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 11-01-2021 , and ending 10-31-2022
Name of foundation
SAMPLE FOUNDATION INC
 
Number and street (or P.O. box number if mail is not delivered to street address)PO BOX 279
  Room/suite
City or town, state or province, country, and ZIP or foreign postal code
BILLINGS, MT59103
A Employer identification number

59-6138602
B Telephone number (see instructions)

(406) 245-0550
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$9,686,205J 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) 191,185
2 Check bullet.............
3 Interest on savings and temporary cash investments 8,964 8,964  
4 Dividends and interest from securities... 135,214 135,214  
5a Gross rents............      
b Net rental income or (loss)  
6a Net gain or (loss) from sale of assets not on line 10 10,417
b Gross sales price for all assets on line 6a 4,602,833
7 Capital gain net income (from Part IV, line 2)... 10,417
8 Net short-term capital gain.........  
9 Income modifications........... 6,500
10a Gross sales less returns and allowances  
b Less: Cost of goods sold....  
c Gross profit or (loss) (attach schedule).....    
11 Other income (attach schedule)....... Click to see attachment 14,164 11,157  
12 Total. Add lines 1 through 11........ 359,944 165,752 6,500
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)....... Click to see attachment 4,500 2,250   2,250
c Other professional fees (attach schedule).... Click to see attachment 24,111 24,111   0
17 Interest...............        
18 Taxes (attach schedule) (see instructions)... Click to see attachment 1,792 1,792   0
19 Depreciation (attach schedule) and depletion... Click to see attachment 3,889 0  
20 Occupancy..............        
21 Travel, conferences, and meetings.......        
22 Printing and publications..........        
23 Other expenses (attach schedule)....... Click to see attachment 538 268   0
24 Total operating and administrative expenses.
Add lines 13 through 23.......... 34,830 28,421   2,250
25 Contributions, gifts, grants paid....... 485,585 485,585
26 Total expenses and disbursements. Add lines 24 and 25 520,415 28,421   487,835
27 Subtract line 26 from line 12:
a Excess of revenue over expenses and disbursements -160,471
b Net investment income (if negative, enter -0-) 137,331
c Adjusted net income (if negative, enter -0-)... 6,500
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............. 49,357 44,216 44,216
2 Savings and temporary cash investments.........      
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)....... 2,471,638 Click to see attachment2,471,638 6,584,373
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).......... 3,180,396 Click to see attachment3,025,255 3,054,116
14 Land, buildings, and equipment: basis bullet36,500
Less: accumulated depreciation (attach schedule) bullet33,000 7,389 Click to see attachment3,500 3,500
15 Other assets (describe bullet)      
16 Total assets (to be completed by all filers—see the
instructions. Also, see page 1, item I) 5,708,780 5,544,609 9,686,205
Liabilities 17 Accounts payable and accrued expenses.......... 10,200  
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)......... 10,200 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........ 5,698,580 5,544,609
27 Paid-in or capital surplus, or land, bldg., and equipment fund 0 0
28 Retained earnings, accumulated income, endowment, or other funds 0 0
29 Total net assets or fund balances (see instructions)..... 5,698,580 5,544,609
30 Total liabilities and net assets/fund balances (see instructions). 5,708,780 5,544,609
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
5,698,580
2
Enter amount from Part I, line 27a .....................
2
-160,471
3
Other increases not included in line 2 (itemize) bulletClick to see attachment
3
6,500
4
Add lines 1, 2, and 3 ..........................
4
5,544,609
5
Decreases not included in line 2 (itemize) bullet
5
0
6
Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 29 .
6
5,544,609
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 BNY MELLON - PUBLICLY TRADED SECURITIES   2021-09-13 2022-10-06
b CAPITAL GAINS DIVIDENDS P    
c
d
e
(e)
Gross sales price 		(f)
Depreciation allowed
(or allowable) 		(g)
Cost or other basis
plus expense of sale 		(h)
Gain or (loss)
(e) plus (f) minus (g)
a 4,592,416   4,592,416 0
b 10,417     10,417
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
b       10,417
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 10,417
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 1,909
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 1,909
6 Credits/Payments:
a 2021 estimated tax payments and 2020 overpayment credited to 2021 6a 3,137
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 3,137
8 Enter any penalty for underpayment of estimated tax. Check here if Form 2220 is attached. Click to see attachment 8 0
9 Tax due. If the total of lines 5 and 8 is more than line 7, enter amount owed.......Bullet 9  
10 Overpayment. If line 7 is more than the total of lines 5 and 8, enter the amount overpaid...Bullet 10 1,228
11 Enter the amount of line 10 to be: Credited to 2022 estimated taxBullet1,228 RefundedBullet 11 0
Part VI-A
Statements Regarding Activities
1a
During the tax year, did the foundation attempt to influence any national, state, or local legislation or did
Yes
No
it participate or intervene in any political campaign? ....................
1a
 
