PATCH FOUNDATION: Form 990PF, tax year 2015
View the entire original 990 at ProPublica ↗
- Organization
- PATCH FOUNDATION (EIN 41-1873951)
- Tax period
- 2015-01-01 to 2015-12-31
- Filed
- 2016-05-09
- IRS object ID
- 201641309349100009
- Schema version
- 2015v2.1
- 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
- Form 990-PF
- Schedule B
- Accounting Fees Schedule
- Investments Corp Stock Schedule
- Investments Govt Obligations Sch
- Other Expenses Schedule
- Taxes Schedule
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2016-05-09T08:19:27-05:00 | ReturnTs |
| Tax Period End | 2015-12-31 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 420714325 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RSM US LLP | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 801 NICOLLET MALL SUITE 1100 | AddressLine1Txt |
| City | MINNEAPOLIS | CityNm |
| State Abbreviation | MN | StateAbbreviationCd |
| ZIP | 55402 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990PF | ReturnTypeCd |
| Tax Period Begin | 2015-01-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 411873951 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | THE PATCH FOUNDATION | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | PATC | BusinessNameControlTxt |
| Phone | 6127817677 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 3201 RANKIN ROAD | AddressLine1Txt |
| City | MINNEAPOLIS | CityNm |
| State Abbreviation | MN | StateAbbreviationCd |
| ZIP | 55418 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | CAROLYN SAMPLE | PersonNm |
| Person Title | PRESIDENT | PersonTitleTxt |
| Phone | 6127817677 | PhoneNum |
| Signature | 2016-05-04 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | TODD A JACKSON | PreparerPersonNm |
| PTIN | P00092672 | PTIN |
| Phone | 6123324300 | PhoneNum |
| Preparation | 2016-05-04 | PreparationDt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2015 | TaxYr |
| Build TS | 2016-09-27 15:27:22Z | BuildTS |
Form 990-PF IRS990PF
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization501c3 Exempt PF | Yes (X) | Organization501c3ExemptPFInd |
| FMV Assets EOY | $11,065,000 | FMVAssetsEOYAmt |
| Method Of Accounting Cash | Yes (X) | MethodOfAccountingCashInd |
Analysis Of Revenue And Expenses AnalysisOfRevenueAndExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contri Rcvd Rev And Expnss | $200,000 | ContriRcvdRevAndExpnssAmt |
| Interest On Sav Rev And Expnss | $4,669 | InterestOnSavRevAndExpnssAmt |
| Interest On Sav Net Invst Incm | $69 | InterestOnSavNetInvstIncmAmt |
| Dividends Rev And Expnss | $95,772 | DividendsRevAndExpnssAmt |
| Dividends Net Invst Incm | $95,772 | DividendsNetInvstIncmAmt |
| Net Gain Sale Ast Rev And Expnss | $6,668,287 | NetGainSaleAstRevAndExpnssAmt |
| Gross Sales Price | $9,848,750 | GrossSalesPriceAmt |
| Cap Gain Net Incm Net Invst Incm | $5,645,250 | CapGainNetIncmNetInvstIncmAmt |
| Total Rev And Expnss | $6,968,728 | TotalRevAndExpnssAmt |
| Total Net Invst Incm | $5,741,091 | TotalNetInvstIncmAmt |
| Comp Ofcr Dir Trst Rev And Expnss | $0 | CompOfcrDirTrstRevAndExpnssAmt |
| Comp Ofcr Dir Trst Net Invst Incm | $0 | CompOfcrDirTrstNetInvstIncmAmt |
| Comp Ofcr Dir Trst Dsbrs Chrtbl | $0 | CompOfcrDirTrstDsbrsChrtblAmt |
| Accounting Fees Rev And Expnss | $2,600 | AccountingFeesRevAndExpnssAmt |
| Accounting Fees Net Invst Incm | $1,300 | AccountingFeesNetInvstIncmAmt |
| Accounting Fees Chrtbl Prps | $1,300 | AccountingFeesChrtblPrpsAmt |
| Taxes Rev And Expnss | $24,967 | TaxesRevAndExpnssAmt |
| Taxes Net Invst Incm | $0 | TaxesNetInvstIncmAmt |
| Taxes Dsbrs Chrtbl | $0 | TaxesDsbrsChrtblAmt |
| Other Expenses Rev And Expnss | $25 | OtherExpensesRevAndExpnssAmt |
| Other Expenses Net Invst Incm | $0 | OtherExpensesNetInvstIncmAmt |
| Other Expenses Dsbrs Chrtbl | $25 | OtherExpensesDsbrsChrtblAmt |
