Form990-PF
Click to see attachment

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
2020
Open to Public Inspection
For calendar year 2020, or tax year beginning 01-01-2020 , and ending 12-31-2020
Name of foundation
SAMARITAN FOUNDATION
 
Number and street (or P.O. box number if mail is not delivered to street address)PO BOX 97
  Room/suite
City or town, state or province, country, and ZIP or foreign postal code
HAVILAND, OH458510097
A Employer identification number

34-1957355
B Telephone number (see instructions)

(419) 622-4611
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$13,102,105J 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) 2,402,777
2 Check bullet.............
3 Interest on savings and temporary cash investments 12,775 12,775 12,775
4 Dividends and interest from securities... 48,387 48,387 48,387
5a Gross rents............      
b Net rental income or (loss)  
6a Net gain or (loss) from sale of assets not on line 10  
b Gross sales price for all assets on line 6a  
7 Capital gain net income (from Part IV, line 2)...  
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........ 2,463,939 61,162 61,162
Operating and Administrative Expenses 13 Compensation of officers, directors, trustees, etc.        
14 Other employee salaries and wages......        
15 Pension plans, employee benefits.......        
16a Legal fees (attach schedule)......... Click to see attachment 200 200    
b Accounting fees (attach schedule)....... Click to see attachment 1,545 773 773 773
c Other professional fees (attach schedule).... Click to see attachment 26 13 13 13
17 Interest...............        
18 Taxes (attach schedule) (see instructions)... Click to see attachment 834      
19 Depreciation (attach schedule) and depletion...      
20 Occupancy..............        
21 Travel, conferences, and meetings.......        
22 Printing and publications..........        
23 Other expenses (attach schedule)....... Click to see attachment 388 194 194 194
24 Total operating and administrative expenses.
Add lines 13 through 23.......... 2,993 1,180 980 980
25 Contributions, gifts, grants paid....... 2,041,370 2,041,370
26 Total expenses and disbursements. Add lines 24 and 25 2,044,363 1,180 980 2,042,350
27 Subtract line 26 from line 12:
a Excess of revenue over expenses and disbursements 419,576
b Net investment income (if negative, enter -0-) 59,982
c Adjusted net income (if negative, enter -0-)... 60,182
For Paperwork Reduction Act Notice, see instructions.
Cat. No. 11289X Form 990-PF (2020)
Form 990-PF (2020)
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......... 2,695,640 2,935,055 2,623,249
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)      
b Investments—corporate stock (attach schedule)....... 2,602,843 Click to see attachment2,782,062 10,478,190
c Investments—corporate bonds (attach schedule).......      
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 attachment666 Click to see attachment666
16 Total assets (to be completed by all filers—see the
instructions. Also, see page 1, item I) 5,298,483 5,717,783 13,102,105
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 attachment276  
23 Total liabilities (add lines 17 through 22)......... 276 0
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........... 5,298,207 5,717,783
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........    
27 Paid-in or capital surplus, or land, bldg., and equipment fund    
28 Retained earnings, accumulated income, endowment, or other funds    
29 Total net assets or fund balances (see instructions)..... 5,298,207 5,717,783
30 Total liabilities and net assets/fund balances (see instructions). 5,298,483 5,717,783
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
5,298,207
2
Enter amount from Part I, line 27a .....................
2
419,576
3
Other increases not included in line 2 (itemize) bullet
3
 
