2016-11-08T14:44:52-06:00 2015-12-31 540504608 BROWN EDWARDS & COMPANY LLP 319 MCCLANAHAN STREET SW ROANOKE VA 24014 990 2015-01-01 453230862 DELTA DENTAL OF VIRGINIA FOUNDATION DELT 5409898000 4818 STARKEY ROAD ROANOKE VA 24018 GEORGE A LEVICKI PRESIDENT 5409898000 2016-11-08 1 M C WINGFIELD P00005971 5403450936 2015 2017-02-10 21:41:12Z GEORGE A LEVICKI 4818 STARKEY ROAD ROANOKE VA 24018 92042 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 435947 92039 0 0 27 3 0 0 435974 92042 917500 475000 0 0 0 0 0 0 0 13069 8932 930569 483932 -494595 -391890 662032 270142 0 0 662032 270142 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 475000 475000 PROMOTION OF ORAL HEALTH CARE THROUGH EDUCATION, RESEARCH AND INCREASED ACCESS TO ORAL HEALTH CARE IN THE COMMONWEALTH OF VIRGINIA. 475000 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 5 4 0 0 0 0 0 1 0 1 1 0 0 1 1 1 1 0 0 0 0 0 X LYNDELL B BROOKS 5409898000 4818 STARKEY ROAD ROANOKE VA 24018 MR LYNDELL B BROOKS TREASURER 1.00 10.00 X X 0 33190 0 DR BARRY WOLFE SECRETARY 1.00 3.00 X X 0 29197 0 DR HAROLD J BARRETT JR DIRECTOR 1.00 2.00 X 0 20000 0 DR EMANUEL W MICHAELS DIRECTOR 1.00 3.00 X 0 20354 0 DR GEORGE A LEVICKI PRESIDENT 1.00 41.00 X X 0 2625536 68336 0 2728277 68336 0 0 1 0 0 92039 92039 3 3 92042 0 0 3 475000 475000 -3200 -3200 8111 8111 DENTAL CLAIMS 4021 4021 483932 475000 8932 0 662032 270142 662032 270142 0 0 X 0 0 0 0 662032 270142 662032 270142 662032 270142 -391890 0 X X 0 1 X 1 0 X X 1 DELTA DENTAL OF VIRGINIA 540844477 9 1 475000 0 1 475000 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 VERFIY 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 MID-YEAR AND END-OF-YEAR UPDATES DETAILING HOW THE GRANT MONIES WERE USED. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 X 92042 0 92042 0 92042 483933 0 483933 -1 -1 483932 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, 2015 AND 2014. THE FEDERAL INFORMATIONAL RETURNS ARE SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE, GENERALLY FOR THREE YEARS AFTER THEY ARE FILED. PART XII, LINE 4B - OTHER ADJUSTMENTS: ROUNDING -1. 1 CHILD HEALTH INVESTMENT PARTNERSHIP 1201 THIRD STREET SW ROANOKE VA 24016 541566451 501(C)(3) 5000 "BEGIN WITH A GRIN" PROGRAM BRADLEY FREE CLINIC 1240 THIRD STREET SW ROANOKE VA 24016 237380491 501(C)(3) 10000 SPONSOR VCU DENTAL STUDENTS OLIVET MEDICAL MINISTRY INC AKA LACKEY FREE CLINIC 1620 OLD WILLIAMSBURG ROAD WILLIAMSBURG VA 23690 541850915 501(C)(3) 5000 DENTAL EQUIPMENT & SUPPLIES FOR TREATING PATIENTS PIEDMONT REGIONAL DENTAL CLINIC INC 13296 JAMES MADISON HWY STE B ORANGE VA 22960 270625764 501(C)(3) 5000 EXPANSION OF FOR SMILE TIME SCHOOL BASED EXAMS PROGRAM FOR GREENE COUNTY SCHOOLS RESCUE MISSION OF ROANOKE INC 402 4TH STREET SE ROANOKE VA 24013 540573900 501(C)(3) 4500 PURCHASE OF EQUIPMENT FOR DENTAL SERVICES VCU SCHOOL