TY 2021 Form 990PF

- TIN:

Form990-PF
Click to see attachment

Department of the Treasury
Internal Revenue Service

Return of Private Foundation

or Section 4947(a)(1) Trust Treated as Private Foundation

Do not enter social security numbers on this form as it may be made public.
bullet

Go 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 09-01-2021 , and ending 08-31-2022

Name of foundation
THE PARK HOME

Number and street (or P.O. box number if mail is not delivered to street address)2160 WARRENSVILLE ROAD
Room/suite

City or town, state or province, country, and ZIP or foreign postal code
MONTOURSVILLE, PA17754

A Employer identification number

24-0522575

B Telephone number (see instructions)

(570) 433-4663

C If exemption application is pending, check here bullet

G Check all that apply: Initial returnInitial return of a former public charity
Final returnAmended return
Address change Name change

D 1. Foreign organizations, check here............. bullet

2. Foreign organizations meeting the 85%
test, check here and attach computation ... bullet

E If private foundation status was terminated
under section 507(b)(1)(A), check here ....... bullet

H Check type of organization: Section 501(c)(3) exempt private foundation
Section 4947(a)(1) nonexempt charitable trust Other taxable private foundation

F If the foundation is in a 60-month termination
under section 507(b)(1)(B), check here ....... bullet

I Fair market value of all assets at end
of year (from Part II, col. (c),
line 16) bullet

$23,831,369J Accounting method: Cash Accrual
Other (specify)
(Part I, column (d) must be on cash basis.)

	Analysis of Revenue and Expenses (The total of amounts in columns (b), (c), and (d) may not necessarily equal the amounts in column (a) (see instructions).)	(a) Revenue and expenses per books		(b) Net investment income	(c) Adjusted net income	(d) Disbursements for charitable purposes (cash basis only)


1	Contributions, gifts, grants, etc., received (attach schedule)	26,584
2	Check .............
3	Interest on savings and temporary cash investments
4	Dividends and interest from securities...	347,194		347,194	347,194
5a	Gross rents............
b	Net rental income or (loss)
6a	Net gain or (loss) from sale of assets not on line 10		897,307
b	Gross sales price for all assets on line 6a 8,697,106
7	Capital gain net income (from Part IV, line 2)...			897,307
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).......		1,229,983		1,229,983
12	Total. Add lines 1 through 11........	2,501,068		1,244,501	1,577,177
13	Compensation of officers, directors, trustees, etc.	19,800
14	Other employee salaries and wages......	1,113,533				626,051
15	Pension plans, employee benefits.......	255,755				255,755
16a	Legal fees (attach schedule).........		1,245			1,245
b	Accounting fees (attach schedule).......		20,531			20,531
c	Other professional fees (attach schedule)....		108,746	107,435		1,311
17	Interest...............
18	Taxes (attach schedule) (see instructions)...		16,347	16,347
19	Depreciation (attach schedule) and depletion...		174,235
20	Occupancy..............
21	Travel, conferences, and meetings.......	3,997				3,997
22	Printing and publications..........
23	Other expenses (attach schedule).......		737,524	5,434		732,090
24	Total operating and administrative expenses.
	Add lines 13 through 23..........	2,451,713		129,216		1,640,980
25	Contributions, gifts, grants paid.......	0				0
26	Total expenses and disbursements. Add lines 24 and 25	2,451,713		129,216		1,640,980
27	Subtract line 26 from line 12:
a	Excess of revenue over expenses and disbursements	49,355
b	Net investment income (if negative, enter -0-)			1,115,285
c	Adjusted net income (if negative, enter -0-)...				1,577,177

For Paperwork Reduction Act Notice, see instructions.

Cat. No. 11289X Form 990-PF (2021)

Form 990-PF (2021)