4
Add lines 1, 2, and 3 ..........................
4
5,717,783
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
5,717,783
Form 990-PF (2020)
Form 990-PF (2020)
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.)
1a
b
c
d
e
(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
b
c
d
e
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
b
c
d
e
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  
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  
Part V
Qualification Under Section 4940(e) for Reduced Tax on Net Investment Income
SECTION 4940(e) REPEALED ON DECEMBER 20, 2019 - DO NOT COMPLETE
1 Reserved
(a)
Reserved 		(b)
Reserved 		(c)
Reserved 		(d)
Reserved
2
Reserved...........................
2
3
Reserved...........................
3
4
Reserved...........................
4
5
Reserved...........................
5
6
Reserved...........................
6
7
Reserved...........................
7
8
Reserved,..........................
8
Form 990-PF (2020)
Form 990-PF (2020)
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 for line 1a
Date of ruling or determination letter:   (attach copy of letter if necessary–see instructions)
b Reserved................................ 1 834
c All other domestic foundations enter 1.39% 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........................... 3 834
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- ..... 5 834
6 Credits/Payments:
a 2020 estimated tax payments and 2019 overpayment credited to 2020 6a 1,500
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 1,500
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  
10 Overpayment. If line 7 is more than the total of lines 5 and 8, enter the amount overpaid...Bullet 10 666
11 Enter the amount of line 10 to be: Credited to 2021 estimated taxBullet666 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 the instructions
for the 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)
    bulletOH
    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 2020 or the taxable year beginning in 2020? 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 (2020)
    Form 990-PF (2020)
    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 ofbulletTODD STOLLER Telephone no.bullet (419) 622-4611

    Located atbulletPO BOX 97HAVILANDOH ZIP+4bullet45851
    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 2020, 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
     
     
    ........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 2020?.............
    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 2020, did the foundation have any undistributed income (lines 6d
    and 6e, Part XIII) for tax year(s) beginning before 2020?.............
    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 2020 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 2020.)..................
    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 2020?
    4b
     
    No
    Form 990-PF (2020)
    Form 990-PF (2020)
    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
    CRAIG STOLLER PRESIDENT
    0.50     		0 0 0
    12783 RD 82 APT 16
    PAULDING,OH45879
    TODD STOLLER VICE PRESIDE
    0.50     		0 0 0
    4824 ROAD 71
    PAYNE,OH45880
    HOLLY BLUME SEC - TREAS
    0.50     		0 0 0
    14027 ROAD 12
    SCOTT,OH45886
    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 (2020)
    Form 990-PF (2020)
    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 (2020)
    Form 990-PF (2020)
    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
    9,083,500
    b
    Average of monthly cash balances.......................
    1b
    1,895,786
    c
    Fair market value of all other assets (see instructions)................
    1c
    0
    d
    Total (add lines 1a, b, and c).........................
    1d
    10,979,286
    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
    10,979,286
    4
    Cash deemed held for charitable activities. Enter 1 1/2% of line 3 (for greater amount, see
    instructions) .............................
    4
    164,689
    5
    Net value of noncharitable-use assets. Subtract line 4 from line 3. Enter here and on Part V, line 4
    5
    10,814,597
    6
    Minimum investment return. Enter 5% of line 5..................
    6
    540,730
    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
    540,730
    2a
    Tax on investment income for 2020 from Part VI, line 5......
    2a
    834
    b
    Income tax for 2020. (This does not include the tax from Part VI.)...
    2b
     
    c
    Add lines 2a and 2b............................
    2c
    834
    3
    Distributable amount before adjustments. Subtract line 2c from line 1............
    3
    539,896
    4
    Recoveries of amounts treated as qualifying distributions................
    4
     
    5
    Add lines 3 and 4............................
    5
    539,896
    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
    539,896
    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
    2,042,350
    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
    2,042,350
    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
    2,042,350
    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 (2020)
    Form 990-PF (2020)
    Page 9
    Part XIII
    Undistributed Income (see instructions)
    (a)
    Corpus     		(b)
    Years prior to 2019     		(c)
    2019     		(d)
    2020
    1 Distributable amount for 2020 from Part XI, line 7 539,896
    2 Undistributed income, if any, as of the end of 2020:
    a Enter amount for 2019 only.......  
    b Total for prior years:20, 20, 20  
    3 Excess distributions carryover, if any, to 2020:
    a From 2015...... 519,198
    b From 2016...... 1,190,100
    c From 2017...... 1,953,809
    d From 2018...... 1,117,667
    e From 2019...... 921,199
    fTotal of lines 3a through e........ 5,701,973
    4Qualifying distributions for 2020 from Part
    XII, line 4: bullet$ 2,042,350
    a Applied to 2019, 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 2020 distributable amount..... 539,896
    e Remaining amount distributed out of corpus 1,502,454
    5 Excess distributions carryover applied to 2020.    
    (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 7,204,427
    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 2019. Subtract line
    4a from line 2a. Taxable amount—see
    instructions .............     		 
    f Undistributed income for 2020. Subtract
    lines 4d and 5 from line 1. This amount must
    be distributed in 2021 ..........     		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 2015 not
    applied on line 5 or line 7 (see instructions) ...     		519,198
    9Excess distributions carryover to 2021.
    Subtract lines 7 and 8 from line 6a ......     		6,685,229
    10 Analysis of line 9:
    a Excess from 2016.... 1,190,100
    b Excess from 2017.... 1,953,809
    c Excess from 2018.... 1,117,667
    d Excess from 2019.... 921,199
    e Excess from 2020.... 1,502,454
    Form 990-PF (2020)
    Form 990-PF (2020)
    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 2020, 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) 2020 (b) 2019 (c) 2018 (d) 2017
             
