2019-11-12T09:34:37-06:00 2018-12-31 540504608 BROWN EDWARDS & COMPANY LLP 319 MCCLANAHAN STREET SW ROANOKE VA 24014 990 2018-01-01 453230862 DELTA DENTAL OF VIRGINIA FOUNDATION DELT 5409898000 4818 STARKEY ROAD ROANOKE VA 24018 FRANK L LUCIA PRESIDENT & CEO 5409898000 2019-11-08 1 M C WINGFIELD P00005971 5403450936 2019-11-08 206.248.228.130 2019-11-08 15:33:18 ES P C6B7EFC27ADC1D591699B7D67A64703C90C79A72 D0156BD46B4B1FE921C9503B1D7FFBF99E37DBAB 2018 2020-03-31 21:24:44Z FRANK L LUCIA 4818 STARKEY ROAD ROANOKE VA 24018 562052 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 459868 562052 0 0 0 0 0 0 459868 562052 370500 546500 0 0 0 0 0 0 0 33498 27712 403998 574212 55870 -12160 397024 520838 0 135974 397024 384864 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 546500 546500 PROMOTION OF ORAL HEALTH CARE THROUGH EDUCATION, RESEARCH AND INCREASED ACCESS TO ORAL HEALTH CARE IN THE COMMONWEALTH OF VIRGINIA. 546500 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 MR LYNDELL B BROOKS TREASURER 1.00 2.00 X X 0 32092 0 DR BARRY WOLFE SECRETARY 1.00 3.00 X X 0 36256 0 DR HAROLD J BARRETT JR DIRECTOR 1.00 1.00 X 0 24915 0 MR GORDON L GENTRY JR DIRECTOR 1.00 1.00 X 0 27256 0 MR FRANK L LUCIA PRESIDENT & CEO 1.00 41.00 X X 0 956368 31106 DR GEORGE A LEVICKI FORMER PRESIDENT 0.00 40.00 X 0 763409 60038 DR EMANUEL W MICHAELS FORMER DIRECTOR 0.00 0.00 X 0 22500 0 0 1862796 91144 0 1 1 0 0 562052 562052 562052 0 0 0 546500 546500 1742 1742 19619 19619 DENTAL CLAIMS 6351 6351 574212 546500 27712 0 386371 520489 10653 349 397024 520838 974 135000 0 135974 X 397024 384864 397024 384864 397024 520838 -12160 0 X X 0 1 X 1 0 X X 1 DELTA DENTAL OF VIRGINIA 540844477 10 1 546500 0 1 546500 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 562052 0 562052 0 562052 574212 0 574212 0 574212 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, 2018 AND 2017. 1 CHILD HEALTH INVESTMENT PARTNERSHIP OF ROANOKE VALLEY 1201 THIRD STREET SW ROANOKE VA 24016 541566451 501(C)(3) 5000 SUPPORT TO PROVIDE FLUORIDE VARNISH TREATMENTS AND CONDUCT DENTAL FAIRS BRADLEY FREE CLINIC 1240 THIRD STREET SW ROANOKE VA 24016 237380491 501(C)(3) 15000 SPONSOR VCU DENTAL STUDENTS PROVIDING SERVICES AT THE CLINIC OLIVET MEDICAL MINISTRY INC AKA LACKEY FREE CLINIC 1620 OLD WILLIAMSBURG ROAD YORKTOWN VA 23690 541850915 501(C)(3) 10000 EXPANSION OF DENTAL TREATMENT PIEDMONT REGIONAL DENTAL CLINIC INC 13296 JAMES MADISON HWY STE B ORANGE VA 22960 270625764 501(C)(3) 5000 SUPPORT SENIOR SMILE TIME PROGRAM FOR SENIORS BRADLEY FREE CLINIC 1240 THIRD STREET SW ROANOKE VA 24016 