Form990-PF

Department of the Treasury
Internal Revenue Service

Return of Private Foundation
or Section 4947(a)(1) Trust Treated as Private Foundation
Do not enter social security numbers on this form as it may be made public.
Go to www.irs.gov/Form990PF for instructions and the latest information.
OMB No. 1545-0047
2025
Open to Public Inspection
For calendar year 2025, or tax year beginning 01 - 01 2025, and ending 12 - 31, 20 25
Name of foundation
Surgoinsville Medical Center Inc
 
Number and street (or P.O. box number if mail is not delivered to street address) PO Box 262
  Room/suite
City or town
Surgoinsville
State or province
TN
Country  
ZIP or foreign postal code
37873
A Employer identification number

62-1093541
B Telephone number (see instructions)

7728018800
C
G Check all that apply:

D 1. Foreign organizations, check here.............
2. Foreign organizations meeting the 85%
test, check here and attach computation ...
E
H Check type of organization:
F
I Fair market value of all assets at end
of year (from Part II, col. (c),
line 16)$117,322J 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)  
2 Check .................
3 Interest on savings and temporary cash investments 2,205 2,205 2,205
4 Dividends and interest from securities... 0 0 0
5a Gross rents............ 28,138 28,138 28,138
b Net rental income or (loss)  
6a Net gain or (loss) from sale of assets not on line 10 0
b Gross sales price for all assets on line 6a 0
7 Capital gain net income (from Part IV, line 2)... 0
8 Net short-term capital gain.........  
9 Income modifications........... 0
10a Gross sales less returns and allowances 0
b Less: Cost of goods sold.... 0
c Gross profit or (loss) (attach schedule)..... 0 0
11 Other income (attach schedule)....... 0 0 0
12 Total. Add lines 1 through 11........ 30,343 30,343 30,343
Operating and Administrative Expenses 13 Compensation of officers, directors, trustees, etc. 0 0 0 0
14 Other employee salaries and wages...... 0 0 0 0
15 Pension plans, employee benefits....... 0 0 0 0
16a Legal fees (attach schedule)......... 0 0 0 0
b Accounting fees (attach schedule)....... 0 0 0 0
c Other professional fees (attach schedule).... 0 0 0 0
17 Interest............... 0 0 0 0
18 Taxes (attach schedule) (see instructions)... Click to see attachment
List of Attached Documents:
// Content
3,253 3,253 3,253 0
19 Depreciation (attach schedule) and depletion... Click to see attachment
List of Attached Documents:
// Content
1,689 0 0
20 Occupancy.............. 19,931 0 0 19,931
21 Travel, conferences, and meetings....... 0 0 0 0
22 Printing and publications.......... 0 0 0 0
23 Other expenses (attach schedule)....... Click to see list of attachments
List of Attached Documents:
// Content
9,900 0 0 0
24 Total operating and administrative expenses.
Add lines 13 through 23.......... 34,773 3,253 3,253 19,931
25 Contributions, gifts, grants paid....... 0 0
26 Total expenses and disbursements. Add lines 24 and 25 ................ 34,773 3,253 3,253 19,931
27 Subtract line 26 from line 12:
a Excess of revenue over expenses and disbursements -4,430
b Net investment income (if negative, enter -0-) 27,090
c Adjusted net income (if negative, enter -0-)... 27,090
For Paperwork Reduction Act Notice, see instructions.
Cat. No. 11289X Form 990-PF (2025)
Form 990-PF (2025)
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............. 19,246 14,307 14,307
2 Savings and temporary cash investments......... 48,328 50,526 50,526
3 Accounts receivable  
Less: allowance for doubtful accounts        
4 Pledges receivable  
Less: allowance for doubtful accounts        
5 Grants receivable.................      
6 Receivables due from officers, directors, trustees, and other
disqualified persons (attach schedule) (see instructions)..... 0 0  
7 Other notes and loans receivable (attach schedule)  
Less: allowance for doubtful accounts   0 0  
8 Inventories for sale or use..............      
9 Prepaid expenses and deferred charges..........      
10a Investments—U.S. and state government obligations (attach schedule)   0  
b Investments—corporate stock (attach schedule)....... 0 0  
c Investments—corporate bonds (attach schedule).......   0  
11 Investments—land, buildings, and equipment: basis 17,757
Less: accumulated depreciation (attach schedule) 2,874 15,050 Click to see attachment
List of Attached Documents:
// Content
14,883 		14,883
12 Investments—mortgage loans.............      
13 Investments—other (attach schedule)..........   0  
14 Land, buildings, and equipment: basis 172,856
Less: accumulated depreciation (attach schedule) 135,250 39,128 Click to see attachment
List of Attached Documents:
// Content
37,606 		37,606
15 Other assets (describe ) 0 0 0
16 Total assets (to be completed by all filers—see the
instructions. Also, see page 1, item I) 121,752 117,322 117,322
Liabilities 17 Accounts payable and accrued expenses.......... 0 0
18 Grants payable................. 0 0
19 Deferred revenue................. 0 0
20 Loans from officers, directors, trustees, and other disqualified persons 0 0
21 Mortgages and other notes payable (attach schedule)......   0
22 Other liabilities (describe ) Click to see attachment
List of Attached Documents:
// Content
0 		Click to see attachment
List of Attached Documents:
// Content
0
23 Total liabilities (add lines 17 through 22)......... 0 0
Net Assets or Fund Balances Foundations that follow FASB ASC 958, check here
and complete lines 24, 25, 29 and 30.
24 Net assets without donor restrictions........... 121,752 117,322
25 Net assets with donor restrictions............    
Foundations that do not follow FASB ASC 958, check here
and complete lines 26 through 30.
26 Capital stock, trust principal, or current funds........    
27 Paid-in or capital surplus, or land, bldg., and equipment fund    
28 Retained earnings, accumulated income, endowment, or other funds    
29 Total net assets or fund balances (see instructions)..... 121,752 117,322
30 Total liabilities and net assets/fund balances (see instructions). 121,752 117,322
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
121,752
2
Enter amount from Part I, line 27a .....................
2
-4,430
3
Other increases not included in line 2 (itemize)
3
 
