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
JX GIVES BACK FAMILY FOUNDATION INC
C/O MARK MUSKEVITSCH
Number and street (or P.O. box number if mail is not delivered to street address)925 WALNUT RIDGE DRIVE 150
  Room/suite
City or town, state or province, country, and ZIP or foreign postal code
HARTLAND, WI53029
A Employer identification number

83-4706547
B Telephone number (see instructions)

(262) 513-5066
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$72,107J 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) 235,795
2 Check bullet.............
3 Interest on savings and temporary cash investments 32 32  
4 Dividends and interest from securities...      
5a Gross rents............      
b Net rental income or (loss)  
6a Net gain or (loss) from sale of assets not on line 10  
b Gross sales price for all assets on line 6a  
7 Capital gain net income (from Part IV, line 2)... 0
8 Net short-term capital gain.........  
9 Income modifications...........  
10a Gross sales less returns and allowances  
b Less: Cost of goods sold....  
c Gross profit or (loss) (attach schedule).....    
11 Other income (attach schedule).......      
12 Total. Add lines 1 through 11........ 235,827 32  
Operating and Administrative Expenses 13 Compensation of officers, directors, trustees, etc. 0 0   0
14 Other employee salaries and wages......        
15 Pension plans, employee benefits.......        
16a Legal fees (attach schedule).........        
b Accounting fees (attach schedule).......        
c Other professional fees (attach schedule)....        
17 Interest...............        
18 Taxes (attach schedule) (see instructions)...        
19 Depreciation (attach schedule) and depletion...      
20 Occupancy..............        
21 Travel, conferences, and meetings.......        
22 Printing and publications..........        
23 Other expenses (attach schedule)....... Click to see attachment 10 10   0
24 Total operating and administrative expenses.
Add lines 13 through 23.......... 10 10   0
25 Contributions, gifts, grants paid....... 178,459 178,459
26 Total expenses and disbursements. Add lines 24 and 25 178,469 10   178,459
27 Subtract line 26 from line 12:
a Excess of revenue over expenses and disbursements 57,358
b Net investment income (if negative, enter -0-) 22
c Adjusted net income (if negative, enter -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......... 14,753 72,107 72,107
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).......      
c Investments—corporate bonds (attach schedule).......      
11 Investments—land, buildings, and equipment: basis bullet  
Less: accumulated depreciation (attach schedule) bullet        
12 Investments—mortgage loans.............      
13 Investments—other (attach schedule)..........      
14 Land, buildings, and equipment: basis bullet  
Less: accumulated depreciation (attach schedule) bullet        
15 Other assets (describe bullet)      
16 Total assets (to be completed by all filers—see the
instructions. Also, see page 1, item I) 14,753 72,107 72,107
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........... 14,753 72,107
25 Net assets with donor restrictions............    
Foundations that do not follow FASB ASC 958, check here bullet
and complete lines 26 through 30.
26 Capital stock, trust principal, or current funds........    
27 Paid-in or capital surplus, or land, bldg., and equipment fund    
28 Retained earnings, accumulated income, endowment, or other funds    
29 Total net assets or fund balances (see instructions)..... 14,753 72,107
30 Total liabilities and net assets/fund balances (see instructions). 14,753 72,107
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
14,753
2
Enter amount from Part I, line 27a .....................
2
57,358
3
Other increases not included in line 2 (itemize) bullet
3
0
4
Add lines 1, 2, and 3 ..........................
4
72,111
5
Decreases not included in line 2 (itemize) bulletClick to see attachment
5
4
6
Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 29 .
6
72,107
Form 990-PF (2021)
Form 990-PF (2021)
Page 3
Part IV
Capital Gains and Losses for Tax on Investment Income
(a) List and describe the kind(s) of property sold (e.g., real estate,
2-story brick warehouse; or common stock, 200 shs. MLC Co.)		 (b)
How acquired
P—Purchase
D—Donation 		(c)
Date acquired
(mo., day, yr.) 		(d)
Date sold
(mo., day, yr.)
1a
b
c
d
e
(e)
Gross sales price 		(f)
Depreciation allowed
(or allowable) 		(g)
Cost or other basis
plus expense of sale 		(h)
Gain or (loss)
(e) plus (f) minus (g)
a
b
c
d
e
Complete only for assets showing gain in column (h) and owned by the foundation on 12/31/69 (l)
Gains (Col. (h) gain minus
col. (k), but not less than -0-) or
Losses (from col.(h))
(i)
F.M.V. as of 12/31/69 		(j)
Adjusted basis
as of 12/31/69 		(k)
Excess of col. (i)
over col. (j), if any
a
b
c
d
e
2 Capital gain net income or (net capital loss) Bracket If gain, also enter in Part I, line 7
If (loss), enter -0- in Part I, line 7		 Bracket 2  
3 Net short-term capital gain or (loss) as defined in sections 1222(5) and (6):
If gain, also enter in Part I, line 8, column (c) (see instructions). If (loss), enter -0-
in Part I, line 8 ................... 		Bracket 3  
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 0
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 0
6 Credits/Payments:
a 2021 estimated tax payments and 2020 overpayment credited to 2021 6a 0
b Exempt foreign organizations—tax withheld at source...... 6b 0
c Tax paid with application for extension of time to file (Form 8868)... 6c 0
d Backup withholding erroneously withheld ........... 6d 0
7 Total credits and payments. Add lines 6a through 6d.............. 7 0
8 Enter any penalty for underpayment of estimated tax. Check here if Form 2220 is attached. 8 0
9 Tax due. If the total of lines 5 and 8 is more than line 7, enter amount owed.......Bullet 9 0
10 Overpayment. If line 7 is more than the total of lines 5 and 8, enter the amount overpaid...Bullet 10  
11 Enter the amount of line 10 to be: Credited to 2022 estimated taxBullet   RefundedBullet 11  
Part VI-A
Statements Regarding Activities
1a
During the tax year, did the foundation attempt to influence any national, state, or local legislation or did
Yes
No
it participate or intervene in any political campaign? ....................
1a
 
