2014-11-10T12:35:18-06:00 2013-12-31 540504608 BROWN EDWARDS & COMPANY LLP 319 MCCLANAHAN ST ROANOKE VA 24014 990 2013-01-01 453230862 DELTA DENTAL OF VIRGINIA FOUNDATION DELT 5409898000 4818 STARKEY ROAD ROANOKE VA 24018 GEORGE A LEVICKI PRESIDENT 5409898000 2014-11-05 1 M C WINGFIELD P00005971 5403450936 2013 2015-11-30 17:44:51Z GEORGE A LEVICKI 4818 STARKEY ROAD ROANOKE VA 24018 419277 0 X WWW.DELTADENTALVA.COM/DDVAFOUNDATION.ASPX X 2011 VA IMPROVE THE PUBLIC'S ORAL HEALTH IN THE COMMONWEALTH OF VIRGINIA. 3 2 0 0 0 0 563348 419277 0 0 22 0 0 0 563370 419277 1137000 1083500 0 0 0 0 0 0 0 4829 111691 1141829 1195191 -578459 -775914 1926326 1156620 4785 10993 1921541 1145627 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 1083500 1083500 PROMOTION OF ORAL HEALTH CARE THROUGH EDUCATION, RESEARCH AND INCREASED ACCESS TO ORAL HEALTH CARE IN THE COMMONWEALTH OF VIRGINIA. 1083500 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 3 2 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 GEORGE A LEVICKI PRESIDENT 1.00 41.00 X X 0 2448406 73071 LYNDELL B BROOKS TREASURER 1.00 5.00 X X 0 31226 0 DR BARRY WOLFE SECRETARY 1.00 3.00 X X 0 26390 0 0 2506022 73071 0 0 1 0 0 419277 419277 419277 0 0 0 1083500 1083500 17113 17113 39480 39480 RADIO DISNEY 48517 48517 DENTAL CLAIMS 6581 6581 1195191 1083500 111691 0 1926326 1143593 13027 1926326 1156620 4785 10993 4785 10993 X 0 0 0 0 1921541 1145627 1921541 1145627 1926326 1156620 -775914 0 X X 0 1 X 1 0 X X X 0 0 0 DELTA DENTAL OF VIRGINIA 540844477 501(C)(4) 1 1 1 1083500 1 1083500 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 X 419277 0 419277 0 419277 1195191 0 1195191 0 1195191 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, 2013 AND 2012. THE FEDERAL INFORMATIONAL RETURNS FOR 2011 AND 2012 ARE SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE, GENERALLY FOR THREE YEARS AFTER THEY ARE FILED. 1 BOYS & GIRLS CLUBS OF SOUTHWEST VA 1714 9TH STREET SE ROANOKE VA 24013 541867366 501(C)(3) 5000 DELTA DENTAL SMART SMILES AT THE DENTIST PROGRAM CHILD HEALTH INVESTMENT PARTNERSHIP 1201 THIRD STREET SW ROANOKE VA 24016 541566451 501(C)(3) 10000 FLORIDE VARNISH TREATMENTS FOR CHILDREN FROM TOOTH BUD TO AGE 36 MONTHS STAFFING OF THE CLINIC'S DENTAL PROGRAM COUNCIL OF COMMUNITY SERVICES 502 CAMPBELL AVENUE ROANOKE VA 24016 540718859 501(C)(3) 20000 ROANOKE MOM (MISSION OF MERCY) PROJECTS CRAIG COUNTY RURAL HEALTH CARE CORPORATION 226 MARKET STREET PO BOX 370 NEW CASTLE VA 24127 562569389 501(C)(3) 10000 SCHOOL BASED DENTAL PROGRAM GOOCHLAND FREE CLINIC & FAMILY SERVICES 1800 SANDY HOOK ROAD GOOCHLAND VA 23063 541967650 501(C)(3) 10000 EXPAND DENTAL SERVICES HORIZON HEALTH SERVICES INC 8579 IVOR ROAD IVOR VA 23866 541103176 501(C)(3) 10000 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 OLIVET MEDICAL MINISTRY INC DBA LACKEY FREE