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 09-01-2021 , and ending 08-31-2022
Name of foundation
Ann A Mergens Foundation Inc
 
Number and street (or P.O. box number if mail is not delivered to street address)PO Box 662
  Room/suite
City or town, state or province, country, and ZIP or foreign postal code
Shelburne, VT05482
A Employer identification number

27-4113304
B Telephone number (see instructions)

(802) 863-5933
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$6,989,130J 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) 0
2 Check bullet.............
3 Interest on savings and temporary cash investments 140 140  
4 Dividends and interest from securities... 103,241 103,241  
5a Gross rents............      
b Net rental income or (loss)  
6a Net gain or (loss) from sale of assets not on line 10 Click to see attachment 289,719
b Gross sales price for all assets on line 6a 882,768
7 Capital gain net income (from Part IV, line 2)... 289,719
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)..... 0  
11 Other income (attach schedule)....... 0    
12 Total. Add lines 1 through 11........ 393,100 393,100  
Operating and Administrative Expenses 13 Compensation of officers, directors, trustees, etc. 30,000 0   30,000
14 Other employee salaries and wages...... 0      
15 Pension plans, employee benefits....... 0      
16a Legal fees (attach schedule)......... 0      
b Accounting fees (attach schedule)....... Click to see attachment 1,850 925   925
c Other professional fees (attach schedule).... Click to see attachment 8,076 8,076   0
17 Interest............... 0 0   0
18 Taxes (attach schedule) (see instructions)... Click to see attachment 10,490 0   0
19 Depreciation (attach schedule) and depletion... 0 0  
20 Occupancy.............. 0 0   0
21 Travel, conferences, and meetings....... 0 0   0
22 Printing and publications.......... 0 0   0
23 Other expenses (attach schedule)....... Click to see attachment 71,504 21,390   50,114
24 Total operating and administrative expenses.
Add lines 13 through 23.......... 121,920 30,391   81,039
25 Contributions, gifts, grants paid....... 280,000 280,000
26 Total expenses and disbursements. Add lines 24 and 25 401,920 30,391   361,039
27 Subtract line 26 from line 12:
a Excess of revenue over expenses and disbursements -8,820
b Net investment income (if negative, enter -0-) 362,709
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............. 6,255 0 0
2 Savings and temporary cash investments......... 47,855 269,355 269,355
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).....   0  
7 Other notes and loans receivable (attach schedule) bullet  
Less: allowance for doubtful accounts bullet     0  
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)....... 4,952,181 Click to see attachment4,741,874 5,314,738
c Investments—corporate bonds (attach schedule)....... 1,559,426 Click to see attachment1,545,668 1,405,037
11 Investments—land, buildings, and equipment: basis bullet  
Less: accumulated depreciation (attach schedule) bullet     0  
12 Investments—mortgage loans.............      
13 Investments—other (attach schedule)..........   0  
14 Land, buildings, and equipment: basis bullet  
Less: accumulated depreciation (attach schedule) bullet     0  
15 Other assets (describe bullet) 0 0 0
16 Total assets (to be completed by all filers—see the
instructions. Also, see page 1, item I) 6,565,717 6,556,897 6,989,130
Liabilities 17 Accounts payable and accrued expenses.......... 0 0
18 Grants payable.................    
19 Deferred revenue.................    
20 Loans from officers, directors, trustees, and other disqualified persons   0
21 Mortgages and other notes payable (attach schedule)......   0
22 Other liabilities (describe bullet) 0 0
23 Total liabilities (add lines 17 through 22)......... 0 0
Net Assets or Fund Balances Foundations that follow FASB ASC 958, check here bullet
and complete lines 24, 25, 29 and 30.
24 Net assets without donor restrictions...........    
25 Net assets with donor restrictions............    
Foundations that do not follow FASB ASC 958, check here bullet
and complete lines 26 through 30.
26 Capital stock, trust principal, or current funds........ 0 0
27 Paid-in or capital surplus, or land, bldg., and equipment fund 0 0
28 Retained earnings, accumulated income, endowment, or other funds 6,565,717 6,556,897
29 Total net assets or fund balances (see instructions)..... 6,565,717 6,556,897
30 Total liabilities and net assets/fund balances (see instructions). 6,565,717 6,556,897
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
6,565,717
2
Enter amount from Part I, line 27a .....................
2
-8,820
3
Other increases not included in line 2 (itemize) bullet
3
 
