PF Return of Private Foundation

Form
9g0- PF Return of Private Foundatio n
or Section 4947(a)(1) Nonexempt Charitable Trust
Treated as a Private Foundatio n
•
Depart ment of the Trq ssuty
Internal Revenue Service
1, 2003 ,and end
Final return Amended retur r
G Check all that apply:
0 Initial return
Name
of
organization
Use the I RS
pri nt
Address change U
Employer identificati on numbe r
99-033291 5
ABMAN HAWAII ,
Room/ swte g Telephone numbe r
Number and street (or P O box number if mad is not del ivered to street address )
or type , 0 . BOX 2 51 1
See Spec ifi c
City or town, state, and ZIP code
Inst r uctio ns .
C if exempt ion appl icat ion is pend ing , check here
pol. L J
D 1 . Foreign organizations, check here
10-E]
2 . Foreign organ izations meeti ng the 85% test ,
check here and a ttach computatio n
H Check type of organization: LXJ Section 50 1 (c)(3) exempt private foundatio n
Q Section 4947(a)(1) nonexempt charitable trust 0 Other taxable private foundation
►~
E If private foundation status was terminate d
under section 507(b)( 1 )( A ), chec k here ► 0
I Fair market value of all assets at end of year J Accounting method : [Y] Cash
[
Accru a l
(from Pa rt fl, co l (c), line 16)
Q Other (specify )
111l
18 6 0 7 4 . (Part 1, column (d) must be on cash ba ss;
Part I Analysis of Revenue and Expenses ( a ) Revenue an d
(b) Net investment
(The total of amounts in columns (b), (c), and (d) may not
expenses pe r book s
income
necessar ily e qual the am ount s in column (a))
I
2003
Note : The organ iza ti on may be ab le to use a copy of thi s return to satisfy state reporting requ irements
For ca len dar ye ar 2003 , or tax yea r b e g i nn i ng
label .
Otherwise,
O MB No 154 5-005 2
F If the foundation is in a 60-month termination
under section 507(b)(1 B chec k h er e
( d ) D isbursements
for ch aritable purposes
(cash basis only )
( c) Adjusted net
income
154,352 .
Contributions, gifts, grants, etc ., received
Check lilo- Q H the foundation is not requi red to attach Sch B
2
3
4
Distributions from split-interest trusts
Interest on savings and temporary
192 .
cash investments
2
Dividends and interest from securitie s
5a Gross rents 6 5 8 0 .
6,580 .
b (Net rental i ncome or (loss)
Net ga in or ( loss) from sa le of assets not on
sa line 10
is Gross sales price for all
~
> assets on li ne Ba
~
<64 .
2,064 .
d
cc 7
8
9
2 .064 .
Capi tal gai n net income (from P art IV, l ine 2)
Net short-term capital gai n
Income modification s
Gross sal es less return s
10fl and allowances
b less Cost of goods sol d
c Gross profit or (loss )
11 Other income
1,681 .
162,741 .
12 Total . Add lines 1 through 11
13
18
19
5
Taxes
}
R~~4 TL~. - 6 Depreciation, an 'dep letion- - --- -- I
.5
0
20 Occupancy
21 Travel, confeM esN&ee4inbs '4/~~j/~ CY)
r- 22 Printing and pul~hcabons,
2 3 Other expenses
~~~~°
~
7
v 24 Total opera i and 'admlmstrative
T~y
-a
0
LIJ
expenses . Add lines 13 through 23
Contributions, gifts, grants paid
25
26 Total expenses and disbursements .
Add lines 2 4 and 25
27
0 .
0.
30,297 .
2,920 .
16 .
Compensat ion of officers, d irector s , trustees , etc
14 Other employee sala ri es and wages
y 15 Pension plans, employee benefits
16a Legal fee s
a
b Accounting fees
S TMT
c Other professional fee s
17 Interest
2
.J .
833.
3,181 .
51,647 . 1
5,515 .
1,868 .
J V
1 J 4
6.
2,904 .
5.
2,848 .
2.
8.
0.
2,911 .
5 .485 .
10 .
927 .
96,136 .
195, 324 .
195, 324 .
1 . 2
Subtract line 26 from line 12 :
a Excess of revenue over expenses and disbursements
<32, 583 .
b Net investment income
c Adjusted net income (if negative, enter -0-)
(if negative, enter -0 -)
iz3os 03 LH A For Paperwork Reduction Act Notice , see the instruct i ons .
11131104 758876 9124
1
2003 .06030 CABMAN HAWAII, INC .
Form 990-PF (2003 )
9124 1
Form 990-PF (2003) C ABMAN HAWAII, INC .
Balance Sheets Attached schedules and amounts in the descriptio n
Pa rt II
colu m n s hould he lor e nd-0 f-year a m o unts only
1
77-~
End of
Book Value I
nning of ye .
Boo k Value
2
(c) Fair M ark et Val u e
Cash - non-interest-bearin g
76 .1 85 .305 .1 8 5
2 Savings and temporary cash investments
3 Accounts receivable ►
Less: allowance for doubtful accounts ►
4 Pledges recewable ►
Less: allowance for doubtful accounts ►
5
6
Grants receivabl e
Receivables due from officers, directors, trustees, and other
disqualified person s
7 O th e r not esan d loa ns recelvabte
00.
Less: allowance for doubtful accounts ►
m
8
9
10a
b
Inventories for sale or use
Prepai d expenses and deferred charge s
Investments - U .S. and state government obligations
Invest ment s - corporate stoc k
c Invest ment s - corporate bon d s
11 Investments • Wn O ,buildings, and eq uipme nl Gasis
101.
Less accumulated depreciation 100.
12
Inves t ments - mortgage loan s
13 Inves t men ts - other
14 L and, buildings, and equipment : basis ►
259,062
Less acc umulate d depreciation
►
169,004
15 Other assets (describe ►
STATEMENT 8
10 .711 .
10
17 Accounts p ayable and accrued expenses
18 Grants p ayable
~ 19 Deferred revenue
:=03 20
Loans from officers, d irectors, trustees , and other disqual i fi ed persons
21 M ortgages and other notes payable
J 22 Other liabilities (describe ►
STATEMENT
Organ ization s that fo ll ow SFAS 11 7, c he ck here
9
169 .
10
► M
and complete lines 24 through 26 and lines 30 and 31 .
°~' 24 Unrestricte d
3 25 Tem p orarily restricted
co 26 Permanent ly restricte d
C
Organizations that do not follow SFAS 117 , check here
L` and complete lines 27 through 31 .
..,°~ 27
28
<
29
► Q
Capital stoc k, trust principal, or current funds
Paid-in or capital sur p lus, or land, b ldg ., and equipment fun d
Retained earnings, accumulated income, endowment, or other funds
z 30 Total net assets or fund balance s
225 .
Part III Analysis of Changes in Net Assets or Fund Balances
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 prior year's return )
2 Enter amount from Part I, line 27 a
3 Other increases not included in line 2 (itemize) ►
4 A dd lines 1 , 2, and 3
5 Decreases not include d in line 2 (itemize) ►
6 Total net assets or fund b alances at end of year (line 4 minus line 5) - Part II, column (b), line 3 0
1
207 .808 .
17 5
Form 990- PF (2003 )
3 235 11
12-05-03
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11131104 758876 9124 2003 .06030 CABMAN HAWAII, INC .
9124
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99-0332915 Page3
Form 990-PF
apital Gains and Losses for Tax on Investment
( 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 . )
how acquired (c) Date acquired (d) Date sol d
Purchase mo ., day, yr .) (mo., day, yr.)
