SUSAN DEW HOFF MEMORIAL CLINIC INC: Form 990, tax year 2012

View the entire original 990 at ProPublica ↗

Organization: SUSAN DEW HOFF MEMORIAL CLINIC INC (EIN 55-0768457)
Tax period: 2012-01-01 to 2012-12-31
Filed: 2013-05-14
IRS object ID: 201341349349302964
Schema version: 2012v2.1
Source: Download XML · Original 990 at ProPublica

Every field in the e-filed return. Faint text is the IRS element name, for citing.

Return header
Form 990
Schedule A
Schedule B
Schedule D
Schedule L
Schedule O

Return header ReturnHeader

Field	Value	IRS element (for citing)
Timestamp	2013-05-14T11:49:19-05:00	Timestamp
Tax Period End Date	2012-12-31	TaxPeriodEndDate

Preparer Firm PreparerFirm

Field	Value	IRS element (for citing)
EIN	550486667	EIN

Preparer Firm Business Name PreparerFirmBusinessName

Field	Value	IRS element (for citing)
Business Name Line1	ARNETT FOSTER TOOTHMAN PLLC	BusinessNameLine1

Preparer Firm US Address PreparerFirmUSAddress

Field	Value	IRS element (for citing)
Address Line1	PO BOX 908	AddressLine1
City	BRIDGEPORT	City
State	WV	State
ZIP Code	26330	ZIPCode

Field	Value	IRS element (for citing)
Return Type	990	ReturnType
Tax Period Begin Date	2012-01-01	TaxPeriodBeginDate

Filer Filer

Field	Value	IRS element (for citing)
EIN	550768457	EIN

Name Name

Field	Value	IRS element (for citing)
Business Name Line1	SUSAN DEW HOFF MEMORIAL CLINIC INC	BusinessNameLine1

Field	Value	IRS element (for citing)
Name Control	SUSA	NameControl
Phone	3047453700	Phone

US Address USAddress

Field	Value	IRS element (for citing)
Address Line1	925 LIBERTY AVENUE	AddressLine1
City	WEST MILFORD	City
State	WV	State
ZIP Code	26451	ZIPCode

Officer Officer

Field	Value	IRS element (for citing)
Name	SISTER MARY REBECCA FIDLER	Name
Title	CEO	Title
Phone	3047453700	Phone
Date Signed	2013-05-09	DateSigned
Authorize Third Party	1	AuthorizeThirdParty

Preparer Preparer

Field	Value	IRS element (for citing)
Name	STACIE MILLER	Name
PTIN	P00247848	PTIN
Phone	3046245471	Phone
Date Prepared	2013-05-09	DatePrepared

Field	Value	IRS element (for citing)
Tax Year	2012	TaxYear
Build TS	2016-02-24 21:20:13Z	BuildTS

Form 990 IRS990

Doing Business As DoingBusinessAs

Field	Value	IRS element (for citing)
Business Name Line1	SUSAN DEW HOFF MEMORIAL CLINIC	BusinessNameLine1

Field	Value	IRS element (for citing)
Name Of Principal Officer Person	SISTER MARY REBECCA FIDLE	NameOfPrincipalOfficerPerson

Address Principal Officer US AddressPrincipalOfficerUS

Field	Value	IRS element (for citing)
Address Line1	925 LIBERTY AVENUE	AddressLine1
City	WEST MILFORD	City
State	WV	State
ZIP Code	26451	ZIPCode

