Form990-PF


Department of the Treasury
Internal Revenue Service

Return of Private Foundation
or Section 4947(a)(1) Trust Treated as Private Foundation
bulletDo not enter social security numbers on this form as it may be made public.
bulletGo to www.irs.gov/Form990PF for instructions and the latest information.
OMB No. 1545-0047
2021
Open to Public Inspection
For calendar year 2021, or tax year beginning 01-01-2021 , and ending 12-31-2021
Name of foundation
PROVIDENT HEALTH FOUNDATION
OF MARINETTE/MENOMINEE INC
Number and street (or P.O. box number if mail is not delivered to street address)962 1ST STREET
  Room/suite
City or town, state or province, country, and ZIP or foreign postal code
MENOMINEE, MI49858
A Employer identification number

83-4140310
B Telephone number (see instructions)

(906) 424-4028
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$19,470,742J 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) 15,299
2 Check bullet.............
3 Interest on savings and temporary cash investments 17,430 17,430  
4 Dividends and interest from securities... 294,179 294,179  
5a Gross rents............      
b Net rental income or (loss)  
6a Net gain or (loss) from sale of assets not on line 10 552,670
b Gross sales price for all assets on line 6a 1,251,204
7 Capital gain net income (from Part IV, line 2)... 552,670
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)....... Click to see attachment 2,029 0 0
12 Total. Add lines 1 through 11........ 881,607 864,279 0
Operating and Administrative Expenses 13 Compensation of officers, directors, trustees, etc. 44,172 22,086 0 22,086
14 Other employee salaries and wages......        
15 Pension plans, employee benefits.......        
16a Legal fees (attach schedule)......... Click to see attachment 150 75 0 75
b Accounting fees (attach schedule)....... Click to see attachment 3,000 1,500 0 1,500
c Other professional fees (attach schedule).... Click to see attachment 54,975 51,066 0 3,909
17 Interest...............        
18 Taxes (attach schedule) (see instructions)...        
19 Depreciation (attach schedule) and depletion...      
20 Occupancy.............. 9,677 9,677 0 0
21 Travel, conferences, and meetings....... 332 0 0 332
22 Printing and publications..........        
23 Other expenses (attach schedule)....... Click to see attachment 19,035 144 0 17,299
24 Total operating and administrative expenses.
Add lines 13 through 23.......... 131,341 84,548 0 45,201
25 Contributions, gifts, grants paid....... 2,260,540 2,260,540
26 Total expenses and disbursements. Add lines 24 and 25 2,391,881 84,548 0 2,305,741
27 Subtract line 26 from line 12:
a Excess of revenue over expenses and disbursements -1,510,274
b Net investment income (if negative, enter -0-) 779,731
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
Assets 1 Cash—non-interest-bearing.............      
2 Savings and temporary cash investments......... 10,418,537 6,644,492 6,644,492
3 Accounts receivable bullet  
Less: allowance for doubtful accounts bullet        
4 Pledges receivable bullet  
Less: allowance for doubtful accounts bullet        
5 Grants receivable.................      
6 Receivables due from officers, directors, trustees, and other
disqualified persons (attach schedule) (see instructions).....      
7 Other notes and loans receivable (attach schedule) bullet  
Less: allowance for doubtful accounts bullet        
8 Inventories for sale or use..............      
9 Prepaid expenses and deferred charges..........      
10a Investments—U.S. and state government obligations (attach schedule)      
b Investments—corporate stock (attach schedule)....... 5,029,035 Click to see attachment6,488,110 8,644,352
c Investments—corporate bonds (attach schedule)....... 3,387,729 Click to see attachment4,192,425 4,181,898
11 Investments—land, buildings, and equipment: basis bullet  
Less: accumulated depreciation (attach schedule) bullet        
12 Investments—mortgage loans.............      
13 Investments—other (attach schedule)..........      
14 Land, buildings, and equipment: basis bullet  
Less: accumulated depreciation (attach schedule) bullet        
15 Other assets (describe bullet)      
16 Total assets (to be completed by all filers—see the
instructions. Also, see page 1, item I) 18,835,301 17,325,027 19,470,742
Liabilities 17 Accounts payable and accrued expenses..........    
18 Grants payable.................    
19 Deferred revenue.................    
20 Loans from officers, directors, trustees, and other disqualified persons    
21 Mortgages and other notes payable (attach schedule)......    
22 Other liabilities (describe bullet)    
23 Total liabilities (add lines 17 through 22)......... 0 0
Net Assets or Fund Balances Foundations that follow FASB ASC 958, check here bullet
and complete lines 24, 25, 29 and 30.
24 Net assets without donor restrictions...........    
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........ 0 0
27 Paid-in or capital surplus, or land, bldg., and equipment fund 0 0
28 Retained earnings, accumulated income, endowment, or other funds 18,835,301 17,325,027
29 Total net assets or fund balances (see instructions)..... 18,835,301 17,325,027
30 Total liabilities and net assets/fund balances (see instructions). 18,835,301 17,325,027
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
18,835,301
2
Enter amount from Part I, line 27a .....................
2
-1,510,274
3
Other increases not included in line 2 (itemize) bullet
3
0
4
Add lines 1, 2, and 3 ..........................
4
17,325,027
5
Decreases not included in line 2 (itemize) bullet
5
0
6
Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 29 .
6
17,325,027
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 PUBLICLY TRADED SECURITIES P    
b CAPITAL GAINS DIVIDENDS P    
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 813,365   698,534 114,831
b 437,839     437,839
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       114,831
b       437,839
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 2 552,670
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 0
3 Add lines 1 and 2........................... 3 10,838
4 Subtitle A (income) tax (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-) 4 0
5 Tax based on investment income. Subtract line 4 from line 3. If zero or less, enter -0- ..... 5 10,838
6 Credits/Payments:
a 2021 estimated tax payments and 2020 overpayment credited to 2021 6a 4,758
b Exempt foreign organizations—tax withheld at source...... 6b 0
c Tax paid with application for extension of time to file (Form 8868)... 6c 18,000
d Backup withholding erroneously withheld ........... 6d 649
7 Total credits and payments. Add lines 6a through 6d.............. 7 23,407
8 Enter any penalty for underpayment of estimated tax. Check here if Form 2220 is attached. Click to see attachment 8 0
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 12,569
11 Enter the amount of line 10 to be: Credited to 2022 estimated taxBullet12,569 RefundedBullet 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. bullet$ 0(2) On foundation managers.bullet$ 0
e
Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed
on foundation managers.bullet$ 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
    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)
    bulletWI
    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 addressbulletWWW.PROVIDENTHEALTH.ORG
    14
    The books are in care ofbulletJOHN HOFER Telephone no.bullet (906) 424-4028