    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:
    TODD CRAIG STOLLER
    PO BOX 97
    HAVILAND,OH45851
    (419) 622-4611
    bThe form in which applications should be submitted and information and materials they should include:
    SEE ATTACHED APPLICATION FORM
    cAny submission deadlines:
    NONE
    dAny restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other
    factors:
    SEE ATTACHED
    Form 990-PF (2020)
    Form 990-PF (2020)
    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
    RAY KUPFERSMITH JR
    824 W WAYNE ST
    PAULDING,OH45879     		NONE PRIVATE MEDICAL EXPENSES 49,700
    ALEJANDRO ZUMARAN GARCIA
    8743 SR 114
    HAVILAND,OH45851     		NONE PRIVATE NEEDY INDIVIDUAL 600
    ANDRIEL THIAGO CARDOSO
    8743 SR 114
    HAVILAND,OH45851     		NONE PRIVATE NEEDY INDIVIDUAL 82
    BEN MEGHAN MOORE
    4295 S 600 W
    HUNTINGTON,IN46750     		NONE PRIVATE MEDICAL 5,000
    BREAKLOOSE
    PO BOX 82530
    ROCHESTER,MI48308     		NONE PRIVATE HUMAITARIAN 5,000
    AMERICAN HEART ASSOCIATION
    PO BOX 78851
    PHOENIX,AZ850628851     		NONE PUBLIC HUMANITARIAN 500
    AMERICAN RED CROSS
    1111 RESEARCH DR
    TOLEDO,OH43614     		NONE PUBLIC HUMANITARIAN 5,000
    APOSTOLIC CHRISTIAN ALMS FUND - LAT
    DUANE SINN 14725 RD 72
    HAVILAND,OH45851     		NONE PUBLIC LOCAL SEWING FUND 7,500
    APOSTOLIC CHRISTIAN FELLOWSHIP HALL
    14725 RD 72
    HAVILAND,OH45851     		NONE PUBLIC HUMANITARIAN 25,000
    APOSTOLIC CHRISTIAN ALMS FUND
    -LATTY
    14725 RD 72
    HAVILAND,OH45851     		NONE PUBLIC HUMANITARIAN 10,000
    APOSTOLIC CHRISTIAN ALMS FUND
    -LATTY
    4186 RD 71
    PAYNE,OH45880     		NONE PUBLIC HUMANITARIAN 100,000
    APOSTOLIC CHRISTIAN HARVEST CALL
    14725 RD 72
    HAVILAND,OH45851     		NONE PUBLIC HUMANITARIAN 350,000
    APOSTOLIC CHRISTIAN HARVEST CALL
    14725 RD 72
    HAVILAND,OH45851     		NONE PUBLIC HUMANITARIAN 5,000
    ASHES TO GLORY FOUNDATION
    PO BOX 532176
    LIVONIA,MI48153     		NONE PUBLIC HUMANITARIAN 20,000
    BROKEN CHAINS MINISTRY
    PO BOX 502
    AKRON,OH44309     		NONE PUBLIC HUMANITARAN 5,000
    CARE
    NORMAN SENSENIG 5192
    OLIVESBURG GREENWICH RD
    GREENWICH,OH44837     		NONE PUBLIC HUMANITARIAN 500
    CHRISTIAN AID MINISTRIES
    PO BOX 360
    BERLIN,OH446100360     		NONE PUBLIC HUMANITARIAN 143,000
    CHRISTMAS FOR KIDS
    401 E JACKSON ST
    PAULDING,OH45879     		NONE PUBLIC HUMANITARIAN 2,500
    COMMUNITY HARVEST
    PO BOX 10967
    FT WAYNE,IN46855     		NONE PUBLIC HUMANITARIAN 6,000
    FRIENDS OF CHIMBOTE
    PO BOX 717
    WEST FARGO,ND58078     		NONE PUBLIC HUMANITARIAN 3,500
    GALILEAN HOME MINISTRIES
    PO BOX 880
    LIBERTY,KY425390880     		NONE PUBLIC GENERAL PURPOSES / HUMANITARIAN AID 125,000