4
Add lines 1, 2, and 3 ..........................
4
117,322
5
Decreases not included in line 2 (itemize)
5
 
6
Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, line 29, column (b) ..
6
117,322
Form 990-PF (2025)
Form 990-PF (2025)
Page 3
Part IV
Capital Gains and Losses for Tax on Investment Income
(a) List and describe the kind(s) of property sold (e.g., real estate,
2-story brick warehouse; or common stock, 200 shs. MLC Co.)		 (b)
How acquired
P—Purchase
D—Donation 		(c)
Date acquired
(mo., day, yr.) 		(d)
Date sold
(mo., day, yr.)
1a
b
c
d
e
(e)
Gross sales price 		(f)
Depreciation allowed
(or allowable) 		(g)
Cost or other basis
plus expense of sale 		(h)
Gain or (loss)
(e) plus (f) minus (g)
a
b
c
d
e
Complete only for assets showing gain in column (h) and owned by the foundation on 12/31/69 (l)
Gains (Col. (h) gain minus
col. (k), but not less than -0-) or
Losses (from col.(h))
(i)
F.M.V. as of 12/31/69 		(j)
Adjusted basis
as of 12/31/69 		(k)
Excess of col. (i)
over col. (j), if any
a
b
c
d
e
2 Capital gain net income or (net capital loss) Bracket If gain, also enter in Part I, line 7
If (loss), enter -0- in Part I, line 7		 Bracket 2  
3 Net short-term capital gain or (loss) as defined in sections 1222(5) and (6):
If gain, also enter in Part I, line 8, column (c) (see instructions). If (loss), enter -0-
in Part I, line 8 ......................... 		Bracket 3  
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 and enter “N/A" on line 1. Bracket for line 1a
Date of ruling or determination letter: 1986-06-01(attach copy of letter if necessary–see instructions) 1 N/A
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  
3 Add lines 1 and 2........................... 3  
4 Subtitle A (income) tax (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-) 4  
5 Tax based on investment income. Subtract line 4 from line 3. If zero or less, enter -0- ..... 5  
6 Credits/Payments:
a 2025 estimated tax payments and 2024 overpayment credited to 2025 6a  
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.............. 7  
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....... 9  
10 Overpayment. If line 7 is more than the total of lines 5 and 8, enter the amount overpaid... 10  
11 Enter the amount of line 10 to be: Credited to 2026 estimated tax   Refunded 11  
For Refunded amount, also complete and attach Form 8050. See instructions.
Form 990-PF (2025)
Form 990-PF (2025)
Page 4
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. $ 0(2) On foundation managers.$ 0
e
Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed
on foundation managers.$ 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:
round bullet By language in the governing instrument, or
round bullet 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
 
