Return of Private Foundation. or Section 4947( a)(1) Nonexempt Charitable Trust Treated as a Private Foundation. Name chang e

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1 C cl^j 990 -PFI Return of Private Foundation Fonn or Section 4947( a)(1) Nonexempt Charitable Trust Treated as a Private Foundation Department of the Treasury Internal Revenue Sennce Note The foundation may be able to use a copy of this return to satisfy state reporting requirements For calendar year 2012 or tax year beginning 12/01, 2012, and endii Name of foundation JACK ADJMT FAMILY FOUNDATION. INC. Number and street ( or P 0 box number If mail is not delivered to street address ) 463 SEVENTH AVENUE, 4TH FLOOR City or town, state, and ZIP code NEW YORK, NY A OMB No / Employer identification number Room/suite B Telephone number ( see instructions) (212) C If exemption application is, q pending, check here G Check all that apply : Initial return Initial return of a former public charity D 1 Foreign organ izations. check here El Final return Amended return 2 Foreign organizations meeting the 85% test, check here and attach Address change Name chang e computation... H Check type of organization X Section 501 ( cj 3 exempt private foundation E If private foundation status was terminated Section 4947 ( a )( 1 nonexem p t charitable trust Other taxable p rivate foundation under section 507(bxlXA ), check here. Ill. El I Fair market value of all assets at end J Accountin g method X Cash L_J Accrual of year (from Part Il, col. (c), line 16) 10- $ 17 0, Analysis of Revenue and Expenses (The total of amounts in columns (b), (c), and (d) may not necessarily equal the amounts in column (a) (see instructions 0 Other ( specify) (Part 1, column (d) must be on cash basis) (a ) Revenue and expenses per books, 1 Contributions Rts, grants, etc received ( attach schedule ) 3,750, Check if the foundation is not required to attach Sch B Interest on savings and temporary cash investments 4 Dividends and interest from securities 5a Gross rents b Net rental income or (loss) o 6a Net gain or ( loss) from sale of assets not on line 10 O 0 b Gross sales puce for all o assets on line 6a w 7 Capital gain net income (from Part IV, line 2) LIA 8 Net short -term capital gain Income modifications a Gross sales less returns and allowances b Less Cost of goods sold, c Gross profit or (loss ) ( attach schedule),,,, 11 Other income ( attach schedule ),,,, 12 Total. Add lines 1 throu g h 11 3, 750, Compensation of officers, directors, trustees, etc 0 14 Other employee salps3 / Iti QvapesC D. 15 Pension pla s, Iove^e-beeneCflt_sv E X 16a Legal fees ( Oeh schedule ).., W b Accounting Qi (att3e sehque)2a14 > c Other profe slonal fees ( attach schedule). 17 Interest..-. ^ p 18 Taxes ( attach LS1I UT 19 Depreciation (attach schedule ) and depletion. 20 Occupancy Travel, conferences, and meetings....., Printing and publications ,, 23 Other expenses (attach schedule )A.TCH.L 1 (b) Net investment income 2, , 497. F If the foundation is in a 60-month termination under section 507(b )( 1)(B), check here ( c) Adjusted net income (d) Disbursements for charitable purposes ( cash basis onl y) 24 Total operating and administrative expenses. Add lines 13 through 23. 2,497. 2, Contributions, gifts, grants paid , 769, ,769, Total expenses and disbursements Add lines 24 and 25 3,772,360. 2,497. 3, 7 69, Subtract line 26 from line 12 a Excess of revenue over expenses and disbursements -21,752. b Net investment income ( if negative, enter -0-) 0 c Adjusted net income ( if negative, enter -0- ).. JSA For Paperwork Reduction Act Notice, see instructions. Form UUU-Pt- (2012) 2E /1/^' V' V

2 Form 990-PF ( 2012 ) JACK ADJMI FAMILY FOUNDATION, INC Page 2 Attached schedules and amounts in the Beginning of year End of year Balance Sheets description column should be for endof-year amounts only (See instructions ) ( a) Book Value ( b) Book Value (c) Fair Market Value ' Cash - non-interest - bearing , , , Savings and temporary cash investments Accounts receivable Less - allowance for doubtful accounts Pledges receivable Less allowance for doubtful accounts 5 Grants receivable Receivables due from officers, directors, trustees, and other disqualified persons ( attach schedule ) ( see instructions),,,, 7 Other notes and loans receivable ( attach schedule ) Less- allowance for doubtful accounts Inventories for sale or use 9 Prepaid expenses and deferred charges a Investments - U S and state government obligations ( attach schedule), b Investments - corporate stock ( attach schedule ),,,,.... c Investments - corporate bonds ( attach schedule ),,,,,,,, 11 Investments - land, buildings, and equipment basis Less accumulated depreciation (attach schedule ) Investments - mortgage loans Investments - other ( attach schedule ) Land, buildings, and equipment basis Less accumulated depreciation (attach schedule ) Other assets ( describe ) 16 Total assets ( to be completed by all filers - see the instructions Also, see page 1, item I). 191, , , Accounts payable and accrued expenses,,,,,,,,,,, 18 Grants payable,,,,,,,,,,,,,,,,,,,,,,, 19 Deferred revenue Loans from officers, directors, trustees, and other disqualified persons m_ 21 Mortgages and other notes payable ( attach schedule)..... J 22 Other liabilities ( describe ) U) d co 23 Total liabilities ( add lines 17 through 22). 0 Foundations that follow SFAS 117, check here and complete lines 24 through 26 and lines 30 and Unrestricted R 25 Temporarily restricted n N 26 Permanently restricted Foundations that do not follow SFAS 117, check here and complete lines 27 through Capital stock, trust principal, or current funds,,,,,,,,, 28 Paid - in or capital surplus, or land, bldg, and equipment fund..... Q 29 Retained earnings, accumulated income, endowment, or other funds, 191, ,240. m 30 Total net assets or fund balances ( see instructions ),,,,,, 191, ,240. Z 31 Total liabilities and net assets /fund balances (see instructions ) , ,240. Analysis of Chan g es in Net Assets or Fund Balances 1 Total net assets or fund balances at beginning of year - Part II, column (a), line 30 ( must agree with end-of- year figure reported on pnor year ' s return ),,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 1 191, Enter amount from Part I, line 27a ,752 3 Other increases not included in line 2 ( Itemize) Add lines 1, 2, and ,240 5 Decreases not included in line 2 ( itemize )Ill. _ 5 6 Total net assets or fund balances at end ofearline 4 minus line 5 - Part II, column ( b ), line ,240 Form 990-PF (2012) JSA 2E

3 JACK ADJMI FAMILY FOUNDATION, INC Form 990-PF(2012) Page 3 1a b c d e a b c d e a Capital Gains and Losses for Tax on Investment Income (e) Gross sales price (a) List and describe the kind(s) of property sold (e g real estate, 2-story brick warehouse, or common stock, 200 shs MLC Co) (f) Depreciation allowed (or allowable) (g) Cost or other basis plus expense of sale acquired D - Don on (c) Date acquired (mo, day, yr) (h) Gain or (loss) (e) plus (f) minus (g) (d) Date sold (mo, day, yr ) Com p lete onl y for assets showin g gain in column ( h ) and owned by the foundation on 12/31/69 (I) Gains (Col (h) gain minus (I) F M V as of 12/31/69 (l) Adjusted basis (k) Excess of col (i) col (k), but not less than -0-) or as of 12/31/69 over col 0), if any Losses (from col (h)) b c d e If gain, also enter in Part I, line 7 2 Capital gain net income or (net capital loss) { If (loss), enter -0- in Part I, line 7 } 2 3 Net short-term capital gain or (loss) as defined in sections 1222(5) and (6) If gain, also enter in Part I, line 8, column (c) (see instructions). If (loss), enter -0- in Part I, line 8 J 3 IMM Qualification Under Section 4940 ( e) for Reduced Tax on Net Investment Income (For optional use by domestic private foundations subject to the section 4940(a) tax on net investment income.) If section 4940(d)(2) applies, leave this part blank. Was the foundation liable for the section 4942 tax on the distributable amount of any year in the base period? q Yes No If "Yes," the foundation does not qualify under section 4940(e). Do not complete this part. i enter the appropriate amount in eacn column Tor eacn ear ; see the instructions Derore makln any entries. Base period years Calendar year ( or tax year beginning in) Adjusted qualifying distributions Net value of noncharrtable use assets Distribution ratio (col (b ) divided by col (c)) ,569, , ,115, , ,888, , ,894, , ,716, , Total of line 1, column (d) Average distribution ratio for the 5 - year base period - divide the total on line 2 by 5, or by the number of years the foundation has been in existence if less than 5 years.,,......, Enter the net value of noncharltable - use assets for 2012 from Part X, line , Multiply line 4 by line 3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 5 2, 449, Enter 1% of net investment income ( 1% of Part I, line 27b) Add lines 5 and 6 7 2, 449, Enter qualifying distributions from Part XII, line 4 8 3, 769, 863. If line 8 is eaual to or greater than line 7. check the box in Part VI. line lb. and complete t hat D art usina a 1% tax rate See the Part VI Instructions. JsA Form 990-PF (2012) 2E`