    Located atbullet962 1ST STREETMENOMINEEMI ZIP+4bullet49858
    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)
    Yes
     
    (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
    EDWARD HARDING CHAIRPERSON; DIRECTOR
    1.00     		0 0 0
    PO BOX 891
    MARINETTE,WI54143
    TERRI DERUSHA VICE-CHAIR; DIRECTOR (THROUGH AUGUST)
    0.20     		0 0 0
    PO BOX 891
    MARINETTE,WI54143
    GRETA HODGE TREASURER; DIRECTOR
    0.20     		0 0 0
    PO BOX 891
    MARINETTE,WI54143
    MARC JAMO SECRETARY; DIRECTOR
    0.10     		0 0 0
    PO BOX 891
    MARINETTE,WI54143
    KIM BROOKS DIRECTOR
    0.10     		0 0 0
    PO BOX 891
    MARINETTE,WI54143
    DAN COOK DIRECTOR
    0.10     		0 0 0
    PO BOX 891
    MARINETTE,WI54144
    JIM KORONKIEWICZ DIRECTOR
    0.10     		0 0 0
    PO BOX 891
    MARINETTE,WI54146
    DEB KROLL DIRECTOR
    0.10     		0 0 0
    PO BOX 891
    MARINETTE,WI54147
    DARREL LANCOUR DIRECTOR
    0.10     		0 0 0
    PO BOX 891
    MARINETTE,WI54148
    PENNY MULLINS DIRECTOR
    0.10     		0 0 0
    PO BOX 891
    MARINETTE,WI54149
    JENNY SHORT DIRECTOR
    0.10     		0 0 0
    PO BOX 891
    MARINETTE,WI54143
    LYNDA RASTALL DIRECTOR
    0.10     		0 0 0
    PO BOX 891
    MARINETTE,WI54143
    JOHN HOFER EXECUTIVE DIRECTOR
    15.00     		44,172 0 0
    PO BOX 891
    MARINETTE,WI54143
    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 0
    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.............bullet0
    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.........................bullet0
    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
    12,172,840
    b
    Average of monthly cash balances.......................
    1b
    7,236,477
    c
    Fair market value of all other assets (see instructions)................
    1c
    0
    d
    Total (add lines 1a, b, and c).........................
    1d
    19,409,317
    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
    19,409,317
    4
    Cash deemed held for charitable activities. Enter 1.5% (0.015) of line 3 (for greater amount, see
    instructions) .............................
    4
    291,140
    5
    Net value of noncharitable-use assets. Subtract line 4 from line 3. .......
    5
    19,118,177
    6
    Minimum investment return. Enter 5% (0.05) of line 5................
    6
    955,909
    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
    955,909
    2a
    Tax on investment income for 2021 from Part V, line 5.......
    2a
    10,838
    b
    Income tax for 2021. (This does not include the tax from Part V.) ...
    2b
     