| Tot Opr Expenses Rev And Expnss | $27,592 | TotOprExpensesRevAndExpnssAmt |
| Tot Opr Expenses Net Invst Incm | $1,300 | TotOprExpensesNetInvstIncmAmt |
| Tot Opr Expenses Dsbrs Chrtbl | $1,325 | TotOprExpensesDsbrsChrtblAmt |
| Contri Paid Rev And Expnss | $851,000 | ContriPaidRevAndExpnssAmt |
| Contri Paid Dsbrs Chrtbl | $851,000 | ContriPaidDsbrsChrtblAmt |
| Total Expenses Rev And Expnss | $878,592 | TotalExpensesRevAndExpnssAmt |
| Total Expenses Net Invst Incm | $1,300 | TotalExpensesNetInvstIncmAmt |
| Total Expenses Dsbrs Chrtbl | $852,325 | TotalExpensesDsbrsChrtblAmt |
| Excess Revenue Over Expenses | $6,090,136 | ExcessRevenueOverExpensesAmt |
| Net Investment Income | $5,739,791 | NetInvestmentIncomeAmt |
Form990 PF Balance Sheets Form990PFBalanceSheetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cash BOY | $571,459 | CashBOYAmt |
| Cash EOY | $942,867 | CashEOYAmt |
| Cash EOYFMV | $942,867 | CashEOYFMVAmt |
| Sav And Temp Cash Invst BOY | $660,991 | SavAndTempCashInvstBOYAmt |
| Sav And Temp Cash Invst EOY | $33,465 | SavAndTempCashInvstEOYAmt |
| Sav And Temp Cash Invst EOYFMV | $33,465 | SavAndTempCashInvstEOYFMVAmt |
| US Government Obligations BOY | $230,000 | USGovernmentObligationsBOYAmt |
| US Government Obligations EOY | $0 | USGovernmentObligationsEOYAmt |
| US Govt Obligations EOYFMV | $0 | USGovtObligationsEOYFMVAmt |
| Corporate Stock BOY | $3,272,413 | CorporateStockBOYAmt |
| Corporate Stock EOY | $9,848,667 | CorporateStockEOYAmt |
| Corporate Stock EOYFMV | $10,088,668 | CorporateStockEOYFMVAmt |
| Total Assets BOY | $4,734,863 | TotalAssetsBOYAmt |
| Total Assets EOY | $10,824,999 | TotalAssetsEOYAmt |
| Total Assets EOYFMV | $11,065,000 | TotalAssetsEOYFMVAmt |
| Total Liabilities BOY | $0 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $0 | TotalLiabilitiesEOYAmt |
| Org Does Not Follow SFAS117 | Yes (X) | OrgDoesNotFollowSFAS117Ind |
| Capital Stock BOY | $0 | CapitalStockBOYAmt |
| Capital Stock EOY | $0 | CapitalStockEOYAmt |
| Additional Paid In Capital BOY | $0 | AdditionalPaidInCapitalBOYAmt |
| Additional Paid In Capital EOY | $0 | AdditionalPaidInCapitalEOYAmt |
| Retained Earning BOY | $4,734,863 | RetainedEarningBOYAmt |
| Retained Earning EOY | $10,824,999 | RetainedEarningEOYAmt |
| Tot Net Ast Or Fund Balances BOY | $4,734,863 | TotNetAstOrFundBalancesBOYAmt |
| Tot Net Ast Or Fund Balances EOY | $10,824,999 | TotNetAstOrFundBalancesEOYAmt |
| Total Liabilities Net Ast BOY | $4,734,863 | TotalLiabilitiesNetAstBOYAmt |
| Total Liabilities Net Ast EOY | $10,824,999 | TotalLiabilitiesNetAstEOYAmt |
Chg In Net Assets Fund Balances ChgInNetAssetsFundBalancesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tot Net Ast Or Fund Balances BOY | $4,734,863 | TotNetAstOrFundBalancesBOYAmt |
| Excess Revenue Over Expenses | $6,090,136 | ExcessRevenueOverExpensesAmt |
| Other Increases | $0 | OtherIncreasesAmt |
| Subtotal | $10,824,999 | SubtotalAmt |
| Other Decreases | $0 | OtherDecreasesAmt |
| Tot Net Ast Or Fund Balances EOY | $10,824,999 | TotNetAstOrFundBalancesEOYAmt |
Cap Gains Loss Tx Invst Incm Detail CapGainsLossTxInvstIncmDetail
Cap Gains Loss Tx Invst Incm CapGainsLossTxInvstIncmGrp (2 entries)
| PropertyPropertyDesc | How AcquiredHowAcquiredCd | Gross Sales PriceGrossSalesPriceAmt | Cost Or Other BasisCostOrOtherBasisAmt | Gain Or LossGainOrLossAmt | Gains Minus Excess Or LossesGainsMinusExcessOrLossesAmt | SoldSoldDt |
|---|---|---|---|---|---|---|
| PUBLICLY TRADED SECURITIES | D | $230,000 | $230,000 | $0 | $0 | |
| MEDTRONIC INC MERGER TO MEDTRONIC PLC | D | $9,618,750 | $3,973,500 | $5,645,250 | $5,645,250 | 2015-01-27 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Capital Gain Net Income | $5,645,250 | CapitalGainNetIncomeAmt |