4 Form 990 -PF (2012) JACK ADJMI FAMILY FOUNDATION, INC Page4 ONVA Excise Tax Based on Investment Income (Section 4940 ( a), 4940 ( b), 4940 ( e), or see instructions) 1 a Exempt operating foundations described in section 4940(d)(2), check here L_j and enter "N/A" on line 1,,, Cate of ruling or determination letter ( attach copy of letter If necessary - see instructions) b Domestic foundations that meet the section 4940(e) requirements in Part V, check 1 0 here 0 andenter 1 % ofparti, line27b c All other domestic foundations enter 2% of line 27b Exempt foreign organizations enter 4% of Part I, line 12, col. (b). 2 Tax under section 511 (domestic section 4947(a)(1) trusts and taxable foundations only Others enter -0-).,, 2 3 Add lines 1 and Subtitle A (income) tax (domestic section 4947(a)(1) trusts and taxable foundations only Others enter -0-) Tax based on investment income. Subtract line 4 from line 3 If zero or less, enter Credits/Payments a 2012 estimated tax payments and 2011 overpayment credited to 2012,,,, 6a b Exempt foreign organizations - tax withheld at source,,,,,,, 6b c Tax paid with application for extension of time to file (Form 8868),,,,,., 6c d Backup withholding erroneously withheld d 7 Total credits and payments Add lines 6a through 6d Enter any penalty for underpayment of estimated tax Check here q if Form 2220 is attached Tax due. If the total of lines 5 and 8 is more than line 7, enter amount owed Overpayment. If line 7 is more than the total of lines 5 and 8, enter the amount overpaid,,,,,, Enter the amount of line 10 to be Credited to 2013 estimated tax Refunded 11 Statements Regarding Activities 1a During the tax year, did the foundation attempt to influence any national, state, or local legislation or did it participate Yes No or intervene in any political campaign? a X b Did it spend more than $100 during the year (either directly or indirectly) for political purposes (see Instructions for the definition)? b X If the answer is "Yes" to 1a or 1b, attach a detailed description of the activities and copies of any materials published or distributed by the foundation in connection with the activities c Did the foundation file Form POL for this year?,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 1c X d Enter the amount (if any) of tax on political expenditures (section 4955) imposed during the year (1) On the foundation $ (2) On foundation managers $ e Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed on foundation managers $ 2 Has the foundation engaged in any activities that have not previously been reported to the IRS? _, _, _,,,.,., 2 X If "Yes,' attach a detailed description of the activities 3 Has the foundation 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 a conformed copy of the changes X 4a Did the foundation have unrelated business gross income of $1,000 or more during the year? a X b If "Yes," has it filed a tax return on Form 990 -T for this year?,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 4b 5 Was there a liquidation, termination, dissolution, or substantial contraction during the year?,,,,,,,,,,,,,,,,,, 5 X If "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? X 7 Did the foundation have at least $5,000 in assets at any time during the year? If "Yes," complete Part Il, col (c), and Part XV 7 X 8a Enter the states to which the foundation reports or with which it is registered (see instructions) NY, b If the answer is "Yes" to line 7, has the foundation furnished 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 b X 9 Is the foundation claiming status as a private operating foundation within the meaning of section 4942(j)(3) or 4942(j)(5) for calendar year 2012 or the taxable year beginning in 2012 (see instructions for Part XIV)? If "Yes," complete Part XIV... 9 X 10 Did any persons become substantial contributors during the tax year? If "Yes," attach a schedule listing their names and addresses..... ATCH X Form 990-PF (2012) JSA 2E

5 Form 990-PF (2012) JACK ADJMI FAMILY FOUNDATION, INC Page5 Statements Re g arding Activities (continued) 11 At any time during the year, did the foundation, directly or indirectly, own a controlled entity within the rheaning of section 512(b)(13)' If "Yes," attach schedule (see instructions X 12 Did the foundation make a distribution to a donor advised fund over which the foundation or a disqualified person had advisory privileges' If "Yes," attach statement (see instructions) X 13 Did the foundation comply with the public inspection requirements for its annual returns and exemption application? X Website address N/A The books are in care of ADJMI Telephone no Located at, 4TH FLOOR NEW YORK, NY ZIP Section 4947(a)(1) nonexempt charitable trusts filing Form 990-PF in lieu of Form Check here and enter the amount of tax-exempt interest received or accrued during the year At any time during calendar year 2012, did the foundation have an interest in or a signature or other authority Yes No over a bank, securities, or other financial account in a foreign country X See the instructions for exceptions and filing requirements for Form TD F If "Yes," enter the name of the forei g n countr y 01TUR": lip. Statements Re g ardin g Activities for Which Form 4720 May Be Re quired File Form 4720 if any item is checked in the "Yes" column, unless an exception applies. Yes No 1 a During the year did the foundation (either directly or indirectly) (1) Engage in the sale or exchange, or leasing of property with a disqualified person? q Yes q No (2) Borrow money from, lend money to, or otherwise extend credit to (or accept it from) a disqualified person? Yes X No (3) Furnish goods, services, or facilities to (or accept them from) a disqualified person' Yes X No (4) Pay compensation to, or pay or reimburse the expenses of, a disqualified person? Yes X 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)? q Yes No (6) Agree to pay money or property to a government official? ( Exception. Check "No" if the foundation agreed to make a grant to or to employ the official for a period after termination of government service, if terminating within 90 days ) q Yes No b If any answer is "Yes" to la(1)-(6), did any of the acts fail to qualify under the exceptions described in Regulations section (d)-3 or in a current notice regarding disaster assistance (see instructions)' b Organizations relying on a current notice regarding disaster assistance check here q c Did the foundation 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 c X 2 Taxes on failure to distribute income (section 4942) (does not apply for years the foundation was a private operating foundation defined in section 4942(j)(3) or 4942(j)(5)) a At the end of tax year 2012, did the foundation have any undistributed income (lines 6d and 6e, Part XIII) for tax year(s) beginning before q Yes q No If "Yes," list the years ' ' ' b Are there any years listed in 2a for which the foundation is not applying the provisions of section 4942(a)(2) (relating to incorrect valuation of assets) to the year's undistributed income? (If applying section 4942(a)(2) to all years listed, answer "No" and attach statement -see instructions) b X c If the provisions of section 4942(a)(2) are being applied to any of the years listed in 2a, list the years here 3a Did the foundation hold more than a 2% direct or indirect interest in any business enterprise at any time during the year? q Yes No b If "Yes," did it have excess business holdings in 2012 as a result of (1) any purchase by the foundation or disqualified 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) the lapse of the 10-, 15-, or 20-year first phase holding period? (Use Schedule C, Form 4720, to determine if the foundation had excess business holdings in 2012) a Did the foundation invest during the year any amount in a manner that would jeopardize its charitable purposes'..,.. 4a X b Did the foundation make any investment in a prior year (but after December 31, 1969) that could jeopardize its charitable ouroose that had not been removed from ieooardv before the first day of the tax year beainnina in 2012?.. 4b X Form 990-PF (2012) JSA 2E

6 Form PF (2012 ) JACK ADJMI FAMILY FOUNDATION, INC Page 6 Statements Regarding Activities for Which Form 4720 May Be Re q uired (continued) 5a During the year did the foundation pay or incur any amount to (1) Carry on propaganda, or otherwise attempt to influence legislation (section 4945 ( e))? q Yes No (2) Influence the outcome of any specific public election ( see section 4955 ), or to carry on, directly or indirectly, any voter registration drive? Yes X No (3) Provide a grant to an individual for travel, study, or other similar purposes? Yes X No (4) Provide a grant to an organization other than a charitable, etc, organization described in section 509 ( a)(1), (2), or ( 3), or section 4940 ( d)(2)? (see instructions ) q Yes 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, q Yes q No b If any answer is "Yes " to 5a(1 )-( 5), did any of the transactions fail to qualify under the exceptions described in Regulations section or in a current notice regarding disaster assistance ( see instructions )? , 5b Organizations relying on a current notice regarding disaster assistance check here q c If the answer is "Yes" to question 5a ( 4), does the foundation claim exemption from the tax because it maintained expenditure responsibility for the grant? q Yes q No If "Yes," attach the statement required by Regulations section (d) 6a Did the foundation, during the year, receive any funds, directly or indirectly, to pay premiums on a personal benefit contract q Yes q No b Did the foundation, during the year, pay premiums, directly or indirectly, on a personal benefit contract? b X If "Yes" to 6b, file Form a At any time during the tax year, was the foundation a party to a prohibited tax shelter transaction? q Yes q No b If "Yes," did the foundation receive any proceeds or have any net income attributable to the transactions.... 7b Information About Officers, Directors, Trustees, Foundation Managers, Highly Paid Employees, 1 List all officers. directors. trustees. foundation manaaers and their compensation (see instructionsi. ( b) Title, and average (c) Compensation ( d) Contributions to (a) Name and address hours per week ( If not paid, employee benefit plans devoted to p osition enter -0- and deferred compensation ( e) Expense account, other allowances ATCH z Compensation of rive mgnest-pate employees (otner tnan tnose inctudea on line 1 - see instructions). it none, enter "NONE." (a) Name and address of each employee paid more than $50,000 (b) Title, and average ( d) Contributions to hours per week employee benefit (c) Compensation (e) Expense account, devoted to position plans and deferred other allowances compensation NONE Total number of other em p loyees paid over $50,000. Form 990-PF (2012) JSA 2E

