Form990-PF
Click to see attachment
Click to see attachmentClick 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. 1545-0047
2021
Open to Public Inspection
For calendar year 2021, or tax year beginning 01-01-2021 , and ending 12-31-2021
Name of foundation
The Jacquemin Family Foundation Inc
 
Number and street (or P.O. box number if mail is not delivered to street address)45150 Russell Branch Pkwy Ste 102
  Room/suite
City or town, state or province, country, and ZIP or foreign postal code
Ashburn, VA20147
A Employer identification number

54-1887187
B Telephone number (see instructions)

(703) 917-0707
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$18,347,589J Accounting method:
 
(Part I, column (d) must be on cash basis.)
Part I Analysis of Revenue and Expenses (The total of amounts in columns (b), (c), and (d) may not necessarily equal the amounts in column (a) (see instructions).) (a) Revenue and
expenses per
books 		(b) Net investment
income 		(c) Adjusted net
income 		(d) Disbursements
for charitable
purposes
(cash basis only)
Revenue 1 Contributions, gifts, grants, etc., received (attach schedule)  
2 Check bullet.............
3 Interest on savings and temporary cash investments 2,077 2,077 2,077
4 Dividends and interest from securities... 167,256 167,256 167,256
5a Gross rents............      
b Net rental income or (loss)  
6a Net gain or (loss) from sale of assets not on line 10 1,061,478
b Gross sales price for all assets on line 6a 1,145,658
7 Capital gain net income (from Part IV, line 2)... 1,061,478
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........ 1,230,811 1,230,811 169,333
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).........        
b Accounting fees (attach schedule)....... Click to see attachment 4,965 4,965    
c Other professional fees (attach schedule)....        
17 Interest...............        
18 Taxes (attach schedule) (see instructions)... Click to see attachment 27,526 27,526    
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 list of attachments 2,006 2,006    
24 Total operating and administrative expenses.
Add lines 13 through 23.......... 34,497 34,497   0
25 Contributions, gifts, grants paid....... 1,027,000 1,027,000
26 Total expenses and disbursements. Add lines 24 and 25 1,061,497 34,497   1,027,000
27 Subtract line 26 from line 12:
a Excess of revenue over expenses and disbursements 169,314
b Net investment income (if negative, enter -0-) 1,196,314
c Adjusted net income (if negative, enter -0-)... 169,333
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
Assets 1 Cash—non-interest-bearing............. 3,032,564 4,183,451 4,178,451
2 Savings and temporary cash investments......... 2,163,188 1,308,717 1,308,717
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) bullet42,084
Less: allowance for doubtful accounts bullet   8,228 Click to see attachment42,084 42,084
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)....... 13,191,844 12,806,857 12,806,857
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).......... 11,480 11,480 11,480
14 Land, buildings, and equipment: basis bullet  
Less: accumulated depreciation (attach schedule) bullet        
15 Other assets (describe bullet)      
16 Total assets (to be completed by all filers—see the
instructions. Also, see page 1, item I) 18,407,304 18,352,589 18,347,589
Liabilities 17 Accounts payable and accrued expenses.......... 6,000 11,000
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)    
23 Total liabilities (add lines 17 through 22)......... 6,000 11,000
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........... 18,401,304 18,341,589
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)..... 18,401,304 18,341,589
30 Total liabilities and net assets/fund balances (see instructions). 18,407,304 18,352,589
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
18,401,304
2
Enter amount from Part I, line 27a .....................
2
169,314
3
Other increases not included in line 2 (itemize) bullet
3
 
4
Add lines 1, 2, and 3 ..........................
4
18,570,618
5
Decreases not included in line 2 (itemize) bulletClick to see attachment
5
229,029
6
Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 29 .
6
18,341,589
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.)
1 a RJ Noncovered P 2000-01-01 2021-01-01
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 1,145,658   84,180 1,061,478
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       1,061,478
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 1,061,478
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  
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 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 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 16,629
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 16,629
6 Credits/Payments:
a 2021 estimated tax payments and 2020 overpayment credited to 2021 6a 28,000
b Exempt foreign organizations—tax withheld at source...... 6b  
c Tax paid with application for extension of time to file (Form 8868)... 6c 14,000
d Backup withholding erroneously withheld ........... 6d  
7 Total credits and payments. Add lines 6a through 6d.............. 7 42,000
8 Enter any penalty for underpayment of estimated tax. Check here if Form 2220 is attached. Click to see attachment 8 167
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 25,204
11 Enter the amount of line 10 to be: Credited to 2022 estimated taxBullet25,204 RefundedBullet 11  
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. 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 XIV..................................
    7
    Yes
     
    8a
    Enter the states to which the foundation reports or with which it is registered (see instructions)
    bullet
    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
     
    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 (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 addressbulletN/A
    14
    The books are in care ofbulletJohn M Jacquemin Telephone no.bullet (703) 917-0289