4
Add lines 1, 2, and 3 ..........................
4
6,556,897
5
Decreases not included in line 2 (itemize) bullet
5
 
6
Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 29 .
6
6,556,897
Form 990-PF (2021)
Form 990-PF (2021)
Page 3
Part IV
Capital Gains and Losses for Tax on Investment Income
(a) List and describe the kind(s) of property sold (e.g., real estate,
2-story brick warehouse; or common stock, 200 shs. MLC Co.)		 (b)
How acquired
P—Purchase
D—Donation 		(c)
Date acquired
(mo., day, yr.) 		(d)
Date sold
(mo., day, yr.)
1 a Publicly Traded Securities P    
b
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 882,768 0 593,049 289,719
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 0 0 0 289,719
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 2 289,719
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 5,042
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 5,042
6 Credits/Payments:
a 2021 estimated tax payments and 2020 overpayment credited to 2021 6a 7,500
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.............. Part VI Line 7 - Original Return Overpayment: -7500 7 7,500
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.......Bullet 9  
10 Overpayment. If line 7 is more than the total of lines 5 and 8, enter the amount overpaid...Bullet 10 2,458
11 Enter the amount of line 10 to be: Credited to 2022 estimated taxBullet2,458 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)
    bulletVT
    b
    If the answer is "Yes" to line 7, has the foundation furnished a copy of Form 990-PF to the Attorney
    General (or designate) of each state as required by General Instruction G? If "No," attach explanation .
    8b
    Yes
     
    9
    Is the foundation claiming status as a private operating foundation within the meaning of section 4942(j)(3)
    or 4942(j)(5) for calendar year 2021 or the taxable year beginning in 2021? See the instructions for Part XIII.
    If "Yes," complete Part XIII .............................
    9
     
    No
    10
    Did any persons become substantial contributors during the tax year? If "Yes," attach a schedule listing their names
    and addresses. ...............................
    10
     
    No
    Form 990-PF (2021)
    Form 990-PF (2021)
    Page 5
    Part VI-A
    Statements Regarding Activities (continued)
    11
    At any time during the year, did the foundation, directly or indirectly, own a controlled entity within the
    meaning of section 512(b)(13)? If "Yes," attach schedule. See instructions .............
    11
     
    No
    12
    Did the foundation make a distribution to a donor advised fund over which the foundation or a disqualified person had
    advisory privileges? If "Yes," attach statement. See instructions.................
    12
     
    No
    13
    Did the foundation comply with the public inspection requirements for its annual returns and exemption application?
    13
    Yes
     
    Website addressbulletN/A
    14
    The books are in care ofbulletPaul G Mergens Telephone no.bullet (802) 863-5933

    Located atbulletPO Box 662ShelburneVT ZIP+4bullet05482
    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)
    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)
     
    No
    (6) Agree to pay money or property to a government official? (Exception. Check "No"
    if the foundation agreed to make a grant to or to employ the official for a period
    after termination of government service, if terminating within 90 days.) ...............
    1a(6)
     
    No
    b
    If any answer is "Yes" to 1a(1)–(6), did any of the acts fail to qualify under the exceptions described in Regulations
    section 53.4941(d)-3 or in a current notice regarding disaster assistance? See instructions ..........
    1b
     
    No
    c
    ........bullet
    d
    Did the foundation engage in a prior year in any of the acts described in 1a, other than excepted acts,
    that were not corrected before the first day of the tax year beginning in 2021? .............
    1d
     
    No
    2
    Taxes on failure to distribute income (section 4942) (does not apply for years the foundation was a private
    operating foundation defined in section 4942(j)(3) or 4942(j)(5)):
    a
    At the end of tax year 2021, did the foundation have any undistributed income (lines 6d
    and 6e, Part XII) for tax year(s) beginning before 2021?....................
    2a
     