7 JACK ADJMI FAMILY FOUNDATION, INC Form 990 -PF (2012) Page 7 Information About Officers, Directors, Trustees, Foundation Managers, Highly Paid Employees, and Contractors (continued) 3 Five highest - paid independent contractors for professional services ( see instructions ). If none, enter "NONE." (a) Name and address of each person paid more than $50,000 ( b) Type of service (c) Compensation NONE Total number of others receiving over $50,000 for professional services.. Summary of Direct Charitable Activities List the foundation 's four largest direct chartable activities during the tax year Include relevant statistical information such as the number of organizations and other beneficiaries served, conferences convened, research papers produced, etc en 1 N/A i Summary of Proaram - Related Investments (see instructions) Describe the two largest program - related investments made by the foundation during the tax year on lines 1 and 2 Amount 1 NONE All other program -related investments See instructions 3 NONE Total. Add lines 1 throug h 3. Form 990-PF (2012) JSA 2E

8 JACK ADJMI FAMILY FOUNDATION, INC Form 990-PF(2012) Page 8 Minimum investment Return (All domestic foundations must complete this part. Foreign foundations, see instructions.) I Fair market value of assets not used (or held for use) directly in carrying out charitable, etc., purposesa Average monthly fair market value of securities a b Average of monthly cash balances lb 169,371. c Fair market value of all other assets (see instructions)... ic d Total (add lines 1a, b, and c).... id 169,371. e Reduction claimed for blockage or other factors reported on lines 1a and 1c (attach detailed explanation) le 2 Acquisition indebtedness applicable to line 1 assets Subtract line 2 from line ld , Cash deemed held for charitable activities. Enter 1 1/2% of line 3 (for greater amount, see instructions) , Net value of noncharitable - use assets. Subtract line 4 from line 3. Enter here and on Part V, line , Minimum investment return. Enter 5% of line 5 6 8, 342. Distributable Amount (see instructions) (Section 49420)(3) and 0)(5) private operating foundations and certain foreign organizations check here and do not complete this part ) 1 Minimum investment return from Part X, line , a Tax on investment income for 2012 from Part VI, line 5 2a b Income tax for 2012 (This does not include the tax from Part VI.)... 2b c Add lines 2a and 2b 2c 3 Distributable amount before adjustments Subtract line 2c from line 1,,,,,,,,,,,,,,,,,, 3 8, Recoveries of amounts treated as qualifying distributions,,,,,,,,,,,,,,,,,,,,, 4 5 Add lines 3 and , Deduction from distributable amount (see instructions) Distributable amount as adjusted Subtract line 6 from line 5. Enter here and on Part XIII, line 1 7 8,342. Qualifying Distributions (see instructions) I Amounts paid (including administrative expenses) to accomplish chantable, etc, purposesa Expenses, contributions, gifts, etc - total from Part I, column (d), line a 3,769,863. b Program-related investments - total from Part IX-B... 1 b 2 Amounts paid to acquire assets used (or held for use) directly in carrying out charitable, etc., purposes Amounts set aside for specific charitable projects that satisfy he, a Suitability test (prior IRS approval required) 3a b Cash distribution test (attach the required schedule ).....,... 3b 4 Qualifying distributions. Add lines 1 a through 3b Enter here and on Part V, line 8, and Part XIII, line ,769, Foundations that qualify under section 4940(e) for the reduced rate of tax on net investment income. Enter 1 % of Part 1, line 27b (see instructions) Adjusted qualifying distributions. Subtract line 5 from line ,769, 863. Note. The amount on line 6 will be used in Part V, column (b), in subsequent years when cal culati ng whether the foundation qualifies for the section 4940(e) reduction of tax in those years. Form 990-PF (2012) JSA 2E

9 JACK ADJMI FAMILY FOUNDATION, INC Form 990 -PF (2012) Page 9 Undistributed Income ( see instructions) (a) (b) (c) (d) 1 Distributable amount for 2012 from Part XI, Corpus Years prior to line7 8,342., 2 Undistributed income, if any, as of the end of 2012 a Enter amount for 2011 only,,,,.,,,,, b Total for pnoryears 20 10, Excess distributions carryover if any, to 2012 a From ,707,264. b From , 889, 586. c From , 879, 521. d From2010 2,102,087. e From ,563,047. f Total of lines 3a through e,,,, _,,.,. 11,141, Qualifying distributions for 2012 from Part XII, line4 $ 3,769,863. a Applied to 2011, but not more than line 2a b Applied to undistributed income of prior years (Election required - see instructions ) c Treated as distributions out of corpus ( Election required - see instructions ) d Applied to 2012 distributable amount,,,,, 8,342. e Remaining amount distributed out of corpus.. 3,761, Excess distributions carryover applied to 2012, (If an amount appears in column (a), the same amount must be shown in column (a) ) 6 Enter the net total of each column as indicated below: a Corpus Add lines 3f, 4c, and 4e Subtract line 5 14, 903, 026. b Prior years' undistributed income Subtract line 4b from line 2b c Enter the amount of prior years ' undistributed income for which a notice of deficiency has been issued, or on which the section 4942 ( a) tax has been previously assessed d Subtract line 6c from line 6b Taxable amount - see instructions e Undistributed income for 2011 Subtract line 4a from line 2a Taxable amount - see instructions f Undistributed income for 2012 Subtract lines 4d and 5 from line 1 This amount must be distributed in Amounts treated as distributions out of corpus to satisfy requirements imposed by section 170(b )( 1 )(F) or 4942 ( g)(3) (see instructions) 8 Excess distributions carryover from 2007 not applied on line 5 or line 7 (see instructions ).. 2,707, Excess distributions carryover to Subtract lines 7 and 8 from line 6a 12, 195, Analysis of line 9 a Excess from , 889, 586. b Excess from , 879, 521. c Excess from , 102, 087. d Excess from , 563, 047. e Excess from ,761,521. Form 990-PF (2012) JSA 2E

10 Form 990 -PF (2012 ) JACK ADJMI FAMILY FOUNDATION, INC Page10 Private O peratin g Foundations ( see instructions and Part VII-A, q uestion 9 ) NOT APPLICABLE 1 a If the foundation has received a ruling or determination letter that it is a private operating foundation, and the ruling is effective for 2012, enter the date of the ruling b Check box to indicate whether the foundation is a private operating foundation described in section 4942(1)(3) or 4942(1)(5) 2a Enter the lesser of the adjusted net income from Part I or the minimum investment return from Part X for each year listed Tax year Prior 3 years (a) 2012 (b) 2011 (c) 2010 ( d) 2009 (e) T otal b 85% of line 2a C Qualifying distributions from Part XII, line 4 for each year listed. d Amounts included in line 2c not used directly for active conduct of exempt activities..... e Qualifying distributions made directly for active conduct of exempt activities Subtract line 2d from line 2c Complete 3a, b or c for the alternative test relied upon a -Assets" alternative test - enter (1) Value of all assets... (2) Value of assets qualifying under section 49420)(3XBXi)..... b "Endowment" alternative testenter 2/3 of minimum investment return shown in Part X. line 6 for each year listed.. C "Support" alternative test - enter (1) Total support other. than gross investment income (interest, dividends, rents payments on securities loans (section 512(a)(5)), or royalties).... (2) Support from general public and 5 or more exempt organizations as provided in section X3)(Bfw) (3) Largest amount of support from an exempt organization,,,,, ( 4 ) Gross investment income, Supplementary Information (Complete this part only if the foundation had $5, 000 or more in assets at any time during the year - see instructions.) 1 Information Regarding Foundation Managers: a List any managers of the foundation who have contributed more than 2% of the total contributions received by the foundation before the close of any tax year (but only if they have contributed more than $5,000). (See section 507(d)(2).) ERIC ADJMI b List any managers of the foundation who own 10% or more of the stock of a corporation (or an equally large portion of the ownership of a partnership or other entity) of which the foundation has a 10% or greater interest. NONE 2 Information Regarding Contribution, Grant, Gift, Loan, Scholarship, etc., Programs: a Check here q if the foundation only makes contributions to preselected charitable organizations and does not accept unsolicited requests for funds. If the foundation makes gifts, grants, etc. (see instructions) to individuals or organizations under other conditions, complete items 2a, b, c, and d. The name, address, and telephone number or of the person to whom applications should be addressed: ATCH 4 b The form in which applications should be submitted and information and materials they should include c ATCH 5 Any submission deadlines- THERE ARE NO SUBMISSION DEADLINES. d Any restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other factors MUST FURTHER THE GOALS SET OUT IN THE FOUNDATION. 2Et Form 990-PF (2012)