No
b
Did it spend more than $100 during the year (either directly or indirectly) for political purposes? See the instructions
for the definition.................................
1b
 
No
If the answer is "Yes" to 1a or 1b, attach a detailed description of the activities and copies of any materials
published or distributed by the foundation in connection with the activities.
c
Did the foundation file Form 1120-POL for this year?.....................
1c
 
No
d
Enter the amount (if any) of tax on political expenditures (section 4955) imposed during the year:
(1) On the foundation. bullet$ 0(2) On foundation managers.bullet$ 0
e
Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed
on foundation managers.bullet$ 0
2
Has the foundation engaged in any activities that have not previously been reported to the IRS?.......
2
 
No
If "Yes," attach a detailed description of the activities.
3
Has the foundation made any changes, not previously reported to the IRS, in its governing instrument, articles
of incorporation, or bylaws, or other similar instruments? If "Yes," attach a conformed copy of the changes....
3
 
No
4a
Did the foundation have unrelated business gross income of $1,000 or more during the year?.........
4a
 
No
b
If "Yes," has it filed a tax return on Form 990-T for this year?...................
4b
 
 
5
Was there a liquidation, termination, dissolution, or substantial contraction during the year?.........
5
 
No
If "Yes," attach the statement required by General Instruction T.
6
Are the requirements of section 508(e) (relating to sections 4941 through 4945) satisfied either:
  • By language in the governing instrument, or
  • By state legislation that effectively amends the governing instrument so that no mandatory directions
    • that conflict with the state law remain in the governing instrument?................
    6
    Yes
     
    7
    Did the foundation have at least $5,000 in assets at any time during the year? If "Yes," complete Part II, col. (c),
    and Part XIV..................................
    7
    Yes
     
    8a
    Enter the states to which the foundation reports or with which it is registered (see instructions)
    bulletMT
    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 addressbulletSAMPLEFOUNDATION.ORG
    14
    The books are in care ofbulletBARBARA SAMPLE Telephone no.bullet (406) 245-0550

    Located atbulletPO BOX 279BILLINGSMT ZIP+4bullet59103
    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
    JOSEPH S SAMPLE DECEASED 101322 CHAIRMAN
    0.10     		0 0 0
    606 HIGHLAND PARK DRIVE
    BILLINGS,MT59102
    BRIDGET SAMPLE JOYNER DIRECTOR
    0.10     		0 0 0
    1298 TAMMANY LN
    HAMILTON,MT59840
    BARBARA SAMPLE EXEC. DIRECTOR/PRESIDENT
    1.00     		0 0 0
    2517 IRVING PLACE
    BILLINGS,MT59102
    DAVID F SAMPLE DIRECTOR
    0.10     		0 0 0
    34174 CAMDEN LANE
    POLSON,MT59860
    PATRICK G SAMPLE DIRECTOR
    0.10     		0 0 0
    PO BOX 410
    INDEX,WA98256
    RONALD J YATES JR CPA TREASURER
    0.10     		0 0 0
    PO BOX 7112
    BILLINGS,MT591037112
    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
    6,801,506
    b
    Average of monthly cash balances.......................
    1b
    3,245,458
    c
    Fair market value of all other assets (see instructions)................
    1c
    0
    d
    Total (add lines 1a, b, and c).........................
    1d
    10,046,964
    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
    10,046,964
    4
    Cash deemed held for charitable activities. Enter 1.5% (0.015) of line 3 (for greater amount, see
    instructions) .............................
    4
    150,704
    5
    Net value of noncharitable-use assets. Subtract line 4 from line 3. .......
    5
    9,896,260
    6
    Minimum investment return. Enter 5% (0.05) of line 5................
    6
    494,813
    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
    494,813
    2a
    Tax on investment income for 2021 from Part V, line 5.......
    2a
    1,909
    b
    Income tax for 2021. (This does not include the tax from Part V.) ...
    2b
     