No
b
Did it spend more than $100 during the year (either directly or indirectly) for political purposes? See the instructions
for the definition.................................
1b
 
No
If the answer is "Yes" to 1a or 1b, attach a detailed description of the activities and copies of any materials
published or distributed by the foundation in connection with the activities.
c
Did the foundation file Form 1120-POL for this year?.....................
1c
 
No
d
Enter the amount (if any) of tax on political expenditures (section 4955) imposed during the year:
(1) On the foundation. bullet$ 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. Click to see attachment...............................
    10
    Yes
     
    Form 990-PF (2021)
    Form 990-PF (2021)
    Page 5
    Part VI-A
    Statements Regarding Activities (continued)
    11
    At any time during the year, did the foundation, directly or indirectly, own a controlled entity within the
    meaning of section 512(b)(13)? If "Yes," attach schedule. See instructions .............
    11
     
    No
    12
    Did the foundation make a distribution to a donor advised fund over which the foundation or a disqualified person had
    advisory privileges? If "Yes," attach statement. See instructions.................
    12
     
    No
    13
    Did the foundation comply with the public inspection requirements for its annual returns and exemption application?
    13
    Yes
     
    Website addressbulletN/A
    14
    The books are in care ofbulletMARK MUSKEVISCH Telephone no.bullet (262) 513-5066

    Located atbullet925 WALNUT RIDGE DRIVE 150HARTLANDWI ZIP+4bullet53029
    15
    Section 4947(a)(1) nonexempt charitable trusts filing Form 990-PF in lieu of Form 1041 —check here .........bullet
    and enter the amount of tax-exempt interest received or accrued during the year ........bullet
    15
     
    16 At any time during calendar year 2021, did the foundation have an interest in or a signature or other authority over YesNo
    a bank, securities, or other financial account in a foreign country? .................
    16   No
    See the instructions for exceptions and filing requirements for FinCEN Form 114. If "Yes", enter the name of the foreign
    country bullet
    Part VI-B
    Statements Regarding Activities for Which Form 4720 May Be Required
    File Form 4720 if any item is checked in the "Yes" column, unless an exception applies.
    Yes
    No
    1a
    During the year did the foundation (either directly or indirectly):
    (1) Engage in the sale or exchange, or leasing of property with a disqualified person? ...........
    1a(1)
     
    No
    (2) Borrow money from, lend money to, or otherwise extend credit to (or accept it from)
    a disqualified person? ..............................
    1a(2)
     
    No
    (3) Furnish goods, services, or facilities to (or accept them from) a disqualified person? ...........
    1a(3)
     
    No
    (4) Pay compensation to, or pay or reimburse the expenses of, a disqualified person? ............
    1a(4)
     
    No
    (5) Transfer any income or assets to a disqualified person (or make any of either available
    for the benefit or use of a disqualified person)? ......................
    1a(5)
     
    No
    (6) Agree to pay money or property to a government official? (Exception. Check "No"
    if the foundation agreed to make a grant to or to employ the official for a period
    after termination of government service, if terminating within 90 days.) ...............
    1a(6)
     
    No
    b
    If any answer is "Yes" to 1a(1)–(6), did any of the acts fail to qualify under the exceptions described in Regulations
    section 53.4941(d)-3 or in a current notice regarding disaster assistance? See instructions ..........
    1b
     
     
    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
    SARAH JORGENSEN PRESIDENT/DIRECTOR
    0.50     		0 0 0
    925 WALNUT RIDGE DRIVE 150
    HARTLAND,WI53029
    SCOTT SCHMITT SECRETARY/DIRECTOR
    0.50     		0 0 0
    925 WALNUT RIDGE DRIVE 150
    HARTLAND,WI53029
    RICK R KOBRIGER ASST SECR/DIRECTOR
    0.50     		0 0 0
    925 WALNUT RIDGE DRIVE 150
    HARTLAND,WI53029
    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
    0
    b
    Average of monthly cash balances.......................
    1b
    0
    c
    Fair market value of all other assets (see instructions)................
    1c
    81,031
    d
    Total (add lines 1a, b, and c).........................
    1d
    81,031
    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
    81,031
    4
    Cash deemed held for charitable activities. Enter 1.5% (0.015) of line 3 (for greater amount, see
    instructions) .............................
    4
    1,215
    5
    Net value of noncharitable-use assets. Subtract line 4 from line 3. .......
    5
    79,816
    6
    Minimum investment return. Enter 5% (0.05) of line 5................
    6
    3,991
    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
    3,991
    2a
    Tax on investment income for 2021 from Part V, line 5.......
    2a
     