Qlfy Und Sect4940e Reduced Tax QlfyUndSect4940eReducedTaxGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Liable Section4942 Tax | 0 | LiableSection4942TaxInd |
| Adjusted Qlfy Distri Yr1 | $675,925 | AdjustedQlfyDistriYr1Amt |
| Net Vl Noncharitable Assets Yr1 | $8,768,762 | NetVlNoncharitableAssetsYr1Amt |
| Distribution Yr1 | 0.077083 | DistributionYr1Rt |
| Adjusted Qlfy Distri Yr2 | $622,900 | AdjustedQlfyDistriYr2Amt |
| Net Vl Noncharitable Assets Yr2 | $7,300,472 | NetVlNoncharitableAssetsYr2Amt |
| Distribution Yr2 | 0.085323 | DistributionYr2Rt |
| Adjusted Qlfy Distri Yr3 | $700,875 | AdjustedQlfyDistriYr3Amt |
| Net Vl Noncharitable Assets Yr3 | $6,142,529 | NetVlNoncharitableAssetsYr3Amt |
| Distribution Yr3 | 0.114102 | DistributionYr3Rt |
| Adjusted Qlfy Distri Yr4 | $516,025 | AdjustedQlfyDistriYr4Amt |
| Net Vl Noncharitable Assets Yr4 | $6,563,116 | NetVlNoncharitableAssetsYr4Amt |
| Distribution Yr4 | 0.078625 | DistributionYr4Rt |
| Adjusted Qlfy Distri Yr5 | $420,225 | AdjustedQlfyDistriYr5Amt |
| Net Vl Noncharitable Assets Yr5 | $6,583,022 | NetVlNoncharitableAssetsYr5Amt |
| Distribution Yr5 | 0.063835 | DistributionYr5Rt |
| Total Distribution | 0.418968 | TotalDistributionRt |
| Average Distribution | 0.083794 | AverageDistributionRt |
| Net Vl Noncharitable Assets | $10,497,691 | NetVlNoncharitableAssetsAmt |
| Adj Net Vl Noncharitable Assets | $879,644 | AdjNetVlNoncharitableAssetsAmt |
| Net Investment Income Pct | $57,398 | NetInvestmentIncomePctAmt |
| Adj Nonchrtbl Net Invst Incm Pct | $937,042 | AdjNonchrtblNetInvstIncmPctAmt |
| Qualifying Distributions | $852,325 | QualifyingDistributionsAmt |
Excise Tax Based On Invst Incm ExciseTaxBasedOnInvstIncmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Investment Income Excise Tax | $114,796 | InvestmentIncomeExciseTaxAmt |
| Tax Under Section511 | $0 | TaxUnderSection511Amt |
| Subtotal | $114,796 | SubtotalAmt |
| Subtitle A Tax | $0 | SubtitleATaxAmt |
| Tax Based On Investment Income | $114,796 | TaxBasedOnInvestmentIncomeAmt |
| Estimated Plus Ovpmt Incm Tx | $14,240 | EstimatedPlusOvpmtIncmTxAmt |
| Total Payments And Credits | $14,240 | TotalPaymentsAndCreditsAmt |
| Tax Due | $100,556 | TaxDueAmt |
Statements Regarding Acty StatementsRegardingActyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Legislative Political Acty | 0 | LegislativePoliticalActyInd |
| More Than100 Spent | 0 | MoreThan100SpentInd |
| Form1120 POL Filed | 0 | Form1120POLFiledInd |
| Section4955 Organization Tax | $0 | Section4955OrganizationTaxAmt |
| Section4955 Managers Tax | $0 | Section4955ManagersTaxAmt |
| Tax Reimbursed | $0 | TaxReimbursedAmt |
| Activities Not Previously Rpt | 0 | ActivitiesNotPreviouslyRptInd |
| Changes To Articles Or Bylaws | 0 | ChangesToArticlesOrBylawsInd |
| Unrelated Bus Incm Over Limit | 0 | UnrelatedBusIncmOverLimitInd |
| Organization Dissolved Etc | 0 | OrganizationDissolvedEtcInd |
| Section508e Rqr Satisfied | Yes (1) | Section508eRqrSatisfiedInd |
| At Least5000 In Assets | Yes (1) | AtLeast5000InAssetsInd |
| Org Report Or Register State | MN | OrgReportOrRegisterStateCd |
| Form990 PF Filed With Atty Gen | Yes (1) | Form990PFFiledWithAttyGenInd |
| Private Operating Foundation | 0 | PrivateOperatingFoundationInd |
| New Substantial Contributors | 0 | NewSubstantialContributorsInd |
| Own Controlled Entity | 0 | OwnControlledEntityInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Comply With Public Insp Rqr | Yes (1) | ComplyWithPublicInspRqrInd |
| Website Address | N/A | WebsiteAddressTxt |
Persons With Books Name PersonsWithBooksName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | THE FOUNDATION | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 6127817677 | PhoneNum |
Location Of Books US Address LocationOfBooksUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 3201 RANKIN ROAD | AddressLine1Txt |
