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NON-PROFIT CULTURAL GRANT AGREEMENT (2)NON-PROFIT CULTURAL GRANT AGREEMENT 4 This Non -Profit Cultural Grant or Partnership Agreement ("Agreement") is made as ( , 2024 ("the Effective Date"), by and between THE CITY OF CLEARWATER, a municipal corporation ("City"), and CLEARWATER HISTORICIAL SOCIETY INC. ("Applicant") (collectively, "Parties"). WITNESSETH: WHEREAS, on March 11, 2021, President Joseph Biden signed into law the American Rescue Plan Act of 2021 ("ARPA"), Pub. L. 117-2, a $1.9 trillion economic stimulus bill passed by the 117th United States Congress to aid the country with the economic and health effects of the COVID-19 pandemic; and WHEREAS, ARPA included a $350 billion Coronavirus State and Local Fiscal Recovery Funds ("SLFRF") program designed to assist state, local, and tribunal governments in their response to the COVID-19 pandemic; and WHEREAS, the City received a total of $22,483,893.00 under the SLFRF program in two equal tranches on May 19, 2021 and June 6, 2022; and WHEREAS, on August 4, 2022, at a duly -noticed City Council meeting, the Clearwater City Council approved funding allocations from the SLFRF program for twelve proposed project and program types; and WHEREAS, one such funding allocation was in the amount of $1,000,000.00 and made for non-profit cultural grants or partnerships ("the Program") which was intended to be used to provide grant funding to nonprofits and government entities for programs focused on arts and cultural opportunities in the community whose programming, services and/or attendance was negatively impacted because of the COVID-19 pandemic; and WHEREAS, on July 20, 2023, the City made available a second round of applications for the Program; and WHEREAS, on September 29, 2023, the City received an application ("the Application") from the Applicant, a true and correct copy of which is attached to this Agreement as Exhibit "A", requesting financial assistance under the program to preserve and restore the Plumb House. ("the Project"); and WHEREAS, the Application was evaluated and scored by a review committee who recommended approval of the Applicant's financial assistance for the Project request to the Clearwater City Council; and WHEREAS, on December 7, 2023, at a City Council meeting, the Clearwater City Council approved the review committee's recommendation and authorized the City's staff to negotiate a definitive grant agreement with the Applicant; and WHEREAS, on June 20, 2024 at a City Council meeting the Clearwater City Council approved the reallocation of funding from Community Service Foundation Inc. to Clearwater Historical Society Inc. for the same Project (Plumb House renovation). WHEREAS, the City finds that providing financial assistance for the Project is a permissible expenditure under the Program; and WHEREAS, the City finds that the Project promotes the general public welfare of the citizens of Clearwater; NOW, THEREFORE, in consideration of the mutual promises and covenants contained herein, the parties hereby agree as follows: I. GENERAL 1. Recitals. The foregoing recitals are true and correct and are incorporated in and form a part of this Agreement. 2. Intent; Purpose of Agreement. The purpose of this Agreement is to further the implementation of the Program by providing for financial assistance to the non-profit for programs that focus on arts and culture including programming, targeting organizations that have been negatively impacted due to the COVID-19 pandemic. I1. APPLICANT RESPONSIBILITIES 1. Implementation of the Project. The Applicant shall implement the Project in substantial conformity with the Application. The Applicant shall have the scope of repairs approved by the owner of the Plumb House and complete the repairs no later than December 31, 2025. The City Manager may approve a written request for a six-month extension at the discretion of the City Manager. 2. Bi -annual Reporting. The Applicant shall submit bi-annual reports accounting for all Program grant funds disbursed to the Applicant and subsequently used by the Applicant for purposes of the Project. Any Program grant funds disbursed by the City but not used by the Applicant by the Termination Date found in Section 9 shall be returned to the City 14 days after the Termination Date. III. CITY RESPONSIBILITIES 1. Grant Funding. The City shall provide grant funding in the amount of $40,000.00 (forty thousand dollars) within 14 days after the Effective Date of this Agreement. 2. City Manager Word Final. The City Manager retains sole discretion to determine whether the Applicant has successfully submitted bi-annual reports as required by Section 11(2) If the City Manager or designee finds the Applicant has not successfully submitted one bi-annual report in compliance with Section 11(2), then the Parties agree that the City Manager's decision is final, this Agreement shall be null and void, the City shall not owe any additional grant money to the Applicant under the Program, the Applicant shall return the initial $40,000.00 originally disbursed to it plus default interest at rate of 10%, and the Applicant shall have no recourse against the City. IV. APPLICANT DEFAULT 1. Failure to Implement the Program. If the Applicant fails to implement the Project in substantial compliance with the Application as required by Section 11(1), then the Parties agree that the Applicant shall be in default under this Agreement. 2. Failure to Submit Bi -Annual Reporting. If the Applicant fails to submit bi-annual reports as required by Section 11(2), then the Parties agree that the Applicant shall be in default under this Agreement. 3. Application Misrepresentations. If the City determines, at any time and in the City's sole discretion, that any portion of the Application constituted a material misrepresentation, then the Parties agree that the Applicant shall be in default under this Agreement. 4. Other Events of Default. In addition to the foregoing, the occurrence of any one or more of the following after the Effective Date shall also constitute an event of default by the Applicant: A. The Applicant shall make a general assignment for the benefit of its creditors, or shall admit in writing its inability to pay its debts as they become due or shall file a petition in bankruptcy, or shall be adjudicated a bankrupt or insolvent, or shall file a petition seeking any reorganization, arrangement, composition, readjustment, liquidation, dissolution or similar relief under any present or future statute, law or regulation or shall file an answer admitting, or shall fail reasonably to contest, the material allegations of a petition filed against it in any such proceeding, or shall seek or consent to or acquiesce in the appointment of any trustee, receiver or liquidator of the Applicant or any material part of such entity's properties; or B. Within 60 days after the commencement of any proceeding by or against the Applicant seeking any reorganization, arrangement, composition, readjustment, liquidation, dissolution or similar relief under any present or future statute, law or regulation, such proceeding shall not have been dismissed or otherwise terminated, or if, within 60 days after the appointment without the consent or acquiescence of the Applicant of any trustee, receiver or liquidator of any of such entities or of any material part of any of such entity's properties, such appointment shall not have been vacated. 5. Notice of Default and Opportunity to Cure. The City shall provide written notice of any default under this Agreement and provide the Applicant 30 days from the date the notice is sent to cure the default. This notice will be deemed sent when sent by first class mail to the Applicant's notice address or when delivered to the Applicant if sent by a different means. 6. City Remedies. If, after notice and an opportunity to cure, the Applicant fails to cure any of the events of default listed in Section IV of this Agreement, then the Parties agree that: a) this Agreement shall be null and void; b) that the City will have no further responsibility to the Applicant, including the responsibility to tender any remaining Program grant funds to the Applicant; c) that any Program grant funds actually tendered by the City to the Applicant shall be retumed to City along with default interest at a rate of 10% starting from the date of default; and d) the Applicant shall have no recourse against the City. V. MISCELLANEOUS 1. Notices. All notices, demands, requests for approvals or other communications given by either party to another shall be in writing, and shall be sent to the office for each party indicated below and addressed as follows: To the Applicant: Clearwater Historical Society Inc. 610 S Ft. Harrison Clearwater, FL 33756 Attention: Director To the City: City of Clearwater P.O. Box 4748 Clearwater, Florida 33758 Attention: City Clerk with copies to: City of Clearwater P.O. Box 4748 Clearwater, Florida 33758 Attention: City Attorney 2. Unavoidable Delay. Any delay in performance of or inability to perform any obligation under this Agreement (other than an obligation to pay money) due to any event or condition described in this Section as an event of "Unavoidable Delay" shall be excused in the manner provided in this Section. "Unavoidable Delay" means any of the following events or conditions or any combination thereof: acts of God, acts of the public enemy, riot, insurrection, war, pestilence, archaeological excavations required by law, unavailability of materials after timely ordering of same, building moratoria, epidemics, quarantine restrictions, freight embargoes, fire, lightning, hurricanes, earthquakes, tornadoes, floods, extremely abnormal and excessively inclement weather (as indicated by the records of the local weather bureau for a five year period preceding the Effective Date), strikes or labor disturbances, delays due to proceedings under Chapters 73 and 74, Florida Statutes, restoration in connection with any of the foregoing or any other cause beyond the reasonable control of the party performing the obligation in question, including, without limitation, such causes as may arise from the act of the other party to this Agreement, or acts of any govemmental authority (except that acts of the City shall not constitute an Unavoidable Delay with respect to performance by the City). An application by any party hereto for an extension of time pursuant to this Section must be in writing, must set forth in detail the reasons and causes of delay, and must be filed with the other party to this Agreement within 30 days following the occurrence of the event or condition causing the Unavoidable Delay or 30 days following the party becoming aware (or with the exercise of reasonable diligence should have become aware) of such occurrence. The party shall be entitled to an extension of time for an Unavoidable Delay only for the number of days of delay due solely to the occurrence of the event or condition causing such Unavoidable Delay and only to the extent that any such occurrence actually delays that party from proceeding with its rights, duties and obligations under this Agreement affected by such occurrence. 3. Indemnification. The Applicant agrees to assume all risks of inherent in this Agreement and all liability therefore, and shall defend, indemnify, and hold harmless the City and the City's officers, agents, and employees from and against any and all claims of loss, liability and damages of whatever nature, to persons and property, including, without limiting the generality of the foregoing, death of any person and loss of the use of any property. This includes, but is not limited to, matters arising out of or claimed to have been caused by or in any manner related to the Applicant's activities or those of any approved or unapproved invitee, contractor, subcontractor, or other person approved, authorized, or permitted by the Applicant whether or not based on negligence. Nothing herein shall be construed as consent by the City to be sued by third parties, or as a waiver or modification of the provisions or limits of Section 768.28, Florida Statutes or the Doctrine of Sovereign Immunity. 4. Assignability; Complete Agreement. This Agreement is non -assignable by either party and constitutes the entire Agreement between the Applicant and the City and all prior or contemporaneous oral and written agreements or representations of any nature with reference to the subject of the agreement are canceled and superseded by the provisions of this agreement. 5. Applicable Law and Construction. The laws of the State of Florida shall govern the validity, performance, and enforcement of this Agreement. This Agreement has been negotiated by the City and the Applicant, and the Agreement, including, without limitation, the Exhibits, shall not be deemed to have been prepared by the City or the Applicant, but by all equally. 6. Severability. Should any section or part of any section of this Agreement be rendered void, invalid, or unenforceable by any court of law, for any reason, such a determination shall not render void, invalid, or unenforceable any other section or any part of any section in this Agreement. 7. Amendments. This Agreement cannot be changed or revised except by written amendment signed by all parties hereto. 8. Jurisdiction and Venue. For purposes of any suit, action or other proceeding arising out of or relating to this Agreement, the parties hereto do acknowledge, consent and agree that venue thereof is Pinellas County, Florida. Each party to this Agreement hereby submits to the jurisdiction of the State of Florida, Pinellas County and the courts thereof and to the jurisdiction of the United States District Court for the Middle District of Florida, for the purposes of any suit, action or other proceeding arising out of or relating to this Agreement and hereby agrees not to assert by way of a motion as a defense or otherwise that such action is brought in an inconvenient forum or that the venue of such action is improper or that the subject matter thereof may not be enforced in or by such courts. If, at any time during the term of this Agreement, the Applicant is not a resident of the State of Florida or has no office, employee, City, registered agent or general partner thereof available for service of process as a resident of the State of Florida, or if any permitted assignee thereof shall be a foreign corporation, partnership or other entity or shall have no officer, employee, agent, or general partner available for service of process in the State of Florida, the Applicant hereby designates the Secretary of State, State of Florida, its agent for the service of process in any court action between it and the City arising out of or relating to this Agreement and such service shall be made as provided by the laws of the State of Florida for service upon a nonresident; provided, however, that at the time of service on the Florida Secretary of State, a copy of such service shall be delivered to the Applicant at the address for notices as provided in Section V(1). 