    c
    Add lines 2a and 2b............................
    2c
    10,838
    3
    Distributable amount before adjustments. Subtract line 2c from line 1............
    3
    945,071
    4
    Recoveries of amounts treated as qualifying distributions................
    4
    0
    5
    Add lines 3 and 4............................
    5
    945,071
    6
    Deduction from distributable amount (see instructions).................
    6
    0
    7
    Distributable amount as adjusted. Subtract line 6 from line 5. Enter here and on Part XII, line 1 ...
    7
    945,071
    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 7 945,071
    2 Undistributed income, if any, as of the end of 2021:
    a Enter amount for 2020 only....... 0
    b Total for prior years:20, 20, 20 0
    3 Excess distributions carryover, if any, to 2021:
    a From 2016......  
    b From 2017......  
    c From 2018......  
    d From 2019...... 2,921,587
    e From 2020...... 2,128,303
    f Total of lines 3a through e ........ 5,049,890
    4Qualifying distributions for 2021 from Part
    XI, line 4: bullet$ 2,305,741
    a Applied to 2020, but not more than line 2a 0
    b Applied to undistributed income of prior years
    (Election required—see instructions).....     		0
    c Treated as distributions out of corpus (Election
    required—see instructions)........     		0
    d Applied to 2021 distributable amount..... 945,071
    e Remaining amount distributed out of corpus 1,360,670
    5 Excess distributions carryover applied to 2021. 0 0
    (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 6,410,560
    b Prior years’ undistributed income. Subtract
    line 4b from line 2b ..........     		0
    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......     		0
    d Subtract line 6c from line 6b. Taxable amount
    —see instructions ...........     		0
    e Undistributed income for 2019. Subtract line
    4a from line 2a. Taxable amount—see
    instructions .............     		0
    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) .......     		0
    8 Excess distributions carryover from 2016 not
    applied on line 5 or line 7 (see instructions) ...     		0
    9 Excess distributions carryover to 2022.
    Subtract lines 7 and 8 from line 6a ......     		6,410,560
    10 Analysis of line 9:
    a Excess from 2017....  
    b Excess from 2018....  
    c Excess from 2019.... 2,921,587
    d Excess from 2020.... 2,128,303
    e Excess from 2021.... 1,360,670
    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).)
    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 W HOFER
    962 1ST STREET
    MENOMINEE,MI49858
    (906) 429-4028
    JWHOFER@PROVIDENTHEALTH.ORG
    bThe form in which applications should be submitted and information and materials they should include:
    APPLICATIONS ARE TAKEN THROUGH A CLOUD BASED PORTAL, GRANTMAKER BY FOUNDANT TECHNOLOGY. THE MULTIPART APPLICATION, AVAILABLE FOR REVIEW ON THE FOUNDATION WEBSITE INCLUDES INFORMATION ABOUT THE ORGANIZATION'S MISSION, EVIDENCE OF 501C3 STATUS AND GEOGRAPHY SERVED, PROGRAM OF WORK, FINANCIAL PERFORMANCE AND FIDUCIARY PRACTICES, GOVERNING STRUCTURE, COLLABORATION PARTNERSHIP RELATIONSHIPS, SPECIFIC POPULATIONS THE GRANT SUPPORTED ACTIVITY WILL TARGET, A DESCRIPTION OF THE PROGRAM/PROJECT THE GRANT WILL SUPPORT, MEASURES OF SUCCESS AND SUSTAINABILITY PLANS FOR AFTER THE GRANT IS SPENT.
