Return of Private Foundation
or Section 4947(a)(1) Nonexempt Charitable Trust Treated as a Private Foundation
Note The organization may be able to use a copy of this return to satisfy state 2por
OM B N O 1 57 50052
LOOL
Dapartnant of me Thmury Internal fiavenue Swcs
Use the IRS Name of organization label
Otherwise, HOME STATE BANK CHARITABLE FOUNDATION
print NumberenGsVaat(orPO boa number ifrtmlllanotONherbbstreet edUrea)
or type 115 WEST STATE STREET Sea Specific City or town, state and ZIP code
instructions JEFFERSON, IA 50129
H Check type of organization X Section 501(c)(3) exempt private foundation Section 4947(a)(1) nonexempt charitable trust = Othertaxable private foundation I Fair market value of all assets at end of year J Accounting method M Cash
(from Pert ll, cot (c), line 16) = Other (specify)
11104 151 6 5 8 . (Part l, column (a) must be on cash bans )
A I fR dE
42-1378344
RooMSUlte B 7eleDhona number
515-386-2131
II uanPtlon epPllatlon la Pending Uecii nn D 1 Foreign organizations, check here Mo.
2 Foreign organitauom insisting me esx u.t, chock here and eflosch computation E If pnvate foundation status was terminated Accrual under section 507(b)(1)(A), check hare
F If the foundation is in a 60-month tertnination- p~ ~ na ysis a avenue an ipencac (The total of emounb in columns (E) (c) end (d) may not (a) Revenue and (b) Net investment
nmsvily egad me urounn in wWmn W ) expenses per b00k5 Income
0 .
0 .
` 3-0 , 23-8 . 0 .
30 , 2-3-8-,
N/A T
30 , 593 . 0
..~ .... ....W.. f' .. .
<3 847 . ° - -
~~
~ 1 '7 er
firshis o-,
1 /1,..,~
13490424 785304 HOMEST-FOUND 2002 .05030 HOME STATE BANK CHARITABLE HOMEST-1
Form J90-PF
Employer Identification number
1 Contnbutions,pitts,prants,etc received Check ),.= u ve ~ynmem a notrtaWeE m~mCi Sei B 2 Distributions from split-interest trusts
Interest on uvinpa and rompomry Min Irr,sistrrents
4 Urvidends and interest from securities Sa Gross rents
D (Not rental incorries or rose)
j 67 Ne10n or poaa) hvmsere ofurunot on b G1059 5716/ P1Ip for /II
essets on line SO
__ Q ] CepIfeIpelnneilnoo. /homPvINline 7) fV' 8 Net Short-term capital pain Iva 9 Income modifications
p 10a Gmss sde lea mama and BIIOWNW Cr b Less Cost of goods sold
c Gross profit or (loss) 11 Other income
12 Tout Add lines 1 through 11
13 Conwensauon of Officers, airecmn wstaas, ate.
14 Other employee salanes and wages U 15 Pension plans, employee benefits
VI16a Legal lees
o b Accounting fees STMT 2
w c Other professional fees 17 Interest
18 Taxes STMT 3
19 Depreciation and depletion E 20 Occupancy
a 21 Travel, conferences, and meetings v v m 22 Punting and publications
23 Other expenses
m 24 Total operating and a"Itive VV Q
11 23 24
355 .