9. Termination. If not earlier terminated as provided in this Agreement, the term of this Agreement shall expire and this Agreement shall no longer be of any force and effect on December 1, 2026. [Remainder of Page Left Blank Intentionally] IN WITNESS WHEREOF, the Parties have caused this Agreement to be signed in its corporate/legal name by its authorized representative or persons authorized to execute this Agreement on the date and year first above written. Clearwater Historical Society Inc. By: (;) Allison Dolan Director STATE OF FLORIDA ] COUNTY OF PINELLAS j The foregoing instrument was acknowledged before me this, 6day of 3-u/1 - 2024 byf//i Sot) ?30/0_i7 who is personally known to me or who has produced a driver's license as identification. My Commission expires: /9/ 0202 THE CITY OF CLEARWATER, a municipal corporation Lead Assistant City Attorney By: Attest: Je er irr =r City Manager Rosemarie CaII City Clerk C. Project Information Completed by ethiebe@csfhome.org on 9/29/2023 10:34 AM Case Id: 15989 Name: Community Service Foundation - 2023 Address: *No Address Assigned C. Project Information Please provide the following information. C.1. Project Description The Project 1901 is a specific infrastructure project that honors the year the Plumb House became a heritage family home. Its preservation is conservation of culture at its core and represents an opportunity for reinvigorating a sense of community for years to come. Where you live determines your health, well-being, and economic success. From safe drinking water and stable housing to safe parks, clean air, and quality schools it is clear that controlling the spread and withstanding the impact of a deadly virus is only possible when people's most basic human needs are being met. The COVID-19 pandemic reminded us that far too many Americans, disproportionately low-income people lack the essential components of healthy communities. The 1901 Project design leverages private, non-profit and public resources to optimize expenditures and efficiencies. We envision making contemporary use of the Plumb House, which is located on City of Clearwater property and owned by the Clearwater Historical Society, as a destination for arts, culture programs and a community resource center. C.2. Project Goals (minimum 3 required) The first goal is to preserve and restore the Plumb House to safeguard its character -defining elements of this cultural resource to retain it heritage value and extend its physical life. The Plumb House is a two-story Florida Vernacular wooden home originally built in 1896 and only 1 of 2 surviving in the Central Florida area. The Plumb House served as the hardware store for the Belleair community and Biltmore Hotel and was located in downtown Clearwater near the train station. After the Biltmore was completed, the home was bought by C.S. Reynolds to bring his sister from New York to be the first paid teacher in what is now Pinellas County. Pastor Reynolds moved the home to the corner of Lakeview and S Fort Harrison and converted the building into a single- family home in 1901. Since 1983, the Plumb House has been located on real property owned by the City known as Ed C. Wright Park pursuant to various revocable license agreements between the Clearwater Historical Society and the City of Clearwater and recently renewed with a term of July 1, 2022, to June 30, 2037. The second goal is to place the Plumb House on the U.S. National Register of Historical Places and facilitate bi-monthly access to the public to promote awareness of its cultural significance in partnership with the Clearwater Historical Society. The third goal is to make contemporary use of the Plumb House as a hub for arts and culture upon completion of the Plumb House preservation in partnership with the City of Clearwater Ross Norton Recreation Center and Lake Belleview Neighborhood. Printed By: Amber Brice on 6/26/2024 1 of 4 NNeighboriy Software C.3. Project Activities The 1901 Project reconstruction will address the safety, stability, and blight of the Plumb House and is the prime project activity. To facilitate the restoration of the Plumb House in compliance with its historical status, the Foundation has partnered with the Clearwater Historical Society and D- Mar Construction LLC. Future Plumb House activities will include hosting bi-monthly open house visits to promote Clearwater history; artist in residence and preforming artists; weekend cultural and art related festivals, outreach to Lake Belleview youth with musicians and office support to provide speaker series about career development, financial planning and other resources to impact the well-being of neighborhood residents. C.4. Project Impact — Describe how the project/program benefits the Clearwater community. The 1901 Project will preserve a significant historical heritage home, while promoting the history of Clearwater. Much of our history resides within the buildings and landscapes of our communities; family heritage homes are beloved landmarks that remind us of life long ago and help explain our world today. The ARPA grant will not only enhance the environment by eliminating blight, but also will remove barriers to full participation in arts and cultural programming in a location where low-income families already live. Per existing license agreements with the City of Clearwater, Clearwater Historical Society and Community Service Foundation, all improvements made shall become the property of the City of Clearwater. C.5. Project Alignment with Cultural Arts Strategic Plan (select one or more of the following) IZIStrengthen the identity of neighborhoods through an investment in public art at the neighborhood level. ElInvest in iconic public art in strategic locations to bolster the public art experience. ElImplement programs that build the capacities of the arts and culture sector to be more unified in their vision toward the same goal. ElDefine spaces in Clearwater that an investment in the arts can be concentrated for maximum impact. ElSupport neighborhoods through broadening and diversifying arts experiences. C.6. Project Alignment with Greenprint 2.0 — Describe how the project/program supports the goals and objectives of Clearwater Greenprint 2.0 as it pertains to the following: • Education and Awareness • Green Energy and Buildings • Transportation • Livability • Water Conservation • Waste Reduction • Local Food • Green Economy The Plumb House, located on the banks of Lake Belleview, a 30 -acre spring -fed natural resource, will be restored as nearly as possible to its original condition. The Plumb House also is located in Ed Wright Park, a City recreational facility that is being renovated with the intent to encourage local engagement at Lake Belleview and in its surrounding natural environment. The Plumb House repairs are intentional, prioritizing household weatherization, energy Printed By: Amber Brice on 6/26/2024 2 of 4 NNeighborly Software efficiency, and other infrastructure to withstand our changing climate. By ensuring that infrastructure design and construction account for climate risks, we envision the Plumb House to be vibrant for another 100 years. C.7. Project Evaluation • Describe how you will determine goals of the project are achieved. • Who will conduct the evaluation? • Who or what will the evaluation target? • What methods will be used to collect participant feedback? (surveys, evaluation forms, interviews, etc.) • When will you collect this information? • How will you use this information for future programs? The 1901 Project will require City of Clearwater Planning and Development to permit construction per existing requirements and compliance with National Historic Site requirements. Future programming will include coordinating with the Lake Belleview Neighborhood Association, Ross Norton Recreation Center, City of Clearwater Arts/Culture Coordinator and Neighborhood Coordinator Offices and local art/culture organizations. Collaborative programming is at the heart of the Community Service Foundation's community outreach. Our history of coordination with City and Lake Belleview neighborhood resources is documented in this application in the Other Supplement Nos. 9 and 10. C.8. Identify the timeline for implementation of the proposed project/program. 1901 Project will begin upon grant approval; D -Mar Construction and CSF are prepared to begin the preservation project immediately with Phase 1 of the plan to address external building needs that address blight and safety. It is estimated that the exterior of the Plumb House will be completed in 6 months, with expedited permits and collaborative support from Clearwater -based contractors coordinated through D -Mar Construction. C.9. Sustainability — Describe plans to sustain the project/program after grant funds are expended. The Community Service Foundation, a 501-c-3 nonprofit organization has sustained its operations since being founded in 1944; CSF will fund arts and culture programming and resource and its office operations. C.10. Routine Maintenance and Utility Costs — If funding is requested for a capital or infrastructure project, provide the anticipated routine maintenance, including utility costs. Based on current and past expenses to maintain and operate via routine utility costs: the electric-water-trash$230; security system is being donated by Sourcelsolutions; telephone/internet $150 and insurance $180. C.11. Fiscal Condition — Describe the fiscal condition of your organization as it relates to the successful completion of the project/program proposed. Per the last fiscal year audit by Carr, Riggs and ingram, LLC, the Foundation is in compliance with auditing standards generally accepted by the United States. Further, its resources have sustained operations since 1944 to include 70 properties in Pinellas County, property management income, an endowment and ongoing donations to support cause related projects. CSF leads efforts to raise awareness about community betterment projects such as Restoring Lake Belleview; the Belmont Park Restoration; Tieman Village and Hall Street Property Renovations to house homeless citizens and U.S. veterans and the Foundation's programming of cultural events such as the annual Holiday Celebration and Clearwater United World Cup Celebration in partnership with City of Clearwater Recreation Department Ross Norton Center to build a network of donors that will be solicited to support the 1901 Project. C.12. Organization's Fiscal Year October 1,2023 -September 30,2024 C.13. Organizational Operating Budget Summary Expenses Total Cash Expenses In -Kind Contributions Total Operating E Printed By: Amber Brice on 6/26/2024 HNeighborly Software 3 of 4 Salaries and Benefits $315,266.00 $0.00 $315,266.00 Other Expenses/Administration $157,320.00 $0.00 $157,320.00 Community Outreach $25,972.00 $0.00 $25,972.00 Homeowners & Fair Housing Programs Misc $3,500.00 $0.00 $3,500.00 Rental Property Operations $1,388,241.00 $0.00 $1,388,241.00 Ince Total Cash Income in -Kind Contributions Total Operating Income Rental Properties $1,870,576.00 $0.00 $1,870,576.00 Community Outreach $35,033.00 $0.00 $35,033.00 Printed By: Amber Brice on 6/26/2024 4 of 4 MNeighborly Software C. Project Information Completed by ethiebe@csfhome.org on 9/29/2023 10:34 AM Case Id: 15989 Name: Community Service Foundation - 2023 Address: *No Address Assigned C. Project Information Please provide the following information. C.1. Project Description The Project 1901 is a specific infrastructure project that honors the year the Plumb House became a heritage family home. Its preservation is conservation of culture at its core and represents an opportunity for reinvigorating a sense of community for years to come. Where you live determines your health, well-being, and economic success. From safe drinking water and stable housing to safe parks, clean air, and quality schools it is clear that controlling the spread and withstanding the impact of a deadly virus is only possible when people's most basic human needs are being met. The COVID-19 pandemic reminded us that far too many Americans, disproportionately low-income people lack the essential components of healthy communities. The 1901 Project design leverages private, non-profit and public resources to optimize expenditures and efficiencies. We envision making contemporary use of the Plumb House, which is located on City of Clearwater property and owned by the Clearwater Historical Society, as a destination for arts, culture programs and a community resource center. C.2. Project Goals (minimum 3 required) The first goal is to preserve and restore the Plumb House to safeguard its character -defining elements of this cultural resource to retain it heritage value and extend its physical life. The Plumb House is a two-story Florida Vernacular wooden home originally built in 1896 and only 1 of 2 surviving in the Central Florida area. The Plumb House served as the hardware store for the Belleair community and Biltmore Hotel and was located in downtown Clearwater near the train station. After the Biltmore was completed, the home was bought by C.S. Reynolds to bring his sister from New York to be the first paid teacher in what is now Pinellas County. Pastor Reynolds moved the home to the corner of Lakeview and S Fort Harrison and converted the building into a single- family home in 1901. Since 1983, the Plumb House has been located on real property owned by the City known as Ed C. Wright Park pursuant to various revocable license agreements between the Clearwater Historical Society and the City of Clearwater and recently renewed with a term of July 1, 2022, to June 30, 2037. The second goal is to place the Plumb House on the U.S. National Register of Historical Places and facilitate bi-monthly access to the public to promote awareness of its cultural significance in partnership with the Clearwater Historical Society. The third goal is to make contemporary use of the Plumb House as a hub for arts and culture upon completion of the Plumb House preservation in partnership with the City of Clearwater Ross Norton Recreation Center and Lake Belleview Neighborhood. Printed By: Amber Brice on 6/26/2024 1 of 4 H Neighborly Software C.3. Project Activities The 1901 Project reconstruction will address the safety, stability, and blight of the Plumb House and is the prime project activity. To facilitate the restoration of the Plumb House in compliance with its historical status, the Foundation has partnered with the Clearwater Historical Society and D- Mar Construction LLC. Future Plumb House activities will include hosting bi-monthly open house visits to promote Clearwater history; artist in residence and preforming artists; weekend cultural and art related festivals, outreach to Lake Belleview youth with musicians and office support to provide speaker series about career development, financial planning and other resources to impact the well-being of neighborhood residents. C.4. Project Impact — Describe how the project/program benefits the Clearwater community. The 1901 Project will preserve a significant historical heritage home, while promoting the history of Clearwater. Much of our history resides within the buildings and landscapes of our communities; family heritage homes are beloved landmarks that remind us of life long ago and help explain our world today. The ARPA grant will not only enhance the environment by eliminating blight, but also will remove barriers to full participation in arts and cultural programming in a location where low-income families already live. Per existing license agreements with the City of Clearwater, Clearwater Historical Society and Community Service Foundation, all improvements made shall become the property of the City of Clearwater. C.5. Project Alignment with Cultural Arts Strategic Plan (select one or more of the following) QStrengthen the identity of neighborhoods through an investment in public art at the neighborhood level. ▪ Invest in iconic public art in strategic locations to bolster the public art experience. ElImplement programs that build the capacities of the arts and culture sector to be more unified in their vision toward the same goal. 2 Define spaces in Clearwater that an investment in the arts can be concentrated for maximum impact. 