    c
    Add lines 2a and 2b............................
    2c
    1,909
    3
    Distributable amount before adjustments. Subtract line 2c from line 1............
    3
    492,904
    4
    Recoveries of amounts treated as qualifying distributions................
    4
    6,500
    5
    Add lines 3 and 4............................
    5
    499,404
    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
    499,404
    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 7 499,404
    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...... 4,917
    d From 2019......  
    e From 2020......  
    f Total of lines 3a through e ........ 4,917
    4Qualifying distributions for 2021 from Part
    XI, line 4: bullet$ 487,835
    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..... 487,835
    e Remaining amount distributed out of corpus 0
    5 Excess distributions carryover applied to 2021. 4,917 4,917
    (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......     		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 ..........     		6,652
    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....  
    b Excess from 2018....  
    c Excess from 2019....  
    d Excess from 2020....  
    e Excess from 2021....  
    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).)
    JOSEPH S SAMPLE DECEASED 101322
    BARBARA SAMPLE
    DAVID F SAMPLE
    PATRICK G SAMPLE
    bList any managers of the foundation who own 10% or more of the stock of a corporation (or an equally large portion of the
    ownership of a partnership or other entity) of which the foundation has a 10% or greater interest.
    2Information Regarding Contribution, Grant, Gift, Loan, Scholarship, etc., Programs:
    Check here bullet
    aThe name, address, and telephone number or e-mail address of the person to whom applications should be addressed:
    BARBARA SAMPLE
    PO BOX 279
    BILLINGS,MT591030279
    (406) 256-5567
    bThe form in which applications should be submitted and information and materials they should include:
    LETTER GIVING ORGANIZATIONAL BACKGROUND AND PURPOSES, SPECIFIC NEED & AMOUNT REQUESTED. ATTACH 501(C)(3) IRS DETERMINATION LETTER.
    cAny submission deadlines:
    AUGUST 1
    dAny restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other
    factors:
    GENERALLY LIMITED TO ORGANIZATIONS IN THE STATE OF MONTANA & COLLIER COUNTY FLORIDA. NO GRANTS WILL BE PROVIDED TO RELIGIOUS OR POLITICAL ORGANIZATIONS OR TAX SUPPORTED INSTITUTIONS.
    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
    ALLIANCE FOR YOUTH INC
    3220 11TH AVE S
    GREAT FALLS,MT59405     		  PC FURNACES AND HVAC 10,000
    BIG BROTHERS BIG SISTERS OF BIG SKY COUNTRY
    15 S 8TH AVE
    BOZEMAN,MT59715     		  PC TECHNOLOGY UPGRADE 10,000
    BIG SKY SENIOR SERVICES INC
    935 LAKE ELMO DR
    BILLINGS,MT59105     		  PC SAFEGUARDING SENIORS THROUGH IN-HOME SUPPORTS 15,000
    BILLINGS PUBLIC LIBRARY FDN
    510 N 28TH STREET
    BILLINGS,MT59101     		  PC GENERAL SERVICES 6,000
    BILLINGS PUBLIC SCHOOLS
    101 10TH STREET WEST
    BILLINGS,MT59102     		  GOV PLAYGROUND & MAINTENANCE PROJECT 2022 15,000
    BILLINGS SYMPHONY
    2820 2ND AVE N
    BILLINGS,MT59101     		  PC PORTABLE PIANO KEYBOARD 3,500
    BITTER ROOT LAND TRUST
    PO BOX 1806
    HAMILTON,MT59840     		  PC INCREASING CONSERVATION IMPACT 7,000
    BLUE MOUNTAIN CLINIC
    610 N CALIFORNIA ST
    MISSOULA,MT59801     		  PC DESIGNATED 1,000
    BOYCE ANSLEY SCHOOL
    120 RALPH MCGILL BLVD NE BLDG 3
    SUITE B1
    ATLANTA,GA30308     		  PC DESIGNATED 1,000
    BOYS & GIRLS CLUB OF MISSOULA COUNTY
    1515 FAIRVIEW AVE SUITE 243