    No
    If "Yes," list the years bullet20, 20, 20, 20
    b
    Are there any years listed in 2a for which the foundation is not applying the provisions of section 4942(a)(2)
    (relating to incorrect valuation of assets) to the year’s undistributed income? (If applying section 4942(a)(2)
    to all years listed, answer "No" and attach statement—see instructions.) ..............
    2b
     
     
    c
    If the provisions of section 4942(a)(2) are being applied to any of the years listed in 2a, list the years here.
    bullet20, 20, 20, 20
    3a
    Did the foundation hold more than a 2% direct or indirect interest in any business enterprise at
    any time during the year? ..............................
    3a
     
    No
    b
    If "Yes," did it have excess business holdings in 2021 as a result of (1) any purchase by the foundation
    or disqualified persons after May 26, 1969; (2) the lapse of the 5-year period (or longer period approved
    by the Commissioner under section 4943(c)(7)) to dispose of holdings acquired by gift or bequest; or (3)
    the lapse of the 10-, 15-, or 20-year first phase holding period? (Use Schedule C, Form 4720, to determine
    if the foundation had excess business holdings in 2021.) .....................
    3b
     
     
    4a
    Did the foundation invest during the year any amount in a manner that would jeopardize its charitable purposes?
    4a
     
    No
    b
    Did the foundation make any investment in a prior year (but after December 31, 1969) that could jeopardize its
    charitable purpose that had not been removed from jeopardy before the first day of the tax year beginning in 2021? ..
    4b
     
    No
    Form 990-PF (2021)
    Form 990-PF (2021)
    Page 6
    Part VI-B
    Statements Regarding Activities for Which Form 4720 May Be Required (continued)
    5a
    During the year did the foundation pay or incur any amount to:
    Yes
    No
    (1) Carry on propaganda, or otherwise attempt to influence legislation (section 4945(e))? ..........
    5a(1)
     
    No
    (2) Influence the outcome of any specific public election (see section 4955); or to carry
    on, directly or indirectly, any voter registration drive? ....................
    5a(2)
     
    No
    (3) Provide a grant to an individual for travel, study, or other similar purposes? .............
    5a(3)
     
    No
    (4) Provide a grant to an organization other than a charitable, etc., organization described
    in section 4945(d)(4)(A)? See instructions ........................
    5a(4)
     
    No
    (5) Provide for any purpose other than religious, charitable, scientific, literary, or
    educational purposes, or for the prevention of cruelty to children or animals? .............
    5a(5)
     
    No
    b
    If any answer is "Yes" to 5a(1)–(5), did any of the transactions fail to qualify under the exceptions described in
    Regulations section 53.4945 or in a current notice regarding disaster assistance? See instructions ........
    5b
     
     
    c
    .........bullet
    d
    If the answer is "Yes" to question 5a(4), does the foundation claim exemption from the
    tax because it maintained expenditure responsibility for the grant? .................
    5d
     
     
    If "Yes," attach the statement required by Regulations section 53.4945–5(d).
    6a
    Did the foundation, during the year, receive any funds, directly or indirectly, to pay premiums on
    a personal benefit contract? .............................
    6a
     
    No
    b
    Did the foundation, during the year, pay premiums, directly or indirectly, on a personal benefit contract? ....
    6b
     
    No
    If "Yes" to 6b, file Form 8870.
    7a
    At any time during the tax year, was the foundation a party to a prohibited tax shelter transaction?
    7a
     
    No
    b
    If "Yes", did the foundation receive any proceeds or have any net income attributable to the transaction? .....
    7b
     
     
    8
    Is the foundation subject to the section 4960 tax on payment(s) of more than $1,000,000 in remuneration or
    excess parachute payment during the year? .........................
    8
     