Field	Value	IRS element (for citing)
Gross Receipts	173269	GrossReceipts
Group Return For Affiliates	0	GroupReturnForAffiliates
Organization501c3	X	Organization501c3
Web Site	N/A	WebSite
Type Of Organization Corporation	X	TypeOfOrganizationCorporation
Type Of Org Other Description	OTHER	TypeOfOrgOtherDescription
Year Formation	1999	YearFormation
State Legal Domicile	WV	StateLegalDomicile
Activity Or Mission Description	PROVIDE HEALTH AND DENTAL CARE TO THE UNINSURED WORKING POOR.	ActivityOrMissionDescription
Nbr Voting Members Governing Body	22	NbrVotingMembersGoverningBody
Nbr Independent Voting Members	22	NbrIndependentVotingMembers
Total Nbr Employees	0	TotalNbrEmployees
Total Nbr Volunteers	58	TotalNbrVolunteers
Total Gross UBI	0	TotalGrossUBI
Net Unrelated Business Txbl Income	0	NetUnrelatedBusinessTxblIncome
Contributions Grants Prior Year	178695	ContributionsGrantsPriorYear
Contributions Grants Current Year	164705	ContributionsGrantsCurrentYear
Program Service Revenue Prior Year	0	ProgramServiceRevenuePriorYear
Program Service Revenue CY	0	ProgramServiceRevenueCY
Investment Income Prior Year	-9291	InvestmentIncomePriorYear
Investment Income Current Year	8564	InvestmentIncomeCurrentYear
Other Revenue Prior Year	9843	OtherRevenuePriorYear
Other Revenue Current Year	0	OtherRevenueCurrentYear
Total Revenue Prior Year	179247	TotalRevenuePriorYear
Total Revenue Current Year	173269	TotalRevenueCurrentYear
Grants And Similar Amnts Prior Year	2762	GrantsAndSimilarAmntsPriorYear
Grants And Similar Amnts CY	1431	GrantsAndSimilarAmntsCY
Benefits Paid To Members Prior Year	0	BenefitsPaidToMembersPriorYear
Benefits Paid To Members CY	0	BenefitsPaidToMembersCY
Salaries Etc Prior Year	0	SalariesEtcPriorYear
Salaries Etc Current Year	0	SalariesEtcCurrentYear
Total Prof Fundrsng Exp Prior Year	0	TotalProfFundrsngExpPriorYear
Total Prof Fundrsng Exp CY	0	TotalProfFundrsngExpCY
Total Fundrsng Exp Current Year	0	TotalFundrsngExpCurrentYear
Other Expense Prior Year	151615	OtherExpensePriorYear
Other Expenses Current Year	170643	OtherExpensesCurrentYear
Total Expenses Prior Year	154377	TotalExpensesPriorYear
Total Expenses Current Year	172074	TotalExpensesCurrentYear
Revenues Less Expenses Prior Year	24870	RevenuesLessExpensesPriorYear
Revenues Less Expenses CY	1195	RevenuesLessExpensesCY
Total Assets BOY	676893	TotalAssetsBOY
Total Assets EOY	631458	TotalAssetsEOY
Total Liabilities BOY	4462	TotalLiabilitiesBOY
Total Liabilities EOY	17681	TotalLiabilitiesEOY
Net Assets Or Fund Balances BOY	672431	NetAssetsOrFundBalancesBOY
Net Assets Or Fund Balances EOY	613777	NetAssetsOrFundBalancesEOY
Mission Description	TO PROVIDE HEALTH ASSESSMENT, PROMOTION AND REFERRAL SERVICES TO THE WORKING POOR WHO LACK MEDICAL AND DENTAL INSURANCE.	MissionDescription
Significant New Program Services	0	SignificantNewProgramServices
Significant Change	0	SignificantChange
Expense	161569	Expense
Grants	1431	Grants
Description	THE CLINIC PROVIDED IN-CLINIC PROCEDURES WHICH INCLUDED 1,749 DENTAL VISITS RESULTING IN 1,875 RESTORATIVE OR PREVENTATIVE PROCEDURES AND 28 REFERRALS TO OTHER DENTISTS FOR PROCEDURES THE CLINIC COULD NOT ADEQUATELY PERFORM. THESE IN-CLINIC PROCEDURES INCLUDED 81 X-RAYS, 100 CLEANINGS, 753 FILLINGS, 86 PARTIALS AND/OR DENTURES, AND 873 EXTRACTIONS.	Description
Total Program Service Expense	161569	TotalProgramServiceExpense
Described In501 C3	1	DescribedIn501C3
Schedule B Required	1	ScheduleBRequired
Political Activities	0	PoliticalActivities
Lobbying Activities	0	LobbyingActivities
Subject To Proxy Tax	0	SubjectToProxyTax
Donor Advised Funds	0	DonorAdvisedFunds
Conservation Easements	0	ConservationEasements
Collections Of Art	0	CollectionsOfArt
Credit Counseling	0	CreditCounseling
Term Or Permanent Endowments	0	TermOrPermanentEndowments
Report Land Bldg Equip	1	ReportLandBldgEquip