237380491 501(C)(3) 5000 SUPPLIES FOR ACCESS TO DENTAL DAYS EVENTS VIRGINIA HEALTH CARE FOUNDATION 707 EAST MAIN STREET STE 1350 RICHMOND VA 23219 541639924 501(C)(3) 45000 DENTAL OPPORTUNITIES CHAMPION (DOC) BOYS & GIRLS CLUBS OF THE VIRGINIA PENINSULA 11825 ROCK LANDING DRIVE NEWPORT NEWS VA 23606 540538202 501(C)(3) 5000 SUPPORT OF THE SMART SMILES AT THE DENTIST PROGRAM CROSSOVER HEALTHCARE MINISTRY 8600 QUIOCCASIN ROAD SUITE 102 RICHMOND VA 23229 541371067 501(C)(3) 5000 SALARY SUPPORT AND PUERCHASE ESSENTIAL DENTAL SUPPLIESSALARY SUPPORT AND PURCHASE ESSENTIAL DENTAL SUPPLIES NORTHERN NECK-MIDDLESEX FREE HEALTH CLINIC PO BOX 1694 KILMARNOCK VA 22482 541679279 501(C)(3) 7500 SUPPORT OF VCU DENTAL STUDENTS PROVIDING SERVICES AT THE CLINIC WILLIAMSBURG AREA MEDICAL ASSISTANCE DBA OLDE TOWNE MEDICAL & DENTAL CTR 5249 OLDE TOWNE ROAD WILLIAMSBURG VA 23188 541663905 501(C)(3) 5000 DENTAL SUPPLIES AND EQUIPMENT VIRGINIA ORAL HEALTH COALITION 4200 INNSLAKE DRIVE STE 103 GLEN ALLEN VA 23060 274082359 501(C)(3) 7500 EDUCATE MEDICAL & DENTAL PROVIDERS ABOUT THE SAFETY, EFFICACY & IMPORTANCE OF DENTAL CARE DURING PREGNANCY BOYS & GIRLS CLUBS OF SOUTHWEST VIRGINIA 1714 9TH STREET SE ROANOKE VA 24013 541867366 501(C)(3) 5000 SUPPORT OF THE SMART SMILES AT THE DENTIST PROGRAM CHARLOTTESVILLE FREE CLINIC 1138 ROSE HILL DRIVE SUITE 200 CHARLOTTESVILLE VA 22903 541610405 501(C)(3) 5000 DENTAL SUPPLIES CRAIG COUNTY RURAL HEALTH CARE CORPORATION 230 MARKET STREET-BASEMENT NEW CASTLE VA 24127 562569389 501(C)(3) 5000 DENTAL EQUIPMENT DANVILLE PITTSYLVANIA COMMUNITY SERVICES 245 HAIRSTON STREET DANVILLE VA 24540 540937279 501(C)(3) 5000 PROVIDE DENTAL EXAMS FOR ADULTS WITH BEHAVIORAL DISORDERS LUCY CORR FOUNDATION INC 6800 LUCY CORR BOULEVARD CHESTERFIELD VA 23832 542010957 501(C)(3) 10000 EXPAND DENTAL CARE TO ELDERLY IN THE RICHMOND AREA NORTHERN VIRGINIA DENTAL CLINIC INC 8221 WILLOW OAKS CORPORATE DR NO 450 FAIRFAX VA 22031 541646071 501(C)(3) 7500 DENTAL EQUIPMENT PARK PLACE DENTAL CLINIC INC 606 W 29TH STREET NORFOLK VA 23508 453086608 501(C)(3) 5000 SUPPORT VCU DENTAL STUDENTS PIEDMONT VIRGINIA DENTAL HEALTH FOUNDATION 407 STARLING AVE MARTINSVILLE VA 24112 201468244 501(C)(3) 10000 DENTAL SERVICES HANOVER INTERFAITH FREE CLINICS 125 BEVERLY ROAD PO BOX 117 ASHLAND VA 23005 412214314 501(C)(3) 7500 DENTURES FOR LOW INCOME RESIDENTS VIRGINIA DENTAL ASSOCIATION FOUNDATION 3460 MAYLAND COURT SUITE 110 HENRICO VA 23233 541821602 501(C)(3) 15000 EXPAND ACCESS TO CARE WESTERN TIDEWATER FREE CLINIC 2019 MEADE PARKWAY SUFFOLK VA 23434 263302837 501(C)(3) 