2020-11-12T13:43:06-06:00 2019-12-31 540504608 BROWN EDWARDS & COMPANY LLP 319 MCCLANAHAN STREET SW ROANOKE VA 24014 990 2019-01-01 453230862 DELTA DENTAL OF VIRGINIA FOUNDATION DELT 5409898000 4818 STARKEY ROAD ROANOKE VA 24018 FRANK L LUCIA PRESIDENT & CEO 5409898000 2020-11-09 1 M C WINGFIELD P00005971 5403450936 2020-11-09 206.248.228.130 2020-11-09 09:02:24 ES P B8F3A42E1E02DCEFCA8852D9E0619B3AA9DB5E86 99D0D1F6CFEB3F355FC0DB60138D01BD9869373F 2019 2021-01-29 14:40:06Z FRANK L LUCIA 4818 STARKEY ROAD ROANOKE VA 24018 420586 0 X WWW.DELTADENTALVA.COM/DDVAFOUNDATION.ASPX X 2011 VA IMPROVE THE PUBLIC'S ORAL HEALTH IN THE COMMONWEALTH OF VIRGINIA. 5 4 0 0 0 0 562052 420586 0 0 0 0 0 0 562052 420586 546500 409865 0 0 0 0 0 0 0 27712 42793 574212 452658 -12160 -32072 520838 352792 135974 0 384864 352792 THE FOUNDATION WORKS TO IMPROVE THE ORAL HEALTH OF ALL VIRGINIANS THROUGH FINANCIAL SUPPORT OF RESEARCH AND EDUCATION INITIATIVES AND PROGRAMS THAT PROVIDE ACCESS TO CARE FOR THE UNDERSERVED. 0 0 409865 409865 PROMOTION OF ORAL HEALTH CARE THROUGH EDUCATION, RESEARCH AND INCREASED ACCESS TO ORAL HEALTH CARE IN THE COMMONWEALTH OF VIRGINIA. 409865 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 X 5 4 0 0 0 0 0 1 0 1 1 0 0 1 1 1 1 1 1 0 0 0 X RJAMES BARKER 5409898000 4818 STARKEY ROAD ROANOKE VA 24018 DR HAROLD J BARRETT JR DIRECTOR 1.00 2.00 X 0 24407 0 DR LEZLEY P MCILVEEN DIRECTOR 1.00 3.00 X 0 28138 0 DR A CAROLE PRATT DIRECTOR 1.00 3.00 X 0 26050 0 MR JAN S SESSOR DIRECTOR 1.00 3.00 X 0 27450 0 MR FRANK L LUCIA PRESIDENT & CEO 1.00 41.00 X X 0 1072199 25206 DR GEORGE A LEVICKI FORMER PRESIDENT 0.00 0.00 X 0 141199 0 0 1319443 25206 0 1 1 0 0 420586 420586 420586 0 0 0 409865 409865 4406 4406 36074 36074 DENTAL CLAIMS 2313 2313 452658 409865 42793 0 520489 347224 349 5568 520838 352792 974 0 135000 0 135974 0 X 384864 352792 384864 352792 520838 352792 -32072 0 X X 0 1 X 1 0 X X 1 DELTA DENTAL OF VIRGINIA 540844477 10 1 409865 0 1 409865 0 1 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 SCHEDULE A, PART IV, LINE 3B DELTA DENTAL OF VIRGINIA FOUNDATION ANNUALLY REQUESTS FROM DELTA DENTAL A PRO FORMA FORM 990 SCHEDULE A TO VERIFY IT MEETS THE SECTION 509(A)(2) PUBLIC SUPPORT TEST FOR ITS MOST RECENT TAX YEAR. SCHEDULE A, PART IV, LINE 3C DELTA DENTAL OF VIRGINIA FOUNDATION HAS PROCEDURES IN PLACE TO ENSURE THAT ITS SUPPORT IS USED SOLELY FOR CHARITABLE PURPOSES. THE FOUNDATION MONITORS ALL GRANT MONIES AWARDED BY REQUIRING END-OF-YEAR UPDATES DETAILING HOW THE GRANT MONIES WERE USED. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 X 420586 0 420586 0 420586 452658 0 452658 0 452658 PART X, LINE 2: THE FOUNDATION IS EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THERE WAS NO UNRELATED BUSINESS INCOME FOR THE YEARS ENDED DECEMBER 31, 2019 AND 2018. 1 ARLINGTON FREE CLINIC 2921 11TH ST SOUTH ARLINGTON VA 22204 541671883 501(C)(3) 5000 DENTIST SALARY BLAND MINISTRY CENTER AND DENTAL CLINIC 65 SEDDON STREET BLAND VA 24315 541556134 501(C)(3) 15000 DENTAL EQUIPMENT BOYS & GIRLS CLUBS OF SOUTHWEST VIRGINIA 1714 9TH STREET SE ROANOKE VA 24013 541867366 501(C)(3) 5000 STAFF SUPPORT BOYS & GIRLS CLUBS OF THE VIRGINIA PENINSULA 11825 ROCK LANDING DRIVE CHESAPEAKE BUILDING NEWPORT NEWS VA 23606 540538202 501(C)(3) 5000 DENTAL PROVIDER SUPPORT BRADLEY FREE CLINIC 1240 THIRD STREET SW ROANOKE VA 24016 237380491 501(C)(3) 20000 DENTAL STUDENTS CENTRAL VIRGINIA HEALTH SERVICES INC 25892 N JAMES MADISON HWY NEW CANTON VA 23123 540887287 501(C)(3) 7500 DENTAL EQUIPMENT CHARLOTTESVILLE FREE CLINIC 1138 ROSE HILL DRIVE SUITE 200 CHARLOTTESVILLE VA 22903 541610405 501(C)(3) 5000 DENTAL SUPPLIES CHESAPEAKE CARE INC 2145 S MILITARY HIGHWAY CHESAPEAKE VA 23320 541642754 501(C)(3) 5000 DENTAL PROVIDER SUPPORT CHIP OF ROANOKE VALLEY 1201 THIRD STREET SW ROANOKE VA 24016 541566451 501(C)(3) 5000 EDUCATION CROSS-OVER MINISTRY INC 8600 QUIOCCASIN ROAD STE 101 RICHMOND VA 23229 541371067 501(C)(3) 5000 STAFF SUPPORT DANVILLE-PITTSYLVANIA COMMUNITY SERVICES 245 HAIRSTON STREET DANVILLE VA 24540 540937279 501(C)(3) 5000 DENTAL PROVIDER SUPPORT DENTAL CLINIC OF NORTHERN SHENANDOAH VALLEY INC 301 NORTH CAMERON STREET SUITE 200 WINCHESTER VA 22601 450573607 501(C)(3) 5000 SUPPORT STAFF DR RICHARD F CLARK HELP CLINICS 1320 LASALLE AVENUE HAMPTON VA 23669 541209213 501(C)(3) 5000 DENTAL PROVIDER SUPPORT EASTERN SHORE RURAL HEALTH SYSTEM INC 20280 MARKET STREET ONANCOCK VA 23417 510196935 501(C)(3) 10000 DENTAL EQUIPMENT FREE CLINIC OF POWHATAN 3908 OLD BUCKINGHAM ROAD POWHATAN VA 23139 261275136 501(C)(3) 10000 DENTAL EQUIPMENT GLOUCESTER MATHEWS CARE CLINIC 6031 INDUSTRIAL DRIVE GLOUCESTER VA 23061 541875619 501(C)(3) 10000 DENTAL PROVIDER