    b
    Income tax for 2021. (This does not include the tax from Part V.) ...
    2b
     
    c
    Add lines 2a and 2b............................
    2c
    0
    3
    Distributable amount before adjustments. Subtract line 2c from line 1............
    3
    3,991
    4
    Recoveries of amounts treated as qualifying distributions................
    4
    0
    5
    Add lines 3 and 4............................
    5
    3,991
    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
    3,991
    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 3,991
    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......  
    e From 2020...... 24,685
    f Total of lines 3a through e ........ 24,685
    4Qualifying distributions for 2021 from Part
    XI, line 4: bullet$ 178,459
    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..... 3,991
    e Remaining amount distributed out of corpus 174,468
    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 5 199,153
    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 ......     		199,153
    10 Analysis of line 9:
    a Excess from 2017....  
    b Excess from 2018....  
    c Excess from 2019....  
    d Excess from 2020.... 24,685
    e Excess from 2021.... 174,468
    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 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)
    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
    KELLER FAMILY COMMUNITY FOUNDATION
    PO BOX 164
    RICHMOND,MN56368     		NONE PULIC CHARITY PROGRAM SUPPORT 1,062
    GLIDA'S CLUB GRAND RAPIDS
    1806 BRIDGE STREET NW
    GRAND RAPIDS,MI49504     		NONE PULIC CHARITY PROGRAM SUPPORT 1,062
    EXODUS WORLD SERVICE
    780 BUSSE HIGHWAY
    PARK RIDGE,IL60068     		NONE PULIC CHARITY PROGRAM SUPPORT 1,062
    KEEP INDIANAPOLIS BEAUTIFUL
    1029 FLETCHER AVE SUITE 100
    INDIANAPOLIS,IN46203     		NONE PULIC CHARITY PROGRAM SUPPORT 1,062
    COLLEGEREADY
    715 SUPERIOR RD SUITE 102
    GREEN BAY,WI54311     		NONE PULIC CHARITY PROGRAM SUPPORT 1,062
    CHALLENGE MOUNTAIN
    PO BOX 764
    BOYNE CITY,MI49712     		NONE PULIC CHARITY PROGRAM SUPPORT 1,062
    THE BABY FOLD
    108 E WILLOW ST
    NORMAL,IL61761     		NONE PULIC CHARITY PROGRAM SUPPORT 1,062
    SONS OF AMERICAN LEGION POST 294
    231 GOODWIN AVE
    HARLAND,WI53029     		NONE PULIC CHARITY PROGRAM SUPPORT 1,018
    BUIST COMMUNITY ASSISTANCE CENTER
    870 74TH ST SW STE B
    BYRON CENTER,MI49315     		NONE PULIC CHARITY PROGRAM SUPPORT 1,018
    GREAT LAKES RECOVERY CENTERS FOUNDATION
    97 S 4TH ST SUITE C
    ISHPEMING,MI49849     		NONE PULIC CHARITY PROGRAM SUPPORT 1,018
    4 KIDS SAKE INC
    336 DERKE AVE
    BOLINGBROOK,IL60490     		NONE PULIC CHARITY PROGRAM SUPPORT 1,018
    FELINES & CANNIES
    6379 N PAULINA
    CHICAGO,IL60660     		NONE PULIC CHARITY PROGRAM SUPPORT 1,018
    BOYS & GIRLS CLUB OF KENOSHA FOUNDATION INC
    1330 52ND STREET
    KENOSHA,WI53140     		NONE PULIC CHARITY PROGRAM SUPPORT 1,018
    WILDLIFE IN NEED CENTER
    W349 S1480 S WATERVILLE ROAD SUITE
    B
    OCONOMOWOC,WI53066     		NONE PULIC CHARITY PROGRAM SUPPORT 1,018
    HABITAT FOR HUMANITY- WOMEN BUILD FUNDRAISER
    2020 SPRINGDALE ROAD
    WAUKESHA,WI53186     		NONE PULIC CHARITY PROGRAM SUPPORT 5,000
    AMERICAN INDIAN CENTER OF CHICAGO
    3401 W AINSILE ST
    CHICAGO,WI60625     		NONE PULIC CHARITY PROGRAM SUPPORT 821
    THE CARRIAGE HOUSE (FORT WAYNE CLUBHOUSE INC)
    3327 LAKE AVE
    FORT WAYNE,IN46805     		NONE PULIC CHARITY PROGRAM SUPPORT 821
    TRINITY FREE CLINIC
    1045 W 146TH ST SUITE B
    CARMEL,IN46032     		NONE PULIC CHARITY PROGRAM SUPPORT 821
    STARLITE SHORES FAMILY CAMP
    1127 MULLIGAN CT SW
    WYOMING,MI49509     		NONE PULIC CHARITY PROGRAM SUPPORT 3,500
    SUPERIOR WATERSHED PARTNERSHIP