    cAny submission deadlines:
    SUBMISSION DEADLINES ARE DETAILED ON THE GRANT APPLICATION. EMAILS ARE SENT TO REGISTERED APPLICANTS
    dAny restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other
    factors:
    GRANTS ARE CONSIDERED FOR 501C3 ORGANIZATIONS, CITY AND COUNTY GOVERNMENTAL UNITS AND SCHOOL SYSTEMS. THEIR SERVICES MUST BE TARGETED TOWARDS RESIDENTS OF MARINETTE COUNTY WI AND MENOMINEE COUNTY, MI. THE IMPACT OF FUND USE IS MEANT TO IMPROVE THE LOCAL HEALTH CARE AVAILABLE TO RESIDENTS AND TO IMPROVE THEIR HEALTH.
    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
    AURORA MEDICAL CENTER-BAY AREA
    3003 UNIVERSITY DR
    MARINETTE,WI54143     		  PC HOSPITAL OPERATIONS 2,047,602
    AURORA BAY AREA EMERGENCY DEPT
    3003 UNIVERSITY DRIVE
    MARINETTE,WI54143     		  PC EVENT SPONSORSHIP 80
    AURORA HEALTH FOUNDATION
    3003 UNIVERSITY DRIVE
    MARINETTE,WI54143     		  PC JIM HODGE MEMORIAL RUN DONATIONS 8,384
    CASA BROWN COUNTYMARINETTE COUNTY
    414 E WALNUT SUITE 170
    GREEN BAY,WI54301     		  PC TO TRAIN ADDITIONAL COURT APPOINTED SPECIAL ADVOCATES THAT PROVIDE FREE SERVICES TO CHILDREN IN FOSTER CARE AND UNDER THE SUPERVISION OF THE COURT DUE TO NO FAULT OF THEIR OWN IN MARINETTE COUNTY. 21,000
    CASA OF MENOMINEE COUNTY
    PO BOX 456
    MENOMINEE,MI49858     		  PC TO TRAIN ADDITIONAL COURT APPOINTED SPECIAL ADVOCATES THAT PROVIDE FREE SERVICES TO CHILDREN IN FOSTER CARE AND UNDER THE SUPERVISION OF THE COURT DUE TO NO FAULT OF THEIR OWN IN MENOMINEE COUNTY. 19,250
    CRIVITZ FOOD PANTRY
    PO BOX 398
    CRIVITZ,WI54114     		  PC TO PROVIDE WEEKLY, HEALTHY SNACKS AS WELL AS NUTRITION EDUCATION TO THE STUDENTS OF CRIVITZ ELEMENTARY SCHOOL. 15,000
    DAR BOYS AND GIRLS CLUB
    901 8TH AVENUE
    MENOMINEE,MI49858     		  PC TO PROVIDE A SOCIAL EMOTIONAL BEHAVIORAL LEARNING STAFF MEMBER ON STAFF AT THE DAR TO HELP MEET THE SOCIAL/EMOTIONAL AND BEHAVIORAL NEEDS OF THE CHILDREN IN DAR PROGRAMMING AND TO PROVIDE THE DAR WITH THE OPPORTUNITY TO CONTRACT NORTH POINTE BEHAVIORAL CENTER'S SOCIAL BEHAVIORAL COUNSELING FOR THE CHILDREN IN DAR PROGRAMMING. 35,000
    FEEDING AMERICA
    864 WEST RIVER CENTER DRIVE NE
    COMSTOCK PARK,MI49321     		  PC TO PROVIDE MOBILE FOOD PANTRIES IN MENOMINEE COUNTY MONTHLY DURING 2022. 9,600
    GREATER MARINETTE MENOMINEE YMCA
    1600 WEST DRIVE
    MENOMINEE,MI49858     		  PC TO ESTABLISH A HEART AND SOLE SISTERS PROGRAM FOR GIRLS IN THE COMMUNITY GRADES 6-8 TO DECREASE CHILDHOOD OBESITY AND INCREASE SELF-ESTEEM, SELF-REGULATION, AND RESILIENCY AND TO PROVIDE CAPACITY BUILDING SUPPORT TO THE YMCA'S CHILDREN'S ORIENTED ACTIVITY PROGRAMMING IN AN EFFORT TO DECREASE CHILDHOOD OBESITY. 9,500
    HEALTHY YOUTH COALITION
    1201 41ST AVENUE
    MENOMINEE,MI49858     		  PC TO CONTINUE SUBSTANCE ABUSE PREVENTION PROGRAMMING IN MARINETTE AND MENOMINEE SCHOOLS. 15,000
    HOSPITAL SISTERS OF ST FRANCIS FOUNDATION
    PO BOX 11756
    GREEN BAY,WI54307     		  PC TO PROVIDE SUBSTANCE ABUSE COUNSELING TO MENOMINEE COUNTY RESIDENTS WHOSE MEDICARE/MEDICAID WILL NOT PAY FOR MARINETTE TREATMENT SERVICES AT HSHS LIBERTAS. 11,000
    JIM HODGE RUN
    PO 891