SUPPORT GOOCHLAND CARES 2999 RIVER ROAD WEST GOOCHLAND VA 23063 541967650 501(C)(3) 5000 MATERIALS/SUPPLIES GREATER PRINCE WILLIAM COMMUNITY HEALTH CENTER 4379 RIDGEWOOD CENTER DRIVE WOODBRIDGE VA 22192 830435138 501(C)(3) 7500 DENTAL EQUIPMENT HAMPTON ROADS COMMUNITY HEALTH CENTER 664 LINCOLN STREET PORTSMOUTH VA 23704 541626757 501(C)(3) 10000 DENTAL EQUIPMENT HANOVER INTERFAITH FREE CLINICS 125 BEVERLY ROAD PO BOX 117 ASHLAND VA 23005 412214314 501(C)(3) 7500 DENTAL APPLIANCES HEALING HANDS HEALTH CENTER 245 MIDWAY MEDICAL PARK BRISTOL TN 37620 621677000 501(C)(3) 10000 DENTAL SUPPLIES HIGHLAND MEDICAL CENTER 120 JACKSON RIVER ROAD PO BOX 490 MONTEREY VA 24465 541652356 501(C)(3) 7800 DENTAL EQUIPMENT LACKEY CLINIC 1620 OLD WILLIAMSBURG ROAD YORKTOWN VA 23690 541850915 501(C)(3) 10000 DENTAL PROVIDER SUPPORT LEWIS GALE FOUNDATION DBA HEALTH FOCUS OF SOUTHWEST VIRGINIA PO BOX 4692 ROANOKE VA 24015 546051298 501(C)(3) 5000 SCHOLARSHIPS LLOYD F MOSS FREE CLINIC 1301 SAM PERRY BOULEVARD STE 100 FREDERICKSBURG VA 22401 541677934 501(C)(3) 5000 DENTAL SUPPLIES LUCY CORR FOUNDATION 6800 LUCY CORR BOULEVARD CHESTERFIELD VA 23832 542010957 501(C)(3) 10000 STAFF SUPPORT MADISON FREE CLINIC 410 NORTH MAIN STREET PO BOX 914 MADISON VA 22727 311654015 501(C)(3) 5000 DENTAL PROVIDER SUPPORT MEDICAL CARE FOR CHILDREN PARTNERSHIP FOUNDATION 6699 SPRINGFIELD CENTER DRIVE 303 SPRINGFIELD VA 22150 261756738 501(C)(3) 5000 SPECIAL NEEDS DENTAL MEDICAL COLLEGE OF VIRGINIA FOUNDATION 1228 E BROAD STREET RICHMOND VA 23284 546053660 501(C)(3) 10000 GEORGE A. LEVICKI, D.D.S. ENDOWED SCHOLARSHIP FUND MEL LEAMAN FREE CLINIC 601 RADIO HILL ROAD MARION VA 24354 541993876 501(C)(3) 5000 STAFF SUPPORT MISSION DENTAL VIRGINIA INC 15325 LEE HIGHWAY BRISTOL VA 24202 833820038 501(C)(3) 15000 DENTAL SUPPLIES NORTHERN NECK - MIDDLESEX FREE HEALTH CLINIC INC 51 WILLIAM B GRAHAM COURT KILMARNOCK VA 22482 541679279 501(C)(3) 7500 DENTAL STUDENTS NORTHERN VIRGINIA COMMUNITY COLLEGE EDUCATIONAL FOUNDATION 4001 WAKEFIELD CHAPEL ROAD ANNANDALE VA 22003 510249730 501(C)(3) 5000 DENTAL SUPPLIES NORTHERN VIRGINIA DENTAL CLINIC INC 8221 WILLOW OAKS CORPORATE DRIVE SUITE 450 FAIRFAX VA 22031 541646071 501(C)(3) 7500 DENTAL PROVIDER SUPPORT OLD DOMINION UNIVERSITY EDUCATIONAL FOUNDATION 4417 MONARCH WAY 4TH FLOOR NORFOLK VA 23529 541850915 501(C)(3) 4000 DENTAL SUPPLIES