    2 PETER WHITE DR
    MARQUETTE,MI49855     		NONE PULIC CHARITY PROGRAM SUPPORT 1,912
    LAKE COUNTY HAVEN
    PO BOX 127
    LIBERTYVILLE,IL60048     		NONE PULIC CHARITY PROGRAM SUPPORT 1,912
    MIDWEST VETERANS CLOSET
    PO BOX 278
    WADSWORTH,IL60083     		NONE PULIC CHARITY PROGRAM SUPPORT 1,912
    DRIVING FOR DYSLEXIA
    7304 E STOP 11 RD
    INDIANAPOLIS,IN46259     		NONE PULIC CHARITY PROGRAM SUPPORT 1,912
    ROSIE'S SOUTHSIDE ANIMAL SHELTER
    1614 W EDGEWOOD AVENUE
    INDIANAPOLIS,IN46217     		NONE PULIC CHARITY PROGRAM SUPPORT 1,912
    BOYS & GIRLS CLUB OF FOX VALLEY
    160 S BADGER ST
    APPLETON,WI54914     		NONE PULIC CHARITY PROGRAM SUPPORT 1,912
    WAUKESHA ROTARTY BLUESFEST (WAUKESHA ROTARY CLUB CHARITABLE FUND INC)
    PO BOX 1876
    WAUKESHA,WI53187     		NONE PULIC CHARITY PROGRAM SUPPORT 2,694
    PAWS AGAINST PAIN - ROGERS BEHAVORIAL FOUNDATION
    34700 VALLEY RD
    OCONOMOWOC,WI53066     		NONE PULIC CHARITY PROGRAM SUPPORT 2,694
    THE NIKOLAS RITSCHEL FOUNDATION
    1915 STRATFORD LN
    ROCKFORD,IL61107     		NONE PULIC CHARITY PROGRAM SUPPORT 2,694
    ELMHURST-YORKFIELD FOOD PANTRY
    1083 S YORK ST
    ELMHURST,IL60126     		NONE PULIC CHARITY PROGRAM SUPPORT 2,694
    EAST SIDE SOUP KITCHEN
    PO BOX 330
    SAGINAW,MI48606     		NONE PULIC CHARITY PROGRAM SUPPORT 1,347
    KRASL ART CENTER
    707 LAKE BLVD
    ST JOSEPH,MI49085     		NONE PULIC CHARITY PROGRAM SUPPORT 1,347
    RESILIENCE ADVOCATES FOR ENDING VIOLENCE
    411 BUTTERNUT DR
    HOLLAND,MI49424     		NONE PULIC CHARITY PROGRAM SUPPORT 1,347
    THE BARN FOR EQUINE LEARNING
    3203 TIMPSON AVE SE
    LOWELL,MI49331     		NONE PULIC CHARITY PROGRAM SUPPORT 1,347
    LITTLE RED DOOR CANCER AGENCY
    1801 N MERIDIAN ST
    INDIANAPOLIS,IN46202     		NONE PULIC CHARITY PROGRAM SUPPORT 2,694
    THE LANGUAGE CONSERVANCY
    2620 N WALNUT ST 810
    BLOOMINGTON,IN47404     		NONE PULIC CHARITY PROGRAM SUPPORT 2,694
    HEAD AND NECK CANCER ALLIANCE - MENDING CROOKED SMILE FUND -MASSACHUSETTS G
    PO BOX 21688
    CHARLESTON,SC29413     		NONE PULIC CHARITY PROGRAM SUPPORT 2,500
    CYCLING WITHOUT AGE MARATHON COUNTY
    1100 LAKEVIEW DR
    WAUSAU,WI54403     		NONE PULIC CHARITY PROGRAM SUPPORT 1,597
    HARTLAND FIRE DEPARTMENT NATIONAL FIRE SAFETY COUNCIL
    PO BOX 378
    MICHIGAN,MI49254     		NONE PULIC CHARITY PROGRAM SUPPORT 450
    RAGS OF HONOR
    7764 N SHERIDAN RD
    CHICAGO,IL60626     		NONE PULIC CHARITY PROGRAM SUPPORT 1,597
    ILLINOIS STATE POLICE HERITAGE FOUNDATION
    PO BOX 2210
    SPRINGFIELD,IL62705     		NONE PULIC CHARITY PROGRAM SUPPORT 1,597
    SCARCE
    800 S ROHLWING RD ROUTE 53 UNIT D
    ADDISON,IL60101     		NONE PULIC CHARITY PROGRAM SUPPORT 1,597
    DALIS TO THE RESCUE
    303 VALLEY AVE
    ALMA,MI48801     		NONE PULIC CHARITY PROGRAM SUPPORT 1,597
    BLANDFORD NATURE CENTER
    1715 HILLBURN AVE NW
    GRAND RAPIDS,MI49504     		NONE PULIC CHARITY PROGRAM SUPPORT 1,597
    PAWS & THINK
    1346 N DELAWARE ST
    INDIANAPOLIS,IN46202     		NONE PULIC CHARITY PROGRAM SUPPORT 1,600
    ARTS COUNCIL OF INDIANAPOLIS
    924 N PENNSYLVANIA ST
    INDIANAPOLIS,IN46204     		NONE PULIC CHARITY PROGRAM SUPPORT 1,597
    WAUKESHA EDUCATION FOUNDATION INC
    222 MAPLE AVE
    WAUKESHA,WI53186     		NONE PULIC CHARITY PROGRAM SUPPORT 2,240
    DIVEHEART FOUNDATION
    900 OGDEN AVE STE 274
    DOWNERS GROVE,IL60515     		NONE PULIC CHARITY PROGRAM SUPPORT 2,240
    TOGETHER WE COPE
    17010 SOUTH OAK PARK AVE
    TINLEY PARK,IL60477     		NONE PULIC CHARITY PROGRAM SUPPORT 2,240
    WOMEN'S RESOURCE CENTER OF NORTHERN MI
    423 PORTER ST
    PETOSKEY,MI49770     		NONE PULIC CHARITY PROGRAM SUPPORT 2,247
    END THE SILENCE WALK (DELTA COUNTY SUICIDE PREVENTION TASK FORCE)
    1215 N 18TH ST
