2022-05-03T09:02:41-05:00 2021-12-31 420714325 RSM US LLP 227 WEST FIRST STREET SUITE 700 DULUTH MN 55802 990PF 2021-01-01 411873951 THE PATCH FOUNDATION PATC 6127817677 3201 RANKIN ROAD MINNEAPOLIS MN 55418 CAROLYN SAMPLE PRESIDENT 6127817677 2022-05-01 1 CAROLYN SAMPLE 999009999 JULIE BOYER P01278549 2187275025 2022-05-01 3 AAL1 IAL1 2021 2022-09-23 18:48:47Z X 8121279 X X 17 17 189700 189700 281124 1037316 281124 470841 470841 0 0 0 2310 1155 1155 10254 0 0 74 0 74 12638 1155 1229 1110000 1110000 1122638 1155 1111229 -651797 469686 38395 615758 615758 1122988 650021 650021 5759824 5003631 6855500 6921207 6269410 8121279 0 0 X 0 0 0 0 6921207 6269410 6921207 6269410 6921207 6269410 6921207 -651797 0 6269410 0 6269410 MEDTRONIC PLC 1037316 756192 281124 281124 281124 6529 0 6529 0 6529 7760 0 0 0 7760 0 1231 1231 0 0 0 0 0 0 0 0 0 0 0 1 1 MN 1 0 0 0 0 1 N/A THE FOUNDATION 6127817677 3201 RANKIN ROAD MINNEAPOLIS MN 55418 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 CAROLYN SAMPLE 3201 RANKIN RD MINNEAPOLIS MN 55418 PRESIDENT 2.00 0 0 0 WILLIAM C PETERSON 6724 99TH AVE NORTH BROOKLYN PARK MN 55445 DIRECTOR 0.50 0 0 0 ERNEST LINDSTROM-LINDSTROM LAW OFFI 7600 PARKLAWN AVE STE 444 EDINA MN 55435 DIRECTOR 0.50 0 0 0 RONALD K DRAPER 861 OAKGREEN AVE PL N STILLWATER MN 55082 DIRECTOR 0.50 0 0 0 NONE 0 NONE 0 0 9052203 372339 0 9424542 0 0 9424542 141368 9283174 464159 464159 6529 6529 457630 0 457630 0 457630 1111229 0 1111229 457630 0 0 577445 694784 683682 792999 728182 3477092 1111229 0 0 0 457630 653599 0 0 4130691 0 0 0 0 0 0 577445 3553246 694784 683682 792999 728182 653599 CAROLYN SAMPLE CAROLYN P SAMPLE 3201 RANKIN ROAD NE MINNEAPOLIS MN 55418 6127817677 ORGANIZATIONS APPLYING SHOULD PROVIDE INFORMATION SIMILAR TO THAT SET FORTH BELOW: 1. ORGANIZATION NAME AND ADDRESS. 2. STATE IN WHICH APPLICANT IS ORGANIZED AS A NONPROFIT ENTITY. IF NOT SO ORGANIZED, EXPLAIN. 3. ATTACH ANY RULING OR DETERMINATION LETTER FROM INTERNAL REVENUE SERVICE ABOUT EXEMPT STATUS OR PRIVATE FOUNDATION STATUS. 4. COPY OF APPLICANT'S PROPOSED BUDGET AND PURPOSE OF ORGANIZATION. 5. IS APPLICANT CONTROLLED BY, RELATED TO, CONNECT WITH, OR SPONSORED BY ANOTHER ORGANIZATION? IF YES, IDENTIFY PARENT ENTITY. 