Page 2

Part II		Balance Sheets	Beginning of year	End of year
Part II		Balance Sheets	(a) Book Value	(b) Book Value	(c) Fair Market Value
	1	Cash—non-interest-bearing.............	350	350	350
	2	Savings and temporary cash investments.........	381,898	835,842	835,842
	3	Accounts receivable 501
		Less: allowance for doubtful accounts	1,150	501	501
	4	Pledges receivable
		Less: allowance for doubtful accounts
	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)
		Less: allowance for doubtful accounts
	8	Inventories for sale or use..............
	9	Prepaid expenses and deferred charges..........	54,968	57,791	57,791
	10a	Investments—U.S. and state government obligations (attach schedule)	2,785,692	2,427,054	2,427,054
	b	Investments—corporate stock (attach schedule).......	18,121,120	14,069,542	14,069,542
	c	Investments—corporate bonds (attach schedule).......	1,392,077	1,229,523	1,229,523
	11	Investments—land, buildings, and equipment: basis 333,992
		Less: accumulated depreciation (attach schedule)	333,992	333,992	333,992
	12	Investments—mortgage loans.............
	13	Investments—other (attach schedule)..........	18,612	18,600	18,600
	14	Land, buildings, and equipment: basis 4,858,174
		Less: accumulated depreciation (attach schedule) 1,559,580	3,394,130	3,298,594	4,858,174
	15	Other assets (describe )
	16	Total assets (to be completed by all filers—see the
		instructions. Also, see page 1, item I)	26,483,989	22,271,789	23,831,369
	17	Accounts payable and accrued expenses..........	82,098	119,433
	18	Grants payable.................
	19	Deferred revenue.................		6,400
	20	Loans from officers, directors, trustees, and other disqualified persons
	21	Mortgages and other notes payable (attach schedule)......
	22	Other liabilities (describe )	40,527	49,514
	23	Total liabilities (add lines 17 through 22).........	122,625	175,347
		Foundations that follow FASB ASC 958, check here
		and complete lines 24, 25, 29 and 30.
	24	Net assets without donor restrictions...........	26,361,364	22,096,442
	25	Net assets with donor restrictions............
		Foundations that do not follow FASB ASC 958, check here
		and complete lines 26 through 30.
	26	Capital stock, trust principal, or current funds........
	27	Paid-in or capital surplus, or land, bldg., and equipment fund
	28	Retained earnings, accumulated income, endowment, or other funds
	29	Total net assets or fund balances (see instructions).....	26,361,364	22,096,442
	30	Total liabilities and net assets/fund balances (see instructions).	26,483,989	22,271,789

Part III

Analysis of Changes in Net Assets or Fund Balances

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) ...............

26,361,364

Enter amount from Part I, line 27a .....................

49,355

Other increases not included in line 2 (itemize) bullet

Add lines 1, 2, and 3 ..........................

26,410,719

Decreases not included in line 2 (itemize) bullet

4,314,277

Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 29 .

22,096,442

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
1 a	SEE ATTACHED ML AC88804102	P
b	SEE ATTACHED ML AC88804103	P
c
d
e

(e) Gross sales price		(g) Cost or other basis plus expense of sale	(h) Gain or (loss) (e) plus (f) minus (g)
a	7,797,421	6,303,844	1,493,577
b	899,685	1,495,955	-596,270
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			1,493,577
b			-596,270
c
d
e

2	Capital gain net income or (net capital loss)	If gain, also enter in Part I, line 7 If (loss), enter -0- in Part I, line 7	2	897,307
3	Net short-term capital gain or (loss) as defined in sections 1222(5) and (6):
	If gain, also enter in Part I, line 8, column (c) (see instructions). If (loss), enter -0- in Part I, line 8 ...................		3

Form 990-PF (2021)

Page 4

Part V

Excise Tax Based on Investment Income (Section 4940(a), 4940(b), 4940(e), or 4948—see instructions)

1a	Exempt operating foundations described in section 4940(d)(2), check here and enter “N/A" on line 1.
	Date of ruling or determination letter: 1974-10-22(attach copy of letter if necessary–see instructions)
b	All other domestic foundations enter 1.39% (0.0139) of line 27b. Exempt foreign organizations enter 4% (0.04) of Part I, line 12, col. (b)
2	Tax under section 511 (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-)	2
3	Add lines 1 and 2...........................	3
4	Subtitle A (income) tax (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-)	4
5	Tax based on investment income. Subtract line 4 from line 3. If zero or less, enter -0- .....	5
6	Credits/Payments:

a	2021 estimated tax payments and 2020 overpayment credited to 2021	6a
b	Exempt foreign organizations—tax withheld at source......	6b
c	Tax paid with application for extension of time to file (Form 8868)...	6c
d	Backup withholding erroneously withheld ...........	6d

7	Total credits and payments. Add lines 6a through 6d..............		7
8	Enter any penalty for underpayment of estimated tax. Check here if Form 2220 is attached.		8
9	Tax due. If the total of lines 5 and 8 is more than line 7, enter amount owed.......		9
10	Overpayment. If line 7 is more than the total of lines 5 and 8, enter the amount overpaid...		10
11	Enter the amount of line 10 to be: Credited to 2022 estimated tax	Refunded	11

Part VI-A

Statements Regarding Activities

During the tax year, did the foundation attempt to influence any national, state, or local legislation or did

Yes

it participate or intervene in any political campaign? ....................