| City | MINNEAPOLIS | CityNm |
| State Abbreviation | MN | StateAbbreviationCd |
| ZIP | 55418 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Foreign Accounts Question | 0 | ForeignAccountsQuestionInd |
Statements Regarding Acty4720 StatementsRegardingActy4720Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Sale Or Exch Disqualified Prsn | 0 | SaleOrExchDisqualifiedPrsnInd |
| Brrw Or Lend Disqualified Prsn | 0 | BrrwOrLendDisqualifiedPrsnInd |
| Furn Goods Disqualified Prsn | 0 | FurnGoodsDisqualifiedPrsnInd |
| Pay Comp Disqualified Prsn | 0 | PayCompDisqualifiedPrsnInd |
| Transfer Ast Disqualified Prsn | 0 | TransferAstDisqualifiedPrsnInd |
| Payment To Government Official | 0 | PaymentToGovernmentOfficialInd |
| Uncorrected Prior Acts | 0 | UncorrectedPriorActsInd |
| Undistributed Income PY | 0 | UndistributedIncomePYInd |
| Business Holdings | 0 | BusinessHoldingsInd |
| Jeopardy Investments | 0 | JeopardyInvestmentsInd |
| Uncorrected PY Jeopardy Invst | 0 | UncorrectedPYJeopardyInvstInd |
| Influence Legislation | 0 | InfluenceLegislationInd |
| Influence Election | 0 | InfluenceElectionInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Grants To Organizations | 0 | GrantsToOrganizationsInd |
| Noncharitable Purpose | 0 | NoncharitablePurposeInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | 0 | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | 0 | PayPremiumsPrsnlBnftCntrctInd |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
Officer Dir Trst Key Empl Info OfficerDirTrstKeyEmplInfoGrp
Officer Dir Trst Key Empl OfficerDirTrstKeyEmplGrp (3 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | TitleTitleTxt | Average Hrs Per Wk Devoted To PosAverageHrsPerWkDevotedToPosRt | CompensationCompensationAmt | Employee Benefit ProgramEmployeeBenefitProgramAmt | Expense Account Other AllwncExpenseAccountOtherAllwncAmt |
|---|---|---|---|---|---|---|---|---|
| WILLIAM C PETERSON | ||||||||
| 6724 99TH AVE NORTH | BROOKLYN PARK | MN | 55445 | DIRECTOR | 0.50 | $0 | $0 | $0 |
| CAROLYN SAMPLE | ||||||||
| 3201 RANKIN RD | MINNEAPOLIS | MN | 55418 | PRESIDENT | 2.00 | $0 | $0 | $0 |
| ERNEST LINDSTROM-LINDSTROM LAW OFFI | ||||||||
| 7600 PARKLAWN AVE STE 444 | EDINA | MN | 55435 | DIRECTOR | 0.50 | $0 | $0 | $0 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Comp Of Hghst Pd Empl Or NONE | NONE | CompOfHghstPdEmplOrNONETxt |
| Other Employee Paid Over50k | 0 | OtherEmployeePaidOver50kCnt |
| Comp Of Hghst Pd Cntrct Or NONE | NONE | CompOfHghstPdCntrctOrNONETxt |
| Contractor Paid Over50k | 0 | ContractorPaidOver50kCnt |
Sum Of Program Related Invst SumOfProgramRelatedInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $0 | TotalAmt |
Minimum Investment Return MinimumInvestmentReturnGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Average Monthly FMV Of Sec | $9,842,847 | AverageMonthlyFMVOfSecAmt |
| Average Monthly Cash Balances | $814,707 | AverageMonthlyCashBalancesAmt |
| FMV All Other Noncharitable Ast | $0 | FMVAllOtherNoncharitableAstAmt |
| Total FMV Of Unused Assets | $10,657,554 | TotalFMVOfUnusedAssetsAmt |
| Reduction Claimed | $0 | ReductionClaimedAmt |
| Acquisition Indebtedness | $0 | AcquisitionIndebtednessAmt |
| Adjusted Total FMV Of Unused Ast | $10,657,554 | AdjustedTotalFMVOfUnusedAstAmt |
| Cash Deemed Charitable | $159,863 | CashDeemedCharitableAmt |
| Net Vl Noncharitable Assets | $10,497,691 | NetVlNoncharitableAssetsAmt |
| Minimum Investment Return | $524,885 | MinimumInvestmentReturnAmt |
Distributable Amount DistributableAmountGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Minimum Investment Return | $524,885 | MinimumInvestmentReturnAmt |
| Tax Based On Investment Income | $114,796 | TaxBasedOnInvestmentIncomeAmt |
| Total Tax | $114,796 | TotalTaxAmt |
| Distributable Before Adj | $410,089 | DistributableBeforeAdjAmt |
