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LAFOLLETTE MEDICAL FOUNDATION INC: Form 990PF, tax year 2021

View the entire original 990 at ProPublica ↗

Organization
LAFOLLETTE MEDICAL FOUNDATION INC (EIN 20-4901729)
Tax period
2021-01-01 to 2021-12-31
Filed
2022-08-29
IRS object ID
202242419349100869
Schema version
2021v4.2
Source
Download XML · Original 990 at ProPublica

Every field in the e-filed return. Faint text is the IRS element name, for citing.

Return header ReturnHeader

FieldValueIRS element (for citing)
Return2022-08-29T16:14:08-05:00ReturnTs
Tax Period End2021-12-31TaxPeriodEndDt

Preparer Firm PreparerFirmGrp

FieldValueIRS element (for citing)
Preparer Firm EIN621142155PreparerFirmEIN

Preparer Firm Name PreparerFirmName

FieldValueIRS element (for citing)
Business Name Line1PUGH & COMPANY PCBusinessNameLine1Txt

Preparer US Address PreparerUSAddress

FieldValueIRS element (for citing)
Address Line1315 N CEDAR BLUFF RD SUITE 200AddressLine1Txt
CityKNOXVILLECityNm
State AbbreviationTNStateAbbreviationCd
ZIP37923ZIPCd
FieldValueIRS element (for citing)
Return Type990PFReturnTypeCd
Tax Period Begin2021-01-01TaxPeriodBeginDt

Filer Filer

FieldValueIRS element (for citing)
EIN204901729EIN

Business Name BusinessName

FieldValueIRS element (for citing)
Business Name Line1LAFOLLETTE MEDICAL FOUNDATION INCBusinessNameLine1Txt
FieldValueIRS element (for citing)
Business Name ControlLAFOBusinessNameControlTxt
Phone4239126963PhoneNum

US Address USAddress

FieldValueIRS element (for citing)
Address Line1PO BOX 128AddressLine1Txt
CityJACKSBOROCityNm
State AbbreviationTNStateAbbreviationCd
ZIP37757ZIPCd

Business Officer BusinessOfficerGrp

FieldValueIRS element (for citing)
PersonSTACY WOOD-HEATHERLYPersonNm
Person TitlePRESIDENTPersonTitleTxt
Phone4239126963PhoneNum
Signature2022-08-17SignatureDt
Discuss With Paid PreparerYes (1)DiscussWithPaidPreparerInd

Signing Officer SigningOfficerGrp

Person Full Name PersonFullName

FieldValueIRS element (for citing)
Person FirstSTACYPersonFirstNm
Person LastWOOD-HEATHERLYPersonLastNm
FieldValueIRS element (for citing)
SSN999009999SSN

Preparer Person PreparerPersonGrp

FieldValueIRS element (for citing)
Preparer PersonKELLY A TUCKER CPAPreparerPersonNm
PTINP01015909PTIN
Phone8657690660PhoneNum
Preparation2022-08-16PreparationDt

Additional Filer Information AdditionalFilerInformation

Trusted Customer TrustedCustomerGrp

FieldValueIRS element (for citing)
Trusted Customer3TrustedCustomerCd
Authentication Assurance LevelAAL1AuthenticationAssuranceLevelCd
Identity Assurance LevelIAL1IdentityAssuranceLevelCd
FieldValueIRS element (for citing)
Tax2021TaxYr
Build TS2022-09-23 18:48:47ZBuildTS

Form 990-PF IRS990PF

FieldValueIRS element (for citing)
Organization501c3 Exempt PFYes (X)Organization501c3ExemptPFInd
FMV Assets EOY$11,327,212FMVAssetsEOYAmt
Method Of Accounting AccrualYes (X)MethodOfAccountingAccrualInd