(c) Adjusted net
income b
~ NlA t
STATEMENT 1
Paperwork Reduction Act Notice, see the Instructions Form 990-PF (2002)
Organ ixatIons that to llor SFAS 117, check here ~ U and complete lines 24 through 26 and lines 30 and 31
N
24 Unrestricted .2 25 Temporarily restricted W 25 Permanently restricted
Organizations that d0 not follow SFAS 117, check here EXI and complete lines 27 through 31
27 Capital stock, trust principal, or current funds
28 Paid-in or capital surplus, or land, bldg , and equipment fund a 29 Retained earnings, accumulated income, endowment, or other funds
30 Total net assets or fund balances z
0
223511 01 nm
13490424 785304 HOMEST-FOUND 2002 .05030 HOME STATE BANK CHARITABLE HOMEST-1 2 Form 990-PF (2002) HOME STATE BANK CHAI
part ~~ Balance Sheets " '"oHwnemvexaooem
cdumiNMaOeluatrof rXunwntbYy 1 Cash - non-interest-bearing
2 Savings and temporary cash investments 3 Accounts receivable
Less allowance for doubtful accounts 1 4 Pledges receivable
Less allowance for doubtful accounts 5 Grants receivable
B RecervaDles due from officers, directors, trustees, and other disqualified persons
7 OmenmmoiovamanEb
Less allowance for doubtful accounts ~ 8 Inventories for sale or use
9 Prepaid expenses and deferred charges
10a Investments -U S and state government obligations D Investments - corporate stock
a Investments - corporate bonds
11 Inmt~bi6 WdONICryilnOtp110~0as I
LM mrtWtdRqml7CM 1
12 Investments -mortgage loans
13 Investments - other
14 Land, buildings, and equipment basis
L=m=Uraaam~+em 110.
15 Other assets (describe 0'
17 Accounts payable and acerue0 expenses 18 Grants payable
19 Deferred revenue
20 Losna hom olfima dlrectnn truateef WC o0ix disqualified pumna m 21 Mortgages and other notes payable
22 Other liabilities (describe
of ye Value
-1378344 Paae2
Book Value (c) Fair Market Value
15-1 , 65-8 . 151 658 .
0 .
131 Total liabilities and net assets/fund balances 1 155,505 .1 151,658 .1
pWr ~~~ Analysis of Changes in Net Assets or Fund Balances 1 Total not assets or fund balances at beginning o1 year- Part 11, column (a), line 30
(mustagree with end-ot-yearfigure reported onprior years retum) 1 155 , 505 .
2 Enter amount tram Part I, line 27a 2 <3 , 847 . >
3 Other Increases not included in line 2 (itemize) " 3 0 .
4 Add lines 1, 2, and 3 d 151 , 658 .
5 Decreases not included m line 2 (itemize) " 5 0
6 Total net assets or fund balances at end of year (line 4 minus line 5) - Part II, column (b), line 30 6 15 1 , 6 5 8 .
From 990-PF Roozl
79'W" 2002 HOME STATE BANK CHARITABI Capital Gains and Losses for Tax on Investmer
(a) List and describe the kind(s) of property sold (e p , real estate, 2-story bnck warehouse, or common stock, 200 shs MLC Co )
3
the foundation on 17131/69 (t) excess of cot (q
over cot (1), d any in column (h) and owned
(1) Adjusted basis as of 12/31/69 (I) F M V d5 Of 12/31/69
Income
D V¢5 D NO
( it Un ratio )
ded by cot (c))
.3130596 .1782727 .1866333 .1824926 .1778281 1 .0382863 .2076573 15-112-78-
31,414 . 27 . 31 .441 .
7 Add lines 5 and 6
B Enter qualifying distributions from Part %1I, line 4 30,238 .