    HAVILAND DRAINAGE
    PO BOX 97
    HAVILAND,OH45851     		NONE PUBLIC HUMANITARIAN 26,110
    JUST NEIGHBORS INTERFAITH HOMELES
    2925 E STATE
    FORT WAYNE,IN46805     		NONE PUBLIC HUMANITARIAN 15,000
    LIFESONG FOR ORPHANS
    PO BOX 40
    GRIDLEY,IL61744     		NONE PUBLIC HUMANITARIAN / CHILD CARE 250,000
    LOVING SHEPHERD MINISTRIES
    PO BOX 375
    BLUFFTON,IN46714     		NONE PUBLIC HUMANITARIAN 150,000
    MIDWEST FOOD BANK
    5601 DIVISION DR
    FT MYERS,FL33905     		NONE PUBLIC HUMANITARIAN 50,000
    MINERVA UNITED METHODIST CHURCH
    204 N MAIN ST
    MINERVA,OH44657     		NONE PUBLIC HUMANITARIAN 3,000
    NEW JERUSALEM CHURCH
    600 DIVISION STREET
    DEFIANCE,OH43512     		NONE PUBLIC HUMANITARIAN 2,500
    PAULDING CO AREA FOUNDATION
    101 E PERRY ST
    PAULDING,OH45879     		NONE PUBLIC GENERAL PURPOSES 14,500
    SAFE HAVEN BABY BOXES
    PO BOX 185
    WOODBURN,IN46797     		NONE PUBLIC HUMANITARIAN 30,000
    SHRINERS HOSPITALS FOR CHILDREN
    2900 ROCKY POINT DR
    TAMPA,FL33607     		NONE PUBLIC HUMANITARIAN 100,000
    ST JUDE CHILDRENS RESEARCH HOSPITAL
    501 ST JUDE PLACE
    MEMPHIS,TN38105     		NONE PUBLIC HUMANITARIAN 100,000
    THE RESCUE MISSION
    LOCKBOX A1 PO BOX 2589
    FORT WAYNE,IN468012589     		NONE PUBLIC HUMANITARIAN 100,000
    UNITED WAY OF PAULDING COUNTY
    101 E PERRY ST
    PAULDING,OH45879     		NONE PUBLIC HUMANITARIAN 10,000
    WEST OHIO FOOD BANK
    PO BOX 1566
    LIMA,OH458021566     		NONE PUBLIC HUMANITARIAN 20,000
    WREATHS ACROSS AMERICA
    PO BOX 249
    COLUMBIA FALLS,ME04623     		NONE PUBLIC HUMANITARIAN 300
    ANDY HERNANDEZ
    8743 STATE ROUTE 114
    HAVILAND,OH45851     		NONE PRIVATE CHARITY 200
    ALSPACH-GERARHART FUNERAL HOME
    722 S WASHINGTON ST
    VAN WERT,OH45891     		NONE PUBLIC FUNERAL EXP. 3,000
    ASHLYN ROSE LEE EDUCATION FUND
    SHANE LEE 125 N WATER ST
    PAULDING,OH45879     		NONE PUBLIC CHARITY 5,000
    CHIEF SUPERMARKETS
    1107 S SHANNON ST
    VAN WERT,OH45891     		NONE PUBLIC CHARITY 25,000
    CHRISTIAN CHILD CARE COALITION
    4102 N W DONDEE LN
    TOPEKA,KS66618     		NONE PUBLIC CHARITY 3,000
    APOSTLIC CHRISTIAN COUNTRY INN
    12651 COUNTY RD 82
    PAULDING,OH45879     		NONE PUBLIC CHARITY 2,000
    COVENANT HOUSE
    PO BOX 96393 WASHINGTON
    WASHINGTON DC,DC200777114     		NONE PUBLIC CHARITY 20,000
    CINDY ULLINSKEY
    210 N CHERRY ST
    CONVOY,OH45832     		NONE PRIVATE FUNERAL EXPENSES 3,500
    CRAIG AND JAMIE BARD
    322 W JEFFERSON ST
    MONTPELLIER,OH43543     		NONE PRIVATE CHARITY 2,500
    DAN VOGEL
    9237 RD 98
    PAULDING,OH45879     		NONE PRIVATE MEDICAL EXPENSES 5,000
    DAVID MARQUEZ TORRES
    2866 RD 79
