-
TIN:
Form
990-PF
Department of the Treasury
Internal Revenue Service
Return of Private Foundation
or Section 4947(a)(1) Trust Treated as Private Foundation
Do not enter social security numbers on this form as it may be made public.
Go to
www.irs.gov/Form990PF
for instructions and the latest information.
OMB No. 1545-0047
20
21
Open to Public Inspection
For calendar year 2021, or tax year beginning
01-01-2021
, and ending
12-31-2021
Name of foundation
BLUESTONE GIVING FOUNDATION
% Sarah Sundberg
Number and street (or P.O. box number if mail is not delivered to street address)
270 MAIN ST N STE 300
Room/suite
City or town, state or province, country, and ZIP or foreign postal code
STILLWATER
,
MN
550826788
A Employer identification number
46-5218477
B
Telephone number (see instructions)
C
If exemption application is pending, check here
G
Check all that apply:
Initial return
Initial return of a former public charity
Final return
Amended return
Address change
Name change
D 1.
Foreign organizations, check here.............
2
. Foreign organizations meeting the 85%
test, check here and attach computation ...
E
If private foundation status was terminated
under section 507(b)(1)(A), check here .......
H
Check type of organization:
Section 501(c)(3) exempt private foundation
Section 4947(a)(1) nonexempt charitable trust
Other taxable private foundation
F
If the foundation is in a 60-month termination
under section 507(b)(1)(B), check here .......
I
Fair market value of all assets at end
of year (from Part II, col. (c),
line 16)
$
15,479
J
Accounting method:
Cash
Accrual
Other (specify)
(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)
1
Contributions, gifts, grants, etc., received (attach schedule)
33,454
2
Check
.............
3
Interest on savings and temporary cash investments
0
0
0
4
Dividends and interest from securities
...
0
0
0
5a
Gross rents
............
0
0
0
b
Net rental income or (loss)
0
6a
Net gain or (loss) from sale of assets not on line 10
0
b
Gross sales price for all assets on line 6a
0
7
Capital gain net income (from Part IV, line 2)
...
0
8
Net short-term capital gain
.........
9
Income modifications
...........
0
10a
Gross sales less returns and allowances
0
b
Less: Cost of goods sold
....
0
c
Gross profit or (loss) (attach schedule)
.....
0
0
11
Other income (attach schedule)
.......
0
0
0
12
Total.
Add lines 1 through 11
........
33,454
0
0
13
Compensation of officers, directors, trustees, etc.
0
0
0
0
14
Other employee salaries and wages
......
0
0
0
0
15
Pension plans, employee benefits
.......
0
0
0
0
16a
Legal fees (attach schedule)
.........
0
0
0
0
b
Accounting fees (attach schedule)
.......
0
0
0
0
c
Other professional fees (attach schedule)
....
0
0
0
0
17
Interest
...............
0
0
0
0
18
Taxes (attach schedule) (see instructions)
...
0
0
0
0
19
Depreciation (attach schedule) and depletion
...
0
0
0
20
Occupancy
..............
0
0
0
0
21
Travel, conferences, and meetings
.......
0
0
0
0
22
Printing and publications
..........
0
0
0
0
23
Other expenses (attach schedule)
.......
454
0
0
0
24
Total operating and administrative expenses.
Add lines 13 through 23
..........
454
0
0
0
25
Contributions, gifts, grants paid
.......
28,475
28,475
26
Total expenses and disbursements.
Add lines 24 and 25
28,929
0
0
28,475
27
Subtract line 26 from line 12:
a
Excess of revenue over expenses and disbursements
4,525
b
Net investment income
(if negative, enter -0-)
0
c
Adjusted net income
(if negative, enter -0-)
...
0
For Paperwork Reduction Act Notice, see instructions.
Cat. No. 11289X
Form
990-PF
(2021)
Form 990-PF (2021)
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
1
Cash—non-interest-bearing
.............
10,954
15,479
15,479
2
Savings and temporary cash investments
.........
0
0
0
3
Accounts receivable
0
Less: allowance for doubtful accounts
0
0
0
0
4
Pledges receivable
0
Less: allowance for doubtful accounts
0
0
0
0
5
Grants receivable
.................
0
0
0
6
Receivables due from officers, directors, trustees, and other
disqualified persons (attach schedule) (see instructions)
.....
0
0
7
Other notes and loans receivable (attach schedule)
Less: allowance for doubtful accounts
0
0
8
Inventories for sale or use
..............
0
0
0
9
Prepaid expenses and deferred charges
..........
0
0
0
10a
Investments—U.S. and state government obligations (attach schedule)
0
b
Investments—corporate stock (attach schedule)
.......
0
c
Investments—corporate bonds (attach schedule)
.......
0
11
Investments—land, buildings, and equipment: basis
0
Less: accumulated depreciation (attach schedule)
0
0
12
Investments—mortgage loans
.............
0
0
0
13
Investments—other (attach schedule)
..........