    MISSOULA,MT59801     		  PC WHEELCHAIR ACCESSIBLE VAN 13,195
    BOYS & GIRLS CLUB OF RICHLAND COUNTY
    PO BOX 416
    SIDNEY,MT59270     		  PC BGC PLAYGROUND 12,500
    BOYS & GIRLS CLUB OF THE FLATHEAD RESERVATION AND LAKE COUNTY
    PO BOX 334
    RONAN,MT59864     		  PC BUILDING AND STABILIZING FLATHEAD BGC SPORTS 15,000
    BOYS & GIRLS CLUBS OF YELLOWSTONE COUNTY
    505 ORCHARD LANE
    BILLINGS,MT59101     		  PC COMMITMENT TO SAFETY 15,000
    BULLETIN OF ATOMIC SCIENTISTS
    77 W WASHINGTON ST
    CHICAGO,IL60602     		  PC DESIGNATED 1,000
    CASA OF LAKE CTY
    410 1ST STREET E
    POLSON,MT59860     		  PC EXPANDED SERVICES 3,000
    CHILD'S PATH INC (FORMERLY COLLIER CHILD CARE RESOURCES INC - CCCR)
    15275 COLLIER BOULEVARD 201-359
    NAPLES,FL34119     		  PC CREATING SAFE SPACES 30,700
    CHILDREN'S ONCOLOGY FDN
    2110 S JOHNSON ST
    MISSOULA,MT59801     		  PC DESIGNATED 1,500
    COUNCIL GROVES APARTMENTS
    1904 S 3RD STREET W
    MISSOULA,MT59801     		  PC SNOW REMOVAL TRACTOR 15,000
    EAGLE MOUNT BOZEMAN
    6901 GOLDENSTEIN LANE
    BOZEMAN,MT59715     		  PC COMPUTER UPGRADE 8,000
    EASTER SEALS
    157 ROY STREET
    SEATTLE,WA98109     		  PC DESIGNATED 3,500
    EMMA'S HOUSE
    310 N 4TH STREET
    HAMILTON,MT59840     		  PC DESIGNATED 1,000
    FAMILY FIRST LEARNING LAB
    455 E MAIN STREET
    MISSOULA,MT59802     		  PC DESIGNATED 3,000
    FAMILY PROMISE GALLATIN VALLEY
    1603 TSCHACHE LANE
    BOZEMAN,MT59718     		  PC TRANSITIONAL HOUSE RENOVATION 15,000
    FARMING FOR THE FUTURE ACADEMY INC
    80 13TH STREET EAST
    COLUMBIA FALLS,MT59912     		  PC OFF GRID STEAM CLASSROOM 6,000
    FINLEY POINT FIRE DEPT
    35408 MT HIGHWAY 35
    POLSON,MT59860     		  GOV DESIGNATED 1,000
    FLORENCE CRITTENTON HOME & SERVICES
    901 N HARRIS ST
    HELENA,MT59601     		  PC CHILD ENRICHMENT CENTER PLAY ZONES 10,000
    FOCUS FUSION
    128 LINCOLN BLVD
    MIDDLESEX,NJ08846     		  PC DESIGNATED 1,500
    FOUNDATION FOR COMMUNITY HEALTH
    2831 FORT MISSOULA RD
    MISSOULA,MT59804     		  PC MOBILE HEALTH & SAFETY BUS 7,500
    FRIENDS OF HEYBROOK RIDGE
    50606 INDEX-GALENA RD
    INDEX,WA98256     		  PC DESIGNATED 3,500
    FRIENDS OF MT PUBLIC BROADCASTING
    PO BOX 173340
    BOZEMAN,MT59717     		  PC DESIGNATED 5,000
    FRIENDS OF THE CHILDREN - MONTANA
    1649 W CENTRAL
    MISSOULA,MT59801     		  PC PASSENGER VAN 15,000
    FRIENDS OF WHITEPINE GRANGE
    153 CHILDS RD
    TROUT CREEK,MT59874     		  PC FURNACE AND DUCTWORK REPOSITIONING 5,000
    FRIENDSHIP CENTER OF HELENA INC
    1430 N SANDERS
    HELENA,MT59601     		  PC TECHNOLOGY AND EQUIPMENT 10,000
    FUNTIME ACADEMY
    102 12TH ST N
    NAPLES,FL34102     		  PC EQUIPMENT 10,000
    GARNETT PRESERVATION
    PO BOX 18295
    MISSOULA,MT59808     		  PC DESIGNATED 1,500
    GUADALUPE CENTER
    509 HOPE CIRCLE
    IMMOKALEE,FL34142     		  PC BABY FOOD AND FORMULA 11,000
    HABITAT FOR HUMANITY OF MISSOULA
    PO BOX 7181
    MISSOULA,MT59807     		  PC BUILDING HOPE FOR 2022 20,000
    HAVEN
    PO BOX 752
    BOZEMAN,MT597710752     		  PC STORAGE UNITS FOR HAVEN'S NEW SHELTER 10,000
    HELENA FOOD SHARE
    PO BOX 943
    HELENA,MT59624     		  PC COMPUTER REPLACEMENT PROJECT 1,950
    HELP COMMITTEE AND BOYS & GIRLS CLUB OF THE HI-LINE
    500 1ST AVE
    HAVRE,MT59501     		  PC HVAC UPGRADE 7,500
    LIVINGSTON FOOD PANTRY
    202 S 2ND ST
    LIVINGSTON,MT59047     		  PC LOCAL FOOD PROCUREMENT AND DISTRIBUTION 6,176
    MISSOULA AGING SERVICES
    337 STEPHENS AVE
    MISSOULA,MT59801     		  PC MASONRY REPAIR 5,000
    MISSOULA YMCA
    3000 SOUTH RUSSELL
    MISSOULA,MT59801     		  PC SAFE TRAVELS CAR SEAT FUNDING REQUEST 3,413