11 JACK ADJMI FAMILY FOUNDATION, INC Form 990-PF (2012) Page 11 Supplementary Information (continued) 3 Grants and Contributions Paid During the Year or Approved for Future Payment If recipient is an mdmdual. Reci p ient Foundation show any relationship to Purpose of grant or any f A foundation manager mount contribution Name and address (home or business) or su bstantial contnbutor irecip unt p ient a Paid during the year ATCH 6 b Total... 3a 3, 769, 863. Approved for future payment Total JSA 2E b Form 990-PF (2012)

12 JACK ADJMI FAMILY FOUNDATION, INC Form 990-PF (2012 ) Page 12 OREM Analysis of Income - Producing Activities Enter dross amounts unless otherwise indicated Unrelated business income Excluded by section 512, 513, or 514 (e) Related or exempt (a) (b) (c) (d) function income 1 Program service revenue Business code Amount Exclusion code Amount ( See instructions a b c d e f g Fees and contracts from government agencies 2 Membership dues and assessments Interest on savings and temporary cash investments 4 Dividends and interest from securities 5 Net rental income or (loss) from real estate a Debt -financed property,,,,,,.,, b Not debt - financed property,,,,, 6 Net rental income or (loss) from personal property, 7 Other investment income Gain or ( loss) from sales of assets other than inventory 9 Net income or (loss ) from special events 10 Gross profit or ( loss) from sales of inventory. 11 Other revenue a b c d IS 12 Subtotal Add columns ( b), (d), and ( e) 13 Total. Add line 12, columns ( b), (d), and ( e) (See worksheet in line 13 instructions to verify calculations ) 10maxyle :1 Relationship of Activities to the Accomplishment of Exempt Purposes Line No. Explain below how each activity for which income is reported in column (e) of Part XVI-A contributed importantly to the y accomplishment of the foundation ' s exempt purposes ( other than by providing funds for such purposes) (See instructions.) JSA Form 990-PF (2012) 2E

13 Form 990 -PF(2012 ) JACK ADJMI FAMILY FOUNDATION, INC Page 13 Information Regarding Transfers To and Transactions and Relationships With Noncharitable Exempt Organizations a b Did the organization directly or indirectly engage in any of the following with any other organization described in section 501(c) of the Code (other than section 501 (c)(3) organizations) or in section 527, relating to political organizations? Transfers from the reporting foundation to a noncharitable exempt organization of: ( 1 ) Ca s h a1 X (2) Other assets a 2 X Other transactions: (1) Sales of assets to a noncharitable exempt organization b ( i ) X (2) Purchases of assets from a noncharltable exempt organization lb ( 2 ) X (3) Rental of facilities, equipment, or other assets lb ( 3 ) X (4) Reimbursement arrangements lb ( 4 ) X (5) Loans or loan guarantees b ( 5 ) X (6) Performance of services or membership or fundraising solicitations lb ( 6 ) X c Sharing of facilities, equipment, mailing lists, other assets, or paid employees c X d If the answer to any of the above is "Yes," complete the following schedule. Column (b) should always show the fair market value of the goods, other assets, or services given by the reporting foundation If the foundation received less than fair market value in any transaction or sharing arrangement, show in column (d) the value of the goods, other assets, or service s received (a) Line no (b) Amount involved (c) Name of nonchantable exempt organization (d) Description of transfers, transactions, and sharing arrangements N/A N/A 2a Is the foundation directly or indirectly affiliated with, or related to, one or more tax-exempt organizations described in section 501 ( c) of the Code ( other than section 501 (c )( 3)) or in section 527? q Yes No b If "Yes," complete the followinq schedule (a) Name of organization (b) Type of organization (c) Description of relationship Sign Here Under penalties of perlu ec 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 comple la n p parer ( other than taxpayer) is based on all information of which preparer has any knowledge Ma the IRS discuss this return Slgna of officer or trustee Date Print/Type preparer's name Paid o.atthew MULLANEY Preparer's slgnatu 2E

14 Schedule B (Form 990, 990-EZ, or 990-PF) Department of the Treasury Internal Revenue Service Name of the organization JACK ADJMI FAMILY FOUNDATION, INC. Organization type (check one) Schedule of Contributors Attach to Form 990, Form 990-EZ, or Form 990-PF. OMB No Employer identification number Filers of: Form 990 or 990-EZ Section: q 501(c)( ) ( enter number ) organization q 4947( a)(1) nonexempt charitable trust not treated as a private foundation q 527 political organization Form 990-PF 501(c)( 3) exempt private foundation q 4947( a)(1) nonexempt charitable trust treated as a private foundation q 501(c)( 3) taxable private foundation Check if your organization is covered by the General Rule or a Special Rule. Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions General Rule For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, $5,000 or more (in money or property) from any one contributor Complete Parts I and II Special Rules q For a section 501(c)(3) organization filing Form 990 or 990-EZ that met the 33 1/3 % support test of the regulations under sections 509(a)(1) and 170(b)(1)(A)(vi) and received from any one contributor, during the year, a contribution of the greater of (1) $5,000 or (2) 2% of the amount on (I) Form 990, Part VIII, line 1 h, or (it) Form 990-EZ, line 1. Complete Parts I and II. q For a section 501 (c)(7), (8), or (10) organization filing Form 990 or 990-EZ that received from any one contributor, during the year, total contributions of more than $1,000 for use exclusively for religious, charitable, scientific, literary, or educational purposes, or the prevention of cruelty to children or animals Complete Parts I, II, and Ill. q For a section 501(c)(7), (8), or (10) organization filing Form 990 or 990-EZ that received from any one contributor, during the year, contributions for use exclusively for religious, charitable, etc., purposes, but these contributions did not total to more than $1,000. If this box is checked, enter here the total contributions that were received during the year for an exclusively religious, charitable, etc, purpose Do not complete any of the parts unless the General Rule applies to this organization because it received nonexclusively religious, charitable, etc., contributions of $5,000 or more during the year $ Caution. An organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990, 990-EZ, or 990-PF), but it must answer "No" on Part IV, line 2 of its Form 990, or check the box on line H of its Form 990-EZ or on Part I, line 2 of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990, 990-EZ, or 990-PF). For Paperwork Reduction Act Notice, see the Instructions for Form 990, 990-EZ, or 990-PF Schedule B (Form 990, 990-EZ, or 990-PF) (2012) JSA 2E

15 Schedule B ( Form 990, 990-EZ, or 990 -PF) (2012) Page 2 Name of organization JACK ADJMI FAMILY FOUNDATION, INC. 7 Contributors (see instructions). Use duplicate copies of Part I if additional space is needed. Employer identification number (a) (b) (c) (d) No. Name, address, and ZIP + 4 Total contributions Type of contribution 1 - ERIC -ADJMI Person Payroll 463 7TH AVENUE, 4TH FLOOR $ - 43, Noncash (Complete Part II If there is NEW YORK, NY a noncash contribution ) (a) (b) (c) (d) No. Name, address, and ZIP + 4 Total contributions Type of contribution 2- BELU GA -INC TH AVENUE, 4TH FLOOR Person Payroll $ -91, Noncash (Complete Part II If there is NEW YORK, NY a noncash contribution.) (a) (b) (c) (d) No. Name, address, and ZIP + 4 Total contributions Type of contribution 3- I FG CORPORATION Person Payroll 463-7TH - AVENUE, - 4TH - FLOOR $ ,829,000_ Noncash (Complete Part II If there is NEW YORK, NY a noncash contribution ) (a) (b) (c) (d) No. Name, address, and ZIP + 4 Total contributions Type of contribution 4 KIM- DABAH Person Payroll 463 7TH AVENUE, 4TH FLOOR Noncash (Complete Part II if there is NEW YORK, NY a noncash contribution ) (a) (b) (c) (d) No. Name, address, and ZIP + 4 Total contributions Type of contribution 5- MARK-ADJMI Person Payroll 463 7TH AVENUE, 4TH FLOOR $ _ ,000 _ Noncash (Complete Part II if there is NEW YORK, NY a noncash contribution.) (a) (b) (c) (d) No. Name, address, and ZIP + 4 Total contributions Type of contribution 6- RACH EL - ADJMI Person Payroll 463-7TH - AVENUE, - 4TH - FLOOR $ _ 60,000. Noncash (Complete Part II if there is NEW YORK, NY a noncash contribution ) JSA Schedule B (Form 990, 990-EZ, or 990-PF) (2012) 2E

