Attach to Form 990 or Form 990-EZ.
Go to
www.irs.gov/Form990 for instructions and the latest information.
| (i) Name of supported organization | (ii) EIN | (iii) Type of organization (described on lines 1- 10 above (see instructions)) | (iv) Is the organization listed in your governing document? | (v) Amount of monetary support (see instructions) | (vi) Amount of other support (see instructions) | |
|---|---|---|---|---|---|---|
| Yes | No | |||||
|
Total |
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Calendar year
(or fiscal year beginning in)
![]() |
(a) 2019 | (b) 2020 | (c) 2021 | (d) 2022 | (e) 2023 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") .. | ||||||
| 2 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf .... | ||||||
| 3 | The value of services or facilities furnished by a governmental unit to the organization without charge.. | ||||||
| 4 | Total. Add lines 1 through 3 | ||||||
| 5 | The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f) .. | ||||||
| 6 | Public support. Subtract line 5 from line 4. | ||||||
Calendar year
(or fiscal year beginning in)
![]() |
(a) 2019 | (b) 2020 | (c) 2021 | (d) 2022 | (e) 2023 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 7 | Amounts from line 4.. | ||||||
| 8 | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources... | ||||||
| 9 | Net income from unrelated business activities, whether or not the business is regularly carried on.. | ||||||
| 10 | Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.).. | ||||||
| 11 | Total support. Add lines 7 through 10 | ||||||
Calendar year (or fiscal
year beginning in) ![]() |
(a) 2019 | (b) 2020 | (c) 2021 | (d) 2022 | (e) 2023 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") . | 88,236 | 116,359 | 88,212 | 77,037 | 63,671 | 433,515 |
| 2 | Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose | ||||||
| 3 | Gross receipts from activities that are not an unrelated trade or business under section 513 ..... | 19,386 | 21,186 | 40,572 | |||
| 4 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf... | ||||||
| 5 | The value of services or facilities furnished by a governmental unit to the organization without charge | ||||||
| 6 | Total. Add lines 1 through 5 | 88,236 | 116,359 | 88,212 | 96,423 | 84,857 | 474,087 |
| 7a | Amounts included on lines 1, 2, and 3 received from disqualified persons | 0 | |||||
| b | Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year. | 0 | |||||
| c | Add lines 7a and 7b.. | 0 | |||||
| 8 | Public support. (Subtract line 7c from line 6.) | 474,087 | |||||
Calendar year
(or fiscal year beginning in)
![]() |
(a) 2019 | (b) 2020 | (c) 2021 | (d) 2022 | (e) 2023 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | 88,236 | 116,359 | 88,212 | 96,423 | 84,857 | 474,087 |
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | 136 | 1,742 | 417 | 433 | 2,429 | 5,157 |
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | ||||||
| c | Add lines 10a and 10b. | 136 | 1,742 | 417 | 433 | 2,429 | 5,157 |
| 11 | Net income from unrelated business activities not included on line 10b, whether or not the business is regularly carried on. | ||||||
| 12 | Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.) .. | ||||||
| 13 | Total support. (Add lines 9, 10c, 11, and 12.).. | 88,372 | 118,101 | 88,629 | 96,856 | 87,286 | 479,244 |
| Section A - Adjusted Net Income | (A) Prior Year |
(B) Current Year (optional) |
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| 1 | Net short-term capital gain | 1 | ||||
| 2 | Recoveries of prior-year distributions | 2 | ||||
| 3 | Other gross income (see instructions) | 3 | ||||
| 4 | Add lines 1 through 3 | 4 | ||||
| 5 | Depreciation and depletion | 5 | ||||
| 6 | Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions) | 6 | ||||
| 7 | Other expenses (see instructions) | 7 | ||||
| 8 | Adjusted Net Income (subtract lines 5, 6 and 7 from line 4) | 8 | ||||
| Section B - Minimum Asset Amount | (A) Prior Year |
(B) Current Year (optional) |
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| 1 | Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year): | 1 | ||||
| a | Average monthly value of securities | 1a | ||||
| b | Average monthly cash balances | 1b | ||||
| c | Fair market value of other non-exempt-use assets | 1c | ||||
| d | Total (add lines 1a, 1b, and 1c) | 1d | ||||
| e |
Discount claimed for blockage or other factors (explain in detail in Part VI): |
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| 2 | Acquisition indebtedness applicable to non-exempt use assets | 2 | ||||
| 3 | Subtract line 2 from line 1d | 3 | ||||
| 4 | Cash deemed held for exempt use. Enter 0.015 of line 3 (for greater amount, see instructions). | 4 | ||||
| 5 | Net value of non-exempt-use assets (subtract line 4 from line 3) | 5 | ||||
| 6 | Multiply line 5 by 0.035 | 6 | ||||
| 7 | Recoveries of prior-year distributions | 7 | ||||
| 8 | Minimum Asset Amount (add line 7 to line 6) | 8 | ||||
| Section C - Distributable Amount | Current Year | |||||
| 1 | Adjusted net income for prior year (from Section A, line 8, Column A) | 1 | ||||
| 2 | Enter 85% of line 1 | 2 | ||||
| 3 | Minimum asset amount for prior year (from Section B, line 8, Column A) | 3 | ||||
| 4 | Enter greater of line 2 or line 3 | 4 | ||||
| 5 | Income tax imposed in prior year | 5 | ||||
| 6 | Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions) | 6 | ||||
| Section D - Distributions | Current Year | |
|---|---|---|
| 1 Amounts paid to supported organizations to accomplish exempt purposes | 1 | |
|
2
Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity |
2 | |
| 3 Administrative expenses paid to accomplish exempt purposes of supported organizations | 3 | |
| 4 Amounts paid to acquire exempt-use assets | 4 | |
| 5 Qualified set-aside amounts (prior IRS approval required - provide details in Part VI) | 5 | |
| 6 Other distributions (describe in Part VI). See instructions | 6 | |
| 7Total annual distributions. Add lines 1 through 6. | 7 | |
|
8
Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions |
8 | |
| 9 Distributable amount for 2023 from Section C, line 6 | 9 | |
| 10 Line 8 amount divided by Line 9 amount | 10 | |
| Section E - Distribution Allocations (see instructions) |
(i) Excess Distributions |
(ii) Underdistributions Pre-2023 |
(iii) Distributable Amount for 2023 |
|
|---|---|---|---|---|
| 1 Distributable amount for 2023 from Section C, line 6 | ||||
|
2
Underdistributions, if any, for years prior to 2023 (reasonable cause required-- explain in Part VI).