If line 8 is equal to or greater than line 7, check the box in Part Vi, line to and compete that part using a t % tax rate See the Pad VI instructions
zz35z1A1 z3m rom 990-PF Rural
3
(e) Gross sales price
for assets
(Q Depreciation allowed
(or allowable) (g) Cost or other basis plus expense of sale
2 Capital pain net income or (net capital loss) ~ It Q ain, also enter in Part I, line 7 1 If (loss) enter-0-in Pad I, line 7 3 Net short-term wpdal gain or (loss) as defined in sections 1222(5) and (6)
It gain, also enter in Part I, line 8, column (c) It (loss) . enter -0- in Part I . line 8
(For optional use by domestic private foundations subject to the section 4940(a) tax on net investment income ~ If section 4940(4)(2) applies, leave this part blank
Was the organization liable for the section 4942 tax on the distnbutable amount of any year in the base DenoO9 1 Enter the appropriate amount in each column tar each year, see instructions before making any entnes
1b1 1c1
Base Denod years
Calnndar vnar fnr fax vear henmnlnn inl Adjusted qualifying distributions Net value of nonchantable-use assets
2 Total of line 1, column (d)
3 Average distribution ratio for the 5-year base DenoO - divide the total on line 2 by 5, or by the number of years the foundation has been in existence d less than 5 years
4 Enter the net value of noncharitable-use assets for 2002 from Part %, line 5
5 Multiply line 4 byline 3
6 Enter 1% at net investment income (1% of Part I, line 27b)
(c) Date acquired (d) Date sold (mo,day,yr) I (mo,day,yr)
(h) lain or (loss) (e) plus (f) minus (p)
(I) Gains (Col (h) pain minus cot (k), but not less than -0-) or
Losses (from cot (n))
arm 990-PF(2002) HOME STATE BANK CHARITABLE FOUNDATION Part VI Excise Tax Based on Investment Income (Section 4940(a), 4940(b), 49401
1 a Exempt operating foundations described in section 4940(0)(2), check here " 0 and enter'WA' on line 1 Date of ruling letter (attach copy of ruling letter if necessary-see instruction:) D Domestic organizations that meet the section 4940(e) requirements in Part V, check here 1 0 and enter 1%
of Part I, line 27b
c All other domestic organisations enter 2% of line 27b Exempt foreign organizations enter 4% of Part 1, line 72, cot (b) 2 Tax under section 511 (domestic section 4947(a)(1) trusts and taxable foundations only Others enter -0-)
3 Add lines 1 and 2
4 Subtitle A (income) tax (domestic section 4947(a)(1) trusts and taxable foundations only Others enter -0-) 5 Tai based on Investment Income Subtract line 4 from line 3 If zero or lass, enter -0-
6 Credits/Payments
a 2002 estimated fax payments and 2001 overpayment credited to 2002 6a
b Exempt foreign organizations -tax withheld at source 66
c Tax paid with application for extension of time to tale (Form 8868) 6c
d Backup withholding erroneously withheld 6d
7 Total credits and payments Add lines 6a through 6d
B Enter any penalty for underpayment of estimated tax Check here = if Form 2220 is attached 9 Tai due It the total of lines 5 and 8 is more than line 7, enter amount owed
10 Overpayment If line 7 is more than the total of lines 5 and 8, enter the amount overpaid
11 Enter tie amount of line 10 to be Credited to 2003 estimated tax " I F1eh
s 55 .
0 . 10- 8 s 55 .
10
" 11
D If the answer is 'Yes' to line 7, has the organization famished a copy of Form 990-PF to the Attorney General (or designate) of each state as required by General Instruction G? If 'No,' attach explanation
9 I5 the organization claiming status as a private operating foundation within the meaning of section 4942(j)(3) or 4942(j)(5) far calendar year 2002 or the taxable year beginning m 2002 (see instructions for Part XIV)? If 'Yes,' complete Part X1V
10 did any persons become substantial contributors during the tax years a vm .god, . w,.am. a+n~o ma.~ u,a .ea~,o 11 Did the organization campy with tie public inspection requirements for its annual returns and exemption appl¢atian9
websdeaddress " N/A
12 The books are in care of " DOUG MCDERMOTT Telephone no "L
Located at " HOME STATE BANK, JEFFERSON, IOWA ZiPa
13 Section 4947(a)(1) nonexempt charitable trusts filing Form 990-PF in lieu at Farm 1041 - Check here Zz3vi
01 23-03 F,. 990-PF oo2l
13490424 785304 HOMEST-FOUND 2002 .05030 HOME STATE BANK CHARITABLE HOMEST-1 4
'. , .
`~55 .