    Located atbullet8609 Westwood Center Drive Suite 45ViennaVA ZIP+4bullet22182
    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 2021, 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 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
     
    No
    c
    ........bullet
    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 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? ..............................
    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
    .........bullet
    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
     
    No
    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
    John M Jacquemin Manager
    0.00     		0    
    8609 Westwood Center Dr 450
    Vienna,VA22182
    Tracie J Jaquemin Secretary
    1.00     		0    
    8609 Westwood Center Dr 450
    Vienna,VA22182
    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 (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
    NONE
    Total number of others receiving over $50,000 for professional services.............bullet  
    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  
    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.........................bullet  
    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
    13,306,886
    b
    Average of monthly cash balances.......................
    1b
    6,218,994
    c
    Fair market value of all other assets (see instructions)................
    1c
    11,480
    d
    Total (add lines 1a, b, and c).........................
    1d
    19,537,360
    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
     
    3
    Subtract line 2 from line 1d.........................
    3
    19,537,360
    4
    Cash deemed held for charitable activities. Enter 1.5% (0.015) of line 3 (for greater amount, see
    instructions) .............................
    4
    293,060
    5
    Net value of noncharitable-use assets. Subtract line 4 from line 3. .......
    5
    19,244,300
    6
    Minimum investment return. Enter 5% (0.05) of line 5................
    6
    962,215
    Part X
    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 IX, line 6..................
    1
    962,215
    2a
    Tax on investment income for 2021 from Part V, line 5.......
    2a
    16,629
    b
    Income tax for 2021. (This does not include the tax from Part V.) ...
    2b
     
    c
    Add lines 2a and 2b............................
    2c
    16,629
    3
    Distributable amount before adjustments. Subtract line 2c from line 1............
    3
    945,586
    4
    Recoveries of amounts treated as qualifying distributions................
    4
     
    5
    Add lines 3 and 4............................
    5
    945,586
    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
    945,586
    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 7 945,586
    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...... 46,833
    e From 2020......  
    f Total of lines 3a through e ........ 46,833
    4Qualifying distributions for 2021 from Part
    XI, line 4: bullet$ 1,027,000
    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)........     		0
    d Applied to 2021 distributable amount..... 945,586
    e Remaining amount distributed out of corpus 81,414
    5 Excess distributions carryover applied to 2021.    
    (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 5 128,247
    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 ..........     		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 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 ......     		128,247
    10 Analysis of line 9:
    a Excess from 2017....  
    b Excess from 2018....  
    c Excess from 2019.... 46,833
    d Excess from 2020....  
    e Excess from 2021.... 81,414
    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 ....... 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) 2021 (b) 2020 (c) 2019 (d) 2018
             
