Form990-PF

Department of the Treasury
Internal Revenue Service

Return of Private Foundation
or Section 4947(a)(1) Trust Treated as Private Foundation
bulletDo not enter social security numbers on this form as it may be made public.
bulletGo to www.irs.gov/Form990PF for instructions and the latest information.
OMB No. 1545-0052
2019
Open to Public Inspection
For calendar year 2019, or tax year beginning 11-01-2017 , and ending 10-31-2018
Name of foundation
HARRY & THELMA SURRENA MEMORIAL
 
Number and street (or P.O. box number if mail is not delivered to street address)P O BOX 603
  Room/suite
City or town, state or province, country, and ZIP or foreign postal code
SHERIDAN, WY82801
A Employer identification number

23-7435554
B Telephone number (see instructions)

(307) 672-6494
C bullet
G Check all that apply:

D 1. Foreign organizations, check here............. bullet
2. Foreign organizations meeting the 85%
test, check here and attach computation ... bullet
E bullet
H Check type of organization:
F bullet
I Fair market value of all assets at end
of year (from Part II, col. (c),
line 16)bullet$5,610,330J Accounting method:
 
(Part I, column (d) must be on cash basis.)
Part I Analysis of Revenue and Expenses (The total of amounts in columns (b), (c), and (d) may not necessarily equal the amounts in column (a) (see instructions).) (a) Revenue and
expenses per
books 		(b) Net investment
income 		(c) Adjusted net
income 		(d) Disbursements
for charitable
purposes
(cash basis only)
Revenue 1 Contributions, gifts, grants, etc., received (attach schedule)  
2 Check bullet.............
3 Interest on savings and temporary cash investments 11,792 11,792  
4 Dividends and interest from securities... 137,591 137,591  
5a Gross rents............      
b Net rental income or (loss)  
6a Net gain or (loss) from sale of assets not on line 10 549,350
b Gross sales price for all assets on line 6a 2,478,656
7 Capital gain net income (from Part IV, line 2)... 549,350
8 Net short-term capital gain.........  
9 Income modifications...........  
10a Gross sales less returns and allowances  
b Less: Cost of goods sold....  
c Gross profit or (loss) (attach schedule).....    
11 Other income (attach schedule).......      
12 Total. Add lines 1 through 11........ 698,733 698,733  
Operating and Administrative Expenses 13 Compensation of officers, directors, trustees, etc. 38,982 19,491   19,491
14 Other employee salaries and wages......        
15 Pension plans, employee benefits.......        
16a Legal fees (attach schedule).........        
b Accounting fees (attach schedule)....... Click to see attachment 2,200 1,650   550
c Other professional fees (attach schedule).... Click to see attachment 32,988 32,988    
17 Interest...............        
18 Taxes (attach schedule) (see instructions)... Click to see attachment 16,519 2,180   1,491
19 Depreciation (attach schedule) and depletion...      
20 Occupancy..............        
21 Travel, conferences, and meetings.......        
22 Printing and publications..........        
23 Other expenses (attach schedule).......        
24 Total operating and administrative expenses.
Add lines 13 through 23.......... 90,689 56,309   21,532
25 Contributions, gifts, grants paid....... 264,000 264,000
26 Total expenses and disbursements. Add lines 24 and 25 354,689 56,309   285,532
27 Subtract line 26 from line 12:
a Excess of revenue over expenses and disbursements 344,044
b Net investment income (if negative, enter -0-) 642,424
c Adjusted net income (if negative, enter -0-)...  
For Paperwork Reduction Act Notice, see instructions.
Cat. No. 11289X Form 990-PF (2019)
Form 990-PF (2019)
Page 2
Part II Balance Sheets Attached schedules and amounts in the description column
should be for end-of-year amounts only. (See instructions.) 		Beginning of year End of year
(a) Book Value (b) Book Value (c) Fair Market Value
Assets 1 Cash—non-interest-bearing.............      
2 Savings and temporary cash investments......... 77,663 92,201 92,467
3 Accounts receivable bullet  
Less: allowance for doubtful accounts bullet        
4 Pledges receivable bullet  
Less: allowance for doubtful accounts bullet        
5 Grants receivable.................      
6 Receivables due from officers, directors, trustees, and other
disqualified persons (attach schedule) (see instructions).....      
7 Other notes and loans receivable (attach schedule) bullet  
Less: allowance for doubtful accounts bullet        
8 Inventories for sale or use..............      
9 Prepaid expenses and deferred charges..........      
10a Investments—U.S. and state government obligations (attach schedule) 150,000 Click to see attachment400,000 382,329
b Investments—corporate stock (attach schedule)....... 3,031,188 Click to see attachment3,336,122 4,105,035
c Investments—corporate bonds (attach schedule)....... 1,260,109 Click to see attachment1,033,499 1,007,517
11 Investments—land, buildings, and equipment: basis bullet  
Less: accumulated depreciation (attach schedule) bullet        
12 Investments—mortgage loans.............      
13 Investments—other (attach schedule)..........      
14 Land, buildings, and equipment: basis bullet  
Less: accumulated depreciation (attach schedule) bullet        
15 Other assets (describe bullet) Click to see attachment22,982 Click to see attachment22,982 Click to see attachment22,982
16 Total assets (to be completed by all filers—see the
instructions. Also, see page 1, item I) 4,541,942 4,884,804 5,610,330
Liabilities 17 Accounts payable and accrued expenses..........    
18 Grants payable.................    
19 Deferred revenue.................    
20 Loans from officers, directors, trustees, and other disqualified persons    
21 Mortgages and other notes payable (attach schedule)......    
22 Other liabilities (describe bullet) Click to see attachment6,180 Click to see attachment4,998
23 Total liabilities (add lines 17 through 22)......... 6,180 4,998
Net Assets or Fund Balances Foundations that follow FASB ASC 958, check here bullet
and complete lines 24, 25, 29 and 30.
24 Net assets without donor restrictions...........    
25 Net assets with donor restrictions............    
Foundations that do not follow FASB ASC 958, check here bullet
and complete lines 26 through 30.
26 Capital stock, trust principal, or current funds........ 2,443,594 2,443,594
27 Paid-in or capital surplus, or land, bldg., and equipment fund    
28 Retained earnings, accumulated income, endowment, or other funds 2,092,168 2,436,212
29 Total net assets or fund balances (see instructions)..... 4,535,762 4,879,806
30 Total liabilities and net assets/fund balances (see instructions). 4,541,942 4,884,804
Part III
Analysis of Changes in Net Assets or Fund Balances
1
Total net assets or fund balances at beginning of year—Part II, column (a), line 29 (must agree with end-of-year figure reported on prior year’s return) ...............
1
4,535,762
2
Enter amount from Part I, line 27a .....................
2
344,044
3
Other increases not included in line 2 (itemize) bullet
3
 