Analysis Of Revenue And Expenses AnalysisOfRevenueAndExpenses

FieldValueIRS element (for citing)
Contri Rcvd Rev And Expnss$0ContriRcvdRevAndExpnssAmt
Schedule B Not RequiredYes (X)ScheduleBNotRequiredInd
Interest On Sav Rev And Expnss$53InterestOnSavRevAndExpnssAmt
Interest On Sav Net Invst Incm$53InterestOnSavNetInvstIncmAmt
Dividends Rev And Expnss$197,589DividendsRevAndExpnssAmt
Dividends Net Invst Incm$197,589DividendsNetInvstIncmAmt
Net Gain Sale Ast Rev And Expnss$742,788NetGainSaleAstRevAndExpnssAmt
Gross Sales Price$2,876,442GrossSalesPriceAmt
Cap Gain Net Incm Net Invst Incm$742,788CapGainNetIncmNetInvstIncmAmt
Incm Modifications Adj Net Incm$38,704IncmModificationsAdjNetIncmAmt
Total Rev And Expnss$940,430TotalRevAndExpnssAmt
Total Net Invst Incm$940,430TotalNetInvstIncmAmt
Total Adj Net Incm$38,704TotalAdjNetIncmAmt
Comp Ofcr Dir Trst Rev And Expnss$0CompOfcrDirTrstRevAndExpnssAmt
Comp Ofcr Dir Trst Net Invst Incm$0CompOfcrDirTrstNetInvstIncmAmt
Comp Ofcr Dir Trst Dsbrs Chrtbl$0CompOfcrDirTrstDsbrsChrtblAmt
Legal Fees Rev And Expnss$5,143LegalFeesRevAndExpnssAmt
Legal Fees Net Invst Incm$3,857LegalFeesNetInvstIncmAmt
Legal Fees Dsbrs Chrtbl$1,286LegalFeesDsbrsChrtblAmt
Accounting Fees Rev And Expnss$15,305AccountingFeesRevAndExpnssAmt
Accounting Fees Net Invst Incm$10,220AccountingFeesNetInvstIncmAmt
Accounting Fees Chrtbl Prps$5,085AccountingFeesChrtblPrpsAmt
Other Prof Fees Rev And Expnss$71,873OtherProfFeesRevAndExpnssAmt
Other Prof Fees Net Invst Incm$71,873OtherProfFeesNetInvstIncmAmt
Other Prof Fees Dsbrs Chrtbl$0OtherProfFeesDsbrsChrtblAmt
Taxes Rev And Expnss$15,033TaxesRevAndExpnssAmt
Taxes Net Invst Incm$3,481TaxesNetInvstIncmAmt
Taxes Dsbrs Chrtbl$0TaxesDsbrsChrtblAmt
Other Expenses Rev And Expnss$22,751OtherExpensesRevAndExpnssAmt
Other Expenses Net Invst Incm$9,000OtherExpensesNetInvstIncmAmt
Other Expenses Dsbrs Chrtbl$13,852OtherExpensesDsbrsChrtblAmt
Tot Opr Expenses Rev And Expnss$130,105TotOprExpensesRevAndExpnssAmt
Tot Opr Expenses Net Invst Incm$98,431TotOprExpensesNetInvstIncmAmt
Tot Opr Expenses Dsbrs Chrtbl$20,223TotOprExpensesDsbrsChrtblAmt
Contri Paid Rev And Expnss$683,056ContriPaidRevAndExpnssAmt
Contri Paid Dsbrs Chrtbl$721,760ContriPaidDsbrsChrtblAmt
Total Expenses Rev And Expnss$813,161TotalExpensesRevAndExpnssAmt
Total Expenses Net Invst Incm$98,431TotalExpensesNetInvstIncmAmt
Total Expenses Dsbrs Chrtbl$741,983TotalExpensesDsbrsChrtblAmt
Excess Revenue Over Expenses$127,269ExcessRevenueOverExpensesAmt
Net Investment Income$841,999NetInvestmentIncomeAmt
Adjusted Net Income$38,704AdjustedNetIncomeAmt

Form990 PF Balance Sheets Form990PFBalanceSheetsGrp

FieldValueIRS element (for citing)
Sav And Temp Cash Invst BOY$647,918SavAndTempCashInvstBOYAmt
Sav And Temp Cash Invst EOY$669,412SavAndTempCashInvstEOYAmt
Sav And Temp Cash Invst EOYFMV$669,412SavAndTempCashInvstEOYFMVAmt
US Government Obligations BOY$803,751USGovernmentObligationsBOYAmt
US Government Obligations EOY$1,004,129USGovernmentObligationsEOYAmt
US Govt Obligations EOYFMV$1,004,129USGovtObligationsEOYFMVAmt
Corporate Stock BOY$8,826,030CorporateStockBOYAmt
Corporate Stock EOY$9,130,934CorporateStockEOYAmt
Corporate Stock EOYFMV$9,130,414CorporateStockEOYFMVAmt
Corporate Bonds BOY$582,923CorporateBondsBOYAmt
Corporate Bonds EOY$515,295CorporateBondsEOYAmt
Corporate Bonds EOYFMV$515,295CorporateBondsEOYFMVAmt
Other Assets BOY$6,932OtherAssetsBOYAmt
Other Assets EOY$7,962OtherAssetsEOYAmt
Other Assets EOYFMV$7,962OtherAssetsEOYFMVAmt
Total Assets BOY$10,867,554TotalAssetsBOYAmt
Total Assets EOY$11,327,732TotalAssetsEOYAmt
Total Assets EOYFMV$11,327,212TotalAssetsEOYFMVAmt
Grants Payable BOY$20,000GrantsPayableBOYAmt
Grants Payable EOY$8,000GrantsPayableEOYAmt
Other Liabilities BOY$3,180OtherLiabilitiesBOYAmt
Other Liabilities EOY$5,320OtherLiabilitiesEOYAmt
Total Liabilities BOY$23,180TotalLiabilitiesBOYAmt
Total Liabilities EOY$13,320TotalLiabilitiesEOYAmt
Organization Follows FASB117Yes (X)OrganizationFollowsFASB117Ind
No Donor Rstr Net Assests BOY$10,844,374NoDonorRstrNetAssestsBOYAmt
No Donor Rstr Net Assests EOY$11,314,412NoDonorRstrNetAssestsEOYAmt
Tot Net Ast Or Fund Balances BOY$10,844,374TotNetAstOrFundBalancesBOYAmt
Tot Net Ast Or Fund Balances EOY$11,314,412TotNetAstOrFundBalancesEOYAmt
Total Liabilities Net Ast BOY$10,867,554TotalLiabilitiesNetAstBOYAmt
Total Liabilities Net Ast EOY$11,327,732TotalLiabilitiesNetAstEOYAmt