Report Invest Oth Securities	0	ReportInvestOthSecurities
Report Prog Rel Invest	0	ReportProgRelInvest
Report Other Assets	0	ReportOtherAssets
Report Other Liabilities	1	ReportOtherLiabilities
Report Fin48 Footnote	1	ReportFin48Footnote
Independent Audit Financial Stmt	1	IndependentAuditFinancialStmt
Consolidated Audit Financial Stmt	0	ConsolidatedAuditFinancialStmt
School	0	School
Foreign Office	0	ForeignOffice
Foreign Activities	0	ForeignActivities
More Than5000 K To Organizations	0	MoreThan5000KToOrganizations
More Than5000 K To Individuals	0	MoreThan5000KToIndividuals
Professional Fundraising	0	ProfessionalFundraising
Fundraising Activities	0	FundraisingActivities
Gaming	0	Gaming
Hospital	0	Hospital
Grants To Organizations	0	GrantsToOrganizations
Grants To Individuals	0	GrantsToIndividuals
Schedule J Required	0	ScheduleJRequired
Tax Exempt Bonds	0	TaxExemptBonds
Excess Benefit Transaction	0	ExcessBenefitTransaction
Prior Excess Benefit Transaction	0	PriorExcessBenefitTransaction
Loan To Officer Or DQP	0	LoanToOfficerOrDQP
Grant To Related Person	0	GrantToRelatedPerson
Bsnss Rltnshp With Organization	0	BsnssRltnshpWithOrganization
Bsnss Rltnshp Thru Family Member	0	BsnssRltnshpThruFamilyMember
Officer Entity With Bsnss Rltnshp	1	OfficerEntityWithBsnssRltnshp
Deductible Non Cash Contributions	0	DeductibleNonCashContributions
Deductible Contributions Of Art	0	DeductibleContributionsOfArt
Terminated	0	Terminated
Partial Liquidation	0	PartialLiquidation
Disregarded Entity	0	DisregardedEntity
Related Entity	0	RelatedEntity
Related Org Controlled Entity	0	RelatedOrgControlledEntity
Transfers To Exempt Non Chrtbl Org	0	TransfersToExemptNonChrtblOrg
Activities Conducted Partnership	0	ActivitiesConductedPartnership
Schedule O Required	1	ScheduleORequired
Number Forms Transmitted With1096	3	NumberFormsTransmittedWith1096
Number W2 G Included	0	NumberW2GIncluded
Compliance With Backup Witholding	0	ComplianceWithBackupWitholding
Number Of Employees	0	NumberOfEmployees
Unrelated Business Income	0	UnrelatedBusinessIncome
Foreign Financial Account	0	ForeignFinancialAccount
Prohibited Tax Shelter Trans	0	ProhibitedTaxShelterTrans
Taxable Party Notification	0	TaxablePartyNotification
Non Deductible Contributions	0	NonDeductibleContributions
Quid Pro Quo Contributions	0	QuidProQuoContributions
Form8282 Property Disposed Of	0	Form8282PropertyDisposedOf
Indoor Tanning Services	0	IndoorTanningServices
Info In Schedule O Part VI	X	InfoInScheduleOPartVI
Nbr Voting Governing Body Members	22	NbrVotingGoverningBodyMembers
Number Independent Voting Members	22	NumberIndependentVotingMembers
Family Or Business Relationship	0	FamilyOrBusinessRelationship
Delegation Of Management Duties	0	DelegationOfManagementDuties
Changes To Organizing Docs	0	ChangesToOrganizingDocs
Material Diversion Or Misuse	0	MaterialDiversionOrMisuse
Members Or Stockholders	0	MembersOrStockholders
Election Of Board Members	0	ElectionOfBoardMembers
Decisions Subject To Approval	0	DecisionsSubjectToApproval
Minutes Of Governing Body	1	MinutesOfGoverningBody
Minutes Of Committees	1	MinutesOfCommittees
Officer Mailing Address	0	OfficerMailingAddress
Local Chapters	0	LocalChapters
Form990 Provided To Governing Body	1	Form990ProvidedToGoverningBody
Conflict Of Interest Policy	1	ConflictOfInterestPolicy
Annual Disclosure Covered Persons	1	AnnualDisclosureCoveredPersons
Regular Monitoring Enforcement	1	RegularMonitoringEnforcement
Whistleblower Policy	0	WhistleblowerPolicy
Document Retention Policy	0	DocumentRetentionPolicy
Compensation Process CEO	0	CompensationProcessCEO
Compensation Process Other	0	CompensationProcessOther
Investment In Joint Venture	0	InvestmentInJointVenture
States Where Copy Of Return Is Filed	WV	StatesWhereCopyOfReturnIsFiled
Other Website	X	OtherWebsite
Upon Request	X	UponRequest