6. SHOW AMOUNT REQUESTED AND HOW IT WILL BE USED. 7. SIGNED BY AUTHORIZED PERSON. NONE IN AWARDING GRANTS, THE FOUNDATION GIVES PREFERENCE TO MINNESOTA CHARITABLE ORGANIZATIONS. MEDICAL FOUNDATIONS, EDUCATION AND THE ARTS RECEIVE PRIME CONSIDERATION. GRANTS ARE NORMALLY RESTRICTED TO $1,000 OR LESS. APPLICANTS ARE USUALLY NOTIFIED WITHIN TWO MONTHS THAT THEIR APPLICATION HAS BEEN APPROVED OR REJECTED, OR THAT ADDITIONAL INFORMATION IS NEEDED. FOUNDATION DOES NOT PROVIDE APPLICATION FORMS. ALASKA CHRISTIAN COLLEGE 35109 ROYAL PLACE SOLDNOTNA AK 99669 NONE PC EDUCATIONAL 7000 BANYAN COMMUNITY 2529 13TH AVE SO MINNEAPOLIS MN 55404 NONE PC EDUCATIONAL 5000 BETHEL UNIVERSITY 3900 BETHEL DR ST PAUL MN 55112 NONE PC EDUCATIONAL 5000 CAMP KNUTSON 11169 WHITEFISH AVENUE CROSSLAKE MN 56442 NONE PC RELIGIOUS 5000 CARE 111 W ILLINOIS ST 5TH FLOOR CHICAGO IL 60654 NONE PC PROGRAM SUPPORT 10000 CATHOLIC CHARITIES 1200 SECOND AVENUE SO MINNEAPOLIS MN 55403 NONE PC RELIGIOUS 5000 COURAGE KENNY REHABILITATION INSTITUTE 3915 GOLDEN VALLEY RD MINNEAPOLIS MN 55422 NONE PC HEALTH 20000 COVENANT WORLD RELIEF PO BOX 773420 CHICAGO IL 60677 NONE PC RELIGIOUS 150000 CRISTO REY JESUIT HIGH SCHOOL 2924 4TH AVENUE SOUTH MINNEAPOLIS MN 55408 NONE PC EDUCATIONAL 5000 CROSS SERVICES 12915 WEINAND CIRCLE ROGERS MN 55374 NONE PC PROGRAM SUPPORT 3000 DUNWOODY COLLEGE OF TECHNOLOGY 818 DUNWOODY BLVD MINNEAPOLIS MN 55403 NONE PC EDUCATIONAL 15000 EVANGELICAL COVENANT CHURCH PO BOX 773420 CHICAGO IL 60677 NONE PC RELIGIOUS 200000 EXODUS LENDING CO HOLY TRINITY CHURCH 2380 WYCLIFF ST SUITE B-100 ST PAUL MN 55114 NONE PC PROGRAM SUPPORT 5000 FAMILY VALUES FOR LIFE 1280 ARCADE ST ST PAUL MN 55106 NONE PC PROGRAM SUPPORT 7000 FEED MY STARVING CHILDREN 401 93RD AVE NW COON RAPIDS MN 54433 NONE PC RELIGIOUS 30000 GREATER MINNEAPOLIS CRISIS NURSERY 4544 4TH AVE SOUTH MINNEAPOLIS MN 55419 NONE PC PROGRAM SUPPORT 5000 HABITAT FOR HUMANITY 1954 UNIVERSITY AVE W ST PAUL MN 55104 NONE PC PROGRAM SUPPORT 15000 HENNEPIN TECHNICAL COLLEGE 9000 BROOKLYN BLVD BROOKLYN PARK MN 55445 NONE PC EDUCATIONAL 5000 HOMEWARD BOUND 12805 HIGHWAY 55 STE 400 PLYMOUTH MN 55441 NONE PC HEALTH 10000 HOPE ACADEMY 2300 CHICAGO AVE MINNEAPOLIS MN 55404 NONE PC PROGRAM SUPPORT 5000 HOPE DENTAL CLINIC 800 MINNEHAHA AVENUE EAST 465 ST PAUL MN 55106 NONE PC PROGRAM SUPPORT 3000 KIWANIS CLUB OF NE MPLS 729 MARSHALL ST NE MINNEAPOLIS MN 55413 NONE PC PROGRAM SUPPORT 1000 LOAVES AND FISHES 