16 Schedule B (Form 990, 990-EZ, or 990 -PF) (2012) Page 2 Name of organization JACK ADJMI FAMILY FOUNDATION, INC. Employer Identification number Contributors ( see instructions ). Use duplicate copies of Part I if additional space is needed. (a) (b) (c) (d) No. Name, address, and ZIP + 4 Total contributions Type of contribution 7- RONALD ADJMI - - Person Payroll 463-7TH - AVENUE, - 4TH - FLOOR $ ,500_ Noncash (Complete Part II if there is NEW YORK, NY a noncash contribution.) (a) (b) (c) (d) No. Name, address, and ZIP + 4 Total contributions Type of contribution 8- MAG -BRANDS Person Payroll 463-7TH - AVENUE, - 4TH - FLOOR $ ,878_ Noncash (Complete Part II if there is NEW YORK, NY a noncash contribution.) (a) (b) (c) (d) No. Name, address, and ZIP + 4 Total contributions Type of contribution 9- PS- - BRANDS Person Payroll 463-7TH - AVENUE, - 4TH - FLOOR 7,066_ Noncash NEW YORK, NY (Complete Part II If there is a noncash contribution.) (a) (b) (d) No. Name, address, and ZIP + 4 tions Type of contribution Person Payroll Noncash (Complete Part II if there is a noncash contribution.) (a) (b) (d) No. Name, address, and ZIP + 4 utions Type of contribution Person Payroll Noncash (Complete Part II if there is a noncash contribution ) (a) (b) (c) (d) No. Name, address, and ZIP + 4 Total contributions Type of contribution Person Payroll $ Noncash (Complete Part II If there is a noncash contribution ) JSA Schedule B (Form 990, 990-EZ, or 990-PF) (2012) 2E

17 Schedule B (Form 990, 990-EZ, or 990 -PF) (2012) Pa Name of organization JACK ADJMI FAMILY FOUNDATION, INC. Employer identification number Noncash Property ( see instructions ). Use duplicate copies of Part II if additional space is needed (a) No. (c) from (b) FMV (or estimate) (d) Description of noncash property given Date received Part I (see instructions) (a) No. (c) from (b) FMV (or estimate) (d) Description of noncash property given Date received Part I (see instructions) a No. from (b) FMV (or estimate) (d) Description of noncash property given Date received Part I (see instructions) (a) No. (c) from (b) FMV (or estimate) (d) Description of noncash property given Date received Part I (see instructions) (a) No. from Part I b (c) ( ) FMV (or estimate) Description of noncash property given (see instructions) d ( ) Date received ano. from (b) FMV (or estimate) (d) Description of noncash property given Date received Part I (see instructions) JSA Schedule B (Form 990, 990-EZ, or 990 -PF) (2012) 2E

18 Schedule B (Form 990, 990-EZ, or 990-PF) (2012) JACK ADJMI FAMILY FOUNDATION, INC Exclusively religious, charitable, etc., individual contributions to section 501(c )( 7), (8), or ( 10) organizations that total more than $1, 000 for the year. Complete columns (a) through ( e) and the following line entry. (a) No. from Part i For organizations completing Part III, enter the total of exclusively religious, charitable, etc., contributions of $1,000 or less for the year. (Enter this information once. See instructions.) $ Use duplicate copies of Part III if additional space is needed. (b) Purpose of gift (c) Use of gift (d) Description of how gift is held (e) Transfer of gift Transferee's name, address, and ZIP + 4 Relationship of transferor to transferee (a) No. from Part l (b) Purpose of gift (c) Use of gift (d) Description of how gift is held (e) Transfer of gift Transferee's name, address, and ZIP + 4 Relationship of transferor to transferee (a) No. from Part I (b) Purpose of gift (c) Use of gift (d) Description of how gift is held (e) Transfer of gift Transferee's name, address, and ZIP + 4 Relationship of transferor to transferee (a) No. from Part I (b) Purpose of gift (c) Use of gift (d) Description of how gift is held (e) Transfer of gift Transferee's name, address, and ZIP + 4 Relationship of transferor to transferee JSA Schedule B (Form 990,990-EZ,or 990-PF) (2012) 2E

19 JACK ADJMI FAMILY FOUNDATION, INC ATTACHMENT 1 FORM 990PF, PART I - OTHER EXPENSES DESCRIPTION BANK CHARGE ADMINISTRATIVE EXPENSES REVENUE AND EXPENSES PER BOOKS ,000. NET INVESTMENT INCOME TOTALS 2,497. 2,497. ATTACHMENT 1

20 JACK ADJMI FAMILY FOUNDATION, INC. FORM 990PF, PART VII-A, LINE 10 - NEW SUBSTANTIAL CONTRIBUTORS ATTACHMENT NAME AND ADDRESS DATE DIRECT PUBLIC SUPPORT KIM DABAH 463 7TH AVENUE, 4TH FLOOR NEW YORK, NY MAG BRANDS 463 7TH AVENUE, 4TH FLOOR NEW YORK, NY PS BRANDS 463 7TH AVENUE, 4TH FLOOR NEW YORK, NY TOTAL CONTRIBUTION AMOUNTS 11/30/ /30/ /30/ , , , , 944. ATTACHMENT 2

21 JACK ADJMI FAMILY FOUNDATION, INC FORM 990PF, PART VIII - LIST OF OFFICERS, DIRECTORS, AND TRUSTEES ATTACHMENT 3 NAME AND ADDRESS TITLE AND AVERAGE HOURS PER WEEK DEVOTED TO POSITION CONTRIBUTIONS EXPENSE ACCT TO EMPLOYEE AND OTHER COMPENSATION BENEFIT PLANS ALLOWANCES RACHEL ADJMI DIRECTOR TH AVENUE, 4TH FLOOR 2.00 NEW YORK, NY ERIC ADJMI DIRECTOR TH AVENUE, 4TH FLOOR 2.00 NEW YORK, NY GRAND TOTALS ATTACHMENT 3

22 JACK ADJMI FAMILY FOUNDATION, INC ATTACHMENT 4 FORM 990PF, PART XV - NAME, ADDRESS AND PHONE FOR APPLICATIONS RACHEL ADJMI 463 7TH AVENUE, 4TH FLOOR NEW YORK, NY 10018

23 JACK ADJMI FAMILY FOUNDATION, INC ATTACHMENT 5 990PF, PART XV - FORM AND CONTENTS OF SUBMITTED APPLICATIONS SUBMIT WRITTEN APPLICATION DESCRIBING APPLICANT, GOALS, USE OF FUNDS, REPORTING PROCEDURES AND BENEFIT TO FOUNDATION.

24 JACK ADJMI FAMILY FOUNDATION, INC RELATIONSHIP TO SUBSTANTIAL CONTRIBUTOR AND RECIPIENT NAME AND ADDRESS FOUNDATION STATUS OF RECIPIENT PURPOSE OF GRANT OR CONTRIBUTION AMOUNT SEE ATTACHED NONE GENERAL CHARITABLE, RELIGIOUS AND EDUCATIONAL PUBLIC CHARITIES PURPOSES 3,769,863 TOTAL CONTRIBUTIONS PAID ATTACHMENT 6