    b 85% (0.85) of line 2a .........          
    c Qualifying distributions from Part XI,
    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 IX, 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 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.)
    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).)
    John M Jacquemin
    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:
    John M Jacquemin
    8609 Westwood Center Drive Suite 45
    Vienna,VA22182
    (703) 917-0707
    bThe form in which applications should be submitted and information and materials they should include:
    No form required
    cAny submission deadlines:
    None
    dAny restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other
    factors:
    no
    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)
    aPaid during the year
    Main Street Child Development Cente
    4401 Sideburn Road
    Fairfax,VA22030     		None 501(c)(3) Main Street provides 3,000 hours of nationally-accredited educational instruction and enrichment for at-risk children (ages 2 to 5) each year. 10,000
    Martha's Table Inc
    2114 14th Street NW
    Washington DC,DC20009     		None 501(c)(3) Marthas Table transforms lives by engaging the community in developing sustainable solutions to poverty. They meet core needs of their clients with education, nutrition, clothing, and family support programs that prepare young people, from infancy through adulthood, for a promising future. 5,000
    Rappahannock Animal Welfare League
    PO Box 396
    Amissville,VA20106     		None 501(c)(3) To assist in the rescue of at risk animals and the maintenance of an animal shelter. 2,000
    Bright Beginnings
    128 M Street NW Ste 150
    Washington,DC20001     		None 501(c)(3) Provides safe, nurturing environment and childcare for homeless infants, toddlers, and preschoolers and helps their parents to end their homelessness. 30,000
    Kenya Education Fund KEF
    PO Box 7015
    Mclean,VA22106     		None 501(c)(3) Funds the high school education of 40 needy and nomadic students in Kenya. 30,000
    Kid Pan Alley
    PO Box 38
    Washington,VA22747     		None 501(c)(3) Funds the process of inspiring and empowering children to work together to become creators of their own music and rekindles creativity as a core value in education. 25,000
    Inner City Inner Child
    3133 Dumbarton Street NW
    Washington,DC20007     		None 501(c)(3) Provides books for childrenigniting a passion for reading and creating a literacy-rich environment for the youngest children by working with child care centers where the kids spends most of their day. 5,000
    University at Buffalo BNAC
    PO Box 730
    Buffalo,NY14226     		None 501(c)(3) Supports the Buffalo Neuroimaging Analysis Center Fund in the School of Medicine and Biomedical Sciences in particular research in multiple sclerosis. This research allows clinicians, researchers and medical students from around the world to advance their understanding of multiple sclerosis and other diseases of the brain, spinal cord and optic nerve . 20,000
    Second Story
    PO Box 694
    Dun Loring,VA22027     		None 501(c)(3) Funds shelter for runaway, abused and homeless teens by offering safe and accessible places where teens can get help, development important life skills, and improve family relationships. 10,000
    Homestretch
    303 South Maple Ave Suite 400
    Falls Church,VA22046     		None 501(c)(3) Empowers homeless families to return to stable housing and self-sufficiency by providing them with the skills to become productive participants in Northern Virginia. 15,000
    The Elephant Sanctuary
    27 East Main St
    Hohenwald,TN38462     		None 501(c)(3) The nations largest natural habitat refuge developed specifically for African and Asian elephants. It provides captive elephants a natural habitat, individualized care and the opportunity to live out their lives in a safe haven dedicated to their wellbeing. 5,000
    Hopecam
    12100 Sunset Hills Rd C10
    Reston,VA20190     		None 501(c)(3) Hopecam connects children undergoing treatment for cancer with their friends at school usingtablet computers, high speed internet connections and web cameras. 5,000
    Rappahannock Pantry
    602 Mt Salem Ave
    Washington,VA22747     		None 501(c)(3) distributes food to residents in need. 10,000
    The Arc of Northern Virginia
    2755 Harland Road Suite 200
    Falls Church,VA22043     		None 501(c)(3) To promotes and protect the human right of people. 10,000
    ArtStream
    8401 Connecticut Ave 1230
    Chevy Chase,MD20815     		None 501(c)(3) To creates artistic opportunities for communities underserved by the arts, mainly individuals with disabilities. 10,000
    Headwaters
    12018 Lee Hwy
    Sperryville,VA22740     		None PF To foster educational excellence in Rappahannock County by cultivating the cooperative spirit and resources of the whole community to benefit all students. 10,000
    Inova Kellar
    11204 Waples Mill Rd
    Fairfax,VA22030     		None 501(c)(3) Inova Kellar Center has provided behavioral health services for children, adolescents and their families for twenty years. Our comprehensive mental health and substance abuse treatment programs and an innovative special education school support families throughout Northern Virginia and continue to expand to meet future needs. 5,000
    RAAC
    PO Box 24
    Washington,VA22747     		None 501(c)(3) RAAC is an organization in Rappahannock country that focuses on enhancing the lives of the community through exposure to and participation in the arts. 5,000
    SAGWA Suzuki Association
    2349 Belleview Ave
    Cheverly,MD20785     		None 501(c)(3) To improving childrens lives through music education. Our mission is to inspire an appreciation for the untapped possibilities of children through promoting the understanding and use of the music teaching approach and educational philosophy of Dr. Shinichi Suzuki for the greater happiness of all children. 3,000