Chg In Net Assets Fund Balances ChgInNetAssetsFundBalancesGrp

FieldValueIRS element (for citing)
Tot Net Ast Or Fund Balances BOY$10,844,374TotNetAstOrFundBalancesBOYAmt
Excess Revenue Over Expenses$127,269ExcessRevenueOverExpensesAmt
Other Increases$342,769OtherIncreasesAmt
Subtotal$11,314,412SubtotalAmt
Other Decreases$0OtherDecreasesAmt
Tot Net Ast Or Fund Balances EOY$11,314,412TotNetAstOrFundBalancesEOYAmt

Cap Gains Loss Tx Invst Incm Detail CapGainsLossTxInvstIncmDetail

Cap Gains Loss Tx Invst Incm CapGainsLossTxInvstIncmGrp (2 entries)

PropertyPropertyDescGross Sales PriceGrossSalesPriceAmtCost Or Other BasisCostOrOtherBasisAmtGain Or LossGainOrLossAmtGains Minus Excess Or LossesGainsMinusExcessOrLossesAmtHow AcquiredHowAcquiredCd
LT - PUBLICLY TRADED SECURITIES HELD IN BROKERAGE ACCOUNT$2,248,300$1,513,125$735,175$735,175
ST - PUBLICLY TRADED SECURITIES HELD IN BROKERAGE ACCOUNT$628,142$620,529$7,613$7,613P
FieldValueIRS element (for citing)
Capital Gain Net Income$742,788CapitalGainNetIncomeAmt

Excise Tax Based On Invst Incm ExciseTaxBasedOnInvstIncmGrp

FieldValueIRS element (for citing)
Investment Income Excise Tax$11,704InvestmentIncomeExciseTaxAmt
Tax Under Section511$0TaxUnderSection511Amt
Subtotal$11,704SubtotalAmt
Subtitle A Tax$0SubtitleATaxAmt
Tax Based On Investment Income$11,704TaxBasedOnInvestmentIncomeAmt
Estimated Plus Ovpmt Incm Tx$6,480EstimatedPlusOvpmtIncmTxAmt
Exempt Frgn Org Tax Wthld At Srce$0ExemptFrgnOrgTaxWthldAtSrceAmt
Extsn Request Income Tax Paid$15,000ExtsnRequestIncomeTaxPaidAmt
Backup Withholding Withheld$0BackupWithholdingWithheldAmt
Total Payments And Credits$21,480TotalPaymentsAndCreditsAmt
Es Penalty$0EsPenaltyAmt
Overpayment$9,776OverpaymentAmt
Applied To ES Tax$9,776AppliedToESTaxAmt
Refund$0RefundAmt