The Books Are In Care Of TheBooksAreInCareOf

Name Business NameBusiness

Field	Value	IRS element (for citing)
Business Name Line1	SUSAN DEW HOFF MEMORIAL CLINIC INC	BusinessNameLine1

Field	Value	IRS element (for citing)
Telephone Number	3047453700	TelephoneNumber

Address US AddressUS

Field	Value	IRS element (for citing)
Address Line1	925 LIBERTY STREET	AddressLine1
City	WEST MILFORD	City
State	WV	State
ZIP Code	26451	ZIPCode

Field	Value	IRS element (for citing)
No Listed Persons Compensated	X	NoListedPersonsCompensated

Form990 Part VII Section A Form990PartVIISectionA (22 entries)

TitleTitle	Average Hours Per WeekAverageHoursPerWeek	Individual Trustee Or DirectorIndividualTrusteeOrDirector	Reportable Comp From OrganizationReportableCompFromOrganization	Reportable Comp From Related OrgsReportableCompFromRelatedOrgs	Other CompensationOtherCompensation	OfficerOfficer
JAMES YOHE
DIRECTOR	1.00	X	0	0	0
NANCY GALL
DIRECTOR	1.00	X	0	0	0
GINA SHARPS
DIRECTOR	1.00	X	0	0	0
VALARIE DUNLEVY
DIRECTOR	1.00	X	0	0	0
BERNICE JEAN LUCAS
DIRECTOR	1.00	X	0	0	0
DINO COLOMBO DDS
DIRECTOR	1.00	X	0	0	0
THOMAS CONDRON DDS
DIRECTOR	1.00	X	0	0	0
SANDY GANS
DIRECTOR	1.00	X	0	0	0
PAUL GANS
DIRECTOR	1.00	X	0	0	0
ROBERT HAROLD
DIRECTOR	1.00	X	0	0	0
REV LEON LYDON
DIRECTOR	1.00	X	0	0	0
MARY LOU VARGO
DIRECTOR	1.00	X	0	0	0
JOHN S WILSON
DIRECTOR	1.00	X	0	0	0
DR ROBERT WRANKER DDS
DIRECTOR	1.00	X	0	0	0
FRANK NUZUM ACCOUNTANT
DIRECTOR	1.00	X	0	0	0
SISTER BEATRICE BURKLE
DIRECTOR	1.00	X	0	0	0
PASTOR CHRIS MULLETT
DIRECTOR	1.00	X	0	0	0
HERBERT UNDERWOOD
CHAIRMAN	1.00		0	0	0	X
MAGGIE FISHER
VICE CHAIRMAN	1.00		0	0	0	X
VICTOR FOLIO
SECRETARY	1.00		0	0	0	X
ANGIE CAVANAUGH
TREASURER	6.00		0	0	0	X
SISTER MARY REBECCA FIDLER
CEO	70.00		0	0	0	X

Field	Value	IRS element (for citing)
Total Reportable Comp From Org	0	TotalReportableCompFromOrg
Total Reportable Comp Frm Rltd Orgs	0	TotalReportableCompFrmRltdOrgs
Total Other Compensation	0	TotalOtherCompensation
Number Individuals GT100 K	0	NumberIndividualsGT100K
Formers Listed	0	FormersListed
Total Comp GT150 K	0	TotalCompGT150K
Compensation From Other Sources	0	CompensationFromOtherSources
Number Of Contractors GT100 K	0	NumberOfContractorsGT100K
All Other Contributions	164705	AllOtherContributions
Total Contributions	164705	TotalContributions

Investment Income InvestmentIncome

Field	Value	IRS element (for citing)
Total Revenue Column	8564	TotalRevenueColumn
Exclusion	$8,564	ExclusionAmount