4
Add lines 1, 2, and 3 ..........................
4
4,879,806
5
Decreases not included in line 2 (itemize) bullet
5
 
6
Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 29 .
6
4,879,806
Form 990-PF (2019)
Form 990-PF (2019)
Page 3
Part IV
Capital Gains and Losses for Tax on Investment Income
(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.)		 (b)
How acquired
P—Purchase
D—Donation 		(c)
Date acquired
(mo., day, yr.) 		(d)
Date sold
(mo., day, yr.)
1 a 15-SHRS-ALPHABET INC CAP STK CL A P 2016-11-18 2018-05-22
b 68-SHRS-BRISTOL-MYERS SQUIBB CO P 2013-02-05 2018-05-22
c 20-SHRS-WALT DISNEY CO/THE P 2010-03-12 2018-05-22
d 2048-SHRS-FORD MOTOR CO P 2014-10-20 2018-03-16
e 6-SHRS-MCKESSON CORP P 2012-09-13 2018-05-22
332-SHRS-QUALCOMM INC P 2004-02-25 2018-03-27
72-SHRS-INDUSTRIAL SELECT SECTOR SPD P 2018-02-02 2018-05-22
504-SHRS-WELLS FARGO & CO P 2016-10-27 2018-03-27
3880.071-SHRS-VANGUARD HIGH-YIELD CO P 2011-10-25 2018-05-23
201-SHRS-AMERICAN EXPRESS CO P 2013-08-29 2017-11-02
281-SHRS-CELGENE CORP P 2012-12-11 2017-11-02
13-SHRS-DOWDUPONT INC P 2010-10-26 2017-11-02
648-SHRS-GENERAL ELECTRIC CO P 2008-12-02 2017-11-02
274-SHRS-MICROSOFT CORP P 2013-08-15 2017-11-02
533-SHRS-QUALCOMM INC P 2016-03-11 2018-03-27
194-SHRS-SKYWORKS SOLUTIONS INC P 2013-08-23 2017-11-02
8250.964-SHRS-OPPENHEIMER INTERNATIO P 2014-09-12 2018-02-15
4496.403-SHRS-VANGUARD HIGH-YIELD CO P 2011-11-23 2018-05-23
4-SHRS-AMERICAN EXPRESS CO P 2013-08-29 2018-05-22
19-SHRS-CELGENE CORP P 2012-12-11 2018-05-22
159-SHRS-DOWDUPONT INC P 2010-10-26 2018-05-22
962-SHRS-GENERAL ELECTRIC CO P 2013-08-15 2017-11-02
15-SHRS-MICROSOFT CORP P 2013-08-15 2018-05-22
533-SHRS-QUALCOMM INC P 2016-03-11 2018-03-27
48-SHRS-SKYWORKS SOLUTIONS INC P 2013-08-23 2018-05-22
36.655-SHRS-OPPENHEIMER INTERNATIONA P 2014-03-03 2018-02-15
4791.868-SHRS-VANGUARD HIGH-YIELD CO P 2016-01-27 2018-05-23
56-SHRS-APACHE CORP P 2012-08-20 2018-04-04
256-SHRS-CELGENE CORP P 2012-12-11 2018-08-14
50000-SHRS-EATON CORP 1.5% 02 NOV 20 P 2014-03-03 2017-11-02
142-SHRS-GENERAL ELECTRIC CO P 2017-07-26 2017-11-02
339-SHRS-MONDELEZ INTERNATIONAL INC P 2010-06-02 2017-11-02
592-SHRS-QUALCOMM INC P 2017-02-02 2018-03-27
1000-SHRS-SOUTHERN CO/THE P 1986-01-24 2018-10-17
4065.206-SHRS-OPPENHEIMER INTERNATIO P 2014-05-13 2018-02-15
2688.172-SHRS-VANGUARD INTERMEDIATE- P 2017-02-02 2018-10-18
495-SHRS-APACHE CORP P 2015-09-14 2018-04-04
222-SHRS-CELGENE CORP P 2014-04-15 2018-08-14
3-SHRS-EMERSON ELECTRIC CO P 2001-02-05 2018-05-22
962-SHRS-GENERAL ELECTRIC CO P 2013-07-30 2018-02-01
96-SHRS-MONDELEZ INTERNATIONAL INC P 2010-08-06 2017-11-02
332-SHRS-QUALCOMM INC P 2004-02-25 2018-03-27
239-SHRS-STARBUCKS CORP P 2016-04-18 2018-05-22
36.655-SHRS-OPPENHEIMER INTERNATIONA P 2014-03-03 2018-02-15
4681.647-SHRS-VANGUARD SHORT-TERM IN P 2017-11-03 2018-10-18
33-SHRS-APPLE INC P 2011-01-06 2017-11-02
283-SHRS-CELGENE CORP P 2016-04-18 2018-08-14
39-SHRS-EMERSON ELECTRIC CO P 2004-02-25 2018-05-22
142-SHRS-GENERAL ELECTRIC CO P 2017-07-10 2018-02-01
171-SHRS-NIKE INC P 2016-10-12 2018-05-22
79-SHRS-QUALCOMM INC P 2004-02-25 2018-05-22
191-SHRS-UNION PACIFIC CORP P 2013-11-20 2017-11-02
8250.964-SHRS-OPPENHEIMER INTERNATIO P 2014-09-12 2018-02-15
121.427-SHRS-VANGUARD SHORT-TERM INV P 2014-11-19 2018-10-18
157-SHRS-APPLE INC P 2013-01-22 2017-11-02
112-SHRS-CHEVRON CORP P 2003-06-16 2018-05-22
466-SHRS-EXELON CORP P 2015-03-31 2017-11-02
1726-SHRS-GENERAL ELECTRIC CO P 2017-07-26 2018-02-01
47-SHRS-PEPSICO INC P 1996-05-29 2017-11-02
253-SHRS-QUALCOMM INC P 2004-02-25 2018-08-14
19-SHRS-UNION PACIFIC CORP P 2013-11-20 2018-05-22
4065.206-SHRS-OPPENHEIMER INTERNATIO P 2014-05-13 2018-02-15
216.654-SHRS-VANGUARD 500 INDEX FUND P 2017-12-21 2018-05-23
34-SHRS-APPLE INC P 2013-01-22 2018-05-22
453-SHRS-CISCO SYSTEMS INC P 2004-02-25 2018-05-16
32-SHRS-EXELON CORP P 2015-03-31 2018-05-22
1748-SHRS-GENERAL ELECTRIC CO P 2017-10-17 2018-02-01
112-SHRS-PEPSICO INC P 1997-03-21 2017-11-02
436-SHRS-QUALCOMM INC P 2016-03-11 2018-08-14
133-SHRS-UNION PACIFIC CORP P 2013-11-20 2018-06-19
795.99-SHRS-HARBOR INTERNATIONAL FUN P 2004-11-12 2018-01-17
123-SHRS-APPLE INC P 2013-01-22 2018-10-31
36-SHRS-APPLE INC P 2013-01-22 2018-10-31
86-SHRS-CISCO SYSTEMS INC P 2004-02-25 2018-05-22
255-SHRS-EXXON MOBIL CORP P 1983-06-24 2017-11-02
114-SHRS-GILEAD SCIENCES INC P 2012-05-04 2018-05-22
21-SHRS-PEPSICO INC P 1997-03-21 2018-05-22
471-SHRS-ROCHE HOLDINGS AG SPN ADR E P 2012-12-11 2017-11-02
98-SHRS-UNITEDHEALTH GROUP INC P 2012-09-27 2017-11-02
582.751-SHRS-HARBOR INTERNATIONAL FU P 2005-06-24 2018-01-17
662-SHRS-CITIGROUP INC P 2015-03-05 2018-10-31
28-SHRS-APPLE INC P 2014-03-28 2018-10-31
545-SHRS-CITIGROUP INC P 2014-10-20 2017-11-02
49-SHRS-EXXON MOBIL CORP P 1983-06-24 2018-05-22
178-SHRS-JPMORGAN CHASE & CO P 2011-10-25 2017-11-02
28-SHRS-QUALCOMM INC P 2000-03-03 2017-11-02
295-SHRS-ROCHE HOLDINGS AG SPN ADR E P 2012-12-12 2017-11-02
13-SHRS-UNITEDHEALTH GROUP INC P 2012-09-27 2018-05-22
434.278-SHRS-HARBOR INTERNATIONAL FU P 2015-04-01 2018-01-17
876-SHRS-CITIGROUP INC P 2015-03-05 2018-10-31
682-SHRS-BAKER HUGHES A GE CO P 2012-03-05 2017-12-20
109-SHRS-CITIGROUP INC P 2014-10-20 2018-05-22