    No
    Part VII
    Information About Officers, Directors, Trustees, Foundation Managers, Highly Paid Employees,
    and Contractors
    1 List all officers, directors, trustees, foundation managers and their compensation. See instructions
    (a) Name and address (b) Title, and average
    hours per week
    devoted to position     		(c) Compensation
     (If not paid, enter
    -0-)     		(d) Contributions to employee benefit plans and deferred compensation (e) Expense account,
    other allowances
    Mary Mergens-Loughran Chair & Exec. Director
    7.50     		30,000 0 0
    PO Box 662
    Shelburne,VT05482
    Paul G Mergens Vice-President
    2.00     		0 0 0
    PO Box 662
    Shelburne,VT05482
    William H Wiltshire Secretary
    2.00     		0 0 0
    PO Box 633
    Milton,VT05468
    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.........................bullet  
    Form 990-PF (2021)
    Form 990-PF (2021)
    Page 8
    Part IX
    Minimum Investment Return (All domestic foundations must complete this part. Foreign foundations, see instructions.)
    1
    Fair market value of assets not used (or held for use) directly in carrying out charitable, etc.,
    purposes:
    a
    Average monthly fair market value of securities...................
    1a
    7,803,662
    b
    Average of monthly cash balances.......................
    1b
    299,277
    c
    Fair market value of all other assets (see instructions)................
    1c
    0
    d
    Total (add lines 1a, b, and c).........................
    1d
    8,102,939
    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
    8,102,939
    4
    Cash deemed held for charitable activities. Enter 1.5% (0.015) of line 3 (for greater amount, see
    instructions) .............................
    4
    121,544
    5
    Net value of noncharitable-use assets. Subtract line 4 from line 3. .......
    5
    7,981,395
    6
    Minimum investment return. Enter 5% (0.05) of line 5................
    6
    399,070
    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
    399,070
    2a
    Tax on investment income for 2021 from Part V, line 5.......
    2a
    5,042
    b
    Income tax for 2021. (This does not include the tax from Part V.) ...
    2b
    0
    c
    Add lines 2a and 2b............................
    2c
    5,042
    3
    Distributable amount before adjustments. Subtract line 2c from line 1............
    3
    394,028
    4
    Recoveries of amounts treated as qualifying distributions................
    4
    0
    5
    Add lines 3 and 4............................
    5
    394,028
    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
    394,028
    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 7 394,028
    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  
    3 Excess distributions carryover, if any, to 2021:
    a From 2016...... 0
    b From 2017...... 463
    c From 2018...... 0
    d From 2019...... 0
    e From 2020...... 21,872
    f Total of lines 3a through e ........ 22,335
    4Qualifying distributions for 2021 from Part
    XI, line 4: bullet$ 361,039
    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..... 361,039
    e Remaining amount distributed out of corpus 0
    5 Excess distributions carryover applied to 2021. 22,335 22,335
    (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 0
    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......     		 
    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 ..........     		10,654
    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 ......     		0
    10 Analysis of line 9:
    a Excess from 2017.... 0
    b Excess from 2018.... 0
    c Excess from 2019.... 0
    d Excess from 2020.... 0
    e Excess from 2021.... 0
    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).)
    None
    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.
    None
    2Information Regarding Contribution, Grant, Gift, Loan, Scholarship, etc., Programs:
    Check here bullet
    aThe name, address, and telephone number or e-mail address of the person to whom applications should be addressed:
    Mary Mergens-Loughran
    PO Box 662
    Shelburne,VT05482
    (802) 863-5933
    bThe form in which applications should be submitted and information and materials they should include:
    Any form of application is acceptable. Include organizational information and intended charitable use of the funds.
    cAny submission deadlines:
    None
    dAny restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other
    factors:
    None
    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
    Live Like Jake Foundation
    PO Box 31652
    West Palm Beach,FL33420     		  PC General OperatingSupport 100,000
    Burlington City Arts
    135 Church Street
    Burlington,VT05401     		  PC Art from theHeart Program 10,000
    Shelburne Farms
    1161 Harbor Road
    Shelburne,VT05482     		  PC Farm Barn Facilityand Programming 40,000
    Stern Center
    183 Talcott Road
    Williston,VT05495     		  PC Neil ShapiroScholarship Fund 30,000
    Center for Creative Education
    425 24th Street
    West Palm Beach,FL33407     		  PC General OperatingSupport 25,000
    Loggerhead Marine Life Center
    14200 US Highway 1
    North Palm Beach,FL33408     		  PC CapitalCampaign 20,000
    Greater Burlington YMCA
    266 College Street
    Burlington,VT05401     		  PC CapitalCampaign 15,000
    Busch Wildlife Sanctuary
    2500 Jupiter Park Drive
    Jupiter,FL33458     		  PC General OperatingSupport 10,000
    Champlain College
    PO Box 670
    Burlington,VT05402     		  PC General OperatingSupport 15,000
    Jupiter Hills Community Foundation
    PO Box 3582
    Tequesta,FL33469     		  PC General OperatingSupport 15,000
    Total .................................bullet 3a 280,000
    bApproved for future payment
    Total .................................bullet 3b  
    Form 990-PF (2021)
    Form 990-PF (2021)
    Page 12
    Part XV-A
    Analysis of Income-Producing Activities
    Enter gross amounts unless otherwise indicated. Unrelated business income Excluded by section 512, 513, or 514 (e)
    Related or exempt
    function income
    (See instructions.)
    1Program service revenue: (a)
    Business code     		(b)
    Amount     		(c)
    Exclusion code     		(d)
    Amount
    a
    b
    c
    d
    e
    f
    gFees and contracts from government agencies          
    2 Membership dues and assessments ....          
    3 Interest on savings and temporary cash
    investments ...........     		    14 140  
    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 ............     		    18 289,719  
    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) ..   393,100  
    13Total. Add line 12, columns (b), (d), and (e)..................
    13
    393,100
    (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:  
    Part VI Line 7 -Original Return Overpayment: -7,500