Total Revenue TotalRevenue

Field	Value	IRS element (for citing)
Total Revenue Column	173269	TotalRevenueColumn
Related Or Exempt Function Income	0	RelatedOrExemptFunctionIncome
Unrelated Business Revenue	0	UnrelatedBusinessRevenue
Exclusion	$8,564	ExclusionAmount

Grants To Domestic Individuals GrantsToDomesticIndividuals

Field	Value	IRS element (for citing)
Total	1431	Total
Program Services	1431	ProgramServices

Fees For Services Accounting FeesForServicesAccounting

Field	Value	IRS element (for citing)
Total	10505	Total
Management And General	10505	ManagementAndGeneral

Advertising Advertising

Field	Value	IRS element (for citing)
Total	200	Total
Program Services	200	ProgramServices

Office Expenses OfficeExpenses

Field	Value	IRS element (for citing)
Total	863	Total
Program Services	863	ProgramServices

Occupancy Occupancy

Field	Value	IRS element (for citing)
Total	4688	Total
Program Services	4688	ProgramServices

Travel Travel

Field	Value	IRS element (for citing)
Total	2722	Total
Program Services	2722	ProgramServices

Depreciation Depletion DepreciationDepletion

Field	Value	IRS element (for citing)
Total	7283	Total
Program Services	7283	ProgramServices

Insurance Insurance

Field	Value	IRS element (for citing)
Total	9752	Total
Program Services	9752	ProgramServices

Other Expenses OtherExpenses (4 entries)

DescriptionDescription	TotalTotal	Program ServicesProgramServices
CONTRACTED DENTAL SERVI	50858	50858
DENTAL LAB WORK	36451	36451
OTHER CONTRACTED SERVIC	21492	21492
LOAN GUARANTEE EXPENSE	10000	10000

All Other Expenses AllOtherExpenses

Field	Value	IRS element (for citing)
Total	15829	Total
Program Services	15829	ProgramServices

Total Functional Expenses TotalFunctionalExpenses

Field	Value	IRS element (for citing)
Total	172074	Total
Program Services	161569	ProgramServices
Management And General	10505	ManagementAndGeneral
Fundraising	0	Fundraising

Cash Non Interest Bearing CashNonInterestBearing

Field	Value	IRS element (for citing)
BOY	102277	BOY
EOY	108436	EOY

Savings And Temp Cash Investments SavingsAndTempCashInvestments

Field	Value	IRS element (for citing)
BOY	467008	BOY
EOY	388938	EOY

Accounts Receivable AccountsReceivable

Field	Value	IRS element (for citing)
EOY	11288	EOY

Other Notes Loans Receivable Net OtherNotesLoansReceivableNet

Field	Value	IRS element (for citing)
BOY	16068	BOY
EOY	13498	EOY

Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges

Field	Value	IRS element (for citing)
BOY	7075	BOY
EOY	7161	EOY

Field	Value	IRS element (for citing)
Land Buildings Equipment Basis	170634	LandBuildingsEquipmentBasis
Land Bldg Equipment Accum Deprec	68497	LandBldgEquipmentAccumDeprec

Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet

Field	Value	IRS element (for citing)
BOY	84465	BOY
EOY	102137	EOY

Total Assets TotalAssets

Field	Value	IRS element (for citing)
BOY	676893	BOY
EOY	631458	EOY

Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses

Field	Value	IRS element (for citing)
BOY	4462	BOY
EOY	7681	EOY

Other Liabilities OtherLiabilities

Field	Value	IRS element (for citing)
BOY	0	BOY
EOY	10000	EOY

Total Liabilities TotalLiabilities

Field	Value	IRS element (for citing)
BOY	4462	BOY
EOY	17681	EOY

Field	Value	IRS element (for citing)
Follow SFAS117	X	FollowSFAS117

Unrestricted Net Assets UnrestrictedNetAssets

Field	Value	IRS element (for citing)
BOY	672431	BOY
EOY	613777	EOY

Total Net Assets Fund Balances TotalNetAssetsFundBalances

Field	Value	IRS element (for citing)
BOY	672431	BOY
EOY	613777	EOY

Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances

Field	Value	IRS element (for citing)
BOY	676893	BOY
EOY	631458	EOY

Field	Value	IRS element (for citing)
Reconcilation Revenue Expenses	1195	ReconcilationRevenueExpenses
Reconcilation Prior Adjustment	-59849	ReconcilationPriorAdjustment
Reconcilation Other Changes	0	ReconcilationOtherChanges
Info In Schedule O Part XII	X	InfoInScheduleOPartXII
Method Of Accounting Accrual	X	MethodOfAccountingAccrual
Accountant Compile Or Review	0	AccountantCompileOrReview
FS Audited	1	FSAudited