    HAVILAND,OH45851     		NONE PRIVATE CHARITY 600
    EDGAR ADRIAN OROZCO FRANCO
    8743 ST ROUTE 114
    HAVILAND,OH45851     		NONE PRIVATE MEDICAL EXPENSES 1,000
    EDUARDO GONZALEZ HERRERA
    106 HARRISON ST
    HAVILAND,OH45851     		NONE PRIVATE CHARITY 600
    EMIGDIO PEREX POLO
    5743 ST ROUTE 114
    HAVILAND,OH45851     		NONE PRIVATE MEDICAL EXPENSE 1,000
    ESTHER FLORES
    9511 BREININGER RD
    MARK CENTER,OH43536     		NONE PRIVATE MEDICAL EXP. 1,000
    FORT WAYNE AREA HOME SCHOOLS
    9904 S COUNTRY KNOLL
    NEW HAVEN,IN46774     		NONE PUBLIC CHARITY 250
    FOUNDATION OF COMMUNITY MEMORIAL HO
    208 N COLUMBUS ST
    HICKSVILLE,OH43526     		NONE PUBLIC CHARITY 500
    GATEWAY WOODS
    14505 KLOPFENSTEIN RD
    LEO,IN46765     		NONE PUBLIC CHARITY 5,000
    GERARDO BALDERAS FUENTES
    106 HARRISON ST
    HAVILAND,OH45851     		NONE PRIVATE CHARITY 600
    GROVER HILL LIONS CLUB
    104 S MAIN ST
    GROVER HILL,OH45849     		NONE PRIVATE PLAYGROUND EQUIPMENT 2,000
    HEARTEN HOUSE
    DCIC PO BOX 807
    AUBURN,IN46706     		NONE PUBLIC CHARITY 11,500
    INTERNATIONAL FELLOWSHIP OF ST JOHN
    PO BOX 954
    BLAIRSVILLE,GA30514     		NONE PUBLIC CHARITY 2,000
    IRVIN NAVA CASTILLO
    119 W PERRY ST
    PAULDING,OH45879     		NONE PRIVATE CHARITY 600
    JOE AND ANNA MAE ROME
    2117 TARA DRIVE
    GARDEN CITY,KS67846     		NONE PRIVATE CHARITY 1,000
    JOHN DUER
    835 SKINNER ST APT 46
    DELPHOS,OH45833     		NONE PRIVATE FUNERAL EXPENSES 2,500
    JONATHAN ALCANTRA
    106 HARRISON ST
    HAVILAND,OH45851     		NONE PRIVATE CHARITY 600
    KEY BETTER DAYS SOCIETY
    215 GARFIELD ST
    MIDDLETOWN,OH45044     		NONE PUBLIC CHARITY 500
    LIFEWISE ACADEMY WAYNE TRACE
    PO BOX 612
    PAYNE,OH45880     		NONE PUBLIC CHARITY 10,000
    LUIS HERNANDEZ SUAREZ
    8743 ST ROUTE 114
    HAVILAND,OH45851     		NONE PRIVATE MEDICAL 1,000
    MARCELINO CRUZ SOTO
    119 W PERRY ST
    PAULDING,OH45879     		NONE PRIVATE CHARITY 600
    MARCO COYOL PEREZ
    106 HARRISON ST
    HAVILAND,OH45851     		NONE PRIVATE CHARITY 600
    MARIA ANTONIO USCANGA
    2211/2 S DEWITT ST
    PAULDING,OH45879     		NONE PRIVATE CHARITY 763
    MAXIMILIANO HERNANDEZ SANTOS
    8743 SR 114
    HAVILAND,OH45851     		NONE PRIVATE FUNERAL EXP 1,000
    MELESIO MARTINEZ HERNANDEZ
    12658 DENNIS ST
    PAULDING,OH45879     		NONE PRIVATE MEDICAL 250
    NORMAN BAIR
    105 CHICAGO ST
    PAULDING,OH43506     		NONE PRIVATE CHARITY 1,500
    OSCAR RODRIGUEZ MARTINEZ
    2866 RD 79
    HAVILAND,OH45851     		NONE PRIVATE CHARITY 600
    OSU EXTENSION SERVICE AT PAULDING
    503 FAIRGROUND DR
    PAULDING,OH45879     		NONE PUBLIC CHARITY 2,000
    OUTA-SIGHT STORAGE
    12495 BUCKEYE DR