Statements Regarding Acty StatementsRegardingActyGrp

FieldValueIRS element (for citing)
Legislative Political Acty0LegislativePoliticalActyInd
More Than100 Spent0MoreThan100SpentInd
Form1120 POL Filed0Form1120POLFiledInd
Section4955 Organization Tax$0Section4955OrganizationTaxAmt
Section4955 Managers Tax$0Section4955ManagersTaxAmt
Tax Reimbursed$0TaxReimbursedAmt
Activities Not Previously Rpt0ActivitiesNotPreviouslyRptInd
Changes To Articles Or Bylaws0ChangesToArticlesOrBylawsInd
Unrelated Bus Incm Over Limit0UnrelatedBusIncmOverLimitInd
Organization Dissolved Etc0OrganizationDissolvedEtcInd
Section508e Rqr SatisfiedYes (1)Section508eRqrSatisfiedInd
At Least5000 In AssetsYes (1)AtLeast5000InAssetsInd
Org Report Or Register StateTNOrgReportOrRegisterStateCd
Form990 PF Filed With Atty GenYes (1)Form990PFFiledWithAttyGenInd
Private Operating Foundation0PrivateOperatingFoundationInd
New Substantial Contributors0NewSubstantialContributorsInd
Own Controlled Entity0OwnControlledEntityInd
Donor Advised Fund0DonorAdvisedFundInd
Comply With Public Insp RqrYes (1)ComplyWithPublicInspRqrInd
Website AddressWWW.LAFOLLETTEMEDICALFOUNDATION.ORGWebsiteAddressTxt
Individual With BooksJUNE WILBURNIndividualWithBooksNm
Phone4239126963PhoneNum

Location Of Books US Address LocationOfBooksUSAddress

FieldValueIRS element (for citing)
Address Line1905 RIVERVIEW DRIVEAddressLine1Txt
CityLAFOLLETTECityNm
State AbbreviationTNStateAbbreviationCd
ZIP37766ZIPCd
FieldValueIRS element (for citing)
Foreign Accounts Question0ForeignAccountsQuestionInd

Statements Regarding Acty4720 StatementsRegardingActy4720Grp

FieldValueIRS element (for citing)
Sale Or Exch Disqualified Prsn0SaleOrExchDisqualifiedPrsnInd
Brrw Or Lend Disqualified Prsn0BrrwOrLendDisqualifiedPrsnInd
Furn Goods Disqualified Prsn0FurnGoodsDisqualifiedPrsnInd
Pay Comp Disqualified Prsn0PayCompDisqualifiedPrsnInd
Transfer Ast Disqualified Prsn0TransferAstDisqualifiedPrsnInd
Payment To Government Official0PaymentToGovernmentOfficialInd
Uncorrected Prior Acts0UncorrectedPriorActsInd
Undistributed Income PY0UndistributedIncomePYInd
Business Holdings0BusinessHoldingsInd
Jeopardy Investments0JeopardyInvestmentsInd
Uncorrected PY Jeopardy Invst0UncorrectedPYJeopardyInvstInd
Influence Legislation0InfluenceLegislationInd
Influence Election0InfluenceElectionInd
Grants To Individuals0GrantsToIndividualsInd
Grants To Organizations0GrantsToOrganizationsInd
Noncharitable Purpose0NoncharitablePurposeInd
Rcv Fnds To Pay Prsnl Bnft Cntrct0RcvFndsToPayPrsnlBnftCntrctInd
Pay Premiums Prsnl Bnft Cntrct0PayPremiumsPrsnlBnftCntrctInd
Prohibited Tax Shelter Trans0ProhibitedTaxShelterTransInd
Subj To Tax Rmnrtn Ex Prcht Pymt0SubjToTaxRmnrtnExPrchtPymtInd

Officer Dir Trst Key Empl Info OfficerDirTrstKeyEmplInfoGrp

Officer Dir Trst Key Empl OfficerDirTrstKeyEmplGrp (7 entries)

Address Line1USAddress/AddressLine1TxtCityUSAddress/CityNmState AbbreviationUSAddress/StateAbbreviationCdZIPUSAddress/ZIPCdTitleTitleTxtAverage Hrs Per Wk Devoted To PosAverageHrsPerWkDevotedToPosRtCompensationCompensationAmtEmployee Benefit ProgramEmployeeBenefitProgramAmtExpense Account Other AllwncExpenseAccountOtherAllwncAmt
DR JAMES FARRIS
PO BOX 128JACKSBOROTN37757DIRECTOR1.00$0$0$0
DR DEBRA AYERS NELSON
PO BOX 128JACKSBOROTN37757DIRECTOR1.00$0$0$0
TRACI CHAMBERS
PO BOX 128JACKSBOROTN37757DIRECTOR1.00$0$0$0
MAYOR MIKE STANFIELD
PO BOX 128JACKSBOROTN37757PRESIDENT1.00$0$0$0
DR RICHARD BURDEAUX
PO BOX 128JACKSBOROTN37757DIRECTOR1.00$0$0$0
STACEY WOOD-HEATHERLY
PO BOX 128JACKSBOROTN37757SECRETARY1.00$0$0$0
MICHEAL E WALDEN
PO BOX 128JACKSBOROTN37757TREASURER1.00$0$0$0
FieldValueIRS element (for citing)
Comp Of Hghst Pd Empl Or NONENONECompOfHghstPdEmplOrNONETxt
Other Employee Paid Over50k0OtherEmployeePaidOver50kCnt
Comp Of Hghst Pd Cntrct Or NONENONECompOfHghstPdCntrctOrNONETxt
Contractor Paid Over50k0ContractorPaidOver50kCnt