50-SHRS-FACEBOOK INC P 2016-11-18 2018-05-22
275-SHRS-JPMORGAN CHASE & CO P 2012-05-25 2017-11-02
468-SHRS-QUALCOMM INC P 2004-02-25 2017-11-02
703-SHRS-ROCHE HOLDINGS AG SPN ADR E P 2012-12-12 2018-04-04
181-SHRS-UNITEDHEALTH GROUP INC P 2012-09-27 2018-08-14
357.756-SHRS-HARBOR INTERNATIONAL FU P 2017-11-03 2018-01-17
444-SHRS-CONSUMER STAPLES SELECT SEC P 2018-05-16 2018-10-31
450-SHRS-BAKER HUGHES A GE CO P 2012-04-05 2017-12-20
81-SHRS-COSTCO WHOLESALE CORP P 2010-05-14 2018-05-16
81-SHRS-FEDEX CORP P 2015-12-14 2017-11-02
255-SHRS-JPMORGAN CHASE & CO P 2012-05-25 2018-03-16
332-SHRS-QUALCOMM INC P 2004-02-25 2018-03-27
1024-SHRS-ROCHE HOLDINGS AG SPN ADR P 2013-01-29 2018-04-04
120-SHRS-WALMART INC P 2016-01-25 2018-05-22
7929.492-SHRS-VANGUARD HIGH-YIELD CO P 2015-04-01 2017-11-02
532-SHRS-BAKER HUGHES A GE CO P 2014-10-20 2017-12-20
200-SHRS-COSTCO WHOLESALE CORP P 2010-08-06 2018-05-16
7-SHRS-FEDEX CORP P 2015-12-14 2018-05-22
216-SHRS-LOWE'S COS INC P 2016-10-19 2017-11-02
533-SHRS-QUALCOMM INC P 2016-03-11 2018-03-27
43-SHRS-SCHLUMBERGER LTD P 2011-11-23 2018-05-22
50000-SHRS-ANTHEM INC 2.3% 15 JUL 20 P 2014-09-12 2018-07-16
445.718-SHRS-VANGUARD HIGH-YIELD COR P 2012-07-27 2017-11-02
68-SHRS-BERKSHIRE HATHAWAY B SHARES P 2010-02-17 2018-05-22
157-SHRS-WALT DISNEY CO/THE P 2009-01-15 2017-11-02
1195-SHRS-FORD MOTOR CO P 2012-07-05 2018-03-16
43-SHRS-LOWE'S COS INC P 2016-10-19 2018-05-22
592-SHRS-QUALCOMM INC P 2017-02-02 2018-03-27
239-SHRS-CONSUMER STAPLES SELECT SEC P 2018-05-16 2018-05-22
265-SHRS-WELLS FARGO & CO P 2016-10-27 2017-11-02
4268.087-SHRS-VANGUARD HIGH-YIELD CO P 2012-07-27 2018-05-23
100-SHRS-BOEING CO/THE P 2011-11-04 2017-11-02
18-SHRS-WALT DISNEY CO/THE P 2010-03-12 2017-11-02
1578-SHRS-FORD MOTOR CO P 2012-08-03 2018-03-16
140-SHRS-MCKESSON CORP P 2012-09-13 2017-11-02
592-SHRS-QUALCOMM INC P 2017-02-02 2018-03-27
79-SHRS-CONSUMER DISCRETIONARY SELEC P 2018-03-16 2018-05-22
503-SHRS-WELLS FARGO & CO P 2016-10-27 2018-03-27
8787.346-SHRS-VANGUARD HIGH-YIELD CO P 2016-05-26 2018-05-23
(e)
Gross sales price 		(f)
Depreciation allowed
(or allowable) 		(g)
Cost or other basis
plus expense of sale 		(h)
Gain or (loss)
(e) plus (f) minus (g)
a 16,183   11,686 4,497
b 3,579   2,513 1,066
c 2,085   674 1,411
d 22,816   28,966 -6,150
e 880   528 352
10,083   10,083  
5,466   5,700 -234
25,689   23,592 2,097
22,194   22,000 194
19,235   14,567 4,668
28,094   11,631 16,463
934   454 480
12,805   11,156 1,649
22,958   8,704 14,254
27,504   27,504  
21,364   4,879 16,485
49,946   49,946  
25,719   25,000 719
411   290 121
1,457   786 671
10,847   5,548 5,299
19,011   19,011  
1,468   476 992
27,200   27,200  
4,821   1,207 3,614
222   222  
27,409   26,019 1,390
2,110   5,006 -2,896
23,355   10,596 12,759
50,000   50,062 -62
2,806   2,806  
14,011   6,252 7,759
30,463   30,463  
44,311   6,839 37,472
24,973   24,973  
25,000   25,968 -968
18,647   19,840 -1,193
20,253   15,386 4,867
221   111 110
15,354   26,499 -11,145
3,968   1,849 2,119
9,894   9,894  
13,637   14,586 -949
221   221  
48,736   50,000 -1,264
5,499   1,573 3,926
25,818   30,483 -4,665
2,876   1,221 1,655
2,266   4,142 -1,876
12,228   8,997 3,231
4,554   2,309 2,245
22,311   15,177 7,134
49,819   49,819  
1,264   1,300 -36
26,161   11,166 14,995
14,468   4,209 10,259
18,627   15,571 3,056
27,547   44,357 -16,810
5,160   1,448 3,712
16,399   7,395 9,004
2,736   1,510 1,226
24,911   24,911  
54,829   53,931 898
6,380   2,418 3,962
20,470   10,614 9,856
1,274   1,069 205
27,898   40,603 -12,705
12,297   3,444 8,853
28,261   22,001 6,260
19,550   10,569 8,981
56,420   33,089 23,331
26,865   8,747 18,118
7,866   2,560 5,306
3,768   2,015 1,753
21,252   1,102 20,150
7,771   2,892 4,879
2,095   646 1,449
13,673   11,955 1,718
20,556   5,523 15,033
41,305   25,000 16,305
43,285   35,482 7,803
6,118   2,146 3,972
40,294   27,549 12,745
4,011   212 3,799
17,930   6,002 11,928
1,539   1,754 -215
8,564   7,479 1,085
3,178   733 2,445
30,782   30,000 782
57,215   44,390 12,825
22,104   32,772 -10,668
7,789   5,510 2,279
9,222   5,856 3,366
27,701   9,248 18,453
25,722   13,680 12,042
19,541   17,823 1,718
47,161   10,201 36,960
25,358   25,000 358
24,387   22,046 2,341
14,585   18,572 -3,987
16,043   4,678 11,365
18,174   11,514 6,660
29,662   8,576 21,086
10,259   10,259  
28,464   28,182 282
10,039   7,645 2,394
47,339   47,577 -238
17,242   28,015 -10,773
39,613   11,320 28,293
1,780   995 785
16,652   15,012 1,640
27,786   27,786  
3,196   2,868 328
50,000   50,218 -218
2,661   2,648 13
13,494   5,183 8,311
15,465   3,156 12,309
13,313   11,484 1,829
3,711   2,988 723
31,114   31,114  
11,878   11,867 11
14,800   12,404 2,396
24,413   25,352 -939
26,043   6,582 19,461
1,773   607 1,166
17,580   14,358 3,222
19,395   12,310 7,085
30,800   30,800  
8,314   8,349 -35
25,627   23,545 2,082
50,264   50,000 264
Complete only for assets showing gain in column (h) and owned by the foundation on 12/31/69 (l)
Gains (Col. (h) gain minus
col. (k), but not less than -0-) or
Losses (from col.(h))
(i)
F.M.V. as of 12/31/69 		(j)
Adjusted basis
as of 12/31/69 		(k)
Excess of col. (i)
over col. (j), if any
a       4,497
b       1,066
c       1,411
d       -6,150
e       352
       