25 Jack Adjmi Family Foundation Charitable Contributions December 1, 2012 through November 30, 2013 Charity Amount A O.M $ Afula Education Center Agudat Ahaba Ve Achva 5000 Agudat Israel Of Borough Park Agudat Israel Of Long Island 1, Agudat Israel Of Madison 1, Agudat Refuah Vechaim Ahaba VeAhva Of Ocean Parkway Ahavas Chesed Ahavat Chaim V'Chesed 1, Ahavat Shalom 1, AN Ezer Congregation 1, AN Ezer Yeshiva 20,00100 Aliyat Bet Chanania 1, Aliyos Shlomo Alzheimer's Association 1, American Friends Irgun Tomchei Torah-Kollelei Ramtot American Cancer Society American Friends Of Agudat Ahaba Ahaba Ve Achva American Friends Of Agudat Ahava Veahva American Friends Of Ahavat Israel American Friends Of Aram Soba 2,00000 American Friends Of Ayelet Hashachar Inc 1,25000 American Friends Of Bais Yitzchak American Friends Of Bait Shemaya 90, American Friends Of Bat Ayin Yeshiva American Friends Of Beer Chaim Yitzchok 3, American Friends Of Be'er Hatorah American Friends Of Beis Maoz American Friends Of Bet Yosef Maron American Friends Of Binyan Av 3,50000 American Friends Of Birkat Efraim 10, American Friends Of Carmei Hair American Friends Of Chaim Layeled American Friends Of Chochmat Shlomo Netiv Meir Inc American Friends Of Darchei Avot American Friends Of Darchei Hashleimus American Friends Of Darchei Noam 1, American Friends Of Dvar Avraham 1, American Friends Of Epirion Shlomo L'Torah VChesed 5, American Friends Of Hebron Yeshiva In Jerusalem Inc 10, American Friends Of I T T K R American Friends Of Imrei Da'at 3, American Friends Of Imrei Noam American Friends Of Institution Noam Hatorah American Friends Of Irgun Tomchei Torah-Kollelei Ramtot American Friends Of Kehilat Kaminetz American Friends Of Kindness & Charity Inc American Friends Of Kiryat Chinuch Lebanim American Friends Of Kol Itzhak American Friends Of Kol Torah Jerusalem 1, American Friends Of Kol Yehuda American Friends Of Kolel Tiferes Yisroel American Friends Of Kollel Avrechim American Friends Of Lev Aharon 9, American Friends Of Levush Malchus American Friends Of Lilmod Ulelamed American Friends Of L'Maan Daat American Friends Of Lomdei Torah American Friends Of Maayanei Torah L'Moshe American Friends Of Meah Shearim 60000

26 Charity Amount American Friends Of Merkaz Hatorah 2, American Friends Of Michkane Meir 19, American Friends Of Mifal Chesed American Friends Of Mosdot Ner David American Friends Of Mosdot Zera Yitzhak American Friends Of Nezer Hatorah American Friends Of Ohev Yisroel American Friends Of Ohr Yosef American Friends Of Oseh Chayil 1, American Friends Of Peer Hashalom American Friends Of Pischei Teshuvah American Friends Of Rabbi Eliezer Hagadol American Friends Of Ramot Torah Schools 1, American Friends Of RTC American Friends Of Ruach Chaim 1, American Friends Of Shaar Hatorah American Friends Of Shehebar Sephardic Center American Friends Of Shemaya School American Friends Of Shetile Zetim 6,05200 American Friends Of Shevach American Friends Of Shoshanim L'David Inc American Friends Of Shuba Israel 3, American Friends Of Sucath David 3,12600 American Friends Of Sutherland Kollel American Friends Of Tiferes Chaim 1,00000 American Friends Of Tiferes Yehoshua American Friends Of Tiferet Zvi 1, American Friends Of Toras Chaim American Friends Of Torat Devash American Friends Of Torat Meir American Friends Of Tzohar American Friends Of Yad Eliezer 1,10000 American Friends Of Yad Shlomo 3,50000 American Friends Of Yeshiva Ahava Torah American Friends Of Yeshiva Birchas Mordechai 1,00000 American Friends Of Yeshiva D'mir 10, American Friends Of Yeshiva Kodshin 1, American Friends Of Yeshiva Mekor Chaim American Friends Of Yeshiva Reishit Chochmah 1,00000 American Friends Of Yeshivas Shearis Yosef Asher Inc American Friends Of Yeshivat Ahavat Torah 1, American Friends Of Yeshivat Chochmat Shlomo American Friends Of Yeshivat Hadrat Melech American Friends Of Yeshivat Nahalat David 1,00000 American Friends Of Yeshivat Oraysoh American Friends Of Yeshivat Rekhasim 8,00000 American Friends Of Yeshivat Shares Ezra American Friends Of Yeshivat Tifrach American Friends Of Yirgun Y R A 2, American Friends Of Zichron Ehyahu 1, American Friends Of Zichron Nachum American Friiends Of Michkane Meir Inc American Yedidim 19, Amudei Chesed 7, Anshe Ma'amed Foundation Ateret Aharon Ateret Avot Ateret Israel Ateret Moshe 1, Ateret Shalom Ateret Torah Center 196, Avenue R Sephardic Congregation 4, Ayelet Hashachar B C A. Inc B M O R

27 Charity Amount Bais Avrohom Bais Binyamin Academy Of Connecticut 3,00000 Bais Chuna Bais Isaac Zvi Bais Medrash Of Rockland Bais Ulpana D'rabeinu Yochanon Bais Y L (Baas Yosef Lehova) 1,50000 Barkai Yeshivah 2, Beer Yitzhak Foundation Beis Midrash Taharos Beit Ariel Beit Yehuda Inc Bet Medrash Gadol Ateret Torah 676, Bet Medrash Hechal Shemuel 1, Bet Medrash Torat Chaim Bet Midrash Torah Vehoraah 1, Bet Midrash Torah Vehorea Bet Raphael Bet Yaakov Of The Jersey Shore 81, Bet Yaakov Ohr Sarah 9, Bet Yaakov Orot Sarah 1, Beth Jacobs Hachassidi Beth Midrash Govoha 5, Beth Midrash Of Asbury Park Inc 6, Beth Cloth Beth Torah Charity Fund 1, Biala Yeshiva Bina Brain Injury Assistance 3, Birchat Mordechai Birkat Hatorah Birkat Mordechai Bnei Aram Soba 2, Bnei Binyamin Bnei Binyamin Congregation Bnei Binyamin Torah Center Bnei Yerushalayim Bnos Brocha Bnot Rachel High School 3, Bnot Yisrael 4, Bonei Olam 3, Carmei Hair International Center For Torah VeChesed Central Fund Of Israel 1, Chabad Of Flushing Chabad Schools, Israel 1,00000 Chabad Vocational Schools Chai Lifeline 1, Chasdei Shalom Chasdei Yisroel 1, Chasdey Moshe V'shalom Chasdi Dovid Chavrusa Trust Chaye Clam Torah Institution Cheder Chedvat Yaakov 12, Chelkas Yaakov Chesed Avraham Chesed Boys Child Life Society 1, Children's Aid Fund Children's Wish Foundation Chizuk USA CHMOL Chomat Zion Chug Chasam Sofer 35000

28 Charity Amount Cong Beth Medrash Govoha Ertz Yisroel-Lakewd Cong Magen Abraham Of W Long Branch Congregation & Kollel Harabanim Aram Soba 10, Congregation & Yeshiva Beth Hillel 1,60000 Congregation Ahavat Shalom 1, Congregation Amudei Chesed Congregation Ateres Mechoel Congregation Bais Aharon Congregation Bais Yisroel Congregation Beth Hatfilah Congregation Beth Jehudah 2600 Congregation Beth Midrash Govoha 3, Congregation Beth Midrash Yam Hatorah 1, Congregation Beth Torah 13, Congregation Bnei Yakov 3, Congregation Bnei Yeshiva 6, Congregation Chaye Olom Inc Congregation Chemdot Shlomo Congregation Chesed L'Avraham 3, Congregation Chesed L'Yisrael Congregation Edmond Safra Congregation Emunas Yisroel 8, Congregation Eshel Avraham Congregation Gmach Isheh LA Congregation Hisacdis Yerim Congregation Kehal Premishlan Congregation Keter Sion 7, Congregation Keter Torah 6, Congregation Khal Adas Krasna Congregation Kiruv Krovim 1, Congregation Kol Shimon Congregation Kollel Bnei Hayeshivos Congregation Lmahn Achai Congregation Magen David Of West Deal 4, Congregation Matok Midvash Congregation Mecon Sheish Veargaman Congregation Meor Yisroel Inc Congregation Mercaz Harav Yeshivas Yehud Congregation Minyan Mir 1, Congregation Mishan Menachem Inc Congregation Nachlas Yisroel 5, Congregation Ner Ehyahu Congregation Ohel Simha Congregation Pirchei Shoshanim Congregation Ramat Shlomo Congregation Sar Shalom Congregation Sfat Tammim 1, Congregation Shaare Rahamim 29, Congregation Shaare Tefilah 9, Congregation Toldos Adam Congregation Torah Temimah Congregation Torat Hanachal Congregation Tov L'kol Congregation Yeshiva Eitz Chaim Kletzk 2, Congregation Yeshiva Ohr Hameir 5, Congregation Yeshiva Yad Moishe 1, Congregation Yeshivat Avir Yakov Congregation Yeshivat Breslav Of Bnei Brak Congregation Z Y C 3, Congregation Zichron Binyamin 14, Congregation Zichron Mayer Leib Congregation Lemaan Achai Darchei David Foundation 9, Darchei Ish Yeshiva Deal Sephardic Youth Center 10,360 00