    MISSOULA INTERFAITH COLLABORATIVE
    2205 34TH STREET
    MISSOULA,MT59801     		  PC IRRIGATION COMPRESSOR 5,000
    MISSOULA URBAN DEMONSTRATION PROJECT
    1527 WYOMING ST
    MISSOULA,MT59801     		  PC MUD TRUCK SHARE 10,000
    MONTANA FOOD BANK NETWORK
    5625 EXPRESSWAY
    MISSOULA,MT59808     		  PC VOLUNTEER REPACK ROOM CAPITAL EXPENSE 15,000
    MONTANA NON PROFIT
    7 W 6TH AVE
    HELENA,MT59601     		  PC DESIGNATED 3,000
    MONTANA WILDERNESS SCHOOL
    PO BOX 1183
    BOZEMAN,MT59771     		  PC EMPOWERING YOUTH OUTDOORS 9,000
    MOUNTAIN HOME
    2606 SOUTH AVE W
    MISSOULA,MT59804     		  PC DESIGNATED 1,000
    MUSIC FOR NEWMAN SCHOOL
    605 S BILLINGS BLVD
    BILLINGS,MT59101     		  PC DESIGNATED 3,500
    NAPLES COMMUNITY HOSPITAL
    680 2ND AVE N STE 304
    NAPLES,FL34102     		  PC DESIGNATED 1,000
    NORTH STAR SCHOOL DISTRICT 99M
    105 3RD AVE NE
    RUDYARD,MT59540     		  GOV GROW IT 10,000
    NORTHEAST MONTANA HEALTH SERVICES CHARITABLE FOUNDATION
    PO BOX 341
    POPLAR,MT59255     		  PC VAN PURCHASE 3,000
    OUTDOORS FOR ALL
    6344 NE 74TH ST STE 102
    SEATTLE,WA98115     		  PC DESIGNATED 3,500
    PED WILLOW LEARNING CENTER
    700 SOUTH AVENUE WEST
    MISSOULA,MT59801     		  PC FREEDOM ON THE INSIDE 3,468
    REDLODGE YOUTH SOCCER
    PO BOX 2167
    RED LODGE,MT59068     		  PC YOUTH SOCCER FIELD 5,000
    ROCKY MOUNTAIN COLLEGE
    1511 POLY DRIVE
    BILLINGS,MT59102     		  PC SERVICES FOR ACADEMIC SUCCESS CULTURAL ENRICHMENT PROGRAM 3,500
    RONALD MCDONALD HOUSE CHARITIES OF WESTERN MONTANA
    3003 FORT MISSOULA RD
    MISSOULA,MT59804     		  PC DESIGNATED 3,000
    SAFE HARBOR
    PO BOX 497
    RONAN,MT59864     		  PC SECURITY & MAINTENANCE 12,000
    ST JOESPH HOSPITAL
    6 13TH AVE E
    POLSON,MT59860     		  PC DESIGNATED 3,500
    START UP EVENT CENTER
    14315 366TH AVE SE
    STARTUP,WA98293     		  PC DESIGNATED 1,500
    THOREAU ELEMENTARY PTO
    3870 NAKOMA RD
    MADISON,WI53711     		  PC DESIGNATED 1,000
    UNIVERSITY OF MONTANA
    950 ARTHUR AVE
    MISSOULA,MT59807     		  GOV DESIGNATED 1,500
    WATSON CHILDREN'S CENTER
    4978 BUCKHOUSE LANE
    MISSOULA,MT59804     		  PC SEPTIC SYSTEM UPGRADE 8,000
    WESTERN MONTANA LGBT COMMUNITY CENTER
    127 N HIGGINS ST STE 202
    MISSOULA,MT59802     		  PC OWL VIDEO CONFERENCE CAMERA 999
    YELLOWSTONE CASA INC
    PO BOX 688
    BILLINGS,MT59103     		  PC SECURITY AND SUPPORT 2,986
    YELLOWSTONE PUBLIC RADIO
    1500 UNIVERSITY DR
    BILLINGS,MT59101     		  PC DESIGNATED 5,000
    YES YOUTH EMPOWERMENT SERVICES
    221 OAK STREET
    ANACONDA,MT59711     		  PC YES LET'S CODE 2,198
    YRPA
    PO BOX 1201
    BILLINGS,MT59013     		  PC DESIGNATED 5,000
    YWCA MISSOULA
    1800 S 3RD ST W
    MISSOULA,MT59801     		  PC WHEELCHAIR ACCESSIBLE SHOWERS 10,000
    EASTERN MONTANA CASA GAL INC
    2200 BOX ELDER ST
    MILES CITY,MT59301     		  PC TRAVEL EXPENSE 6,000
    Total .................................bullet 3a 485,585
    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 8,964  
    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 10,417  
    9 Net income or (loss) from special events:          
    10 Gross profit or (loss) from sales of inventory          
    11 Other revenue:
    aENTERPRISE PRODS PARTNERS     		    18 11,130  
    bOTHER INCOME     18 27  
    cNONDIVIDEND DISTRIBUTIONS     18 3,007  
    d
    e
    12 Subtotal. Add columns (b), (d), and (e) .. 0 168,759 0
    13Total. Add line 12, columns (b), (d), and (e)..................
    13
    168,759
    (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
    SAMPLE FOUNDATION INC
     