    PAULDING,OH45879     		NONE PUBLIC CHARITY 390
    PAULDING EAGLES LADY AUXILIARY
    220 NORTH DIX ST
    PAULDING,OH45879     		NONE PUBLIC CHARITY 1,000
    RAFAEL VEGA DAVILA
    2866 RD 79
    HAVILAND,OH45851     		NONE PRIVATE CHARITY 600
    RAUL CALDERON VALDEZ
    8743 ST ROUTE 114
    HAVILAND,OH45851     		NONE PRIVATE CHARITY 500
    SAUL SOTO POSADA
    2866 RD 79
    HAVILAND,OH45851     		NONE PRIVATE CHARITY 763
    SCHAFFER FUNERAL HOME
    529 JEFFERSON AVE
    DEFIANCE,OH43512     		NONE PUBLIC FUNERAL EXPENSES 4,200
    SERGIO CUEVAS RAMOS
    2211/2 S DEWITT ST
    PAULDING,OH45879     		NONE PRIVATE CHARITY 762
    ST JOSEPH MISSIONS
    2200 LAKE AVENUE
    FORT WAYNE,IN46805     		NONE PUBLIC WOMEN SHELTER 5,000
    STEVE CROSBY CO BALL FAMILY
    1030 OSAGE ST
    FORT WAYNE,IN46808     		NONE PUBLIC FUNERAL EXPENSES 1,500
    STEVE CROSBY CO KRAMER FAMILY
    1030 OSAGE ST
    FORT WAYNE,IN46808     		NONE PUBLIC FUNERAL EXPENSES 1,000
    TIM MABIS
    121 ARTURUS ST
    PAYNE,OH45880     		NONE PRIVATE CHARITY 1,000
    TO BENEFIT TAMMY SAUL 1322
    905 N WILLIAMS ST
    PAULDING,OH45879     		NONE PUBLIC MEDICAL 5,000
    TOM AND LEAN MATHEWS
    RD 87
    PAULDING,OH45879     		NONE PRIVATE FUNERAL EXPENSES 3,500
    VICTOR RODRIGUEZ CHAVEZ
    106 HARRISON ST
    HAVILAND,OH45851     		NONE PRIVATE CHARITY 600
    VICTOR CARRASCO HERNANDEZ
    8743 STATE ROUTE 114
    HAVILAND,OH45851     		NONE PRIVATE MEDICAL 500
    YURIDIA PETRIZ CELAYA
    8743 STATE ROUTE 114
    HAVILAND,OH45851     		NONE PRIVATE MEDICAL 1,000
    APOSTOLIC CHRISTIAN ALMS FUND - LAT
    DUANE SINN 14725 RD 72
    HAVILAND,OH45852     		NONE PUBLIC CHURCH UPKEEP 50,000
    APOSTOLIC CHRISTAIN ALMS FUND LATTY
    DUANE SINN 14725 RD 72
    HAVILAND,OH45853     		NONE PUBLIC LIFE POINTS 100,000
    APOSTOLIC CHRISTAIN ALMS FUND LATTY
    HOSPITA LUMIERE POBOX 227
    ERUEKA,IL61530     		NONE PUBLIC HOSPITAL LUMIERE 5,000
    Total .................................bullet 3a 2,041,370
    bApproved for future payment
    Total .................................bullet 3b  
    Form 990-PF (2020)
    Form 990-PF (2020)
    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 12,775  
    4 Dividends and interest from securities....     14 48,387  
    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 ............     		         
    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)..   61,162  
    13Total. Add line 12, columns (b), (d), and (e)..................
    13
    61,162
    (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 (2020)
    Form 990-PF (2020)
    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 instructions.
    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 (2020)
    Additional Data