No
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)
TN
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 2025 or the taxable year beginning in 2025? See the instructions for Part XIII.
If "Yes," complete Part XIII .............................
9
Yes
 
10
Did any persons become substantial contributors during the tax year? If "Yes," attach a schedule listing their names
and addresses. ...............................
10
 
No
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 addressN A
14
The books are in care ofMark Barnes Telephone no. (772) 801-8800

Located atPO Box 262SurgoinsvilleTN ZIP+437873
15
Section 4947(a)(1) nonexempt charitable trusts filing Form 990-PF in lieu of Form 1041 —check here .........
and enter the amount of tax-exempt interest received or accrued during the year ........
15
 
16 At any time during calendar year 2025, 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
Form 990-PF (2025)
Form 990-PF (2025)
Page 5
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
Organizations relying on a current notice regarding disaster assistance check here ........
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 2025? .............
1d
 
 
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 2025, did the foundation have any undistributed income (Part XII, lines 6d
and 6e) for tax year(s) beginning before 2025?....................
2a
 
No
If "Yes," list the years 20, 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
 
No
c
If the provisions of section 4942(a)(2) are being applied to any of the years listed in 2a, list the years here.
20, 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 2025 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 Form 4720, Schedule C, to determine
if the foundation had excess business holdings in 2025.).....................
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 2025? ..
4b
 
No
Form 990-PF (2025)
Form 990-PF (2025)
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
Organizations relying on a current notice regarding disaster assistance check .........
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
 
 
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
MARK BARNESClick to see attachment
List of Attached Documents:
// Content
TREASURER
3.00 		0 0 0
1607 MAIN STREET
SURGOINSVILLE,TN37873
JACK PIERCEClick to see attachment
List of Attached Documents:
// Content
VICE PRESIDENT
2.00 		0 0 0
191 HICKORY LANE
SURGOINSVILLE,TN37873
CARYLYN NOVKOVClick to see attachment
List of Attached Documents:
// Content
B MEMBER
0.00 		0 0 0
390 SURGOINSVILLE CR ROAD
SURGOINSVILLE,TN37873
NICK LUSKAClick to see attachment
List of Attached Documents:
// Content
B MEMBER
0.00 		0 0 0
109 ELM ST
SURGOINSVILLE,TN37873
TERESA GREERClick to see attachment
List of Attached Documents:
// Content
PRESIDENT
3.00 		0 0 0
116 HILL AVENUE
SURGOINSVILLE,TN37873
JEAN KEIRSEYClick to see attachment
List of Attached Documents:
// Content
SECRETARY
0.00 		0 0 0
122 SIZEMORE LANE
SURGOINSVILLE,TN37873
MARY NILE SOUTHAMClick to see attachment
List of Attached Documents:
// Content
B MEMBER
0.00 		0 0 0
208 BERNARD AVE
CHURCH HILL,TN37642
JEAN BLEDSOEClick to see attachment
List of Attached Documents:
// Content
B MEMBER
0.00 		0 0 0
135 HONEYSUCKLE AVE
SURGOINSVILLE,TN37873
BRIGITTE BUTTRYClick to see attachment
List of Attached Documents:
// Content
B MEMBER
0.00 		0 0 0
1960 LINGS BEND PIKE
SURGOINSVILLE,TN37873
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
 