Donation
~
D
D
D
D
D
10 SHS AVAYA I
(e) Gross sales pric e
(f) Depreciation allowed
(g) Cost or other basis
(or allowable) plus expense of sal e
12/09/03 12/10/03
12/09/03 12/10/03
12/09/03 12/10/03
12/09/03 12/10/03
12/09/03 12/10/03
(h) Gain or (loss)
(e) plus (f) minus (g)
850
9
219
105
881
only for asset s
(i) F . M .V . as o f 1 2/3 1 /69
in column (h) and owned by the foundation on 12/31/69
(j) Ad juste d basis
(k) E xcess of col . (i)
as of 1 2/3 1 /69 over col . (j), if an y
2 Capi tal gain
net income
or net capital
loss
g
(
1
3
.
.
.
.
.
(I) Gains (Col . (h) gain minu s
col . (k), but not less than -0-) or
Losses (from col. (h) )
. If ain, also enter in Part I, line 7
~ I f loss), enter -0- in Part I, line 7 }
Net short-term capital gain or (loss) as defined in sections 1222(5) and (6) :
If gain, also en t er in P art I, line 8, column (c) .
If (loss), enter -0- in Part I, line 8
I part v I caua utication unaer Section 4v4 ute ) for neaucea i ax on rvet investment income
(For opt ional use by domest ic private foundations subject to the section 4940(a) tax on net investment income . )
If section 4940(d)(2) applies, leave this part blank .
Was t he organization liable for t h e section 4942 tax on t he distributable amount of any year in the base p eriod ?
If 'Yes," the organization does not qualify under section 4940(e) . Do not complete this part.
1 Enter the appro p riate amount in each column for each year ; see instruc tions before ma king any entries.
Base
pereod
yearsin)
Adjusted quali~ing d istributions
Calendar year
(or tax
year beginning
2002
2001
0 Yes E2:1 No
nonchantable-use Distribution ratio
N et value of
(col
. (b) divided by col. (c) )
66 .584 .
7.
44,951 .
1 . 4 81257 4
466 .
388 .
1 .9618980
.185696 0
2000
2
2 Total of line 1, column (d )
3 Avera g e dist ribution ratio for the 5-year base period - divide the total on line 2 by 5, or b y the number of years
the foundation has b een in existence if less than 5 year s
4
10 .1789893
3
2 .0357979
4
Enter the net value of noncharitable-use assets for 2003 from Part X, line 5
76 .844 .
5 M ultiply line 4 by line 3
6
Enter 1% of net investment income (1% of Part I, line 27b )
7 Add lines 5 an d 6
8
Enter qualifying distributions from Part XII, line 4
1
8
152,255 .
I f line 8 is equal to or greater t han line 7, chec k the box in P art V I, line 1 b, an d com p lete that part usin g a 1% ta x rate.
See the Part VI instructions.
323521/12 -05 -03
3
11131104 758876 9124 2003 .06030 CABMAN HAWAII, INC .
Form 990-PF (2003 )
9124
1
99-0332915 Pa9e A
or 4948 - see instruction s)
Form 990-PF
ax Lsased on
1a Exempt operating foundations described in section 4 94 0(d)(2), chec k here ► U and enter ' N/A' on line 1 .
Date of ruling letter:
(a ttach copy of ruling le tter i f necessa ry- see instructions )
b D omestic organizations tha t meet the sect ion 4940(e) requirements in Part V, chec k here ► Q and enter 1 %
o f Part I, line 27 b
c All ot her d omestic or g anizations enter 2% of line 27b . Exempt foreign organizations enter 4% of Part I, line 12, col . (b)
2 Tax under section 5 11 (domestic section 4947(a)(1) trusts an d taxable foundations only . Others enter -0- )
1
152 .
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 Tax based on investment income . Subtract line 4 from line 3 . If zero or less, enter -0-
6 Credits/Payments :
a 2003 estimated tax payments and 2002 overpayment credited to 2003
6a
b Exempt f oreign organiza t ions - tax withheld at source
6b
c T ax paid with ap p lication for extension of time to file (Form 8868)
6c
d B ackup wi t hholdi n g erroneously withhel d
6d
7 Total credits and payments. Add lines 6a through 6d
8 Enter any pe nalty for underpayment of estimated tax Check here 0 if Form 2220 is attached
9 Tax due . I f t he total of lines 5 and 8 is more than line 7, enter amount owe d
10 Overpayment . I f line 7 is more than the to tal of lines 5 and 8, enter the amount overpaid
11 Enter the a m oun t of line 1 0 t o b e: Credited to 2004 estimated tax ►
R efun d e d
No
1a Durin g the t a x year, did the organization attemp t to influence any national, state, or local legislation or did it participate or in t ervene in
any p olitical cam paign?
b Did it spen d more than $1 00 during the year (either directly or indirectly) for political purposes (see instructions for defmition) 9
If the a ns wer is ° Ye s ° to I a or 1 b , a ttac h a detailed de scrip tion of th e activities an d copies of any materials pu b lished or
distributed by the organization in connection with the activities
c Did t h e organization file Form 1120-POL for this year?
d Enter the amount (if any) of tax on political expenditures (section 4955) imposed during the year :
( 1) On the organization . ► $
0 . ( 2 ) On organization managers . ► $
0.
e Enter the reimbursement (if 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 a detailed 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 a conformed copy of the changes
4a Did the organization have unrelated business gross income of $1,000 or more during the year?
b It 'Yes,' has it filed a tax return on Form 990 -T for this year?
N/A
5 Was there a liquidation, termination, dissolution, or substantial contraction during the year ?
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 instrumen t
7 Did the organization have at least $5,000 in assets at any time during the year?
X
X
If "Yes, "complete Part ll, col. (c), and Part XV.
8a Enter the states to which the foundation reports or with which it is registered (see instructions) ►
HAWA I I
b If the answer is ' Yes° to line 7, has the organization 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
9 Is the organization claiming status as a private operating foundation within the meaning of section 4942(j)(3) or 4942(j)(5) for calendar
year 2003 or the taxable year beginning in 2003 (see instructions for Part XIV)? If "Yes," complete Part XI V
1 0 Did any persons become substantial cont ri butors du ri ng the tax year? If "Yes, " attach a schedule l istin g their names and addresses
STMT
8b I X
9 1 X
10
11 Did the organization comply with the public inspection requirements for its annual returns and exemp t ion application?
11 I X
Web site address ► WWW . CABMAN . ORG
1 2 The books are in care of ► LAURA M . DI ERENF I ELD
Telephone n o. ' ( ( 8808) 885-2132
►
Located at
6 7 -112 3 MAMALA HOA HWY . #116, K.AMiJELA, HI ZIP+4 ►9 6 7 4 3
13 Section 4 947( a )( 1 ) nonexem pt charitable trusts f ilin g Form 990-P F in lieu of Form 1041 - Check here
an d enter the amount of tax-exempt interest received or accrued du ri ng the year
;z s
oo3
►Q
► 1 13 I
N/A
Form 990- PF (2003 )
4
11131104 758876 9124 2003 .06030 CABMAN HAWAII, INC .
9124
1
Form 990-PF (2003 )
F ile F orm ,4720 if a ny ite m is ch ec ked i n th e "Yes" co l umn, unless an exce ptio n a pp lies.
1a During the year did the organization (either directly or indirectly) :
(1) Engage in the sale or exchange, or leasing of property with a disqualified p erson?
(2) B orrow money from, lend money to, or otherwise extend credit to (or accept it from)
a disqualified person ?
(3) Furnish goods, services, or facilities to (or accept them from) a disqualified p erson
(4) Pay com p ensation to, or pay or reimburse the expenses of, a disqualified person ?
( 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)?