    ESCANABA,MI49829     		NONE PULIC CHARITY PROGRAM SUPPORT 2,240
    HONORING OUR HERO'S
    209 S BROADWAY
    PERU,IN46970     		NONE PULIC CHARITY PROGRAM SUPPORT 2,240
    NATURAL RESOURCES FOUNDATION OF WISCONSIN
    211 SOUTH PATERSON STREET STE 100
    MADISON,WI53703     		NONE PULIC CHARITY PROGRAM SUPPORT 2,240
    JOHNATHON DANIEL LUOMA FOUNDATION
    PO BOX 309
    BROKAW,WI54417     		NONE PULIC CHARITY PROGRAM SUPPORT 1,592
    THE OASIS PROJECT
    732 LOCHTYN RDG
    WALES,WI53183     		NONE PULIC CHARITY PROGRAM SUPPORT 1,592
    SPECIAL OLYMPICS
    2310 CROSSROADS DR STE 1000
    MADISON,WI53718     		NONE PULIC CHARITY PROGRAM SUPPORT 1,592
    VETERANS PATH TO HOPE
    805 S MCHENRY AVE APT D
    CRYSTAL LAKE,IL60014     		NONE PULIC CHARITY PROGRAM SUPPORT 1,592
    WILD DOG RESCUE
    3309 ROBBINS RD STE 109
    SPRINGFIELD,IL62704     		NONE PULIC CHARITY PROGRAM SUPPORT 1,592
    BLACK BUSINESS ALLIANCE PEORIA CHAPTER INC
    2139 SW ADAMS ST
    PEORIA,IL61602     		NONE PULIC CHARITY PROGRAM SUPPORT 1,594
    BEYOND 26
    4340 BURLINGAME AVE SW
    WYOMING,MI49509     		NONE PULIC CHARITY PROGRAM SUPPORT 1,592
    OTSEGO COMMUNITY FOUNDATION
    316 W MAIN ST
    GAYLORD,MI49735     		NONE PULIC CHARITY PROGRAM SUPPORT 1,592
    INDIANA YOUTH INSTITUTE
    603 EAST WASHINGTON ST STE 800
    INDIANAPOLIS,IN46206     		NONE PULIC CHARITY PROGRAM SUPPORT 1,592
    TRUCKERS AGAINST TRAFFICKING
    PO BOX 816
    ENGLEWOOD,CO80151     		NONE PULIC CHARITY PROGRAM SUPPORT 1,000
    COMMUNITY ACTION COALITION FOR SOUTH CENTRAL WISCONSIN
    4101 E TOWNE BLVD
    MADISON,WI53704     		NONE PULIC CHARITY PROGRAM SUPPORT 1,696
    THE HANNAH CENTER
    212 E 3RD ST
    MARSHFIELD,WI54449     		NONE PULIC CHARITY PROGRAM SUPPORT 1,696
    FLIGHT TO THE NORTH POLE LTD
    N20W24912 SUNNYRIDGE LN
    PEWAUKEE,WI53072     		NONE PULIC CHARITY PROGRAM SUPPORT 1,696
    CAMBR NORTH
    336 PATRICIA LN
    BARLET,IL60103     		NONE PULIC CHARITY PROGRAM SUPPORT 1,696
    PAWS ASSISTING WOUNDED WARRIORS INC
    9935 S 76TH AVE UNIT H
    BRIDGEVIEW,IL60455     		NONE PULIC CHARITY PROGRAM SUPPORT 1,698
    CAMP BLODGET
    528 BRIDGE ST NW STE 6
    GRAND RAPIDS,MI49504     		NONE PULIC CHARITY PROGRAM SUPPORT 1,696
    ISABELLA COMMUNITY SOUP KITCHEN
    PO BOX 872
    MT PLEASANT,MI48804     		NONE PULIC CHARITY PROGRAM SUPPORT 1,696
    HOPE FOR ANIMALS
    1333 MAYCREST DR
    FORT WAYNE,IN46805     		NONE PULIC CHARITY PROGRAM SUPPORT 1,696
    FOOD FINDERS FOOD BANK INC
    1204 GREENBUSH STREET
    LAFAYETTE,IN47904     		NONE PULIC CHARITY PROGRAM SUPPORT 1,696
    K9'S 4 VETRANS
    2312 OLDE MILL ROAD
    PLAINFIELD,IL60586     		NONE PULIC CHARITY PROGRAM SUPPORT 7,500
    CARY GROVE FOOD PANTRY
    8901 CARY ALGONQUIN RD
    CARY,IL60013     		NONE PULIC CHARITY PROGRAM SUPPORT 300
    EASTVIEW CHRISTIAN CHURCH
    1500 NORTH AIRPORT RD
    NORMAL,IL61704     		NONE PULIC CHARITY PROGRAM SUPPORT 300
    DUPAGE TOWNSHIP FOOD PANTRY
    719 PARKWOOD AVE
    ROMEOVILLE,IL60446     		NONE PULIC CHARITY PROGRAM SUPPORT 300
    EASTERN ILLINOIS FOODBANK
    2405 NORTH SHORE DRIVE
    URBANA,IL61802     		NONE PULIC CHARITY PROGRAM SUPPORT 300
    THORNTON TOWNSHIP PANTRY
    15340 PAGE STREET
    HARVEY,IL60426     		NONE PULIC CHARITY PROGRAM SUPPORT 300
    WE CARE INC
    622 W JACKSON
    MORTON,IL61550     		NONE PULIC CHARITY PROGRAM SUPPORT 300
    ROCK RIVER VALLEY FOOD PANTRY
    421 S ROCKTON AVE
    ROCKFORD,IL61102     		NONE PULIC CHARITY PROGRAM SUPPORT 300
    GREATER CHICAGO FOOD DEPOSITORY
    4100 W ANN LURIE PLACE
    CHICAGO,IL60632     		NONE PULIC CHARITY PROGRAM SUPPORT 300
    OPEN ARMS MISSION
    1548 MAIN STREET
    ANTIOCH,IL60002     		NONE PULIC CHARITY PROGRAM SUPPORT 300
    TOGETHER WE COPE
    17010 OAK PARK AVE