0
14
Land, buildings, and equipment: basis
0
Less: accumulated depreciation (attach schedule)
0
0
15
Other assets (describe
)
0
0
0
16
Total assets
(to be completed by all filers—see the
instructions. Also, see page 1, item I)
10,954
15,479
15,479
17
Accounts payable and accrued expenses
..........
0
0
18
Grants payable
.................
0
0
19
Deferred revenue
.................
0
0
20
Loans from officers, directors, trustees, and other disqualified persons
0
0
21
Mortgages and other notes payable (attach schedule)
......
0
22
Other liabilities (describe
)
0
0
23
Total liabilities
(add lines 17 through 22)
.........
0
0
Foundations that follow FASB ASC 958, check here
and complete lines 24, 25, 29 and 30.
24
Net assets without donor restrictions
...........
10,954
15,479
25
Net assets with donor restrictions
............
0
0
Foundations that do not follow FASB ASC 958, check here
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)
.....
10,954
15,479
30
Total liabilities and net assets/fund balances
(see instructions)
.
10,954
15,479
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
10,954
2
Enter amount from Part I, line 27a
.....................
2
4,525
3
Other increases not included in line 2 (itemize)
3
4
Add lines 1, 2, and 3
..........................
4
15,479
5
Decreases not included in line 2 (itemize)
5
6
Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 29
.
6
15,479
Form
990-PF
(2021)
Form 990-PF (2021)
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)
If gain, also enter in Part I, line 7
If (loss), enter -0- in Part I, line 7
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
...................
3
Form
990-PF
(2021)
Form 990-PF (2021)
Page
4
Part V
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
and enter “N/A" on line 1.
Date of ruling or determination letter:
(attach copy of letter if necessary–see instructions)
b
All other domestic foundations enter 1.39% (0.0139) of line 27b. Exempt foreign organizations enter 4% (0.04) 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
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
6
Credits/Payments:
a
2021 estimated tax payments and 2020 overpayment credited to 2021
6a
0
b
Exempt foreign organizations—tax withheld at source
......
6b
c
Tax paid with application for extension of time to file (Form 8868)
...
6c
0
d
Backup withholding erroneously withheld
...........
6d
0
7
Total credits and payments. Add lines 6a through 6d
..............
7
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
.......
9
0
10
Overpayment.
If line 7 is more than the total of lines 5 and 8, enter the
amount overpaid
...
10
11
Enter the amount of line 10 to be:
Credited to 2022 estimated tax
0
Refunded
11
0
Part VI-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.
$
0
(2)
On foundation managers.
$
0
e
Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed
on foundation managers.
$
0
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
No
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 XIV.
.................................
7
Yes
8a
Enter the states to which the foundation reports or with which it is registered (see instructions)
MN
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 2021 or the taxable year beginning in 2021? See the instructions for Part XIII.
If "Yes," complete Part XIII
.............................
9
Yes
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
(2021)
Form 990-PF (2021)
Page
5
Part VI-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 address
http://www.bluestonemd.com/about-us/bluestone-giving-foundation/
14
The books are in care of
Sarah Sundberg
Telephone no.
(612) 409-2932
Located at
270 MAIN ST N STE 300
STILLWATER
MN
ZIP+4
550826788
15
Section 4947(a)(1) nonexempt charitable trusts filing Form 990-PF in lieu of
Form 1041
—check here
.........
and enter the amount of tax-exempt interest received or accrued during the year
........
15
16
At any time during calendar year 2021, did the foundation have an interest in or a signature or other authority over
Yes
No
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
Part VI-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?
...........
1a(1)
No
(2)
Borrow money from, lend money to, or otherwise extend credit to (or accept it from)
a disqualified person?
..............................
1a(2)
No
(3)
Furnish goods, services, or facilities to (or accept them from) a disqualified person?
...........
1a(3)
No
(4)
Pay compensation to, or pay or reimburse the expenses of, a disqualified person?
............
1a(4)
No
(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)?
......................
1a(5)
No
(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.)
...............
1a(6)
No
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
c
Organizations relying on a current notice regarding disaster assistance check here
........
d
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 2021?
.............
1d
No
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 2021, did the foundation have any undistributed income (lines 6d
and 6e, Part XII) for tax year(s) beginning before 2021?
....................
2a
No
If "Yes," list the years
20
,
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.
20
,
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?
..............................
3a
No
b
If "Yes," did it have excess business holdings in 2021 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 2021.)
.....................
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 2021?
..
4b
No
Form
990-PF
(2021)
Form 990-PF (2021)
Page
6
Part VI-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))?
..........
5a(1)
No
(2)
Influence the outcome of any specific public election (see section 4955); or to carry
on, directly or indirectly, any voter registration drive?
....................
5a(2)
No
(3)
Provide a grant to an individual for travel, study, or other similar purposes?
.............
