2012-09-11T16:33:48-05:00 2012-05-31 204193611 Batts Morrison Wales & Lee PA 801 North Orange Avenue Suite 800 Orlando FL 32801 990PF 2011-06-01 593010451 Hans and Cay Jacobsen Charitable Foundation Inc HANS 4078106672 PO Box 2149 Winter Park FL 32790 Teresa W Borcheck 4078106672 2012-09-04 Michele M Wales P00428093 4077706000 2012-09-04 2011 2016-02-24 21:20:13Z X 5078873 X X 112340 112340 390173 8744985 390173 26 26 502539 502539 28000 7000 21000 12415 12415 0 28889 14445 14444 11667 0 0 4970 4970 0 2941 2941 0 88882 41771 35444 185735 185735 274617 41771 221179 227922 460768 1322 5905 5905 -10124 0 0 2602006 3414063 3651771 2000952 1402110 1421197 4594156 4822078 5078873 0 0 X 4594156 4822078 4594156 4822078 4594156 4822078 4594156 227922 0 4822078 0 4822078 Publicly traded securities P 8716266 8354812 361454 361454 Capital Gains Dividends P 28719 28719 28719 390173 0 226363 4972921 0.045519 283894 4719818 0.060149 68969 4536229 0.015204 433742 5901418 0.073498 384094 5970095 0.064336 0.258706 0.051741 5121082 264970 4608 269578 221179 9215 0 9215 0 9215 7300 7300 1915 0 0 0 0 0 0 0 0 0 0 1 1 FL 1 0 0 0 0 1 www.hansandcayjacobsenfoundation.org Capital City Trust Company 8668209671 PO Box 1549 Tallahassee FL 323021549 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Teresa W Borcheck PO Box 2149 Winter Park FL 32790 10.00 10000 0 0 W Thomas Brooks PO Box 2149 Winter Park FL 32790 2.00 6000 0 0 Shannon Carlyle PO Box 2149 Winter Park FL 32790 2.00 6000 0 0 Brian Brooks PO Box 2149 Winter Park FL 32790 2.00 6000 0 0 NONE 0 NONE 0 0 5196717 2351 0 5199068 0 0 5199068 77986 5121082 256054 256054 9215 9215 246839 0 246839 0 246839 221179 0 221179 0 221179 246839 0 0 5274 5274 221179 0 0 0 221179 0 5274 5274 0 0 0 0 0 20386 0 0 0 Teresa Borcheck President Post Office Box 2149 Winter Park FL 32790 4078106672 Contact the Foundation directly or visit the Foundation's website at www.hansandcayjacobsenfoundation.org for information regarding form and content of applications. Requests are to be received no later than May 1 and November 1 of each year for consideration at the Grants are generally restricted to programs which assist children and young adults, in the areas of health, education, culture, recreation, and any other programs that will add to the betterment of their life and their participation as good citizens. Grants are generally restricted to programs conducted in Lake and Sumter County, Florida. Association of Small Foundations 1720 North Street NW Washington DC 20036 None Exempt Org. Operating support 500 Boys & Girls Clubs of Lake & Sumter Counties Inc 400 Executive Boulevard Leesburg FL 34748 None Exempt Org. Project Learn 40000 The Boggy Creek Gang Inc 30500 Brantley Branch Road Eustis FL 32736 None Exempt Org. Theraputic camp programs & operating support 10000 Christian Care Center Inc 115 N 13th Street Leesburg FL 34748 None Exempt Org. Summer Boys & Girls Club Scholarships for residents of Children's Shelter 5000 Christian Home and Bible School 301 W 13th Avenue Mount Dora FL 32757 None Exempt Org. Scholarships to fund extracurricular activities for residents of Children's Home 20000 Early Learning Coalition of Lake County 1300 Citizens Boulevard Suite 206 Leesburg FL 34748 None Exempt Org. Operating support 5000 Educational Foundation of Lake County Inc 201 West Burleigh Boulevard Tavares FL 32778 None Exempt Org. Teachers Bright Ideas Program 10000 Lifestream Behavioral Center Inc PO Box 491000 Leesburg FL 34749 None Exempt Org. Anthony House Restoration 10000 Haven of Lake and Sumter Counties Inc 2600 South Street Leesburg FL 34748 None Exempt Org. SAVE Kids Program 20000 Lake Sumter Children's Advocacy Center Inc 300 South Canal Street Leesburg FL 34748 None Exempt Org. Operating support 15000 Leesburg High School 10935 SE 177th Place Summerfield FL 34491 None Exempt Org. Athletic and band program support 9735 Southern Scholarship Foundation Inc 322 Stadium Dr Tallahassee FL 32304 None Exempt Org. Rent free housing & scholarships 6000 Special Olympics Florida Inc 1915 Don Wickham Dr Clermont FL 34711 None Exempt