      -234
      2,097
      194
      4,668
      16,463
      480
      1,649
      14,254
       
      16,485
       
      719
      121
      671
      5,299
       
      992
       
      3,614
       
      1,390
      -2,896
      12,759
      -62
       
      7,759
       
      37,472
       
      -968
      -1,193
      4,867
      110
      -11,145
      2,119
       
      -949
       
      -1,264
      3,926
      -4,665
      1,655
      -1,876
      3,231
      2,245
      7,134
       
      -36
      14,995
      10,259
      3,056
      -16,810
      3,712
      9,004
      1,226
       
      898
      3,962
      9,856
      205
      -12,705
      8,853
      6,260
      8,981
      23,331
      18,118
      5,306
      1,753
      20,150
      4,879
      1,449
      1,718
      15,033
      16,305
      7,803
      3,972
      12,745
      3,799
      11,928
      -215
      1,085
      2,445
      782
      12,825
      -10,668
      2,279
      3,366
      18,453
      12,042
      1,718
      36,960
      358
      2,341
      -3,987
      11,365
      6,660
      21,086
       
      282
      2,394
      -238
      -10,773
      28,293
      785
      1,640
       
      328
      -218
      13
      8,311
      12,309
      1,829
      723
       
      11
      2,396
      -939
      19,461
      1,166
      3,222
      7,085
       
      -35
      2,082
      264
2 Capital gain net income or (net capital loss) Bracket If gain, also enter in Part I, line 7
If (loss), enter -0- in Part I, line 7		 Bracket 2 549,350
3 Net short-term capital gain or (loss) as defined in sections 1222(5) and (6):
If gain, also enter in Part I, line 8, column (c) (see instructions). If (loss), enter -0-
in Part I, line 8 ................... 		Bracket 3 -29,316
Part V
Qualification Under Section 4940(e) for Reduced Tax on Net Investment Income
(For optional use by domestic private foundations subject to the section 4940(a) tax on net investment income.)

If section 4940(d)(2) applies, leave this part blank.
Was the foundation liable for the section 4942 tax on the distributable amount of any year in the base period?
If "Yes," the foundation does not qualify under section 4940(e). Do not complete this part.
1 Enter the appropriate amount in each column for each year; see instructions before making any entries.
(a)
Base period years Calendar
year (or tax year beginning in) 		(b)
Adjusted qualifying distributions 		(c)
Net value of noncharitable-use assets 		(d)
Distribution ratio
(col. (b) divided by col. (c))
2018 285,507 5,836,340 0.048919
2017 295,282 5,544,325 0.053258
2016 308,616 5,532,056 0.055787
2015 303,292 5,560,400 0.054545
2014 258,436 5,125,398 0.050423
2
Total of line 1, column (d) .....................
2
0.262932
3
Average distribution ratio for the 5-year base period—divide the total on line 2 by 5.0, or by the number of years the foundation has been in existence if less than 5 years ......
3
0.052586
4
Enter the net value of noncharitable-use assets for 2019 from Part X, line 5......
4
5,920,934
5
Multiply line 4 by line 3......................
5
311,358
6
Enter 1% of net investment income (1% of Part I, line 27b)...........
6
6,424
7
Add lines 5 and 6........................
7
317,782
8
Enter qualifying distributions from Part XII, line 4,.............
8
285,532
If line 8 is equal to or greater than line 7, check the box in Part VI, line 1b, and complete that part using a 1% tax rate. See the Part VI instructions.
Form 990-PF (2019)
Form 990-PF (2019)
Page 4
Part VI
Excise Tax Based on Investment Income (Section 4940(a), 4940(b), 4940(e), or 4948—see instructions)
1a Exempt operating foundations described in section 4940(d)(2), check here Bullet and enter “N/A" on line 1. Bracket includes lines 1a and 1b
Date of ruling or determination letter:   (attach copy of letter if necessary–see instructions)
b Domestic foundations that meet the section 4940(e) requirements in Part V, check 1 12,848
hereBulletand enter 1% of Part I, line 27b...................
c All other domestic foundations enter 2% of line 27b. Exempt foreign organizations enter 4% of Part I, line 12, col. (b)
2 Tax under section 511 (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-) 2  
3 Add lines 1 and 2........................... 3 12,848
4 Subtitle A (income) tax (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-) 4  
5 Tax based on investment income. Subtract line 4 from line 3. If zero or less, enter -0- ..... 5 12,848
6 Credits/Payments:
a 2019 estimated tax payments and 2018 overpayment credited to 2019 6a 7,850
b Exempt foreign organizations—tax withheld at source...... 6b
c Tax paid with application for extension of time to file (Form 8868)... 6c  
d Backup withholding erroneously withheld ........... 6d  
7 Total credits and payments. Add lines 6a through 6d.............. 7 7,850
8 Enter any penalty for underpayment of estimated tax. Check here if Form 2220 is attached. 8  
9 Tax due. If the total of lines 5 and 8 is more than line 7, enter amount owed.......Bullet 9 4,998
10 Overpayment. If line 7 is more than the total of lines 5 and 8, enter the amount overpaid...Bullet 10  
11 Enter the amount of line 10 to be: Credited to 2020 estimated taxBullet   RefundedBullet 11  
Part VII-A
Statements Regarding Activities
1a
During the tax year, did the foundation attempt to influence any national, state, or local legislation or did
Yes
No
it participate or intervene in any political campaign? ....................
1a
 
No
b
Did it spend more than $100 during the year (either directly or indirectly) for political purposes? (see Instructions
for definition).................................
1b
 
No
If the answer is "Yes" to 1a or 1b, attach a detailed description of the activities and copies of any materials
published or distributed by the foundation in connection with the activities.
c
Did the foundation file Form 1120-POL for this year?.....................
1c
 
No
d
Enter the amount (if any) of tax on political expenditures (section 4955) imposed during the year:
(1) On the foundation. bullet$   (2) On foundation managers.bullet$  
e
Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed
on foundation managers.bullet$  
2
Has the foundation engaged in any activities that have not previously been reported to the IRS?.......
2
 
No
If "Yes," attach a detailed description of the activities.
3
Has the foundation 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....
3
 
No
4a
Did the foundation have unrelated business gross income of $1,000 or more during the year?........
4a
 
No
b
If "Yes," has it filed a tax return on Form 990-T for this year?...................
4b
 
 
5
Was there a liquidation, termination, dissolution, or substantial contraction during the year?.........
5
 
No
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 instrument?................
    6
    Yes
     
    7
    Did the foundation have at least $5,000 in assets at any time during the year? If "Yes," complete Part II, col. (c),
    and Part XV..................................
    7
    Yes
     
    8a
    Enter the states to which the foundation reports or with which it is registered (see instructions)
    bulletWY
    b
    If the answer is "Yes" to line 7, has the foundation 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 .
    8b
    Yes
     
    9
    Is the foundation claiming status as a private operating foundation within the meaning of section 4942(j)(3)
    or 4942(j)(5) for calendar year 2019 or the taxable year beginning in 2019? See the instructions for Part XIV.
    If "Yes," complete Part XIV .............................
    9
     
    No
    10
    Did any persons become substantial contributors during the tax year? If "Yes," attach a schedule listing their names
    and addresses. ...............................
    10
     
    No
    Form 990-PF (2019)
    Form 990-PF (2019)
    Page 5
    Part VII-A
    Statements Regarding Activities (continued)
    11
    At any time during the year, did the foundation, directly or indirectly, own a controlled entity within the
    meaning of section 512(b)(13)? If "Yes," attach schedule. See instructions .............
    11
     
    No
    12
    Did the foundation make a distribution to a donor advised fund over which the foundation or a disqualified person had
    advisory privileges? If "Yes," attach statement. See instructions.................
    12
     
    No
    13
    Did the foundation comply with the public inspection requirements for its annual returns and exemption application?
    13
    Yes
     
    Website addressbulletN/A
    14
    The books are in care ofbulletMOHATT JOHNSON & GODWIN LLP Telephone no.bullet (307) 672-6494