5a(3)
No
(4)
Provide a grant to an organization other than a charitable, etc., organization described
in section 4945(d)(4)(A)? See instructions
........................
5a(4)
No
(5)
Provide for any purpose other than religious, charitable, scientific, literary, or
educational purposes, or for the prevention of cruelty to children or animals?
.............
5a(5)
No
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
c
Organizations relying on a current notice regarding disaster assistance check here
.........
d
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?
.................
5d
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?
.............................
6a
No
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?
7a
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?
.........................
8
No
Part VII
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
Valerie Chestnut
Board Member
0.00
0
0
0
580 Cascade Cir 104
Casselberry
,
FL
32707
Annette Fagerlee
Board Member
0.00
0
0
0
3336 Highcrest Rd NE
Minneapolis
,
MN
55418
Becky Thalacker
Board Member
0.00
0
0
0
631 N Washington Ave
New Richmond
,
WI
54017
Cynthia Stevens
Board Member
0.00
0
0
0
7608 Carillon Plaza E
Woodbury
,
MN
55125
Jennifer Redman
Board Member
0.00
0
0
0
2134 15th Ave E
North St Paul
,
MN
55109
Melina Hoehn
Board Member
0.00
0
0
0
535 Selby Ave 4
St Paul
,
MN
55102
Michelle Heyer
Board Member
0.00
0
0
0
15234 Florist Circle
Apple Valley
,
MN
55124
Nancy MacLeslie
Board Member
0.00
0
0
0
14290 Oldfield Rd N
Stillwater
,
MN
55082
Sarah Keenan
Board Member
0.00
0
0
0
174 Ivy Street
Mahtomedi
,
MN
55115
Sarah Sundberg
Board Member
0.00
0
0
0
4605 Helmo Ave N
Oakdale
,
MN
55128
John Henly
Board Member
0.00
0
0
0
1769 Hickory Hill Dr
Eagan
,
MN
55122
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
Total
number of other employees paid over $50,000
...................
Form
990-PF
(2021)
Form 990-PF (2021)
Page
7
Part VII
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
Total
number of others receiving over $50,000 for professional services
.............
Part VIII-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
Supporting various individuals that have requested assistance from the Giving Foundation
28,475
2
3
4
Part VIII-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
2
All other program-related investments. See instructions.
3
Total.
Add lines 1 through 3
.........................
Form
990-PF
(2021)
Form 990-PF (2021)
Page
8
Part IX
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
0
b
Average of monthly cash balances
.......................
1b
14,292
c
Fair market value of all other assets (see instructions)
................
1c
0
d
Total
(add lines 1a, b, and c)
.........................
1d
14,292
e
Reduction claimed for blockage or other factors reported on lines 1a and
1c (attach detailed explanation)
.............
1e
0
2
Acquisition indebtedness applicable to line 1 assets
..................
2
0
3
Subtract line 2 from line 1d
.........................
3
14,292
4
Cash deemed held for charitable activities. Enter 1.5% (0.015) of line 3 (for greater amount, see
instructions)
.............................
4
214
5
Net value of noncharitable-use assets.
Subtract line 4 from line 3.
.......
5
14,078
6
Minimum investment return.
Enter 5% (0.05) of line 5
................
6
704
Part X
Distributable Amount
(see instructions) (Section 4942(j)(3) and (j)(5) private operating foundations and certain foreign organizations check here
and do not complete this part.)
1
Minimum investment return from Part IX, line 6
..................
1
2a
Tax on investment income for 2021 from Part V, line 5
.......
2a
b
Income tax for 2021. (This does not include the tax from Part V.)
...
2b
c
Add lines 2a and 2b
............................
2c
3
Distributable amount before adjustments. Subtract line 2c from line 1
............
3
4
Recoveries of amounts treated as qualifying distributions
................
4
5
Add lines 3 and 4
............................
5
6
Deduction from distributable amount (see instructions)
.................
6
7
Distributable amount
as adjusted. Subtract line 6 from line 5. Enter here and on Part XII, line 1
...
7
Part XI
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
b
Program-related investments—total from Part VIII-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 XII, line 4.
4
Form
990-PF
(2021)
Form 990-PF (2021)
Page
9
Part XII
Undistributed Income
(see instructions)
(a)
Corpus
(b)
Years prior to 2020
(c)
2020
(d)
2021
1
Distributable amount for 2021 from Part X, line 7
2
Undistributed income, if any, as of the end of 2021:
a
Enter amount for 2020 only
.......
b
Total for prior years:
20
,
20
,
20
3
Excess distributions carryover, if any, to 2021:
a
From 2016
......
b
From 2017
......
c
From 2018
......
d
From 2019
......
e
From 2020
......
f
Total
of lines 3a through e
........
4
Qualifying distributions for 2021 from Part
XI, line 4:
$
a
Applied to 2020, 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 2021 distributable amount
.....
e
Remaining amount distributed out of corpus
5
Excess distributions carryover applied to 2021.