(6) A gree to pay money or property to a government officials ( Excepti on . Check "No'
if the organization agreed to mak e a grant to or to employ the official for a period after
termination of government service, if terminating within 90 days.)
b I f any answer is 'Yes' to ia(1)-(6), did any of the acts fail to qualify under the exce ptions described in Regulations
Page 5
0 Yes [11 N o
Q Yes ~ No
Yes 0 N o
Q Yes ~ N o
Yes
EK] N o
0 Yes
EK] N o
section 53 .4941(d)-3 or in a current notice regarding disaster assistance (see page 19 of the instructions) ?
Organizations relyin g on a current no tice re g arding disaster assistance check here
c Did the organization engage in a prior year in any of the acts described in 1a, ot her than except ed acts, t hat were not corrected
►Q
before the first day of the tax year beginning in 2003?
2 Taxes on failure to distribu te income (section 4942) ( d oes not apply f or years the organizatio n was a p rivate operating f oun dation
define d in section 4942(j)(3) or 4 9 4 2(j)(5)) :
a At t he end of tax year 2003, did the organiza t ion have any undis tributed income (lines 6 d an d 6e, P art X III) for tax year(s) beginnin g
before
2003?
0 Yes ~ No
If 'Yes,' list the years ►
b Are there any years listed in 2a for which the organizatio n is not ap plying the provisions of sect ion 49 4 2(a)(2) (relating to incorrect
valuation of asse t s) to t he year's un d ist ri b u te d income? (If applying section 4 9 4 2(a)(2) t o all years list ed, answer "No* and attach
statement - see instructions .)
c If the provisions of section 49 4 2(a)(2) are being applied to any of the years listed in 2a, lis t the years here .
N/ A
3a Did the organization hold more than a 2% direct or indirect interest in any business enter p rise at any tim e
during the year? Yes
M No
b If 'Yes,' did it have excess business holdings in 2003 as a result of (1) any purchase by the organiza t ion or disqualified persons afte r
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 firs t phase holding periods (Use Schedule C,
Form 4 720, to determine if the organization had excess b usiness holdings in 2003.)
N/A
4a Did the organization invest during the year any amount in a manner that would jeopar d ize i ts charitable p urp oses?
b Did the organization make any investment in a prior year (bu t after December 3 1 , 1969) t hat could jeopardize its charitable purpose that
had not been removed from jeop ardy before the first day of the tax year beginning in 2003?
5a During t he year did the organization p ay or incur any amount to:
(1) Carry on propaganda, or otherwise attempt to influence legislation (section 494 5(e))? =1 Yes FXI No
(2) Influence the outcome of any specific p u b lic election (see section 4955) ; or to carry on, directly or indirectly,
any voter registration drive? 0 Yes FXI No
X
( 3 ) Provide a grant to an individual for travel, study, or other similar purposes?
Q Yes M No
( 4 ) Provide a grant to an organization other than a charitable, etc ., organization described in sectio n
509(a)(1), (2), or (3), or section 4940(d)(2)? Q Yes M No
(5) Provid e for any purpose other than religious, charitable, scientific, literary, or educational p urposes, or for
the prevention of cruelty to children or animals? Q Yes DO No
b If any answer is'Yes° to 5a(1)-(5), did any of the transactions fail to qualify under the exceptions described in Regulation s
section 53.4945 or in a current notice regarding disaster assistance (see instruc t ions)?
N/A
Organizations relying on a current notice regarding disaster assistance check here
1Q
c If the answer is "Yes" to question 5a( 4 ), does the organization claim exemption from the tax because it maintaine d
expenditure responsibility for the grant?
N/A
El Yes 0 No
If "Yes," attach the statement required by Regulations section 53 4945-5(d).
6a Did the organization, during the year, receive any funds, d irectly or indirectly, to pay premiums o n
a p ersonal benefit contracts ~ Yes Ell No
b Di d t he organization, during the year, pay premiums, directly or indirectly, on a personal b enefit contract?
If you ans wered "Yes" to 6 b. also file Form 88 70.
Form 990-PF (2003)
323541
12-05-03
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11131104 758876 9124 2003 .06030 CABMAN HAWAII, INC .
9124
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CABMAN HAWAII, INC .
99-033291 5
Part VIII Information About Officers, Directors, Trustees , Foundation Managers , Highly
Paid Employees, and Contractors
Page 6
1 List all officers , directors , tr ustees , foundation managers and their compensation :
(c) Compensation (d~ContA b utl o n s to (e) Expense
(b) Title, and average
(a) Name and address hours per week devoted ( If not paid , °m~ znOeOMerieOp~ns account, other
to position enter -)
I com pe ns ation allowances
W . DOUG LA S
B.
HILLER,
M. D .
P RE S . ,
TREA S .,
DIRE C T
P .O . BOX 2835
. PRES ., SECS ., DIR E
IRECTO R
4
RECTO R
2 Compensation of five highest-paid employees (other than those included on line 1) . If none, enter " NONE."
(b) Title an d avera g e
(a) Name and address of each employee paid more than $50,000 hours per week
(c) Compensation
devoted to position
Total number of other employees paid over $ 50,00 0
3 Five highest - paid independent contractors for professional services . If none , enter " NONE. "
(a) N ame and address of each person paid more than $50,000
(Expense
account, oth er
allowance s
(b) Type of servic e
Total numb er o f others receiving over $50,000 for professional services
Pa rt IX -A Summary of Direct Charitable Activitie s
110-
List the f oun d ation's fo u r largest direct charitable activities during the tax year . Include relevant stat istical informa tion suc h as the
number of organizations and other beneficiaries served, conferences convened, research papers produced, e tc .
Expenses
1
2
SE
3
SE
4
Form 990-PF (2003)
12-05-03
11131104 7 588 7 6
9124
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2003 .0 6 0 30 CABMAN HAWAII ,
INC .
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Form 990-PF (2003) CABMAN HAWAI 2 , INC .
99-0332915
Page 7
Pa rt IX- B Summa ry of Program - Related Investments
Describe the two largest program-related investments made by the foundation during the tax year on lines 1 and 2 .
1
Amoun t
2
All other program-related investments. See instructions.
3
Total . Add lines 1 through 3
Pa rt X
1
Minimum investment Return (All domestic foundations must complete this part Foreign foundations, see instructions .)
Fair mark et value of assets not use d (or held for use) directly in carrying o ut charitable, etc., p ur p oses :
a A verage monthly fair mark et value o f securitie s
b A verage of monthly cash balances
c F air mark et value of all ot her assets
d Total (add lines la, b, and c )
e Reduction claime d for b lockage or other factors reported o n lines la an d
1 c (attach detailed exp lanation)
Ile
2 Acquisition indebtedness applicable to line 1 asset s
3 Subtract line 2 from line 1 d
4 Cas h deemed held for charitable activi t ies . Enter 1 1/2% of line 3 (for greater amoun t, see instructions)
5 Net value of noncharitable -use assets . Su btract line 4 from line 3 . Enter here and on Part V, line 4
6 Minimum i nvestment return . Enter 5% of line 5
Part XI
Distributable Amount (se e i nst ructio n s) (Section 4942(j)(3) and (1)(5) private operating foundations and certain
foreign organizations check here ► Uj and do not complete this part.)