Sum Of Program Related Invst SumOfProgramRelatedInvstGrp

FieldValueIRS element (for citing)
Total$0TotalAmt

Minimum Investment Return MinimumInvestmentReturnGrp

FieldValueIRS element (for citing)
Average Monthly FMV Of Sec$10,553,671AverageMonthlyFMVOfSecAmt
Average Monthly Cash Balances$731,208AverageMonthlyCashBalancesAmt
FMV All Other Noncharitable Ast$0FMVAllOtherNoncharitableAstAmt
Total FMV Of Unused Assets$11,284,879TotalFMVOfUnusedAssetsAmt
Reduction Claimed$0ReductionClaimedAmt
Acquisition Indebtedness$0AcquisitionIndebtednessAmt
Adjusted Total FMV Of Unused Ast$11,284,879AdjustedTotalFMVOfUnusedAstAmt
Cash Deemed Charitable$169,273CashDeemedCharitableAmt
Net Vl Noncharitable Assets$11,115,606NetVlNoncharitableAssetsAmt
Minimum Investment Return$555,780MinimumInvestmentReturnAmt

Distributable Amount DistributableAmountGrp

FieldValueIRS element (for citing)
Minimum Investment Return$555,780MinimumInvestmentReturnAmt
Tax Based On Investment Income$11,704TaxBasedOnInvestmentIncomeAmt
Total Tax$11,704TotalTaxAmt
Distributable Before Adj$544,076DistributableBeforeAdjAmt
Recoveries Qualfied Distri$38,704RecoveriesQualfiedDistriAmt
Distributable Before Ded$582,780DistributableBeforeDedAmt
Deduction From Distributable$0DeductionFromDistributableAmt
Distributable As Adjusted$582,780DistributableAsAdjustedAmt

PF Qualifying Distributions PFQualifyingDistributionsGrp

FieldValueIRS element (for citing)
Expenses And Contributions$741,983ExpensesAndContributionsAmt
Program Related Invst Total$0ProgramRelatedInvstTotalAmt
Qualifying Distributions$741,983QualifyingDistributionsAmt

Undistributed Income UndistributedIncomeGrp

FieldValueIRS element (for citing)
Distributable As Adjusted$582,780DistributableAsAdjustedAmt
Undistributed Income PY$0UndistributedIncomePYAmt
Total For Prior Years$0TotalForPriorYearsAmt
Excess Distribution Cyov Yr4$3,250ExcessDistributionCyovYr4Amt
Excess Distribution Cyov Yr3$7,218ExcessDistributionCyovYr3Amt
Excess Distribution Cyov Yr2$35,051ExcessDistributionCyovYr2Amt
Excess Distribution Cyov Yr1$103,417ExcessDistributionCyovYr1Amt
Total Excess Distribution Cyov$148,936TotalExcessDistributionCyovAmt
Qualifying Distributions$741,983QualifyingDistributionsAmt
Applied To Year1$0AppliedToYear1Amt
Applied To Prior Years$0AppliedToPriorYearsAmt
Treated As Distri From Corpus$0TreatedAsDistriFromCorpusAmt
Applied To Current Year$582,780AppliedToCurrentYearAmt
Remaining Distri From Corpus$159,203RemainingDistriFromCorpusAmt
Excess Distri Cyov App CY Corpus$0ExcessDistriCyovAppCYCorpusAmt
Excess Distribution Cyov App CY$0ExcessDistributionCyovAppCYAmt
Total Corpus$308,139TotalCorpusAmt
Prior Year Undistributed Incm$0PriorYearUndistributedIncmAmt
Prior Year Deficiency Or Tax$0PriorYearDeficiencyOrTaxAmt
Taxable1$0Taxable1Amt
Taxable2$0Taxable2Amt
Undistributed Income CY$0UndistributedIncomeCYAmt
Corpus Distri170b1 E Or4942g3$0CorpusDistri170b1EOr4942g3Amt
Excess Distri Cyov From Yr5$0ExcessDistriCyovFromYr5Amt
Excess Distri Cyov To Next Yr$308,139ExcessDistriCyovToNextYrAmt
Excess From Year4$3,250ExcessFromYear4Amt
Excess From Year3$7,218ExcessFromYear3Amt
Excess From Year2$35,051ExcessFromYear2Amt
Excess From Year1$103,417ExcessFromYear1Amt
Excess From Current Year$159,203ExcessFromCurrentYearAmt