CLINIC 1620 OLD WILLIAMSBURG ROAD YORKTOWN VA 23690 541850915 501(C)(3) 10000 STAFFING OF DENTAL EXPANSION PARK PLACE HEALTH & DENTAL CLINIC INC 606 W 29TH STREET NORFOLK VA 23508 453086608 501(C)(3) 10000 SUPPORT FOR VCU DENTAL STUDENTS & HYGIENISTS WORKING AT THE DENTAL CLINIC PIEDMONT REGIONAL DENTAL CLINIC INC 13296 JAMES MADISON HWY STE B ORANGE VA 22960 270625764 501(C)(3) 10000 OPERATORY EXPANSION FOR VCU AFFILIATION PROGRAM PIEDMONT VIRGINIA DENTAL HEALTH FOUNDATION 407 STARLING AVENUE MARTINSVILLE VA 24112 201468244 501(C)(3) 10000 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) 20000 RESTORATIVE AND EMERGENCY DENTAL SERVICES ROCKBRIDGE AREA FREE CLINIC 25 NORTHRIDGE LANE LEXINGTON VA 24450 541642220 501(C)(3) 10000 STAFFING FOR NEW CLINIC SCIENCE MUSEUM OF WESTERN VIRGINIA 4412 ELECTRIC ROAD ROANOKE VA 24018 541023953 501(C)(3) 8000 BIGMOUTH EXHIBIT UPGRADE SHENANDOAH DENTAL CLINIC 781 SPRING PARKWAY WOODSTOCK VA 22664 680657235 501(C)(3) 10000 HIRE PART TIME DENTAL HYGIENIST VCU SCHOOL OF DENTISTRY PO BOX 980566 RICHMOND VA 23298 546001758 115 125000 SCHOLARSHIP FUNDS FOR DENTAL SCHOOL VIRGINIA DENTAL ASSOCIATION FOUNDATION 3460 MAYLAND COURT STE 110 RICHMOND VA 23298 541821602 501(C)(3) 10000 MOM (MISSION OF MERCY) PROJECTS VIRGINIA HEALTH CARE FOUNDATION 707 EAST MAIN STREET STE 1350 RICHMOND VA 23219 541639924 501(C)(3) 368000 ESTABLISH NEW 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 PERMANENTLY ENDOW THE 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) 7500 CONTINUE DENTAL ACCESS EXPANSION PROJECT FOR LOW INCOME AND 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 FREE CLINIC OF CENTRAL VIRGINIA LYNCHBURG 1016 MAIN STREET LYNCHBURG VA 24504 541420756 501(C)(3) 10000 EXPANSION OF DENTAL SPECIALTY SERVICES HALIFAX REGIONAL HOSPITAL 2204 WILBORN AVE PO BOX 1115 SOUTH BOSTON VA 24592 540648699 501(C)(3) 5000 DENTAL SUPPLIES FOR DENTAL CLINIC LEWIS GALE FOUNDATION DBS 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 IMPLEMENTATION OF ELECTRONIC DENTAL RECORDS SYSTEM NORTHERN NECK FREE HEALTH CLINIC 51 WILLIAM BE GRAHAM COURT PO BOX 1694 KILMARNOCK VA 22482 541679279 501(C)(3) 10000 EXPAND DENTAL SERVICES OLDE TOWNE MEDICAL & DENTAL CENTER 5249 OLDE TOWNE ROAD WILLIAMSBURG VA 23188 541663905 501(C)(3) 10000 ADULT DENTAL CARE EXPANSION PROGRAM 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) 100000 SECURE THE NAMING RIGHTS FOR DENTAL HYGIENE PROGRAM AND DENTAL CLINIC 29 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 GEORGE A LEVICKI PRESIDENT 0 508656 0 132456 0 1807294 0 50000 0 23071 0 2521477 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 PAYMENTS IN 2013 WERE 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 2013: 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 0 0 0 0 DELTA DENTAL OF VIRGINIA C 419277 FAIR MARKET VALUE