1 M inimum investment return from Part X , line 6
2a Tax on investment income for 2003 from Part VI, line 5
b Income tax for 2003. (This does not include the tax from Part V I .)
c Add lines 2a and 2 b
3 Distributable amount before adjustments . Subtract line 2c from line 1
4a R ecoveries of amounts treated as qualifying distribu tions
b Income distributions from section 4 947(a)(2) trusts
c Ad d lines 4a and 4 b
2a
2b
4a
4b
5 Add lines 3 and 4c
6 De d uct ion from distributable amount (see instruc t ions)
7 D istr i butable amount as adjusted . Subtract line 6 from line 5. Enter here and on Part XIII, line 1
Pa rt XII Qualifying Distributions (see instructions)
1 Amounts paid (including administrative expenses) to accomplish charitable, etc., purposes :
a Expenses, contributions, gifts, etc . - total from Part I, column (d), line 26
112
142,260
b Program-related investments - Total from Part IX-B 1b 0
2 Amounts paid to acquire assets used (or held for use) directly in carrying out charitable, etc ., purposes 2
9,995
3 Amounts set aside for specific charitable projects that satisfy the :
a Suitability test (prior IRS approval required) 3a
b Cash distribution test (attach the required schedule) 3 b
4 Qualifying distributions . Add lines la through 3b . Enter here and on Part V, line 8, and Part XIII, line 4 4
152,255
5 Organizations that qualify under section 4940(e) for the reduced rate of tax on net investmen t
income . Enter 1% of Part I, line 27b 5 0
.
.
.
.
.
6 Adjusted qualifying distributions . Subtract line 5 from line 4
6 152,255 .
Note : The amount on line 6 will be used in Part V, column (b), in subsequent years when calculating whether the foundation qualifies for the section
4940(e) reduction of tax in those years .
Form 990-PF (2003 )
323581
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11131104 758876 9124 2003 .06030 CABMAN HAWAII, INC .
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Form 990-PF (2003) CABMAN HAWA2 I , INC .
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Page e
Part XIII Undistributed Income (see instructions )
(
(a)
Corpus Years prior
to 2002
2002
b)
(C)
(d)
200 3
Distributable amoun t
for 2003 from Part XI, line 7
2 Undi str ibuted income , i f any , as of the and 012002
a Enter amount for 2002 only
b Total for prior years :
3 Excess distributions carryover, if any, to 2003 :
a From 199 8
b From 1 999
c From 2000
d From 200 1
e From 200 2
f Total of lines 3a through e
4 Qualifying distributions for 2003 from
Part xll, line 4 : ► $
N/A
a Applied to 2002, but not more than line 2a
b Applied to undistributed income of prior
years (Election required - see instructions )
c Treate d as distributions out of corpus
(Elec tion required - see instructions)
d App lie d to 2003 distributable amount
e R emaining amount distributed out of corpus
5
Excess distributions carryover appl ied to 200 3
Of an amount appears in column (d), the same amount
must be shown i n column (a) )
6 Enter the net total of each column as
ind i cat e d b e l o w:
8 Corpus Add li nes 3f, 4c, and 4e Subtract line 5
b Prior years' undistributed income . Subtract
line 4 b f rom line 2b
c Enter the amount of prior years'
undis tributed income for which a notice of
deficiency has been issue d , or on whic h
the section 4942(a) tax has been previously
assesse d
d Subtract line 6c from line 6b . Taxable
amount - see instruction s
e Undistributed income for 2002 . Subtract line
4a from line 2a . Taxable amount - see instr.
f Undistributed income for 2003 . Subtrac t
lines 4 d and 5 from line 1 . This amount must
be distributed in 200 4
7 Amounts treated as distributions ou t of
corpus to satisfy requirements imposed by
section 1 70(b)(1)(E) or 4942(g)(3 )
0.
8
Excess distributions carryover from 1998
not applied on line 5 or line 7
9 Exces s distributions c arryover to 2004 .
Subtract lines 7 and 8 from line 6 a
10 Analysis of line 9 :
a Excess from 1999
D Excess from 2000
c Excess from 2001
d Excess from 200 2
Form 990-PF (2003 )
323571
12- 0 5-03
8
11131104 758876 9124 2003 .06030 CABMAN HAWAII, INC .
9124
1
Form 990-PF 2003
CABMAN HAWAII, INC .
Pa rt XIV Private Operating Foundations (see instructions and Part vii-A, quest ion 9)
1 a If t he foundation has received a ruling or determination letter t hat it is a private operating
foundation, and the ruling is effective for 2003, enter the date of the ruling o . L
b Check box to indicate whether the organization is a private operating foundation described in section
2 a Enter the lesser of the adjusted net Tax year Prior 3 yea
income from Part I or the minimum (a) 2003 ( b ) 2002 (c) 200 1
99-033291
4 94
(d) 2000
(e) Tota l
investment return from Part X fo r
each year liste d
b 85% of line 2 a
c qualifying distributions from Part XII,
line 4 for each year liste d
d Amounts included in line 2c not
used direc tly for active conduct of
exempt activitie s
e qualifying distributions made directly
3,842 .
2,227 .
3,266 . 1,893 .
2,255 . 66,584 .
0.
0.
for active conduct o f exempt activities .
Subtract line 2d from line 2c
Complete 3a, b, or c for th e
alternative test relied upon:
a Assets ' alternative tes t - enter:
(1) V alue of all assets
(2) Value of assets qualifying
un d er section 4 9 4 2(j)(3)( B )(Q
b En d owmenC alternative test - Ente r
2/3 of minimum investment return
shown in Part X, line 6 for each year
liste d
c Su p porC alternative tes t - enter :
(1) Total support other than gross
investment income (interest,
dividends, rents, payments on
securities loans (section
5 1 2(a)(5)), or royalties )
(2) Su p port from general public
and 5 or more exempt
organizations as provided in
section 4942(j)(3)(B)(u Q
(3) Largest amount of support from
an exempt organization
Supplementa ry Informat i on (Complete th is part only if the o f
at any time dur i ng the year-see page 25 of the ins tructions .)
I
or more i n
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 o f any tax
year ( b u t only if they have contribu ted more than $5,000). (See section 507(d)(2). )
NON E
b List any managers of the foundation who own 10% or more of the stock of a corporat ion (or an equally large p ortion of the ownership of a p artnership or
other entity) of which t he foundation has a 1 0% or greater interest .
N O NE
2 Information Regarding Contribution , Grant , Gift , Loan , Scholarship , etc ., Programs:
Check here ► M if the organization only makes contributions to preselected charitable organizations and does not accept unsolicited requests for funds . If
the organization makes gifts, grants, etc. (see instructions) to individuals or organizations under other conditions, complete items 2a, b, c, and d .
a The name, address, and telephone number of the person to whom applications should be addressed :
b The form in which applications should be submitted and information and materials they should include :
c A ny submission deadlines :
d Any restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other factors:
323581/01 -20-04
9
11131104 758876 9124 2003 .06030 CABMAN HAWAII, INC .
Form 990- PF (2003)
9124
1
Form 990-PF (2003)
323801/12 -05- 03
1
0
11131104 758876 9124 2003 .06030 CABMAN HAWAII, INC .
9124
1
Form 990-PF (2003) CAB MAN HAWAII, INC .
Pape 11
99-0332915
Pa rt XVI - A Analysis of Income - Producing Activities
Enter gross amounts unless otherwise indicated. unrelaiea ousiness incorne Excluded by section 512, 513, or 514
(e )
(a) (b)
E ~~r„Related or exem pt
(d)
Business Amount 5 tO " Amount function income
e
code
rod
1 Program service revenue:
a
b
c
d
e
f
g Fees and contracts from government agencie s
2 Membershi p dues and assessment s
3 Interest on savings and temporary cash
investments
4 Dividends and interest from securitie s
18
192 .
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 persona l
property
7 Other inves tme n t incom e
17 6,580 .
8 Gain or (loss) from sales of assets othe r
than
inventory
18
<64 . >
9 Net income or (loss) from special events
10 Gross profit or (loss) from sales o f inventory
1,681 .