5000 DENTAL SUPPLIES ARLINGTON FREE CLINIC 2921 11TH STREET SOUTH ARLINGTON VA 22204 541671883 501(C)(3) 5000 DENTAL EQUIPMENT CENTRAL VIRGINIA HEALTH SERVICES PO BOX 220 25892 N JAMES MADISON HWY NEW CANTON VA 23123 540887287 501(C)(3) 7500 DENTAL EQUIPMENT CHRISTIAN FREE CLINIC OF BOTETOURT 7330 ROANOKE ROAD FINCASTLE VA 24090 204342697 501(C)(3) 2000 DENTAL EQUIPMENT HEALING HANDS HEALTH CENTER INC 245 MIDWAY MEDICAL PARK BRISTOL TN 37620 621677000 501(C)(3) 10000 DENTAL SERVICES LEWIS-GALE FOUNDATION DBA HEALTH FOCUS OF SOUTHWEST VA 1902 BRAEBURN DRIVE SALEM VA 24153 546051298 501(C)(3) 5000 SUPPORT DELTA DENTAL SCHOLARSHIP ENDOWMENT PRINCE WILLIAM AREA FREE CLINIC 13900 CHURCH HILL DRIVE WOODBRIDGE VA 22191 541619202 501(C)(3) 7500 DENTAL SERVICES THE FENWICK FOUNDATION 23 N FENWICK STREET ARLINGTON VA 22201 274879033 501(C)(3) 5000 PROVIDE DENTAL SERVICES TO LOW-INCOME PATIENTS VIRGINIA TECH-CARILION SCHOOL OF MEDICINE TWO RIVERSIDE CIRCLE ROANOKE VA 24016 264556177 501(C)(3) 50000 2ND YEAR OF PILOT PROGRAM (SMART SMILES AT THE DOCTOR) INTEGRATING ORAL HEALTH EXAMS & FLUORIDE VARNISHING FOR CHILDREN INTO FAMILY MEDICINE & PEDIATRIC PRACTICES VIRGINIA WESTERN COMMUNITY COLLEGE EDUCATIONAL FOUNDATION INC 3093 COLONIAL AVENUE ROANOKE VA 24015 521200913 501(C)(3) 10000 DENTAL HYGIENE PROGRAM AND THE SERVICES PROVIDED THROUGH THE FREE COMMUNITY CLINICS AUGUSTA REGIONAL FREE CLINIC 342 MULE ACADEMY ROAD FISHERSVILLE VA 22939 541651896 501(C)(3) 10000 SUPPORT FOR AND ADDITIONAL DENTIST AT CLINIC BLAND MINISTRY CENTER AND DENTAL CLINIC 65 SEDDON STREET BLAND VA 24315 541556134 501(C)(3) 5000 DENTAL TREATMENT CHESAPEAKE CARE INC 2145 S MILITARY HIGHWAY CHESAPEAKE VA 23320 541642754 501(C)(3) 5000 SUPPORT PART-TIME HYGIENIST DENTAL CLINIC OF NORTHERN SHENANDOAH VALLEY INC 301 NORTH CAMERON STREET SUITE 200 WINCHESTER VA 22601 540573607 501(C)(3) 5000 EXPANSION OF DENTAL SERVICES HAMPTON ECUMENICAL LODGING & PROVISIONS (AKA DR RICHARD CLARK HELP CLINIC) 1320 LASALLE AVENUE HAMPTON VA 23669 541209213 501(C)(3) 5000 EXPANSION OF DENTAL SERVICES FREE CLINIC OF CENTRAL VIRGINIA 1016 MAIN STREET LYNCHBURG VA 24504 541420756 501(C)(3) 10000 EXPANSION OF DENTAL SERVICES FREE CLINIC OF CULPEPER DBA CULPEPER WELLNESS FOUNDATION 311 S EAST STREET SUITE 100 CULPEPER VA 22701 521366700 501(C)(3) 3000 DENTAL SERVICES FREE CLINIC OF THE NEW RIVER VALLEYINC -DBA COMMUNITY HEALTH CENTER OF NRV 215 ROANOKE STREET CHRISTIANSBURG VA 24073 510247098 501(C)(3) 10000 DENTAL EQUIPMENT GREATER PRINCE WILLIAM COMMUNITY HEALTH CENTER 4379 RIDGEWOOD CENTER DRIVE STE 102 