Supplementary Information SupplementaryInformationGrp

Application Submission Info ApplicationSubmissionInfoGrp

FieldValueIRS element (for citing)
Recipient PersonLAFOLLETTE MEDICAL FOUNDATIONRecipientPersonNm

Recipient US Address RecipientUSAddress

FieldValueIRS element (for citing)
Address Line1PO BOX 128AddressLine1Txt
CityJACKSBOROCityNm
State AbbreviationTNStateAbbreviationCd
ZIP37757ZIPCd
FieldValueIRS element (for citing)
Recipient Phone4239126963RecipientPhoneNum
Recipient Email AddressGRANTS@LAFOLLETTEMEDICALFOUNDATION.ORGRecipientEmailAddressTxt
Form And Info And MaterialsPLEASE VISIT THE ORGANIZATION'S WEBSITE AT WWW.LAFOLLETTEMEDICALFOUNDATION.ORG TO OBTAIN THE GRANT APPLICATIONFormAndInfoAndMaterialsTxt
Submission DeadlinesNONESubmissionDeadlinesTxt
Restrictions On AwardsIN ORDER TO BE ELIGIBLE FOR A GRANT FROM THE FOUNDATION, AN ORGANIZATION MUST QUALIFY FOR EXEMPTION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND MUST NOT BE A PRIVATE FOUNDATION AS DEFINED BY SECTION 509(A) OF THE CODE, OR IT MUST BE A PUBLIC INSTRUMENTALITY. GRANTS MAY NOT BE MADE TO INDIVIDUALS. THE FOUNDATION MAY MAKE GRANTS TO ORGANIZATIONS PROVIDING SERVICES TO CAMPBELL COUNTY, TN RESIDENTS FOR THE FOLLOWING PURPOSES: HEALTH SERVICES, PREVENTATIVE ILLNESS, CHILDREN HEALTH AND WELL-BEING, SENIOR SAFETY AND WELLNESS AND ANY HEALTH PROGRAM THAT HAS MERIT AND IS RELATED TO THE FOUNDATION'S MISSION AND OBJECTIVES.RestrictionsOnAwardsTxt

Grant Or Contribution Pd Dur Yr GrantOrContributionPdDurYrGrp (16 entries)

Address Line1RecipientUSAddress/AddressLine1TxtCityRecipientUSAddress/CityNmState AbbreviationRecipientUSAddress/StateAbbreviationCdZIPRecipientUSAddress/ZIPCdRecipient RelationshipRecipientRelationshipTxtRecipient Foundation StatusRecipientFoundationStatusTxtGrant Or Contribution PurposeGrantOrContributionPurposeTxtAmtAmt
CAMPBELL COUNTY BOARD OF EDUCATION
172 VALLEY STREETJACKSBOROTN37757NONEGOVERNMENT AGENCYINFLUENZA VACCINATION PROGRAM, JELLICO HIGH SCHOOL ATHLETIC PERSONAL TRAINER$60,850
CAMPBELL COUNTY CHILDREN'S CENTER
203 INDEPENDENCE LANELAFOLLETTETN37766NONE501(C)(3)HEALTH EDUCATION/PREVENTION PROGRAM$42,223
CAMPBELL COUNTY RURAL FIRE SERVICE
4422 VICTORY ROADLAFOLLETTETN37766NONE501(C)(3)FIRE PROTECTION FOR CAMPBELL COUNTY$32,091
CAMPBELL COUNTY SENIOR CITIZENS
102 8TH STREETLAFOLLETTETN37766NONE501(C)(3)HOME DELIVERED MEALS FOR ELIGIBLE SENIORS$70,200
CASA OF CAMPBELL COUNTY
PO BOX 1054JACKSBOROTN37757NONE501(C)(3)VOLUNTEER OUTREACH SERVICES$20,000
CATHOLIC CHARITIES OF EAST TENNESSEE
3009 LAKE BROOK BLVDKNOXVILLETN37909NONE501(C)(3)PREGNANCY HELP CENTER$22,000
CITY OF LAFOLLETTE FIRE DEPARTMENT
105 E BEECH STREETLAFOLLETTETN37766NONEGOVERNMENT AGENCYFIRE PROTECTION FOR THE CITY OF LAFOLLETTE$76,055
COMMUNITY HEALTH OF EAST TENNESSEE
PO BOX 209 507 MAIN STREETJACKSBOROTN37757NONE501(C)(3)DRUG COURT PROGRAM, GENERATION X, PATIENT CARE$79,940
CARYVILLE- FIRE DEPARTMENT
4839 OLD TENNESSEE 63CARYVILLETN37714NONE501(C)(3)CARYVILLE FIRE DEPARTMENT$45,957
EAST TENNESSEE HUMAN RESOURCES AGENCY
9111 CROSS PARK DR STE D10KNOXVILLETN37766NONE501(C)(3)SENIOR SAFETY AND WELLNESS SUPPORT$30,000
FOOD LIFE SERVICES OF CAMPBELL COUNTY
206 S INDIANA AVENUELAFOLLETTETN37766NONE501(C)(3)EXPANDED NUTRITIONAL DISTRIBUTION$5,000
LAFOLLETTE RESCUE SQUAD
222 FIRE RESCUE LNLAFOLLETTETN37766NONEGOVERNMENT AGENCYRESCUE PREPAREDNESS PROJECT$8,444
OPEN ARMS MINISTRY
PO BOX 433CARYVILLETN37714NONE501(C)(3)FEEDING THE NEEDIEST OF CAMPBELL COUNTY$60,000
PINNACLE RESOURCE CENTER
507 MAIN STJACKSBOROTN37757NONE501(C)(3)HELP PROVIDE INDIVIDUALS FACING HOMELESSNESS WITH THE TOOLS AND RESOURCE TO GET BACK ON THEIR FEET$30,000
REMOTE AREA MEDICAL INC
2200 STOCK CREEK BLVDROCKFORDTN37853NONE501(C)(3)PROVIDE FREE QUALITY HEALTHCARE TO THOSE IN NEED$19,000
SPRINGS OF LIFE RECOVERY CENTER
PO BOX 893JELLICOTN37762NONE501(C)(3)RECOVERY CENTER FOR MEN$120,000
FieldValueIRS element (for citing)
Total Grant Or Contri Pd Dur Yr$721,760TotalGrantOrContriPdDurYrAmt
Total Grant Or Contri Apprv Fut$0TotalGrantOrContriApprvFutAmt