    Located atbulletPO BOX 603SHERIDANWY ZIP+4bullet82801
    15
    Section 4947(a)(1) nonexempt charitable trusts filing Form 990-PF in lieu of Form 1041 —check here .........bullet
    and enter the amount of tax-exempt interest received or accrued during the year ........bullet
    15
     
    16 At any time during calendar year 2019, did the foundation have an interest in or a signature or other authority over YesNo
    a bank, securities, or other financial account in a foreign country? .................
    16   No
    See the instructions for exceptions and filing requirements for FinCEN Form 114. If "Yes", enter the name of the foreign
    country bullet
    Part VII-B
    Statements Regarding Activities for Which Form 4720 May Be Required
    File Form 4720 if any item is checked in the "Yes" column, unless an exception applies.
    Yes
    No
    1a
    During the year did the foundation (either directly or indirectly):
    (1) Engage in the sale or exchange, or leasing of property with a disqualified person?
    (2) Borrow 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 person?
    (4) Pay compensation 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) Agree to pay money or property to a government official? (Exception. Check "No"
    if the foundation agreed to make a grant to or to employ the official for a period
    after termination of government service, if terminating within 90 days.).......
    b
    If any answer is "Yes" to 1a(1)–(6), did any of the acts fail to qualify under the exceptions described in Regulations
    section 53.4941(d)-3 or in a current notice regarding disaster assistance? See instructions ........
    1b
     
    No
    ........bullet
    c
    Did the foundation engage in a prior year in any of the acts described in 1a, other than excepted acts,
    that were not corrected before the first day of the tax year beginning in 2019?.............
    1c
     
     
    2
    Taxes on failure to distribute income (section 4942) (does not apply for years the foundation was a private
    operating foundation defined in section 4942(j)(3) or 4942(j)(5)):
    a
    At the end of tax year 2019, did the foundation have any undistributed income (lines 6d
    and 6e, Part XIII) for tax year(s) beginning before 2019?.............
    If "Yes," list the years bullet20, 20, 20, 20
    b
    Are there any years listed in 2a for which the foundation is not applying the provisions of section 4942(a)(2)
    (relating to incorrect valuation of assets) to the year’s undistributed income? (If applying section 4942(a)(2)
    to all years listed, answer "No" and attach statement—see instructions.) ..............
    2b
     
     
    c
    If the provisions of section 4942(a)(2) are being applied to any of the years listed in 2a, list the years here.
    bullet20, 20, 20, 20
    3a
    Did the foundation hold more than a 2% direct or indirect interest in any business enterprise at
    any time during the year?......................
    b
    If "Yes," did it have excess business holdings in 2019 as a result of (1) any purchase by the foundation
    or disqualified persons after 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 first phase holding period? (Use Schedule C, Form 4720, to determine
    if the foundation had excess business holdings in 2019.)..................
    3b
     
     
    4a
    Did the foundation invest during the year any amount in a manner that would jeopardize its charitable purposes?
    4a
     
    No
    b
    Did the foundation make any investment in a prior year (but after December 31, 1969) that could jeopardize its
    charitable purpose that had not been removed from jeopardy before the first day of the tax year beginning in 2019?
    4b
     
    No
    Form 990-PF (2019)
    Form 990-PF (2019)
    Page 6
    Part VII-B
    Statements Regarding Activities for Which Form 4720 May Be Required (continued)
    5a
    During the year did the foundation pay or incur any amount to:
    Yes
    No
    (1) Carry on propaganda, or otherwise attempt to influence legislation (section 4945(e))?
    (2) Influence the outcome of any specific public election (see section 4955); or to carry
    on, directly or indirectly, any voter registration drive?.............
    (3) Provide a grant to an individual for travel, study, or other similar purposes?
    (4) Provide a grant to an organization other than a charitable, etc., organization described
    in section 4945(d)(4)(A)? See instructions................
    (5) Provide for any purpose other than religious, charitable, scientific, literary, or
    educational purposes, or for the prevention of cruelty to children or animals?.....
    b
    If any answer is "Yes" to 5a(1)–(5), did any of the transactions fail to qualify under the exceptions described in
    Regulations section 53.4945 or in a current notice regarding disaster assistance? See instructions ......
    5b
     
     
    .........bullet
    c
    If the answer is "Yes" to question 5a(4), does the foundation claim exemption from the
    tax because it maintained expenditure responsibility for the grant?..........
    If "Yes," attach the statement required by Regulations section 53.4945–5(d).
    6a
    Did the foundation, during the year, receive any funds, directly or indirectly, to pay premiums on
    a personal benefit contract?.....................
    b
    Did the foundation, during the year, pay premiums, directly or indirectly, on a personal benefit contract? ....
    6b
     
    No
    If "Yes" to 6b, file Form 8870.
    7a
    At any time during the tax year, was the foundation a party to a prohibited tax shelter transaction?
    b
    If "Yes", did the foundation receive any proceeds or have any net income attributable to the transaction? ....
    7b
     
     
    8
    Is the foundation subject to the section 4960 tax on payment(s) of more than $1,000,000 in remuneration or
    excess parachute payment during the year? .................
    Part VIII
    Information About Officers, Directors, Trustees, Foundation Managers, Highly Paid Employees,
    and Contractors
    1 List all officers, directors, trustees, foundation managers and their compensation. See instructions
    (a) Name and address (b) Title, and average
    hours per week
    devoted to position     		(c) Compensation
     (If not paid, enter
    -0-)     		(d) Contributions to employee benefit plans and deferred compensation (e) Expense account,
    other allowances
    JOHN PRADERE TRUSTEE
    6.00     		19,491 0 0
    PO BOX 603
    SHERIDAN,WY82801
    ROBERT WYATT TRUSTEE
    6.00     		19,491 0 0
    PO BOX 603
    SHERIDAN,WY82081
    2 Compensation of five highest-paid employees (other than those included on line 1—see instructions). If none, enter “NONE."
    (a) Name and address of each employee paid more than $50,000 (b) Title, and average
    hours per week
    devoted to position     		(c) Compensation (d) Contributions to
    employee benefit
    plans and deferred
    compensation     		(e) Expense account,
    other allowances
    NONE
    Total number of other employees paid over $50,000...................bullet  
    Form 990-PF (2019)
    Form 990-PF (2019)
    Page 7
    Part VIII
    Information About Officers, Directors, Trustees, Foundation Managers, Highly Paid Employees,
    and Contractors (continued)
    3 Five highest-paid independent contractors for professional services (see instructions). If none, enter "NONE".
    (a) Name and address of each person paid more than $50,000 (b) Type of service (c) Compensation
    NONE
    Total number of others receiving over $50,000 for professional services.............bullet  
    Part IX-A
    Summary of Direct Charitable Activities
    List the foundation’s four largest direct charitable activities during the tax year. Include relevant statistical information such as the number of organizations and other beneficiaries served, conferences convened, research papers produced, etc. Expenses
    1  
    2  
    3  
    4  
    Part IX-B
    Summary of Program-Related Investments (see instructions)
    Describe the two largest program-related investments made by the foundation during the tax year on lines 1 and 2. Amount
    1 N/A  
    2  
    All other program-related investments. See instructions.
    3  
    Total. Add lines 1 through 3.........................bullet  
    Form 990-PF (2019)
    Form 990-PF (2019)
    Page 8
    Part X
    Minimum Investment Return (All domestic foundations must complete this part. Foreign foundations, see instructions.)
    1
    Fair market value of assets not used (or held for use) directly in carrying out charitable, etc.,
    purposes:
    a
    Average monthly fair market value of securities...................
    1a
    5,794,888
    b
    Average of monthly cash balances.......................
    1b
    188,451
    c
    Fair market value of all other assets (see instructions)................
    1c
    27,762
    d
    Total (add lines 1a, b, and c).........................
    1d
    6,011,101
    e
    Reduction claimed for blockage or other factors reported on lines 1a and
    1c (attach detailed explanation) .............
    1e
     