    A Forever Home Rescue
    PO Box 22801
    Chantilly,VA20153     		None 501(c)(3) To rescue puppies and dogs from hoaders and backyard breeders, owner surrenders and shelters. 2,000
    Castleton Festival
    663 Castlton View Road
    Castleton,VA22716     		None 501(c)(3) Host the artists, singers, musicians, conductors,designers,directors and stage technician on the picturesque where they create and produce world.class performances. 2,000
    Child Care Learning Center of Rappa
    12763 Lee Highway PO Box 520
    Washington,VA22747     		None 501(c)(3) To provide early childhood programs. 30,000
    SafeSpot Children's Advocacy Center
    PO Box 148
    Fairfax,VA22038     		None 501(c)(3) To provide direct services to child victims of sexual abuse and severe physical abuse. 7,000
    Woft Trap Institute for Early Learn
    1635 Trap Rd
    Vienna,VA22182     		None 501(c)(3) To provide innovative arts-based teaching strategies and services to early chilhood teachers, caregivers, parents, and their children through the disciplines of drama, music, and movement. 10,000
    Assistance League of Northern Virgi
    PO Box 209
    Herdon,VA20172     		None 501(c)(3) To feed, cloth and educate children in need in our community. 5,000
    Fairfax County Animal Shelter
    4500 West Ox Rd
    Fairfax,VA22030     		None 501(c)(3) To provide a safe-haven for dogs, cats, and small animals like guinea pigs, rabbits and pet birds 2,000
    RappCats
    PO Box 307
    Washington,VA22747     		None 501(c)(3) To manage the daily operations of the Rappahannock County animal shelter 3,000
    Friend of Guest House
    1 E Luray Ave
    Alexandria,VA22301     		None 501(c)(3) Guest House helps Northern Virginia women make successful transitions from incarceration back into the community. The program focuses on issues ranging from trauma and addiction to housing and employment, in order to prevent the women from reoffending in the future. Fewer than 10% of Guest House graduates re-offend. 20,000
    Piedmont Environmental Council
    45 Horner St
    Warrenton,VA20186     		None 501(c)(3) To promote and protect the Piedmont area's rural economy, natural resources, history, and beauty. The organization was founded in 1972. 10,000
    RLEP
    PO Box 9
    Washington,VA22747     		None 501(c)(3) To preserving the natural resources and rural character of Rappahannock County, Virginia. 5,000
    THEARC
    1901 Mississippi Ave SE
    Washington,DC20020     		None 501(c)(3) To improve the quality of life for residents of Ward 8, and is home to eleven of Washington, DC's best nonprofit agencies, all of which share the goal of helping children and adults reach their full potential. 20,000
    World Central Kitchen
    1875 Connecticut Ave NW 10th Fl
    Washington,DC20009     		None 501(c)(3) A group of chefs creating smart solutions to hunger and poverty. -15,000
    Kiss the Ground
    4312 W Jefferson Blvd
    Los Angeles,CA90016     		None 501(c)(3) Kiss the Ground is a California-based 501(c)(3) environmental non-profit telling a new story about our ability to regenerate land and reverse climate change by building back healthy soil. We create media, campaigns and educational curriculum that raise awareness and empower individuals to take action. 5,000
    Orphan Kitten Project
    1 Schields Ave
    Davis,CA95617     		None 501(c)(3) The Orphan Kitten Project is an entirely student run rescue organization based out of the UC Davis School of Veterinary Medicine. Their mission is to rescue kittens that are too young to be taken into shelters (less than 8 weeks of age) and raise them in foster homes until they are old enough to be adopted. 1,000
    Rapp at Home
    PO Box 193
    Washington,VA22747     		None 501(c)(3) Rapp at Homes mission is to sustain and enrich Rappahannock County residents who are members of Rapp at Home to age in the community comfortably, safely, independently and with peace of mind by fostering the community supports and services needed to do so. 10,000
    Safe Shores
    429 O Street NW
    Washington,DC20001     		None 501(c)(3) Safe Shores is dedicated to working with and advocating for children and adolescents affected by trauma and violence. 5,000
    Belle Meade Montessory School
    353 FT Valley Rd
    Sperryville,VA22740     		None 501(c)(3) Belle Meade Montessori School provides an exceptional education that emphasizes individual responsibility as well as social and environmental consciousness through experiential learning. 25,000
    Boston Home
    2049 Dorchester Ave
    Boston,MA02124     		None 501(c)(3) The Boston Home is a national model for the care of adults with advanced progressive neurological diseases, primarily Multiple Sclerosis. It provides the highest level of care in a specialized residential facility and is one of few in the nation that does so. 10,000
    Mental Health Association of Fauqui
    321 Walker Dr
    Warrenton,VA20186     		None 501(c)(3) Mental Health Assocation of Fauquier County provides mental health and addiction and substance use resources in Fauquier, Rappahannock, and nearby areas. They promote and facilitate mental wellness in the communities they serve primarily Fauquier and Rappahannock counties in Virginia. 5,000
    Castleton Community Volunteer Fire
    593 Castleton View Road
    Castleton,VA22716     		None 501(c)3 Castleton Community Volunteer Fire Company was established in 1956 as a Fire Company and later added EMS Transport capabilities and continues today as a Fire and Rescue Company. 5,000
    Chaska USA
    844 Summerfield Dr
    Roselle,IL60172     		None 501(c)(3) Chaska, USA provides disaster relief. 15,000
    First Nations Development Institute
    2432 Main St 2nd Floor