721 KASOTA AVE SE MINNEAPOLIS MN 55414 NONE PC RELIGIOUS 25000 METRO HOPE MINISTRIES 2739 CEDAR AVENUE SOUTH MINNEAPOLIS MN 55407 NONE PC PROGRAM SUPPORT 30000 MINNESOTA ADULT AND TEEN CHALLENGE 740 E 24TH ST MINNEAPOLIS MN 55404 NONE PC PROGRAM SUPPORT 25000 NEW LIFE IN CHRIST MINISTRY PO BOX 456 CLEARWATER MN 55320 NONE PC RELIGIOUS 3000 PEOPLE SERVING PEOPLE 614 SOUTH THIRD STREET MINNEAPOLIS MN 55415 NONE PC PROGRAM SUPPORT 25000 RICHFIELD SPARTAN FOUNDATION INC 7229 CLINTON AVENUE RICHFIELD MN 55423 NONE PC EDUCATIONAL 7000 SALEM COVENANT CHURCH 2655 FIFTH STREET NW NEW BRIGHTON MN 55112 NONE PC RELIGIOUS 150000 SCIENCE WITH A MISSION 602 MASSAPOAG AVE SHARON MA 02067 NONE PC PROGRAM SUPPORT 10000 SECOND HARVEST HEARTLAND 7101 WINNETKA AVE N BROOKLYN PARK MN 55428 NONE PC PROGRAM SUPPORT 50000 SHARING & CARING HANDS 425 NORTH SEVENTH ST MINNEAPOLIS MN 55405 NONE PC PROGRAM SUPPORT 7000 SIMPSON HOUSING SERVICES 160 GLENWOOD AVE MINNEAPOLIS MN 55405 NONE PC PROGRAM SUPPORT 25000 ST STEPHEN'S HUMAN SERVICES 2309 NICOLLET AVE MINNEAPOLIS MN 55404 NONE PC PROGRAM SUPPORT 20000 SUNSHINE ACRES CHILDREN'S HOME 3405 NORTH HIGLEY ROAD MESA AZ 85215 NONE PC PROGRAM SUPPORT 7000 THE ARC MINNESOTA 2446 UNIVERSITY AVE W 110 ST PAUL MN 55114 NONE PC PROGRAM SUPPORT 10000 THE GIDEONS INTERNATIONAL PO BOX 403810 ATLANTA GA 30384 NONE PC RELIGIOUS 5000 THE SALVATION ARMY 2445 PRIOR AVENUE NORTH ROSEVILLE MN 55113 NONE PC RELIGIOUS 100000 THRESHOLD TO NEW LIFE 10031 SARATOGA WAY MAPLE GROVE MN 55369 NONE PC RELIGIOUS 5000 TRINITY FIRST LUTHERAN SCHOOL 1115 19TH AVE SO MINNEAPOLIS MN 55404 NONE PC EDUCATIONAL 10000 TRUE FRIENDS 10509 108TH ST NW ANNANDALE MN 55302 NONE PC PROGRAM SUPPORT 10000 UNION GOSPEL MISSION 376 WESTERN AVE N ST PAUL MN 55103 NONE PC PROGRAM SUPPORT 10000 UNIVERSITY OF MINNESOTA FOUNDATION 200 OAK STREET SE 500 MINNEAPOLIS MN 55455 NONE PC EDUCATIONAL 50000 UNIVERSITY OF NORTHWESTERN 3003 SNELLING AVE N ST PAUL MN 55113 NONE PC EDUCATIONAL 5000 URBAN HOMEWORKS PO BOX 11267 MINNEAPOLIS MN 55411 NONE PC RELIGIOUS 5000 1110000 0 14 17 14 189700 18 281124 0 470841 0 470841 0 0 0 0 0 0 0 0 0 0 ACCOUNTING FEES 2310 1155 1155 MEDTRONIC STOCK 4839631 6620800 CHEVRON 164000 234700 STATE OF MN FILING FEE 25 0 25 MISCELLANEOUS FEES 49 0 49 EXCISE TAX PAID - ESTIMATE 7760 0 0 EXCISE TAX PAID - PY 2494 0 0