    2
    Acquisition indebtedness applicable to line 1 assets..................
    2
     
    3
    Subtract line 2 from line 1d.........................
    3
    6,011,101
    4
    Cash deemed held for charitable activities. Enter 1 1/2% of line 3 (for greater amount, see
    instructions) .............................
    4
    90,167
    5
    Net value of noncharitable-use assets. Subtract line 4 from line 3. Enter here and on Part V, line 4
    5
    5,920,934
    6
    Minimum investment return. Enter 5% of line 5..................
    6
    296,047
    Part XI
    Distributable Amount (see instructions) (Section 4942(j)(3) and (j)(5) private operating foundations and certain foreign organizations check here right arrow and do not complete this part.)
    1
    Minimum investment return from Part X, line 6....................
    1
    296,047
    2a
    Tax on investment income for 2019 from Part VI, line 5......
    2a
    12,848
    b
    Income tax for 2019. (This does not include the tax from Part VI.)...
    2b
     
    c
    Add lines 2a and 2b............................
    2c
    12,848
    3
    Distributable amount before adjustments. Subtract line 2c from line 1............
    3
    283,199
    4
    Recoveries of amounts treated as qualifying distributions................
    4
     
    5
    Add lines 3 and 4............................
    5
    283,199
    6
    Deduction from distributable amount (see instructions).................
    6
     
    7
    Distributable amount as adjusted. Subtract line 6 from line 5. Enter here and on Part XIII, line 1 ...
    7
    283,199
    Part 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 ..........
    1a
    285,532
    b
    Program-related investments—total from Part IX-B..................
    1b
     
    2
    Amounts paid to acquire assets used (or held for use) directly in carrying out charitable, etc.,
    purposes...............................
    2
     
    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) .................
    3b
     
    4
    Qualifying distributions. Add lines 1a through 3b. Enter here and on Part V, line 8, and Part XIII, line 4
    4
    285,532
    5
    Foundations that qualify under section 4940(e) for the reduced rate of tax on net investment
    income. Enter 1% of Part I, line 27b. See instructions.................
    5
     
    6
    Adjusted qualifying distributions. Subtract line 5 from line 4..............
    6
    285,532
    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 (2019)
    Form 990-PF (2019)
    Page 9
    Part XIII
    Undistributed Income (see instructions)
    (a)
    Corpus     		(b)
    Years prior to 2018     		(c)
    2018     		(d)
    2019
    1 Distributable amount for 2019 from Part XI, line 7 283,199
    2 Undistributed income, if any, as of the end of 2019:
    a Enter amount for 2018 only.......  
    b Total for prior years:20, 20, 20  
    3 Excess distributions carryover, if any, to 2019:
    a From 2014......  
    b From 2015......  
    c From 2016...... 17,903
    d From 2017...... 20,740
    e From 2018...... 1,533
    fTotal of lines 3a through e........ 40,176
    4Qualifying distributions for 2019 from Part
    XII, line 4: bullet$ 285,532
    a Applied to 2018, but not more than line 2a  
    b Applied to undistributed income of prior years
    (Election required—see instructions).....     		 
    c Treated as distributions out of corpus (Election
    required—see instructions)........     		 
    d Applied to 2019 distributable amount..... 283,199
    e Remaining amount distributed out of corpus 2,333
    5 Excess distributions carryover applied to 2019.    
    (If an amount appears in column (d), the
    same amount must be shown in column (a).)
    6Enter the net total of each column as
    indicated below:
    a Corpus. Add lines 3f, 4c, and 4e. Subtract line 5 42,509
    b Prior years’ undistributed income. Subtract
    line 4b from line 2b ..........     		 
    c Enter the amount of prior years’ undistributed
    income for which a notice of deficiency has
    been issued, or on which the section 4942(a)
    tax has been previously assessed......     		 
    d Subtract line 6c from line 6b. Taxable amount
    —see instructions ...........     		 
    e Undistributed income for 2018. Subtract line
    4a from line 2a. Taxable amount—see
    instructions .............     		 
    f Undistributed income for 2019. Subtract
    lines 4d and 5 from line 1. This amount must
    be distributed in 2020 ..........     		0
    7 Amounts treated as distributions out of
    corpus to satisfy requirements imposed by
    section 170(b)(1)(F) or 4942(g)(3) (Election may
    be required - see instructions) .......     		 
    8 Excess distributions carryover from 2014 not
    applied on line 5 or line 7 (see instructions) ...     		 
    9Excess distributions carryover to 2020.
    Subtract lines 7 and 8 from line 6a ......     		42,509
    10 Analysis of line 9:
    a Excess from 2015....  
    b Excess from 2016.... 17,903
    c Excess from 2017.... 20,740
    d Excess from 2018.... 1,533
    e Excess from 2019.... 2,333
    Form 990-PF (2019)
    Form 990-PF (2019)
    Page 10
    Part XIV
    Private Operating Foundations (see instructions and Part VII-A, question 9)
    1a If the foundation has received a ruling or determination letter that it is a private operating
    foundation, and the ruling is effective for 2019, enter the date of the ruling....... bullet
     
    b Check box to indicate whether the organization is a private operating foundation described in section or
    2a Enter the lesser of the adjusted net
    income from Part I or the minimum
    investment return from Part X for each
    year listed ..........     		Tax year Prior 3 years (e) Total
    (a) 2019 (b) 2018 (c) 2017 (d) 2016
             