Did it spend more than $100 during the year (either directly or indirectly) for political purposes? See the instructions

for the definition.................................

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.

Did the foundation file Form 1120-POL for this year?.....................

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

Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed

on foundation managers. bullet

Has the foundation engaged in any activities that have not previously been reported to the IRS?.......

If "Yes," attach a detailed description of the activities.

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....

Did the foundation have unrelated business gross income of $1,000 or more during the year?.........

If "Yes," has it filed a tax return on Form 990-T for this year?...................

Was there a liquidation, termination, dissolution, or substantial contraction during the year?.........

If "Yes," attach the statement required by General Instruction T.

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?................

Yes

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..................................

Yes

Enter the states to which the foundation reports or with which it is registered (see instructions)

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 .

Yes

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 .............................

Yes

Did any persons become substantial contributors during the tax year? If "Yes," attach a schedule listing their names

and addresses. ...............................

Form 990-PF (2021)

Page 5

Part VI-A

Statements Regarding Activities (continued)

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 .............

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.................

Did the foundation comply with the public inspection requirements for its annual returns and exemption application?

Yes

Website address bullet

WWW.THEPARKHOMEMEADOWS.COM

The books are in care of bullet

EXECUTIVE ASSISTANT Telephone no. bullet

(570) 433-4663

Located at bullet

2160 WARRENSVILLE ROADMONTOURSVILLEPA ZIP+4 bullet

17754

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

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

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)

(2) Borrow money from, lend money to, or otherwise extend credit to (or accept it from)

a disqualified person? ..............................

1a(2)

(3) Furnish goods, services, or facilities to (or accept them from) a disqualified person? ...........

1a(3)

Yes

(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)

(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)

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 ..........

Organizations relying on a current notice regarding disaster assistance check here........ bullet

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? .............

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)):

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?....................

If "Yes," list the years bullet

20, 20, 20, 20

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.) ..............

If the provisions of section 4942(a)(2) are being applied to any of the years listed in 2a, list the years here.

20, 20, 20, 20

Did the foundation hold more than a 2% direct or indirect interest in any business enterprise at

any time during the year? ..............................

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.) .....................

Did the foundation invest during the year any amount in a manner that would jeopardize its charitable purposes?

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? ..

Form 990-PF (2021)

Page 6

Part VI-B

Statements Regarding Activities for Which Form 4720 May Be Required (continued)

During the year did the foundation pay or incur any amount to:

Yes

(1) Carry on propaganda, or otherwise attempt to influence legislation (section 4945(e))? ..........

5a(1)

(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)

(3) Provide a grant to an individual for travel, study, or other similar purposes? .............

5a(3)

(4) Provide a grant to an organization other than a charitable, etc., organization described

in section 4945(d)(4)(A)? See instructions ........................

5a(4)

(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)

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 ........

Organizations relying on a current notice regarding disaster assistance check here ......... bullet

If the answer is "Yes" to question 5a(4), does the foundation claim exemption from the

tax because it maintained expenditure responsibility for the grant? .................

If "Yes," attach the statement required by Regulations section 53.4945–5(d).

Did the foundation, during the year, receive any funds, directly or indirectly, to pay premiums on

a personal benefit contract? .............................

Did the foundation, during the year, pay premiums, directly or indirectly, on a personal benefit contract? ....

If "Yes" to 6b, file Form 8870.

At any time during the tax year, was the foundation a party to a prohibited tax shelter transaction?

If "Yes", did the foundation receive any proceeds or have any net income attributable to the transaction? .....

Is the foundation subject to the section 4960 tax on payment(s) of more than $1,000,000 in remuneration or

excess parachute payment during the year? .........................