FS Audited Basis FSAuditedBasis

Field	Value	IRS element (for citing)
Financial Statement Separate	X	FinancialStatementSeparate

Field	Value	IRS element (for citing)
Audit Committee	1	AuditCommittee
Federal Grant Audit Required	0	FederalGrantAuditRequired

Schedule A IRS990ScheduleA

Field	Value	IRS element (for citing)
Publicly Supported Org170b1 Avi	X	PubliclySupportedOrg170b1Avi

Gifts Grants Contrib Received170 GiftsGrantsContribReceived170

Field	Value	IRS element (for citing)
Current Tax Year Minus4 Years	130842	CurrentTaxYearMinus4Years
Current Tax Year Minus3 Years	122409	CurrentTaxYearMinus3Years
Current Tax Year Minus2 Years	232851	CurrentTaxYearMinus2Years
Current Tax Year Minus1 Year	178695	CurrentTaxYearMinus1Year
Current Tax Year	164705	CurrentTaxYear
Total	829502	Total

Total170 Total170

Field	Value	IRS element (for citing)
Current Tax Year Minus4 Years	130842	CurrentTaxYearMinus4Years
Current Tax Year Minus3 Years	122409	CurrentTaxYearMinus3Years
Current Tax Year Minus2 Years	232851	CurrentTaxYearMinus2Years
Current Tax Year Minus1 Year	178695	CurrentTaxYearMinus1Year
Current Tax Year	164705	CurrentTaxYear
Total	829502	Total

Field	Value	IRS element (for citing)
Public Support Total170	829502	PublicSupportTotal170

Gross Investment Income170 GrossInvestmentIncome170

Field	Value	IRS element (for citing)
Current Tax Year Minus4 Years	11462	CurrentTaxYearMinus4Years
Current Tax Year Minus3 Years	6200	CurrentTaxYearMinus3Years
Current Tax Year Minus2 Years	7017	CurrentTaxYearMinus2Years
Current Tax Year Minus1 Year	7421	CurrentTaxYearMinus1Year
Current Tax Year	8564	CurrentTaxYear
Total	40664	Total

Other Income170 OtherIncome170

Field	Value	IRS element (for citing)
Current Tax Year Minus4 Years	12729	CurrentTaxYearMinus4Years
Current Tax Year Minus3 Years	2193	CurrentTaxYearMinus3Years
Current Tax Year Minus2 Years	7972	CurrentTaxYearMinus2Years
Current Tax Year Minus1 Year	9843	CurrentTaxYearMinus1Year
Total	32737	Total

Field	Value	IRS element (for citing)
Total Support	902903	TotalSupport
Public Support Pertcentage170	0.91870	PublicSupportPertcentage170
Public Support Pertcent Prior Year	0.90910	PublicSupportPertcentPriorYear
Thirty Three Percnt Tests CY170	X	ThirtyThreePercntTestsCY170

Schedule B IRS990ScheduleB

Contributor Info ContributorInfo

Field	Value	IRS element (for citing)
Contributor Number	RESTRICTED	ContributorNumber

Contributor Name Business ContributorNameBusiness

Field	Value	IRS element (for citing)
Business Name Line1	RESTRICTED	BusinessNameLine1

Contributor Address US ContributorAddressUS

Field	Value	IRS element (for citing)
Address Line1	RESTRICTED	AddressLine1
Address Line2	RESTRICTED	AddressLine2
City	RESTRICTED	City
State	RESTRICTED	State
ZIP Code	RESTRICTED	ZIPCode

Field	Value	IRS element (for citing)
Aggregate Contributions	RESTRICTED	AggregateContributions

Schedule D IRS990ScheduleD

Buildings Buildings

Field	Value	IRS element (for citing)
Other Cost Or Other Basis	35323	OtherCostOrOtherBasis
Depreciation	6629	Depreciation
Book Value	28694	BookValue