    Software ID:  
    Software Version:  


    Form 990PF - Special Condition Description:
    Special Condition Description
    Schedule B
    (Form 990, 990-EZ,
    or 990-PF)
    Department of the Treasury
    Internal Revenue Service
    Schedule of Contributors

    Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
    Arrow Bullet Go to www.irs.gov/Form990 for the latest information.
    OMB No. 1545-0047
    2020
    Name of the organization
    SAMARITAN FOUNDATION
     
    Employer identification number

    34-1957355
    Organization type (check one):
    Filers of:
    Section:
    Form 990 or 990-EZ






    Form 990-PF




    Check if your organization is covered by the General Rule or a Special Rule.  
    Note: Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.
    General Rule
    Special Rules
    ......... Arrow Bullet $  
    Caution: An organization that isn't covered by the General Rule and/or the Special Rules doesn't file Schedule B (Form 990,
    990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2, of its Form 990; or check the box on line H of its Form 990-EZ
    or on its Form 990PF, Part I, line 2, to certify that it doesn't meet the filing requirements of Schedule B (Form 990,
    990-EZ, or 990-PF).
    For Paperwork Reduction Act Notice, see the Instructions
    for Form 990, 990-EZ, or 990-PF.
    Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2020)
    Schedule B (Form 990, 990-EZ, or 990-PF) (2020) Page 2
    Name of organization
    SAMARITAN FOUNDATION
          		Employer identification number
    34-1957355
    Part I
    Contributors
    Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
    1
    MODERN PLASTIC RECOVERY INC
     
    PO BOX 38
     
    HAVILAND, OH45851

    		$ 300,000


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
    7
    RYAN KORI STOLLER
    3497 ROAD 49
     
    HAVILAND, OH45851

    		$ 15,000


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
    2
    HAVILAND DRAINAGE PRODUCTS CO
     
    PO BOX 97
     
    HAVILAND, OH45851

    		$ 252,693


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
    8
    GREEN TOP ACRES LLC
     
    8789 STATE ROUTE 114
     
    HAVILAND, OH45851

    		$ 7,984


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
    3
    HAVILAND PLASTIC PRODUCTS CO
     
    PO BOX 38
     
    HAVILAND, OH45851

    		$ 1,500,000


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
    4
    DRAINAGE PRODUCTS INC
    PO BOX 61
     
    HAVILAND, OH45851

    		$ 263,000


    (Complete Part II for noncash contributions.)
    Schedule B (Form 990, 990-EZ, or 990-PF) (2020)
    Name of organization
    SAMARITAN FOUNDATION
          		Employer identification number
    34-1957355
    Part I
    Contributors
    Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
    5
    HAVILAND CULVERT COMPANY INC
     
    PO BOX 97
     
    HAVILAND, OH45851

    		$ 11,600


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
    6
    HAVILAND ENERGY LLC
     
    100 WEST MAIN STREET
     
    HAVILAND, OH45851

    		$ 52,500


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
     
     
     
     

    		$  


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
     
     
     
     

    		$  


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
     
     
     
     

    		$  


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
     
     
     
     

    		$  


    (Complete Part II for noncash contributions.)
    Schedule B (Form 990, 990-EZ, or 990-PF) (2020)
    Schedule B (Form 990, 990-EZ, or 990-PF) (2020)
    Page 3
    Name of organization
    SAMARITAN FOUNDATION
          		Employer identification number

    34-1957355
    Part II
    Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
    (a)
    No. from Part I    		 (b)
    Description of noncash property given    		 (c)
    FMV (or estimate)
    (See instructions)     		(d)
    Date received
     
