SUSAN DEW HOFF MEMORIAL CLINIC INC: Form 990, tax year 2020
View the entire original 990 at ProPublica ↗
- Organization
- SUSAN DEW HOFF MEMORIAL CLINIC INC (EIN 55-0768457)
- Tax period
- 2020-01-01 to 2020-12-31
- Filed
- 2021-09-09
- IRS object ID
- 202142529349301219
- Schema version
- 2020v4.1
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2021-09-09T15:07:20-05:00 | ReturnTs |
| Tax Period End | 2020-12-31 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 550486667 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | ARNETT CARBIS TOOTHMAN LLP | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 908 | AddressLine1Txt |
| City | BRIDGEPORT | CityNm |
| State Abbreviation | WV | StateAbbreviationCd |
| ZIP | 26330 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2020-01-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 550768457 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | SUSAN DEW HOFF MEMORIAL CLINIC INC | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | SUSA | BusinessNameControlTxt |
| Phone | 3047453700 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 623 LIBERTY AVENUE | AddressLine1Txt |
| City | WEST MILFORD | CityNm |
| State Abbreviation | WV | StateAbbreviationCd |
| ZIP | 26451 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | DR JD HISSEM | PersonNm |
| Person Title | EXECUTIVE DIRECTOR | PersonTitleTxt |
| Phone | 3047453700 | PhoneNum |
| Signature | 2021-09-08 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Signing Officer SigningOfficerGrp
Person Full Name PersonFullName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person First | DR | PersonFirstNm |
| Person Last | JD HISSEM | PersonLastNm |
| Field | Value | IRS element (for citing) |
|---|---|---|
| SSN | 999009999 | SSN |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | WILLIAM H PHILLIPS CPA | PreparerPersonNm |
| PTIN | P00197505 | PTIN |
| Phone | 3046245471 | PhoneNum |
| Preparation | 2021-09-08 | PreparationDt |
Additional Filer Information AdditionalFilerInformation
Trusted Customer TrustedCustomerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Trusted Customer | 2 | TrustedCustomerCd |
| Authentication Assurance Level | AAL1 | AuthenticationAssuranceLevelCd |
| Identity Assurance Level | IAL1 | IdentityAssuranceLevelCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2020 | TaxYr |
| Build TS | 2022-09-23 18:48:47Z | BuildTS |
Form 990 IRS990
Doing Business As Name DoingBusinessAsName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | SUSAN DEW HOFF MEMORIAL CLINIC | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | DR JD HISSEM | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 623 LIBERTY AVENUE | AddressLine1Txt |
| City | WEST MILFORD | CityNm |
| State Abbreviation | WV | StateAbbreviationCd |
| ZIP | 26451 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $333,109 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | N/A | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Other Organization Dsc | OTHER | OtherOrganizationDsc |
| Formation | 1999 | FormationYr |
| Legal Domicile State | WV | LegalDomicileStateCd |
| Activity Or Mission | PROVIDE HEALTH AND DENTAL CARE TO THE UNINSURED WORKING POOR. | ActivityOrMissionDesc |
| Voting Members Governing Body | 22 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 22 | VotingMembersIndependentCnt |
| Total Employee | 2 | TotalEmployeeCnt |
| Total Volunteers | 0 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $375,267 | PYContributionsGrantsAmt |
| CY Contributions Grants | $322,963 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $0 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $0 | CYProgramServiceRevenueAmt |
| PY Investment Income | $7,182 | PYInvestmentIncomeAmt |
| CY Investment Income | $10,146 | CYInvestmentIncomeAmt |
| PY Other Revenue | $0 | PYOtherRevenueAmt |
| CY Other Revenue | $0 | CYOtherRevenueAmt |
| PY Total Revenue | $382,449 | PYTotalRevenueAmt |
| CY Total Revenue | $333,109 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $300 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $300 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $69,357 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $71,596 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $344,071 | PYOtherExpensesAmt |