    Form 990PF - Special Condition Description:
    Special Condition Description

    TY 2021 AccountingFeesSchedule
    Name:
    Ann A Mergens Foundation Inc
    EIN:
    27-4113304
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    Vermont CPA Firm Accounting & Tax Preparation 1,850 925   925

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

    TY 2021 GainLossSaleOtherAssetsSch
    Name:
    Ann A Mergens Foundation Inc
    EIN:
    27-4113304
    Name Date Acquired How Acquired Date Sold Purchaser Name Gross Sales Price Basis Basis Method Sales Expenses Total (net) Accumulated Depreciation
    Publicly Traded Securities (including CGDs)   Purchased   Unrelated Third Parties 882,768 593,049 Cost 0 289,719 0

    TY 2021 InvestmentsCorpBondsSchedule
    Name:
    Ann A Mergens Foundation Inc
    EIN:
    27-4113304
    Name of Bond End of Year Book Value End of Year Fair Market Value
    33,401sh OW Fixed Income Fund 376,746 343,700
    7,687sh OW Credit Income Fund 76,691 66,493
    70,792sh OW Fixed Income Fund 794,716 728,453
    16,468sh OW Credit Income Fund 164,291 142,445
    4,315sh Vanguard Short-Term Investment Grade Bond Fund 44,837 43,413
    3,097sh Vanguard Total Bond Market Fund 33,387 30,414
    2,793sh Vanguard Short-Term Investment Grade Bond Fund 30,000 28,101
    2,242sh Vanguard Total Bond Market Fund 25,000 22,018