Total number of other employees paid over $50,000...................  
Form 990-PF (2025)
Form 990-PF (2025)
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
 
Total number of others receiving over $50,000 for professional services.............right arrow  
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 THE SURGOINSVILLE MEDICAL CENTER INC PROVIDES AND SUPPORT THE OPERATIONS AND MAINTENANCE OF THE TOWNS ONLY PUBLIC LIBRARY WHICH INCLUDES PROVIDING OCCUPANCY EXPENSES AND PURCHASES OF BOOKS AND EQUIPMENT ALONG WITH A SMALL MUSEUM. 20,477
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.........................0
Form 990-PF (2025)
Form 990-PF (2025)
Page 8
Part IX
Minimum Investment Return (All domestic foundations must complete this part. Foreign foundations, see instructions.)
1
Fair market value of assets not used (or held for use) directly in carrying out charitable, etc.,
purposes:
a
Average monthly fair market value of securities...................
1a
0
b
Average of monthly cash balances.......................
1b
66,203
c
Fair market value of all other assets (see instructions)................
1c
216,600
d
Total (add lines 1a, 1b, and 1c).......................
1d
282,803
e
Reduction claimed for blockage or other factors reported on lines 1a and
1c (attach detailed explanation) Click to see attachment
List of Attached Documents:
// Content
.............
1e
0
2
Acquisition indebtedness applicable to line 1 assets..................
2
0
3
Subtract line 2 from line 1d.........................
3
282,803
4
Cash deemed held for charitable activities. Enter 1.5% (0.015) of line 3 (for greater amount, see
instructions) .............................
4
4,242
5
Net value of noncharitable-use assets. Subtract line 4 from line 3. ............
5
278,561
6
Minimum investment return. Enter 5% (0.05) of line 5 ................
6
13,928
Part X
Distributable Amount (see instructions) (Section 4942(j)(3) and (j)(5) private operating foundations and certain foreign organizations check here and do not complete this part.)
1
Minimum investment return from Part IX, line 6..................
1
 