29 Charity Amount Deal Synagogue Youth Learning Program 1, Diaspora Yeshiva Toras Yisrael Dysautonomia Foundation Inc. 2, Echo National Jewish Institute For Health 1, Edmond J. Safra Synangogue Of Deal, NJ 15, Educational Institute Oholei Torah Eim Beisrael Ein Beyisroel Inc Em Od Milvado{Princeton Ave Night Kollel 2, Etz Hadaat Inc Etz Hayim Even Hachaim Institutions Foundation 2, Ezer Mizion 2, Ezras Yisroel Charitable Foundation Inc Ezrat Cholim Veyoldot Ezrat Israel Inc 1, Ezrat Yisrael Flatbush Minyan Inc 1, Freehold Kollel 1, Friends Of Ahavat Shalom 61, Friends Of Arachim 5,00000 Friends Of Barditshev 23, Friends Of Darchei Rochel Inc Friends Of Darchey Hillel Inc 1, Friends Of Eeyun Hatalmud Friends Of Hadar Zion Friends Of Hatorah 2, Friends Of Hatzolah Darom Friends Of Mitzvos HaAretz Friends Of Mosdot Goor Inc Friends Of N Biinyamin Inc Friends Of Ohel Moshe Institute 11, Friends Of Or Yisrael Friends Of Shaarei Torah Vechesed Friends Of Shearim Hametsuyaniim Inc Friends Of Yeshiva Mishkan Shelomo Friends Of Yeshiva Ohr Elchonon 2,00000 Friends Of Zrvhay Zedek Gateway To The Future Inc 1, Gemach ABG Gemach Chasdei Yitzchak 4, Gesher Yehuda GIOH Girls Town Girls Town / Or Chadash 4, Girls Town Bert Chana Global Jewish Assistance & Relief Network Graciousness Of Mashiach Harmony 1, Hasdei Esther Charity Fund {p}{r Eliyahu Barry) Hatzalah Volunteer E M S - Jersey Shore Division 4, Hechal Shemuel 6, Hesed Foundation 3, Hillel Yeshiva 27, Hochmot Shlomo 1, Ichud Mosdos Hachinuch 8, Ilan High School 4, Imagine Academy 17, Institute For Dayanim Institute Of Talmudic Law Israel Cancer Research Fund 7, IUC Jerusalem Center For Research Jesse Dweck Learning Center Jewish Education For Girls

30 Charity Amount Jewish Experience Of Madison 1, Just One Life 3, K I.D S. 10, Kahal Jaredim Flores 1, Kahal Kiryat Sefer 1, Kamenetz Yeshiva Kamenitzer Yeshiva Of Jerusalem Inc 6, Kerem Ezra Keren Ahavat Chesed 15, Keren Bnei Torah Keren Ezra 1, Keren Hachasodim Of Bais Medrash Keren Hachesed Keren Hasaot Vechinuch 13, Keren Hatorah Trust Kol Yaakov Campaign 1, Keren Hayeled Keren HaYeshivot Trust 67, Keren Latorah 5, Keren Lev David 4, Keren Ner Tomid Keren Simchas Kallah Keren Yehoshua & Yisroel Keren Yehudit Shwekey 1, Keren Yom Tov 4, Keren Zichron Rosh Keren Zichron Shmuel Zonvill Keter David 3, Keter Shlomo Foundation 4, Keter Zion Torah Center {Messilat Hahaim} 1, Khal Adas Taimon{Chaim B'Ahava} Khal Bnei Torah 2, Khal Chasidei Lelov Khal Veretzky KHT Kol Yaakov C 3, Kmyanei Hatorah Yeshiva 1, Kneses Hatorah 1, Kneset Mordechai Knesset Yehuda Kolel Jafetz Jaim Kollel Bet Aharon 1, Kollel Hadrat Kodesh Kollel International 5, Kollel Jafetz Jaim Kollel Of The Jersey Shore 13, Kollel Ohel Surah Kollel Ohr Moshe Lahav Of North America 2, Learning & Network Le'Maan Achai 8, Lev Chana 3,30000 Lev Chana Of Congregation Keren Hachesed 1, Life Vest Inside Inc 1, L'Maan Achai 9, L'maan Tishma Foundation L'tzion Berina Maale Amos Yeshiva Maayan Hatorah Mabas Fund 3,00000 Machon Beth-Aryeh Inc Machon Hahalacha Macon Ruth Madison Torah Center Magen Avraham Fund Magen David Synagogue 1, Magen David Yeshiva 73,576 00

31 Charity Amount Mann Hatorah Inc Ma'or Yeshiva High School 3,80000 Maoz Torat Asaf Mareh Keren Torah Mary Tawil Foundation 1,50000 Maskeal El Dal Fund 1, Maskeel El Dal Society 3, Maskeret Halfon 2, Mateh Aharon Mattan Basseter 1, Matteh Moshe 1, Mayan Hatorah Mazkeret Halfon 1, Mechon L'Hoyroa Meir Panim Lachayal Menachem Learning Institute 3, Me'ohr Bais Yaakov Meor Hatorah 5, Meor Yitzchok Inc 10, Meorot Mercaz Hatorah Of Belle Harbor 2, Merkaz Eshel Avraham Merkaz Jerusalem 1,50000 Merkaz Le Torah Merkaz Lechinuch Torani Merkaz L'Shiurei Torah Mesamche Lev Mesivta Bevet Chazon Ish 2, Mesivta Of Long Beach Mestvta Tifereth Jerusalem Of America 1, Mesivta Yeshiva Rabbi Chaim Berlin 5, Midrash Bet Nassi 1, Midrash Shaare Chayim 2, Mifael Chasodim Tovim Mifal Ezra Zichron Yehide Mifal Hatrumah 5,05000 Mifal Torah Vodaath Mikdash Eliyahu 1, Mikdash Melech Mikdash Shaul 1, Millinery Center Synagogue Mirrer Yeshiva Central Institute 5, Mishkan Moshe Institution Mishkan Shlomo Mishkan Yitzchak Corporation Mishmeret Kevarim 1, Mission Critical Inc Mitzadei Gaver Mitzvah Man Foundation Corp Moriah Birchas Mordechai Mosdot Bet Yaakov 1, Mosdot Botoshan Mosdot Rabbenu Yoel For Sephardim Nachal Novea Mekor Chochma Nachalas Shai Nachalot Yehoshua 1, Nahalat Moshe Inc Navat Yisrael Inc 3, Nefesh Academy 2, Nefesh Hachaim 1, Nesach Yisrael Institution 2, Netrv Meir Netivey Hatora Netivey Ohr Yaakov Inc Netivos Olam 76 00

32 Charity Amount Netzach Yisrael Inc 1, Netzrvas Chaim Neve Eretz Yeshiva 2, Neve Yerushalayim Nevei Hachesed Nezer Aharon Nissim Veniflaot Inc 1, Noam Ezra Noam Hatorah Zichron Sinai 1, Ofek Yehuda Ohel Leah Ve Rachel 1, Ohel Malka Institutions Ohel Simha Superfund 21, Ohel Yosef 19, Ohr Habitachon 5, Ohr Hagalil 1, Ohr Haganuz Inc Ohr Hahalacha Ohr Hameir Ohr Joseph Institutions 33, Ohr La Yehudim 1, Ohr Nosson Ohr Shmuel Ohr Simcha Ohr Yaakov Inc 2, Ohr Zaruah Or Eliyahu Or Hachayim Inc 22, Or Haddash Institutions Inc Or Hashalom Or Litzion Yeshiva 1, Or Torah Of Argentina Foundation Ora Vesimcha Orot Sarah Oz Hachaim Czar Hatorah Inc {FR484} 6, P E F 1,80000 P E F Israel Endowment Funds, Inc 4, P'eylim/Lev L'Achim 5, Porat Yosef Foundation 1, Project Extreme Rabbi Kanarek 1, Rabbi Meir Baal Haness Rabbinical College Of Long Island Ramaz School 1, Rav Hesed Rav Pealim Institution Reach For The Stars Learning Center 21, Rehovot Hanahar 1, Renewal Of Life 2, Revach V'Hazalah Rochel Leah Chesed Fund 4, Rosh Yeshiva Trust BMG SAFE. 15, S E A D 10, Sarah Dabah School Sephardic Academy Of Manhattan 1, Sephardic Bikur Holim 22, Sephardic Community Center 11, Sephardic Congregation Of Lakewood Sephardic Congregation Of Nostrand Sephardic Food Fund 12, Sephardic Institute Sephardic Press 10, Sephardic Torah Center 20,00000