Analysis Income Producing Acty AnalysisIncomeProducingActyGrp

Int On Sav And Temp Cash Invst IntOnSavAndTempCashInvstGrp

FieldValueIRS element (for citing)
Exclusion14ExclusionCd
Exclusion$53ExclusionAmt

Dividends And Interest From Sec Dtl DividendsAndInterestFromSecDtl

FieldValueIRS element (for citing)
Exclusion14ExclusionCd
Exclusion$197,589ExclusionAmt

Gain Sales Ast Oth Than Invntry GainSalesAstOthThanInvntryGrp

FieldValueIRS element (for citing)
Exclusion18ExclusionCd
Exclusion$742,788ExclusionAmt

Subtotals Incm Producing Acty SubtotalsIncmProducingActyGrp

FieldValueIRS element (for citing)
Unrelated Business Taxbl Incm$0UnrelatedBusinessTaxblIncmAmt
Exclusion$940,430ExclusionAmt
Related Or Exempt Function Incm$0RelatedOrExemptFunctionIncmAmt
FieldValueIRS element (for citing)
Total Income Producing Acty$940,430TotalIncomeProducingActyAmt

Trnsfr Trans Rln Nonchrtbl EO TrnsfrTransRlnNonchrtblEOGrp

FieldValueIRS element (for citing)
Trnsfr Of Cash To Nonchrtbl EO0TrnsfrOfCashToNonchrtblEOInd
Trnsfr Other Asset Nonchrtbl EO0TrnsfrOtherAssetNonchrtblEOInd
Sales Or Exchanges Of Assets0SalesOrExchangesOfAssetsInd
Purchase Of Assets Nonchrtbl EO0PurchaseOfAssetsNonchrtblEOInd
Rental Of Facilities Oth Assets0RentalOfFacilitiesOthAssetsInd
Reimbursement Arrangements0ReimbursementArrangementsInd
Loans Or Loan Guarantees0LoansOrLoanGuaranteesInd
Performance Of Services Etc0PerformanceOfServicesEtcInd
Sharing Of Facilities Etc0SharingOfFacilitiesEtcInd
Relationships Nonchrtbl EO0RelationshipsNonchrtblEOInd

Accounting Fees Schedule AccountingFeesSchedule

Accounting Fees Detail AccountingFeesDetail

FieldValueIRS element (for citing)
CategoryACCOUNTING FEESCategoryTxt
Amt$15,305Amt
Net Investment Income$10,220NetInvestmentIncomeAmt
Disbursements Charitable Prps$5,085DisbursementsCharitablePrpsAmt