2a
Tax on investment income for 2025 from Part V, line 5 .......
2a
 
b
Income tax for 2025. (This does not include the tax from Part V.) ...
2b
 
c
Add lines 2a and 2b............................
2c
 
3
Distributable amount before adjustments. Subtract line 2c from line 1............
3
 
4
Recoveries of amounts treated as qualifying distributions................
4
 
5
Add lines 3 and 4............................
5
 
6
Deduction from distributable amount (see instructions) .................
6
 
7
Distributable amount as adjusted. Subtract line 6 from line 5. Enter here and on Part XII, line 1 ...
7
 
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, line 26, column (d) ..........
1a
19,931
b
Program-related investments—total from Part VIII-B..................
1b
0
2
Amounts paid to acquire assets used (or held for use) directly in carrying out charitable, etc.,
purposes...............................
2
0
3
Amounts set aside for specific charitable projects that satisfy the:
a
Suitability test (prior IRS approval required)....................
3a
0
b
Cash distribution test (attach the required schedule) Click to see attachment
List of Attached Documents:
// Content
.................
3b
0
4
Qualifying distributions. Add lines 1a through 3b. Enter here and on Part XII, line 4. .......
4
19,931
Form 990-PF (2025)
Form 990-PF (2025)
Page 9
Part XII
Undistributed Income (see instructions)
(a)
Corpus 		(b)
Years prior to 2024 		(c)
2024 		(d)
2025
1 Distributable amount for 2025 from Part X, line 7  
2 Undistributed income, if any, as of the end of 2025:
a Enter amount for 2024 only.......  
b Total for prior years:20 , 20, 20  
3 Excess distributions carryover, if any, to 2025:
a From 2020......  
b From 2021......  
c From 2022......  
d From 2023......  
e From 2024......  
f Total of lines 3a through e ........  
4Qualifying distributions for 2025 from Part
XI, line 4: $  
a Applied to 2024, but not more than line 2a  
b Applied to undistributed income of prior years
(Election required—see instructions) ..... 		 
c Treated as distributions out of corpus (Election
required—see instructions) ........ 		 
d Applied to 2025 distributable amount.....  
e Remaining amount distributed out of corpus  
5 Excess distributions carryover applied to 2025.    
(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  
b Prior years’ undistributed income. Subtract
line 4b from line 2b .......... 		 
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 ........... 		 
e Undistributed income for 2024. Subtract line
4a from line 2a. Taxable amount—see
instructions ............. 		 
f Undistributed income for 2025. Subtract
lines 4d and 5 from line 1. This amount must
be distributed in 2026 .......... 		 
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) ....... 		 
8 Excess distributions carryover from 2020 not
applied on line 5 or line 7 (see instructions) ... 		 
9 Excess distributions carryover to 2026.
Subtract lines 7 and 8 from line 6a ...... 		 
10 Analysis of line 9:
a Excess from 2021 ....  
b Excess from 2022 ....  
c Excess from 2023 ....  
d Excess from 2024 ....  
e Excess from 2025 ....  
Form 990-PF (2025)
Form 990-PF (2025)
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 2025, enter the date of the ruling ......
1986-06-01
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 IX for each
year listed .......... 		Tax year Prior 3 years (e) Total
(a) 2025 (b) 2024 (c) 2023 (d) 2022
13,928 13,745 13,714 13,406 54,793
b 85% (0.85) of line 2a ....... 11,839 11,683 11,657 11,395 46,574
c Qualifying distributions from Part XI,
line 4 for each year listed ..... 		19,931 15,005 10,404 13,248 58,588
d Amounts included in line 2c not used directly
for active conduct of exempt activities .......... 		0 0 0 0 0
e Qualifying distributions made directly
for active conduct of exempt activities.
Subtract line 2d from line 2c .... 		19,931 15,005 10,404 13,248 58,588
3 Complete 3a, 3b, or 3c for the
alternative test relied upon:
a “Assets" alternative test—enter:
(1) Value of all assets ...... 0 0 125,523 113,151 238,674
(2) Value of assets qualifying
under section 4942(j)(3)(B)(i)		 0 0 56,549 58,244 114,793
b “Endowment" alternative test— enter 2/3
of minimum investment return shown in
Part IX, line 6 for each year listed .. 		9,285 9,163 13,714 8,937 41,099
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) .... 		0 0 0 0 0
(2) Support from general public
and 5 or more exempt
organizations as provided in
section 4942(j)(3)(B)(iii).... 		0 0 0 1,000 1,000
(3) Largest amount of support
from an exempt organization		 0 0 0 0 0
(4) Gross investment income 0 0 28,261 21,292 49,553
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).)
NA
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.
NA
2Information Regarding Contribution, Grant, Gift, Loan, Scholarship, etc., Programs:
Check here if the foundation only makes contributions to preselected charitable organizations and does not accept
unsolicited requests for funds. If the foundation makes gifts, grants, etc. to individuals or organizations under
other conditions, complete items 2a, 2b, 2c, and 2d. See instructions
aThe name, address, and telephone number or email address of the person to whom applications should be addressed:
bThe form in which applications should be submitted and information and materials they should include:
cAny submission deadlines:
dAny restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other
factors:
Form 990-PF (2025)
Form 990-PF (2025)
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
Total ................................. 3a  
bApproved for future payment
Total ................................. 3b  
Form 990-PF (2025)
Form 990-PF (2025)
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     0   0 0
b     0   0 0
c     0   0 0
d     0   0 0
e     0   0 0
f     0   0 0
    0   0 0
gFees and contracts from government agencies          
2 Membership dues and assessments ....   0   0 0
3 Interest on savings and temporary cash
investments ........... 		  0   0 2,205
4 Dividends and interest from securities ....   0   0 0
5 Net rental income or (loss) from real estate:
aDebt-financed property......   0   0 0
bNot debt-financed property.....   0   0 0
6 Net rental income or (loss) from personal property   0   0 0
7 Other investment income .....   0   0 0
8 Gain or (loss) from sales of assets other than
inventory ............ 		  0   0 0
9 Net income or (loss) from special events:   0   0 0
10 Gross profit or (loss) from sales of inventory   0   0 0
11 Other revenue:
a   		  0   0 0
b     0   0 0
c     0   0 0
d     0   0 0
e     0   0 0
12 Subtotal. Add columns (b), (d), and (e) .. 0 0 2,205
13Total. Add line 12, columns (b), (d), and (e)..................
13
2,205
(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.)
3 Interest on Checking Savings and Certificate of Deposit.
Form 990-PF (2025)
Form 990-PF (2025)
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.
May the IRS discuss this return
with the preparer shown below?
See instructions.
Signature of officer or trustee Date Title
Paid Preparer Use Only Preparer's name Preparer's Signature Date Check if self-
employed 		PTIN
Firm's name
Firm's EIN
Firm's address