2 Support neighborhoods through broadening and diversifying arts experiences. C.6. Project Alignment with Greenprint 2.0 — Describe how the project/program supports the goals and objectives of Clearwater Greenprint 2.0 as it pertains to the following: • Education and Awareness • Green Energy and Buildings • Transportation • Livability • Water Conservation • Waste Reduction • Local Food • Green Economy The Plumb House, located on the banks of Lake Belleview, a 30 -acre spring -fed natural resource, will be restored as nearly as possible to its original condition. The Plumb House also is located in Ed Wright Park, a City recreational facility that is being renovated with the intent to encourage local engagement at Lake Belleview and in its surrounding natural environment. The Plumb House repairs are intentional, prioritizing household weatherization, energy Printed By: Amber Brice on 6/26/2024 2 of 4 Neighborly Software efficiency, and other infrastructure to withstand our changing climate. By ensuring that infrastructure design and construction account for climate risks, we envision the Plumb House to be vibrant for another 100 years. C.7. Project Evaluation • Describe how you will determine goals of the project are achieved. • Who will conduct the evaluation? • Who or what will the evaluation target? • What methods will be used to collect participant feedback? (surveys, evaluation forms, interviews, etc.) • When will you collect this information? • How will you use this information for future programs? The 1901 Project will require City of Clearwater Planning and Development to permit construction per existing requirements and compliance with National Historic Site requirements. Future programming will include coordinating with the Lake Belleview Neighborhood Association, Ross Norton Recreation Center, City of Clearwater Arts/Culture Coordinator and Neighborhood Coordinator Offices and local art/culture organizations. Collaborative programming is at the heart of the Community Service Foundation's community outreach. Our history of coordination with City and Lake Belleview neighborhood resources is documented in this application in the Other Supplement Nos. 9 and 10. C.8. Identify the timeline for implementation of the proposed project/program. 1901 Project will begin upon grant approval; D -Mar Construction and CSF are prepared to begin the preservation project immediately with Phase 1 of the plan to address external building needs that address blight and safety. It is estimated that the exterior of the Plumb House will be completed in 6 months, with expedited permits and collaborative support from Clearwater -based contractors coordinated through D -Mar Construction. C.9. Sustainability — Describe plans to sustain the project/program after grant funds are expended. The Community Service Foundation, a 501-c-3 nonprofit organization has sustained its operations since being founded in 1944; CSF will fund arts and culture programming and resource and its office operations. C.10. Routine Maintenance and Utility Costs — If funding is requested for a capital or infrastructure project, provide the anticipated routine maintenance, including utility costs. Based on current and past expenses to maintain and operate via routine utility costs: the electric-water-trash$230; security system is being donated by Sourcelsolutions; telephone/internet $150 and insurance $180. C.11. Fiscal Condition — Describe the fiscal condition of your organization as it relates to the successful completion of the project/program proposed. Per the last fiscal year audit by Carr, Riggs and ingram, LLC, the Foundation is in compliance with auditing standards generally accepted by the United States. Further, its resources have sustained operations since 1944 to include 70 properties in Pinellas County, property management income, an endowment and ongoing donations to support cause related projects. CSF leads efforts to raise awareness about community betterment projects such as Restoring Lake Belleview; the Belmont Park Restoration; Tieman Village and Hall Street Property Renovations to house homeless citizens and U.S. veterans and the Foundation's programming of cultural events such as the annual Holiday Celebration and Clearwater United World Cup Celebration in partnership with City of Clearwater Recreation Department Ross Norton Center to build a network of donors that will be solicited to support the 1901 Project. C.12. Organization's Fiscal Year October 1,2023 -September 30,2024 C.13. Organizational Operating Budget Summary Expenses Total Cash Expenses In -Kind Contributions Total Opera Printed By: Amber Brice on 6/26/2024 HNeighborly Software 3 of 4 Salaries and Benefits $315,266.00 $0.00 $315,266.00 Other Expenses/Administration $157,320.00 $0.00 $157,320.00 Community Outreach $25,972.00 $0.00 $25,972.00 Homeowners & Fair Housing Programs Misc $3,500.00 $0.00 $3,500.00 Rental Property Operations $1,388,241.00 $0.00 $1,388,241.00 Income Total Cash Income In -Kind Contributions Total Operating Income Rental Properties $1,870,576.00 $0.00 $1,870,576.00 Community Outreach $35,033.00 $0.00 $35,033.00 Printed By: Amber Brice on 6/26/2024 4 of 4 NNeighborly Software D. Funding Request Completed by ethiebe@csfhome.org on 9/29/2023 10:03 AM Case Id: 15989 Name: Community Service Foundation - 2023 Address: *No Address Assigned D. Funding Request Please provide the following information. D.1. Funding Request Table If you selected "Other" please provide expenses in detail Please see detailed budget estimate information in supplement No.8, to review a line -item budget that accounts for Phase 1 and Phase 2 project expenses. D.2. City of Clearwater Cultural Affairs Nonprofit grant funds requested? Note: Allocation of the grant funds will be paid on a case-by-case basis after consulting with awardees their need for the funds. $0.00 D.3. Does this project/program anticipate the use of funds or assistance from other organizations? Due to the ARPA Arts/Culture grant allocation limit of $250,000.00. the project was designed in 2 phases; Phase 1 will be completed with City of Clearwater ARPA funding. D.4. Describe your plans to use other funds on this project. In this section, only describe funds that are secured. Provide the source of funds, amounts, and how these funds will be used. No other funds are being used on this project application for Phase 1 funding. Printed By: Amber Brice on 6/26/2024 HNeighborly Software 1 of 2 Project Estimate Funding Request Amount From Other Funding Sources Souk of Other o Funding Personnel: Administrative $0.00 $0.00 $0.00 Personnel: Programmatic $0.00 $0.00 $0.00 Outside Fees and Services: Administrative $0.00 $0.00 $0.00 Outside Fees and Services: Programmatic $0.00 $0.00 $0.00 Outside Fees and Services: Other $0.00 $0.00 $0.00 Space Rental $0.00 $0.00 $0.00 Marketing $0.00 $0.00 $0.00 Other $500,000.00 $250,000.00 $250,000.00 For Projects: Utility Costs $0.00 $0.00 $0.00 $500,000.00 $250,000.00 $250,000.00 If you selected "Other" please provide expenses in detail Please see detailed budget estimate information in supplement No.8, to review a line -item budget that accounts for Phase 1 and Phase 2 project expenses. D.2. City of Clearwater Cultural Affairs Nonprofit grant funds requested? Note: Allocation of the grant funds will be paid on a case-by-case basis after consulting with awardees their need for the funds. $0.00 D.3. Does this project/program anticipate the use of funds or assistance from other organizations? Due to the ARPA Arts/Culture grant allocation limit of $250,000.00. the project was designed in 2 phases; Phase 1 will be completed with City of Clearwater ARPA funding. D.4. Describe your plans to use other funds on this project. In this section, only describe funds that are secured. Provide the source of funds, amounts, and how these funds will be used. No other funds are being used on this project application for Phase 1 funding. Printed By: Amber Brice on 6/26/2024 HNeighborly Software 1 of 2 D.S. Describe your plans to seek new funding to supplement ARPA funding. Describe the sources to which you will apply, the amounts sought, and the proposed use of those funds. Phase 2 of the project will require $250,000.00 of City of Clearwater funding to be included in the Ed Wright Park renovation project budget. D.6. What will happen if this project is not funded? The City will manage a blighted property within the Ed Wright Park renovation and will incur additional costs to renovate the Plumb House as it deteriorates while the non -profit -private coalition to support this project is dissolved. D.7. What will happen if this project is partially funded? The safety of the public is compromised with a partially renovated property. It is likely that the 1901 Project coalition's support will terminate with a construction project that partially addresses the safety of the public. Printed By: Amber Brice on 6/26/2024 2 of 2 HNeighborly Software Form W -9 (Rev. October 2018) Department of the Treasury Internal Revenue Service Request for Taxpayer Identification Number and Certification ► Go to www.irs.gov/FormW9 for instructions and the latest information. Give Form to the requester. Do not send to the IRS. 1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank. Clearwater Historical Society, Inc. 2 Business name/disregarded entity name, if different from above Clearwater Historical Society Museum and Cultural Center 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes. ❑ Individual/sole proprietor or ❑ C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate single -member LLC ❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ► Note: Check the appropriate box in the line above for the tax classification of the single -member owner. Do not check LLC if the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner. ❑✓ Other (see instructions) ► 501 c(3) Tax Exempt 4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3): Exempt payee code (if any) Exemption from FATCA reporting code (if any) (Applies to accounts maintained outside the U.S.) 5 Address (number, street, and apt. or suite no.) See instructions. 610 S Fort Harrison Ave 6 City, state, and ZIP code Clearwater, Florida 33756 Requester's name and address (optional) 7 List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later. Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter. Part I1 Social security number or Employer identification number 5 9 1 9 3 8 8 2 4 Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. I am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax retum. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part 11, later. Sign Here Signature of U.S. person ► Date ► General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9. Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following. • Form 1099 -INT (interest earned or paid) • Form 1099 -DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not retum Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. Cat. No. 10231X Form W-9 (Rev. 10-2018) Form W-9 (Rev. 10-2018) Page 2 By signing the filled -out form, you: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income, and 4. Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting, later, for further information. Note: If you are a U.S. person and a requester gives you a form other than Form W-9 to request your TIN, you must use the requester's form if it is substantially similar to this Form W-9. Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are: • An individual who is a U.S. citizen or U.S. resident alien; • A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States; • An estate (other than a foreign estate); or • A domestic trust (as defined in Regulations section 301.7701-7). Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax under section 1446 on any foreign partners' share of effectively connected taxable income from such business. Further, in certain cases where a Form W-9 has not been received, the rules under section 1446 require a partnership to presume that a partner is a foreign person, and pay the section 1446 withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid section 1446 withholding on your share of partnership income. In the cases below, the following person must give Form W-9 to the partnership for purposes of establishing its U.S. status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States. • In the case of a disregarded entity with a U.S. owner, the U.S. owner of the disregarded entity and not the entity; • In the case of a grantor trust with a U.S. grantor or other U.S. owner, generally, the U.S. grantor or other U.S. owner of the grantor trust and not the trust; and • In the case of a U.S. trust (other than a grantor trust), the U.S. trust (other than a grantor trust) and not the beneficiaries of the trust. Foreign person. If you are a foreign person or the U.S. branch of a foreign bank that has elected to be treated as a U.S. person, do not use Form W-9. Instead, use the appropriate Form W-8 or Form 8233 (see Pub. 515, Withholding of Tax on Nonresident Aliens and Foreign Entities). Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a "saving clause." Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise become a U.S. resident alien for tax purposes. If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income, you must attach a statement to Form W-9 that specifies the following five items. 1. The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien. 2. The treaty article addressing the income. 3. The article number (or location) in the tax treaty that contains the saving clause and its exceptions. 4. The type and amount of income that qualifies for the exemption from tax. 5. Sufficient facts to justify the exemption from tax under the terms of the treaty article. Example. Article 20 of the U.S.-China income tax treaty allows an exemption from tax for scholarship income received by a Chinese student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years. However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (under paragraph 2 of the first protocol) and is relying on this exception to claim an exemption from tax on his or her scholarship or fellowship income would attach to Form W-9 a statement that includes the information described above to support that exemption. If you are a nonresident alien or a foreign entity, give the requester the appropriate completed Form W-8 or Form 8233. Backup Withholding What is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS 24% of such payments. This is called "backup withholding." Payments that may be subject to backup withholding include interest, tax-exempt interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, payments made in settlement of payment card and third party network transactions, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding. You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return. Payments you receive will be subject to backup withholding if: 1. You do not furnish your TIN to the requester, 2. You do not certify your TIN when required (see the instructions for Part II for details), 3. The IRS tells the requester that you furnished an incorrect TIN, 4. The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only), or 5. You do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only). Certain payees and payments are exempt from backup withholding. See Exempt payee code, later, and the separate Instructions for the Requester of Form W-9 for more information. Also see Special rules for partnerships, earlier. What is FATCA Reporting? The Foreign Account Tax Compliance Act (FATCA) requires a participating foreign financial institution to report all United States account holders that are specified United States persons. Certain payees are exempt from FATCA reporting. See Exemption from FATCA reporting code, later, and the Instructions for the Requester of Form W-9 for more information. Updating Your Information You must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future from this person. For example, you may need to provide updated information if you are a C corporation that elects to be an S corporation, or if you no longer are tax exempt. In addition, you must furnish a new Form W-9 if the name or TIN changes for the account; for example, if the grantor of a grantor trust dies. Penalties Failure to fumish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect. Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty. a Form11111-9 (Rev. October 2018) Department of the Treasury Internal Revenue Service Request for Taxpayer Identification Number and Certification ► Go to www.irs.gov/FormW9 for instructions and the latest information. Give Form to the requester. Do not send to the IRS. Print or type. See Specific Instructions on page 3. 1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank. Clearwater Historical Society, Inc. 2 Business name/disregarded entity name, if different from above Clearwater Historical Society Museum and Cultural Center 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes. 4 Exemptions certain entities, instructions Exempt payee Exemption code (if any) (Applies to accounts (codes apply only to not individuals; see on page 3): code (if any) • IndividuaVsole proprietor or 0 C Corporation ii■ S Corporation 11• Partnership i• Trust/estate single -member LLC company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) the appropriate box in the line above for the tax classification of the single -member owner. is classified as a single -member LLC that is disregarded from the owner unless the owner is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single from the owner should check the appropriate box for the tax classification of its owner. ► 501 c(3) Tax Exempt ► • Limited liability Note: Check LLC if the LLC another LLC that is disregarded from FATCA reporting Do not check of the LLC is -member LLC that maintained outside the U.S.) ■ Other (see instructions) 5 Address (number, street, and apt, or suite no.) See instructions. 610 S Fort Harrison Ave Requester's name and address (optional) 6 City, state, and ZIP code Clearwater, Florida 33756 7 List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later. Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter. Part II Social security number � or Employer identification number 5 9 1 9 3 8 8 2 4 Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. I am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later. Sign Here Signature of �/�0/l D /1 �ri2�w�� Z7/96-4, U.S. tore o ► �Y &45, Q� Date ► W2-7/2—‘71 General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9. Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following. • Form 1099 -INT (interest earned or paid) • Form 1099 -DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. Cat. No. 10231X Form W-9 (Rev. 10-2018) D Internal Revenue Service Department of the Treasury District Director Date: °CT z 3 1985 Clearwater Historical Society, Inc. 1350 Greenwood Avenue PO Box 175 Clearwater, FL 33517 Dear Applicant: Employer Identification Number: 59-1938824 Accounting Period Ending: November 30 Form 990 Required: 44 Yes o No Person to Contact: R. Van Meter/bz Contact Telephone Number. (404) 221-4516 File Folder Number: 580062902. Based on information supplied, and assuming your operations will be as stated in your application for recognition of exemption, we have determined you are exempt from Federal income tax under section 501(c)(3) of the Internal Revenue Code. We have further determined that you are not a private foundation within the meaning of section 509(a) of the Code, because you are an organization described in section 509(a)(2). - If your sources of support, or your purposes, character, or method of operation change, please let us know so we can consider the effect of the change on your exempt status and foundation status. Also, you should inform us of all changes in your name or address. As of January 1, 1984, you are liable for taxes under the Federal Insurance Contributions Act(social security taxes) on remuneration of $100 or more you pay to each of your employees during a calendar year. You are not liable for the tax imposed under the Federal Unemployment Tax Act (FUTA). Since you are not a private foundation, you are not subject to the excise taxes under Chapter 42 of the Code. However, you are not automatically exempt from other Federal excise taxes. If you have any questions about excise, employment, or other Federal taxes, please let us know. Donors may deduct contributions to you as provided in section 170 of the Code. Bequests, legacies, devises, transfers, or gifts to you or for your use are deductible for Federal estate and gift tax purposes if they meet the applicable provisions of sections 2055, 2106, and 2522 of the Code. The box checked in the heading of this letter shows whether you must file Form 990, Return of Organization Exempt from Income Tax. If Yes is checked, you are required to file Form 990 only if your gross receipts each year are normally more than $25,000. If a return is required, it must be filed by the 15th day of the fifth month after the end of your annual accounting period. The law imposes a penalty of $10 a day, up to a maximum of $5,000, when a return is filed late, unless there is reasonable cause for the delay. P. 0. Box 1055, Atlanta, GA 30370 (over) Letter 947(DO) (Rev. 10-83 A� i® CERTIFICATE OF LIABILITY INSURANCE 6;2;;202/4 Y) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Lancaster Insurance 510 Druid Rd E., Ste. #CA P 0 Box 2856 Clearwater FL 33757 NACAMEACT Sherry Wilt PHONE.).Ext). (727) 461-3704 FAX No): (727) 441-3298 CRESS: Sherry@lancins . corn INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Southern–Owners Insurance 10190 INSURED Clearwater Historical Society Inc P 0 Box 175 Clearwater FL 33757-0175 INSURER B : 20 954 975 INSURER C : 8/7/2029 INSURER D : $ 1,000,000 INSURER E : $ 50,000 INSURERF: COVERAGES CERTIFICATE NUMBER:CL148707469 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF (MMIDD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY X 20 954 975 8/7/2023 8/7/2029 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 50,000 CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: 371 POLICY n FCT n LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS SCHEDULED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB — OCCUR CLAIMS -MADE • EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N /A WC STATU- TORY LIMITS OTH- ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, AddlUonal Remarks Schedule, if more space is required) The certifcate holder is listed as additional insured with respect to the general liability insurance. 610 S Fort Harrison Ave Clearwater, FL 33757-0175 1380 South Martin Luther King Ave Clearwater, FL 33756 CERTIFICATE HOLDER CANCELLATION clearwaterhistory@gmail . corn City of Clearwater 100 S. Myrtle Ave. Clearwater, FL 33756 I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WRH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Sherry Wilt/SLW 47644 ACORD 25 (2010/05) INS025 (201005).01 © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CLHS 02/27/2023 3:43 PM Form 990 Department of the Treasury Internal Revenue Service A B ❑ Name Chang ❑ Initial return ri Final return/ LJ terminated ❑ Amended return ❑ Application pending Return of Organization Exempt From Income Tax Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private foundations) ► Do not enter social security numbers on this form as it may be made public. ► Go to www.irs.gov/Form990 for instructions and the latest information. For the 2021 calendar year, or tax year beginning 11/01/21 , and ending 10/31/22 Check if applicable: Address chane C Name of organization Clea ter Historical Socie ilea oinybk_. mail is it d 'livered ya stm t i •idret City or town, state or province, country, and ZIP or foreign postal code Clearwater FL 33757 Inc OMB No. 1545-0047 2021 Open to Public Inspection Wm/suite D Employer identification number G Gross receipts$ 119,864 F Name and address of principal officer. Allison Dolan P 0 Box 175 Clearwater FL 33757 Tax-exempt status: [J 501(c)(3) ❑ 501(c) ( ) 4 (insert no.) ❑ 4947(a)(1) or • webske:► clearwaterhistoricalsociety.org K Form of organization: 01 Corporation D Trust ❑ Association ❑ Other ► ❑ 527 H(a) Is this a group return for subordinates?❑ Yes a No H(b) Are all subordinates included? ❑ Yes ❑ No If "No," attach a list. See instructions H(c) Group exemption number ► L Year of formation: 1979 M State of legal domicile: FL Part! : Summary Activities & Governance I Briefly describe the organization's mission or most significant activities: To preserve the collection of artifacts, relics and documents relating the history of the City of Clearwater and to operate the museum for to those archives. 2 Check this box ►❑ if the organization discontinued its operations or disposed of more than 25% of its net assets. 3 Number of voting members of the governing body (Part VI, line la) 4 Number of independent voting members of the goveming body (Part VI, line 1 b) 5 Total number of individuals employed in calendar year 2021 (Part V, line 2a) 6 Total number of volunteers (estimate if necessary) 7a Total unrelated business revenue from Part VIII, column (C), line 12 b Net unrelated business taxable income from Form 990-T, Part I, line 11 access 3 to 9 4 9 5 0 6 50 7a 0 7b 0 Revenue l 8 Contributions and grants (Part VIII, line 1h) 9 Program service revenue (Part VIII, line 2g) 10 Investment income (Part VIII, column (A), lines 3, 4, and 7d) 11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 12 Total revenue — add lines 8 through 11 (must equal Part VIII, column (A), line 12) Prior Year Current Year 65,871 94,466 25,473 25,386 13 12 0 91,357 119,864 Expenses 13 Grants and similar amounts paid (Part IX, column (A), lines 1-3) 14 Benefits paid to or for members (Part IX, column (A), line 4) 15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5-10) 16a Professional fundraising fees (Part IX, column (A), line 11e) b Total fundraising expenses (Part IX, column (D), line 25) ► 5,000 17 Other expenses (Part IX, column (A), lines 11a -11d, 11f -24e) 18 Total expenses. Add lines 13-17 (must equal Part IX, column (A), line 25) 19 Revenue less expenses. Subtract line 18 from line 12 0 0 0 4,500 5,000 156,610 109,087 161,110 114,087 —69 , 753 5,777 (Net Assets or Fund Balance 20 Total assets (Part X, line 16) 21 Total liabilities (Part X, line 26) 22 Net assets or fund balances. Subtract line 21 from line 20 Beginning of Current Year End of Year 485,695 411,995 1,193 1, 242 484,502 410,753 Part H Signature Block 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 officer) is based on all information of which preparer has any knowledge. Sign Here Signature of officer Allison Dolan President Date Type or print name and title Paid Preparer Use Only Print/Type preparer's name Preparers signature Date Check 11 if self-employed PTIN Firm's name ► This tax return Firm's EIN ► prepared by a Firm's address ► non -paid preparer. Phone no. May the IRS discuss this retum with the preparer shown above? See instructions For Paperwork Reduction Act Notice, see the separate instructions. DAA nYes nNo Form 990 (2021) CLHS 02/27/2023 3:43 PM Form 990 (2021) Clearwater Historical Society, Inc 59-1938824 Page 2 Part 111 Statement of Program Service Accomplishments Check if Schedule 0 contains a response or note to any line in this Part III 0 1 Briefly describe the organization's mission: The Mission of the Clearwater Historical Society is to Educate, Collect, Pres E • d Pr mo a the Peoplea pure and is of Clea t. 2 Did the organization undertake any significant program services &ring the year which were not listed on the prior Form 990 or 990 -EZ? Yes 0 No If "Yes," describe these new services on Schedule O. 3 Did the organization cease conducting, or make significant changes in how it conducts, any program services? Yes No If "Yes," describe these changes on Schedule O. 4 Describe the organization's program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported. 4a (Code: ) (Expenses $ 59,496 including grants of $ ) (Revenue $ ) Catalog & maintain security of historic artifacts & collections and to display the collection at the Clearwater Museum at the former site of the South Ward School complex. 4b (Code: ) (Expenses $ 6, 007 including grants of $ ) (Revenue $ Maintenance and operations of the historice 19th century Plumb House. 4c (Code: N/A (Expenses $ including grants of $ ) (Revenue $ 4d Other program services (Describe on Schedule 0.) (Expenses $ including grants of $ (Revenue $ 4e Total program service expenses ► 65,503 CAA Form 990 (2021) CLHS 02/27/2023 3:43 PM Fomi 990 (2021) Clearwater Historical Society, Inc 59-1938824 Part IV Checklist of Required Schedules Pa•e 3 1 2 3 Is the organization described in complete Schedule A Is the .. t n req r • toy Did the candid. '- section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If "Yes," pl ...- Scheduche ndirect s for i . 1 , s, -; plete 4 Section 501(c)(3) organizations. Did the organization engage lobbying activities, or have a section 501(h) election in effect during the tax year? If "Yes," complete Schedule C, Part II 5 Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Rev. Proc. 98-19? If "Yes," complete Schedule C, Part Ill 6 Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If "Yes," complete Schedule D, Part I 7 Did the organization receive or hold a conservation easement, including easements to preserve open space, the environment, historic land areas, or historic structures? If "Yes," complete Schedule D, Part Il 8 Did the organization maintain collections of works of art, historical treasures, or other similar assets? If "Yes," complete Schedule D, Part Ill 9 Did the organization report an amount in Part X, line 21, for escrow or custodial account liability, serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If "Yes," complete Schedule D, Part IV 10 Did the organization, directly or through a related organization, hold assets in donor -restricted endowments or in quasi endowments? If "Yes," complete Schedule D, Part V 11 If the organization's answer to any of the following questions is "Yes," then complete Schedule D, Parts VI, VII, VIII, IX, or X, as applicable. a Did the organization report an amount for land, buildings, and equipment in Part X, line 10? If "Yes," complete Schedule D, Part VI b Did the organization report an amount for investments—other securities in Part X, line 12, that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part VII c Did the organization report an amount for investments—program related in Part X, line 13, that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part VIII d Did the organization report an amount for other assets in Part X, line 15, that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part IX e Did the organization report an amount for other liabilities in Part X, line 25? If "Yes," complete Schedule D, Part X f Did the organization's separate or consolidated financial statements for the tax year include a footnote that addresses the organization's liability for uncertain tax positions under FIN 48 (ASC 740)? If "Yes," complete Schedule D, Part X X 12a Did the organization obtain separate, independent audited financial statements for the tax year? If "Yes," complete Schedule D, Parts XI and XII X b Was the organization included in consolidated, independent audited financial statements for the tax year? If "Yes," and if the organization answered "No" to line 12a, then completing Schedule D, Parts XI and XII is optional 12b X 13 Is the organization a school described in section 170(b)(1)(A)(ii)? If "Yes," complete Schedule E 13 X 14a Did the organization maintain an office, employees, or agents outside of the United States? 