(If an amount appears in column (d), the
same amount must be shown in column (a).)
6
Enter the net total of each column as
indicated below:
a
Corpus. Add lines 3f, 4c, and 4e. Subtract line 5
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 2021. Subtract
lines 4d and 5 from line 1. This amount must
be distributed in 2022
..........
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 2016 not
applied on line 5 or line 7 (see instructions)
...
9
Excess distributions carryover to 2022.
Subtract lines 7 and 8 from line 6a
......
10
Analysis of line 9:
a
Excess from 2017
....
b
Excess from 2018
....
c
Excess from 2019
....
d
Excess from 2020
....
e
Excess from 2021
....
Form
990-PF
(2021)
Form 990-PF (2021)
Page
10
Part XIII
Private Operating Foundations
(see instructions and Part VI-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 2021, enter the date of the ruling
.......
b
Check box to indicate whether the organization is a private operating foundation described in section
4942(j)(3)
or
4942(j)(5)
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)
2021
(b)
2020
(c)
2019
(d)
2018
0
0
0
0
0
b
85% (0.85) of line 2a
.........
0
0
0
0
0
c
Qualifying distributions from Part XI,
line 4 for each year listed
.....
28,475
23,382
33,085
17,721
102,663
d
Amounts included in line 2c not used directly
for active conduct of exempt activities
..........
0
0
0
0
0
e
Qualifying distributions made directly
for active conduct of exempt activities.
Subtract line 2d from line 2c
....
28,475
23,382
33,085
17,721
102,663
3
Complete 3a, b, or c for the
alternative test relied upon:
a
“Assets" alternative test—enter:
(1)
Value of all assets
......
0
10,954
7,961
9,462
28,377
(2)
Value of assets qualifying
under section 4942(j)(3)(B)(i)
0
0
0
0
0
b
“Endowment" alternative test— enter 2/3
of minimum investment return shown in
Part IX, line 6 for each year listed
..
469
307
311
229
1,317
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)
....
0
0
0
0
0
(2)
Support from general public
and 5 or more exempt
organizations as provided in
section 4942(j)(3)(B)(iii)
....
0
0
0
0
0
(3)
Largest amount of support
from an exempt organization
0
0
0
0
0
(4)
Gross investment income
0
0
0
0
0
Part XIV
Supplementary Information (Complete this part only if the foundation had $5,000 or more in
assets at any time during the year—see instructions.)
1
Information Regarding Foundation Managers:
a
List 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).)
N A
b
List 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.
N A
2
Information Regarding Contribution, Grant, Gift, Loan, Scholarship, etc., Programs:
Check here
if the foundation only makes contributions to preselected charitable organizations and does not accept
unsolicited requests for funds. If the foundation makes gifts, grants, etc. to individuals or organizations under
other conditions, complete items 2a, b, c, and d. See instructions
a
The name, address, and telephone number or e-mail address of the person to whom applications should be addressed:
Bluestone Giving Foundation
270 Main Street N Ste 300
Stillwater
,
MN
55082
(612) 409-2932
b
The form in which applications should be submitted and information and materials they should include:
Allocations Committee
c
Any submission deadlines:
N A
d
Any restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other
factors:
N A
Form
990-PF
(2021)
Form 990-PF (2021)
Page
11
Part XIV
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)
a
Paid during the year
Bluestone Giving Foundation
404 3rd St NW
PO Box 664
Dodge Center
,
MN
55927
No
I
Car Payment
1,895
Bluestone Giving Foundation
400 Western Ave N
St Paul
,
MN
55103
No
I
Moving Expenses
1,555
Bluestone Giving Foundation
600 E Nicollet Blvd
Apt 220
Burnsville
,
MN
55337
No
I
Dental Work - connective tissue graft
1,500
Bluestone Giving Foundation
123 Unavailable
St Paul
,
MN
55105
No
I
Recliner with lift
1,411
Bluestone Giving Foundation
