2011-09-29T08:34:05-05:00 2011-05-31 Batts Morrison Wales & Lee PA 801 North Orange Avenue Suite 800 Orlando FL 32801 990PF 2010-06-01 593010451 Hans and Cay Jacobsen Charitable Foundation Inc HANS 4078106672 PO Box 2149 Winter Park FL 32790 Teresa W Borcheck 4078106672 2011-08-30 Michele M Wales 4077706000 2011-08-30 2010 2016-03-07 17:11:31Z X X 5425697 X X 109181 109181 276975 3104336 276975 2803 2803 388959 388959 24000 6000 18000 150 150 0 12338 12338 0 8664 4332 4332 5330 0 0 4605 4605 0 55087 27425 22332 204031 204031 259118 27425 226363 129841 361534 2251 1322 1322 74785 -10124 -10124 2584516 2602006 3394657 1802763 2000952 2039842 4464315 4594156 5425697 0 0 X 4464315 4594156 4464315 4594156 4464315 4594156 4464315 129841 0 4594156 0 4594156 Publicly traded securities 3017668 2827361 190307 190307 Capital Gains Dividends P 86668 86668 86668 276975 0 283894 4719818 0.060149 68969 4536229 0.015204 433742 5901418 0.073498 384094 5970095 0.064336 162546 5297734 0.030682 0.243869 0.048774 4972921 242549 3615 246164 226363 7231 0 7231 0 7231 2934 2934 70 4367 0 0 0 0 0 0 0 0 0 0 1 1 FL 1 0 0 0 0 1 N/A 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 2.00 6000 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 5014290 34361 0 5048651 0 0 5048651 75730 4972921 248646 248646 7231 7231 241415 0 241415 0 241415 226363 0 226363 0 226363 241415 0 0 45326 45326 226363 0 0 0 226363 0 15052 15052 30274 0 0 0 0 0 0 0 30274 30274 Teresa Borcheck President Post Office Box 2149 Winter Park FL 32790 4078106672 Contact the Foundation 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. Boggy Creek Gang Inc 30500 Brantley Branch Rd Eustis FL 32736 None Exempt Org. Theraputic camp programs & operating support 10000 Boys & Girls Clubs of Lake & Sumter Counties Inc 400 Executive Blvd Leesburg FL 34748 None Exempt Org. Project Learn 65000 Christian Home and Bible School 301 W 13th Ave Mount Dora FL 32757 None Exempt Org. Transportation for children/house parents & operating support 32500 Christian Worship Center of Central Florida Inc 929 County Road 468 Leesburg FL 34748 None Exempt Org. Challenge grant for basketball court 21000 Haven of Lake and Sumter Counties Inc 2600 South St Leesburg FL 34748 None Exempt Org. SAVE Kids Program 20000 Lake-Sumter Community College Foundation Inc 9501 US Highway 441 Leesburg FL 34788 None Exempt Org. Student Ambassador Program 8400 Leesburg High School Foundation Inc PO Box 492722 Leesburg FL 34749 None Exempt Org. Graduation & weight room equipment 18500 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 5131 Wildwood High School 700 Huey Street Wildwood FL 34785 None Exempt Org. Project graduation 2500 204031 Special Olympics Florida Inc 1915 Don Wickham Dr Clermont FL 34711 None Exempt Org. Athlete healthcare & operating support 15000 15000 14 109181 14 2803 14 276975 0 388959 0 388959 0 0 0 0 0 0 0 0 0 0 Accounting and tax advisory services 12338 12338 0 iShares Tr Barclays Tips DF FD 93511 98665 Pimco Fds Pac Invt Mgmt Ser Total Return Fd Instl Cl 197186 199709 Ridgeworth Fd - Total Return Bd 593483 595118 Ridgeworth Fd - Seix High Yield 72113 81384 Vanguard Bd Index Fd Inc 0 0 Pimco Fds Low Duration Fd Instl Cl 234575 237507 Pimco Fds Pac Invt Mgmt Ser Invt Grade Corp Bd Fd Instl Cl 308055 315616 Ridgeworth Fd - Seix Fltg Rt High Incm I 135950 135349 Ridgeworth Fd - Ltd Term Fed Mtg Secs 135950 138772 Templeton Income TR Global Bd Fd Advisor Cl 230129 237722 Dreyfus/The Boston Co 0 0 Federated Equity Fds 0 0 Legg Mason Global Tr Inc 183506 245724 MFS Ser Tr I Research Intl Fd Instl Cl 233141 332261 Pimco Commodity Real Return Strategy 71065 113383 Ridgeworth Fd - Midcap Val Equity 103719 207439 Ridgeworth Fd - Largecap Value Equity 172715 273532 T Rowe Price Real Estate Fd 0 0 Goldman Sachs Tr Growth Opportunities Fd Instl Cl 182361 255578 Hartford Mut Fds Inc 260735 294966 iShares Tr Russell 1000 Growth Index Fd 0 0 Janus Fds Perkins Small Cap Value Fd Cl 0 0 Jensen Portfolio Inc 359905 421454 Advisors Inner Circle Fd Cambiar Small Cap Fd Instl Cl 107141 109956 Harbor Fd Cap Appreciation Fd Instl Cl 337533 428195 Invesco Growth Ser Small Cap Growth Fd Cl Instl 123295 138138 JPMorgan TR I US Equity Rd Instl Cl 466890 574031 Attorney fees 150 150 0 Dues & Subscriptions 495 495 0 Licenses 61 61 0 Insurance 1272 1272 0 Miscellaneous 2777 2777 0 Miscellaneous 2803 2803 2803 Trustee & executor fees 8664 4332 4332 Estimated Federal Taxes 5330 0 0