Part 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-)
JEFFERY B SIMS	DIRECTOR/PRE 000.00	1,800
2160 WARRENSVILLE ROAD MONTOURSVILLE,PA17754	DIRECTOR/PRE 000.00	1,800
JAMES K GATES II	DIRECTOR/VIC 000.00	1,800
2160 WARRENSVILLE ROAD MONTOURSVILLE,PA17754	DIRECTOR/VIC 000.00	1,800
MARY K GIBBS SMITH	DIRECTOR/SEC 000.00	1,800
2160 WARRENSVILLE ROAD MONTOURSVILLE,PA17754	DIRECTOR/SEC 000.00	1,800
GEORGE D GOLDEN	DIRECTOR/TRE 000.00	1,800
2160 WARRENSVILLE ROAD MONTOURSVILLE,PA17754	DIRECTOR/TRE 000.00	1,800
GEORGE BIERMAN	DIRECTOR 000.00	1,800
2160 WARRENSVILLE ROAD MONTOURSVILLE,PA17754	DIRECTOR 000.00	1,800
J BUDD BELL	DIRECTOR 000.00	1,800
2160 WARRENSVILLE ROAD MONTOURSVILLE,PA17754	DIRECTOR 000.00	1,800
LINDA DIEFFENBACH	DIRECTOR 000.00	1,800
2160 WARRENSVILLE ROAD MONTOURSVILLE,PA17754	DIRECTOR 000.00	1,800
ROBERT BEUCLER	DIRECTOR 000.00	1,800
2160 WARRENSVILLE ROAD MONTOURSVILLE,PA17754	DIRECTOR 000.00	1,800
BOBBIE WOOLCOCK	DIRECTOR 000.00	1,800
2160 WARRENSVILLE ROAD MONTOURSVILLE,PA17754	DIRECTOR 000.00	1,800
ALLEN PAGE IV	DIRECTOR 000.00	1,800
2160 WARRENSVILLE ROAD MONTOURSVILLE,PA17754	DIRECTOR 000.00	1,800
JAMES FUREY II	DIRECTOR 000.00	1,800
2160 WARRENSVILLE ROAD MONTOURSVILLE,PA17754	DIRECTOR 000.00	1,800

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
KELLY WIKE	ADMINISTRATO 000.00	133,077
2160 WARRENSVILLE RD MONTOURSVILLE,PA17754	ADMINISTRATO 000.00	133,077
MARGARET ERGOTT	DIET SUPER 000.00	98,666
2160 WARRENSVILLE ROAD MONTOURSVILLE,PA17754	DIET SUPER 000.00	98,666
DENISE BOWER	EXECUTIVE AS 000.00	98,150
2160 WARRENSVILLE ROAD MONTOURSVILLE,PA17754	EXECUTIVE AS 000.00	98,150
CHERYLYN SAUTER	NURSE 000.00	84,283
2160 WARRENSVILLE RD MONTOURSVILLE,PA17754	NURSE 000.00	84,283
HEATHER HILNER	NURSE 000.00	73,306
2160 WARRENSVILLE RD MONTOURSVILLE,PA17754	NURSE 000.00	73,306
Total number of other employees paid over $50,000...................

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	THE FOUNDATION'S ONLY DIRECT CHARITABLE ACTIVITY CONDUCTED IS THE OPERATION OF A PERSONAL CARE FACILITY. THIS FACILITY PROVIDES HOUSING, DINING, ENTERTAINMENT ACTIVITIES, MEDICAL SERVICES AND HYGIENE RELATED ASSISTANCE TO ITS RESIDENTS.	2,322,497
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	N/A
2


All other program-related investments. See instructions.
3

Total. Add lines 1 through 3......................... bullet

Form 990-PF (2021)

Page 8

Part IX

Minimum Investment Return (All domestic foundations must complete this part. Foreign foundations, see instructions.)

Fair market value of assets not used (or held for use) directly in carrying out charitable, etc.,

purposes:

Average monthly fair market value of securities...................

20,261,673

Average of monthly cash balances.......................

344,970

Fair market value of all other assets (see instructions)................

353,433

Total (add lines 1a, b, and c).........................

20,960,076

Reduction claimed for blockage or other factors reported on lines 1a and

1c (attach detailed explanation) .............

Acquisition indebtedness applicable to line 1 assets..................

Subtract line 2 from line 1d.........................

20,960,076

Cash deemed held for charitable activities. Enter 1.5% (0.015) of line 3 (for greater amount, see

instructions) .............................

314,401

Net value of noncharitable-use assets. Subtract line 4 from line 3. .......

20,645,675

Minimum investment return. Enter 5% (0.05) of line 5................

1,032,284

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.)

Minimum investment return from Part IX, line 6..................

Tax on investment income for 2021 from Part V, line 5.......

Income tax for 2021. (This does not include the tax from Part V.) ...