14a X b Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States, or aggregate foreign investments valued at $100,000 or more? If "Yes," complete Schedule F, Parts I and IV 14b X 15 Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or other assistance to or Yes No 1 X 2 X X 4 X 5 X 6 X 7 X 8 X 9 X 10 11a X 11b X 11c X 11d 11e X X 11f 12a for any foreign organization? If "Yes," complete Schedule F, Parts II and IV 15 X 16 Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or other assistance to or for foreign individuals? If "Yes," complete Schedule F, Parts III and IV 16 X 17 Did the organization report a total of more than $15,000 of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If "Yes," complete Schedule G, Part I. See instructions 17 X 18 Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If "Yes," complete Schedule G, Part ll 18 X 19 Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If "Yes," complete Schedule G, Part III 19 X 20a Did the organization operate one or more hospital facilities? If `Yes," complete Schedule H 20a X b If "Yes" to line 20a, did the organization attach a copy of its audited financial statements to this return? 21 Did the organization report more than $5,000 of grants or other assistance to any domestic organization or domestic government on Part IX, column (A), line 1? If `Yes," complete Schedule I, Parts I and II 20b 21 DAA X Form 990 (2021) CLHS 02/27/2023 3:43 PM Form 990 (2021) Clearwater Historical Society, Inc 59-1938824 Part IV Checklist of Required Schedules (continued) Page 4 22 Did the organization report more than $5,000 of grants or other assistance to or for domestic individuals on Part IX, column (A), line 2? If "Yes," complete Schedule I, Parts I and III 22 X Yes No 23 Did the ationa u r'' s to rt VII, S organiz employ ''s? If , direct J ion A. lin cornoen�tion ortne 24a Did the organization have a tax-exempt bond issue with an outstllhding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If "Yes," answer lines 24b through 24d and complete Schedule K. If "No," go to line 25a b Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception? c Did the organization maintain an escrow account other than a refunding escrow at any time during the year to defease any tax-exempt bonds? d Did the organization act as an "on behalf of issuer for bonds outstanding at any time during the year? 25a Section 501(c)(3), 501(c)(4), and 501(c)(29) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If "Yes," complete Schedule L, Part I b Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization's prior Forms 990 or 990 -EZ? If "Yes," complete Schedule L, Part I p 26 Did the organization report any amount on Part X, line 5 or 22, for receivables from or payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons? If "Yes," complete Schedule L, Part 11 27 Did the organization provide a grant or other assistance to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity (including an employee thereof) or family member of any of these persons? If "Yes," complete Schedule L, Part Ill 28 Was the organization a party to a business transaction with one of the following parties (see the Schedule L, Part IV, instructions for applicable filing thresholds, conditions, and exceptions): a A current or former officer, director, trustee, key employee, creator or founder, or substantial contributor? If "Yes," complete Schedule L, Part IV b A family member of any individual described in line 28a? If "Yes," complete Schedule L, Part IV c A 35% controlled entity of one or more individuals and/or organizations described in line 28a or 28b? If "Yes," complete Schedule L, Part IV 29 Did the organization receive more than $25,000 in non-cash contributions? If "Yes," complete Schedule M 30 Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If "Yes," complete Schedule M 31 Did the organization liquidate, terminate, or dissolve and cease operations? If "Yes," complete Schedule N, Part I 32 Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If "Yes," complete Schedule N, Part ll 33 Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If Wes," complete Schedule R, Part I 34 Was the organization related to any tax-exempt or taxable entity? If "Yes," complete Schedule R, Part II, Ill, or IV, and Part V, line 1 35a Did the organization have a controlled entity within the meaning of section 512(b)(13)? b If "Yes" to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If "Yes," complete Schedule R, Part V, line 2 36 Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non -charitable related organization? If "Yes," complete Schedule R, Part V, line 2 37 Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If "Yes," complete Schedule R, Part VI 38 Did the organization complete Schedule 0 and provide explanations on Schedule 0 for Part VI, lines 11 b and 19? Note: All Form 990 filers are required to complete Schedule O. Part V Statements Regarding Other IRS Filings and Tax Compliance Check if Schedule 0 contains a response or note to any line in this Part V Y 24a X X 24b 24c 24d 25a X 25b X 26 X 27 28a X 28b X 28c X 29 X 30 X 31 X 32 X 33 X 34 X 35a X 35b 36 X 37 X 38 X 1 a Enter the number reported in box 3 of Form 1096. Enter -0- if not applicable b Enter the number of Forms W -2G included on line 1a. Enter -0- if not applicable c Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? DAA Yes 1a 1b 1c X Form 990 (2021) CLI -IS 02/27/2023 3:43 PM Form 990 (2021) Clearwater Historical Society Inc 59-1938824 Part V Statements Regarding Other IRS Filings and Tax Compliance (continued 2a Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax Statements, filed for the calendar year ending with or within the year covered by this return 2a I 0 b If at least one is reported on line 2a, did the organization file all required federal employment tax returns? Note: of Vin:. a a a i . reater th 25yo ayb-requi ;d to ea a in. actio 3a Did th b If "Yes, has it ess g year? Pa.e 5 Yes No 4a At any time during the calendar year, did the organization have interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account, securities account, or other financial account)? b If "Yes," enter the name of the foreign country ► See instructions for filing requirements for FinCEN Form 114, Report of Foreign Bank and Financial Accounts (FBAR). 5a Was the organization a party to a prohibited tax shelter transaction at any time during the tax year? b Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction? c If "Yes" to line 5a or 5b, did the organization file Form 8886-T? 6a Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible as charitable contributions? b If "Yes," did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible? 7 Organizations that may receive deductible contributions under section 170(c). a Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor? b If "Yes," did the organization notify the donor of the value of the goods or services provided? c Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282? d If "Yes," indicate the number of Forms 8282 filed during the year I 7d 2b 4a 5a 5b 5c 6a X 6b 7a 7b 7c e Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract? f Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract? g If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required? h If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C? 8 Sponsoring organizations maintaining donor advised funds. Did a donor advised fund maintained by the sponsoring organization have excess business holdings at any time during the year? 9 Sponsoring organizations maintaining donor advised funds. a Did the sponsoring organization make any taxable distributions under section 4966? b Did the sponsoring organization make a distribution to a donor, donor advisor, or related person? 10 Section 501(c)(7) organizations. Enter: a Initiation fees and capital contributions included on Part VIII, line 12 110a b Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities 10b 7e 7f 7g 7h 8 9a 9b 11 Section 501(c)(12) organizations. Enter: a Gross income from members or shareholders 11a b Gross income from other sources. (Do not net amounts due or paid to other sources against amounts due or received from them.) 11b 12a Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041? b If "Yes," enter the amount of tax-exempt interest received or accrued during the year 12b 13 Section 501(c)(29) qualified nonprofit health insurance issuers. a Is the organization licensed to issue qualified health plans in more than one state? 12a Note: See the instructions for additional information the organization must report on Schedule 0. b Enter the amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans c Enter the amount of reserves on hand 13b 13a 13c 14a Did the organization receive any payments for indoor tanning services during the tax year? b If "Yes," has it filed a Form 720 to report these payments? If "No," provide an explanation on Schedule 0 15 Is the organization subject to the section 4960 tax on payment(s) of more than $1,000,000 in remuneration or excess parachute payment(s) during the year? If "Yes," see instructions and file Form 4720, Schedule N. 16 Is the organization an educational institution subject to the section 4968 excise tax on net investment income? If "Yes," complete Form 4720, Schedule 0. 17 Section 501(c)(21) organizations. Did the trust, any disqualified person, or mine operator engage in activities that would result in the imposition of an excise tax under section 4951, 4952 or 4953? If "Yes," complete Form 6069. 14a X 14b 15 16 17 DAA Form 990 (2021) CLHS 02/27/2023 3:43 PM Form 990 (2021) Clearwater Historical Society, Inc 59-1938824 Part VI Governance, Management, and Disclosure For each 'Yes" response to lines 2 through 7b below, and for a "No" response to line 8a, 8b, or 10b below, describe the circumstances, processes, or changes on Schedule 0. See instructions. Check if Schedule 0 contains a response or note to any line in this Part VI Section A. Governing Body and Management Page 6 1 a Enter t b o Pez:taspe�t ri iif the governing body delegated broad authority to an executivettee or similar committee, explain on Schedule O. b Enter the number of voting members included on line 1a, above, who are independent 2 Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? 3 Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors, trustees, or key employees to a management company or other person? 4 Did the organization make any significant changes to its governing documents since the prior Form 990 was filed? 5 Did the organization become aware during the year of a significant diversion of the organization's assets? 6 Did the organization have members or stockholders? 7a Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? b Are any govemance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? 8 Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following: a The governing body? b Each committee with authority to act on behalf of the governing body? 9 Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization's mailing address? If "Yes," provide the names and addresses on Schedule 0 1b 9 p Yes 2 3 4 5 6 7a X 7b 8a X 8b X 9 X Section B. Policies (This Section B requests information about policies not required by the Internal Revenue Code. 10a Did the organization have local chapters, branches, or affiliates? b If "Yes," did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes? 11a Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form? b Describe on Schedule 0 the process, if any, used by the organization to review this Form 990. 12a Did the organization have a written conflict of interest policy? If Wo," go to line 13 b Were officers, directors, or trustees, and key employees required to disclose annually interests that could give rise to conflicts? c Did the organization regularly and consistently monitor and enforce compliance with the policy? If "Yes," describe on Schedule 0 how this was done 13 Did the organization have a written whistleblower policy? 14 Did the organization have a written document retention and destruction policy? 15 Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision? a The organization's CEO, Executive Director, or top management official b Other officers or key employees of the organization If "Yes" to line 15a or 15b, describe the process on Schedule O. See instructions. 16a Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? b If "Yes," did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization's exempt status with respect to such arrangements? Section C. Disclosure Yes 10a No X 10b 1 1 a 12a X 12b X 12c X X 13 14 15a 15b 16a 16b 17 List the states with which a copy of this Form 990 is required to be filed ► FL 18 Section 6104 requires an organization to make its Forms 1023 (1024 or 1024-A, if applicable), 990, and 990-T (section 501(c) (3)s only) available for public inspection. Indicate how you made these available. Check all that apply. El Own website OX Another's website ❑X Upon request Other (explain on Schedule 0) 19 Describe on Schedule 0 whether (and if so, how) the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year. 20 State the name, address, and telephone number of the person who possesses the organization's books and records ► Allison Dolan P O Box 175 Clearwater FL 33757 727-754-8019 DAA Form 990 (2021) CLHS 02/27/2023 3:43 PM Fomt 990 (2021) Clearwater Historical Society Inc 59-1938824 Page 7 Part VII Compensation of Officers, Directors, Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors Check if Schedule 0 contains a response or note to any line in this Part VII ❑ Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees 1 a Complete y ag for al peso %qu' d to be Ite repo co • - satio for tn r r e, •;. • with or organization' • List all the o f o rs, dies, ee t yn i a . ), gardles compensation. Enter - - In co umns , ( , and (F) no compensatiwas pal . • List all of the organization's current key employees, if any. See instructions for definition of "key employee." • List the organization's five current highest compensated employees (other than an officer, director, trustee, or key employee) who received reportable compensation (box 5 of Form W-2, Form 1099-MISC, and/or box 1 of Form 1099 -NEC) of more than $100,000 from the organization and any related organizations. • List all of the organization's former officers, key employees, and highest compensated employees who received more than $100,000 of reportable compensation from the organization and any related organizations. • List all of the organization's former directors or trustees that received, in the capacity as a former director or trustee of the organization, more than $10,000 of reportable compensation from the organization and any related organizations. See the instructions for the order in which to list the persons above. J unecK tris oox it nelmer me organization nor any reiatea organization compensate° any current °nicer, arrector, or trustee. (A) Name and title (B) Average hours per week (list any hours for related organizations below dotted line) (c) Position (do not check more than one box unless person is both an officerand a directorttrustee) (D) Reportable compensation from the organization (W-2/ 1099-MISC/ 1099 -NEC) (E) Reportable compensation from related organizations (W-2/ 1099-MISC/ 1099 -NEC) (F) Estimated amount of other compensation from the organization and related organizations [Individual trustee or director Institutional trustee Officer Key employee Highest compensated employee Former (1)Allison Dolan President 0.00 0.00 X X 0 0 0 (2) Suz Priest Treasurer 0.00 0.00 X X 0 0 0 (3) Jeanne Holmquist Secretary 0.00 0.00 X X 0 0 0 (4)William Wallace Past President0.00 0.00 X 0 0 0 (5) Elizabeth Childress Director 0.00 0.00 X 0 0 0 (6) Jerry Coltman Director 0.00 0.00 X 0 0 0 (7) Lila Grant Director 0.00 0.00 X 0 0 0 (a)Susan Raineri Director 0.00 0.00 X 0 0 0 (9)Dean Robinson Director 0.00 0.00 X 0 0 0 (10) (11) Form `.!