    MARINETTE,WI54143     		  PC TO PROVIDE SPONSORSHIP OF THE JIM HODGE MEMORIAL RUN IN AN EFFORT TO DECREASE CHILDHOOD OBESITY AND INCREASE COMMUNITY HEALTH AND WELL-BEING. 80
    M&M CHAMBER OF COMMERCE
    601 MARINETTE AVENUE
    MARINETTE,WI54143     		  PC EVENT SPONSORSHIP 105
    MARINETTE COUNTY ADRC
    2500 HALL AVENUE
    MARINETTE,WI54143     		  PC EVENT SPONSORSHIP 80
    MARINETTE COUNTY GROUP HOME ASSOCIATION
    900 WELLS AVENUE
    MARINETTE,WI54143     		  PC TO MATCH A FEDERAL GRANT IN PROVIDING TECHNOLOGY TO THE ESTABLISHMENT OF THE BRIDGES TO RECOVERY IN-PATIENT SUBSTANCE ABUSE RECOVERY PROGRAM. 15,000
    MARINETTE COUNTY HEALTH AND HUMAN SERVICES
    2500 HALL AVENUE
    MARINETTE,WI54143     		  GOV TO EXPAND THE MENTAL HEALTH COURT SERVICES IN MARINETTE COUNTY TO INCLUDE RANDOM DRUG TESTING AS WELL AS HOUSING AID TO PROGRAM PARTICIPANTS. 15,000
    MARINETTE RECREATION DEPARTMENT
    2501 PIERCE AVENUE
    MARINETTE,WI54143     		  GOV TO PROVIDE PROGRAM SUPPLIES TO THE REC CENTER'S DAY CAMPS FOR CHILDREN IN AN EFFORT TO COMBAT CHILDHOOD OBESITY. 5,000
    MENOMINEE COUNTY SHERIFF VICTIM SERVICES
    839 10TH AVENUE
    MENOMINEE,MI49858     		  PC TO PROVIDE TRAINING AND PROGRAM SUPPLIES TO THOSE THAT CARE FOR MENOMINEE RESIDENTS ON-SITE OF A CATASTROPHIC EVENT SUCH AS FIRE, DROWNING, CRIME, ETC. 774
    MENOMINEE HIGH SCHOOL
    2101 18TH STREET
    MENOMINEE,MI49858     		  GOV EVENT SPONSORSHIP 80
    MENOMINEE KIWANIS
    N4420 M-35
    MENOMINEE,MI49858     		  PC FUNDRAISING EVENT SPONSORSHIP 80
    PESHTIGO PLAYGROUND
    PO BOX 10772
    GREEN BAY,WI54307     		  PC TO PROVIDE SPONSORSHIP TO THE NEW PLAYGROUND BEING BUILT IN MARINETTE COUNTY THAT WILL WORK TO DECREASE CHILDHOOD OBESITY. 175
    RAINBOW HOUSE DOMESTIC ABUSE SERVICES
    PO BOX 1172
    MARINETTE,WI54143     		  PC TO ESTABLISH AN IN-HOUSE COUNSELING PROGRAM FOR WOMEN AND CHILDREN WHO ARE RESIDING IN THE RAINBOW HOUSE SHELTER FOR DOMESTIC ABUSE. 11,000
    RIVER CITIES COMMUNITY POOL
    1125 UNIVERSITY AVENUE
    MARINETTE,WI54143     		  PC TO PROVIDE CHILDREN'S SWIM PROGRAMMING AT THE RIVER CITIES COMMUNITY POOL IN AN EFFORT TO INCREASE WATER SAFETY AND DECREASE CHILDHOOD OBESITY. 10,000
    ST VINCENT DEPAUL
    PO BOX 1111
    MARINETTE,WI54143     		  PC TO PROVIDE CAPACITY BUILDING SUPPORT TO THE THRIFT STORE, FOOD PANTRY, AND OTHER PROGRAMS DUE TO COVID LOSS OF INCOME FOR THE ORGANIZATION. 11,000
    SUPERIOR HEALTH FOUNDATION
    121 NORTH FRONT STREET
    MARQUETTE,MI49855     		  PC GRANT MATCH 750
    Total .................................bullet 3a 2,260,540
    bApproved for future payment
    Total .................................bullet 3b 0
    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 17,430  
    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 ............     		    18 552,670  
    9 Net income or (loss) from special events:          
    10 Gross profit or (loss) from sales of inventory          
    11 Other revenue:
    aIRS REFUND     		    14 2,029  
    b
    c
    d
    e
    12 Subtotal. Add columns (b), (d), and (e) .. 0 866,308 0
    13Total. Add line 12, columns (b), (d), and (e)..................
    13
    866,308
    (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.)
    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:  
    Software Version:  