    b 85% of line 2a .........          
    c Qualifying distributions from Part XII,
    line 4 for each year listed .....     		         
    d Amounts included in line 2c not used directly
    for active conduct of exempt activities ..........     		         
    e Qualifying distributions made directly
    for active conduct of exempt activities.
    Subtract line 2d from line 2c ....     		         
    3 Complete 3a, b, or c for the
    alternative test relied upon:
    a “Assets" alternative test—enter:
    (1) Value of all assets ......          
    (2) Value of assets qualifying
    under section 4942(j)(3)(B)(i)    		          
    b “Endowment" alternative test— enter 2/3
    of minimum investment return shown in
    Part X, line 6 for each year listed...     		         
    c “Support" alternative test—enter:
    (1) Total support other than gross
    investment income (interest,
    dividends, rents, payments
    on securities loans (section
    512(a)(5)), or royalties) ....     		         
    (2) Support from general public
    and 5 or more exempt
    organizations as provided in
    section 4942(j)(3)(B)(iii)....     		         
    (3) Largest amount of support
    from an exempt organization    		          
    (4) Gross investment income          
    Part XV
    Supplementary Information (Complete this part only if the foundation had $5,000 or more in
    assets at any time during the year—see instructions.)
    1Information Regarding Foundation Managers:
    aList any managers of the foundation who have contributed more than 2% of the total contributions received by the foundation
    before the close of any tax year (but only if they have contributed more than $5,000). (See section 507(d)(2).)
    bList any managers of the foundation who own 10% or more of the stock of a corporation (or an equally large portion of the
    ownership of a partnership or other entity) of which the foundation has a 10% or greater interest.
    2Information Regarding Contribution, Grant, Gift, Loan, Scholarship, etc., Programs:
    Check here bullet
    aThe name, address, and telephone number or e-mail address of the person to whom applications should be addressed:
    SURRENA MEMORIAL FUND
    PO BOX 603
    SHERIDAN,WY82801
    (307) 752-6855
    bThe form in which applications should be submitted and information and materials they should include:
    WRITTEN APPLICATION
    cAny submission deadlines:
    NONE
    dAny restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other
    factors:
    CHARITABLE, RELIGIOUS, SCIENTIFIC, & EDUCATIONAL PURPOSES IN THE U.S.
    Form 990-PF (2019)
    Form 990-PF (2019)
    Page 11
    Part XV
    Supplementary Information (continued)
    3 Grants and Contributions Paid During the Year or Approved for Future Payment
    Recipient If recipient is an individual,
    show any relationship to
    any foundation manager
    or substantial contributor
    		 Foundation
    status of
    recipient     		Purpose of grant or
    contribution     		Amount
    Name and address (home or business)
    aPaid during the year
    BREAD OF LIFE
    PO BOX 909
    BUFFALO,WY82834     		NONE EXEMPT ORG. GENERAL OPERATIONS 7,500
    BUFFALO SENIOR CENTER
    PO BOX 941
    BUFFALO,WY82834     		NONE EXEMPT ORG. GENERAL OPERATIONS 7,500
    CHILDREN'S CENTER
    863 HIGHLAND AVE
    SHERIDAN,WY82801     		NONE EXEMPT ORG. GENERAL OPERATIONS 30,000
    CHILDREN'S CENTER - BUFFALO
    151 KLONDIKE
    BUFFALO,WY82834     		NONE EXEMPT ORG. GENERAL OPERATIONS 50,000
    CLEARMONT COMMUNITY LIBRARY
    PO BOX 26
    CLEARMONT,WY82835     		NONE EXEMPT ORG. GENERAL OPERATIONS 5,000
    GENESIS FOUNDATION
    444 CRESCENT DR
    SHERIDAN,WY82801     		NONE EXEMPT ORG. GENERAL OPERATIONS 25,000
    JOHNSON COUNTY LIBRARY
    FOUNDATION
    171 N ADAMS
    BUFFALO,WY82834     		NONE EXEMPT ORG. GENERAL OPERATIONS 5,000
    HABITAT FOR HUMANITY
    OF THE EASTERN BIGHORNS
    PO BOX 6196
    SHERIDAN,WY82801     		NONE EXEMPT ORG. GENERAL OPERATIONS 7,500
    JOHNSON COUNTY YMCA
    101 SOUTH KLONDIKE
    BUFFALO,WY82834     		NONE EXEMPT ORG. GENERAL OPERATIONS 20,000
    LUNCH TOGETHER SOUP KITCHEN
    102 S CONNER ST
    SHERIDAN,WY82801     		NONE EXEMPT ORG. GENERAL OPERATIONS 7,500
    METHODIST CHURCH
    OF BUFFALO WYOMING
    132 N ADAMS AVE
    BUFFALO,WY82834     		NONE EXEMPT ORG. GENERAL OPERATIONS 5,000
    METHODIST CHURCH
    OF SHERIDAN WYOMING
    215 W WORKS
    SHERIDAN,WY82801     		NONE EXEMPT ORG. GENERAL OPERATIONS 5,000
    MOUNTAIN PLAINS HERITAGE
    PO BOX 1034
    BUFFALO,WY82834     		NONE EXEMPT ORG. GENERAL OPERATIONS 2,500
    SENIOR CITIZENS COUNCIL
    211 SMITH STREET
    SHERIDAN,WY82801     		NONE EXEMPT ORG. GENERAL OPERATIONS 7,500
    SHERIDAN COLLEGE
    FOUNDATION
    3059 COFFEEN AVE
    SHERIDAN,WY82801     		NONE EXEMPT ORG. SCHOLARSHIPS 10,000
    SHERIDAN COUNTY LIBRARY
    FOUNDATION INC
    335 W ALGER
    SHERIDAN,WY82801     		NONE EXEMPT ORG. GENERAL OPERATIONS 5,000
    SHERIDAN COUNTY YMCA
    417 NORTH JEFFERSON
    SHERIDAN,WY82801     		NONE EXEMPT ORG. GENERAL OPERATIONS 20,000
    STORY BRANCH LIBRARY
    PO BOX 188
    STORY,WY82842     		NONE EXEMPT ORG. GENERAL OPERATIONS 5,000
    STORY COMMUNITY CHURCH
    PO BOX 415
    STORY,WY82842     		NONE EXEMPT ORG. GENERAL OPERATIONS 5,000
    THE FOOD GROUP
    51 COFFEEN AVE-SUITE 101
    SHERIDAN,WY82801     		NONE EXEMPT ORG. GENERAL OPERATIONS 5,000
    TONGUE RIVER BRANCH
    LIBRARY
    PO BOX 909
    RANCHESTER,WY82839     		NONE EXEMPT ORG. GENERAL OPERATIONS 5,000
    TONGUE RIVER CHILD'S
    PLACE
    PO BOX 232
    RANCHESTER,WY82839     		NONE EXEMPT ORG. GENERAL OPERATIONS 15,000
    VOLUNTEERS OF AMERICA OF
    WYOMING AND MONTANA
    1876 S SHERIDAN AVE
    SHERIDAN,WY82801     		NONE EXEMPT ORG. HOMELESS SHELTER 4,000
    COMPASS-CENTER FOR FAMILIES
    PO BOX 6022
    SHERIDAN,WY82801     		NONE EXEMPT ORG. CASA PROGRAM 5,000
    Total .................................bullet 3a 264,000
    bApproved for future payment
    Total .................................bullet 3b  
    Form 990-PF (2019)
    Form 990-PF (2019)
    Page 12
    Part XVI-A
    Analysis of Income-Producing Activities
    Enter gross amounts unless otherwise indicated. Unrelated business income Excluded by section 512, 513, or 514 (e)
    Related or exempt
    function income
    (See instructions.)
    1Program service revenue: (a)
    Business code     		(b)
    Amount     		(c)
    Exclusion code     		(d)
    Amount
    a
    b
    c
    d
    e
    f
    gFees and contracts from government agencies          
    2 Membership dues and assessments....          
    3 Interest on savings and temporary cash
    investments ...........     		    14 11,792  
    4 Dividends and interest from securities....     14 137,591  
    5 Net rental income or (loss) from real estate:
    aDebt-financed property......          
    bNot debt-financed property.....          
    6 Net rental income or (loss) from personal property          
    7 Other investment income.....          
    8 Gain or (loss) from sales of assets other than
    inventory ............     		    18 549,350  
    9 Net income or (loss) from special events:          
    10 Gross profit or (loss) from sales of inventory          
    11 Other revenue: a
    b
    c
    d
    e
    12 Subtotal. Add columns (b), (d), and (e)..   698,733  
    13Total. Add line 12, columns (b), (d), and (e)..................
    13
    698,733
    (See worksheet in line 13 instructions to verify calculations.)
    Part XVI-B
    Relationship of Activities to the Accomplishment of Exempt Purposes
    Line No.
    DownArrow     		Explain below how each activity for which income is reported in column (e) of Part XVI-A contributed importantly to
    the accomplishment of the foundation’s exempt purposes (other than by providing funds for such purposes). (See
    instructions.)
    Form 990-PF (2019)
    Form 990-PF (2019)
    Page 13
    Part XVII
    Information Regarding Transfers To and Transactions and Relationships With Noncharitable Exempt Organizations
    1
    Did the organization directly or indirectly engage in any of the following with any other organization described in section 501(c) (other than section 501(c)(3) organizations) or in section 527, relating to political organizations?
    Yes
    No
    a
    Transfers from the reporting foundation to a noncharitable exempt organization of:
    (1) Cash...................................
    1a(1)
     
    No
    (2) Other assets.................................
    1a(2)
     
    No
    b
    Other transactions:
    (1) Sales of assets to a noncharitable exempt organization....................
    1b(1)
     
    No
    (2) Purchases of assets from a noncharitable exempt organization..................
    1b(2)
     
    No
    (3) Rental of facilities, equipment, or other assets.......................
    1b(3)
     
    No
    (4) Reimbursement arrangements...........................
    1b(4)
     
    No
    (5) Loans or loan guarantees.............................
    1b(5)
     
    No
    (6) Performance of services or membership or fundraising solicitations................
    1b(6)
     
    No
    c
    Sharing of facilities, equipment, mailing lists, other assets, or paid employees..............
    1c
     
    No
    d
    If the answer to any of the above is "Yes," complete the following schedule. Column (b) should always show the fair market value
    of the goods, other assets, or services given by the reporting foundation. If the foundation received less than fair market value
    in any transaction or sharing arrangement, show in column (d) the value of the goods, other assets, or services received.