`Ju (2021) DAA CLHS 02/27/2023 3:43 PM Form 990 (2021) Clearwater Historical Society, Inc 59-1938824 Part VII Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued) Page 8 (A) Name and title (B) Average hours per week (list any fated ns dotted line) (C) Position (do not check more than one box, unless person is both an officer and a director/trustee) N N a 8 2 CD M a - (D) Reportable compensation from the organ' n -2/ (E) Reportable compensation from related organizetj 10 109 (F) Estimated amount of other compensation from the pyn and nizations lb Subtotal c Total from continuation sheets to Part VII, Section A d Total (add lines lb and 1c). 2 Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organization ► 0 ► ► 3 Did the organization list any former officer, director, trustee, key employee, or highest compensated employee on line 1 a? If "Yes," complete Schedule J for such individual 4 For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If "Yes," complete Schedule J for such individual 5 Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If "Yes," complete Schedule J for such person Yes 3 4 5 Section B. Independent Contractors 1 Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization's tax year. (A)(B) Name and business address Descriptin ofoervices Compensation 2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization ► 0 DAA Form 990 (2021) CLHS 02/27/2023 3:43 PM Form 990 (2021) Clearwater Historical Society, Inc 59-1938824 Part VIII Statement of Revenue Check if Schedule 0 contains a response or note to any line in this Part VIII Page 9 Form 990 (2021) DAA i s 1a (A) Total revenue ection (B) Related or exempt function revenue (C) Unrelated business revenue op (D) Revenue excluded from tax under sections 512-514 Contributions, Gifts, GrantS and Other Similar Amount 1a F m b Me bershi lb c Fundraising events d Related organizations e Government grants (contributions) f All other contributions, gifts, grants, and similar amounts not included above g Noncash contributions included in linesla-1f h Total. Add lines la -1f 1c 94,466 1d 1e 24,900 1f 64,946 1g $ 4,355 ► Pro ram Service Revenue 2a . Exhibtion —Sponsors b Museum Admissions c d e f All other program service revenue g Total. Add lines 2a -2f Business Code 23,204 23,204 2,182 2,182 ► 25,386 Other Revenue 3 Investment income (including dividends, interest, and other similar amounts) ► 4 Income from investment of tax-exempt bond proceeds ► 5 Royalties ► 12 12 6a Gross rents b Less: rental expenses C Rental inc. or (loss) d Net rental income 7a Gross amount from sales of assets other than inventory b Less: cost or other basis and sales exps. c Gain or (loss) d Net gain or (loss) 8a Gross income from (not including $ of contributions reported 1c). See Part IV, line b Less: direct expenses c Net income or (loss) 9a Gross income from activities. See Part b Less: direct expenses c Net income or (loss) 10a Gross sales of inventory, retums and allowances b Less: cost of goods c Net income or (loss) 6a (i) Real (ii) Personal 6b 6C or (oss) ► 7a (i) Securities (ii) Other 7b 7c fundraising events on line 18 from fundraising gaming IV, line 19 from gaming activities less sold from sales of inventory ► 8a 8b events ► 9a 9b ► 10a 10b ► Miscellaneous Revenue 11a b c d All other revenue e Total. Add lines 11 a-11 d Business Code ► 12 Total revenue. See instructions ► 119,864 0 0 25,398 Form 990 (2021) DAA CLHS 02/27/2023 3:43 PM Form 990 (2021) Clearwater Historical Society, Inc 59-1938824 Part IX. Statement of Functional Expenses Page 10 Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A). Check if Schedule 0 contains a resp onse or note to any line in this Part IX Do not include amounts reported on lines 6b, 7b 8b, 9b, and jRt `:` 'art VII 1 Grants a 'ons and do c govern - , e 2 Grants and other assistance to domestic individuals. See Part IV, line 22 3 Grants and other assistance to foreign organizations, foreign governments, and foreign individuals. See Part IV, lines 15 and 16 4 Benefits paid to or for members 5 Compensation of current officers, directors, trustees, and key employees 6 Compensation not induded above to disqualified persons (as defined under section 4958(0(1)) and persons described in section 4958(c)(3)(B) 7 Other salaries and wages 8 Pension plan accruals and contributions (indude section 401(k) and 403(b) employer contributions) 9 Other employee benefits 10 Payroll taxes 11 Fees for services (nonemployees): a Management b Legal c Accounting d Lobbying e Professional fundraising services. See Part IV, line 17 f Investment management fees g Other. (If line 11g amount exceeds 10% of line 25, column (A) amount, list fne 11g expenses on Schedule 0.) 12 Advertising and promotion 13 Office expenses 14 Information technology 15 Royalties 16 Occupancy 17 Travel 18 Payments of travel or entertainment expenses for any federal, state, or local public officials 19 Conferences, conventions, and meetings 20 Interest 21 Payments to affiliates 22 Depreciation, depletion, and amortization 23 Insurance 24 Other expenses. Itemize expenses not covered above (List miscellaneous expenses on line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule 0.) a Museum Exhibits b Women's History Exhibit c Museum Special Events d Volunteer Appreciation e All other expenses 25 Total functional expenses. Add lines 1 through 24e „ , 26 Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign d fundraising solicitation. Check here ► if following SOP 98-2 (ASC 958-720) (A) Total expenses nsp (B) ecThoProgram (C) Managem d general n (D) Fundraising expenses 13,000 13,000 5,171 5,171 5,000 5,000 1,229 1,229 10,563 5,581 4,982 1,714 1,714 52,595 33,451 19,144 2,573 1,286 1,287 12,916 12,916 7,490 7,490 869 869 633 633 334 334 114,087 65,503 43,584 5,000 DAA Form 990 (2021) CLHS 02/27/2023 3:43 PM Form 990 (2021) Clearwater Historical Society, Inc 59-1938824 Part X Balance Sheet Page 11 Form 990 (2021) DAA (A) Beginning of year (B) End of year Assets 1 Ca -inters n 2 Sa n to i es ants 3 PI es an i 4 Accounts receivable, net 5 Loans and other receivables from any current or former trustee, key employee, creator or founder, substantial contributor, controlled entity or family member of any of these persons 6 Loans and other receivables from other disqualified persons under section 4958(f)(1)), and persons described in section 7 Notes and loans receivable, net 8 Inventories for sale or use 9 Prepaid expenses and deferred charges 10a Land, buildings, and equipment cost or other basis. Complete Part VI of Schedule D b Less: accumulated depredation 11 Investments—publicly traded securities 12 Investments—other securities. See Part IV, line 11 13 Investments—program-related. See Part IV, line 11 14 Intangible assets 15 Other assets. See Part IV, line 11 16 Total assets. Add lines 1 through 15 (must equal line 33) officer, (as 4958(c)(3)(B) 10a director, or 35% defined 614,888 18 15,822 on 79€3b 8,367 4 5 6 7 8 1,000 9 850 386,482 1oc 316, 956 lob 297,932 11 12 13 14 15 485,695 16 411, 995 e R —J 17 Accounts payable and accrued expenses 18 Grants payable 19 Deferred revenue 20 Tax-exempt bond liabilities 21 Escrow or custodial account liability. Complete Part IV of Schedule 22 Loans and other payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, controlled entity or family member of any of these persons 23 Secured mortgages and notes payable to unrelated third parties 24 Unsecured notes and loans payable to unrelated third parties 25 Other liabilities (including federal income tax, payables to related parties, and other liabilities not included on lines 17-24). Complete of Schedule D 26 Total liabilities. Add lines 17 through 25 D or 35% third Part X 9 17 1,242 18 1,184 19 20 21 22 23 24 25 1,193 26 11242 Net Assets or Fund Balances Organizations that follow FASB ASC 958, check here ON and complete lines 27, 28, 32, and 33. 27 Net assets without donor restrictions 28 Net assets with donor restrictions Organizations that do not follow FASB ASC 958, check here and complete lines 29 through 33. 29 Capital stock or trust principal, or current funds 30 Paid -in or capital surplus, or land, building, or equipment fund 31 Retained eamings, endowment, accumulated income, or other 32 Total net assets or fund balances 33 Total liabilities and net assets/fund balances ► funds 484,502 27 410,753 28 29 30 31 484,502 32 410,753 485,695 33 411, 995 Form 990 (2021) DAA CLI -IS 02/27/2023 3:43 PM Form 990 (2021) Clearwater Historical Society, Inc 59-1938824 Part XI Reconciliation of Net Assets Check if Schedule 0 contains a response or note to an y Page 12 line in this Part XI 1 Total revenue (must equal Part VIII, column (A), line 12) 2 Total expenses (must equal Part IX, column (A), line 25) 3 Reven '' a ensu ubt cif lin from lin 1 4 Net as b� nin of yea 5 Net un alized (I ) n n ents 6 Donated services and use of facilities 7 Investment expenses 8 Prior period adjustments 9 Other changes in net assets or fund balances (explain on Schedule 0) 10 Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 32, column (B)) Part XII Financial Statements and Reporting Check if Schedule 0 contains a response or note to an y line in this Part XII 1 2 119 864 114 087 5,777 ply4 4,502 6 7 8 9 -10 000 -69,526 10 410,753 1 Accounting method used to prepare the Form 990: El Cash a Accrual El Other If the organization changed its method of accounting from a prior year or checked "Other," explain on Schedule O. 2a Were the organization's financial statements compiled or reviewed by an independent accountant? If "Yes," check a box below to indicate whether the financial statements for the year were compiled or reviewed on a separate basis, consolidated basis, or both: ElSeparate basis ❑ Consolidated basis Both consolidated and separate basis b Were the organization's financial statements audited by an independent accountant? If "Yes," check a box below to indicate whether the financial statements for the year were audited on a separate basis, consolidated basis, or both: ❑ Separate basis ❑ Consolidated basis ❑ Both consolidated and separate basis c If "Yes" to line 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant? If the organization changed either its oversight process or selection process during the tax year, explain on Schedule O. 3a As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133? b If "Yes," did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why on Schedule 0 and describe any steps taken to undergo such audits Yes 2a 2b 2c 3a 3b Form 990 (2021) DAA CLI -IS 02/27/2023 3:43 PM SCHEDULE A (Form 990) Department of the Treasury Internal Revenue Service Public Charity Status and Public Support Complete If the organization Is a section 501(c)(3) organization or a section 4947(a)(1) nonexempt charitable trust. ► Attach to Form 990 or Form 990 -EZ. ► Go to www.irs.gov/Form990 for instructions and the latest information. OMB No. 1545-0047 2021 Open to Public Inspection Name of the o Part I ',` Rea f I rity St( The organization is not a private foundation because it is: (For lines 1 rough 12, check only one box.) e Hi fhlipart.) mp 59 r call n mbar • 2 1 A church, convention of churches, or association of churches described in section 170(b)(1)(A)(i). 2 A school described in section 170(b)(1)(A)(ii). (Attach Schedule E (Form 990).) 3 A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii). 4 A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the hospital's name, city, and state: 5 0 An organization operated for the benefit of a college or university owned or operated by a governmental unit described in section 170(b)(1)(A)(iv). (Complete Part II.) 6 _ A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v). 7 _ An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 170(b)(1)(A)(vi). (Complete Part II.) 8 _ A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.) 9 ` An agricultural research organization described in section 170(b)(1)(A)(ix) operated in conjunction with a land-grant college or university or a non -land-grant college of agriculture (see instructions). Enter the name, city, and state of the college or university: 10 0 An organization that normally receives (1) more than 33 1/3% of its support from contributions, membership fees, and gross receipts from activities related to its exempt functions, subject to certain exceptions; and (2) no more than 331/3% of its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part Ill.) 11 _ An organization organized and operated exclusively to test for public safety. See section 509(a)(4). 12 _ An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box on lines 12a through 12d that describes the type of supporting organization and complete lines 12e, 12f, and 12g. a 0 Type I. A supporting organization operated, supervised, or controlled by its supported organization(s), typically by giving the supported organization(s) the power to regularly appoint or elect a majority of the directors or trustees of the supporting organization. You must complete Part IV, Sections A and B. b 0 Type II. A supporting organization supervised or controlled in connection with its supported organization(s), by having control or management of the supporting organization vested in the same persons that control or manage the supported organization(s). You must complete Part IV, Sections A and C. c 0 Type III functionally integrated. A supporting organization operated in connection with, and functionally integrated with, its supported organization(s) (see instructions). You must complete Part IV, Sections A, D, and E. d 0 Type III non functionally integrated. A supporting organization operated in connection with its supported organization(s) that is not functionally integrated. The organization generally must satisfy a distribution requirement and an attentiveness requirement (see instructions). You must complete Part IV, Sections A and D, and Part V. e 0 Check this box if the organization received a written determination from the IRS that it is a Type I, Type II, Type III functionally integrated, or Type III non -functionally integrated supporting organization. Enter the number of supported organizations f g Provide the following information about the supported organization(s). (I) Name of supported organization (II) EIN (Ill) 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 (A) (B) (C) (D) (E) Total For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990 -EZ. DAA Schedule A (Form 990) 2021 CLHS 02/27/2023 3:43 PM Schedule A (Form 990) 2021 Clearwater Historical Society, Inc 59-1938824 Page 2 Part II Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.) Section A. Public Support Calendar year • I year eginni gin) ► 1 Gifts ants ceitri t ns,' inti memb hip fe . (C1b hof include any "unusual grants.") 