    TINLEY PARK,IL60477     		NONE PULIC CHARITY PROGRAM SUPPORT 300
    ST JOSEPHS FOOD PROGRAM
    1465A OPPORTUNITY WAY
    MENASHA,WI54952     		NONE PULIC CHARITY PROGRAM SUPPORT 300
    HARTLAND FOOD BANK
    555 D INDUSTRIAL DR SUITE 7
    HARTLAND,WI53072     		NONE PULIC CHARITY PROGRAM SUPPORT 300
    DEPERE CHRISTIAN OUTREACH FOOD PANTY
    1827 CHICAGO STREET
    DEPERE,WI54115     		NONE PULIC CHARITY PROGRAM SUPPORT 300
    SECOND HARVEST FOOD BANK OF SE WI
    2802 DAIRY DRIVE
    MADISON,WI53718     		NONE PULIC CHARITY PROGRAM SUPPORT 300
    HUMAN CONCERN
    1029 MILWAUKEE AVE
    MILWAUKEE,WI53172     		NONE PULIC CHARITY PROGRAM SUPPORT 300
    WAUKESHA FOOD PANTRY
    1301 SENTRY DRIVE
    WAUKESHA,WI53186     		NONE PULIC CHARITY PROGRAM SUPPORT 300
    MERRILL COMMUNITY FOOD PANTRY
    503 S CENTER AVENUE
    MERRILL,WI54452     		NONE PULIC CHARITY PROGRAM SUPPORT 300
    POINTER FOOD PANTRY
    PO BOX 123
    MINERAL POINT,WI53565     		NONE PULIC CHARITY PROGRAM SUPPORT 300
    THE SHALOM CENTER
    4314 39TH AVENUE
    KENOSHA,WI53144     		NONE PULIC CHARITY PROGRAM SUPPORT 300
    OTSEGO COUNTY FOOD PANTRY
    116 E 5TH ST
    GAYLORD,MI49735     		NONE PULIC CHARITY PROGRAM SUPPORT 300
    FAMILY NETWORK OF WYOMING
    1029 44TH ST SW
    WYOMING,MI49509     		NONE PULIC CHARITY PROGRAM SUPPORT 300
    KALAMAZOO LOAVES & FISHES
    901 PORTAGE ST
    KALAMAZOO,MI49001     		NONE PULIC CHARITY PROGRAM SUPPORT 300
    COMMUNITY COMPASSION NETWORK
    1114 W HIGH STREET
    MOUNT PLEASANT,MI48858     		NONE PULIC CHARITY PROGRAM SUPPORT 300
    COMMUNITY ACTION ALGER-MARQUETTE
    1125 COMMERCE DRIVE
    MARQUETTE,MI49855     		NONE PULIC CHARITY PROGRAM SUPPORT 300
    FIRST PRESBYTERIAN CHURCH
    13 S 4TH STREET
    NILES,MI49120     		NONE PULIC CHARITY PROGRAM SUPPORT 300
    GEORGE T GOODWIN COMMUNITY CENTER
    3935 MOORESVILLE ROAD
    INDIANAPOLIS,IN46221     		NONE PULIC CHARITY PROGRAM SUPPORT 300
    COMMUNITY HARVEST FOOD BANK
    999 E TILLMAN ROAD
    FORT WAYNE,IN46816     		NONE PULIC CHARITY PROGRAM SUPPORT 300
    LAFAYETTE URBAN MINISTRY (LUM)
    420 N 4TH STREET
    LAFAYETTE,IN47901     		NONE PULIC CHARITY PROGRAM SUPPORT 300
    ANGELS OF THE ROAD RIDE FOR VETERANS
    N16W26443 MEADOWGRASS LN
    PEWAUKEE,WI53072     		NONE PULIC CHARITY PROGRAM SUPPORT 2,500
    STARS AND STRIPES HONOR FLIGHT
    PO BOX 867
    MENOMONEE FALLS,WI53052     		NONE PULIC CHARITY PROGRAM SUPPORT 2,500
    MILWAUKEE CHILDREN'S CHOIR
    427 E STEWART ST STE 100
    MILWAUKEE,WI53207     		NONE PULIC CHARITY PROGRAM SUPPORT 2,500
    SPECIAL OLYMPICS ILLINOIS
    605 E WILLOW ST
    NORMAL,IL61761     		NONE PULIC CHARITY PROGRAM SUPPORT 2,500
    SANTA CLAUS GIRLS OF KENT COUNTY
    PO BOX 543
    COMSTOCK PARK,MI49321     		NONE PULIC CHARITY PROGRAM SUPPORT 2,500
    INDIAN CREEK BAND BOOSTERS
    803 W INDIAN CREEK DRIVE
    TRAFALGAAR,IN46181     		NONE PULIC CHARITY PROGRAM SUPPORT 2,500
    VETERAN'S OUTREACH OF WISCONSIN
    1624 YOUT ST
    RACINE,WI53404     		NONE PULIC CHARITY PROGRAM SUPPORT 2,000
    FEEDING OUR FUTURE
    700 HIGH STREET
    MOSINEE,WI54455     		NONE PULIC CHARITY PROGRAM SUPPORT 2,000
    ADOPTIVE ADVENTURES
    9053 HARLAN STREET STE 34
    WESTMINSTER,CO80031     		NONE PULIC CHARITY PROGRAM SUPPORT 2,000
    STABEN HOUSE
    149 SOUTH GENESEE STREET
    WAUKEGAN,IL60085     		NONE PULIC CHARITY PROGRAM SUPPORT 2,000
    THE MANNA FOOD PROJECT
    8791 MCBRIDE PARK COURT
    HARBOR SPRINGS,MI49740     		NONE PULIC CHARITY PROGRAM SUPPORT 2,000
    MISS CARLY'S
    1125 5TH AVE
    ROCKFORD,IL61104     		NONE PULIC CHARITY PROGRAM SUPPORT 2,000
    ST JOSEPH FOOD PROGRAM
    1465A OPPORTUNITY WAY
    MENASHA,WI54952     		NONE PULIC CHARITY PROGRAM SUPPORT 500
    HARTLAND FOOD PANTRY