Is Dunnp the tax year, did the organization attempt to influence any national, state, or local legislation or did it participate or intervene in any political campaign9
b Did it spend more than $700 during the year (either directly or indirectly) for political purposes (see instructions for definition)?
lfthe answer is 'Yes' to 1 a or 1 h, attach e detected description o/ the actrvrties end copies o! any matenels published or distributed by the organization in connection with the activities
c Did the organization file Form 1120-POL for this yeah
0 Enter tie amount (d any) of tax an political expenditures (section 4955) Imposed during the year
(1) On the organization " $ 0 . (2) On organization managers " $ 0 e Enter the reimbursement (d any) paid by the organization during the year for political expenditure tax imposed on organization
managers " $ 0 .-
2 Has the organization engaged in any activities that have not previously been reported to the IRS If 'Yes,' attach e deleted description of the activities
3 Has the organization made any changes, not previously reported to the IRS, in its governing instrument, articles of incorporation, or bylaws, or other similar instruments If 'Yes,' attach e conformed copy of the changes
4a Did the organization have unrelated business gross income 0151,000 or more Ounng the yeah
6 If Yes,' has it filed a tax return on Form 990-T tar this years N/A
5 Was there a liquidation, termination, dissolution, or substantial contraction during the year II 'Yes,' attach the statement required by General Instruction T
6 Are the requirements of section 508(e) (relating to sections 4941 through 4945) satisfied either
" By language in the governing instrument or
" By state legislation that effectively amends the governing instrument so that no mandatory directions that conflict with the state law remain in the governing instrument?
7 Did the organization have at least $5.000 in assets at any time Ounnp the year9 11 'Yes,' complete Part II, cot (c), end Pert XV
8a Enter the states to which the foundation reports or with which it is registered (see instructions) ~
X
X
I X
a X
h X
. .
BANK CHARITABLE FOUNDATION 42-1378344 Pages Form 990-PF
(B) Agree to pay money or property to a government official? (Exception Check 'No*
if the organization agreed to make a grant to or to employ the official for a period otter
termination of government service, A terminating within 90 days ) D Yes ~ No
D If any answer is 'Yes' to 1x(1)-(6), did any of the acts tail to quality under the exceptions described in Regulations ' section 53 4941(d)-3 or in a current notice regarding disaster assistance (see gape 19 of the instrucuons)9 N/A Ill
Organizations relying on a current notice regarding disaster assistance check here ll~ 0
c Did lie organization engage in a prior year in any of the acts described in la, other than excepted acts, that were not corrected
before the first day of the tax year beginning in 2002 '1 c
2 Taxes on tenure to distribute income (section 4942) (Goes not apply for years the organization was a private operating foundation defined in section 4942(1)(3) or 4942(j)(5))
a At the end of tax year 2002, did the organization have any undistributed income (lines 6d and tie, Part XIII) for tax year(s) beginning
Yes D No
before 2002 If Yes; list the years
6 Are there any years listed in 2a for which the organization is not applying the provisions of section 4942(a)(2) (relating to incorrect valuation of assets) to the years undistributed incomes (If applying section 4942(x)(2) to all years listed, answer 'No' and attach
statement -seeinstructions ) N/A 2b A
c If the provisions of section 4942(x)(2) are being applied to any of the years listed in 2a, list the years here
3a Did the organization X010 more than a 2% direct or indirect interest in any business enterprise at any time
during the year? Yes U] No
D II Yes,' did it have excess business holdings in 2002 as a result of (1) any purchase by the organization or dispualrfied persons after May 26, 1969,(2) the lapse of the 5-year period (or longer period approved by the Commissioner under section 4943(c)(7)) to dispose of holdings acquired by gift or bequest, or (3) tie lapse of the 10-, 15-, or 20-year first phase holding penod9 (Use Schedule C,