Add lines 2a and 2b............................

Distributable amount before adjustments. Subtract line 2c from line 1............

Recoveries of amounts treated as qualifying distributions................

Add lines 3 and 4............................

Deduction from distributable amount (see instructions).................

Distributable amount as adjusted. Subtract line 6 from line 5. Enter here and on Part XII, line 1 ...

Part XI

Qualifying Distributions (see instructions)

Amounts paid (including administrative expenses) to accomplish charitable, etc., purposes:

Expenses, contributions, gifts, etc.—total from Part I, column (d), line 26 ..........

Program-related investments—total from Part VIII-B..................

Amounts paid to acquire assets used (or held for use) directly in carrying out charitable, etc.,

purposes...............................

Amounts set aside for specific charitable projects that satisfy the:

Suitability test (prior IRS approval required)....................

Cash distribution test (attach the required schedule) .................

Qualifying distributions. Add lines 1a through 3b. Enter here and on Part XII, line 4.

Form 990-PF (2021)

Page 9

Part XII

Undistributed Income (see instructions)

		(a) Corpus	(b) Years prior to 2020	(c) 2020	(d) 2021
1 Distributable amount for 2021 from Part X, line 7
2 Undistributed income, if any, as of the end of 2021:
a Enter amount for 2020 only.......
b Total for prior years:20, 20, 20
3 Excess distributions carryover, if any, to 2021:
a From 2016......
b From 2017......
c From 2018......
d From 2019......
e From 2020......
f Total of lines 3a through e ........
4Qualifying distributions for 2021 from Part
XI, line 4: $ 1,719,680
a Applied to 2020, but not more than line 2a
b Applied to undistributed income of prior years (Election required—see instructions).....
c Treated as distributions out of corpus (Election required—see instructions)........
d Applied to 2021 distributable amount.....
e Remaining amount distributed out of corpus		1,719,680
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		1,719,680
b Prior years’ undistributed income. Subtract line 4b from line 2b ..........
c Enter the amount of prior years’ undistributed income for which a notice of deficiency has been issued, or on which the section 4942(a) tax has been previously assessed......
d Subtract line 6c from line 6b. Taxable amount —see instructions ...........
e Undistributed income for 2019. Subtract line 4a from line 2a. Taxable amount—see instructions .............
f Undistributed income for 2021. Subtract lines 4d and 5 from line 1. This amount must be distributed in 2022 ..........
7 Amounts treated as distributions out of corpus to satisfy requirements imposed by section 170(b)(1)(F) or 4942(g)(3) (Election may be required - see instructions) .......
8 Excess distributions carryover from 2016 not applied on line 5 or line 7 (see instructions) ...
9 Excess distributions carryover to 2022. Subtract lines 7 and 8 from line 6a ......
10 Analysis of line 9:
a Excess from 2017....
b Excess from 2018....
c Excess from 2019....
d Excess from 2020....
e Excess from 2021....

Form 990-PF (2021)

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

1974-10-22

b Check box to indicate whether the organization is a private operating foundation described in section 4942(j)(3) or4942(j)(5)

2a Enter the lesser of the adjusted net income from Part I or the minimum investment return from Part X for each year listed ..........	Tax year	Prior 3 years			(e) Total
	(a) 2021	(b) 2020	(c) 2019	(d) 2018	(e) Total
	0				0
b 85% (0.85) of line 2a .........
c Qualifying distributions from Part XI, line 4 for each year listed .....	1,719,680	2,158,327	2,090,465	1,963,981	7,932,453
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 ....	1,719,680	2,158,327	2,090,465	1,963,981	7,932,453
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 ..	688,189	768,073	667,233	606,277	2,729,772
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

if the foundation only makes contributions to preselected charitable organizations and does not accept
unsolicited requests for funds. If the foundation makes gifts, grants, etc. to individuals or organizations under
other conditions, complete items 2a, b, c, and d. See instructions

aThe name, address, and telephone number or email address of the person to whom applications should be addressed:

bThe form in which applications should be submitted and information and materials they should include:

cAny submission deadlines:

dAny restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other
factors:

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)		Foundation status of recipient	Purpose of grant or contribution	Amount
aPaid during the year

Total ................................. 3a

bApproved for future payment

Total ................................. 3b

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	(e) Related or exempt function income (See instructions.)
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 ...........
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	897,307
9 Net income or (loss) from special events:
10 Gross profit or (loss) from sales of inventory
11 Other revenue: aMISCELLANEOUS					928
b
c
d
e
12 Subtotal. Add columns (b), (d), and (e) ..				1,244,501	1,229,983

13Total. Add line 12, columns (b), (d), and (e)..................