33 Charity Amount Shaar Hatalmud 1, Shaare Emunah Shaare Tefilah 1, Shaare Torah S000 Shaare Torah Teachers Fund Sha'are Yosef Kollel Shaare Zion Congregation Inc 1, Shaarei Arazim Shalhevet Inc Shalom Torah Centers Shalvat Chayim Sheent David Colel Shivat Zion Torah Center Inc Shmiras Hasdonm Sid Jacobson Jewish Community Center 3,60000 Special Children's Fund 1, Springfield Yeshiva 1, Stam Gemach 1, Stanford Yeshiva Sulam TAG Flatbush 106, Talmud Torah Mekor Chaim 18, Talmud Torah Mola Or Shraga Tashbar Of Lakewood TAT Yeshiva Of Philadelphia 1, The Angel Fund 13, The Breast Cancer Research Foundation The Cheder The David Memorial Fund The Jewish Community Center-Chabad Of Vail The Lakewood Cheder 2, The Leukemia & Lymphoma Society The Rambam Foundation The Sarah Dabah Elementary School 10, The Special Children's Center 18, Tiferes Achim Toldot Avraham Yitzchak Tomche Torah Gur Aryeh Tomchei Tzedakah Of Lakewood 1, Torah Academy Of Brooklyn 8, Torah Learning Resources Ltd 9, Torah Ore Seminary 13, Torah Temimah Institutions Torah Umesorah Torah Yisrael Torat Chesed Trust 4, Torat Haim Congregation 1, Torat Moshe Yeshiva Tov Vachesed Inc 2, Tzadakah Vachesed UJA Federation Of New York 5, United Institute Karlin Stolin 1, Uniting Against Lung Cancer 2, Vaad Harabonim Vaad L'Hachnusat Orchim 1, Vzos LeYehuda West Coast Va'ad HaChesed WIZO Y & Y Charity Yad Aharon Inc Yad Ezra V'shulamit Yad L'Achim Hamachme Hatorah Yad LeAzor Torah VoChesed Fund 1, Yad Michael Yad Yosef 12,500 00

34 Charity Amount Yad Yosef Bridal Fund 10, Yad Yosef Congregation 496, Yad Yosef Kollel Yad Yosef Torah Center 130, Yagdil Torah Inc Yakirei Yerushalaim 2, Yerucham Center Of Torah Education Yeshiva Beer Avrohom Yeshiva Beit Rafael 1, Yeshiva Birkat Israel 1, Yeshiva Chayei Olam Yeshiva Chemdas Hatorah Yeshiva Derech Chaim Yeshiva Dvar Torah Yeshiva Gedola Bais Yisroel Yeshiva Gedola Beer Hatorah Yeshiva Gedola Lubavitch Yeshiva Gedola Of Bayonne 8, Yeshiva Kesser Torah Yeshiva Magen Avraham 2, Yeshiva Maor Hatorah 1, Yeshiva Marbeh Torah 1, Yeshiva Merkaz Hatorah Yeshiva Ner Eliezer Yeshiva Noam Ezra Yeshiva Of Bayonne 3, Yeshiva Of Brooklyn 1, Yeshiva Of Far Rockaway 1, Yeshiva Of Flatbush 10, Yeshiva Of Ocean 1, Yeshiva Of Telshe Riverdale 2, Yeshiva Of The Telshe Alumni 15, Yeshiva Ohel Torah 1, Yeshiva Ohr Hameir 6, Yeshiva Ohr Shraga 7, Yeshiva Ohr Yitzchok 2, Yeshiva Shaare Yosher 1, Yeshiva Tiferes Baruch 1, Yeshiva Tiferes Naftali Yeshiva Tiferet Baruch 2, Yeshiva Zichron Mayir Yeshivas Beis Yosef Novardok Yeshivas Chasan Sofer Yeshivas Tiferet Baruch Yeshivat Amudei Ore Yeshivat Ateret Torah 172,95100 Yeshivat Beth Meir Yeshivat Birkat David 1, Yeshivat Chomat Zion Yeshivat Darchei Eres Inc. 26, Yeshivat Keter Torah 11, Yeshivat Magen Abraham 17, Yeshivat Mekor Haim 1,00000 Yeshivat Mikdash Melech 19, Yeshivat Mikdash Melech Jerusalem 1,00000 Yeshivat Mikdash Melech 1,50000 Yeshivat Nahalat Moshe 8, Yeshivat Nachalat Yosef Yeshivat Ohel Torah 8, Yeshivat Or Hachaim Of Lakewood 1, Yeshivat Or Hatorah 14, Yeshivat Or Yosef Yeshivat Shaare Teshuva Vehaim 1, Yeshivat Shaare Torah 50, Yeshivat Sheenth Yosef 1,92600

35 Charity Amount Yeshivat Tiferet Moshe 1, Yeshivat Yagdil Torah 7, Yeshivat Zichron Yehoshua Yeshua Abraham 1, Yeshuas Yosef Young Israel Of New Rochelle Charity Fund 1, YTA 5, YZL Zichron Avrohom Eliyahu Zichron Binyamin Zichron Menachem Zichron Naftuli Hertzka Zichron Yaakov 1, Zichron Yehuda Foundation Ziv Israel Zohar Zohar Hatorah 17, TOTAL CHARITABLE CONTRIBUTIONS: $ 3,769,863.00

36 F(xm (Rev. January 2013) DWwtTti*d d the Tmnury Ine m& plew" SWAM Application for Extension of Time To File an Exempt Organization Return OMB No Flea for each r+etum. If you are filing for an Automatic 3-Month Extension, complete only Part I and check this box It you are filing for an Additional (Not Automatic) 3-Month Extension, complete only Part 11 (on page 2 of this form). 00 not complete part 11 unless you have already been granted an automatic 3-month extension on a previously filed Form Elect o do filing (e-fie). You can electronically No Form 8868 if you need a 3-month automatic extension of time to file (6 months for a corporation required to file Form 990-T), or an additional (not automatic) 3-month extension of time. You can electronically file Form 8868 to request an extension of time to file any of the forms listed In Part I or Part II with the exception of Form 8870, Information Return for Transfers Associated With Certain Personal Benefit Contracts, which must be sent to the IRS In paper format (see instructions). For more details on the electronic filing of this form, visit www i v/efrlle and click on a-fide for Charities & Non fits. Part I, Automatic 3-Month Extension of Time. Only submit original (no copies needed). A corporation required to file Form 990-T and requesting an automatic 6-mon h extension - check this box and complete Part I only... All other corporations (Including 1120-C filers), partnerships, REMJCs, and trusts must use Form 7004 to request an extension of time to file Income tax returns. Type or Name of exempt organization or other filer, see Instructions. Employer Identification number (EIN) or prim JACK ADJMI FAMILY FOUNDATION, INC by a- d,,, dft for Number, street, and room or suite no. If a P.O. box, see Instructions. 1 Social security number (SSN) d May- 34 WEST 33RD STREET City, town or post office, state, and 23P code. For a fore address, see Instructions. NEW YORK, NY Enter the Return code for the return that this application Is for (file a separate application for each return) ru-m Application Is For Return Code Application Is For Return Code Form 890 or Form 990-EZ 01 Form 990-T (corporaton) 07 Form 990-BL 02 Form 1041-A 08 Form 4720 (InidividuaD 03 Form Form 990-PP 04 Form Form 990-T sec. 401 or 408 (a) 05 Form Form 990-T (trust other than above) 06 Form ERIC ADJMI The books we in the care of SEVENTH AVENUE, 4TH FLOOR - NEW YORK, NY Telephone No M FAX No. If the organization does not have an office or place of business in the United States, check this box... If this is for a Group Return, enter the organization 's four digit Group Exemption Number (GEN). If this is for the whole group, check this box 0. If it is for part of the group, check this box 0 and attach a list with the names and BNs of all members the extension is for. I I request an automatic 3-month (6 months for a corporation required to ft Form 990-T) extension of time until JULY 15, 2 014, to file the exempt organization return for the organization named above. The extension is for the organization 's return for. 0 calendar year or tax year beginning DEC 1, 2 012, and ending NOV 30, If the tax year entered In fine 1 Is for less than 12 months, check reason : El Initial return El Final return 0 Change in accounting period 3a If this application is for Form 990 -BL, 990-PF. 990-T, 4720, or 6069, enter the tentative tax, less any 71 b If this applicawn is for Form 990-PF, 990-T, 4720, or 6069, enter any refundable credits and c Balance due. Subtract line 3b from line 3a. Include your payment with this form, If required, by using EFTPS (Bectronic Federal Tax Payment System). See instructions. I 3c 1 $ 0. Caution. If you are coins to make an electronic fund withdrawal with this Form see Form 8453-EO and Form 8879-EO for payment Instructions. LHA For Privacy Act and Paperwork Reduction Act Notice, see Instructions. For, (Rev ) a CKJAF JACK ADJMI FAMILY FOUNDATIO 4CKJAF1