| Recoveries Qualfied Distri | $0 | RecoveriesQualfiedDistriAmt |
| Distributable Before Ded | $410,089 | DistributableBeforeDedAmt |
| Deduction From Distributable | $0 | DeductionFromDistributableAmt |
| Distributable As Adjusted | $410,089 | DistributableAsAdjustedAmt |
Qualifying Distri Part XII QualifyingDistriPartXIIGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expenses And Contributions | $852,325 | ExpensesAndContributionsAmt |
| Program Related Invst Total | $0 | ProgramRelatedInvstTotalAmt |
| Qualifying Distributions | $852,325 | QualifyingDistributionsAmt |
| Pct Sect4940e Org Net Invst Incm | $0 | PctSect4940eOrgNetInvstIncmAmt |
| Adjusted Qualifying Distri | $852,325 | AdjustedQualifyingDistriAmt |
Undistributed Income UndistributedIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Distributable As Adjusted | $410,089 | DistributableAsAdjustedAmt |
| Undistributed Income PY | $0 | UndistributedIncomePYAmt |
| Total For Prior Years | $0 | TotalForPriorYearsAmt |
| Excess Distribution Cyov Yr5 | $93,591 | ExcessDistributionCyovYr5Amt |
| Excess Distribution Cyov Yr4 | $190,767 | ExcessDistributionCyovYr4Amt |
| Excess Distribution Cyov Yr3 | $397,524 | ExcessDistributionCyovYr3Amt |
| Excess Distribution Cyov Yr2 | $260,938 | ExcessDistributionCyovYr2Amt |
| Excess Distribution Cyov Yr1 | $251,714 | ExcessDistributionCyovYr1Amt |
| Total Excess Distribution Cyov | $1,194,534 | TotalExcessDistributionCyovAmt |
| Qualifying Distributions | $852,325 | QualifyingDistributionsAmt |
| Applied To Year1 | $0 | AppliedToYear1Amt |
| Applied To Prior Years | $0 | AppliedToPriorYearsAmt |
| Treated As Distri From Corpus | $0 | TreatedAsDistriFromCorpusAmt |
| Applied To Current Year | $410,089 | AppliedToCurrentYearAmt |
| Remaining Distri From Corpus | $442,236 | RemainingDistriFromCorpusAmt |
| Excess Distri Cyov App CY Corpus | $0 | ExcessDistriCyovAppCYCorpusAmt |
| Excess Distribution Cyov App CY | $0 | ExcessDistributionCyovAppCYAmt |
| Total Corpus | $1,636,770 | TotalCorpusAmt |
| Prior Year Undistributed Incm | $0 | PriorYearUndistributedIncmAmt |
| Prior Year Deficiency Or Tax | $0 | PriorYearDeficiencyOrTaxAmt |
| Taxable1 | $0 | Taxable1Amt |
| Taxable2 | $0 | Taxable2Amt |
| Undistributed Income CY | $0 | UndistributedIncomeCYAmt |
| Corpus Distri170b1 E Or4942g3 | $0 | CorpusDistri170b1EOr4942g3Amt |
| Excess Distri Cyov From Yr5 | $93,591 | ExcessDistriCyovFromYr5Amt |
| Excess Distri Cyov To Next Yr | $1,543,179 | ExcessDistriCyovToNextYrAmt |
| Excess From Year4 | $190,767 | ExcessFromYear4Amt |
| Excess From Year3 | $397,524 | ExcessFromYear3Amt |
| Excess From Year2 | $260,938 | ExcessFromYear2Amt |
| Excess From Year1 | $251,714 | ExcessFromYear1Amt |
| Excess From Current Year | $442,236 | ExcessFromCurrentYearAmt |
Supplementary Information SupplementaryInformationGrp
Application Submission Info ApplicationSubmissionInfoGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Recipient Person | CAROLYN P SAMPLE | RecipientPersonNm |
Recipient US Address RecipientUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 3201 RANKIN ROAD NE | AddressLine1Txt |
| City | MINNEAPOLIS | CityNm |
| State Abbreviation | MN | StateAbbreviationCd |
| ZIP | 55418 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Recipient Phone | 6127817677 | RecipientPhoneNum |
| Form And Info And Materials | SEE STATEMENT 7 | FormAndInfoAndMaterialsTxt |
| Submission Deadlines | SEE STATEMENT 7 | SubmissionDeadlinesTxt |
| Restrictions On Awards | SEE STATEMENT 7 | RestrictionsOnAwardsTxt |
Grant Or Contribution Pd Dur Yr GrantOrContributionPdDurYrGrp (48 entries)
| Address Line1RecipientUSAddress/AddressLine1Txt | CityRecipientUSAddress/CityNm | State AbbreviationRecipientUSAddress/StateAbbreviationCd | ZIPRecipientUSAddress/ZIPCd | Recipient RelationshipRecipientRelationshipTxt | Recipient Foundation StatusRecipientFoundationStatusTxt | Grant Or Contribution PurposeGrantOrContributionPurposeTxt | AmtAmt |