    		$    
    (a)
    No. from Part I    		 (b)
    Description of noncash property given    		 (c)
    FMV (or estimate)
    (See instructions)     		(d)
    Date received
     
    		$    
    (a)
    No. from Part I    		 (b)
    Description of noncash property given    		 (c)
    FMV (or estimate)
    (See instructions)     		(d)
    Date received
     
    		$    
    (a)
    No. from Part I    		 (b)
    Description of noncash property given    		 (c)
    FMV (or estimate)
    (See instructions)     		(d)
    Date received
     
    		$    
    (a)
    No. from Part I    		 (b)
    Description of noncash property given    		 (c)
    FMV (or estimate)
    (See instructions)     		(d)
    Date received
     
    		$    
    (a)
    No. from Part I    		 (b)
    Description of noncash property given    		 (c)
    FMV (or estimate)
    (See instructions)     		(d)
    Date received
     
    		$    
    Schedule B (Form 990, 990-EZ, or 990-PF) (2020)
    Schedule B (Form 990, 990-EZ, or 990-PF) (2020)
    Page 4
    Name of organization
    SAMARITAN FOUNDATION
          		Employer identification number

    34-1957355
    Part III
    Exclusively religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10) that total more than $1,000 for the year from any one contributor. Complete columns (a) through (e) and the following line entry. For organizations completing Part III, enter the total of exclusively religious, charitable, etc., contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet$  
    Use duplicate copies of Part III if additional space is needed.
    (a)
    No. from Part I    		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
     
    (e) Transfer of gift
    Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
     
     
         
     
    (a)
    No. from Part I    		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
     
    (e) Transfer of gift
    Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
     
     
         
     
    (a)
    No. from Part I    		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
     
    (e) Transfer of gift
    Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
     
     
         
     
    (a)
    No. from Part I    		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
     
    (e) Transfer of gift
    Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
     
     
         
     
    Schedule B (Form 990, 990-EZ, or 990-PF) (2020)
    Additional Data


    Software ID:  
    Software Version:  

    TY 2020 AccountingFeesSchedule
    Name:
    SAMARITAN FOUNDATION
    EIN:
    34-1957355
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    ACCOUNTING FEES 1,545 773 773 773

    TY 2020 InvestmentsCorpStockSchedule
    Name:
    SAMARITAN FOUNDATION
    EIN:
    34-1957355
    Name of Stock End of Year Book Value End of Year Fair Market Value
    BERKSHIRE HATHAWAY 1,737,316 5,959,059
    WAL-MART 237,001 735,165
    AMERICAN EXPRESS 81,820 241,820
    GENERAL ELECTRIC 153,810 54,000
    SHERWIN WILLIAMS 428,970 3,160,113
    US BANCORP 141,115 326,130
    WABTEC CORP 2,030 1,903

    TY 2020 LegalFeesSchedule
    Name:
    SAMARITAN FOUNDATION
    EIN:
    34-1957355
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    INDIRECT LEGAL FEES 200 200    


    TY 2020 OtherAssetsSchedule
    Name:
    SAMARITAN FOUNDATION
    EIN:
    34-1957355
    Description Beginning of Year - Book Value End of Year - Book Value End of Year - Fair Market Value
    EXCISE TAX OVERPAYMENT   666 666


    TY 2020 OtherExpensesSchedule
    Name:
    SAMARITAN FOUNDATION
    EIN:
    34-1957355
    Description Revenue and Expenses per Books Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    EXPENSES        
    STATE FILING FEES 388 194 194 194


    TY 2020 OtherLiabilitiesSchedule
    Name:
    SAMARITAN FOUNDATION
    EIN:
    34-1957355
    Description Beginning of Year - Book Value End of Year - Book Value
    FEDERAL TAX 276  


    TY 2020 OtherProfessionalFeesSchedule
    Name:
    SAMARITAN FOUNDATION
    EIN:
    34-1957355
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    INDIRECT OTHER PROFESSIONAL FEES 26 13 13 13


    TY 2020 TaxesSchedule
    Name:
    SAMARITAN FOUNDATION
    EIN:
    34-1957355
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    EXCISE TAX 834