11 Other revenue:
a
b
c
d
e
12 Subtotal. Add columns (b) , (d), and
13 Total . A dd line 1 2, columns (b), (d), an d (e)
(See worksheet in line 1 3 in structions to verify calculations . )
(e) 0 .
6,708 . 1,681 .
13
8,389 .
Part XVI - B Relationship of Activities to the Accomplishment of Exempt Purpose s
Line No .
Explain below how each activity for which income is repo rted in column (e) of Part XVI-A cont ri buted impo rtantly to the accomplishment of
the organization 's exempt purposes (other than by provid in g funds for such purposes) .
'COME FROM USE OF ORGANIZATION'S EQUIPMENT FOR MEDICAL TESTS A
szseii
12 - OS -03
11131104 758876 9124
Form 990- PF (2003 )
11
2003 .06030 CABMAN HAWAII, INC .
9124
1
Form 990-PF (2003) CA BMAN HAWAII, INC .
99-0332915 Page 12
Pa rt XVII Information Regarding Transfers To and Transactions and Relationships With Noncharitable
Exempt Organizations
Yes No
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 ?
a Transfers from the reporting organization to a nonchantable exempt organization o f
(1) Cash
(2) Other assets
b Other transactions :
( 1) Sales of assets t o a noncharitable exempt organization
( 2) Purchases of assets from a noncharitable exempt organization
( 3) Ren tal of facilities, equipment, or o t her assets
( 4) Reimbursement arrangements
(5) Loans or loan guarantees
( 6 ) Performance of services or membership or fundraising solicitations
la(l)
la(2)
X
X
lb(l)
X
1b 2 X
UP)
X
lb(4)
X
lb(S)
X
lb(6 )
X
c Sharing of facilities, equipment, mailing lists, other assets, or paid employees
1c X
If
the
answer
to
any
of
the
above
is
"Yes,'
complete
the
following
schedule
.
Column
(b)
should
always
show
the
fair
mark
et
value
of
the
g
oods,
other
asse t s,
d
or services g iven by the reporting organization . If the organization received less than fair market value in any transaction or sharing arrangement, show i n
2a Is the organization directly or indirectly affiliated with, or related to, one or more tax-exempt or g anizations describe d
in section 501(c) of the Code (other than section 501(c)(3)) or in section 527? Q Yes Q No
b I f 'Yes. ' comple te the following schedule .
Name o f organization
(b) Type of organization
N/A
(c) Desc ri ption of relationship
Under penalti es of perdu ; I declar e that I have am d his return , includi ng accompanyi ng schedules and statements , and to the best of my knowledge and beli ef , it i s true , correct ,
and complete Decl arati n p er t or fiducia ry) is based on all information of which r er has an knowledge
Signature of is or tr u
e
D
Preparer' s
~ signature
~
y
Arm's name ( oryoun
k- :) If self-employed),
address, and ZIP code
Q
H BERG, FRE ITA S, KING
733 B IS H O P ST REE T, S UI T
unrT nr .r Tr .rT
i7 A TAT A T T
D
r
S21 Z
323821
1 2- 05 - 03
11131104 758876 9124 2003 .0603 0
Schedule B
(F orm 99 0, 99 0 - EZ , or
990- P F)
Dep artm ent of th e Trdasury
Internal Revenue service
Schedule of Contributors
O MB N o 1 54 5-0 047
Su pp lement ary I nf orm a tion for
line 1 of Form 990, 990- EZ, and 99 0- P F (see instructions )
2003
E m ployer i dentification number
N am e of orga n i zat io n
00-('111101 r,
Organization type (check one) .
Filers of:
Section:
F orm 990 o r 990-EZ 0 501 (c)( ) (e nt er n umber) organizatio n
Q 4947(a)(1) nonexempt charitable trust no t treated as a private foundation
Q 527 political organizatio n
501(c)(3) exempt private foundation
Form 990-PF
Q 4947(a)(1) nonexempt chartable trust treated as a private foundation
Q 501 (c)(3) taxable private foundation
Check if your organization is covered by the Genera l Rule or a Sp ecial R ule . (No te: Only a sec tion 501(c)(7), (8), or (10) organization can check box(es)
for both the General Rule and a Special Rule-see instructions .)
General RuleI-XI organizations filing Form 990 , 990 - EZ , or 990 - PF that received , during the year, $5 , 000 or more (i n money or prope rty) from any one
contributor. (Complete Part s I and II )
Sp ecial RulesF-1
For a section 501 (c)(3) organization filing Form 990, or Form 990-EZ, that met the 33 1/3% support test of the regulations under
sections 509(a)(1)/170(b)(1)(A)(vi) and received from any one contributor, during the year, a contribution of the greater of $5,000 or 2 %
o f the amou n t o n lin e 1 o f th ese form s . (Co m p let e P arts I an d II . )
Q For a section 501(c)(7), (8), or (10) organization filing Form 990, or Form 990-EZ, that received from any one contributor, during the year,
aggregate contributions or bequests 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 III )
Q For a section 501(c)(7),(8), or (10) organization filing Form 990, or Form 990-EZ, that received from any one contributor, during the year,
some contributions for use exclusively for religious, charitable, etc., purposes, but these contributions did not aggregate 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 Ge n era l R ule applies to this organization because it receive d
nonexclusive ly religious , charitable, etc , contributions of $5 , 000 or more du ring the year)
11111.
Caution: Organizations that are not covered by the General Rule and/or the Special Rules do not file Schedule B (Form 990, 990-EZ, or 990-PF), but
they m ust check the box in the heading of their Form 990, Form 990-EZ, or on line 1 of their Form 990-PF, to certify that they do not meet the filing
requirements of Schedule B (Form 990, 990-EZ, or 990-PF).
LHA F or P aperw ork R e d uction Act N otice, see t he I nstruc tions Schedule B (Form 990, 990-EZ, or 990-PF) (2003 )
for Form 990 and Form 990 - EZ
323451 12-05-03
11131104 758876 9124
13
2003 .06030 CABMAN HAWAII, INC .
9124
1
Sched ul e B (Form 980 , 990-EZ, or 990 -PFD
(2003)
Page
1 to
1 of Part i
N ame of organization Employer identification numbe r
CABMAN HAWAII,
INC .
99-0332915
Part I Contributors (See Specific Instructions )
(a)
No.
(b)
(c)
(d)
N ame, add ress, a nd ZIP + 4
Aggregate contr ibutions Typ e of c on trib utio n
Person
Payrol l
1 JOHN M . SIMPSON
30 N . LASALLE #1232
$
75,000 .
Noncash 0
(Complete Part II if there
CHICAGO, IL 6 0 6 0 2 is a noncash contribution .)
(a)
N o.
(b )
(c)
N ame, address, and ZI P + 4
(d)
A ggregate contr ibutions Type of contri bution
P erso n
P ayr oll
N on cas h
$
Q
Q
Q
(Complete Part II if there
is a noncash contnbution .)
(a)
No .
(b)
ass . and ZIP + 4
(c)
(d)
con tri but i ons
Type of contr ibution
Per son
Payroll
Nonca sh
Q
0
0
(Com ple te Part II i f there
is a noncash contribution .)
(a)
No .
( b)
ss, and ZIP + 4
(c)
c on tribut i ons
(d)
Type of con tributio n
Pers on
Payroll
Non cash
Q
Q
Q
(Complete Part II if there
is a noncash contribution . )
(a)
No .