    Longmont,CO80501     		None 501(c)(3) First Nations mission is to strengthen American Indian economies to support healthy Native communities. We invest in and create innovative institutions and models that strengthen asset control and support economic development for American Indian people and their communities. 10,000
    Rappahannock Communities
    15 Over Jordan Farm Lane
    Flint Hill,VA22627     		None 501(c)(3) Rappahannock communities mission is to work collaboratively toward the creation of lasting solutions for at-risk families, children and individuals in rappahannock. rc will advocate for a continuum of housing and a variety of services to improve the heath, well-being and stability of those it serves. 25,000
    Scrabble School
    PO Box 356
    Sperryville,VA22740     		None 501(c)(3) The Scrabble School Preservation Foundation's mission is to preserve the school's history and to share its legacy through public outreach and educational programs. 2,000
    Insight Memory Care Center
    3953 Pender Dr Ste 100
    Fairfax,VA22030     		None 501(c)(3) Insight Memory Care Center (IMCC) is a nonprofit adult day health and resource center providing specialized care, support, and education for individuals with Alzheimers. 10,000
    Cheyenne River Youth Project
    PO Box 410 702 4th Street
    Eagle Butte,SD57625     		None 501(c)(3) The mission of the Cheyenne River Youth Project is to give the Lakota youth of the Cheyenne River Sioux reservation access to a vibrant and secure future through our culturally sensitive programs, projects, and facilities ensuring strong, self-sufficient families and communities. 5,000
    Soul Fire Farm Institute Inc
    1972 Ny Highway 2
    Petersburg,NY12138     		None 501(c)(3) Soul Fire Farm is committed to ending racism and injustice in the food system. We raise life-giving food and act in solidarity with people marginalized by food apartheid. With deep reverence for the land and wisdom of our ancestors, we work to reclaim our collective right to belong to the earth and to have agency in the food system. We bring diverse communities together on this healing land to share skills on sustainable agriculture, natural building, spiritual activism, health and environmental justice. We are training the next generation of activist-farmers and strengthening the movements for food sovereignty and community self-determination. 10,000
    Norcal Resist Fund
    PO Box 188331
    Sacramento,CA95818     		None 501(c)(3) Norcal Resist is community members organizing for a better world, and we invite you to join us. We believe that as activists and organizers, we must not only stand in opposition to policies, politicians, and systems that harm our communities, but also begin building the better world we want to live in. That's why it's our mission to fight injustice through making a positive impact in our communities. We host educational events and trainings, organize actions, and maintain a variety of resources and programs that provide support to those in need. 10,000
    Greenwave Organization Corp
    315 Front St
    New Haven,CT06513     		None 501(c)(3) Greenwaves mission is the development and implementation of education programs in the fields of ocean restoration, ocean farming, climate change, and sustainable food sources. 2,500
    Saddles Smiles Inc
    155 Bensland Rd
    Davis,WV26260     		None 501(c)(3) Our Mission is to provide equine assisted learning experiences for children, teens, and young adults living with a variety of challenges so that each participant can reach his or her highest potential. 2,500
    Silvie Bells Inc
    7546 Sally Lyn Ln
    Lake Worth,FL33467     		None 501(c)(3) Silvie Bell's mission is to give families with sick and preemie babies in the Neonatal Intensive Care Unit (NICU) care packages, including a home pulse-oxemitry monitor to keep track of medically fragile baby's vitals. 1,000
    Gender Health Center
    2020 29th St Ste 201
    Sacramento,CA95817     		None 501(c)(3) The Gender Health Center is committed to creating access to healthcare for all as an act of social justice. To affect change that alleviates the systematic oppression of transgender people- especially those at the intersection of identities- through advocacy and direct services, while using a mental health-centered model and social justice lens. 10,000
    Sogorea Te Land Trust
    2501 Harrison St
    Oakland,CA94612     		None 501(c)(3) Sogorea Te Land Trust is an urban Indigenous women-led land trust based in the San Francisco Bay Area that facilitates the return of Indigenous land to Indigenous people. Through the practices of rematriation, cultural revitalization, and land restoration, Sogorea Te calls on native and non-native peoples to heal and transform the legacies of colonization, genocide, and patriarchy and to do the work our ancestors and future generations are calling us to do. 5,000
    Maine Childrens Home for Little Wan
    93 Silver St
    Waterville,ME04901     		None 501(c)(3) Maine Childrens Homes mission is to build and strengthen families and their children, instilling hope for the future and a better quality of life. 1,000
    Serendipity Equine Inc
    162 Rollins Ford Rd
    Amissville,VA20106     		None 501(c)(3) Serendipity Equine strives to develop Educational and Equine-Assisted Learning programs and to meet a growing need for rescue and rehabilitation services, which partners youth and their families, veterans, first-responders and their families with rehabilitated equines. To create programs in which each participant and horse will be treated as an individual and they themselves will determine how quickly or slowly their training takes place. Serendipitys goal is to provide these programs to the community at large regardless of social or economic standing and create an inclusive community equestrian center where integration, not segregation, of individuals at-risk or those with disabilities is the rule. 5,000
    Sango-Kenya Inc
    196 Walnut Grove Ln
