2018-11-15T14:47:07-06:00 2017-12-31 540504608 BROWN EDWARDS & COMPANY LLP 319 MCCLANAHAN STREET SW ROANOKE VA 24014 990 2017-01-01 453230862 DELTA DENTAL OF VIRGINIA FOUNDATION DELT 5409898000 4818 STARKEY ROAD ROANOKE VA 24018 FRANK L LUCIA PRESIDENT & CEO 5409898000 2018-11-05 1 M C WINGFIELD P00005971 5403450936 2018-11-05 206.248.228.130 2018-11-05 10:04:14 ES P D0156BD46B4B1FE921C9503B1D7FFBF99E37DBAB CE530EA759AC3AF6BB0EECEF8950573E07121913 2017 2019-02-21 02:37:17Z FRANK L LUCIA 4818 STARKEY ROAD ROANOKE VA 24018 459868 0 X WWW.DELTADENTALVA.COM/DDVAFOUNDATION.ASPX X 2011 VA IMPROVE THE PUBLIC'S ORAL HEALTH IN THE COMMONWEALTH OF VIRGINIA. 6 4 0 0 0 0 322259 459868 0 0 0 0 0 0 322259 459868 231500 370500 0 0 0 0 0 0 0 19747 33498 251247 403998 71012 55870 341970 397024 816 0 341154 397024 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 370500 370500 PROMOTION OF ORAL HEALTH CARE THROUGH EDUCATION, RESEARCH AND INCREASED ACCESS TO ORAL HEALTH CARE IN THE COMMONWEALTH OF VIRGINIA. 370500 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 1 0 1 0 0 0 0 0 0 0 0 0 0 0 X 6 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 14.00 X X 0 38071 0 DR BARRY WOLFE SECRETARY 1.00 4.00 X X 0 28715 0 DR HAROLD J BARRETT JR DIRECTOR 1.00 2.00 X 0 21860 0 MR GORDON L GENTRY JR DIRECTOR 1.00 5.00 X 0 34944 0 DR GEORGE A LEVICKI PRESIDENT - RETIRED 11/2017 1.00 41.00 X X 0 1197351 71596 MR FRANK L LUCIA PRESIDENT & CEO, 11/2017 1.00 41.00 X X 0 61009 1678 DR EMANUEL W MICHAELS FORMER DIRECTOR 0.00 0.00 X 0 22500 0 0 1404450 73274 0 1 1 0 0 459868 459868 459868 0 0 0 370500 370500 -1141 -1141 27644 27644 DENTAL CLAIMS 6995 6995 403998 370500 33498 0 341970 386371 10653 341970 397024 816 816 0 X 0 0 0 0 341154 397024 341154 397024 341970 397024 55870 0 X 0 1 X 1 0 X X 1 DELTA DENTAL OF VIRGINIA 540844477 10 1 370500 0 1 370500 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. 0 X 459868 0 459868 0 459868 403998 0 403998 0 403998 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, 2017 AND 2016. 1 CHILD HEALTH INVESTMENT PARTNERSHIP 1201 THIRD STREET SW ROANOKE VA 24016 541566451 501(C)(3) 5000 FLUORIDE VARNISH TREATMENTS/IN-HOME DENTAL EDUCATION 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 DENTAL SUPPLIES PIEDMONT REGIONAL DENTAL CLINIC INC 13296 JAMES MADISON HWY STE B ORANGE VA 22960 270625764 501(C)(3) 5000 SUPPORT FOR "SMILE TIME", A SCHOOL BASED DENTAL CHECK-UP PROGRAM BRADLEY FREE CLINIC 1240 THIRD STREET SW ROANOKE VA 24016 237380491 501(C)(3) 5000 DENTAL SUPPLIES 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 "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 DENTAL SUPPLIES NORTHERN NECK-MIDDLESEX FREE HEALTH CLINIC 51 WILLIAM B GRAHAM COURT KILMARNOCK VA 22482 541679279 501(C)(3) 7500 SUPPORT OF VCU DENTAL STUDENTS PROVIDING SERVICES AT THE CLINIC OLDE TOWNE MEDICAL & DENTAL CENTER 5249 OLDE TOWNE ROAD WILLIAMSBURG VA 23188 541663905 501(C)(3) 5000 DENTAL SUPPLIES VIRGINIA ORAL HEALTH COALITION 4200 INNSLAKE DRIVE GLEN ALLEN VA 23060 274082359 501(C)(3) 7500 EDUCATION OF 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 "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 HAMPTON ECUMENICAL LODDGING & PROVISIONS (AKS DR RICHARD CLARK HELP CLINIC) PO BOX 120525 NEWPORT NEWS VA 23612 541209213 501(C)(3) 5000 EXPAND DENTAL SERVICES CRAIG COUNTY RURAL HEALTH CARE CORPORATION PO BOX 223 NEW CASTLE VA 24127 562569389 501(C)(3) 10000 EXPANSION OF SCHOOL BASED ORAL HEALTH SERVICES IN CRAIG COUNTY VA DANVILLE PITTSYLVANIA COMMUNITY SERVICES 245 HAIRSTON STREET DANVILLE VA 24540 540937279 501(C)(3) 3000 DENTAL EXAMS FOR ADULTS WITH DEVELOPMENTAL DISABILITIES COMMUNITY YOUTH PROGRAM AT