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

    Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
    Arrow Bullet Go to www.irs.gov/Form990 for the latest information.
    OMB No. 1545-0047
    2021
    Name of the organization
    PROVIDENT HEALTH FOUNDATION
    OF MARINETTE/MENOMINEE INC
    Employer identification number

    83-4140310
    Organization type (check one):
    Filers of:
    Section:
    Form 990 or 990-EZ






    Form 990-PF




    Check if your organization is covered by the General Rule or a Special Rule.  
    Note: Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.
    General Rule
    Special Rules
    ......... Arrow Bullet $  
    Caution: An organization that isn't covered by the General Rule and/or the Special Rules doesn't file Schedule B (Form 990,
    990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2, of its Form 990; or check the box on line H of its Form 990-EZ
    or on its Form 990PF, Part I, line 2, to certify that it doesn't meet the filing requirements of Schedule B (Form 990,
    990-EZ, or 990-PF).
    For Paperwork Reduction Act Notice, see the Instructions
    for Form 990, 990-EZ, or 990-PF.
    Cat. No. 30613XSchedule B (Form 990) (2021)
    Schedule B (Form 990) (2021) Page 2
    Name of organization
    PROVIDENT HEALTH FOUNDATION
    OF MARINETTE/MENOMINEE INC         		Employer identification number
    83-4140310
    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
    ROBERT THEUERKAUF
    46808 GRATIOT
     
    CHESTERFILED, MI48051

    		$ 5,000


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

    		$  


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

    		$  


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

    		$  


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

    		$  


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

    		$  


    (Complete Part II for noncash contributions.)
    Schedule B (Form 990) (2021)
    Schedule B (Form 990) (2021)
    Page 3
    Name of organization
    PROVIDENT HEALTH FOUNDATION
    OF MARINETTE/MENOMINEE INC         		Employer identification number

    83-4140310
    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
    PROVIDENT HEALTH FOUNDATION
    OF MARINETTE/MENOMINEE INC         		Employer identification number

    83-4140310
    Part III
    Exclusively religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10) that total more than $1,000 for the year from any one contributor. Complete columns (a) through (e) and the following line entry. For organizations completing Part III, enter the total of exclusively religious, charitable, etc., contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet$  
    Use duplicate copies of Part III if additional space is needed.
    (a)
    No. from Part I    		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
     
    (e) Transfer of gift
    Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
     
     
         
     
    (a)
    No. from Part I    		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
     
    (e) Transfer of gift
    Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
     
     
         
     
    (a)
    No. from Part I    		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
     
    (e) Transfer of gift
    Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
     
     
         
     
    (a)
    No. from Part I    		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
     
    (e) Transfer of gift
    Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
     
     
         
     
    Schedule B (Form 990) (2021)
    Additional Data


    Software ID:  
    Software Version:  

    TY 2021 AccountingFeesSchedule
    Name:
    PROVIDENT HEALTH FOUNDATION
     
    OF MARINETTE/MENOMINEE INC
    EIN:
    83-4140310
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    ACCOUNTING FEES 3,000 1,500 0 1,500