OF DENTISTRY LYONS DENTAL BUILDING 520N 12TH STREET RICHMOND VA 232980566 546053660 501(C)(3) 125000 SCHOLARSHIP FUNDS FOR DENTAL SCHOOL VIRGINIA HEALTH CARE FOUNDATION 707 EAST MAIN STREET STE 1350 RICHMOND VA 23219 541639924 501(C)(3) 20000 DENTAL OPPORTUNITIES CHAMPION (DOC) VIRGINIA TECH-CARILION SCHOOL OF MEDICINE INC TWO RIVERSIDE CIRCLE ROANOKE VA 24016 264556177 501(C)(3) 250000 ENDOW DELTA DENTAL ORAL HEALTH TEACHING CURRICULUM 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 RESTORATIVE AND PREVENTIVE DENTAL SERVICES FOR THE MEDICALLY INDIGENT PATIENTS NORTHERN NECK FREE HEALTH CLINIC 51 WILLIAM B GRAHAM COURT PO BOX 1694 KILMARNOCK VA 22482 541679279 501(C)(3) 5000 EXPANSION OF DENTAL SERVICES OLDE TOWNE MEDICAL & DENTAL CENTER 5249 OLDE TOWNE ROAD WILLIAMSBURG VA 23188 541663905 501(C)(3) 5000 NEW AUTOCLAVE FOR INSTRUMENT STERILIZATION AND OTHER DENTAL SUPPLIES VIRGINIA ORAL HEALTH COALITION 4200 INNSLAKE DRIVE GLEN ALLEN VA 23060 274082359 501(C)(3) 5000 SUPPORT FOR ORAL HEALTH MESSAGE DURING PREGNANCY BOYS & GIRLS CLUBS OF SOUTHWEST VIRGINIA 1714 9TH STREET SE ROANOKE VA 24013 541867366 501(C)(3) 2500 "SMART SMILES AT THE DENTIST" PROGRAM BRADLEY FREE CLINIC 1240 THIRD STREET SW ROANOKE VA 24016 237380491 501(C)(3) 5000 UPGRADE TO DIGITAL IMAGING EQUIPMENT DANVILLE PITTSYLVANIA COMMUNITY SERVICES 245 HAIRSTON STREET DANVILLE VA 24540 540937279 501(C)(3) 3000 RESTORATIVE AND PREVENTIVE DENTAL SERVICES FOR THE MEDICALLY INDIGENT PATIENTS FREE CLINIC OF CENTRAL VIRGINIA 1016 MAIN STEET LYNCHBURG VA 24504 541420756 501(C)(3) 5000 EXPANSION OF DENTAL SERVICES FOR LOW- INCOME, UNINSURED & UNDERINSURED GOOCHLAND FREE CLINIC & FAMILY SERVICES 1800 SANDY HOOK ROAD PO BOX 116 GOOCHLAND VA 23063 541967650 501(C)(3) 5000 EXPANSION OF PREVENTATIVE DENTAL SERVICES GLOUCESTER-MATHEWS FREE CLINIC 6031 INDUSTRIAL DRIVE GLOUCESTER VA 23061 541875619 501(C)(3) 5000 EXPANSION OF DENTAL SERVICES FOR PATIENTS NEEDING DENTURES 17 1 PART I, LINE 2: THE FOUNDATION REQUESTS A MID-YEAR AND YEAR-END UPDATE OF HOW THE GRANT FUNDS WERE USED. 0 1 0 0 0 0 0 0 0 DR GEORGE A LEVICKI PRESIDENT 0 556125 0 262417 0 1806994 0 53000 0 15336 0 2693872 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 2015 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 409(A). THE FOLLOWING AMOUNT WAS PAID FROM A RELATED ORGANIZATION IN 2015: EMPLOYEE AMOUNT GEORGE A. LEVICKI $1,800,000 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 11 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 ONEMIND HEALTH (OMH) 4818 STARKEY ROAD ROANOKE VA 24018 204203105 PROVIDES CLEARINGHOUSE SERVICES TO DENTAL OFFICES VA N/A C 0 CORVESTA SOFTWARE SOLUTIONS PVT LTD 4818 STARKEY ROAD ROANOKE VA 24018 PROVIDES SOFTWARD DEVELOPMENT, PROGRAMMING & PRODUCTION OF COMPUTER SOFTWARE 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 1 0 0 0