    Employer identification number

    59-6138602
    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
    SAMPLE FOUNDATION INC
          		Employer identification number
    59-6138602
    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
    DAVID F SAMPLE
     
    34174 CAMDEN LANE
     
    POLSON, MT59860

    		$ 59,101


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
    2
    JOSEPH S SAMPLE (DECEASED 10132022)
     
    606 HIGHLAND PARK DRIVE
     
    BILLINGS, MT59102

    		$ 18,222


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
    3
    PATRICK G SAMPLE
     
    PO BOX 410
     
    INDEX, WA98256

    		$ 59,085


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
    4
    BARBARA MSAMPLE
     
    2517 IRVING PLACE
     
    BILLINGS, MT59102

    		$ 54,777


    (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
    SAMPLE FOUNDATION INC
          		Employer identification number

    59-6138602
    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
    SAMPLE FOUNDATION INC
          		Employer identification number

    59-6138602
    Part III
    Exclusively religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10) that total more than $1,000 for the year from any one contributor. Complete columns (a) through (e) and the following line entry. For organizations completing Part III, enter the total of exclusively religious, charitable, etc., contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet$  
    Use duplicate copies of Part III if additional space is needed.
    (a)
    No. from Part I    		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
     
    (e) Transfer of gift
    Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
     
     
         
     
    (a)
    No. from Part I    		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
     
    (e) Transfer of gift
    Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
     
     
         
     
    (a)
    No. from Part I    		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
     
    (e) Transfer of gift
    Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
     
     
         
     
    (a)
    No. from Part I    		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
     
    (e) Transfer of gift
    Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
     
     
         
     
    Schedule B (Form 990) (2021)
    Additional Data


    Software ID:  
    Software Version:  

    TY 2021 AccountingFeesSchedule
    Name:
    SAMPLE FOUNDATION INC
    EIN:
    59-6138602
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    ACCOUNTING FEES 4,500 2,250   2,250