| CY Other Expenses | $221,580 | CYOtherExpensesAmt |
| PY Total Expenses | $413,728 | PYTotalExpensesAmt |
| CY Total Expenses | $293,476 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | -$31,279 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $39,633 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $607,838 | TotalAssetsBOYAmt |
| Total Assets EOY | $646,423 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $7,275 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $6,227 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $600,563 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $640,196 | NetAssetsOrFundBalancesEOYAmt |
| Mission | TO PROVIDE HEALTH ASSESSMENT, PROMOTION AND REFERRAL SERVICES TO THE WORKING POOR WHO LACK MEDICAL AND DENTAL INSURANCE. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $221,021 | ExpenseAmt |
| Grant | $300 | GrantAmt |
| Desc | IN 2020 THE CLINIC HELD 88 CLINICS AND SAW 964 PATIENTS. THE CLINIC PERFORMED 1805 PROCEDURES WHICH INCLUDED: 559 X-RAYS, 47 CLEANINGS, 564 FILLINGS, FASHIONED 13 FULL DENTURES AND 17 PARTIALS, 12 REPAIR/RELINES, 374 EXTRACTIONS, 9 ROOT CANALS, 9 CROWNS, 1 REFERRAL TO AN ORAL SURGEON, AND 200 REFERRALS TO OUR CONTRACTED OUTSIDE DENTIST. INCLUDED IN THIS WAS SERVICE TO 126 NEW PATIENTS AND 62 VETERAN VISITS, THOSE WHO NO LONGER QUALIFY FOR CARE AT THE LOCAL VA HOSPITAL. | Desc |
| Total Program Service Expenses | $221,021 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (1) | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | 0 | LobbyingActivitiesInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | 0 | CreditCounselingInd |
| Donor Rstr Or Quasi Endowments | 0 | DonorRstrOrQuasiEndowmentsInd |
| Report Land Building Equipment | Yes (1) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | 0 | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | 0 | ReportProgramRelatedInvstInd |
| Report Other Assets | 0 | ReportOtherAssetsInd |
| Report Other Liabilities | 0 | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (1) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | Yes (1) | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | 0 | ConsolidatedAuditFinclStmtInd |
| School Operating | 0 | SchoolOperatingInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Foreign Activities | 0 | ForeignActivitiesInd |
| More Than5000 K To Org | 0 | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividualsInd |
| Professional Fundraising | 0 | ProfessionalFundraisingInd |
| Fundraising Activities | 0 | FundraisingActivitiesInd |
| Gaming Activities | 0 | GamingActivitiesInd |
| Operate Hospital | 0 | OperateHospitalInd |
| Grants To Organizations | 0 | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Schedule J Required | 0 | ScheduleJRequiredInd |
| Tax Exempt Bonds | 0 | TaxExemptBondsInd |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | 0 | PYExcessBenefitTransInd |
| Loan Outstanding | 0 | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | 0 | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | 0 | BusinessRlnWithFamMemInd |
| Business Rln With35 Ctrl Ent | 0 | BusinessRlnWith35CtrlEntInd |
| Deductible Non Cash Contri | 0 | DeductibleNonCashContriInd |
| Deductible Art Contribution | 0 | DeductibleArtContributionInd |
| Terminate Operations | 0 | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | 0 | DisregardedEntityInd |
| Related Entity | 0 | RelatedEntityInd |
| Related Organization Ctrl Ent | 0 | RelatedOrganizationCtrlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 6 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Employee | 2 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (1) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | 0 | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | 0 | TaxablePartyNotificationInd |
| Nondeductible Contributions | 0 | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOfInd |
| Indoor Tanning Services | 0 | IndoorTanningServicesInd |
| Subj To Tax Rmnrtn Ex Prcht Pymt | 0 | SubjToTaxRmnrtnExPrchtPymtInd |
| Subject To Excs Tax Net Invst Inc | 0 | SubjectToExcsTaxNetInvstIncInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 22 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 22 | IndependentVotingMemberCnt |