ST JOHN'S INC PO BOX 257 ROANOKE VA 24002 541855451 501(C)(3) 4000 ORAL HEALTH OUTREACH EDUCATION EASTERN SHORE RURAL HEALTH SYTEM INC 20280 MARKET STREET ONANCOCK VA 23417 510196935 501(C)(3) 15000 DENTAL CHAIR TO ACCOMMODATE WHEELCHAIR BOUND PATIENTS FAQUIER FREE CLINIC 35 ROCK POINTE LANE WARRENTON VA 20186 541669652 501(C)(3) 4000 DENTAL EQUIPMENT GOOCHLAND FREE CLINIC & FAMILY SERVICES 1800 SANDY HOOK ROAD PO BOX 116 GLOOCHLAND VA 23063 541967650 501(C)(3) 5000 EXPAND DENTAL SERVICES ISLE OF WIGHT CHRISTIAN OUTREACH PROGRAM PO BOX 253 SMITHFIELD VA 23431 541638727 501(C)(3) 5000 EXPAND DENTAL PROGRAM LLOYD F MOSS FREE CLINIC 1301 SAM PERRY BOULEVARD STE 100 FREDERICKSBURG VA 22401 541677934 501(C)(3) 5000 DENTAL SUPPLIES LUCY CORR FOUNDATION INC 6800 LUCY CORR BOULEVARD CHESTERFIELD VA 23832 542010957 501(C)(3) 10000 EXPAND DENTAL CARE TO ELDERLY IN RICHMOND VA AREA MEL LEAMAN FREE CLINIC AT EMORY & HENRY COLLEGE PO BOX 1273 MARION VA 24354 541993876 501(C)(3) 5000 DENTAL SUPPLIES NORTHERN VIRGINIA DENTAL CLINIC INC 8221 WILLOW OAKS CORPORATE DR NO 450 FAIRFAX VA 22031 541646071 501(C)(3) 5000 DENTAL SUPPLIES PARK PLACE DENTAL CLINIC INC 606 W 29TH STREET NORFOLK VA 23508 453086608 501(C)(3) 5000 DENTAL SUPPLIES PIEDMONT VIRGINIA DENTAL HEALTH FOUNDATION 407 STARLING AVE MARTINSVILLE VA 24112 201468244 501(C)(3) 10000 SUPPORT FOR DENTAL CLINIC PROVIDING SERVICES TO LOW INCOME ADULTS AND CHILDREN HANOVER INTERFAITH FREE CLINICS PO BOX 117 ASHLAND VA 23005 412214314 501(C)(3) 7500 DENTURES FOR LOW INCOME RESIDENTS VIRGINIA DENTAL ASSOCIATION FOUNDATION 3460 MAYLAND COURT HENRICO VA 23233 541821602 501(C)(3) 15000 MOBILE DENTAL EQUIPMENT REPLACEMENT/REPAIR & SUPPLIES FOR MISSION OF MERCY PROGRAM 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 PO BOX 890 DALEVILLE VA 24083 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 PO BOX 4692 ROANOKE VA 24015 546051298 501(C)(3) 5000 DENTAL SCHOLARSHIPS KUUMBA COMMUNITY HEALTH & WELLNESS CENTER INC 3716 MELROSE AVENUE NW ROANOKE VA 24017 541937835 501(C)(3) 5000 TRAIN DENTAL ASSISTANT AS A COMMUNITY DENTAL HEALTH COORDINATOR 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 DENTAL SERVICES TO LOW-INCOME RESIDENTS IN LONG-TERM HEALTH CARE CENTERS REMOTE AREA MEDICAL INC VIRGINIA BRANCH 2200 STOCK CREEK BLVE ROCKFORD TN 37853 581647546 501(C)(3) 10000 DENTAL SERVICES IN RURAL VA COMMUNITIES VIRGINIA TECH-CARILION SCHOOL OF MEDICINE TWO RIVERSIDE CIRCLE ROANOKE VA 24016 264556177 501(C)(3) 50000 PILOT A PROGRAM 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) 20000 DENTAL HYGIENE PROGRAM & SERVICES PROVIDED THROUGH THE FREE COMMUNITY CLINICS 40 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 DR GEORGE A LEVICKI PRESIDENT - RETIRED 11/2017 0 587010 0 455347 0 154994 0 54000 0 17596 0 1268947 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 PAYMENTS BY A RELATED ORGANIZATION HAVE BEEN INCLUDED IN COLUMN B-III OF SCHEDULE J, PART II. THE LUMP SUM PAYMENT IN 2017 WAS EARNED OVER A PRECEDING MULTI-YEAR PERIOD. THE 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. THE 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 2017: EMPLOYEE AMOUNT GEORGE A. LEVICKI $142,092 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 THE BOARD OF DIRECTORS COMPLETE CONFLICT OF INTEREST FORMS ANNUALLY. ALL ARE FILED IN THE CORPORATE MINUTE BOOK WHICH IS REVIEWED BY OUR AUDITORS. 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 CORVESTA SOFTWARE SOLUTIONS PVT LTD 4818 STARKEY ROAD ROANOKE VA 24018 PROVIDES SOFTWARE DEVELOPMENT & PROGRAMMING IN N/A C 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 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0