2015-05-13T07:36:27-05:00 2014-12-31 420714325 MCGLADREY LLP 801 NICOLLET MALL SUITE 1100 MINNEAPOLIS MN 55402 990PF 2014-01-01 411873951 THE PATCH FOUNDATION PATC 6127817677 3201 RANKIN ROAD MINNEAPOLIS MN 55418 CAROLYN SAMPLE PRESIDENT 6127817677 2015-05-12 1 TODD A JACKSON P00092672 6123324300 2014 2016-03-07 17:11:31Z X 11032947 X 1374000 28 28 164701 155492 557538 1046413 557538 2096267 713058 0 0 0 1800 900 900 780 780 0 2562 0 0 40 15 25 5182 1695 925 675000 675000 680182 1695 675925 1416085 711363 25861 571459 571459 675629 660991 660991 255000 230000 230713 3730888 3272413 9569784 4687378 4734863 11032947 0 0 X 0 0 0 0 4687378 4734863 4687378 4734863 4687378 4734863 4687378 1416085 0 6103463 1368600 4734863 PUBLICLY TRADED SECURITIES D 1046413 488875 557538 557538 557538 0 622900 7300472 0.085323 700875 6142529 0.114102 516025 6563116 0.078625 420225 6583022 0.063835 353125 6380069 0.055348 0.397233 0.079447 8768762 696652 7114 703766 675925 14227 0 14227 0 14227 3500 3500 10727 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 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 MI 55435 DIRECTOR 0.50 0 0 0 NONE 0 NONE 0 0 8556268 346028 0 8902296 0 0 8902296 133534 8768762 438438 438438 14227 14227 424211 0 424211 0 424211 675925 0 675925 0 675925 424211 0 0 37229 93591 190767 397524 260938 980049 675925 0 0 0 424211 251714 0 0 1231763 0 0 0 0 0 0 37229 1194534 93591 190767 397524 260938 251714 CAROLYN P SAMPLE 3201 RANKIN ROAD NE MINNEAPOLIS MN 55418 6127817677 SEE STATEMENT 7 SEE STATEMENT 7 SEE STATEMENT 7 AMERICAN HEART ASSOCIATION PO BOX 78851 PHOENIX AZ 85062 NONE PUBLIC CHARITY PROGRAM SUPPORT 1000 AMERICAN LUNG ASSOCIATION PO BOX 7000 ALBERT LEA MN 56007 NONE PUBLIC CHARITY PROGRAM SUPPORT 1000 ARC GREATER TWIN CITIES 2446 UNIVERSITY AVE W 110 ST PAUL MN 55114 NONE PUBLIC CHARITY PROGRAM SUPPORT 5000 BETHEL UNIVERSITY 3900 BETHEL DR ST PAUL MN 55112 NONE PUBLIC CHARITY PROGRAM SUPPORT 5000 CAMP KNUTSON 11169 WHITE FISH AVENUE CROSSLAKE MN 56442 NONE PUBLIC CHARITY PROGRAM SUPPORT 5000 CARE PO BOX 1870 MERRIFIELD VA 22116 NONE PUBLIC CHARITY PROGRAM SUPPORT 5000 CATHOLIC CHARITIES 1200 SECOND AVENUE SO MINNEAPOLIS MN 55403 NONE PUBLIC CHARITY PROGRAM SUPPORT 5000 CHILDREN'S HOME SOCIETY 1605 EUSTIS STREET ST PAUL MN 55108 NONE PUBLIC CHARITY PROGRAM SUPPORT 3000 COURAGE KENNY REHABILITATION INSTITUTE 3915 GOLDEN VALLEY RD MINNEAPOLIS MN 55422 NONE PUBLIC CHARITY PROGRAM SUPPORT 15000 COVENANT RETIREMENT COMMUNITIES OF MN 5800 ST CROIX AVENUE N GOLDEN VALLEY MN 55422 NONE RELIGIOUS PROGRAM SUPPORT 5000 COVENANT WORLD RELIEF 5101 NORTH FRANCISCO AVENUE CHICAGO IL 60625 NONE PUBLIC CHARITY PROGRAM SUPPORT 100000 DUNWOODY COLLEGE OF TECHNOLOGY 818 DUNWOODY BLVD 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PUBLIC CHARITY PROGRAM SUPPORT 3000 PEOPLE SERVING PEOPLE 614 SOUTH THIRD STREET MINNEAPOLIS MN 55415 NONE PUBLIC CHARITY PROGRAM SUPPORT 15000 SALEM COVENANT CHURCH 2655 FIFTH STREET NW NEW BRIGHTON MN 55112 NONE RELIGIOUS PROGRAM SUPPORT 125000 SCIENCE WITH A MISSION 602 MASSAPOAG AVE SHARON MA 02067 NONE PUBLIC CHARITY PROGRAM SUPPORT 3000 SECOND HARVEST FOOD BANK 1140 GERVAIS AVENUE ST PAUL MN 55109 NONE PUBLIC CHARITY PROGRAM SUPPORT 20000 SHARING & CARING HANDS 425 NORTH SEVENTH ST MINNEAPOLIS MN 55405 NONE PUBLIC CHARITY PROGRAM SUPPORT 3000 SIMPSON HOUSING SERVICES 2100 PILSBURY AVE SO MINNEAPOLIS MN 55404 NONE PUBLIC CHARITY PROGRAM SUPPORT 15000 SUNSHINE ACRES 3405 NORTH HIGLEY ROAD MESA AZ 85215 NONE PUBLIC CHARITY PROGRAM SUPPORT 5000 THE GIDEONS PO BOX 140800 NASHVILLE TN 37214 NONE PUBLIC CHARITY PROGRAM SUPPORT 3000 THE RICHFIELD SPARTAN FOUNDATION 6638 KNOX AVE S RICHFIELD MN 55423 NONE EDUCATIONAL PROGRAM SUPPORT 2000 THE SALVATION ARMY 2445 PRIOR AVENUE NORTH ROSEVILLE MN 55113 NONE RELIGIOUS PROGRAM SUPPORT 50000 TRUE FRIENDS 10509 108TH ST NW ANNANDALE MN 55302 NONE PUBLIC CHARITY PROGRAM SUPPORT 10000 UNION GOSPEL MISSION 77 NINTH STREET E ST PAUL MN 55101 NONE RELIGIOUS PROGRAM SUPPORT 10000 UNIVERSITY OF MINNESOTA FOUNDATION 200 OAK STREET SE 500 MINNEAPOLIS MN 55455 NONE EDUCATIONAL PROGRAM SUPPORT 35000 URBAN HOMEWORKS 2015 EMERSON AVE N MINNEAPOLIS MN 55411 NONE PUBLIC CHARITY PROGRAM SUPPORT 3000 675000 0 14 28 14 164701 18 557538 0 722267 0 722267 0 0 0 0 0 0 0 0 0 0 X X 1 CAROLYN P SAMPLE TRUST 3201 RANKIN ROAD MINNEAPOLIS MN 55418 1374000 X 1 20,000 SHS MEDTRONIC STOCK 1374000 2014-11-05 ACCOUNTING FEES 1800 900 900 MEDTRONIC STOCK 2950463 9025000 3M 157950 320424 CHEVRON 164000 224360 0 0 230000 230713 ADJUSTMENT FOR 20,000 SHS MEDTRONIC STOCK DONATION - BOOK TO FMV 1368600 STATE OF MN FILING FEE 25 0 25 SERVICE FEES 15 15 0 BROKER COMMISSIONS 780 780 0 ESTIMATED EXCISE TAX PAID - CURRENT YEAR 2562 0 0