| Family Or Business Rln | 0 | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | 0 | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | 0 | MembersOrStockholdersInd |
| Election Of Board Members | 0 | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | 0 | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (1) | MinutesOfCommitteesInd |
| Officer Mailing Address | 0 | OfficerMailingAddressInd |
| Local Chapters | 0 | LocalChaptersInd |
| Form990 Provided To Gvrn Body | Yes (1) | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (1) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (1) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (1) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | 0 | WhistleblowerPolicyInd |
| Document Retention Policy | 0 | DocumentRetentionPolicyInd |
| Compensation Process CEO | 0 | CompensationProcessCEOInd |
| Compensation Process Other | 0 | CompensationProcessOtherInd |
| Investment In Joint Venture | 0 | InvestmentInJointVentureInd |
| States Where Copy Of Return Is Fld | WV | StatesWhereCopyOfReturnIsFldCd |
| Other Website | Yes (X) | OtherWebsiteInd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | SUSAN DEW HOFF MEMORIAL CLINIC INC | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 3047453700 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 623 LIBERTY STREET | AddressLine1Txt |
| City | WEST MILFORD | CityNm |
| State Abbreviation | WV | StateAbbreviationCd |
| ZIP | 26451 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| No Listed Persons Compensated | Yes (X) | NoListedPersonsCompensatedInd |
Form990 Part VII Section A Form990PartVIISectionAGrp (22 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | OfficerOfficerInd |
|---|---|---|---|---|---|---|
| GINA SHARPS | ||||||
| DIRECTOR | 1.00 | Yes (X) | $0 | $0 | $0 | |
| BERNICE JEAN LUCAS | ||||||
| DIRECTOR | 1.00 | Yes (X) | $0 | $0 | $0 | |
| MARY LOU VARGO | ||||||
| DIRECTOR | 1.00 | Yes (X) | $0 | $0 | $0 | |
| DR ROBERT WRANKER DDS | ||||||
| DIRECTOR | 1.00 | Yes (X) | $0 | $0 | $0 | |
| FRANK NUZUM | ||||||
| DIRECTOR | 1.00 | Yes (X) | $0 | $0 | $0 | |
| DR MARY BETH HINKLE DDS | ||||||
| DIRECTOR | 1.00 | Yes (X) | $0 | $0 | $0 | |
| DR ANDREW MINIGH DDS | ||||||
| DIRECTOR | 1.00 | Yes (X) | $0 | $0 | $0 | |
| LADONNE WETZEL | ||||||
| DIRECTOR | 1.00 | Yes (X) | $0 | $0 | $0 | |
| GARY WETZEL | ||||||
| DIRECTOR | 1.00 | Yes (X) | $0 | $0 | $0 | |
| SANDRA MANO | ||||||
| DIRECTOR | 1.00 | Yes (X) | $0 | $0 | $0 | |
| DR MARK SPIKER DDS | ||||||
| DIRECTOR | 1.00 | Yes (X) | $0 | $0 | $0 | |
| ANDY WHARTON | ||||||
| DIRECTOR | 1.00 | Yes (X) | $0 | $0 | $0 | |
| CECILIA REID | ||||||
| DIRECTOR | 1.00 | Yes (X) | $0 | $0 | $0 | |
| BEVERLY TALBERT | ||||||
| DIRECTOR | 1.00 | Yes (X) | $0 | $0 | $0 | |
| JOELLEN KEMMNER | ||||||
| CHAIR | 1.00 | Yes (X) | $0 | $0 | $0 | |
| TODD SOMMERS | ||||||
| DIRECTOR | 1.00 | Yes (X) | $0 | $0 | $0 | |
| LOU ORTENZIO | ||||||
| DIRECTOR | 1.00 | Yes (X) | $0 | $0 | $0 | |
| SISTER MARY REBECCA FIDLER RSM MD | ||||||
| CEO | 5.00 | $0 | $0 | $0 | Yes (X) | |
| DR JD HISSEM DDS | ||||||
| EXECUTIVE DIRECTOR | 10.00 | $0 | $0 | $0 | Yes (X) | |
| DR RICHARD MECKSTROTH DDS | ||||||
| VICE-CHAIR | 1.00 | $0 | $0 | $0 | Yes (X) | |
| TERRY WAXMAN | ||||||
| SECRETARY | 1.00 | $0 | $0 | $0 | Yes (X) | |
| BARBARA PRINCE | ||||||
| TREASURER | 1.00 | $0 | $0 | $0 | Yes (X) | |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $0 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $0 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 0 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | 0 | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | 0 | CompensationFromOtherSrcsInd |
| Cntrct Rcvd Greater Than100 K | 0 | CntrctRcvdGreaterThan100KCnt |
| All Other Contributions | $322,963 | AllOtherContributionsAmt |
| Total Contributions | $322,963 | TotalContributionsAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $10,146 | TotalRevenueColumnAmt |
| Exclusion | $10,146 | ExclusionAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $333,109 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $0 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $10,146 | ExclusionAmt |
