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 | |||||
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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.") . | 8,185 | 14,820 | 17,625 | 13,780 | 21,316 | 75,726 |
| 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 ..... | 52,082 | 28,862 | 29,563 | 132,068 | 124,541 | 367,116 |
| 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 | 60,267 | 43,682 | 47,188 | 145,848 | 145,857 | 442,842 |
| 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. | 180 | 8,000 | 11,500 | 19,680 | ||
| c | Add lines 7a and 7b.. | 180 | 8,000 | 11,500 | 19,680 | ||
| 8 | Public support. (Subtract line 7c from line 6.) | 423,162 | |||||
Calendar year
(or fiscal year beginning in)
![]() |
(a) 2019 | (b) 2020 | (c) 2021 | (d) 2022 | (e) 2023 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | 60,267 | 43,682 | 47,188 | 145,848 | 145,857 | 442,842 |
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | 18 | 1 | 1 | 38 | 38 | 96 |
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | ||||||
| c | Add lines 10a and 10b. | 18 | 1 | 1 | 38 | 38 | 96 |
| 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.).. | 60,285 | 43,683 | 47,189 | 145,886 | 145,895 | 442,938 |
| 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 8 - OTHER REVENUE | DESCRIPTION: INTEREST INCOME. AMOUNT: 38. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: EDUCATIONAL SCHOLARSHIP. GRANTEE NAME: HAILEY STINES. GRANTEE RELATIONSHIP: NONE. AMOUNT GIVEN: 500. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: PROGRAMS FOR AT RISK TEENS & FAMILIES. GRANTEE NAME: YOUNG LIFE. GRANTEE ADDRESS: PO BOX 14861 JACKSON, WY 83002. GRANTEE RELATIONSHIP: NONE. AMOUNT GIVEN: 3,000. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: PROVIDE HELP FOR DOMESTIC VIOLENCE SHELTER. GRANTEE NAME: COMMUNITY SAFETY NETWORK VIA COMMUNITY FOUNDATION GRANTEE NAME: COMMUNITY SAFETY NETWORK VIA COMMUNITY FOUNDATION. GRANTEE ADDRESS: PO BOX 1328 JACKSON, WY 83001. GRANTEE RELATIONSHIP: NONE. AMOUNT GIVEN: 1,500. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: PROGRAMS FOR AT RISK TEENS & FAMILIES. GRANTEE NAME: TETON COUNTY YOUTH & FAMILY SERVICES VIA GRANTEE NAME: TETON COUNTY YOUTH & FAMILY SERVICES VIA. GRANTEE ADDRESS: PO BOX 2631 JACKSON, WY 83001. GRANTEE RELATIONSHIP: NONE. AMOUNT GIVEN: 1,500. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: PROGRAMS FOR AT RISK TEENS & FAMILIES. GRANTEE NAME: LOVE WITH ACTIONS. GRANTEE ADDRESS: 3831 S AMES ST DENVER, CO 80235. GRANTEE RELATIONSHIP: NONE. AMOUNT GIVEN: 3,000. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: EQUINE THERAPY FOR AT RISK CHILDREN. GRANTEE NAME: HORSE WARRIORS VIA COMMUNITY FOUNDATION OF JH. GRANTEE ADDRESS: PO BOX 602 JACKSON, WY 83001. GRANTEE RELATIONSHIP: NONE. AMOUNT GIVEN: 2,500. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: HELP PROVIDE MENTAL HEALTH SERVICES FOR LOCAL RESIDENTS. GRANTEE NAME: MENTAL HEALTH SERVICES OF JH VIA COMMUNITY GRANTEE NAME: MENTAL HEALTH SERVICES OF JH VIA COMMUNITY. GRANTEE ADDRESS: PO BOX 1868 JACKSON, WY 83001. GRANTEE RELATIONSHIP: NONE. AMOUNT GIVEN: 3,000. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: HELPING LOCAL CITIZENS WHO ARE NOT ABLE TO AFFORD MEALS. GRANTEE NAME: SENIOR CENTER OF JH VIA COMMUNITY FOUNDATION OF GRANTEE NAME: SENIOR CENTER OF JH VIA COMMUNITY FOUNDATION OF. GRANTEE ADDRESS: PO BOX 568 JACKSON, WY 83001. GRANTEE RELATIONSHIP: NONE. AMOUNT GIVEN: 2,500. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: HELPING LOCAL CITIZENS WHO ARE NOT ABLE TO AFFORD MEALS. GRANTEE NAME: HOLE FOOD RESCUE VIA COMMUNITY FOUNDATION OF JH. GRANTEE ADDRESS: 1524 MARTIN LANE JACKSON, WY 83001. GRANTEE RELATIONSHIP: NONE. AMOUNT GIVEN: 500. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: RENT AND MEDICAL ASSISTANCE FOR LOCAL WOMEN IN NEED. GRANTEE NAME: WHOLE HEALTH IMAGING. GRANTEE ADDRESS: PO BOX 2249 JACKSON, WY 83001. GRANTEE RELATIONSHIP: NONE. AMOUNT GIVEN: 19,121. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: PROVIDE WORKFORCE TRAINING FOR SINGLE MOTHERS. GRANTEE NAME: CLIMB WYOMING VIA COMMUNITY FOUNDATION OF JH. GRANTEE ADDRESS: PO BOX 9494 JACKSON, WY 83001. GRANTEE RELATIONSHIP: NONE. AMOUNT GIVEN: 500. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: PROVIDE FEMININE HYGIENE PRODUCTS TO WOMEN AND GIRLS. GRANTEE NAME: PERIOD POVERTY PROJECT. GRANTEE ADDRESS: PO BOX 1690 JACKSON, WY 83001. GRANTEE RELATIONSHIP: NONE. AMOUNT GIVEN: 2,000. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: EDUCATIONAL SCHOLARSHIPS. GRANTEE NAME: FUND FOR PUBLIC EDUCATION. GRANTEE ADDRESS: PO BOX 1048 JACKSON, WY 83001. GRANTEE RELATIONSHIP: NONE. AMOUNT GIVEN: 16,000. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: PROGRAMS FOR AT RISK TEENS & FAMILIES. GRANTEE NAME: COOMBS OUTDOORS. GRANTEE ADDRESS: 85 W SNOW KING AVE JACKSON, WY 83001. GRANTEE RELATIONSHIP: NONE. AMOUNT GIVEN: 500. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: HELP PROVIDE CULTURAL AND LEADERSHIP OPPORTUNITIES FOR LOCAL GIRLS. GRANTEE NAME: MODEL UN C/O WONDER INSTITUTE. GRANTEE ADDRESS: 535 DEER DRIVE #513 JACKSON, WY 83001. GRANTEE RELATIONSHIP: NONE. AMOUNT GIVEN: 1,000. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: HELP PROVIDE CULTURAL AND LEADERSHIP OPPORTUNITIES FOR LOCAL GIRLS. GRANTEE NAME: GIRLS ACTIVELY PARTICIPATING-GAP!. GRANTEE ADDRESS: PO BOX 6971 JACKSON, WY 83002. GRANTEE RELATIONSHIP: NONE. AMOUNT GIVEN: 2,500. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: HELP PROVIDE CULTURAL AND LEADERSHIP OPPORTUNITIES FOR LOCAL GIRLS. GRANTEE NAME: 4-H CITIZENSHIP CLUB. GRANTEE ADDRESS: PO BOX 9239 JACKSON, WY 83002. GRANTEE RELATIONSHIP: NONE. AMOUNT GIVEN: 1,600. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: RENT AND MEDICAL ASSISTANCE FOR LOCAL WOMEN IN NEED. GRANTEE NAME: TETON FREE CLINIC. GRANTEE ADDRESS: 505 E BROADWAY AVE JACKSON, WY 83001. GRANTEE RELATIONSHIP: NONE. AMOUNT GIVEN: 500. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: RENT AND MEDICAL ASSISTANCE FOR LOCAL WOMEN IN NEED. GRANTEE NAME: ST JOHN'S HOSPITAL FOUNDATION. GRANTEE ADDRESS: PO BOX 428 JACKSON, WY 83001. GRANTEE RELATIONSHIP: NONE. AMOUNT GIVEN: 38,242. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: HELP PROVIDE CULTURAL AND LEADERSHIP OPPORTUNITIES FOR LOCAL GIRLS. GRANTEE NAME: TETON JUNIOR GOLF ASSOCIATION. GRANTEE ADDRESS: 4850 RUNWAY ROAD JACKSON, WY 83001. GRANTEE RELATIONSHIP: NONE. AMOUNT GIVEN: 1,800. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: EDUCATIONAL SCHOLARSHIP. GRANTEE NAME: ELLA WATKINS. GRANTEE RELATIONSHIP: NONE. AMOUNT GIVEN: 500. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: EDUCATIONAL SCHOLARSHIP. GRANTEE NAME: MIA BRAZIL. GRANTEE RELATIONSHIP: NONE. AMOUNT GIVEN: 500. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: EDUCATIONAL SCHOLARSHIP. GRANTEE NAME: PRISCILLA MARDEN. GRANTEE RELATIONSHIP: NONE. AMOUNT GIVEN: 500. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: EDUCATIONAL SCHOLARSHIP. GRANTEE NAME: BETH SHIDNER. GRANTEE RELATIONSHIP: NONE. AMOUNT GIVEN: 500. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: EQUINE THERAPY FOR AT RISK CHILDREN. GRANTEE NAME: HORSE WARRIORS. GRANTEE ADDRESS: PO BOX 602 JACKSON, WY 83001. GRANTEE RELATIONSHIP: NONE. AMOUNT GIVEN: 2,500. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: PROVIDE HELP FOR DOMESTIC VIOLENCE SHELTER. GRANTEE NAME: COMMUNITY SAFETY NETWORK. GRANTEE ADDRESS: PO BOX 1328 JACKSON, WY 83001. GRANTEE RELATIONSHIP: NONE. AMOUNT GIVEN: 2,500. TOTAL INCLUDED ON FORM 990-EZ, LINE 10: 108,763. |
| FORM 990-EZ, PART I, LINE 16 - OTHER EXPENSES | DESCRIPTION: STORAGE RENT. AMOUNT: 4,705. DESCRIPTION: DUES AND SUBSCRIPTIONS. AMOUNT: 3,993. DESCRIPTION: OVERHEAD. AMOUNT: 2,992. DESCRIPTION: BANKCARD MONTHLY FEES. AMOUNT: 476. DESCRIPTION: CLUB ADVERTISING. AMOUNT: 450. DESCRIPTION: SOCIALS. AMOUNT: 908. TOTAL TO FORM 990-EZ, LINE 16: 13,524. |
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| Software Version: |