2,474,484

(See worksheet in line 13 instructions to verify calculations.)

Part XV-B

Relationship of Activities to the Accomplishment of Exempt Purposes

Line No.	Explain below how each activity for which income is reported in column (e) of Part XV-A contributed importantly to the accomplishment of the foundation’s exempt purposes (other than by providing funds for such purposes). (See instructions.)
1A	OPERATION OF A PERSONAL CARE FACILITY

Form 990-PF (2021)

Page 13

Part XVI

Information Regarding Transfers To and Transactions and Relationships With Noncharitable Exempt Organizations

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

Transfers from the reporting foundation to a noncharitable exempt organization of:

(1) Cash...................................

1a(1)

(2) Other assets.................................

1a(2)

Other transactions:

(1) Sales of assets to a noncharitable exempt organization....................

1b(1)

(2) Purchases of assets from a noncharitable exempt organization..................

1b(2)

(3) Rental of facilities, equipment, or other assets.......................

1b(3)

(4) Reimbursement arrangements...........................

1b(4)

(5) Loans or loan guarantees.............................

1b(5)

(6) Performance of services or membership or fundraising solicitations................

1b(6)

Sharing of facilities, equipment, mailing lists, other assets, or paid employees..............

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

Is the foundation directly or indirectly affiliated with, or related to, one or more tax-exempt organizations
described in section 501(c) (other than section 501(c)(3)) or in section 527? ...........Yes No

If "Yes," complete the following schedule.

(a) Name of organization	(b) Type of organization	(c) Description of relationship

Sign Here

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
				May the IRS discuss this return with the preparer shown below? See instructions. Yes No
	Signature of officer or trustee	Date	Title

Paid Preparer Use Only	Print/Type preparer's name	Preparer's Signature	Date	Check if self- employed	PTIN
	Firm's name				Firm's EIN
	Firm's address				Phone no.

Form 990-PF (2021)

Additional Data

Software ID:
Software Version:

Form 990PF - Special Condition Description:

Special Condition Description

- TIN:

TY 2021 AccountingFeesSchedule

Name:

THE PARK HOME

EIN:

24-0522575

Category	Amount	Net Investment Income	Adjusted Net Income	Disbursements for Charitable Purposes
AUDITING & TAX SERVICES	20,531			20,531

- TIN:

Note: To capture the full content of this document, please select landscape mode (11" x 8.5") when printing.

TY 2021 DepreciationSchedule

Name:

THE PARK HOME

EIN:

24-0522575

Description of Property	Date Acquired	Cost or Other Basis	Prior Years' Depreciation	Computation Method	Rate / Life (# of years)	Current Year's Depreciation Expense
REFRIGERATOR	2011-08-17	201	201	S/L	5.0000
FOLDING TABLES & CHAIRS	2012-11-30	498	498	200DB	7.0000
COMPUTER & MONITOR	2011-05-13	526	526	S/L	5.0000
FURNITURE	2011-08-17	1,378	1,378	S/L	7.0000
SHARP MX-B201D COPIER	2012-04-17	1,437	1,437	S/L	5.0000
SHARP MX-2310U COPIER	2011-09-28	5,201	5,201	S/L	5.0000
MODEL HOME-FURN & FIXTURES	2012-07-26	46,623	46,623	S/L	7.0000
BUILDING (MEADOWS)	2014-12-31	3,104,311	533,968	S/L	39.0000	79,598
FURN & EQUIPMENT (MEADOWS)	2014-12-31	587,000	545,071	S/L	7.0000	41,929
2004 CHRYSLER 300	2014-12-31	5,000	5,000	S/L	5.0000
10 TON HEAT PUMP-MEADOWS	2014-09-01	25,300	4,514	S/L	39.0000	649
BEAUTY PARLOR FURN/EQUIP UPGRADES	2015-04-08	2,030	1,885	S/L	7.0000	145
SURFACE PRO 3 & NETWORK	2015-04-22	12,253	12,253	S/L	5.0000
IMPAIRMENT LOSS - CIP	2012-09-01
3 METAL SHELVES	2001-08-08	245	245	S/L	10.0000
HP COMPUTER, PRINTER & SOFTWARE	2000-02-01	1,314	1,314	S/L	5.0000
PIANO DISC CFX228 PLAYBACK SYSTEM	2008-02-12	7,800	4,030	S/L	5.0000
LAUNDRY ROOM EQUIP - WATER HEATER	2008-06-24	10,744	2,149	S/L	10.0000
CIP-JVT CAPITALIZED INTEREST	2011-08-31	12,718
CONSTRUCTION IN PROGRESS	2011-08-31	850,979
LAND (MEADOWS)	2014-12-31	142,669
WINDOW TREATMENTS	2016-07-31	54,884	40,183	S/L	7.0000	7,841
DINING ROOM CHAIRS	2016-08-18	31,679	23,193	S/L	7.0000	4,526
FINANCE/MARKETING WORKSTATION	2016-07-12	4,797	4,797	S/L	5.0000
MODEL ROOM 200 HALL	2016-05-02	9,629	1,307	S/L	39.0000	246
NORTH LIVING ROOM FURNISHINGS	2016-04-18	6,081	4,669	S/L	7.0000	869
20834 & 20835 EQUIPMENT	2016-08-25	7,556	7,556	S/L	5.0000
STAMPED PATIO AREA	2016-05-11	12,278	4,365	S/L	15.0000	819
HAND RAILS	2016-05-02	16,383	2,223	S/L	39.0000	420
LANDSCAPING FRONT ENTRANCE	2016-06-21	2,085	765	S/L	15.0000	139
200 WING RENOVATION PROJECT	2016-08-16	13,879	1,794	S/L	39.0000	356
BASEBOARD INSTALLATION	2016-08-31	11,705	1,513	S/L	39.0000	300
DINING ROOM CEILING REPLACEMENT	2016-07-13	21,430	2,816	S/L	39.0000	550
FLOORING PROJECT	2016-08-24	77,834	10,062	S/L	39.0000	1,996
14970 & 14971 BUILDING IMPROVEMENT	2016-08-25	27,630	3,572	S/L	39.0000	708
PARKING LOT & ENTRANCE PAVING	2016-06-16	95,311	32,829	S/L	15.0000	6,354
FURNITURE	2016-01-06	1,624	1,305	S/L	7.0000	232
2016 FORD VAN	2016-10-14	39,800	36,300	S/L	5.0000	3,500
2016 FORD VAN MODIFICATIONS	2017-03-30	2,827	2,544	S/L	5.0000	283
BUILDING RENOVATIONS	2017-08-31	163,101	16,903	S/L	39.0000	4,182
FREEDOM BATHTUB	2018-05-31	10,366	6,997	S/L	5.0000	2,073
SECURITY CAMERA SYSTEM	2018-06-30	11,288	7,055	S/L	5.0000	2,257
CIP-INDEPENDENT LIVING	2021-08-31	12,122
WATER HEATER SYSTEM	2021-07-20	33,320	185	S/L	15.0000	2,221
MAINTENANCE BUILDING	2020-10-12	140,442	3,301	S/L	39.0000	3,601
BIPOLAR IONIZATION UNITS	2020-11-30	8,355	1,253	S/L	5.0000	1,671
SIDE ENTRY BATHTUB	2020-09-29	8,538	1,565	S/L	5.0000	1,708
SAGE WANDER GUARD SYSTEM	2022-02-04	37,000		S/L	15.0000	1,439
CIP - INDEPENDENT LIVING PROJECT	2022-07-22	14,035
FURNITURE	2021-09-17	27,665		S/L	7.0000	3,623

- TIN:

TY 2021 InvestmentsCorpBondsSchedule

Name:

THE PARK HOME

EIN:

24-0522575

Name of Bond	End of Year Book Value	End of Year Fair Market Value
CORPORATE BONDS	1,229,523	1,229,523

- TIN:

TY 2021 InvestmentsCorpStockSchedule

Name:

THE PARK HOME

EIN:

24-0522575

Name of Stock	End of Year Book Value	End of Year Fair Market Value
CORPORATE EQUITIES & MUTUAL FUNDS	14,069,542	14,069,542

- TIN:

TY 2021 InvestmentsGovtObligationsSch

Name:

THE PARK HOME

EIN:

24-0522575

US Government Securities - End of Year Book Value:

2,427,054

US Government Securities - End of Year Fair Market Value:

2,427,054

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

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

- TIN:

TY 2021 InvestmentsLandSchedule2

Name:

THE PARK HOME

EIN:

24-0522575

Category/ Item	Cost/Other Basis	Accumulated Depreciation	Book Value	End of Year Fair Market Value
LAND	333,992		333,992	333,992

- TIN:

TY 2021 InvestmentsOtherSchedule2

Name:

THE PARK HOME

EIN:

24-0522575

Category/ Item	Listed at Cost or FMV	Book Value	End of Year Fair Market Value
ACCRUED INTEREST RECEIVABLE	FMV	18,600	18,600

- TIN:

TY 2021 LandEtcSchedule2

Name:

THE PARK HOME

EIN:

24-0522575

Category / Item	Cost / Other Basis	Accumulated Depreciation	Book Value	End of Year Fair Market Value
FURNITURE/EQUIPMENT/VEHICLES	932,639	842,602	90,037	932,639
BUILDING	3,782,866	716,978	3,065,888	3,782,866
LAND	142,669		142,669	142,669

- TIN:

TY 2021 LegalFeesSchedule

Name:

THE PARK HOME

EIN:

24-0522575

Category	Amount	Net Investment Income	Adjusted Net Income	Disbursements for Charitable Purposes
LEGAL FEES	1,245			1,245

- TIN:

TY 2021 OtherDecreasesSchedule

Name:

THE PARK HOME

EIN:

24-0522575

Description	Amount
UNREALIZED LOSS ON INVESTMENTS HELD	4,314,277

- TIN:

TY 2021 OtherExpensesSchedule

Name:

THE PARK HOME

EIN:

24-0522575

Description	Revenue and Expenses per Books	Net Investment Income	Disbursements for Charitable Purposes
EXPENSES
ADVERTISING	38,942		38,942
AUTOMOBILE EXPENSES	2,951		2,951
BANK FEES	187		187
COMPUTER MAINTENANCE & SOFTWA	13,689		13,689
CONTINUING EDUCATION	8,778		8,778
COVID 19 EXPENSES	33,400		33,400
CRIMINAL BACKGROUND & DRUG TE	1,885		1,885
DONATION	50		50
DUES & SUBSCRIPTIONS	2,093		2,093
FIRE PROTECTION	9,901		9,901
FLOWERS & DECORATIONS	10,022		10,022
FOOD SERVICE	179,322		179,322
GARBAGE REMOVAL	4,636		4,636
INSURANCE	115,245	5,434	109,811
JANITORIAL SUPPLIES	13,583		13,583
JOB RECRUITING	18,187		18,187
LAUNDRY & LINEN	31,277		31,277
LICENSES	221		221
MEALS	2,555		2,555
MAINTENANCE SUPPLIES	22,718		22,718
NURSING SUPPLIES	10,399		10,399
OFFICE SUPPLIES	13,843		13,843
PAYROLL SERVICE	6,400		6,400
PEST CONTROL	1,781		1,781
POSTAGE & COURIERS	1,274		1,274
REPAIRS & MAINTENANCE	58,275		58,275
RESIDENT ENTERTAINMENT	2,959		2,959
SECURITY	445		445
TELEPHONE	6,071		6,071
UTILITIES & CABLE	126,435		126,435

- TIN:

TY 2021 OtherIncomeSchedule2

Name:

THE PARK HOME

EIN:

24-0522575

Description	Revenue And Expenses Per Books	Net Investment Income	Adjusted Net Income
PERSONAL CARE FACILITY	1,229,055		1,229,055
MISCELLANEOUS	928		928

- TIN:

TY 2021 OtherLiabilitiesSchedule

Name:

THE PARK HOME

EIN:

24-0522575

Description	Beginning of Year - Book Value	End of Year - Book Value
REFUNDABLE DEPOSITS	40,527	49,514

- TIN:

TY 2021 OtherProfessionalFeesSchedule

Name:

THE PARK HOME

EIN:

24-0522575

Category	Amount	Net Investment Income	Adjusted Net Income	Disbursements for Charitable Purposes
PORTFOLIO MANAGEMENT FEES	107,435	107,435
PENSION PLAN ADMINISTRATION FEE	1,311			1,311

- TIN:

TY 2021 TaxesSchedule

Name:

THE PARK HOME

EIN:

24-0522575

Category	Amount	Net Investment Income	Adjusted Net Income	Disbursements for Charitable Purposes
FOREIGN TAXES ON DIVIDENDS	15,428	15,428
REAL ESTATE TAXES	919	919