Grants To Domestic Orgs GrantsToDomesticOrgsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $300 | TotalAmt |
| Program Services | $300 | ProgramServicesAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $65,990 | TotalAmt |
| Program Services | $24,000 | ProgramServicesAmt |
| Management And General | $41,990 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $5,606 | TotalAmt |
| Management And General | $5,606 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,606 | TotalAmt |
| Management And General | $1,606 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $13,847 | TotalAmt |
| Management And General | $13,847 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $8,775 | TotalAmt |
| Management And General | $8,775 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $26,732 | TotalAmt |
| Program Services | $26,732 | ProgramServicesAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $2,254 | TotalAmt |
| Program Services | $2,254 | ProgramServicesAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $10,527 | TotalAmt |
| Program Services | $10,527 | ProgramServicesAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt |
|---|---|---|
| CONTRACT SERVICES | $147,626 | $147,626 |
| DENTAL SUPPLIES | $4,885 | $4,885 |
| OTHER EXPENSES | $2,663 | $2,663 |
| UTILITIES | $2,034 | $2,034 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $631 | TotalAmt |
| Management And General | $631 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $293,476 | TotalAmt |
| Program Services | $221,021 | ProgramServicesAmt |
| Management And General | $72,455 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $77,692 | BOYAmt |
| EOY | $107,856 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $512,814 | BOYAmt |
| EOY | $515,616 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $0 | BOYAmt |
| EOY | $7,500 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $6,743 | BOYAmt |
| EOY | $7,117 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $57,079 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $48,745 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $10,589 | BOYAmt |
| EOY | $8,334 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $607,838 | BOYAmt |
| EOY | $646,423 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $7,275 | BOYAmt |
| EOY | $6,227 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $7,275 | BOYAmt |
| EOY | $6,227 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows FASB117 | Yes (X) | OrganizationFollowsFASB117Ind |
No Donor Restriction Net Assets NoDonorRestrictionNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $600,563 | BOYAmt |
| EOY | $640,196 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $600,563 | BOYAmt |
| EOY | $640,196 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $607,838 | BOYAmt |
| EOY | $646,423 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Reconcilation Revenue Expnss | $39,633 | ReconcilationRevenueExpnssAmt |
| Other Changes In Net Assets | $0 | OtherChangesInNetAssetsAmt |
| Info In Schedule O Part XII | Yes (X) | InfoInScheduleOPartXIIInd |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | 0 | AccountantCompileOrReviewInd |
| FS Audited | 0 | FSAuditedInd |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequiredInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Public Organization170 | Yes (X) | PublicOrganization170Ind |
Gifts Grants Contri Rcvd170 GiftsGrantsContriRcvd170Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | $196,214 | CurrentTaxYearMinus4YearsAmt |
| Current Tax Year Minus3 Years | $281,379 | CurrentTaxYearMinus3YearsAmt |
| Current Tax Year Minus2 Years | $331,104 | CurrentTaxYearMinus2YearsAmt |
| Current Tax Year Minus1 Year | $375,267 | CurrentTaxYearMinus1YearAmt |
| Current Tax Year | $322,963 | CurrentTaxYearAmt |
| Total | $1,506,927 | TotalAmt |
Total Calendar Year170 TotalCalendarYear170Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | $196,214 | CurrentTaxYearMinus4YearsAmt |
| Current Tax Year Minus3 Years | $281,379 | CurrentTaxYearMinus3YearsAmt |
| Current Tax Year Minus2 Years | $331,104 | CurrentTaxYearMinus2YearsAmt |
| Current Tax Year Minus1 Year | $375,267 | CurrentTaxYearMinus1YearAmt |