1505 Pheasantwood Trl
Northfield
,
MN
55057
No
I
Adjustable bed frame
1,334
Bluestone Giving Foundation
123 Unavailable
St Paul
,
MN
55105
No
I
Feeding Pump
1,315
Bluestone Giving Foundation
913 Deer Ridge St NW
Lonsdale
,
MN
55046
No
I
Dental Work - Posts removed for dentures
1,224
Bluestone Giving Foundation
13822 Widgeon Lane
Rogers
,
MN
55374
No
I
Discount Tire
938
Bluestone Giving Foundation
3425 53rd Ave N
Apt 202
Brooklyn Center
,
MN
55429
No
I
Dental Work - 2 crowns
819
Bluestone Giving Foundation
1225 East Division St
320
St Cloud
,
MN
56304
No
I
Cost of Anesthesia for Dental Work
785
Bluestone Giving Foundation
715 1st St N
S4
Cold Spring
,
MN
56320
No
I
Pharmacy Bill
750
Bluestone Giving Foundation
PO Box 1094
Faribault
,
MN
55021
No
I
Security Deposit for Rental Home
750
Bluestone Giving Foundation
123 Unavailable
St Paul
,
MN
55105
No
I
Moving Expenses
540
Bluestone Giving Foundation
4101 Parklawn Avenue
303
Minneapolis
,
MN
55435
No
I
50% Car Insurance Deductible
500
Bluestone Giving Foundation
12446 Jamestown St NE
Blaine
,
MN
55449
No
I
Moving Expenses
500
Bluestone Giving Foundation
220 Olive St W
Stillwater
,
MN
55082
No
I
Security Deposit for Assisted Living
500
Bluestone Giving Foundation
11039 So Bird Avenue
Leota
,
MN
56153
No
I
Dental Work - Rotting Teeth
450
Bluestone Giving Foundation
420 Marshall Ave
St Paul
,
MN
55102
No
I
Moving Expenses
420
Bluestone Giving Foundation
512 Humbold Ave
St Paul
,
MN
55107
No
I
Twin bed frame and delivery
419
Bluestone Giving Foundation
3235 Aldrich Ave N
Apt 1
Minneapolis
,
MN
55412
No
I
Moving Expenses
400
Bluestone Giving Foundation
521 7th Ave S
Apt 2
Hopkins
,
MN
55343
No
I
Manual Bariatric Wheelchair
384
Bluestone Giving Foundation
13713 E Wellington Crescent
Burnsville
,
MN
55337
No
I
Outstanding Medical Bill
360
Bluestone Giving Foundation
514 Marnie St S
St Paul
,
MN
55119
No
I
Bariatric Exercise Bike
344
Bluestone Giving Foundation
10669 Ulysses St NE
Blaine
,
MN
55434
No
I
Moving Expenses
316
Bluestone Giving Foundation
2235 Rockwood Ave
Apt 702
St Paul
,
MN
55116
No
I
Moving Expenses
315
Bluestone Giving Foundation
282 Ruth St N
St Paul
,
MN
55119
No
I
Adult Tricycle
313
Bluestone Giving Foundation
9056 Buchanan Trail
Rm 31
Inver Grove Heights
,
MN
55076
No
I
Temperature Regulation Sheets for quadriplegic
309
Bluestone Giving Foundation
150 Homestead Rd
Mankato
,
MN
56001
No
I
Moving Expenses
274
Bluestone Giving Foundation
8925 Stevens Ave S
Bloomington
,
MN
55420
No
I
Dental Work - Remove Bridges
265
Bluestone Giving Foundation
1226 Division St E
St Cloud
,
MN
56304
No
I
Eye Exam Visual Field Test Sensory Motor Exam
253
Bluestone Giving Foundation
350 E International Speedway Blvd
Room 307
Deland
,
FL
32724
No
I
Call pendant for necklace
250
Bluestone Giving Foundation
2000 W Broadway Ave
Apt 310
Minneapolis
,
MN
55411
No
I
Security Deposit for Apartment
250
Bluestone Giving Foundation
7007 139th Lane NW
5
Ramsey
,
MN
55303
No
I
Prevalon Blue Heel Boots - Hospital lost original pair
232
Bluestone Giving Foundation
315 Lowry Ave N
Apt 204
Minneapolis
,
MN
55411
No
I
Window A C unit to help with Asthma
226
Bluestone Giving Foundation
1599 St Anthony Ave
Apt 4
St Paul
,
MN
55104
No
I
Refurbished Laptop for new job
200
Bluestone Giving Foundation
2300 Hastings Ave
438
Newport
,
MN
55055
No
I
Nebulizer
199
Bluestone Giving Foundation
1161 St Clair Ave
11
St Paul
,
MN
55105
No
I
Nebulizer
199
Bluestone Giving Foundation
1801 Gervais Ave
Rm 240
Maplewood
,
MN
55109
No
I
Pocketalker to help reduce anxiety
198
Bluestone Giving Foundation
1435 Sunrise Dr
Apt 205
Saint Peter
,
MN
56082
No
I
Scoop Fit Machine to continue range of motion in knee
180
Bluestone Giving Foundation
500 2nd Street
Unit 17
Brooten
,
MN
56313
No
I
2 Hotel nights to help patient to make it to their cardiac appt
177
Bluestone Giving Foundation
1311 5th Ave NW
Austin
,
MN
56313
No
I
Tire Brake repair for walker
172
Bluestone Giving Foundation