    TY 2021 InvestmentsCorpBondsSchedule
    Name:
    PROVIDENT HEALTH FOUNDATION
     
    OF MARINETTE/MENOMINEE INC
    EIN:
    83-4140310
    Name of Bond End of Year Book Value End of Year Fair Market Value
    FEDERATED HERMES INSTL HIGH YIELD BOND 427,787 447,255
    FEDERATED HERMES TOTAL RETURN BOND 1,349,595 1,319,845
    FEDERATED HERMES ULTRASHORT BOND 94,590 94,218
    PIMCO SHORT TERM FUND INSTL 82,885 82,512
    VANGUARD SHORT-TERM INVST-GRADE ADM 33,254 33,191
    LORD ABBETT HIGH YIELD 420,743 447,747
    PGIM HIGH YIELD FUND 445,233 443,727
    VOYA INTERMEDIATE BOND 1,338,338 1,313,403

    TY 2021 InvestmentsCorpStockSchedule
    Name:
    PROVIDENT HEALTH FOUNDATION
     
    OF MARINETTE/MENOMINEE INC
    EIN:
    83-4140310
    Name of Stock End of Year Book Value End of Year Fair Market Value
    AMERICAN BEACON SMALL CAP VALUE 193,219 294,917
    ARTISAN INTERNATIONAL 138,734 129,324
    BLACKROCK MID-CAP GROWTH EQUITY 380,937 585,815
    BROWN CAPITAL MGMT SMALL CO 257,152 295,298
    DIAMOND HILL LARGE CAP 1,305,140 1,750,983
    GOLDMAN SACHS EMERGING MKTS EQUITY INISGHTS 497,934 426,719
    INVESCO OPPENHEIMER DEVELOPING MARKETS 503,782 461,565
    T ROWE PRICE INSTL LARGE CAP CORE GROWTH 1,235,093 1,678,948
    VANGUARD EMERGING MARKETS INDEX ETF 77,655 74,190
    VANGUARD FTSE DEVELOPED MARKETS INDEX ETF 130,418 153,180
    VANGUARD INTL GROWTH FUND ADM 101,271 134,250
    VANGUARD MID CAP ETF 277,998 458,586
    VANGUARD MID CAP VALUE INDEX FD 421,597 629,410
    VANGUARD S&P 500 INDEX ETF 779,252 1,266,053
    VANGUARD SMALL-CAP ETF 187,928 305,114

    TY 2021 LegalFeesSchedule
    Name:
    PROVIDENT HEALTH FOUNDATION
     
    OF MARINETTE/MENOMINEE INC
    EIN:
    83-4140310
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    LEGAL FEES 150 75 0 75


    TY 2021 OtherExpensesSchedule
    Name:
    PROVIDENT HEALTH FOUNDATION
     
    OF MARINETTE/MENOMINEE INC
    EIN:
    83-4140310
    Description Revenue and Expenses per Books Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    DUES AND SUBSCRIPTIONS 295 0 0 295
    ENTERTAINMENT 465 0 0 465
    HODGE RUN 5,769 0 0 5,769
    MISCELLANEOUS 394 0 0 394
    POSTAGE 287 144 0 143
    SOFTWARE 9,165 0 0 9,165
    SUPPLIES 468 0 0 468
    WEBSITE DEVELOPMENT 600 0 0 600
    FEDERAL EXCISE TAX PAID FOR MERGED ORGANIZATION 943 0 0 0
    BACKUP WITHHOLDING ERRONEOUSLY WITHHELD 649 0 0 0


    TY 2021 OtherIncomeSchedule2
    Name:
    PROVIDENT HEALTH FOUNDATION
     
    OF MARINETTE/MENOMINEE INC
    EIN:
    83-4140310
    Description Revenue And Expenses Per Books Net Investment Income Adjusted Net Income
    IRS REFUND 2,029   0


    TY 2021 OtherProfessionalFeesSchedule
    Name:
    PROVIDENT HEALTH FOUNDATION
     
    OF MARINETTE/MENOMINEE INC
    EIN:
    83-4140310
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    INVESTMENT ADVISORY FEES 47,156 47,156 0 0
    PROFESSIONAL FEES 7,819 3,910 0 3,909