| Current Tax Year | $322,963 | CurrentTaxYearAmt |
| Total | $1,506,927 | TotalAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Public Support Total170 | $1,506,927 | PublicSupportTotal170Amt |
Gross Investment Income170 GrossInvestmentIncome170Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | $13,212 | CurrentTaxYearMinus4YearsAmt |
| Current Tax Year Minus3 Years | $12,312 | CurrentTaxYearMinus3YearsAmt |
| Current Tax Year Minus2 Years | $6,379 | CurrentTaxYearMinus2YearsAmt |
| Current Tax Year Minus1 Year | $7,182 | CurrentTaxYearMinus1YearAmt |
| Current Tax Year | $10,146 | CurrentTaxYearAmt |
| Total | $49,231 | TotalAmt |
Other Income170 OtherIncome170Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | $2,718 | CurrentTaxYearMinus4YearsAmt |
| Current Tax Year Minus3 Years | $3,666 | CurrentTaxYearMinus3YearsAmt |
| Total | $6,384 | TotalAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Support | $1,562,542 | TotalSupportAmt |
| Public Support CY170 | 0.96440 | PublicSupportCY170Pct |
| Public Support PY170 | 0.96800 | PublicSupportPY170Pct |
| Thirty Thr Pct Suprt Tests CY170 | Yes (X) | ThirtyThrPctSuprtTestsCY170Ind |
Schedule B IRS990ScheduleB
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | RESTRICTED | ContributorNum |
Contributor Business Name ContributorBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor US Address ContributorUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Contributions | RESTRICTED | TotalContributionsAmt |
Schedule D IRS990ScheduleD
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $57,079 | OtherCostOrOtherBasisAmt |
| Depreciation | $48,745 | DepreciationAmt |
| Book Value | $8,334 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $8,334 | TotalBookValueLandBuildingsAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
| Total Rev Etc Audited Fincl Stmt | $333,109 | TotalRevEtcAuditedFinclStmtAmt |
| Revenue Not Reported | $0 | RevenueNotReportedAmt |
| Revenue Subtotal | $333,109 | RevenueSubtotalAmt |
| Revenue Not Reported Fincl Stmt | $0 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $333,109 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $293,476 | TotExpnsEtcAuditedFinclStmtAmt |
| Expenses Not Reported | $0 | ExpensesNotReportedAmt |
| Expenses Subtotal | $293,476 | ExpensesSubtotalAmt |
| Expenses Not Rpt Fincl Stmt | $0 | ExpensesNotRptFinclStmtAmt |
| Total Expenses Per Form990 | $293,476 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART X, LINE 2: | FormAndLineReferenceDesc |
| Explanation | INCOME TAXES: THE CLINIC IS A NOT-FOR-PROFIT ENTITY THAT IS EXEMPT FROM INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (IRC). IN ADDITION, THE CLINIC QUALIFIES FOR THE CHARITABLE CONTRIBUTION DEDUCTION UNDER SECTION 170(B)(1)(A) AND HAS BEEN CLASSIFIED AS AN ENTITY THAT IS NOT A PRIVATE FOUNDATION UNDER 509(A)(1). THE CLINIC HAD NO UNRELATED BUSINESS INCOME DURING THE YEAR ENDED DECEMBER 31, 2020. ACCORDINGLY, NO PROVISION FOR INCOME TAXES HAS BEEN PROVIDED. THE CLINIC FOLLOWS GUIDANCE FOR ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN THE CLINIC'S FINANCIAL STATEMENTS THAT PRESCRIBES A RECOGNITION THRESHOLD OF MORE-LIKELY-THAN-NOT TO BE SUSTAINED UPON EXAMINATION BY THE APPROPRIATE TAXING AUTHORITIES. THERE WERE NO UNCERTAIN TAX POSITIONS RECOGNIZED IN THE FINANCIAL STATEMENTS AS A RESULT OF THIS GUIDANCE. GENERALLY, THE TAX RETURNS FOR THE YEARS ENDED DECEMBER 31, 2017, AND THEREAFTER REMAIN SUBJECT TO EXAMINATION BY THE FEDERAL AND STATE TAXING AUTHORITIES. | ExplanationTxt |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (4 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PART VI, SECTION B, LINE 11B | THE BOARD MEMBERS ARE PROVIDED A COPY OF THE 990 AND IT IS REVIEWED AT BOARD MEETING. |
| FORM 990, PART VI, SECTION B, LINE 12C | THE CLINIC ENFORCES AN ANNUAL DISCLOSURE REQUIREMENT WITH ITS CONFLICT OF INTEREST POLICY. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE CLINIC MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. |
| FORM 990, PART XI, LINE 2C | THE ORGANIZATION HAS A COMMITEE THAT ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS. THE SELECTION PROCESS FOR CHOOSING AN INDEPENDENT ACCOUNTANT HAS NOT CHANGED FROM THE PREVIOUS YEAR. |