2015-11-06T13:25:28-06:00 2014-12-31 540504608 BROWN EDWARDS & COMPANY LLP 319 MCCLANAHAN STREET SW ROANOKE VA 24014 990 2014-01-01 453230862 DELTA DENTAL OF VIRGINIA FOUNDATION DELT 5409898000 4818 STARKEY ROAD ROANOKE VA 24018 GEORGE A LEVICKI PRESIDENT 5409898000 2015-11-04 1 M C WINGFIELD P00005971 5403450936 2014 2016-04-25 22:37:26Z GEORGE A LEVICKI 4818 STARKEY ROAD ROANOKE VA 24018 435974 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 419277 435947 0 0 0 27 0 0 419277 435974 1083500 917500 0 0 0 0 0 0 0 111691 13069 1195191 930569 -775914 -494595 1156620 662032 10993 0 1145627 662032 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 917500 917500 PROMOTION OF ORAL HEALTH CARE THROUGH EDUCATION, RESEARCH AND INCREASED ACCESS TO ORAL HEALTH CARE IN THE COMMONWEALTH OF VIRGINIA. 917500 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 0 0 0 0 0 X LYNDELL B BROOKS 5409898000 4818 STARKEY ROAD ROANOKE VA 24018 DR GEORGE A LEVICKI PRESIDENT 1.00 41.00 X X 0 790269 72741 MR LYNDELL B BROOKS TREASURER 1.00 10.00 X X 0 27059 0 DR BARRY WOLFE SECRETARY 1.00 3.00 X X 0 22706 0 DR HAROLD J BARRETT JR DIRECTOR 1.00 2.00 X 0 17900 0 DR EMANUEL W MICHAELS DIRECTOR 1.00 3.00 X 0 20575 0 0 878509 72741 0 0 1 0 0 435947 435947 27 27 435974 0 0 27 917500 917500 7489 7489 326 326 1693 1693 DENTAL CLAIMS 3561 3561 930569 917500 13069 0 1143593 662032 13027 1156620 662032 10993 10993 0 X 0 0 0 0 1145627 662032 1145627 662032 1156620 662032 X -494595 20000 -9000 X X 0 1 X 1 0 X X 1 DELTA DENTAL OF VIRGINIA 540844477 501(C)(4) 1 917500 0 1 917500 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 426974 0 426974 9000 9000 435974 910569 -20000 -20000 930569 0 930569 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 YEAR ENDED DECEMBER 31, 2014 AND 2013. THE FEDERAL INFORMATIONAL RETURNS FOR 2012 AND 2013 ARE SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE, GENERALLY FOR THREE YEARS AFTER THEY ARE FILED. PART XI, LINE 4B - OTHER ADJUSTMENTS: GRANT ATTRIBUTABLE TO DDVA 9,000. 1 CHIP OF ROANOKE VALLEY 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 EXPANSION OF DENTAL SPECIALTY SERVICES CRAIG COUNTY RURAL HEALTH CARE CORPORATION 226 MARKET STREET PO BOX 370 NEW CASTLE VA 24127 562569389 501(C)(3) 7500 CRAIG COUNTY DENTAL CENTER SCHOOL BASED DENTAL PROGRAM GOOCHLAND FREE CLINIC & FAMILY SERVICES 1800 SANDY HOOK ROAD PO BOX 116 GOOCHLAND VA 23063 541967650 501(C)(3) 5000 EXPANSION OF DENTAL SERVICES HORIZON HEALTH SERVICES INC 8579 IVOR ROAD IVOR VA 23866 541103176 501(C)(3) 5000 SUBSIDIZE THE DENTIST'S SALARY AT THE IVOR DENTAL CENTER NORTHERN VIRGINIA DENTAL CLINIC INC 5827 COLUMBIA PIKE STE 405 FALLS CHURCH VA 22041 541646071 501(C)(3) 10000 PURCHASE DENTAL SUPPLIES AND EQUIPMENT OLIVET MEDICAL MINISTRY INC AKA LACKEY FREE CLINIC 1620 OLD WILLIAMSBURG ROAD YORKTOWN VA 23690 541850915 501(C)(3) 5000 DENTAL EQUIPMENT & SUPPLIES FOR TREATING PATIENTS PARK PLACE HEALTH & DENTAL CLINIC INC 606 W 29TH STREET NORFOLK VA 23508 453086608 501(C)(3) 10000 DENTAL SERVICES FOR THE UNDERSERVED LOW INCOME POPULATIONS OF THE NORFOLK AREA PIEDMONT REGIONAL DENTAL CLINIC INC 13296 JAMES MADISON HWY STE B ORANGE VA 22960 270625764 501(C)(3) 5000 PURCHASE OF EQUIPMENT FOR SMILE TIME MOBILE UNIT PIEDMONT VIRGINIA DENTAL HEALTH FOUNDATION 