1493 State Hwy 76
Houston
,
MN
55943
No
I
Standard Hosptial Bed Mattress
160
Bluestone Giving Foundation
1225 Divison St E
St Cloud
,
MN
56304
No
I
Eye Exam Visual Field Test Sensory Motor Exam
159
Bluestone Giving Foundation
521 7th Ave S
Apt 2
Hopkins
,
MN
55343
No
I
Fee to Return Wheelchair
150
Bluestone Giving Foundation
1306 Alton St
St Paul
,
MN
55116
No
I
Baby Doll and Fidget Muff for residents at Memory Care Facility
150
Bluestone Giving Foundation
214 Hoosac St W
Apt 104
Waterville
,
MN
56096
No
I
Progressive Lenses to reduce migraines
145
Bluestone Giving Foundation
3555 Dupont Ave N
Minneapolis
,
MN
55412
No
I
4 Twin Beds for patients young children
130
Bluestone Giving Foundation
11774 Crooked Lake Blvd NW
Coon Rapids
,
MN
55433
No
I
Supplies needed for incontinence care
120
Bluestone Giving Foundation
3330 Edinborough Way
Room 433
Edina
,
MN
55436
No
I
Joy for All Cat
118
Bluestone Giving Foundation
6630 Hudson Blvd
Apt 108
Oakdale
,
MN
55128
No
I
Nitrous Oxide for getting teeth pulled
108
Bluestone Giving Foundation
1225 Divison St E
St Cloud
,
MN
56303
No
I
New Clothing for patient with soiled clothes
100
Bluestone Giving Foundation
19 Kistler Ct
La Crescent
,
MN
55947
No
I
Pill Dispenser with Lock and Alarm
100
Bluestone Giving Foundation
2933 W Columbus Drive
Tampa
,
FL
33607
No
I
Nicotine patches to help quit smoking
90
Bluestone Giving Foundation
4050 Maureen Dr NE
Unit 103
Columbia Heights
,
MN
55421
No
I
Blood Pressure Cuff after Coronary Artery Bypass Graft surgery
88
Bluestone Giving Foundation
2485 Seppala Blvd
N St Paul
,
MN
55109
No
I
Needs larger blood pressure cuff
88
Bluestone Giving Foundation
34070 730th Ave
St James
,
MN
56081
No
I
Medication needed to help with facial flushing
87
Bluestone Giving Foundation
306 Mallard Lane
Mankato
,
MN
56001
No
I
Automatic pill dispenser
86
Bluestone Giving Foundation
200 10th St E
Apt 210
Saint Paul
,
MN
55101
No
I
Lost EBT card - Gift card for Groceries
80
Bluestone Giving Foundation
123 Birchridge Dr
Brainerd
,
MN
56401
No
I
Pill Organizer and Reminder System
69
Bluestone Giving Foundation
12446 Jamestown St NE
Apt 7
Blaine
,
MN
55449
No
I
Countertop microwave due to patient being in a wheelchair
68
Bluestone Giving Foundation
1305 Lakeland Drive NE
Willmar
,
MN
56201
No
I
TENS unit not covered by insurance
65
Bluestone Giving Foundation
214 Hoosac St W
Apt 104
Waterville
,
MN
56096
No
I
Anti-Reflective Coating for glasses to reduce migraines
65
Bluestone Giving Foundation
15079 Riverside Dr
4
Brainerd
,
MN
56401
No
I
Leg rests for wheel chair after tibia surgery
65
Bluestone Giving Foundation
414 10th St S
Cleveland
,
MN
56017
No
I
Dystonia causing pain needs heating pad to relieve pain
65
Bluestone Giving Foundation
503 S Prairie Ave
Fairmont
,
MN
56031
No
I
Electric Wheel Chair Repair
60
Bluestone Giving Foundation
204 N Front St
Okabena
,
MN
56161
No
I
Seated Wheeled Walker with brakes
56
Bluestone Giving Foundation
100 W River Woods Pkwy
Glendale
,
WI
53212
No
I
Cannula Tubing for trial oxygen source
55
Bluestone Giving Foundation
1156 Barclay St
4
St Paul
,
MN
55106
No
I
College transcripts to return to school
55
Bluestone Giving Foundation
10669 Ulysses St NE
Blaine
,
MN
55434
No
I
Moving Expenses
53
Bluestone Giving Foundation
16258 Kenyon Ave
Lakeville
,
MN
55044
No
I
Fidget Muff for Memory Care Program
50
Bluestone Giving Foundation
1144 Drake Ave
Windom
,
MN
56101
No
I
Smaller Shower bench to fit in shower
48
Bluestone Giving Foundation
3434 Heritage Drive
Apt 409
Edina
,
MN
55435
No
I
Smart Love snuggle puppy to help with anxiety isolation due to COVID
48
Bluestone Giving Foundation
413 N 4th St
Apt 300
Mankato
,
MN
56001
No
I
Book pillow to assist with reading
43
Bluestone Giving Foundation
1536 Western Ave NW
Faribault
,
MN
55021
No
I
Pool Punch card to help with pain from spinal fusion surgery
43
Bluestone Giving Foundation
602 James St
Lot 26
Brainerd
,
MN
56401
No
I