PARK PLACE HEALTH AND DENTAL CLINIC 606 WEST 29TH STREET NORFOLK VA 23508 542026502 501(C)(3) 5000 DENTAL STUDENTS PIEDMONT REGIONAL DENTAL CLINIC 13296 JAMES MADISON HIGHWAY ORANGE VA 22960 270625764 501(C)(3) 5000 DENTAL EQUIPMENT FOR MOBILE PIEDMONT VIRGINIA DENTAL HEALTH FOUNDATION 407 STARLING AVENUE MARTINSVILLE VA 24112 541626757 501(C)(3) 10000 DENTAL SUPPLIES PRINCE WILLIAM AREA FREE CLINIC 13900 CHURCH HILL DRIVE WOODBRIDGE VA 22191 541619202 501(C)(3) 5000 DENTAL PROVIDER SUPPORT RESCUE MISSION OF ROANOKE INC P O BOX 11525 ROANOKE VA 24022 540573900 501(C)(3) 10000 DENTAL PROVIDER SUPPORT SOUTHEASTERN VIRGINIA HEALTH SYSTEM 10330 28TH STREET 2ND FLOOR NEWPORT NEWS VA 23607 541083954 501(C)(3) 4500 DENTAL SUPPLIES ST LUKE'S COMMUNITY CLINIC 316 NORTH ROYAL AVENUE FRONT ROYAL VA 22630 541801220 501(C)(3) 5000 DENTAL EQUIPMENT THE FENWICK FOUNDATION 23 N FENWICK STREET ARLINGTON VA 22201 541013637 501(C)(3) 5000 MOBILE CLINIC THE LAMB CENTER 3160 CAMPBELL DRIVE FAIRFAX VA 22031 412222581 501(C)(3) 3000 DENTAL SUPPLIES THE VIRGINIA HEALTH CARE FOUNDATION 707 EAST MAIN STREET STE 1350 RICHMOND VA 23219 541639924 501(C)(3) 45000 DENTAL PROVIDER SUPPORT TOTAL ACTION AGAINST POVERTY 302 2ND STREET SW ROANOKE VA 24011 541639924 501(C)(3) 5000 DENTAL PROVIDER SUPPORT VIRGINIA DENTAL ASSOCIATION FOUNDATION 3460 MAYLAND COURT SUITE 110 RICHMOND VA 23233 541821602 501(C)(3) 15000 MOBILE CLINIC VIRGINIA HEALTH CATALYST 4200 INNSLAKE DRIVE STE 103 GLEN ALLEN VA 23060 274082359 501(C)(3) 7500 EDUCATION VIRGINIA WESTERN COMMUNITY COLLEGE EDUCATIONAL FOUNDATION INC 3093 COLONIAL AVE ROANOKE VA 24015 541268273 501(C)(3) 10000 EDUCATION WESTERN TIDEWATER FREE CLINIC 2019 MEADE PARKWAY SUFFOLK VA 23434 263302837 501(C)(3) 5000 DENTAL SUPPLIES WILLIAMSBURG AREA MEDICAL ASSIST CORP DBA OLDE TOWN MEDICAL & DENTAL 5249 OLDE TOWNE ROAD SUITE D WILLIAMSBURG VA 23188 541663905 501(C)(3) 5565 DENTAL SUPPLIES AND EQUIPMENT 51 PART I, LINE 2: THE FOUNDATION REQUESTS A YEAR-END UPDATE OF HOW THE GRANT FUNDS WERE USED. 0 1 0 0 0 0 0 0 0 MR FRANK L LUCIA PRESIDENT & CEO 0 638542 0 416478 0 17179 0 0 0 25206 0 1097405 0 0 DR GEORGE A LEVICKI FORMER PRESIDENT 0 0 0 0 0 141199 0 0 0 0 0 141199 0 0 PART I, LINE 1B NOT APPLICABLE PART I, LINE 4B THE FOLLOWING LUMP SUM PAYMENT BY A RELATED ORGANIZATION HAS BEEN INCLUDED IN COLUMN B-III OF