    Washington,VA22747     		None 501(c)(3) SANGO-Kenya partners with the most vulnerable communities to help them become resilient to the acute and long-term effects of climate and other shocks on farming and nutrition. 5,000
    Baileys Crossroads Health AccessCul
    PO Box 8332
    Falls Church,VA22041     		None 501(c)(3) The clinic provides high quality, culturally appropriate health services to the uninsured individuals in low-income communities in Northern Virginia the clinic, provides vital service, vital navigation, and vital education to achieve improved health outcomes for the Bailey's Crossroads community of Fairfax County of Virginia.The clinic provides high quality, culturally appropriate health services to the uninsured individuals in low-income communities in Northern Virginia the clinic, provides vital service, vital navigation, and vital education to achieve improved health outcomes for the Bailey's Crossroads community of Fairfax County of Virginia 5,000
    Arlington Free Clinic Inc
    2921 11th Street South
    Arlington,VA22204     		None 501(c)(3) Arlington Free Clinic provides free, high-quality medical care to low-income, uninsured Arlington County adults through the generosity of donors and volunteers. 5,000
    Capital Area Food Bank CAFB
    4900 Puerto Rico Avenue NE
    Washington,DC20017     		None 501(c)(3) The mission of the Capital Area Food Bank is to create access to good, healthy food in every community. 5,000
    Greater DC Diaper Bank
    1532 A Street NE
    Washington,DC20002     		None 501(c)(3) Greater DC Diaper Bank empowers families and individuals in need throughout DC, Maryland, and Virginia by providing an adequate and reliable source for basic baby needs and personal hygiene products. 5,000
    Miriam's Kitchen
    2401 Virginia Avenue NW
    Washington,DC20037     		None 501(c)(3) Miriam's Kitchen works to end chronic (long-term) homelessness in Washington DC. From meals to housing, we provide a variety of services to honor the dignity of people experiencing homelessness, create a place of belonging and achieve long term change. Unlike most organizations that provide services directly to people experiencing homelessness in DC, we work at the system level to address root causes and to bring about change. We are pleased to be part of a cross-sector partnership that has brought down veteran homelessness 40% and chronic homelessness 22% since 2013. Our mission is to collaborate across sectors to end all chronic homelessness in our nation's capital. 5,000
    Nirvana Ridge Ferret Rescue
    19524 Swamp Poodle Lane
    Brandy Station,VA22714     		None 501(c)(3) The Nirvana Ridge Ferret Rescue (NRFR) is a registered 501(c)(3) non-profit and no-kill animal welfare organization, established to benefit the domestic ferret (Mustela putorius furo). Our mission is to protect and provide for any ferret(s) in need, regardless of health, age or origin, until a permanent loving home can be found. Our mission includes the educational promotion of the domestic ferret as extraordinary, curious and endearing pets. 1,000
    PathForward Inc A-SPAN
    PO Box 10073
    Arlington,VA22210     		None 501(c)(3) PathForward's mission is to secure permanent housing and provide life-sustaining services for Arlingtons most vulnerable individuals through outreach and relationships built on trust and respect. 10,000
    ALIVE
    2723 King Street
    Alexandria,VA22302     		None 501(c)(3) ALIVE!s mission is to help Alexandrians faced with emergency situations or long-term needs become capable of assuming self-reliant roles in the community. ALIVE!s programmatic work focuses on the following service areas: Food, Shelter, and Emergency Help. 10,000
    Casa Ruby Inc
    7530 Georgia Avenue NW
    Washington,DC20012     		None 501(c)(3) Casa Rubys mission is to create success life stories among transgender, genderqueer, gender non-conforming, gay, lesbian and bisexual individuals. Our vision is to create a world where transgender, genderqueer, and gender non-conforming people pursue their dreams and achieve success in their lives without fear of discrimination, harassment, or violence due to their sexual orientation and or gender identity/gender expression. 10,000
    Arlington Food Assistance Center AF
    PO Box 6261
    Arlington,VA22206     		None 501(c)(3) AFAC is an independent, community-based non-profit food pantry that provides dignified access to nutritious supplemental groceries to all our Arlington neighbors in need. In doing so, AFAC makes it possible for vulnerable families in our community to devote their limited resources to financial obligations such as housing, utilities, and other basic needs. 5,000
    Acclerated Cure Project
    460 Totten Pond Rd STE 140
    Waltham,MA02451     		None 501(c)(3) The Accelerated Cure Project for MS believes that research is the only way to greatly improve the outlook for people with MS. The organization promotes scientific collaboration and accelerates research by rapidly and cost-effectively providing researchers with data and biospecimens they need to explore novel research ideas that can lead to better care for people with MS. 10,000
    Allegheny Mountain Institute
    PO Box 542
    Staunton,VA24402     		None 501(c)(3) Allegheny Mountain Institute (AMI) is an educational non-profit organization with the mission to cultivate healthy communities through food and education. The vision of AMI is a thriving network of collaborative, vibrant communities who value the connection between food and health. 2,500
    Association for Colonial Theater
    PO Box 712
    Phoenixville,PA19460     		None 501(c)(3) The Association for the Colonial Theaters mission is to nurture community by celebrating the power of film and the performing arts to entertain, inform and reveal meaning. 2,000
    Blue Ridge Wildlife Center
    106 Island Farm Land