Other Land Buildings OtherLandBuildings

Field	Value	IRS element (for citing)
Other Cost Or Other Basis	135311	OtherCostOrOtherBasis
Depreciation	61868	Depreciation
Book Value	73443	BookValue

Field	Value	IRS element (for citing)
Total Of Book Value Land Buildings	102137	TotalOfBookValueLandBuildings

Other Liabilities OtherLiabilities

Field	Value	IRS element (for citing)
Description	LOAN GUARANTEE PAYABLE	Description
Amount	$10,000	Amount

Field	Value	IRS element (for citing)
Total Of Amounts	10000	TotalOfAmounts
Footnote In Part XIII	X	FootnoteInPartXIII
Tot Revenue Etc Audited Fincl Stmt	331783	TotRevenueEtcAuditedFinclStmt
Donated Srvc And Use Of Facilities	158514	DonatedSrvcAndUseOfFacilities
Revenue Not Rptd F990	158514	RevenueNotRptdF990
Revenue Subtotal	173269	RevenueSubtotal
Revenue Not Rptd On Fin Stmt	0	RevenueNotRptdOnFinStmt
Total Revenue Per Form990	173269	TotalRevenuePerForm990
Tot Expenses Etc Audited Fincl Stmt	330588	TotExpensesEtcAuditedFinclStmt
Donated Services Use Of Facilities	158514	DonatedServicesUseOfFacilities
Expenses Not Rptd F990	158514	ExpensesNotRptdF990
Expenses Subtotal	172074	ExpensesSubtotal
Expenses Not Rptd On Fin Stmt	0	ExpensesNotRptdOnFinStmt
Total Expenses Per Form990	172074	TotalExpensesPerForm990

Form990 Schedule D Part XIII Form990ScheduleDPartXIII

Field	Value	IRS element (for citing)
Identifier	DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48:	Identifier
Return Reference	PART X, LINE 2:	ReturnReference
Explanation	ACCOUNTING STANDARDS CODIFICATION TOPIC 740-10 PRESCRIBES A RECOGNITION THRESHOLD AND MEASUREMENT ATTRIBUTE FOR A TAX POSITION TAKEN OR EXPECTED TO BE TAKEN IN A TAX RETURN WHERE THERE IS UNCERTAINTY ABOUT WHETHER A TAX POSITION WILL ULTIMATELY BE SUSTAINED UPON EXAMINATION. THE CLINIC DOES NOT BELIEVE ITS FINANCIAL STATEMENTS INCLUDE (OR REFLECT) ANY UNCERTAIN TAX POSITIONS.	Explanation

Schedule L IRS990ScheduleL

Form990 Schedule L Part IV Form990ScheduleLPartIV

Name Of Interested Person NameOfInterestedPerson

Name Business NameBusiness

Field	Value	IRS element (for citing)
Business Name Line1	CLARKSBURG MISSION	BusinessNameLine1

Field	Value	IRS element (for citing)
Relationship	COMMON OFFICER	Relationship
Amount Of Transaction	10000	AmountOfTransaction
Description Of Transaction	THE ORGANIZATION WAS A LOAN GUARANTOR FOR ANOTHER ORGANIZATION IN WHICH THEY SHARE A COMMON OFFICER. A LOAN GUARANTEE PAYABLE WAS RECORDED AT YEAR END.	DescriptionOfTransaction
Sharing Of Revenues	0	SharingOfRevenues

Schedule O IRS990ScheduleO

General Explanation GeneralExplanation (4 entries)

Return ReferenceReturnReference	ExplanationExplanation
FORM 990, PART VI, SECTION B, LINE 11	THE BOARD MEMBERS ARE PROVIDED A COPY OF THE 990 AND IT IS REVIEWED AT BOARD MEETING.
FORM 990, PART VI, SECTION B, LINE 12C	THE CLINIC ENFORCES AN ANNUAL DISCLOSURE REQUIREMENT WITH ITS CONFLICT OF INTEREST POLICY.
FORM 990, PART VI, SECTION C, LINE 19	THE CLINIC MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST.
FORM 990, PART XI, LINE 2C	THE ORGANIZATION HAS A COMMITEE THAT ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS. THE SELECTION PROCESS FOR CHOOSING AN INDEPENDENT ACCOUNTANT HAS NOT CHANGED FROM THE PREVIOUS YEAR.