See instructions. |
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| 3 Excess distributions carryover, if any, to 2023: | ||||
| a From 2018....... | ||||
| b From 2019....... | ||||
| c From 2020....... | ||||
| d From 2021....... | ||||
| e From 2022....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2023 distributable amount | ||||
|
i
Carryover from 2018 not applied (see instructions) |
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| j Remainder. Subtract lines 3g, 3h, and 3i from line 3f. | ||||
| 4Distributions for 2023 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2023 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from line 4. | ||||
|
5
Remaining underdistributions for years prior to 2023, if any. Subtract lines 3g and 4a from line 2. If the amount is greater than zero, explain in Part VI. See instructions. |
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|
6
Remaining underdistributions for 2023. Subtract lines 3h and 4b from line 1. If the amount is greater than zero, explain in Part VI. See instructions. |
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|
7 Excess distributions carryover to 2024. Add lines 3j and 4c. |
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| 8 Breakdown of line 7: | ||||
| a Excess from 2019..... | ||||
| b Excess from 2020..... | ||||
| c Excess from 2021..... | ||||
| d Excess from 2022..... | ||||
| e Excess from 2023..... | ||||
| Facts And Circumstances Test |
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| Return Reference | Explanation |
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| Software ID: | |
| Software Version: |
| Return Reference | Explanation |
|---|---|
| FORM 990-EZ, PART I, LINE 4 - OTHER INVESTMENT INCOME | DESCRIPTION: INTEREST INCOME. AMOUNT: 2,079. DESCRIPTION: DIVIDEND INCOME. AMOUNT: 175. TOTAL INCLUDED ON FORM 990-EZ, LINE 4: 2,254. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: PROGRAM SERVICES. GRANTEE NAME: BARRON COUNTY NUTRITION - MEALS ON WHEELS. GRANTEE ADDRESS: 530 RIVER AVE S PRAIRIE FARM, WI 54762. METHOD USED TO DETERMINE BOOK VALUE: CASH. METHOD USED TO DETERMINE FMV: CASH. DATE OF GIFT: 12/31/23. AMOUNT GIVEN: 8,000. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: PROGRAM SERVICES. GRANTEE NAME: BENJAMINS HOUSE. GRANTEE ADDRESS: 1108 HEART ISLAND PKWY RICE LAKE, WI 54868. METHOD USED TO DETERMINE BOOK VALUE: CASH. METHOD USED TO DETERMINE FMV: CASH. DATE OF GIFT: 12/31/23. AMOUNT GIVEN: 7,500. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: PROGRAM SERVICES. GRANTEE NAME: CHIPPEWA VALLEY BOY SCOUTS. GRANTEE ADDRESS: 710 S HASTINGS WAY EAU CLAIRE, WI 54701. METHOD USED TO DETERMINE BOOK VALUE: CASH. METHOD USED TO DETERMINE FMV: CASH. DATE OF GIFT: 12/31/23. AMOUNT GIVEN: 1,500. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: PROGRAM SERVICES. GRANTEE NAME: DAYBREAK RESPITE CARE. GRANTEE ADDRESS: 105 N 1ST ST EAGLE RIVER, WI 54521. METHOD USED TO DETERMINE BOOK VALUE: CASH. METHOD USED TO DETERMINE FMV: CASH. DATE OF GIFT: 12/31/23. AMOUNT GIVEN: 8,000. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: PROGRAM SERVICES. GRANTEE NAME: GIRL SCOUTS - NORTHWESTER GREAT LAKES. GRANTEE ADDRESS: 4693 N LYNNDALE DR. APPLETON, WI 54913. METHOD USED TO DETERMINE BOOK VALUE: CASH. METHOD USED TO DETERMINE FMV: CASH. DATE OF GIFT: 12/31/23. AMOUNT GIVEN: 1,500. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: PROGRAM SERVICES. GRANTEE NAME: HEART ISLAND FAMILY ENRICHMENT CENTER. GRANTEE ADDRESS: 1108 HEART ISLAND PKWY RICE LAKE, WI 54868. METHOD USED TO DETERMINE BOOK VALUE: CASH. METHOD USED TO DETERMINE FMV: CASH. DATE OF GIFT: 12/31/23. AMOUNT GIVEN: 7,500. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: PROGRAM SERVICES. GRANTEE NAME: KINSHIP. GRANTEE ADDRESS: 35 W MESSENGER ST RICE LAKE, WI 54868. METHOD USED TO DETERMINE BOOK VALUE: CASH. METHOD USED TO DETERMINE FMV: CASH. DATE OF GIFT: 12/31/23. AMOUNT GIVEN: 5,000. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: PROGRAM SERVICES. GRANTEE NAME: LAKEVIEW MEDICAL HOSPICE CARE. GRANTEE ADDRESS: 2304 S MAIN ST RICE LAKE, WI 54868. METHOD USED TO DETERMINE BOOK VALUE: CASH. METHOD USED TO DETERMINE FMV: CASH. DATE OF GIFT: 12/31/23. AMOUNT GIVEN: 3,500. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: PROGRAM SERVICES. GRANTEE NAME: NORTHWEST CONNECTION FAMILY RESOURCES. GRANTEE ADDRESS: 15896 W 3RD ST HAYWARD, WI 54843. METHOD USED TO DETERMINE BOOK VALUE: CASH. METHOD USED TO DETERMINE FMV: CASH. DATE OF GIFT: 12/31/23. AMOUNT GIVEN: 2,000. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: PROGRAM SERVICES. GRANTEE NAME: RICE LAKE SENIOR CENTER. GRANTEE ADDRESS: 12 W HUMBIRD ST RICE LAKE, WI 54868. METHOD USED TO DETERMINE BOOK VALUE: CASH. METHOD USED TO DETERMINE FMV: CASH. DATE OF GIFT: 12/31/23. AMOUNT GIVEN: 7,500. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: PROGRAM SERVICES. GRANTEE NAME: WESTCAP. GRANTEE ADDRESS: 1107 HEART ISLAND PKWY RICE LAKE, WI 54868. METHOD USED TO DETERMINE BOOK VALUE: CASH. METHOD USED TO DETERMINE FMV: CASH. DATE OF GIFT: 12/31/23. AMOUNT GIVEN: 5,000. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: PROGRAM SERVICES. GRANTEE NAME: RICE LAKE BRAIN TRAUMA. GRANTEE ADDRESS: 221 HAVEL ROAD RICE LAKE, WI 54868. METHOD USED TO DETERMINE BOOK VALUE: CASH. METHOD USED TO DETERMINE FMV: CASH. DATE OF GIFT: 12/31/23. AMOUNT GIVEN: 2,000. TOTAL INCLUDED ON FORM 990-EZ, LINE 10: 59,000. |
| FORM 990-EZ, PART I, LINE 16 - OTHER EXPENSES | DESCRIPTION: ADVERTISING. AMOUNT: 2,170. DESCRIPTION: DUES AND SUBSCRIPTIONS. AMOUNT: 2,443. DESCRIPTION: INSURANCE. AMOUNT: 1,051. DESCRIPTION: OFFICE. AMOUNT: 539. DESCRIPTION: LICENSES AND PERMITS. AMOUNT: 51. DESCRIPTION: UNCOLLECTIBLE PLEDGES. AMOUNT: 5,333. DESCRIPTION: DONATIONS TO OTHER ORGANIZATIONS COVID RELIEF. AMOUNT: 2,580. TOTAL TO FORM 990-EZ, LINE 16: 14,167. |
| FORM 990-EZ, PART I, LINE 20 - OTHER CHANGES IN NET ASSETS | DESCRIPTION: UNREALIZED LOSS ON INVESTMENTS. AMOUNT: -449. |
| FORM 990-EZ, PART II, LINE 24 - OTHER ASSETS | DESCRIPTION: PLEDGES RECEIVABLE. BEG. OF YEAR AMOUNT: 10,607. END OF YEAR AMOUNT: 13,436. DESCRIPTION: INTEREST RECEIVABLE. BEG. OF YEAR AMOUNT: 200. END OF YEAR AMOUNT: 1,677. DESCRIPTION: ALLOWANCE UNCOLLECTABLE PLEDGES. BEG. OF YEAR AMOUNT: -2,300. END OF YEAR AMOUNT: -4,000. DESCRIPTION: UPS STOCK. BEG. OF YEAR AMOUNT: 4,694. END OF YEAR AMOUNT: 4,245. |
| FORM 990-EZ, PART II, LINE 26 - OTHER LIABILITIES | DESCRIPTION: ACCOUNTS AND ALLOCATIONS PAYABLE. BEG. OF YEAR AMOUNT: 63,017. END OF YEAR AMOUNT: 60,675. |
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| Software Version: |