    TY 2021 InvestmentsCorpStockSchedule
    Name:
    Ann A Mergens Foundation Inc
    EIN:
    27-4113304
    Name of Stock End of Year Book Value End of Year Fair Market Value
    60sh Alphabet Inc. 3,766 6,549
    20sh Meta Platforms Inc. 3,786 3,258
    30sh Take-2 Interactive 3,815 3,676
    100sh Amazon.com Inc. 8,925 12,677
    20sh Aptiv PLC 2,879 1,868
    8sh Dollar General Corporation 2,069 1,899
    25sh Hilton Worldwide Holdings 2,184 3,184
    30sh Consumer Staples Index Fund 2,320 2,193
    2sh Costco Wholesale Corporation 995 1,044
    35sh Pepsico Inc. 4,748 6,029
    25sh Walmart Inc. 3,803 3,313
    85sh ConocoPhillips 4,241 9,303
    15sh Pioneer Natural Resources 1,703 3,798
    10sh AON PLC 2,785 2,792
    230sh Bank of America Corporation 6,288 7,730
    25sh Blackstone Inc. 1,278 2,348
    35sh Brookfield Asset Management 1,991 1,683
    40sh JPMorgan Chase & Company 6,072 4,549
    6sh MSCI Inc. 2,525 2,695
    13sh S&P Global Inc. 4,712 4,578
    75sh Charles Schwab Corporation 3,815 5,321
    25sh Catalent Inc. 2,598 2,200
    20sh Danaher Corporation 2,764 5,398
    19sh Health Care Select SPDR 2,632 2,370
    20sh IQVIA Holdings Inc. 2,740 4,253
    7sh Thermo Fisher Scientific 1,986 3,817
    15sh UnitedHealth Group Inc. 3,593 7,789
    30sh Zoetis Inc. 3,779 4,695
    10sh Copart Inc. 1,158 1,196
    35sh Eaton Corporation PLC 4,973 4,782
    90sh Howmet Aerospace Inc. 3,096 3,188
    9sh Northrop Grumman Corporation 3,249 4,301
    26sh Union Pacific Corporation 4,604 5,837
    8sh Adobe Inc. 5,003 2,987
    55sh Amphenol Corporation 2,648 4,044
    110sh Apple Inc. 7,046 17,294
    85sh Microsoft Corporation 12,536 22,224
    16sh Motorola Solutions Inc. 3,934 3,894
    17sh Nvidia Corporation 4,472 2,565
    5sh Servicenow Inc. 1,275 2,173
    30sh Texas Instruments Inc. 3,645 4,956
    50sh Visa Inc. 8,913 9,935
    30sh Vulcan Materials 5,506 4,994
    25sh American Tower Corporation 5,900 6,351
    20sh Prologis Inc. 2,972 2,490
    35sh Ameren Corporation 2,541 3,241
    15sh American Water Works Company 1,806 2,226
    15sh Sea Limited ADR 1,451 930
    240sh Anta Sports Products Limited 3,149 2,900
    5sh LVMH Moet Hennessy Vuitton 2,048 3,237
    7sh ASML Holdings 3,463 3,392
    60sh IShares China Large Cap ETF 2,267 1,812
    32,915sh OW Large Cap Strategies Fund 346,593 484,831
    11,594sh OW Small & Midcap Strategies Fund 135,508 161,272
    200sh Alphabet Inc. 12,554 21,830
    35sh Meta Platforms Inc. 6,626 5,702
    65sh Take-2 Interactive 8,282 7,966
    160sh Amazon.com Inc. 16,032 20,283
    40sh Aptiv PLC 5,758 3,737
    21sh Dollar General Corporation 5,329 4,985
    50sh Hilton Worldwide Holdings 4,399 6,368
    4sh Mercadolibre Inc. 5,509 3,421
    55sh Consumer Staples Index Fund 4,253 4,021
    5sh Costco Wholesale Corporation 2,489 2,610
    75sh Pepsico Inc. 10,184 12,920
    50sh Walmart Inc. 7,607 6,627
    160sh ConocoPhillips 7,867 17,512
    30sh Pioneer Natural Resources 3,406 7,596
    20sh AON PLC 5,471 5,585
    445sh Bank of Amerca Corporation 11,983 14,956
    55sh Blackstone Inc. 2,811 5,166
    75sh Brookfield Asset Management 4,266 3,608
    85sh JPMorgan Chase & Company 12,792 9,667
    9sh MSCI Inc. 3,788 4,043
    27sh S&P Global Inc. 8,754 9,508
    160sh Charles Schwabe Corporation 8,251 11,352
    55sh Catalent Inc. 5,763 4,840
    40sh Danaher Corporation 5,637 10,796
    35sh Health Care Select SPDR 4,848 4,366
    45sh IQVIA Holdings 6,196 9,569