407 STARLING AVENUE MARTINSVILLE VA 24112 201468244 501(C)(3) 7500 SUPPORT FOR VCU STUDENTS PROVIDING RESTORATIVE AND EMERGENCY DENTAL SERVICES RESCUE MISSION OF ROANOKE INC 402 4TH STREET SE ROANOKE VA 24013 540573900 501(C)(3) 5000 PURCHASE OF EQUIPMENT FOR DENTAL SERVICES SCIENCE MUSEUM OF WESTERN VIRGINIA 4412 ELECTRIC ROAD ROANOKE VA 24018 541023953 501(C)(3) 8000 BIGMOUTH EXHIBIT UPGRADE VCU SCHOOL OF DENTISTRY PO BOX 980566 RICHMOND VA 23298 546001758 501(C)(3) 125000 SCHOLARSHIP FUNDS FOR DENTAL SCHOOL VIRGINIA DENTAL ASSOCIATION FOUNDATION 3460 MAYLAND COURT STE 110 RICHMOND VA 23298 541821602 501(C)(3) 10000 STATEWIDE MOM (MISSION OF MERCY) PROJECTS VIRGINIA HEALTH CARE FOUNDATION 707 EAST MAIN STREET STE 1350 RICHMOND VA 23219 541639924 501(C)(3) 368000 HELP ESTABLISH DENTAL SAFETY NET ORGANIZATIONS & 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 CHESAPEAKE CARE INC DBA HAMPTON ROADS DENTAL CENTER 2145 SOUTH MILITARY HWY CHESAPEAKE VA 23320 541642754 501(C)(3) 5000 EXPANSION OF ACCESS TO DENTAL CARE FOR LOW INCOME, UNINSURED ADULTS 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 HALIFAX REGIONAL HOSPITAL 2204 WILBORN AVE PO BOX 1115 SOUTH BOSTON VA 24592 540648699 501(C)(3) 5000 MOBILE DENTAL EQUIPMENT FOR COMMUNITY OUTREACH LEWIS-GALE FOUNDATION DBA HEALTH FOCUS OF SOUTHWEST VA 1902 BRAEBURN DRIVE SALEM VA 24153 546051298 501(C)(3) 5000 SCHOLARSHIP ENDOWMENT FUND FOR DENTAL AND HYGIENE STUDENTS LLOYD F MOSS FREE CLINIC 1301 SAM PERRY BLVD FREDERICKSBURG VA 22401 541677934 501(C)(3) 5000 UPGRADE TO DIGITAL X-RAY EQUIPMENT NORTHERN NECK FREE HEALTH CLINIC 51 WILLIAM B GRAHAM COURT PO BOX 1694 KILMARNOCK VA 22482 541679279 501(C)(3) 10000 EXPANSION OF DENTAL SERVICES OLDE TOWNE MEDICAL & DENTAL CENTER 5249 OLDE TOWNE ROAD WILLIAMSBURG VA 23188 541663905 501(C)(3) 5000 DENTAL EQUIPMENT & SUPPLIES FOR TREATING PATIENTS VIRGINIA ORAL HEALTH COALITION 4200 INNSLAKE DRIVE GLEN ALLEN VA 23060 274082359 501(C)(3) 5000 COALITION SUPPORT TO SHARE ORAL HEALTH INFORMATION VIRGINIA WESTERN COMMUNITY COLLEGE EDUCATION FOUNDATION 3093 COLONIAL AVE ROANOKE VA 24015 521200913 501(C)(3) SECURE THE NAMING RIGHTS FOR DENTAL HYGIENE PROGRAM AND DENTAL CLINIC PROJECT ACCESS OF THE ROANOKE VALLEY 541 LUCK AVE STE 200 ROANOKE VA 24016 200549137 501(C)(3) 10000 MINI-MOM PROJECT UNITED COMMUNITY MINISTRIES 7511 FORDSON ROAD ALEXANDRIA VA 22306 540850780 501(C)(3) 5000 DENTAL EQUIPMENT AND SUPPLIES WESTERN TIDEWATER FREE CLINIC INC 2019 MEADE PARKWAY SUFFOLK VA 23434 263302837 501(C)(3) 5000 ACCESS TO DENTURES PROJECT AMERICA'S DENTISTS CARE FOUNDATION 9110 EAST 35TH STREET NORTH WICHITA KS 67226 262275291 501(C)(3) 9000 EQUIPMENT PURCHASE OF 40-OPERATORY PROTABLE DENTAL CLINIC & TRUCK FOR MINI-MOMS (MISSIONS OF MERCY) 28 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 538404 0 245116 0 6749 0 51000 0 21741 0 863010 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 2014 WAS EARNED OVER A PRECEDING MULTI-YEAR PERIOD. THE PLAN WAS ESTABLISHED VIA THE RELATED ORGANIZATION'S EXECUTIVE 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 2014: EMPLOYEE AMOUNT GEORGE A. LEVICKI $0 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 XI, LINE 9: GRANT ATTRIBUTABLE TO DDVA -9,000. 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