New tennis shoes to wear at work
43
Bluestone Giving Foundation
PO Box 50863
340th E St 103
Mendota
,
MN
55150
No
I
SAD lamp
43
Bluestone Giving Foundation
14538 Taconite St NE
Ham Lake
,
MN
55304
No
I
Healthex Wedge Bed Pillow to with breathing while laying down
43
Bluestone Giving Foundation
873 Galtier Street
Apt 1
St Paul
,
MN
55117
No
I
White t-shirts for wound care
40
Bluestone Giving Foundation
1711 Riggs Road
Apt 1
Saint Peter
,
MN
56082
No
I
New weighted blanket - original was lost in house fire
40
Bluestone Giving Foundation
300 7th Street NW
Apt 217
Willmar
,
MN
56201
No
I
Bus pass to get to food shelf grocery shopping etc
39
Bluestone Giving Foundation
321 1st Ave SE
Apt 8
Lonsdale
,
MN
55046
No
I
TENS unit not covered by insurance
38
Bluestone Giving Foundation
12446 Jamestown St NE
Blaine
,
MN
55449
No
I
Oensie's needed due to defecating in common areas
37
Bluestone Giving Foundation
12446 Jamestown St NE
Blaine
,
MN
55449
No
I
Oensie's needed due to defecating in common areas
35
Bluestone Giving Foundation
4650 White Bear Parkway
White Bear Lake
,
MN
55110
No
I
Personal care items body wash vaseline etc
35
Bluestone Giving Foundation
10940 Crooked Lake Blvd NW
Apt 409
Coon Rapids
,
MN
55433
No
I
Thera Cane Massager for pain relief
32
Bluestone Giving Foundation
7979 Hargis Pkwy
Woodbury
,
MN
55129
No
I
Covering medical bill
32
Bluestone Giving Foundation
230 Bradley St
Mankato
,
MN
56001
No
I
Massage Acupuncture book for self care at home
24
Bluestone Giving Foundation
200 14th St SE
Austin
,
MN
55912
No
I
Bathroom Scale
20
Bluestone Giving Foundation
1717 University Dr SE
46
Saint Cloud
,
MN
56304
No
I
No personal funds to pay for OTC medication
20
Bluestone Giving Foundation
7531 Greenfield Ave
303
Mounds View
,
MN
55112
No
I
Grab Bar for tub
17
Bluestone Giving Foundation
5312 Queen Ave N
Brooklyn Center
,
MN
55430
No
I
Past due medication copays
15
Bluestone Giving Foundation
441 E Page Street
Floor 1
St Paul
,
MN
55107
No
I
Replace broken grabber
15
Bluestone Giving Foundation
1024 Oak St
Brainerd
,
MN
56401
No
I
Larger AM PM pill box organizer
14
Bluestone Giving Foundation
16500 92nd Ave N
301
Maple Grove
,
MN
55311
No
I
Incentive Spirometer
13
Bluestone Giving Foundation
913 Deer Ridge St NW
Lonsdale
,
MN
55046
No
I
Pedometer to encourage movement
13
Bluestone Giving Foundation
3330 Edinborough Way
Rm 433
Edina
,
MN
55435
No
I
Joy for all Cat for companionship
13
Bluestone Giving Foundation
1161 St Clair Ave
11
St Paul
,
MN
55105
No
I
Medical information bag for chair
10
Bluestone Giving Foundation
120 4th St
Balaton
,
MN
56115
No
I
Shipping cost for RX glasses
6
Bluestone Giving Foundation
11774 Crooked Lake Blvd NW
Coon Rapids
,
MN
55433
No
I
Disposable masks
6
Bluestone Giving Foundation
123 Unavailable
St Paul
,
MN
55105
No
I
Moving Expenses
100
Bluestone Giving Foundation
1730 2nd St SW
Faribault
,
MN
55021
No
I
Head coverings from losing hair due to chemo
22
Bluestone Giving Foundation
800 Rice St
St Paul
,
MN
55117
No
I
Help Cover Rent
185
Bluestone Giving Foundation
123 Unavailable
St Paul
,
MN
55105
No
I
Apple Tree Dental Work
1,237
Total
.................................
3a
28,475
b
Approved for future payment
Total
.................................
3b
Form
990-PF
(2021)
Form 990-PF (2021)
Page
12
Part XV-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.)
1
Program service revenue:
(a)
Business code
(b)
Amount
(c)
Exclusion code
(d)
Amount
a
b
c
d
e
f
g
Fees and contracts from government agencies
2
Membership dues and assessments
....
0
0
0
3
Interest on savings and temporary cash
investments
...........
0
0
0
4
Dividends and interest from securities
....
5
Net rental income or (loss) from real estate:
a
Debt-financed property
......
0
0
0
b
Not debt-financed property
.....
0
0
0
6
Net rental income or (loss) from personal property
0
0
0
7
Other investment income
.....
8
Gain or (loss) from sales of assets other than
inventory
............