    555 D INDUSTRIAL DR SUITE 7
    HARTLAND,WI53072     		NONE PULIC CHARITY PROGRAM SUPPORT 500
    DE PERE OUTREACH
    1827 CHICAGO STREET
    DEPERE,WI54115     		NONE PULIC CHARITY PROGRAM SUPPORT 500
    POINTER PANTRY
    PO BOX 123
    MINERAL POINT,WI53565     		NONE PULIC CHARITY PROGRAM SUPPORT 500
    SECOND HARVEST FOOD BANK
    2802 DAIRY DRIVE
    MADISON,WI53718     		NONE PULIC CHARITY PROGRAM SUPPORT 500
    S MILWAUKEE HUMAN CONCERNS
    1029 MILWAUKEE AVE SOUTH
    MILWAUKEE,WI53172     		NONE PULIC CHARITY PROGRAM SUPPORT 500
    WAUKESHA FOOD PANTRY
    1301 SENTRY DRIVE
    WAUKESHA,WI53186     		NONE PULIC CHARITY PROGRAM SUPPORT 500
    HOME SWEET HOME MINISTRY
    303 E OAKLAND
    BLOOMINGTON,IL61701     		NONE PULIC CHARITY PROGRAM SUPPORT 500
    THORNTON TOWNSHIP FOOD PROGRAM
    15340 PAGE STREET
    HARVEY,IL60426     		NONE PULIC CHARITY PROGRAM SUPPORT 500
    DUPAGE TOWNSHIP FOOD PANTRY
    719 PARKWOOD AVE
    ROMEOVILLE,IL60446     		NONE PULIC CHARITY PROGRAM SUPPORT 500
    ELMHURSTYORKFIELD FOOD PANTRY
    1083 S YORK RD
    ELMHURST,IL60126     		NONE PULIC CHARITY PROGRAM SUPPORT 500
    WE CARE OF MORTON
    622 W JACKSON
    MORTON,IL61550     		NONE PULIC CHARITY PROGRAM SUPPORT 500
    ROCK RIVER VALLEY FOOD PANTRY
    421 S ROCKTON AVE
    ROCKFORD,IL61102     		NONE PULIC CHARITY PROGRAM SUPPORT 500
    SALT & LIGHT CHAMPAIGN
    1819 SD PHILO ROAD
    URBANA,IL61802     		NONE PULIC CHARITY PROGRAM SUPPORT 500
    GREATER CHICAGO FOOD DEPOSITORY
    4100 W ANN LURIE PLACE
    CHICAGO,IL60632     		NONE PULIC CHARITY PROGRAM SUPPORT 500
    NORTHERN ILLINOIS FOOD BANK
    237 DEARBORN COURT
    GENEVA,IL60134     		NONE PULIC CHARITY PROGRAM SUPPORT 500
    VILLAGE PANTRY COALITION
    3450 W 97TH ST
    EVERGREEN PARK,IL60805     		NONE PULIC CHARITY PROGRAM SUPPORT 500
    FOOD BANK OF NORTHERN INDIANA
    702 CHAPIN STREET
    SOUTH BEND,IN46601     		NONE PULIC CHARITY PROGRAM SUPPORT 500
    COMMUNITY COMPASSION NETWORK
    1114 W HIGH STREET
    MOUNT PLEASANT,MI48858     		NONE PULIC CHARITY PROGRAM SUPPORT 500
    KALAMAZOO DREAM CENTER
    1122 PORTAGE RD
    KALAMAZOO,MI49001     		NONE PULIC CHARITY PROGRAM SUPPORT 500
    NMU FOUNDATION FOOD PANTRY
    607 COHODAS HALL 1401
    MARQUETTE,MI49855     		NONE PULIC CHARITY PROGRAM SUPPORT 500
    FAMILY NETWORK
    1029 44TH ST SW
    WYOMING,MI49509     		NONE PULIC CHARITY PROGRAM SUPPORT 500
    OSTEGO COUNTY PANTRY
    116 E 5TH ST
    GAYLORD,MI49735     		NONE PULIC CHARITY PROGRAM SUPPORT 500
    SOCIETY OF ST VINCENT DEPAUL
    2119 PRESQUE ISLE AVENUE
    MARQUETTE,MI49855     		NONE PULIC CHARITY PROGRAM SUPPORT 500
    MISS VIRGINIA'S FOOD PANTRY
    1312 S HANNA ST
    FORT WAYNE,IN46802     		NONE PULIC CHARITY PROGRAM SUPPORT 500
    THE REFUGE
    65 AIRPORT PARKWAY SUITE 114
    GREENWOOD,IN47904     		NONE PULIC CHARITY PROGRAM SUPPORT 500
    FOOD FINDERS FOOD BANK
    1204 GREENBUSH STREET
    LAFAYETTE,IN47904     		NONE PULIC CHARITY PROGRAM SUPPORT 500
    UNITED WAY OF DENTON COUNTY
    1314 TEASLEY LN
    DENTON,TX76205     		NONE PULIC CHARITY PROGRAM SUPPORT 1,500
    Total .................................bullet 3a 178,459
    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 32  
    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 ............     		         
    9 Net income or (loss) from special events:          
    10 Gross profit or (loss) from sales of inventory          
    11 Other revenue: a
    b
    c
    d
    e
    12 Subtotal. Add columns (b), (d), and (e) .. 0 32 0
    13Total. Add line 12, columns (b), (d), and (e)..................
    13
    32
    (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
    JX GIVES BACK FAMILY FOUNDATION INC
    C/O MARK MUSKEVITSCH
    Employer identification number