( b)
ss. an d ZIP + 4
(c)
contributio n s
(d)
Typ e of co ntribu t io n
P erso n
P ayr oll Q
N oncas h
(Complete Part II if there
is a noncash contribution . )
(a)
No.
ass, an d ZIP + 4
Aggregat e contr i b utions
Typ e of c o ntribu t io n
P erso n
P ayroll
Noncash
$
(Complete Part II if there
is a noncash contribution )
Sche d ule B (Form 990, 990-EZ, o r 990- P F) (20 0 3)
323452 12 -05-03
14
11131104 758876 912 4
2003 .06030 CABMAN HAWAII, INC .
9124
1
99 - 033291 5
CABMAN HAWAII, INC .
FORM 990-PF. GAIN OR (LOSS) FROM SALE OF ASSET S
STATEMENT
1
(A)
DESCRIPTION OF PROPERTY
MANNER DATE
ACQUIRED ACQUIRED DATE SOLD
120 SHS AT&T WIRELES S
DONATED 12/09/03 12/10/0 3
(B)
(C)
GROSS VALUE AT
SALES PRICE TIME OF ACQ .
850 .
(A)
DESCRIPTION OF
3
SHS
AGERE
(D)
(E)
(F)
EXPENSE O F
SALE DEPREC . GAIN OR LOSS
841 .
0 .
MANNER
PROPERTY ACQUIRED
SYSTEMS
INC
CL
A
0.
9.
DATE
ACQUIRED DATE
DONATED
12/09/03
SOLD
12/10/0 3
(B)
(C)
(D)
(E)
(F)
GROSS VALUE AT EXPENSE O F
SALES PRICE TIME OF ACQ . SALE DEPREC . GAIN OR LOSS
9.
9.
0.
(A)
MANNER
DESCRIPTION OF PROPERTY ACQUIRED
83
SHS
AGERE
SYSTEMS
INC
CL
B
0.
0.
DAT E
ACQUIRED DATE
DONATED
12/09/03
SOLD
12/10/03
(B)
(C)
(D)
(E)
(F )
GROSS VALUE AT EXPENSE O F
SALES PRICE TIME OF ACQ . SALE DEPREC . GAIN OR LOSS
219 .
237 .
0.
0.
<18 . >
15
STATEMENT(S)
1
9124
1
11131104 758876 9124 2003 .06030 CABMAN HAWAII, INC .
CABMAN HAWAII ,
INC .
( A)
DESCRIPTION
10
SHS
99 - 033291 5
MANNER
DATE
OF PROPERTY ACQUIRED ACQUIRED DATE
AVAYA
INC
DONATED
12/09/03
SOLD
12/10/0 3
(B)
(C)
(D)
(E)
(F)
GROSS VALUE AT EXPENSE O F
SALES PRICE TIME OF ACQ . SALE DEPREC . GAIN OR LOSS
105 .
(A)
DESCRIPTION OF
320
SHS
107 .
0 .
MANNER
PROPERTY ACQUIRED
LUCENT
TECH
INC
DONATED
0.
<2 . >
DATE
ACQUIRED DATE
12/09/03
SOLD
12/10/0 3
(B)
(C)
(D)
(E)
(F)
GROSS VALUE AT EXPENSE O F
SALES PRICE TIME OF ACQ . SALE DEPREC . GAIN OR LOSS
881 .
CAPITAL
TOTAL
TO
GAINS
FORM
934 .
0.
DIVIDENDS
990-PF,
FROM
PART
I,
<53 . >
0 .
PART
LINE
IV
6A
<64 . >
FORM 990- PF INTEREST ON SAVINGS AND TEMPORARY CASH INVESTMENTS STATEMENT
2
AMOUNT
SOURCE
187 .
5.
BANK OF HAWAI I
SMITH BARNEY CITI GROU P
TOTAL TO FORM 9 90 -PF ,
0 .
PART I ,
LINE 3 ,
COLUMN A
192 .
16 STATEMENT(S) 1, 2
9124
1
11131104 758876 9124 2003 .06030 CABMAN HAWAII, INC .
99 - 033291 5
LABNlAN HAWAII, INC .
FORM 990 - PF
RENTAL INCOM E
STATEMENT
ACTIVITY GROSS
NUMBER RENTAL INCOME
KIND AND LOCATION OF PROPERTY
1
LABMOBILE RENT
TOTAL TO FORM 990- PF ,
6,580 .
6,580 .
PART I, LINE 5A
FORM 990-PF
3
OTHER
INCOME
STATEMENT
DESCRIPTION
4
AMOUNT
GROSS INCOME FROM SPECIAL FUNDRAISING EVENTS
1,681 .
TOTAL TO FORM 990 - PF, PART I, LINE 11, COLUMN A
1,681 .
FORM 990 - PF
ACCOUNTING
FEES
STATEMENT
5
(A)
(B)
(C)
(D)
EXPENSES NET INVEST- ADJUSTED CHARITABLE
PER BOOKS MENT INCOME NET INCOME PURPOSE S
DESCRIPTIO N
ACCOUNTING
2,833 .
15 .
15 .
2,848 .
TO FORM 990 - PF, PG 1, LN 16 B
2,833 .
15 .
15 .
2,848 .
FORM 990 - P F
TAXE S
( A)
(B)
EXPENSES NET INVESTPER BOOKS MENT INCOM E
DESCRIPTION
PAYROLL TAXES
GENERAL EXCISE TAX
FEDERAL TA X
TO FORM 990- PF,
STATEMENT
PG 1 ,
LN 18
(C)
ADJUSTED
NET INCOME
6
( D)
CHARITABL E
PURPOSES
2,927 .
16 .
196 .
196 .
58 .
0.
16 .
196 .
0.
2 , 911 .
0.
0.
3,181 .
212 .
2 , 911 .
212 .
17 STATEMENT(S) 3, 4, 5, 6
11131104 758876 9124 2003 .06030 CABMAN HAWAII, INC .
9124
1
99 - 033291 5
CABMAN HAWAII, INC .
FORM 990-PF.
OTHER
(A)
EXPENSES
PER BOOK S
DESCRIPTION
EXPENSES
(B)
NET INVESTMENT INCOM E
STATEMENT
(C)
ADJUSTE D
NET INCOME
7
(D)
CHARITABL E
PURPOSES
BANK CHARGES
ENTERTAINMENT
INSURANC E
INTERNET EXPENSE
OUTSIDE SERVICES
OFFICE EXPENSE
POSTAGE & DELIVERY
RACE EXPENSE
EDUCATION
COMMUNITY SERVICE
EVENT EXPENSE
LICENSE & FEES
PENALTIE S
RESEARCH
TELEPHONE
ADVERTISING
CONTRIBUTIONS
PROMOTION
AMORTIZATIO N
426 .
1,360 .
8,060 .
1,235 .
250 .
1,278 .
771 .
55 .
737 .
336 .
73,047 .
5.
227 .
5,557 .
2,163 .
25 .
329 .
81 .
194 .
426 .
7.
44 .
7.
1.
6.
4.
0.
4.
2.
0.
0.
0.
0.
12 .
0.
2.
0.
0.
426 .
7.
44 .
7.
1.
6.
4.
0.
4.
2.
0.
0.
0.
0.
12 .
0.
2.
0.
194 .
0.
1,353 .
8,016 .
1,228 .
249 .
1,272 .
767 .
55 .
733 .
334 .
73,047 .
5.
0.
5,557 .
2,151 .
25 .
327 .
81 .
0.
TO FORM 990 - PF, PG 1, LN 23
96,136 .
515 .
709 .
95,200 .
FORM 990 - PF
OTHER
ASSETS
DESCRIPTION
STATEMENT
BOOK VALUE
ORGANIZATION COSTS, NET
OTHER RECEIVABLE
EMPLOYEE ADVANCE S
DEPT OF EDUCATION ASSET S
0.
76 .
221 .
10,414 .