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 ) 2017 b 2018 ( 2019 d) 2020 (e 2021 f) Total Section B. Total Support Calendar year (or fiscal year beginning in) ► 7 Amounts from line 4 8 Gross income from interest, dividends, payments received on securities loans, rents, royalties, and income from similar sources (a) 2017 (b) 2018 (c) 2019 (d) 2020 (e) 2021 (f) Total 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 12 Gross receipts from related activities, etc. (see instructions) 13 12 First 5 years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization, check this box and stop here ► I I Section C. Computation of Public Support Percentage 14 Public support percentage for 2021 (line 6, column (f) divided by line 11, column (f)) 15 Public support percentage from 2020 Schedule A, Part II, line 14 16a 33 1/3% support test -2021. If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box and stop here. The organization qualifies as a publicly supported organization ► b 33 1/3% support test -2020. If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this box and stop here. The organization qualifies as a publicly supported organization ► ❑ 17a 10% -facts -and -circumstances test -2021. If the organization did not check a box on line 13, 16a, or 16b, and line 14 is 10% or more, and if the organization meets the facts -and -circumstances test, check this box and stop here. Explain in Part VI how the organization meets the facts -and -circumstances test. The organization qualifies as a publicly supported organization ► ❑ b 10% -facts -and -circumstances test -2020. If the organization did not check a box on line 13, 16a, 16b, or 17a, and line 15 is 10% or more, and if the organization meets the facts -and -circumstances test, check this box and stop here. Explain in Part VI how the organization meets the facts -and -circumstances test. The organization qualifies as a publicly supported organization ► 18 Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see instructions ► 14 15 Ok Schedule A (Form 990) 2021 DAA CLI -IS 02/27/2023 3:43 PM Schedule A (Form 990) 2021 Clearwater Historical Society, Inc 59-1938824 Page 3 Part HI Support Schedule for Organizations Described in Section 509(a)(2) (Complete only if you checked the box on line 10 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.) Section A. Public Support Calendar yea 1 year inni �'h) ► 1 Gifts, gra P <n receiveda not in e n °' a � .�,,.,. 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 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 7a Amounts included on lines 1, 2, and 3 received from disqualified persons b Amounts induded 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 c Add lines 7a and 7b 8 Public support. (Subtract line 7c from line 6.) ) 2017 (b 2018 2 19 (d) 2020 l ' (e) 2021 (f) Total 38 yea.,__. 1 .. •_ '357 ;{...-:� p .: " 65, 8 .0 fit- ,,. � I � 479,565 3,964 3,407 7,371 3,407 5,873 25,473 25,386 60,139 142,119 94,311 99,449 91,344 119,852 547,075 547,075 Section B. Total Support Calendar year (or fiscal year beginning in) ► 9 Amounts from line 6 10a Gross income from interest, dividends, payments received on securities loans, rents, royalties, and income from similar sources b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975 c Add lines 10a and 10b 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.) (a) 2017 (b) 2018 (c) 2019 (d) 2020 (e) 2021 (f) Total 547,075 142,119 94,311 99,449 91,344 119,852 112 13 12 137 112 13 12 137 142,119 94,311 99,561 91,357 119,864 547,212 14 First 5 years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization, check this box and stop here ► Section C. Computation of Public Support Percentage 15 Public support percentage for 2021 (line 8, column (f), divided by line 13, column (f)) 16 Public support percentage from 2020 Schedule A, Part Ill, line 15 15 99.97% 16 99.98% Section D. Computation of Investment Income Percentage 17 Investment income percentage for 2021 (line 10c, column (f), divided by line 13, column (f)) 18 Investment income percentage from 2020 Schedule A, Part Ill, line 17 19a 33 1/3% support tests -2021. If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ► 0 b 33 1/3% support tests -2020. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3%, and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ► ❑ 20 Private foundation. If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions ► ❑ 17 18 Schedule A (Form 990) 2021 DAA CLHS 02/27/2023 3:43 PM Schedule A (Form 990) 2021 Clearwater Historical Society, Inc 59-1938824 Page 4 Part IV Supporting Organizations (Complete only if you checked a box in line 12 on Part I. If you checked box 12a, Part I, complete Sections A and B. If you checked box 12b, Part I, complete Sections A and C. If you checked box 12c, Part I, complete Sections A, D, and E. If you checked box 12d, Part I, complete Sections A and D, and complete Part V. Section Su • • in • ! anization s 1 Are of thei s p organi tit, s l`t a documents? If "No," describe in Part VI how the supported o nizations are designated. If designated by class or purpose, describe the designation. If historic and continuing relationship, explain. 2 Did the organization have any supported organization that does not have an IRS determination of status under section 509(a)(1) or (2)? If "Yes," explain in Part VI how the organization determined that the supported organization was described in section 509(a)(1) or (2). 3a Did the organization have a supported organization described in section 501(c)(4), (5), or (6)? If "Yes," answer lines 3b and 3c below. b Did the organization confirm that each supported organization qualified under section 501(c)(4), (5), or (6) and satisfied the public support tests under section 509(a)(2)? If "Yes," describe in Part VI when and how the organization made the determination. c Did the organization ensure that all support to such organizations was used exclusively for section 170(c)(2)(B) purposes? If "Yes," explain in Part VI what controls the organization put in place to ensure such use. 4a Was any supported organization not organized in the United States ("foreign supported organization")? If "Yes," and if you checked box 12a or 12b in Part I, answer lines 4b and 4c below. b Did the organization have ultimate control and discretion in deciding whether to make grants to the foreign supported organization? If "Yes," describe in Part VI how the organization had such control and discretion despite being controlled or supervised by or in connection with its supported organizations. c Did the organization support any foreign supported organization that does not have an IRS determination under sections 501(c)(3) and 509(a)(1) or (2)? If "Yes," explain in Part VI what controls the organization used to ensure that all support to the foreign supported organization was used exclusively for section 170(c)(2)(B) purposes. 5a Did the organization add, substitute, or remove any supported organizations during the tax year? If "Yes," answer lines 5b and 5c below (if applicable). Also, provide detail in Part VI, including (i) the names and EIN numbers of the supported organizations added, substituted, or removed; (ii) the reasons for each such action; (iii) the authority under the organization's organizing document authorizing such action; and (iv) how the action was accomplished (such as by amendment to the organizing document). b Type I or Type II only. Was any added or substituted supported organization part of a class already designated in the organization's organizing document? c Substitutions only. Was the substitution the result of an event beyond the organization's control? 6 Did the organization provide support (whether in the form of grants or the provision of services or facilities) to anyone other than (i) its supported organizations, (ii) individuals that are part of the charitable class benefited by one or more of its supported organizations, or (iii) other supporting organizations that also support or benefit one or more of the filing organization's supported organizations? If "Yes," provide detail in Part VI. 7 Did the organization provide a grant, loan, compensation, or other similar payment to a substantial contributor (as defined in section 4958(c)(3)(C)), a family member of a substantial contributor, or a 35% controlled entity with regard to a substantial contributor? If "Yes," complete Part I of Schedule L (Form 990). 8 Did the organization make a loan to a disqualified person (as defined in section 4958) not described on line 7? If "Yes," complete Part I of Schedule L (Form 990). 9a Was the organization controlled directly or indirectly at any time during the tax year by one or more disqualified persons, as defined in section 4946 (other than foundation managers and organizations described in section 509(a)(1) or (2))? If "Yes," provide detail in Part VI. b Did one or more disqualified persons (as defined on line 9a) hold a controlling interest in any entity in which the supporting organization had an interest? If "Yes," provide detail in Part VI. c Did a disqualified person (as defined on line 9a) have an ownership interest in, or derive any personal benefit from, assets in which the supporting organization also had an interest? If "Yes," provide detail in Part VI. 10a Was the organization subject to the excess business holdings rules of section 4943 because of section 4943(t) (regarding certain Type II supporting organizations, and all Type III non -functionally integrated supporting organizations)? If "Yes," answer line 10b below. b Did the organization have any excess business holdings in the tax year? (Use Schedule C, Form 4720, to determine whether the organization had excess business holdings.) 2 3a 3b 3c 4a 4b 4c 5a 5b 5c 6 7 8 9a 9b 9c 10a 10b Schedule A (Form 990) 2021 DAA CLHS 02127/2023 3:43 PM Schedule A (Form 990) 2021 Clearwater Historical Society, Inc 59-1938824 Part IV Supporting Organizations (continued) 11 Has the organization accepted a gift or contribution from any of the following persons? a A person who directly or indirectly controls, either alone or together with persons described on lines 11 b and 11c gove i b' of upporte a ' at'- c A 35 cribed n ne 1 b A fa on lin 1 i contro a =`� ■1 provide detail in Part VI. ectionic, Co Page 5 Yes No 1 Section B. Type I Supporting Organizations 1 Did the governing body, members of the governing body, officers acting in their official capacity, or membership of one or more supported organizations have the power to regularly appoint or elect at least a majority of the organization's officers, directors, or trustees at all times during the tax year? If "No," describe in Part VI how the supported organization(s) effectively operated, supervised, or controlled the organization's activities. If the organization had more than one supported organization, describe how the powers to appoint and/or remove officers, directors, or trustees were allocated among the supported organizations and what conditions or restrictions, if any, applied to such powers during the tax year. 2 Did the organization operate for the benefit of any supported organization other than the supported organization(s) that operated, supervised, or controlled the supporting organization? If "Yes," explain in Part VI how providing such benefit carried out the purposes of the supported organization(s) that operated, supervised, or controlled the supporting organization. Yes 1 2 Section C. Type II Supporting Organizations 1 Were a majority of the organization's directors or trustees during the tax year also a majority of the directors or trustees of each of the organization's supported organization(s)? If "No," describe in Part VI how control or management of the supporting organization was vested in the same persons that controlled or managed the supported organization(s). Section D. All Type III Supporting Organizations Yes 1 1 Did the organization provide to each of its supported organizations, by the last day of the fifth month of the organization's tax year, (i) a written notice describing the type and amount of support provided during the prior tax year, (ii) a copy of the Form 990 that was most recently filed as of the date of notification, and (iii) copies of the organization's governing documents in effect on the date of notification, to the extent not previously provided? 2 Were any of the organization's officers, directors, or trustees either (i) appointed or elected by the supported organization(s) or (ii) serving on the governing body of a supported organization? If "No," explain in Part VI how the organization maintained a close and continuous working relationship with the supported organization(s). 3 By reason of the relationship described on line 2, above, did the organization's supported organizations have a significant voice in the organization's investment policies and in directing the use of the organization's income or assets at all times during the tax year? If "Yes," describe in Part VI the role the organization's supported organizations played in this regard. Yes 1 2 3 Section E. Type III Functionally Integrated Supporting Organizations 1 Check the box next to the method that the organization used to satisfy the Integral Part Test during the year (see instructions). a _ The organization satisfied the Activities Test. Complete line 2 below. b _ The organization is the parent of each of its supported organizations. Complete line 3 below. c _ The organization supported a governmental entity. Describe in Part VI how you supported a governmental entity (see instructions). 2 Activities Test. Answer lines 2a and 2b below. a Did substantially all of the organization's activities during the tax year directly further the exempt purposes of the supported organization(s) to which the organization was responsive? If "Yes," then in Part VI identify those supported organizations and explain how these activities directly furthered their exempt purposes, how the organization was responsive to those supported organizations, and how the organization determined that these activities constituted substantially all of its activities. b Did the activities described on line 2a, above, constitute activities that, but for the organization's involvement, one or more of the organization's supported organization(s) would have been engaged in? If "Yes," explain in Part VI the reasons for the organization's position that its supported organization(s) would have engaged in these activities but for the organization's involvement. 3 Parent of Supported Organizations. Answer lines 3a and 3b below. a Did the organization have the power to regularly appoint or elect a majority of the officers, directors, or trustees of each of the supported organizations? If "Yes" or "No," provide details in Part VI. b Did the organization exercise a substantial degree of direction over the policies, programs, and activities of each of its supported organizations? If "Yes," describe in Part VI the role played by the organization in this regard. DAA Yes 2a 2b 3a 3b Schedule A (Form 990) 2021 CLHS 02/27/2023 3:43 PM Schedule A (Form 990) 2021 Clearwater Historical Society, Inc 59-1938824 Part V Type III Non -Functionally Integrated 509(a)(3) Supporting Organizations Page 6 1 U Check here if the organization satisfied the Integral Part Test as a qualifying trust on Nov. 20, 1970 (explain in Part VI). See instructions. All other Type III non -functionally integrated supporting organizations must complete Sections A through E. Section A — usted Ne Inco (A) Prio r (B) Current Year optional) Ne , Inspect on op , i ti 2 Ret ' ries o - 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) 1 Aggregate fair market value of all non -exempt -use assets (see instructions for short tax year or assets held for part of year): a Average monthly value of securities 1a b Average monthly cash balances 1 b c Fair market value of other non -exempt -use assets 1c d Total (add lines la, lb, and 1c) 1d e Discount claimed for blockage or other factors (explain in detail in Part VO: 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 0.85 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 7 I I Check here if the current year is the organization's first as a non -functionally integrated Type Ill supporting organization (see instructions). Schedule A (Form 990) 2021 DAA CLHS 02/27/2023 3:43 PM Schedule A (Form 990) 2021 Clearwater Historical Society Inc 59-1938824 Part V Type III Non -Functionally Integrated 509(a)(3) Supporting Organizations (continued) Section D — Distributions Pa e 7 Current Year 1 Amounts paid to supported organizations to accomplish exempt purposes 2 Amoi orga•r 'd to • s,�n th directly I fr activi • suanQrtea_ .. nui f➢.Au auvv 'nomm/PaEI W 0'l1Nuan .y., ft... MA, P.111.I"' YYWW" '^a."