0
0
0
9
Net income or (loss) from special events:
0
0
0
10
Gross profit or (loss) from sales of inventory
0
0
0
11
Other revenue:
a
0
0
0
b
0
0
0
c
0
0
0
d
0
0
0
e
0
0
0
12
Subtotal. Add columns (b), (d), and (e)
..
0
0
0
13
Total.
Add line 12, columns (b), (d), and (e)
..................
13
0
(See worksheet in line 13 instructions to verify calculations.)
Part XV-B
Relationship of Activities to the Accomplishment of Exempt Purposes
Line No.
Explain below how each activity for which income is reported in column (e) of Part XV-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
(2021)
Form 990-PF (2021)
Page
13
Part XVI
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?
...........
Yes
No
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.
May the IRS discuss this return
with the preparer shown below?
See instructions.
Yes
No
Signature of officer or trustee
Date
Title
Paid Preparer Use Only
Print/Type preparer's name
Preparer's Signature
Date
Check if self-
employed
PTIN
Firm's name
Firm's EIN
Firm's address
Phone no.
Form
990-PF
(2021)
Additional Data
Software ID:
21013404
Software Version:
V1.0
Part VI Line 7 - Tax Paid with the Original Return:
0
Form 990PF - Special Condition Description:
Special Condition Description
-
TIN:
Schedule B
(Form 990)
Department of the Treasury
Internal Revenue Service
Schedule of Contributors
Attach to Form 990, 990-EZ, or 990-PF.
Go to
www.irs.gov/Form990
for the latest information.
OMB No. 1545-0047
20
21
Name of the organization
BLUESTONE GIVING FOUNDATION
Employer identification number
46-5218477
Organization type
(check one):
Filers of:
Section:
Form 990 or 990-EZ
501(c)(
) (enter number) organization
4947(a)(1) nonexempt charitable trust
not
treated as a private foundation
527 political organization
Form 990-PF
501(c)(3) exempt private foundation
4947(a)(1) nonexempt charitable trust treated as a private foundation
501(c)(3) taxable private foundation
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
For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, contributions totaling $5,000 or more (in money or other property) from any one contributor. Complete Parts I and II. See instructions for determining a contributor's total contributions.
Special Rules
For an organization described in section 501(c)(3) filing Form 990 or 990-EZ that met the 33
1
/3
% support test of the regulations
under sections 509(a)(1) and 170(b)(1)(A)(vi), that checked Schedule A (Form 990 or 990-EZ), Part II, line 13, 16a, or 16b, and that received from any one contributor, during the year, total contributions of the greater of
(1)
$5,000 or
(2)
2% of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1. Complete Parts I and II.
For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, total contributions of more than $1,000
exclusively
for religious, charitable, scientific, literary, or educational purposes, or for the prevention of cruelty to children or animals. Complete Parts I, II, and III.
For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, contributions
exclusively
for religious, charitable, etc., purposes, but no such contributions totaled more than $1,000. If this box is checked, enter here the total contributions that were received during the year for an
exclusively
religious, charitable, etc., purpose. Don't complete any of the parts unless the
General Rule
applies to this organization because it received
nonexclusively
religious, charitable, etc., contributions totaling $5,000 or more during the year
.........
$
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. 30613X
Schedule B (Form 990) (2021)
Schedule B (Form 990) (2021)
Page
2
Name of organization
BLUESTONE GIVING FOUNDATION
Employer identification number
46-5218477
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
Bluestone Employees
270 Main Street N
Ste 300
Stillwater
,
MN
55082
$
33,454
Person
Payroll
Noncash
(Complete Part II for noncash contributions.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Total contributions
(d)
Type of contribution
$
Person
Payroll
Noncash
(Complete Part II for noncash contributions.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Total contributions
(d)
Type of contribution
$
Person
Payroll
Noncash
(Complete Part II for noncash contributions.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Total contributions
(d)
Type of contribution
$
Person
Payroll
Noncash
(Complete Part II for noncash contributions.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Total contributions
(d)
Type of contribution
$
Person
Payroll
Noncash
(Complete Part II for noncash contributions.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Total contributions
(d)
Type of contribution
$
Person
Payroll
Noncash
(Complete Part II for noncash contributions.)
Schedule B (Form 990) (2021)
Schedule B (Form 990) (2021)
Page
3
Name of organization
BLUESTONE GIVING FOUNDATION
Employer identification number
46-5218477
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) (2021)
Schedule B (Form 990) (2021)
Page
4
Name of organization
BLUESTONE GIVING FOUNDATION
Employer identification number
46-5218477
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.)
$
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) (2021)
Additional Data
Software ID:
Software Version:
-
TIN:
TY 2021 OtherExpensesSchedule
Name:
BLUESTONE GIVING FOUNDATION
EIN:
46-5218477
Software ID:
21013404
Software Version:
V1.0
Description
Revenue and Expenses per Books
Net Investment Income
Adjusted Net Income
Disbursements for Charitable Purposes
Electronic Filing fees and Prizes for Advertising
454
0
0
0