Form 4720, to determine d the organization had excess business holdings in 2002 ) N/A 3h
X
w 11
~kh Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract7
zzaset of iym
5
File Forth 4720 if any item Is checked In the "Yes" column, unless an exception applies 7 a During the year did the organization (either directly or Indirectly)
(1) Engage in the sale or exchange, or leasing o1 property with a disqualfie0 persons OYe: D No (2) Borrow money from, lend money lo, or otherwise extend credit to (or accept it tram)
a disqualified persons ~ Ye: ~ No
(3) Furnish goods, serves, or facilities to (or accept them from) a disqualified person? Y No (i) Pay compensation to, or pay or reimburse the expenses of, a disqualified person? Yes No (5) Transfer any income or assets to a disqualified person (or make any of either available
for the benefit or use of a disqualified person) ~ Yes Ell No
X
4a Did the organization invest during the year any amount in a manner that would jeopardize its charrtaDle purposes <a h Did the organization make any investment in a prior year (but otter December 31 1969) that could jeopardize its charitable purpose that
had not been removed from jeopardy before the first day of the tax year beginning in 2002 <b Be During tie year did the organization pay or incur any amount to
(1) Carry on propaganda, or otherwise attempt to influence legislation (section 4945(e))? 0 Yes D No (2) Influence the outcome of any specific public election (see section 4955), or to carry on, directly or indirectly,
any voter registration drrve9 0 Yea EKI No
(3) Provide a pram to an individual for travel, study, or other similar purposes? Yes No (C) Provide a grant to an organization other than a charitable, etc , organization described in section
509(a)(i), (2), or (3), or section 4940(0)2)7 0 Yes 0 No
(5) Provide for any purpose other than religious, charitable, scientific, literary, or educational purposes, or for
the prevention of cruelty to children or animals ~ Yes 0 No
6 If any answer is 'Ves'to 5x(1)-(5), did any of the transactions tail to quality under the exceptions described in Regulations
section 53 4945 or in a current notice regarding disaster assistance (see instNCtions)9 N/A Ss Organizations relying on a current haute regarding disaster assistance check here ~
c If the answer is 'Yes'to question Sa(4), does the organization claim exemption from the tax because it maintained
expenditure responsibility for the grant? N/A Yes No
11 'Yes,' attach the statement required by Regulations section 53 4945-5(d)
6a Did the organization, during the year, receive any funds, dlrectry or Indirectly, to pay premiums on
a personal benefit contacts ~ Yes ~ No w~
Pwm 990-PF Roml
01 23-M coo n 990-PF Rppz~
13490424 785304 HOMEST-FOUND 2002 .05030 HOME STATE BANK CHARITABLE HOMEST-1 6 HOME STATE BANK CHARITABLE FOUNDATION 42-1378344
,Information About Officers, Directors, Trustees, Foundation Managers, Highly Page s Paid Employees, and Contractors
1 List all officers, directors, trustees, foundation managers and their compensation
(6) Title, and averspe (c) Compensation (d~cmewwcnsm (e) Expense other (a~Namean0a0dress ~oursRerweek0evoled (ItnatpalE, _n_~ °'~;d~°'° account ,other ~nnW~~~e~
.1 0 .1 0 .
pensation of five hi ghest-paid employees (other than those included on line 1) 11 none, solar "NONE "
(b) Title and average
(e) Name and address of each employee paid more than E50,000 hours er week (c) Compensation
3 Five highest-paid independent contractors for processional services If none, enter "NONE "
(a) Name and address o1 each person paid more than E50,000 (b) Type of service
Total number of others receiving over $50,000 for professional services Part IX-A Summary of Direct Charitable Activities
List the foundation's tour largest direct charitable activities during the tax year Include relevant statistical information such as the Expenses number of organizations and other beneficiaries sowed, conferences convened, research papers produced, etc
iPROVZDE MONETARY AWARDS TO CHARITABLE RELIGIOUS LITERARY EDUCATIONAL, OR OTHER WORTHY INSTITUTIONAL NEEDS .