General Explanation Attachment GeneralExplanationAttachment

General Explanation GeneralExplanationGrp

FieldValueIRS element (for citing)
IdentifierDETAIL INFO REQUESTIdentifierTxt
Form And Line ReferenceFORM 990 PF, PART II, LINE 10B AND LINE 10CFormAndLineReferenceDesc
Medium ExplanationTHE INSTRUCTIONS FOR FORM 990-PF REQUIRE A SCHEDULE THAT LISTS EACH SECURITY HELD AT THE END OF THE YEAR, AND TO SHOW WHETHER THAT SECURITY IS REPORTED AT COST BASIS OR FMV. ALL SECURITIES ARE HELD IN A BROKERAGE ACCOUNT THROUGHOUT THE YEAR AND ARE REPORTED AT FMV. THIS SCHEDULE CAN BE PROVIDED TO THE IRS AT THEIR REQUEST.MediumExplanationTxt

Investments Corp Bonds Schedule InvestmentsCorpBondsSchedule

Investments Corporate Bonds InvestmentsCorporateBondsGrp

FieldValueIRS element (for citing)
BondUBS #KAXX118 (HELD IN BROKERAGE A/C DETAIL AVAILABLE UPON REQUEST)BondNm
EOY Book Value$515,295EOYBookValueAmt
EOYFMV$515,295EOYFMVAmt

Investments Corp Stock Schedule InvestmentsCorpStockSchedule

Investments Corporate Stock InvestmentsCorporateStockGrp

FieldValueIRS element (for citing)
StockUBS #KAXX118 (HELD IN BROKERAGE ACCOUNT - DETAIL AVAILABLE UPON REQUEST)StockNm
EOY Book Value$9,130,934EOYBookValueAmt
EOYFMV$9,130,414EOYFMVAmt

Investments Govt Obligations Sch InvestmentsGovtObligationsSch

FieldValueIRS element (for citing)
US Govt Obligations Book Vl EOY$1,004,129USGovtObligationsBookVlEOYAmt
US Govt Obligations EOYFMV$1,004,129USGovtObligationsEOYFMVAmt
State Local Sec Book Vl EOY$0StateLocalSecBookVlEOYAmt
State Local Sec EOYFMV$0StateLocalSecEOYFMVAmt

Legal Fees Schedule LegalFeesSchedule

Legal Fees LegalFeesGrp

FieldValueIRS element (for citing)
CategoryLEGAL FEESCategoryTxt
Legal Fees$5,143LegalFeesAmt
Net Investment Income$3,857NetInvestmentIncomeAmt
Disbursements Charitable Prps$1,286DisbursementsCharitablePrpsAmt

Other Assets Schedule OtherAssetsSchedule

Other Assets Schedule OtherAssetsScheduleGrp

FieldValueIRS element (for citing)
DescACCRUED INTEREST RECEIVABLEDesc
BOY Book Value$6,932BOYBookValueAmt
EOY Book Value$7,962EOYBookValueAmt
EOYFMV$7,962EOYFMVAmt

Other Expenses Schedule OtherExpensesSchedule

Other Expenses Schedule OtherExpensesScheduleGrp (3 entries)

DescDescRevenue And Expenses Per BooksRevenueAndExpensesPerBooksAmtNet Investment IncomeNetInvestmentIncomeAmtDisbursements Charitable PrpsDisbursementsCharitablePrpsAmt
INSURANCE$2,632$0$2,632
OFFICE EXPENSES$2,119$0$2,220
CONTRACT LABOR$18,000$9,000$9,000

Other Increases Schedule OtherIncreasesSchedule

Other Increases Detail OtherIncreasesDetail

FieldValueIRS element (for citing)
DescUNREALIZED GAINDesc
Amt$342,769Amt

Other Liabilities Schedule OtherLiabilitiesSchedule

Other Liabilities Detail OtherLiabilitiesDetail

FieldValueIRS element (for citing)
DescTAXES PAYABLEDesc
BOY Book Value$3,180BOYBookValueAmt
EOY Book Value$5,320EOYBookValueAmt

Other Professional Fees Schedule OtherProfessionalFeesSchedule

Other Professional Fees Detail OtherProfessionalFeesDetail

FieldValueIRS element (for citing)
CategoryUBS FEESCategoryTxt
Amt$71,873Amt
Net Investment Income$71,873NetInvestmentIncomeAmt
Disbursements Charitable Prps$0DisbursementsCharitablePrpsAmt

Taxes Schedule TaxesSchedule

Taxes Detail TaxesDetail (2 entries)

CategoryCategoryTxtAmtAmtNet Investment IncomeNetInvestmentIncomeAmtDisbursements Charitable PrpsDisbursementsCharitablePrpsAmt
FEDERAL EXCISE TAX$11,552$0$0
FOREIGN TAX WITHHOLDING$3,481$3,481$0

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