TOTAL TO FORM 990 - PF, PART II, LINE 15
10,711 .
8
FAIR MARKET
VALUE
0.
76 .
221 .
10,414 .
10,711 .
18 STATEMENT(S) 7, 8
9124
1
11131104 758876 9124 2003 .06030 CABMAN HAWAII, INC .
CABMAN HAWAII, INC .
FORM
990-PF
99 - 03329 1
OTHER
LIABILITIES
STATEMENT
DESCRIPTION
9
AMOUNT
PAYROLL TAXES WITHHELD AND PAYABLE
SALARIES PAYABL E
BANK OVERDRAF T
DEPT OF EDUCATION ASSETS PAYABL E
TOTAL TO FORM 9 9 0-PF ,
PART II ,
318 .
0.
117 .
10,414 .
LINE 22 ,
COLUMN B
10,849 .
FORM 990-PF LIST OF SUBSTANTIAL CONTRIBUTORS STATEMENT 10
PART VII-A, LINE 1 0
NAME OF CONTRIBUTO R
ADDRES S
OHN M . SIMPSON
FORM 990 - PF
30 N . LASALLE 1232, CHICA 0,
IL 0 0 2
SUMMARY OF DIRECT CHARITABLE ACTIVITIES STATEMENT 1 1
ACTIVITY ONE
HAWAII ISLAND DIABETIC FOOT STUDY PHASE 1 - THIS PILOT STUDY
EXAMINED THE FOOTWEAR AND FOOT CARE OF TYPE 2 DIABETICS
THROU H OUT NORTH HAWAII AND WAS A COLLABORATIVE PRO ECT
BETWEEN LABMAN HAWAII , NORTH HAWAII COMMUNITY HOSPITAL ,
HAMP,KUA HEALTH CENTER , TUTU S HOUSE , THE CENTER FOR
INDEPENDENT LIVIN AND THE DIABETES EDUCATION AND RESOURCE
CENTER IN HILO . APPROXIMATE TOTAL PEOPLE PARTICIPATED 100
EXPENSE S
TO FORM 990-PF, PART IX-A, LINE 1
11131104
7
887
9124
9,
9.
19 STATEMENT S 9, 10, 11
2003 .0 030 CABMAN HAWAII, INC .
9124
1
99 - 033291 5
CABMAN HAWAII, INC .
FORM 990 - PF,
SUMMARY OF DIRECT CHARITABLE ACTIVITIES STATEMENT 1 2
ACTIVITY TW O
MRI RESEARCH - ASSESSMENT OF THE SHOULDER AMONG SWIMMERS AND
TRIATHLETES : THIS STUDY IS OBTAINING INFORMATION FROM
SWIMMERS AND TRIATHLETES DESIGNED TO CHARACTERIZE THE
SHOULDER JOINT IN THESE HIGHLY ACTIVE POPULATIONS AS A
FOUNDATION AND REFERENCE FOR FUTURE STUDIES ON JOINT HEALTH .
APPROXIMATE TOTAL PEOPLE PARTICIPATED TO DATE : 50 . KINEMATIC
MRI OF THE PATELLOFEMORAL JOINT : THIS STUDY IS AN EXPANSION
FROM OUR FIRST STUDY ON THE KNEES OF TRIATHLETES AND IS
ANALYZING PATELLA TRACKING USING A FORM OF MRI WHICH ALLOWS
THE JOINT MOTION TO BE ANALYZED . APPROXIMATE TOTAL PEOPLE
PARTICIPATED TO DATE : 50 . MULTINUCLEAR SPECTROSCOPY : THIS IS
A PROJECT IN DEVELOPMENT THAT WOULD ESTABLISH MAGNETIC
RESONANCE RESEARCH AT NHCH FOR THE STUDY OF MUSCLE FUNCTION
AND METABOLISM . MAGNETIC RESONANCE SPECTROSCOPY IS A NON INVASIVE TECHNIQUE THAT CAN PROVIDE A "WINDOW " INTO THE
METABOLIC PROCESSES WITHIN EXERCISING SKELETAL MUSCLE .
APPROXIMATE TOTAL PEOPLE PARTICIPATED TO DATE : 1 5
EXPENSE S
TO FORM 990- PF ,
FORM 990 - PF
PART IX - A ,
LINE 2
14,858 .
SUMMARY OF DIRECT CHARITABLE ACTIVITIES STATEMENT 1 3
ACTIVITY THRE E
LIVE ALOHA : LIVE A LIFE OF HEALTH ACTIVITIES - THIS MULTIINSTITUTIONAL PROJECT IS PILOTING A UNIQUE CLASSROOM-BASED
PHYSICAL EDUCATION CURRICULUM DESIGNED BY KOHALA RESIDENT AND
FORMER PRESCHOOL ADMINISTRATOR, VERONICA EUGENIO . THE
PROJECT IS BASED AT KANU 0 KA'AINA CHARTER SCHOOL AND IS
FUNDED BY A $116,281 GRANT FROM THE US DEPT . OF EDUCATION .
APPROXIMATE TOTAL PEOPLE PARTICIPATED TO DATE : 20 0
EXPENSE S
TO FORM 990 - PF, PART IX - A, LINE 3
99,123 .
20 STATEMENT(S) 12,
11131104 758876 9124 2003 .06030 CABMAN HAWAII, INC .
9124
13
1
CABMAN HAWAII, INC .
FORM 990-PF, SUMMARY OF DIRECT CHARITABLE ACTIVITIE S
99 - 033291 5
STATEMENT 1 4
ACTIVITY FOUR
COMMUNITY BASED FITNESS TESTING AND ADVOCACY - IN ADDITION TO
THE RESEARCH PROJECTS WHICH INCORPORATE THE CABMAN MOBILE
LABORATORY AND CLASSROOM, THIS MOBILE RESOURCE HAS BEEN
INCORPORATED INTO AN ONGOING COMMUNITY-BASED FITNESS ADVOCACY
PROGRAM THROUGHOUT HAWAII ISLAND, INCLUDING VISITS TO :
PAHALA, NA'ALEHU, PAUILO, HILO, KONA, HONOKA'A, WAIKOLOA AND
WAIMEA . APPROXIMATE TOTAL PEOPLE PARTICIPATED TO DATE : 50 0
EXPENSES
TO FORM 990 - PF ,
PART IX - A, LINE 4
8 , 359 .
21 STATEMENT(S) 14
11131104 758876 9124 2003 .06030 CABMAN HAWAII, INC .