    20sh Thermo Fisher Scientific 5,932 10,906
    35sh UnitedHealth Group Inc. 8,609 18,176
    55sh Zoetis Inc. 6,940 8,609
    20sh Copart Inc. 2,316 2,393
    70sh Eaton Corporation PLC 9,939 9,564
    180sh Howmet Aerospace Inc. 6,534 6,377
    17sh Northrop Grumman Corporation 6,108 8,125
    54sh Union Pacific Corporation 9,798 12,123
    16sh Adobe Inc. 8,650 5,975
    110sh Amphenol Corporation 5,077 8,088
    210sh Apple Inc. 12,849 33,016
    145sh Microsoft Corporation 20,500 37,913
    33sh Motorola Solutions Inc. 8,108 8,032
    35sh Nvidia Corporation 9,234 5,282
    10sh Servicenow Inc. 2,551 4,346
    55sh Texas Instruments Inc. 6,550 9,086
    100sh Visa Inc. 18,210 19,871
    65sh Vultan Materials 11,822 10,821
    50sh American Tower Corporation 11,828 12,702
    45sh Prologis Inc. 6,722 5,602
    75sh Ameren Corporation 5,507 6,946
    30sh American Water Works Company 3,613 4,453
    30sh Sea Limited ADR 2,903 1,860
    485sh Anta Sports Products Limited 6,470 5,861
    10sh LVMH Moet Hennessy Vuitton 3,878 6,475
    11sh ASML Holdings 5,019 5,331
    110sh IShares China Large Cap ETF 4,156 3,323
    72,586sh OW Large Cap Strategies Fund 964,674 1,069,199
    24,741sh OW Small & Midcap Strategies Fund 376,464 344,151
    1,001sh Vanguard Energy ETF 74,945 113,603
    865sh Vanguard Financials ETF 74,951 70,350
    205sh Vanguard Health Care ETF 35,070 47,470
    1,096sh Vanguard S&P 500 Value ETF 149,905 149,681
    1,382sh Baron Emerging Markets Fund 15,901 18,497
    5,475sh Champlain Mid Cap Institutional Fund 110,000 117,173
    661sh Lazard International Strategic Equity Fund 6,495 8,636
    3,092sh Touchstone Sands Capital Fund 41,598 32,440
    507sh Vanguard Emerging Markets Stock Index Admiral Fund 18,822 17,407
    527sh Vanguard Growth Index Admiral Fund 39,324 64,974
    434sh Vanguard Small Cap Index Admiral Fund 31,812 39,483
    661sh Vanguard Total International Stock Index Admiral Fund 16,531 18,161
    1,273sh Vanguard Total Stock Market Index Admiral Fund 84,846 122,985
    1,028sh Vanguard Value Index Admiral Fund 39,855 54,037
    129sh Vanguard 500 Index Admiral Fund 35,000 47,174
    2,344sh Vanguard Financials ETF 199,929 190,638
    593sh Vanguard Growth ETF 149,999 141,940
    642sh Vanguard Health Care ETF 112,285 148,662
    971sh Vanguard Information Technology ETF 347,655 339,151
    778sh Vanguard Total Stock Market ETF 111,757 154,480
    1,515sh Vanguard Value ETF 199,963 204,283
    6,707sh Champlain Mid Cap Institutional Fund 130,000 143,524
    1,293sh Harbor Capital Appreciation Fund 110,000 90,701
    7,475sh Touchstone Sands Capital Fund 110,000 78,415
    1,130sh Vanguard Total Stock Market Fund 88,867 109,172

    TY 2021 OtherExpensesSchedule
    Name:
    Ann A Mergens Foundation Inc
    EIN:
    27-4113304
    Description Revenue and Expenses per Books Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    Office Expenses 219 0   219
    Operating Cost Reimbursement to G.M. Mergens Foundation 71,285 21,390   49,895


    TY 2021 OtherProfessionalFeesSchedule
    Name:
    Ann A Mergens Foundation Inc
    EIN:
    27-4113304
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    Investment Management Providers Investment Management Services 8,076 8,076   0


    TY 2021 TaxesSchedule
    Name:
    Ann A Mergens Foundation Inc
    EIN:
    27-4113304
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    Federal Excise Taxes 10,490 0   0