEW CREDIT OPPORTUNITES 1592815 1646743 THE EDGBASTON ASIAN EQUITY TRU 1350605 1258937 BERNIE L MADOFF - CLAIM RECEIV 406622 406622 General Consultations 23115 23115 PRI - AMICROBE, INC 250000 250000 PRI - BARAK BALLET 200000 200000 PRI - BIOP MEDICAL 250000 250000 PRI - BRUIN_BIOMETRICS 250000 250000 PRI - BRYN PHARMA LLC F/K/A EP 250000 250000 PRI - CYWAT TECH 507100 507101 PRI - EXTHERA MEDICAL CORP 250000 250000 PRI - MAXQ AI, LTD 250000 250000 PRI - MOTHERS CHOICE 250000 250000 PRI - MOTHERS CHOICE (2) 250000 250000 PRI - OCTHEALTH LLC - 15,000 U 250000 250000 PRI - ONLINE DISRUPTIVE 250000 250000 PRI - ORGENESIS - 32,052 SHARE 294398 183658 PRI - ORGENESIS WTS - 32,052 U 11100 PRI - SER A1 PFD (82,175 UNITS 250000 250000 PRI - SER A2 PFD (15,408 UNITS 37502 37502 PRI - SYNERGIO BIO ACTIVES LTD 100000 100000 PRI - YONALINK LTD 250000 250000 Administrative Fees 87942 87942 Bank Charges 2837 2837 Cell Phone Expense 1699 1699 Foundation Dues & Memberships 3600 3600 Insurance Premiums 1192 1192 K-1 Exp AIR U.S. LIFE FUND III 132085 132085 K-1 Exp AIR US LIFE FUND IV, L 22556 22556 K-1 Exp ALPHA WAVE (F/K/A FALC 11471 11471 K-1 Exp ALTAIR - PACIFIC COAST 17488 17205 K-1 Exp ALTAIR DIRECT LENDING 1732 1732 K-1 Exp ALTAIR SENIOR HOUSING 3165 3099 K-1 Exp ANAGENESIS CAPITAL PAR 168069 164680 K-1 Exp AVANTE CAPITAL PARTNER 21404 21020 K-1 Exp BW GAS & CONVENIENCE O 534 57 K-1 Exp ENLIGHTENMENT CAPITAL 19851 19779 K-1 Exp FIRST EAGLE CLO EQUITY 16202 11170 K-1 Exp FOURTHSTONE SMALL-CAP 5756 5756 K-1 Exp GRANITE CREEK FLEXCAP 9486 9349 K-1 Exp GSO CAPITAL SOLUTIONS 3306 828 K-1 Exp GSO CAPITAL SOLUTIONS 5058 5053 K-1 Exp GSO ENERGY SELECT OPPO 37274 3604 K-1 Exp GSO ENERGY SELECT OPPO 1011 906 K-1 Exp GSO ENERGY SELECT OPPO 25 25 K-1 Exp GSO ENERGY SELECT OPPO 2050 398 K-1 Exp PCCP EQUITY VII, LP 32641 32634 K-1 Exp PCCP EQUITY VIII, LP 6306 6305 K-1 Exp QS CAPITAL STRATEGIES 41033 40894 K-1 Exp SILVERVIEW CREDIT OPPO 1071 1071 K-1 Exp THE EDGBASTON ASIAN EQ 4401 4311 Postage/Delivery Service 160 160 Registered Agent Fee 125 125 State or Local Filing Fees 290 290 Website Hosting/Support 547 547 PARKING FEES 6857 6857 K-1 Inc/Loss AIR US LIFE FUND IV, LP -242 -242 K-1 Inc/Loss ALTAIR - PACIFIC COAST CPTL PTNRS EQU 300 5627 K-1 Inc/Loss ALTAIR DIRECT LENDING FUND, LLC 2465 2465 K-1 Inc/Loss ALTAIR SENIOR HOUSING FUND (AEW), LLC -27958 26 K-1 Inc/Loss ANAGENESIS CAPITAL PARTNERS SBIC FUND 206444 295357 K-1 Inc/Loss AVANTE CAPITAL PARTNERS SBIC III, LP 16149 16488 K-1 Inc/Loss BW GAS & CONVENIENCE ONSHORE FUND, LP -102921 K-1 Inc/Loss ENLIGHTENMENT CAPITAL SOLUTIONS FUND 70016 72443 K-1 Inc/Loss FIRST EAGLE CLO EQUITY FUND I, LP 154554 142034 K-1 Inc/Loss FOURTHSTONE SMALL-CAP FINANCIALS FD L 6201 6201 K-1 Inc/Loss GRANITE CREEK FLEXCAP II, L.P 152194 152008 K-1 Inc/Loss GSO CAPITAL SOLUTIONS FUND II AIV-1 L -27 K-1 Inc/Loss GSO CAPITAL SOLUTIONS FUND II AIV-2 L 86482 58507 K-1 Inc/Loss GSO CAPITAL SOLUTIONS FUND II LP 26683 26344 K-1 Inc/Loss GSO ENERGY SELECT OPPORTUNITIES FUND 137046 -1239 K-1 Inc/Loss GSO ENERGY SELECT OPPORTUNITIES FUND 3609 1225 K-1 Inc/Loss PCCP EQUITY VII, LP -16352 9325 K-1 Inc/Loss PCCP EQUITY VIII, LP 6008 5585 K-1 Inc/Loss QS CAPITAL STRATEGIES II, L.P 22688 22578 K-1 Inc/Loss SILVERVIEW CREDIT OPPORTUNITES OFFSHO 157272 157272 K-1 Inc/Loss THE EDGBASTON ASIAN EQUITY TRUST 56198 56198 Class Action Lawsuit Proceeds 399 399 Foreign Currency Gain 656 656 State Tax Refund 11927 WEBSITE DEVELOPMENT 10878 10878 Investment Management Services 398604 398604 Philanthropic Consulting Srvcs 15000 15000 LOGO DESIGN SERVICES 15000 15000 990-PF Estimated Tax for 2021 15300 990-T Extension for 2020 124500 Foreign Tax Paid 13725 13725 STATE UBTI TAX 2020 55800 STATE UBTI TAX 2019 12635