WOODBRIDGE VA 22192 830435138 501(C)(3) 7500 DENTAL EQUIPMENT MADISON FREE CLINIC 410 NORTH MAIN STEET MADISON VA 22727 311654015 501(C)(3) 5000 DENTAL SERVICES NORTHERN VIRGINIA COMMUNITY COLLEGE EDUCATIONAL FOUNDATION 4001 WAKEFIELD CHAPEL ROAD ANNANDALE VA 22003 510249730 501(C)(3) 5000 DENTAL EQUIPMENT OLD DOMINION UNIVERSITY EDUCATIONAL FOUNDATION 4417 MONARCH WAY 4TH FLOOR NORFOLK VA 23529 546052014 501(C)(3) 4000 DENTAL EQUIPMENT FOR ODU SCHOOL OF HYGIENE PIEDMONT ACCESS TO HEALTH SERVICES INC(PATHS) 705 MAIN STREET DANVILLE VA 24541 542026502 501(C)(3) 5000 DENTAL EQUIPMENT PORTSMOUTH COMMUNITY HEALTH CENTER-DBA HAMPTON ROADS COMMUNITY HEALTH CTR 664 LINCOLN STREET PORTSMOUTH VA 23704 541626757 501(C)(3) 10000 DENTAL SERVICES RESCUE MISSION OF ROANOKE INC 402 4TH STREET SE ROANOKE VA 24014 540573900 501(C)(3) 10000 DENTAL EQUIPMENT SPECIAL OLYMPICS VIRGINIA INC 3212 SKIPWITH ROAD SUITE 100 RICHMOND VA 23294 541013637 501(C)(3) 5000 SUPPORT SPECIAL SMILES CLINIC VALLEY AREA COMMUNITY SUPPORT INC 418 DUPONT AVENUE PO BOX 1907 STAUNTON VA 24401 270132429 501(C)(3) 5000 SUPPORT ACCESS TO CARE FOR LOW-INCOME ADULTS 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 - ACCRUED AT 12/31/18 & PAID ON 5/29/19 VIRGINIA ORAL HEALTH COALITION INC 4200 INNSLAKE DRIVE STE 103 GLEN ALLEN VA 23060 274082359 501(C)(3) 25000 FALLON PARK PROJECT FOR HEALTH & WELLNESS CLINIC - ACCRUED AT 12/31/18 & PAID ON 1/31/19 FREEDOM FIRST ENTERPRISE - LIFT 5240 VALLEYPARK DRIVE ROANOKE VA 24019 813904720 501(C)(3) 100000 FALLON PARK PROJECT FOR HEALTH & WELLNESS CLINIC - ACCRUED AT 12/31/18 & PAID ON 8/15/19 FREDERICKSBURG AREA REGNAL HEALTH COUNCIL INC DBA LLOYD F MOSS FREE CLINIC 1301 SAM PERRY BOULEVARD STE 100 FREDERICKSBURG VA 22401 541677834 501(C)(3) 5000 EXPANSION OF DENTAL SERVICES 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 612471 0 282510 0 61387 0 5500 0 25606 0 987474 0 0 DR GEORGE A LEVICKI FORMER PRESIDENT 0 201693 0 446095 0 115621 0 55000 0 5038 0 823447 0 0 DR EMANUEL W MICHAELS FORMER DIRECTOR 0 22500 0 0 0 0 0 0 0 0 0 22500 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 2018 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 NONQUALIFIED DEFERRED COMPENSATION PLANS AS PER IRS SECTION 457(F). THE FOLLOWING AMOUNT WAS PAID FROM A RELATED ORGANIZATION IN 2018: EMPLOYEE AMOUNT DR. GEORGE A. LEVICKI $111,915 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 CORVESTA LIFE INSURANCE COMPANY INC 4818 STARKEY ROAD ROANOKE VA 24018 860201136 PROVIDES LIFE INSURANCE POLICIES AZ 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