    (a) Line No. (b) Amount involved (c) Name of noncharitable exempt organization (d) Description of transfers, transactions, and sharing arrangements
    2a
    Is the foundation directly or indirectly affiliated with, or related to, one or more tax-exempt organizations
    described in section 501(c) (other than section 501(c)(3)) or in section 527? ...........
    b
    If "Yes," complete the following schedule.

    (a) Name of organization (b) Type of organization (c) Description of relationship
    Sign Here
    Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
    Bullet Bullet
    May the IRS discuss this return
    with the preparer shown below
    (see instr.)
    Signature of officer or trustee Date Title
    Paid Preparer Use Only Print/Type preparer's name Preparer's Signature Date PTIN
    Firm's name SmallBullet
    		 Firm's EIN SmallBullet
    Firm's address SmallBullet


    		 Phone no.
    Form 990-PF (2019)
    Additional Data


    Software ID:  
    Software Version:  


    Form 990PF - Special Condition Description:
    Special Condition Description

    TY 2017 AccountingFeesSchedule
    Name:
    HARRY & THELMA SURRENA MEMORIAL
    EIN:
    23-7435554
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    ACCOUNTING FEES 2,200 1,650   550

    TY 2017 InvestmentsCorpBondsSchedule
    Name:
    HARRY & THELMA SURRENA MEMORIAL
    EIN:
    23-7435554
    Name of Bond End of Year Book Value End of Year Fair Market Value
    ANTHEM INC    
    BLACKROCK INC 50,000 52,055
    EATON VANCE FLOATING RATE FUND 250,000 249,303
    EATON CORP    
    GENERAL ELECTRIC CAP 5.1% 100,000 101,292
    MORGAN STANLEY 2.8% 50,908 50,079
    OPPENHEIMER INTERNATIONAL BOND FUND 74,757 66,022
    TEMPLETON GLOBAL BOND FUND 135,431 120,981
    TENNESSEE VALLEY AUTHORITY 49,980 48,490
    VANGUARD HIGH YIELD CORPORATE FUND 73,980 78,510
    VANGUARD INTERMEDIATE-TERM INVEST 99,032 95,612
    VANGUARD SHORT-TERM INVESTMENT GRADE 98,700 96,248
    WELLS FARGO & CO 2.5% 50,711 48,925

    TY 2017 InvestmentsCorpStockSchedule
    Name:
    HARRY & THELMA SURRENA MEMORIAL
    EIN:
    23-7435554
    Name of Stock End of Year Book Value End of Year Fair Market Value
    ALPHABET INC CAP STK CL A 42,419 52,348
    AMERICAN EUROPACIFIC GROWTH FUND 118,447 140,103
    AMERICAN EXPRESS 46,859 75,381
    APACHE CORPORATION    
    APPLE COMPUTER INC 36,826 93,891
    BAKER HUGHES INC    
    BERKSHIRE HATHAWAY INC - CL B 19,600 51,115
    BOEING CO 17,816 106,458
    BRISTOL MYERS SQUIBB 30,822 42,484
    CELGENE    
    CHEVRON CORP 17,061 35,281
    CISCO SYSTEMS 25,679 58,286
    CITIGROUP    
    COMMUNICATION SERVICES SEL SPDR 69,031 64,318
    CONSUMER DISCRETIONARY SEL SPDR 45,340 45,208
    CONSUMER STAPLES SEL SECTOR SPDR 22,096 24,479
    COSTCO WHOLESALE CORPORATION    
    DFA COMMODITY STRATEGY PORTFOLIO 275,000 263,957
    DFA EMERGING MARKETS SMALL CAP 150,000 124,863
    DFA GLOBAL REAL ESTATE SECURITIES 187,908 186,883
    DFA US SMALL CAP PORTFOLIO 200,000 219,511
    DOWDUPONT INC 23,433 35,857
    EMERSON ELECTRIC CO 23,823 51,657
    ENERGY SELECT SECTOR SPDR 14,180 14,036
    EXELON CORPORATION 39,396 51,652
    EXXON MOBIL CORP 51,590 62,708
    FACEBOOK INC 46,122 52,671
    FEDEX CORP 29,140 45,170
    FIDELITY INTERNATIONAL INDEX FUND 153,865 132,994
    FINANCIAL SELECT SECTOR SPDR 69,171 68,223
    FORD MOTOR COMPANY    
    GENERAL ELECTRIC CO    
    GILEAD SCIENCES INC. 41,035 62,998
    GOLDMAN SACHS GROUP INC 58,887 58,596
    GOLDMAN SACHS INTERNATIONAL SMALL CA 150,000 145,145
    HARBOR INTERNATIONAL FUND    
    HEALTH CARE SELEC SECTOR SPDR 119,187 123,470
    INDUSTRICAL SELECT SECTOR SPDR 66,814 58,979
    J.P. MORGAN CHASE & CO 34,302 111,200
    LOWE'S COS INC 50,846 67,469
    MATERIALS SELECT SECTOR SPDR 19,464 17,203
    MCKESSON CORPORATION 62,465 58,013
    MICROCHIP TECHNOLOGY INC 27,128 27,233
    MICROSOFT CORPORATION 20,330 68,358
    MONDELEZ INTERNATIONAL INC 25,040 46,262
    NIKE INC 39,566 56,430
    OPPENHEIMER DEVELOPING MARKETS FD 150,799 150,077
    PEPSICO 14,359 52,481
    QUALCOMM INC 35,020 43,331
    ROCHE HOLDINGS AG SPN ADR EACH REP    
    SCHLUMBERGER LIMITED 32,936 24,885
    SKYWORKS SOLUTIONS INC 13,833 47,718
    SOUTHERN CO    
    STARBUCKS CORP 54,921 53,201
    TECHNOLOGY SELECT SECTOR SPDR 94,423 91,823
    UNION PACIFIC 28,686 52,785
    UNITEDHEALTH GROUP INC 10,257 47,566
    VANGUARD 500 INDEX FUND 50,000 72,113
    VANGUARD MID-CAP INDEX FUND 150,000 175,008
    VANUGARD EMERGING MARKETS STOCK INDE 150,000 134,767
    WAL-MART STORES INC 37,005 53,550
    WALT DISNEY 43,195 104,840
    WELLS FARGO & CO    

    TY 2017 InvestmentsGovtObligationsSch
    Name:
    HARRY & THELMA SURRENA MEMORIAL
    EIN:
    23-7435554
    US Government Securities - End of Year Book Value:

    400,000
    US Government Securities - End of Year Fair Market Value:

    382,329
    State & Local Government Securities - End of Year Book Value:


     
    State & Local Government Securities - End of Year Fair Market Value:


     


    TY 2017 OtherAssetsSchedule
    Name:
    HARRY & THELMA SURRENA MEMORIAL
    EIN:
    23-7435554
    Description Beginning of Year - Book Value End of Year - Book Value End of Year - Fair Market Value
    MINERAL RIGHTS 22,982 22,982 22,982


    TY 2017 OtherLiabilitiesSchedule
    Name:
    HARRY & THELMA SURRENA MEMORIAL
    EIN:
    23-7435554
    Description Beginning of Year - Book Value End of Year - Book Value
    FEDERAL TAXES PAYABLE 6,180 4,998


    TY 2017 OtherProfessionalFeesSchedule
    Name:
    HARRY & THELMA SURRENA MEMORIAL
    EIN:
    23-7435554
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    INVESTMENT MANAGEMENT FEES 32,988 32,988    


    TY 2017 TaxesSchedule
    Name:
    HARRY & THELMA SURRENA MEMORIAL
    EIN:
    23-7435554
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    EXCISE TAXES 12,848      
    FOREIGN TAXES 689 689    
    PAYROLL TAXES 2,982 1,491   1,491