    Boyce,VA22620     		None 501(c)(3) Blue Ridge Wildlife Center (BRWC) embraces the compelling mission of caring for native wildlife by integrating veterinary medicine, rehabilitation, education, and research. We are a full-service wildlife teaching hospital and rehabilitation facility that cares for native wildlife by treating animals in need and by educating citizens on how to protect animals and their habitat in perpetuity. With these two goals, we aim for greater native biodiversity and healthy ecosystems for the benefit of all living things. 2,500
    Caring for Kids
    237 Eldorado Ave
    Firecrest,WA98466     		None 501(c)(3) Caring For Kids' mission is to raise happy, healthy, productive kids who are ready to learn. We do this by providing support to school children in need with clothing, emergency food, school supplies and other necessities to be successful in school. 2,000
    Calvary Women's Services
    1217 Good Hope Road SE
    Washington,DC20020     		None 501(c)(3) Calvary Womens Services empowers homeless women in Washington, DC, to transform their lives through housing, health, education, and employment programs. Calvary is committed to providing these services in Anacostia, a neighborhood with the highest poverty rate in the District. Their programs are designed for women who are survivors of violence and trauma, are living with mental illness, or are in recovery from substance addiction. 5,000
    Curtis Institute
    1726 Locust Street
    Philadelphia,PA19103     		None 501(c)(3) The mission of the Curtis Institute of Music is to educate and train exceptionally gifted young musicians to engage a local and global community through the highest level of artistry. 2,000
    District Alliance for Safe Housing
    PO Box 91730
    Washington,DC20090     		None 501(c)(3) The District Alliance for Safe Housing (DASH) is an innovator in providing access to safe housing and services for survivors of domestic and sexual violence and their families as they rebuild their lives on their own terms. We envision a culture where safe housing is a human right shared by everyone. 10,000
    Dreaming Out Loud
    3015 Upton Dr
    Kensington,MD20895     		None 501(c)(3) Crossway Community is a prepared environment, intentionally designed and maintained to be conducive to healthy family interaction healthy development for all ages. Practical Life Skills Coordinators work with FLA mothers to set up and maintain their apartments according to Montessori principles of order, independence, and respect, and reduced stress for the mothers. A robust parent education initiative (including a partnership agreement) is a cornerstone of our Montessori school. Parents and children work together in the on-site garden, learning about healthy eating and nutrition while planting and harvesting vegetables, and celebrating the community through regular social gatherings and celebrations. 2,500
    FAIR Girls
    2021 L Street NW 254
    Washington,DC20036     		None 501(c)(3) FAIR Girls (formerly FAIR Fund) prevents the exploitation of girls with empowerment and education. Through prevention education, compassionate care, and survivor inclusive advocacy, FAIR Girls creates opportunities for girls to become confident, happy, healthy young women. 5,000
    Family Futures
    PO Box 570
    Sperryville,VA22740     		None 501(c)(3) Family Futures mission is to provide financial education, access and tools to residents of Rappahannock County 10,000
    The Fauquier Free Clinic Inc
    PO Box 3138
    Warrenton,VA20188     		None 501(c)(3) The Free Clinic offers quality medical, dental, and mental health care to residents of Fauquier and Rappahannock Counties who lack appropriate alternatives for these services. 5,000
    Free Clinic of Culpeper
    610 Laurel St Ste 3
    Culpeper,VA22701     		None 501(c)(3) Free Clinic of Culpepers mission is to provide out-patient medical care. 5,000
    George Mason University
    4400 University Drive
    Fairfax,VA22030     		None 501(c)(3) George Mason University is a Virginia public higher-education institution. It is the largest public research institution in the state. 226,000
    Give Directly - Georgia Resilience
    Church Street Station PO Box 3221
    New York,NY10008     		None 501(c)(3) The GRO Fund was founded in 2021 and was born out of the work of an Atlanta based Task Force examining inequality in the city. The GRO fund address gap between policy makers, experts, and impacted communities by convening this actors around bold, actionable, community-based initiative and policies. 10,000
    Health Tree Foundation
    1525 Newton St NW
    Washington,DC20010     		None 501(c)(3) The Homeless Children's Playtime Project cultivates resilience in children experiencing family homelessness by providing and expanding access to transformative play experiences. They partner with transitional housing and emergency shelters across the city, where we create safe and fun play spaces in the shelters where the children live. 25,000
    International Myeloma Foundation
    12650 Riverside Dr Ste 206
    North Hollywood,CA91607     		None 501(c)(3) The Mission of the International Myeloma Foundation (IMF) is to improve the quality of life of myeloma patients while working toward prevention and a cure. 20,000
    Jubilee Jumpstart
    2525 Ontario Road NW
    Washington,DC20009     		None 501(c)(3) Jubilee JumpStart is a childcare and education center (located in an affordable housing building) serving low-income families in Washington DCs Ward 1. 10,000
    Kids in Distress
    819 NW 26th Street
    Wilton Manors,FL33305     		None 501(c)(3) Kids in Distress mission is to prevent child abuse, preserve the family and treat children who have been abused and neglected. 10,000
    Kitsap Rescue Mission
    PO Box 1497
    Bremerton,WA98337     		None 501(c)(3) Kitsap Rescue Mission exists to assist the homeless and poor of Kitsap County as they work toward restoration of body, mind and spirit through Christ centered programs. 2,500
    Meals on Wheels