SCHEDULE J, PART II. THE LUMP SUM PAYMENT IN 2019 WAS EARNED OVER A PRECEDING MULTI-YEAR PERIOD. THIS PLAN WAS ESTABLISHED VIA THE RELATED ORGANIZATION'S MANAGEMENT DEVELOPMENT & COMPENSATION COMMITTEE'S COMPENSATION AND BENEFIT REVIEW WHICH IS IN ACCORDANCE WITH THE PROCESS OUTLINED BY THE IRS FOR SETTING REASONABLE COMPENSATION. THIS PLAN IS IN ACCORDANCE WITH SUPPLEMENTAL EXECUTIVE RETIREMENT PLANS AS PER IRS SECTION 409(A). THE FOLLOWING AMOUNT WAS PAID FROM A RELATED ORGANIZATION IN 2019: EMPLOYEE AMOUNT DR. GEORGE A. LEVICKI $141,199 RELATED ORG. FORM 990, PART VI, SECTION A, LINE 7A PURSUANT TO THE ARTICLES OF INCORPORATION, THE FOUNDATION'S BOARD OF DIRECTORS ARE APPOINTED BY THE BOARD OF THE SUPPORTED ORGANIZATION, DELTA DENTAL OF VIRGINIA. FORM 990, PART VI, SECTION B, LINE 11B MEMBERS OF THE BOARD OF DIRECTORS WILL REVIEW THE DOCUMENT AND THE REVIEW WILL BE DOCUMENTED AT THE SUBSEQUENT BOARD MEETING. FORM 990, PART VI, SECTION B, LINE 12C DELTA DENTAL OF VIRGINIA FOUNDATION REQUIRES CORPORATE OFFICERS AND EACH DIRECTOR ON THE BOARD OF DIRECTORS TO COMPLETE AN ANNUAL CONFLICT OF INTEREST DISCLOSURE STATEMENT THAT IS BASED ON IRS GUIDANCE. IN ADDITION, THE CONFLICT OF INTEREST POLICY REQUIRES DISCLOSURE OF ALL CONFLICTS, POTENTIAL CONFLICTS, OR ANY MATTER THAT MAY GIVE RISE TO THE APPEARANCE OF A CONFLICT. THE FORMS ARE REVIEWED BY THE COMPLIANCE OFFICER AND REPORTED TO THE CEO AND THE APPROPRIATE COMMITTEE(S) OF THE BOARD. THE FORMS ARE FURTHER AVAILABLE TO, AND REVIEWED BY, OUR AUDITORS AND THE BOI. FORM 990, PART VI, SECTION C, LINE 19 THE APPLICABLE FORMS ARE AVAILABLE FOR PUBLIC INSPECTION VIA REQUEST AND REGULATORY FILINGS. FORM 990, PART XII, LINE 2C THERE HAVE BEEN NO CHANGES TO DELTA DENTAL OF VIRGINIA FOUNDATION'S OVERSIGHT PROCESS OF THE AUDIT OR ITS SELECTION OF AN INDEPENDENT AUDITOR. DELTA DENTAL OF VIRGINIA 4818 STARKEY ROAD ROANOKE VA 24018 540844477 ADVANCE PUBLIC'S ORAL HEALTH BY PROVIDING QUALITY DENTAL BENEFITS. VA 501(C)(4) CORVESTA INC 0 CORVESTA INC 4818 STARKEY ROAD ROANOKE VA 24018 205945158 HOLDING COMPANY VA 501(C)(4) 0 REVOLV INC 4818 STARKEY ROAD ROANOKE VA 24018 271018474 PROVIDES TPA SERVICES TO DENTAL INSURANCE COMPANIES VA N/A C 0 STRYDEN INC 4818 STARKEY ROAD ROANOKE VA 24018 352637734 PROVIDES VISION CARE INSURANCE VA N/A C 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0