|---|---|---|---|---|---|---|---|
| AMERICAN HEART ASSOCIATION | |||||||
| PO BOX 78851 | PHOENIX | AZ | 85062 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $1,000 |
| AMERICAN LUNG ASSOCIATION | |||||||
| PO BOX 7000 | ALBERT LEA | MN | 56007 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $1,000 |
| ARC GREATER TWIN CITIES | |||||||
| 2446 UNIVERSITY AVE W 110 | ST PAUL | MN | 55114 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $7,000 |
| BANYAN COMMUNITY | |||||||
| 2647 BLOOMINGTON AVE S 100 | MINNEAPOLIS | MN | 55407 | NONE | PUBLIC CHARITY | EDUCATIONAL | $2,000 |
| BETHEL UNIVERSITY | |||||||
| 3900 BETHEL DR | ST PAUL | MN | 55112 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $5,000 |
| CAMP KNUTSON | |||||||
| 11169 WHITEFISH AVENUE | CROSSLAKE | MN | 56442 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $5,000 |
| CARE | |||||||
| PO BOX 1870 | MERRIFIELD | VA | 22116 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $10,000 |
| CATHOLIC CHARITIES | |||||||
| 1200 SECOND AVENUE SO | MINNEAPOLIS | MN | 55403 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $5,000 |
| CHILDREN'S HOME SOCIETY | |||||||
| 1605 EUSTIS STREET | ST PAUL | MN | 55108 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $5,000 |
| COURAGE KENNY REHABILITATION INSTITUTE | |||||||
| 3915 GOLDEN VALLEY RD | MINNEAPOLIS | MN | 55422 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $20,000 |
| COVENANT RETIREMENT COMMUNITIES OF MN | |||||||
| 5800 ST CROIX AVENUE N | GOLDEN VALLEY | MN | 55422 | NONE | PUBLIC CHARITY | RELIGIOUS | $5,000 |
| COVENANT WORLD RELIEF | |||||||
| 5101 NORTH FRANCISCO AVENUE | CHICAGO | IL | 60625 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $125,000 |
| CRISTO REY JESUIT HIGH SCHOOL | |||||||
| 2924 4TH AVENUE SOUTH | MINNEAPOLIS | MN | 55408 | NONE | PUBLIC CHARITY | EDUCATIONAL | $2,000 |
| DOCTORS WITHOUT BORDERS | |||||||
| PO BOX 5023 | HAGERSTOWN | MD | 217415023 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $5,000 |
| DUNWOODY COLLEGE OF TECHNOLOGY | |||||||
| 818 DUNWOODY BLVD | MINNEAPOLIS | MN | 55403 | NONE | PUBLIC CHARITY | EDUCATIONAL | $10,000 |
| EAST SIDE NEIGHBORHOOD SERVICES | |||||||
| 1700 SECOND STREET NE | MINNEAPOLIS | MN | 55413 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $3,000 |
| EVANGELICAL COVENANT CHURCH | |||||||
| 8303 W HIGGINS ROAD | CHICAGO | IL | 60631 | NONE | PUBLIC CHARITY | RELIGIOUS | $135,000 |
| FEED MY STARVING CHILDREN | |||||||
| 401 93RD AVE NW | COON RAPIDS | MN | 55433 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $20,000 |
| GREATER MINNEAPOLIS CRISIS NURSERY | |||||||
| 4544 4TH AVE SOUTH | MINNEAPOLIS | MN | 55419 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $3,000 |
| HABITAT FOR HUMANITY | |||||||
| 3001 4TH ST SE | MINNEAPOLIS | MN | 55414 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $10,000 |
| HOMEWARD BOUND | |||||||
| 12805 HIGHWAY 55 STE 400 | PLYMOUTH | MN | 55441 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $10,000 |
| HOUSE OF CHARITY | |||||||
| 510 SOUTH EIGHTH STREET | MINNEAPOLIS | MN | 55404 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $15,000 |
| KIWANIS CLUB OF NE MINNEAPOLIS | |||||||
| 1612 SECOND ST NE | MINNEAPOLIS | MN | 554131138 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $1,000 |
| LITTLE BROTHERS FRIENDS OF THE ELDERLY | |||||||
| 1845 EAST LAKE STREET | MINNEAPOLIS | MN | 55407 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $15,000 |
| LITTLE SISTERS OF THE POOR | |||||||
| 330 EXCHANGE STREET S | ST PAUL | MN | 55102 | NONE | PUBLIC CHARITY | RELIGIOUS | $3,000 |
| LOAVES AND FISHES | |||||||