9124
1
9124 CABMAN HAWAII , INC.
Tax Asset Detail
11/03/2004 3:31 PM
Page 1
7/01/03 - 6/30/04
FYE : 6/30/2004
Asset
Date I n
P ro perty De scri p tio n S e rvic e
Tax Sec 179 Exp Tax Se c
Tax P rio r Tax Current T ax Tax Net T a x Tax
Co st Cu rrent = c
168 ( k) Amt De preciation Depreciati o n End D e pr Boo k Va lue Metho d Pe rio d
Group : MEDI CAL RE S EARCH EOUIPT
1 RACER-MATE EXERCISE EQilII 1/20/99
2 BLOOD TESTING EQUIPMENT 6/15/99
8 BOD POD-LIFE MEASUREMENT 8/27/99
9 PADDLING ADAPTERS 8/24/00
10 SCALE 8/24/00
11 2 PADDLING ROWERS 9/25/01
13 TEKSCAN FOOT-SCAN/MAT 5/20/02
M E DI CAL RES EAR CH EQUIPT
1 , 208 . 15
2, 885 . 00
30 , 739 . 00
737 . 00
405 . 00
1,300.00
13 , 585 .00
0 00
0. 00
0. 00
0. 00
0. 00
0. 00
0. 00
50 , 859 . 15 O. OO c
0 . 00 927 37 106 . 92 1 ,034 . 29 173 . 86 200D B
0 . 00 2, 160 . 86 251 . 86 2 ,412 . 72 472 .28 200D B
0 . 00 21 , 136 . 13 2 , 744 . 99 23 , 881 . 12 6 ,857 . 88 200D B
0 . 00 414 . 71 92 . 05 506 . 76 230 . 24 200D B
0 . 00 227 . 88 50 . 58 278 . 46 126 . 54 200D B
0 . 00 603 . 59 199 . 03 802 62 497 . 38 200DB
0. 00 4 , 227 . 65 2 , 673 . 53
6,901 18
6 , 683 . 82 200DB
0 . 00 29 , 698 . 19
6 , 118 . 96
35 , 817 . 15
7.0
7.0
7.0
7.0
7. 0
7.0
7.0
15 ,042 . 00
Gro up: O FF ICE EQU IP MEN T
200DB
200DB
200DB
200DB
200DB
200DB
200DB
5 .0
5.0
5. 0
5.0
5 .0
5. 0
5.0
5 CARES SCHiJTTE FLEMING 9 /09/ 98 3 , 768 . 20 0 . 00 0 . 00 3 ,642 . 59 125 61 3 ,768 . 20 0 .00 Amo rt
6 REIMB TO HILLER ORTHOPEDI 9 /09/98 2 , 064 . 56 0 00 0 . 00 1 , 995 . 73 68 . 83 2,064 . 56 0.00 Amort
ORGANIZATIONAL COSTS
5 , 832 . 76 O . OO c
0 . 00 5 , 638 . 32 194 .44 5 , 832 . 76 0.00
5.0
5.0
3 COMPUTER 1/20/99
4 DELL COMPUTER 6/15/99
7 LAB COMPUTER 10/01/99
14 VAIO COMPUTER & 19" MOMT 2/03/04
15 SONY CAMCORDER 2/03/04
16 GATEWAY E-4100-C COMPUTE) 5/25/04
17 LAPTOP HOLDER, CAMCORDE] 6/03/0 4
O FF I CE E Q UEP MEN T
2 , 341 . 66 0.00 0. 00 2 , 176 . 34 165 . 32 2 , 341 . 66 0 . 00
1 ,259. 25 0 . 00 0. 00 1 , 138 .62 120 . 63 1 , 259 .25 0 . 00
1 ,666 . 66 0 . 00 0. 00 1 , 378 66 192 . 00 1 , 570.66 96 . 00
3 , 192. 00 O . OOc 0. 00 0.00 478 . 80 478 . 80 2 , 713 . 20
2 ,410 . 00 O . OOc 0 . 00 0 .00 361 .50 361 . 50
2,04850
1 , 814 . 81 O . OOc 0 . 00 0 . 00 90. 74 90. 74
1, 724 . 07
2 ,578 . 35 0 OOc 0. 00 0.00 128 . 92 128 . 92 2 ,449 . 43
15 ,262 . 73 O . OOc
0 . 00
4 ,693 . 62 1 , 537 . 91
6 , 231 . 53
9 , 031 . 2 0
Grout) : ORGANIZATIONAL COSTS
Group : VEHICL E
12
WINNEBA GO
6 / 18/02 192 , 940 . 56 0.00
VEHICLE
192 ,940. 56 O . OO c
Grand Total
264 ,895 .20 O .OO c
0 . 00 82 , 964 . 44 43 , 990 . 45 126,954 . 89 65 ,985 . 67 200DB
0.00 82 , 964 . 44 43 , 990 . 45 126 , 954 . 89 65 ,985 . 6 7
0 .00 122 , 994 . 57 51 , 841 . 76 174,836 . 33 90,058 . 87
5.0
Election Statement for Taxpayer not Claiming 30 Percent Additional
Depreciation Deduction for Qualified Propert y
CABMAN HAWAII INC
P.O. BOX 2511
KAMUELA, HI 9674 3
Identification Number : 99-033291 5
For the Tax Year Ending: 06/30/2004
The taxpayer elects not to claim the 30 percent additional first year depreciation allowed
by Code Sec . 168(k) for 5 YEAR.
Form
886 8
(December 2000 )
Application for Extension of Time To File an
Exempt Organization Return
Department of the Treasury
Internal Revenue Service
OMB No. 1545-1 70 9
► File a separate application for each return .
• If you are filing for an Automatic 3-Month Extension, complete only Part I and check this box , 10- U
• If you are filing for an Additional (not automatic) 3- M onth Extension, complete only Part II (on page 2 of this form) .
N ote : Do not complete Part 11 unless you have already been granted an automatic 3-month extension on a previously filed
Form 8868.
Automatic 3-Month Extension of Time - Only submit original (no copies needed )
Note : Form 990-T corporations requesting an automatic 6-month extension - check this box and complete Part 1 only . . . . . . ►
All other corporations (including Form 990-C filers) must use Form 7004 to request an extension of time to file income tax
returns . Partnerships, REMICs and trusts must use Form 8736 to request an extension of time to file Form 1065, 1066, or 1041 .
Type or Name of Exempt Organization Employer Identification number
p rint r .anranu HAWAII, INC .
99-033291 5
File by the due Number, street, and room or suite no If a P .O . box, see Instructions .
date for filing C/O HEDBERG,
your return . See
FREITAS,
KING
& T OM, LLP, 733
B ISHOP STREET, SUITE 1220
Instructions City, town or post office, state, and ZIP code . For a foreign address, see Instructions
HONOLULU, HI 9681 3
Check type of return to be flied (file a se crate application for each return) :
Form 990 Form 990-T (corporation) Form 4720
Form 990-BL Form 990-T(sec . 401(a) or 408(a) trust) Form 5227
Form 990-EZ Form 990-T (trust other than above) Form 6069
X
Form
990-PF
Form
1041-A
Form
887 0
• If the organization does not have an office or place of business In the United States, check this box . . . .
,►
. If this is
• If this is for a Group Return, enter the organization's four digit Group Exemption Number (GEN)
and attach a list with the
for the whole group, check this box ► F] . If it is for part of the group, check this box ►
names and EINs of all members the extension will cover.
1
I request an automatic 3-month (6-month, for 990-T corporation) extension of time until FEBRUARY 15 2005
to file the exempt organization return for the organization named above . The extension is for the organization's return for :
ii. calendar year o r
►
x tax year beginning JULY 1 , 2003 and ending JUNE 30 , 200 4
2 If this tax year is for less than 12 months, check reason : E-1 initial return
E] Final return E] Change in accounting perio d
3a If this application is for Form 990-BL , 990-PF, 990-T, 4720 , or 6069, enter the tentative tax, less an y
nonrefundable credits . See instructions,,,,,,,,,,,,,, , ,
b If this application is for Form 990 -PF or 990 - T, enter any refundable credits and estimated tax payment s
made . Include any prior year overpayment allowed as a credit , ,
,
c Balance Due . Subtract line 3b from line 3a . Include your payment with this form, or, if required , deposi t
with FfD coupon or, if required , by using EFTPS (Electronic Federal Tax Payment System) . See
instruct ions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
S i g na ture an d Verificatio n
Under penalties of pe nury, I d ec lare t hat I h ave examined this form , Incl ud in g accomp anyin g schedules and statements, and to the best o f my knowledg e and belief
It Is tr ue, cor rect , an d complete , and that I am authorized to prepare this form .
1110~
For Paperwork Redu c t l d(i Ac t Not ice , see
J SA
3FB 064 1 000
Title ► CPA
Date
► 11/01/0 4
Form 8868 (12-2000 )