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

    TY 2021 DepreciationSchedule
    Name:
    SAMPLE FOUNDATION INC
    EIN:
    59-6138602
    Description of Property Date Acquired Cost or Other Basis Prior Years' Depreciation Computation Method Rate /
    Life (# of years)    		 Current Year's Depreciation Expense Net Investment Income Adjusted Net Income Cost of Goods Sold Not Included
    SOFTWARE 2013-06-20 8,500 8,500 SL 3.000000000000 0 0    
    SOFTWARE 2015-05-12 7,000 7,000 SL 3.000000000000 0 0    
    SOFTWARE 2017-05-20 7,000 7,000 SL 3.000000000000 0 0    
    SOFTWARE 2019-07-02 7,000 5,444 SL 3.000000000000 1,556 0    
    SOFTWARE 2021-05-11 7,000 1,167 SL 3.000000000000 2,333 0    

    TY 2021 InvestmentsCorpStockSchedule
    Name:
    SAMPLE FOUNDATION INC
    EIN:
    59-6138602
    Name of Stock End of Year Book Value End of Year Fair Market Value
    ABBOT LABS 35,390 247,350
    BP AMOCO 57,031 88,059
    BRISTOL MYERS SQUIBB 35,931 309,880
    EMERSON ELECTRIC 17,062 519,600
    JOHNSON & JOHNSON 60,089 403,610
    CANADIAN NATIONAL RAILWAY 30,284 651,420
    PFIZER INC COM 104,972 139,650
    CONOCOPHILLIPS 90,469 441,315
    HONEYWELL INTERNATIONAL INC. 113,673 408,040
    PROCTOR & GAMBLE COMPANY 126,593 269,340
    CHEVRON CORPORATION 153,457 271,350
    PHILLIPS 66 24,387 156,435
    VERIZON COMMUNICATIONS INC. 168,020 119,584
    WEYERHAEUSER COMPANY 121,800 197,952
    ALPHABET INC. 177,094 283,530
    CVS HEALTH CORP COM 180,576 284,100
    INVESCO EXCHANGE TRADED FD TR S&P 500 259,845 366,990
    JP MORGAN CHASE & CO 161,297 188,820
    QUANTA SVCS INC 166,261 710,200
    SELECT SECTOR SPDR TR CONSUMER 232,061 288,060
    QUALCOMM, INC 149,592 235,320
    VIATRIS INC COM 5,754 3,768

    TY 2021 InvestmentsOtherSchedule2
    Name:
    SAMPLE FOUNDATION INC
    EIN:
    59-6138602
    Category/ Item Listed at Cost or FMV Book Value End of Year Fair Market Value
    DREYFUS/U.S. TREASURY OBLIGATIONS AT COST 2,898,190 2,902,616
    ENTERPRISE PRODUCTS PARTNERS LP AT COST 127,065 151,500

    TY 2021 LandEtcSchedule2
    Name:
    SAMPLE FOUNDATION INC
    EIN:
    59-6138602
    Category / Item Cost / Other Basis Accumulated Depreciation Book Value End of Year Fair Market Value
    SOFTWARE 8,500 8,500 0  
    SOFTWARE 7,000 7,000 0  
    SOFTWARE 7,000 7,000 0  
    SOFTWARE 7,000 7,000 0  
    SOFTWARE 7,000 3,500 3,500  


    TY 2021 OtherExpensesSchedule
    Name:
    SAMPLE FOUNDATION INC
    EIN:
    59-6138602
    Description Revenue and Expenses per Books Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    MISCELLANEOUS ADMINISTRATION 538 268   0


    TY 2021 OtherIncomeSchedule2
    Name:
    SAMPLE FOUNDATION INC
    EIN:
    59-6138602
    Description Revenue And Expenses Per Books Net Investment Income Adjusted Net Income
    ENTERPRISE PRODS PARTNERS 11,130 11,130 11,130
    OTHER INCOME 27 27 27
    NONDIVIDEND DISTRIBUTIONS 3,007   3,007


    TY 2021 OtherIncreasesSchedule
    Name:
    SAMPLE FOUNDATION INC
    EIN:
    59-6138602
    Description Amount
    RECOVERY OF AMOUNT TREATED AS QUALIFYING DISTRIBUTIONS 6,500


    TY 2021 OtherProfessionalFeesSchedule
    Name:
    SAMPLE FOUNDATION INC
    EIN:
    59-6138602
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    INVESTMENT/BANK FEES 24,111 24,111   0


    TY 2021 TaxesSchedule
    Name:
    SAMPLE FOUNDATION INC
    EIN:
    59-6138602
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    TAXES 1,792 1,792   0