| 1121 JACKSON STREET NE STE 143 | MINNEAPOLIS | MN | 55413 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $15,000 |
| MARCH OF DIMES | |||||||
| PO BOX 8972 | TOPEKA | KS | 66608 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $1,000 |
| METRO HOPE MINISTRIES | |||||||
| 2739 CEDAR AVENUE SOUTH | MINNEAPOLIS | MN | 55407 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $25,000 |
| MINNEAPOLIS HEART INSTITUTE FOUNDATION | |||||||
| 920 EAST 28TH STREET 100 | MINNEAPOLIS | MN | 55407 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $5,000 |
| MINNESOTA ADULT AND TEEN CHALLENGE | |||||||
| 1619 PORTLANT AVENUE SOUTH | MINNEAPOLIS | MN | 55404 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $15,000 |
| NEW LIFE IN CHRIST MINISTRY | |||||||
| PO BOX 456 | CLEARWATER | MN | 55320 | NONE | PUBLIC CHARITY | RELIGIOUS | $1,000 |
| NORTH HENNEPIN COMMUNITY COLLEGE | |||||||
| 7411 85TH AVENUE NORTH | BROOKLYN PARK | MN | 55445 | NONE | PUBLIC CHARITY | EDUCATIONAL | $5,000 |
| NORTHEAST SENIOR SERVICES | |||||||
| 2580 KENZIE TERRACE SUITE 2A | ST ANTHONY | MN | 55418 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $3,000 |
| PEOPLE SERVING PEOPLE | |||||||
| 614 SOUTH THIRD STREET | MINNEAPOLIS | MN | 55415 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $20,000 |
| SALEM COVENANT CHURCH | |||||||
| 2655 FIFTH STREET NW | NEW BRIGHTON | MN | 55112 | NONE | PUBLIC CHARITY | RELIGIOUS | $125,000 |
| SCIENCE WITH A MISSION | |||||||
| 602 MASSAPOAG AVE | SHARON | MA | 02067 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $5,000 |
| SECOND HARVEST HEARTLAND | |||||||
| 1140 GERVAIS AVENUE | ST PAUL | MN | 55109 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $30,000 |
| SHARING & CARING HANDS | |||||||
| 425 NORTH SEVENTH ST | MINNEAPOLIS | MN | 55405 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $5,000 |
| SIMPSON HOUSING SERVICES | |||||||
| 2100 PILSBURY AVE SO | MINNEAPOLIS | MN | 55404 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $15,000 |
| SUNSHINE ACRES CHILDREN'S HOME | |||||||
| 3405 NORTH HIGLEY ROAD | MESA | AZ | 85215 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $7,000 |
| THE GIDEONS INTERNATIONAL | |||||||
| PO BOX 403810 | ATLANTA | GA | 30384 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $5,000 |
| THE RICHFIELD SPARTAN FOUNDATION | |||||||
| 6638 KNOX AVE S | RICHFIELD | MN | 55423 | NONE | PUBLIC CHARITY | EDUCATIONAL | $5,000 |
| THE SALVATION ARMY | |||||||
| 2445 PRIOR AVENUE NORTH | ROSEVILLE | MN | 55113 | NONE | PUBLIC CHARITY | RELIGIOUS | $75,000 |
| TRUE FRIENDS | |||||||
| 10509 108TH ST NW | ANNANDALE | MN | 55302 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $10,000 |
| UNION GOSPEL MISSION | |||||||
| 77 NINTH STREET E | ST PAUL | MN | 55101 | NONE | PUBLIC CHARITY | RELIGIOUS | $10,000 |
| UNIVERSITY OF MINNESOTA FOUNDATION | |||||||
| 200 OAK STREET SE 500 | MINNEAPOLIS | MN | 55455 | NONE | PUBLIC CHARITY | EDUCATIONAL | $40,000 |
| URBAN HOMEWORKS | |||||||
| 2015 EMERSON AVE N | MINNEAPOLIS | MN | 55411 | NONE | PUBLIC CHARITY | PROGRAM SUPPORT | $4,000 |
| WORLD VISION | |||||||
| PO BOX 9716 | FEDERAL WAY | WA | 980639716 | NONE | PUBLIC CHARITY | RELIGIOUS | $2,000 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Grant Or Contri Pd Dur Yr | $851,000 | TotalGrantOrContriPdDurYrAmt |
| Total Grant Or Contri Apprv Fut | $0 | TotalGrantOrContriApprvFutAmt |
Analysis Income Producing Acty AnalysisIncomeProducingActyGrp
Int On Sav And Temp Cash Invst IntOnSavAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Exclusion | 14 | ExclusionCd |
| Exclusion | $4,669 | ExclusionAmt |
Div And Int From Sec Part VII DivAndIntFromSecPartVIIGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Exclusion | 14 | ExclusionCd |
| Exclusion | $95,772 | ExclusionAmt |