    6909 Laurel Ave 5348
    Takoma Park,MD20913     		None 501(c)(3) We deliver delicious, healthy meals to our homebound neighbors. 5,000
    Public Education Foundation Penn Di
    4350 South Maryland Parkway
    Las Vegas,NV89119     		None 501(c)(3) The Public Education Foundation partners with the community and the Clark County School District to meet immediate, critical education needs that will strengthen our public schools. 50,000
    Rapp Trails
    710 Batle Mountain Road
    Amissville,VA20106     		None 501(c)(3) RappTrails mission is to make the outdoors accessible for Rappahannock County residents and visitors of all ages to safely enjoy walking, jogging, and biking for education, health, fitness, and community through establishment of a public trail system. 1,000
    Smithsonian Institute
    PO Box 418320
    Boston,MA02241     		None 501(c)(3) The Smithsonian Conservation Biology Institute (SCBI) plays a leading role in the Smithsonians global efforts to save wildlife species from extinction and train future generations of conservationists. SCBI spearheads research programs at its headquarters in Front Royal, Virginia, the Smithsonians National Zoo in Washington, D.C., and at field research stations and training sites worldwide. SCBI scientists tackle some of todays most complex conservation challenges by applying and sharing what they learn about animal behavior and reproduction, ecology, genetics, migration and conservation sustainability. 20,000
    Sexual Minority Youth Assistance Le
    410 7th Street SE
    Washington,DC20003     		None 501(c)(3) SMYAL supports and empowers lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth in the Washington, DC metropolitan region. Through youth leadership, SMYAL creates opportunities for LGBTQ youth to build self-confidence, develop critical life skills, and engage their peers and community through service and advocacy. Committed to social change, SMYAL builds, sustains, and advocates for programs, policies, and services that LGBTQ youth need as they grow into adulthood. 5,000
    Their Voice
    109 Oak St
    Bremerton,WA98310     		None 501(c)(3) The mission of "Their Voice" is to educate, network, and advocate for the health, happiness and protection of companion animals. We do this by virtue of public outreach, education, advocacy and by working in conjunction with like minded organizations in pursuance of fundraising and donation of crucial supplies. 2,000
    Virginia Native Plant Society
    400 Blandy Farm Ln Unit 2
    Boyce,VA22620     		None 501(c)(3) The Virginia Native Plant Society is dedicated to the protection and preservation of the native plants of Virginia and their habitats, in order to sustain for generations to come the integrity of the Commonwealths rich natural heritage of ecosystems and biodiversity for purposes of enjoyment, enlightenment, sustainable use, and our own very survival. 2,500
    Wesley Housing Development Corp of
    5515 Cherokee Ave Ste 200
    Alexandria,VA22312     		None 501(c)(3) Wesley Housing builds up the lives of our most vulnerable community members by creating and operating healthy, supportive, stable, affordable housing communities. 10,000
    Wild Virginia Incorporated
    PO Box 1065
    Charlottesville,VA22903     		None 501(c)(3) Wild Virginia Incorporateds mission is protecting and connecting Virginia's wild lands and waters. 2,500
    Total .................................bullet 3a 1,027,000
    bApproved for future payment
    Total .................................bullet 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.)
    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 2,077  
    4 Dividends and interest from securities ....          
    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 ............     		        1,061,478
    9 Net income or (loss) from special events:          
    10 Gross profit or (loss) from sales of inventory          
    11 Other revenue:
    aInv fee reimbursement     		         
    b
    c
    d
    e
    12 Subtotal. Add columns (b), (d), and (e) ..   169,333 1,061,478
    13Total. Add line 12, columns (b), (d), and (e)..................
    13
    1,230,811
    (See worksheet in line 13 instructions to verify calculations.)
    Part XV-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 XV-A contributed importantly to
    the accomplishment of the foundation’s exempt purposes (other than by providing funds for such purposes). (See
    instructions.)
    4 Safe investments of assets
    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? ...........
    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 (2021)
    Additional Data


    Software ID: 21013475
    Software Version: 2021v4.1


    Form 990PF - Special Condition Description:
    Special Condition Description

    TY 2021 AccountingFeesSchedule
    Name:
    The Jacquemin Family Foundation Inc
    EIN:
    54-1887187
    Software ID:
    21013475
    Software Version:
    2021v4.1
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    Accounting fees 4,965 4,965 0 0

    TY 2021 OtherDecreasesSchedule
    Name:
    The Jacquemin Family Foundation Inc
    EIN:
    54-1887187
    Software ID:
    21013475
    Software Version:
    2021v4.1
    Description Amount
    Unrealized loss on investments 229,029


    TY 2021 OtherExpensesSchedule
    Name:
    The Jacquemin Family Foundation Inc
    EIN:
    54-1887187
    Software ID:
    21013475
    Software Version:
    2021v4.1
    Description Revenue and Expenses per Books Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    Bank Service Charges 40 40    
    Filing Fees 146 146    
    Membership Dues 1,820 1,820    


    TY 2021 TaxesSchedule
    Name:
    The Jacquemin Family Foundation Inc
    EIN:
    54-1887187
    Software ID:
    21013475
    Software Version:
    2021v4.1
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    Federal tax expense 27,526 27,526