Org. Athlete healthcare & operating support 15000 Sumter County Youth Center PO Box 2092 Bushnell FL 33513 None Exempt Org. Basketball program 7000 University of Central Florida Foundation Inc 12424 Research Parkway Orlando FL 32826 None Exempt Org. Partnership with Lake Sumter Community College - funding scholarships for the inaugural BSN program on LSCC Campus 12500 185735 Leesburg High School 10935 SE 177th Place Summerfield FL 34491 None Exempt Org. Project Graduation 1500 1500 14 112340 14 26 14 390173 0 502539 0 502539 0 0 0 0 0 0 0 0 0 0 Accounting and tax advisory services 12415 12415 0 Form 990-PF, Part XIII, Line 3d:The Foundation awarded $25,000 to the University of Central Florida Foundation during the year ended 5/31/2008. The grant was reported as a qualifying distribution on the Foundation's 2007 Form 990-PF. Although a check was cut by the Foundation for this grant, the check was not disbursed by the Foundation until such time as certain requirements were met by the grantee. Since such requirements were never met,the disbursement was cancelled in the subsequent year. The Foundation recently discovered that the reversal of the grant payment was inadvertently reported as "other revenue" in the Foundation's financial statements and Form 990-PF for the year ended 5/31/2009, rather than as a recovery of previously granted funds, thereby overstating the Foundation's excess distribution carryover for the years ended 5/31/2009 and 5/31/2010. Given that the Foundation has met its minimum distribution requirement in each subsequent year without taking into account the carryover generated from the recovered grant, the Foundation has merely reduced the qualifying distribution carryover available on the 2011 Form 990-PF by $25,000 to properly account for the reversal of this grant. iShares Barclays Aggregate 302359 306790 iShares Barclays 1-3 YR CRED 500176 502944 Pimco FDS PAC INVT MGMT SER Low Duration 429575 433988 Vanguard Inflat Protected-IV 170000 177475 Legg Mason Global Tr Inc 110683 86435 MFS Ser Tr I Research Intl Fd Instl Cl 233141 261621 Pimco Fds Pac Invt Mgmt Ser Invt Grade Corp Bd Fd Instl Cl 308055 315616 Templeton Income TR Global Bd Fd Advisor Cl 230129 208964 Allstate Corp 28780 39031 American Elec Pwr Inc 22013 22336 Apache Corp Com 58831 52490 Apple Inc 75019 109769 Artisan International 50000 52552 AT&T Inc 30554 36562 BB&T Corp Com 39457 53641 CF Industries Holdings Inc 31917 33337 Cognizant Technology Sol Cl A 42869 37863 Colgate Palmolive Co Com 40633 44235 ConocoPhillips Com 47127 47987 CVS/Caremark Corp 45828 57523 Danaher Corp Del Com 53012 61065 Dodge & Cox Int'l Stock Fund 50000 47556 Exxon Mobil Corp 64565 68408 Federated Investors Income Class B 38889 42993 Fiserv Inc Com 42172 53270 Freeport-McMoran Copper & Gold Inc Cl B 40595 34122 General Dynamics Corp Com 27820 29765 International Business Machs Com 59003 65586 iShares Russel 1000 Index 124620 145580 JP Morgan Chase & Co 44542 45250 Johnson & Johnson 35841 34961 Kohls Corp Com 36458 35281 Laboratory Corp Amer Hldgs 45149 45388 McDonalds Corp 44519 44670 McKesson Corp 50724 57168 Metlife Inc 42437 40602 Microsoft Corp 39504 44223 National Oilwell Varco 62029 67751 Nextera Energy Inc 22169 26463 Oppenheimer Main Str Small Cap Class Y 60000 72159 Oracle Corp Common 55763 49763 Phillips 66 13816 13814 Procter & Gamble Co Com 43642 42980 Public Svc Enterprise Group Com 22359 20585 Qualcomm Inc 50423 55591 Roper Industries Inc 38143 52128 Royce Fd Premier Instl 220000 209450 Scripps Networks Interactive 39435 52853 Standard & Poors Unit Ser 1 112070 131470 Target Corp 37948 42274 Thermo Fisher Scientific Inc Com 43890 43413 Travelers Cos Inc 45640 56241 Union Pac Corp 52101 65169 United Technologies Corp 39848 40019 US Bancorp Del Com New 44365 57242 Verizon Communications 30526 34978 VP Corporation 46406 51479 Walmart Stores Inc Com 42034 51998 Watson Pharmaceuticals Inc 56570 58101 Insurance 1268 1268 0 Dues & subscriptions 1331 1331 0 Miscellaneous 342 342 0 Miscellaneous 26 26 26 Trustee & executor fees 28889 14445 14444 Estimated Federal Taxes 11667 0 0