Gain Sales Ast Oth Than Invntry GainSalesAstOthThanInvntryGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Exclusion | 18 | ExclusionCd |
| Exclusion | $6,668,287 | ExclusionAmt |
Subtotals Incm Producing Acty SubtotalsIncmProducingActyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Unrelated Business Taxbl Incm | $0 | UnrelatedBusinessTaxblIncmAmt |
| Exclusion | $6,768,728 | ExclusionAmt |
| Related Or Exempt Function Incm | $0 | RelatedOrExemptFunctionIncmAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Income Producing Acty | $6,768,728 | TotalIncomeProducingActyAmt |
Trnsfr Trans Rln Nonchrtbl EO TrnsfrTransRlnNonchrtblEOGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Trnsfr Of Cash To Nonchrtbl EO | 0 | TrnsfrOfCashToNonchrtblEOInd |
| Trnsfr Other Asset Nonchrtbl EO | 0 | TrnsfrOtherAssetNonchrtblEOInd |
| Sales Or Exchanges Of Assets | 0 | SalesOrExchangesOfAssetsInd |
| Purchase Of Assets Nonchrtbl EO | 0 | PurchaseOfAssetsNonchrtblEOInd |
| Rental Of Facilities Oth Assets | 0 | RentalOfFacilitiesOthAssetsInd |
| Reimbursement Arrangements | 0 | ReimbursementArrangementsInd |
| Loans Or Loan Guarantees | 0 | LoansOrLoanGuaranteesInd |
| Performance Of Services Etc | 0 | PerformanceOfServicesEtcInd |
| Sharing Of Facilities Etc | 0 | SharingOfFacilitiesEtcInd |
| Relationships Nonchrtbl EO | 0 | RelationshipsNonchrtblEOInd |
Schedule B IRS990ScheduleB
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization501c3 Exempt PF | Yes (X) | Organization501c3ExemptPFInd |
| General Rule | Yes (X) | GeneralRuleInd |
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | 1 | ContributorNum |
| Contributor Person | CAROLYN P SAMPLE TRUST | ContributorPersonNm |
Contributor US Address ContributorUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 3201 RANKIN ROAD | AddressLine1Txt |
| City | MINNEAPOLIS | CityNm |
| State Abbreviation | MN | StateAbbreviationCd |
| ZIP | 55418 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Contributions | $200,000 | TotalContributionsAmt |
| Person Contribution | Yes (X) | PersonContributionInd |
Accounting Fees Schedule AccountingFeesSchedule
Accounting Fees Detail AccountingFeesDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Category | ACCOUNTING FEES | CategoryTxt |
| Amt | $2,600 | Amt |
| Net Investment Income | $1,300 | NetInvestmentIncomeAmt |
| Disbursements Charitable Prps | $1,300 | DisbursementsCharitablePrpsAmt |
Investments Corp Stock Schedule InvestmentsCorpStockSchedule
Investments Corporate Stock InvestmentsCorporateStockGrp (3 entries)
| StockStockNm | EOY Book ValueEOYBookValueAmt | EOYFMVEOYFMVAmt |
|---|---|---|
| MEDTRONIC STOCK | $9,526,717 | $9,615,000 |
| 3M | $157,950 | $293,748 |
| CHEVRON | $164,000 | $179,920 |
Investments Govt Obligations Sch InvestmentsGovtObligationsSch
| Field | Value | IRS element (for citing) |
|---|---|---|
| US Govt Obligations Book Vl EOY | $0 | USGovtObligationsBookVlEOYAmt |
| US Govt Obligations EOYFMV | $0 | USGovtObligationsEOYFMVAmt |
| State Local Sec Book Vl EOY | $0 | StateLocalSecBookVlEOYAmt |
| State Local Sec EOYFMV | $0 | StateLocalSecEOYFMVAmt |
Other Expenses Schedule OtherExpensesSchedule
Other Expenses Schedule OtherExpensesScheduleGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | STATE OF MN FILING FEE | Desc |
| Revenue And Expenses Per Books | $25 | RevenueAndExpensesPerBooksAmt |
| Net Investment Income | $0 | NetInvestmentIncomeAmt |
| Disbursements Charitable Prps | $25 | DisbursementsCharitablePrpsAmt |
Taxes Schedule TaxesSchedule
Taxes Detail TaxesDetail (2 entries)
| CategoryCategoryTxt | AmtAmt | Net Investment IncomeNetInvestmentIncomeAmt | Disbursements Charitable PrpsDisbursementsCharitablePrpsAmt |
|---|---|---|---|
| 2015 ESTIMATED EXCISE TAX PAID | $14,240 | $0 | $0 |
| 2014 FEDERAL EXCISE TAX PAID | $10,727 | $0 | $0 |
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