2
3
4
Part X Minimum Investment Return (All domestic foundations must complete this part Foreign foundations, see instructions ) 1 Fair market value of assets nod used (or held for use) directly in carrying out chantable, etc , purposes
2 Average monthly fair market value of securities b Average of monthly cash balances
C Fair market vows of an other assets 0 Total (add lines 1a, b, and c)
a Reduction claimed for blockage or other factors reported on lines 1a and
1c (attach detailed explanation) 1a
2 Acquisition indebtedness applicable to line 1 assets 3 Subtract line 2 from line 10
d Cash deemed held tar charitable actni6es Enter 1 1/2% of line 3 (for greater amount, see instructions) 5 Not value of nonchanta619-use assets Subtract line 4 from line 3 Enter here and on Part V. line 4 6 Minimum Investment return Enter 5% of line 5
7
Form 990-PF(2002) HOME STATE BANK CHARITABLE FOUNDATION 42-1378344 Page 7 PartlX-8 Summary of Program-Related Investments
two lamest oroaam-related investments made by the foundapon dunno the tax vear on lines 1 and 2 1
2
All other program-related investments See instructions 3
Total Add lines 1 through 3
Gr ~Xl DIStribUtabl6 Amount (see instructions) (Section 4942(j)(3) and (1)(5) private operating foundations and certain foreign organizations check here 1 O and do not complete this part
t Minimum investment return from Part X, line 6 7 7 , 564 .
2a Tax on investment income for 2002 from Part VI, line 5 2a 55 .
6 Income tax for 2002 (This does not include the tax from Pad VI ) 2h
c Add lines 2a and 2b 2s 5 5 .
3 Distnbufable amount before adjustments Subtract line 2c from line 1 3 7 509 .
4 a Recoveries of amounts treated as qualifying distributions 4a 0 .
6 Income distributions from section 4947(a)(2) trusts 4h Q
c Add lines 4a and 4b 4e 0
5 Add lines 3 and 4c 5 7 , 509 .
g Deduction from distnbuta6le amount (see instructions) ~ B ~ 0 .
7 Olatributable amount as adjusted Subtract line 6 from line 5 Enter here and on Part XIII, line 1 7 7,509 . Part X!E Qualifying Distributions see instructions)
1 Amounts paid (including administrative expenses) to accomplish chanWble, etc , purposes
a Expenses, contributions, gifts. etc -total from Part I, column (A), line 26 `la 30 , 238 .
h Program-related investments -Total from Part IX-B 111 0 .
2 Amounts paid to acquire assets used (or held for use) directly in carrying out charitable, etc , purposes 2
3 Amounts set aside for specific charitable projects that satisfy the I
a Suitability test (prior IRS approval required) 3a
h Cash distribution test (attach tie required schedule) 3h
d Qualifying distributions Add lines 1a through 3b Enter here and on Part V, line 8, and Part XIII, line 4 0 30 , 238 . 5 Organizations that quality under section 4940(e) for the reduced ate of tax an net investment
income Enter 1 % of Part I, line 27b 5 0 .
6 Adjusted qua lltylnp OIctrIGUtlonc Subtract line 5 from dine a r 6 ~ 30, T38 .
Note The amount online 6 will be used in Pat V, column (b), in subsequent years when calculating whether the foundation qualifies for the section 4940(e) reduction of tar in those years
Foam 990-PF Rmx) mssi
ai zam
Form 990-PF(2002) HOME STATE BANK CHARITABLE FOUNDATION 42-1378344 Page B Part Xllt Undistributed Income (see instructions)
181 (hl Icl lal
Corpus Years prior to 2001 2001 2002
1 Distnbutabte amount
for2002from Part xl,line 7 509 .
UiqbtriDUte0lnewrq 11 anY, n of lea eM 012001
a Enter amount for 2001 only ~ 0'.
b Total far poor years
3 Excess distributions carryover, it any, to 2002 0 .
' ' eFrom i997 23 , 699 .
hFrom 1998 23 133 . cFrom ts9s 24 , 455 . '
dFrom 2000 22 665 . e From 2007 43 , 301 .
I iouiotlines 3athrough e 137 253 . d ClualiTyinq distributions for 2002 tram
Part 7(Il,line 4 " S 30 , 238 .
a Applied to 2001, but not more than line 2a h Applied to undistributed income of poor
years (Election required -see instructions) 0 .
c Treated as distributions out of corpus ,
(Election required - see instructions) 0 .
d Applied to 2002 Aistributable amount 7 , 509 .
e Remaining amount distributed out of corpus 22 , 7 2 9 .
5 Emus GISMDULOna carryout appllaE to 2002 0 .
of N YIDUnt /PpYl71A COIYRYI (EL We 1N1e ~UlII ,