...a-."."r..., a .c 4 Amounts paid to acquire exempt -use assets 5 Qualified set-aside amounts (prior IRS approval required provide details in Part VI) 6 Other distributions (describe in Part VI). See instructions. 7 Total annual distributions. Add lines 1 through 6. 8 Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions. 9 Distributable amount for 2021 from Section C, line 6 10 Line 8 amount divided by line 9 amount Section E — Distribution Allocations (see instructions) (i) Excess Distributions (ii) Underdistributions Pre 2021 (iii) Distributable Amount for 2021 1 Distributable amount for 2021 from Section C, line 6 2 Underdistributions, if any, for years prior to 2021 (reasonable cause required—explain in Part VI). See instructions. 3 Excess distributions carryover, if any, to 2021 a From 2016 b From 2017 c From 2018 d From 2019 e From 2020 f Total of lines 3a through 3e g Applied to underdistributions of prior years h Applied to 2021 distributable amount i Carryover from 2016 not applied (see instructions) j Remainder. Subtract lines 3g, 3h, and 3i from line 3f. 4 Distributions for 2021 from Section D, line 7: $ a Applied to underdistributions of prior years b Applied to 2021 distributable amount c Remainder. Subtract lines 4a and 4b from line 4. 5 Remaining underdistributions for years prior to 2021, if any. Subtract lines 3g and 4a from line 2. For result greater than zero, explain in Part VI. See instructions. 6 Remaining underdistributions for 2021 Subtract lines 3h and 4b from line 1. For result greater than zero, explain in Part VI. See instructions. 7 Excess distributions carryover to 2022. Add lines 3j and 4c. 8 Breakdown of line 7: a Excess from 2017 b Excess from 2018 c Excess from 2019 d Excess from 2020 e Excess from 2021 Schedule A (Form 990) 2021 DAA CLI -IS 02/27/2023 3:43 PM Schedule A (Form 990) 2021 Clearwater Historical Society, Inc 59-1938824 Page 8 Part VI Supplemental Information. Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; Part III, line 12; Part IV, Section A, lines 1, 2, 3b, 3c, 4b, 4c, 5a, 6, 9a, 9b, 9c, 11a, 11 b, and 11c; Part IV, Section B, lines 1 and 2; Part IV, Section C, line 1; Part IV, Section D, lines 2 and 3; Part IV, Section E, lines lc, 2a, 2b, 3a, and 3b; Part V, line 1; Part V, Section B, line le; Part V, Section D, lines 5, 6, and 8; and Part V, Section E, Ds 2, 5 irer1m p for any dditio al nfrm tion. See in ns DAA Schedule A (Form 990) 2021 CLHS 02/27/2023 3:43 PM SCHEDULE D (Form 990) Department of the Treasury Internal Revenue Service Supplemental Financial Statements ► Complete if the organization answered "Yes" on Form 990, Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b. ► Attach to Form 990. ► Go to www.irs.ciov/Form990 for instructions and the latest information. OMB No. 1545-0047 2021 Open to Public Inspection Name of the organization Clea So Part I Org i ' ing r Complete if the organization answered "Ye on Form 990, Part IV, line 6. ds o Employer Identification number 1 Total number at end of year 2 Aggregate value of contributions to (during year) 3 Aggregate value of grants from (during year) 4 Aggregate value at end of year 5 Did the organization inform all donors and donor advisors in writing that the assets held in donor advised funds are the organization's property, subject to the organization's exclusive legal control? ❑ Yes ❑ No 6 Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ❑ Yes ❑ No Part Conservation Easements. Complete if the organization answered "Yes" on Form 990, Part IV, line 7. 1 Purpose(s) of conservation easements held by the organization (check all that apply). (a) Donor advised funds (b) Funds and other accounts Preservation of land for public use (for example, recreation or education) _ Preservation of a historically important land area Protection of natural habitat Preservation of open space Preservation of a certified historic structure 2 Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year. a Total number of conservation easements b Total acreage restricted by conservation easements c Number of conservation easements on a certified historic structure included in (a) d Number of conservation easements included in (c) acquired after 7/25/06, and not on a historic structure listed in the National Register 3 Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during the tax year ► 4 Number of states where property subject to conservation easement is located ► 5 Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and enforcement of the conservation easements it holds? ❑ Yes ❑ No 6 Staff and volunteer hours devoted to monitoring, inspecting, handling of violations, and enforcing conservation easements during the year Heid at the End of the Tax Year 2a 2b 2c 2d ► 7 Amount of expenses incurred in monitoring, inspecting, handling of violations, and enforcing conservation easements during the year $ 8 Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? ❑ Yes ❑ No 9 In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement and balance sheet, and include, if applicable, the text of the footnote to the organization's financial statements that describes the organization's accounting for conservation easements. Part III Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets. Complete if the organization answered "Yes" on Form 990, Part IV, line 8. la If the organization elected, as permitted under FASB ASC 958, not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide in Part XIII the text of the footnote to its financial statements that describes these items. b If the organization elected, as permitted under FASB ASC 958, to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts relating to these items: (i) Revenue included on Form 990, Part VIII, line 1 ► $ (11) Assets included in Form 990, Part X ► $ 2 If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the following amounts required to be reported under FASB ASC 958 relating to these items: a Revenue included on Form 990, Part VIII, line 1 ► $ b Assets included in Form 990, Part X ► $ For Paperwork Reduction Act Notice, see the Instructions for Form 990. Schedule D (Form 990) 2021 DAA CLHS 02/27/2023 3:43 PM Schedule D (Form 990) 2021 Clearwater Historical Society, Inc 59-1938824 Page 2 Part 111 Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued) 3 Using the organization's acquisition, accession, and other records, check any of the following that make significant use of its collection items (check all that apply): a Public exhibition b_ Sc a - search c __Pr o for a ns 4 Provid i s colle o a XIII. 5 During the year, did the organization Loan or exchange program O er nmPt pG solicit or receive donations of art, historical treasures, or other similar assets to be sold to raise funds rather than to be maintained as part of the organization's collection? ❑ Yes ❑ No Part IV Escrow and Custodial Arrangements. Complete if the organization answered "Yes" on Form 990, Part IV, line 9, or reported an amount on Form 990, Part X, line 21. 1a Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not included on Form 990, Part X? Yes 0 No b If "Yes," explain the arrangement in Part XIII and complete the following table: c Beginning balance d Additions during the year Amount lc 1d e Distributions during the year f Ending balance 2a Did the organization include an amount on Form 990, Part X, line 21, for escrow or custodial account liability? ❑ Yes b If "Yes," explain the arrangement in Part XIII. Check here if the explanation has been provided on Part XIII le 1f No Part V Endowment Funds. Complete if the organizati 1 a Beginning of year balance b Contributions c Net investment earnings, gains, and losses d Grants or scholarships e Other expenditures for facilities and programs f Administrative expenses g End of year balance (a) Current year (b) Prior year (c) Two years back (d) Three years back (e) Four years back la Land b Buildings c Leasehold improvements d Equipment e Other 595,258 280,261 314,997 19,630 17,671 1,959 Total. Add lines 1a through 1 e. (Column (d) must equal Form 990, Part X, column (8), line 10c.) ► 316,956 2 Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as: a Board designated or quasi -endowment ► b Permanent endowment ► % c Term endowment ► OA The percentages on lines 2a, 2b, and 2c should equal 100%. 3a Are there endowment funds not in the possession of the organization that are held and administered for the organization by: (1) Unrelated organizations (ii) Related organizations b If "Yes" on line 3a(ii), are the related organizations listed as required on Schedule R? 4 Describe in Part XIII the intended uses of the organization's endowment funds. Part VI Land, Buildings, and Equipment. Complete if the organization answered "Yes" on Form 990 Yes No 3a(i) 3a(ii) 3b Part Description of property (a) Cost or other basis (investment) (b) Cost or other basis (other) (c) Accumulated depredation (d) Book value la Land b Buildings c Leasehold improvements d Equipment e Other 595,258 280,261 314,997 19,630 17,671 1,959 Total. Add lines 1a through 1 e. (Column (d) must equal Form 990, Part X, column (8), line 10c.) ► 316,956 Schedule D (Form 990) 2021 DM CLHS 02/27/2023 3:43 PM Schedule D (Form 990) 2021 Clearwater Historical Society, Inc 59-1938824 Page 3 Part VII Investments — Other Securities. Complete if the organization answered "Yes" on Form 990, Part IV, line 11 b. See Form 990, Part X, line 12. (a) Description of security or category (including name of security) (b) Book value (c) Method of valuation: Cost or end -of -year market value (1) Financial (2) Closely (3) Other (A) ives 5 1 (B) (C) (D) (E) (F) (G) (H) Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.) ► echo opy Part VIII Investments — Program Related. Complete if the organization answered "Yes" on Form 990, Part IV, line 11c. See Form 990, Part X, line 13. (a) Description of investment (b) Book value (c) Method of valuation: Cost or end -of -year market value (1) (2) (2) (3) (3) (5) (4) (6) (5) (7) (6) (9) (7) Total. (Column (b) must equal Form 990, Part X, col. (B) line 15.) ► (8) (9) Total. (Column (b) must equal Form 990, Part X, col. (8) line 13.) ► Part IX Other Assets. Complete if the organization answered "Yes" on Form 990, Part IV, line 11d. See Form 990, Part X, line 15. (a) Description (b) Book value (1) (2) (3) (4) (5) (6) (7) (8) (9) Total. (Column (b) must equal Form 990, Part X, col. (B) line 15.) ► Pa X Other Liabilities. Complete if the organization answered "Yes" on Form 990, Part IV, line 11e or 11f. See Form 990, Part X, line 25. 1. (a) Description of liability (b) Book value (1) Federal income taxes (2) (3) (4) (5) (6) (7) (8) (9) Total. (Column (b) must equal Form 990, Part X, col. (8) line 25.) ► 2. Liability for uncertain tax positions. In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FASB ASC 740. Check here if the text of the footnote has been provided in Part XIII Schedule D (Form 990) 2021 DAA CLHS 02/27/2023 3:43 PM Schedule D (Form 990) 2021 Clearwater Historical Society, Inc 59-1938824 Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return. Complete if the organization answered "Yes" on Form 990, Part IV, line 12a. Page 4 1 Total revenue, gains, and other support per audited financial statements 2 Amounts included on line 1 but not on Form 990, Part VIII, line 12: a Net un T= • =;= gains (I s) nnve ments b Donate c Recov:° es of p d Other (Describe in Part XIII.) e Add lines 2a through 2d 3 Subtract line 2e from line 1 2d 1 py 2e 3 4 Amounts included on Form 990, Part VIII, line 12, but not on line 1: a Investment expenses not included on Form 990, Part VIII, line 7b b Other (Describe in Part XIII.) c Add lines 4a and 4b 5 Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part 1, line 4a 4b 12.) 4c 5 Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return. Complete if the organization answered "Yes" on Form 990, Part IV, line 12a. 1 Total expenses and losses per audited financial statements 1 2 Amounts included on line 1 but not on Form 990, Part IX, line 25: a Donated services and use of facilities b Prior year adjustments c Other losses d Other (Describe in Part XIII.) e Add lines 2a through 2d 3 Subtract line 2e from line 1 2a 2b 2c 2d 2e 3 4 Amounts included on Fomi 990, Part IX, line 25, but not on line 1: a Investment expenses not included on Form 990, Part VIII, line 7b b Other (Describe in Part XIII.) c Add lines 4a and 4b 4a 4b 5 Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part 1, line 18.) 4c 5 Part XIII Supplemental Information. Provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines la and 4; Part IV, lines 1b and 2b; Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information. Schedule D (Form 990) 2021 DAA CLI -IS 02/27/2023 3:43 PM Schedule D (Form 990) 2021 Clearwater Historical Society, Inc 59-1938824 Part XI11 Supplemental Information (continued) Page 5 uec Schedule D (Form 990) 2021 DAA CLHS 02/27/2023 3:43 PM SCHEDULE 0 (Form 990) Department of the Treasury Internal Revenue Name of the o Supplemental Information to Form 990 or 990 -EZ Complete to provide information for responses to specific questions on Form 990 or 990 -EZ or to provide any additional information. ► Attach to Form 990 or Form 990 -EZ. ► Gto wwwirs.gov/Form990 for the tat information. mploy OMB No. 1545-0047 2021 Form 990, Part III, Line 4d - All Other Accomplishments Gen & Admin Computer Form 990, Part VI, Line llb - Organization's Process to Review Form 990 Treasurer reviews the Form 990 and a draft copy of the return is made available to all Board Members. Form 990, Part VI, Line 19 - Governing Documents Disclosure Explanation Provided on request Form 990, Part XI, Line 9 - Other Changes in Net Assets Explanation Book / Tax Depreciation Difference $ -69,526 For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990 -EZ. Schedule 0 (Form 990) 2021 DAA B. General Information Completed by ethiebe@csfhome.org on 9/27/2023 10:11 AM Case Id: 15989 Name: Community Service Foundation - 2023 Address: *No Address Assigned B. General Information Please provide the following information. B.1. Legal Name of Organization (as shown in Line 1 of REPRESENTATIVE CONTACT INFORMATION W-9) Community Service Foundation Inc. B.10. First Name Edward B.2. DBA (if applicable — as shown in Line 2 of W-9) B.11. Last Name Thiebe B.3. Type of Agency Non -Profit organization B.12. Title of Position Executive Director B.4. Physical Address of Organization 925 Lakeview Road Clearwater, FL 33756 B.13. Primary Email ethiebe@csfhome.org B.S. Taxpayer ID (TIN) (if sole proprietorship, enter social security number of sole proprietor) (As shown in Part 1 of W-9) 59-0866939 B.6. Organization Legal Entity Type (as shown in Line 3 of W-9) c -corporation B.7. Mailing Address for Grant Check (As shown in Line 5 & 6 of W-9) 925 Lakeview Road Clearwater, FL 33756 B.B. Mission Statement of Organization Dedicated to strengthening communities and families. We provide affordable housing and invest in its communities through betterment initiatives. B.9. Applicant Discipline (select all that apply) El Culture ErEducation QHistory Printed By: Amber Brice on 6/26/2024 B.14. Phone Number (727) 873-8731 NNeighborty Software 1 of 2 ❑ Literary Arts ❑ Museum ❑ Performing Arts ❑ Visual Arts ▪ Other Other Explained Affordable housing and related services Printed By: Amber Brice on 6/26/2024 2 of 2 HNeighborly Software