    83-4706547
    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
    JX GIVES BACK FAMILY FOUNDATION INC
    C/O MARK MUSKEVITSCH         		Employer identification number
    83-4706547
    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
    JX ENTERPRISES INC
     
    925 WALNUT RIDGE DRIVE STE 150
     
    WAUKESHA, WI53029

    		$ 107,195


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
    2
    ERIC & SARAH JORGENSEN
     
    925 WALNUT RIDGE DRIVE STE 150
     
    WAUKESHA, WI53029

    		$ 120,000


    (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.)
    Schedule B (Form 990) (2021)
    Schedule B (Form 990) (2021)
    Page 3
    Name of organization
    JX GIVES BACK FAMILY FOUNDATION INC
    C/O MARK MUSKEVITSCH         		Employer identification number

    83-4706547
    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
    JX GIVES BACK FAMILY FOUNDATION INC
    C/O MARK MUSKEVITSCH         		Employer identification number

    83-4706547
    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 OtherDecreasesSchedule
    Name:
    JX GIVES BACK FAMILY FOUNDATION INC
     
    C/O MARK MUSKEVITSCH
    EIN:
    83-4706547
    Description Amount
    ROUNDING ADJUSTMENTS 4


    TY 2021 OtherExpensesSchedule
    Name:
    JX GIVES BACK FAMILY FOUNDATION INC
     
    C/O MARK MUSKEVITSCH
    EIN:
    83-4706547
    Description Revenue and Expenses per Books Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    ADMINISTRATIVE EXPENSE 10 10   0


    TY 2021 SubstantialContributorsSch
    Name:
    JX GIVES BACK FAMILY FOUNDATION INC
     
    C/O MARK MUSKEVITSCH
    EIN:
    83-4706547
    Name Address
    JX ENTERPRISES INC
          		925 WALNUT RIDGE DRIVE 150
    HARTLAND,WI53029