Phone no.
Form 990-PF (2025)
Additional Data


Software ID: 25022704
Software Version: V2.0


Form 990PF - Special Condition Description:
Special Condition Description

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

TY 2025 DepreciationSchedule
Name:
Surgoinsville Medical Center Inc
EIN:
62-1093541
Software ID:
25022704
Software Version:
V2.0
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
Building Improvements 2001-03-01 2,957 1,580 SL 39.000000 76 0 0  
Roof 2012-11-07 6,500 1,524 SL 39.000000 167 0 0  
Roofing 2014-04-10 9,850 1,948 SL 39.000000 253 0 0  
Sewer System Improvements 2014-02-20 2,570 219 SL 39.000000 66 0 0  
HVAC Unit 2020-02-01 6,100 610 SL 15.000000 407 0 0  
Storage Barns 2020-08-01 3,691 369 SL 15.000000 246 0 0  
Library Lighting 2022-05-15 2,500 2,333 SL 15.000000 167 0 0  
Awning 2022-09-15 4,600 4,293 SL 15.000000 307 0 0  

TY 2025 InvestmentsLandSchedule2
Name:
Surgoinsville Medical Center Inc
EIN:
62-1093541
Software ID:
25022704
Software Version:
V2.0
Category/ Item Cost/Other Basis Accumulated Depreciation Book Value End of Year Fair Market Value
Building 0 0 0 0
Sign 0 0 0 0
Paving 0 0 0 0
Paving 0 0 0 0
Roofing 0 0 0 0
Roof 3,793 2,874 3,626 3,626
Land 11,257 0 11,257 11,257

TY 2025 LandEtcSchedule2
Name:
Surgoinsville Medical Center Inc
EIN:
62-1093541
Software ID:
25022704
Software Version:
V2.0
Category / Item Cost / Other Basis Accumulated Depreciation Book Value End of Year Fair Market Value
Sewer System Improvements 1,852 784 1,786 1,786
Improvements 1,149 1,884 1,073 1,073
HVAC Unit 4,270 2,238 3,863 3,863
Storage Barns 2,584 1,353 2,338 2,338
Library Lighting 2,083 584 1,916 1,916
Carpet 0 6,728 0 0
Awning 3,833 1,074 3,526 3,526
Library Equipment 0 5,518 0 0
Typewriter Cabinets 0 369 0 0
Library Shelves 0 1,375 0 0
Paving 0 4,595 0 0
Bookshelves 0 2,962 0 0
Roof 7,143 2,960 6,890 6,890
Improvements 0 2,868 0 0
Land 7,039 0 7,039 7,039
Land 9,175 0 9,175 9,175
Library Building 0 99,958 0 0


TY 2025 OtherExpensesSchedule
Name:
Surgoinsville Medical Center Inc
EIN:
62-1093541
Software ID:
25022704
Software Version:
V2.0
Description Revenue and Expenses per Books Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
Donation to City of Surgoinsville for Youth Basketball Court Paving 9,900 0 0 0


TY 2025 TaxesSchedule
Name:
Surgoinsville Medical Center Inc
EIN:
62-1093541
Software ID:
25022704
Software Version:
V2.0
Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
Property Taxes 3,253 3,253 3,253 0