COMMUNITY CARE CENTER FOR FORSYTH COUNTY: Form 990, tax year 2016

View the entire original 990 at ProPublica ↗

Organization
COMMUNITY CARE CENTER FOR FORSYTH COUNTY (EIN 58-1403699)
Tax period
2016-01-01 to 2016-12-31
Filed
2017-08-21
IRS object ID
201702339349300110
Schema version
2016v3.0
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 ReturnHeader

FieldValueIRS element (for citing)
Return2017-08-21T07:07:41-07:00ReturnTs
Tax Period End2016-12-31TaxPeriodEndDt

Preparer Firm PreparerFirmGrp

Preparer Firm Name PreparerFirmName

FieldValueIRS element (for citing)
Business Name Line1BROWN JENKINS AND ONEYEAR PABusinessNameLine1Txt

Preparer US Address PreparerUSAddress

FieldValueIRS element (for citing)
Address Line1326 South Main StreetAddressLine1Txt
CityWinston SalemCityNm
State AbbreviationNCStateAbbreviationCd
ZIP27101ZIPCd
FieldValueIRS element (for citing)
Return Type990ReturnTypeCd
Tax Period Begin2016-01-01TaxPeriodBeginDt

Filer Filer

FieldValueIRS element (for citing)
EIN581403699EIN

Business Name BusinessName

FieldValueIRS element (for citing)
Business Name Line1Community Care Center for Forsyth CountyBusinessNameLine1Txt
FieldValueIRS element (for citing)
Business Name ControlCOMMBusinessNameControlTxt
Phone3367601235PhoneNum

US Address USAddress

FieldValueIRS element (for citing)
Address Line12135 New Walkertown RoadAddressLine1Txt
CityWinston SalemCityNm
State AbbreviationNCStateAbbreviationCd
ZIP27101ZIPCd

Business Officer BusinessOfficerGrp

FieldValueIRS element (for citing)
PersonJAMES T ROBINSONPersonNm
Person TitleSECRETARY/TREASURERPersonTitleTxt
Phone3367601235PhoneNum
Signature2017-08-17SignatureDt
Discuss With Paid PreparerYes (true)DiscussWithPaidPreparerInd

Preparer Person PreparerPersonGrp

FieldValueIRS element (for citing)
Preparer PersonREBECCA A ONEYEAR CPAPreparerPersonNm
Phone3367610366PhoneNum

Filing Security Information FilingSecurityInformation

IP Address IPAddress

FieldValueIRS element (for citing)
I Pv4 Address70.63.66.146IPv4AddressTxt
FieldValueIRS element (for citing)
IP2017-08-21IPDt
IP Tm07:07:29IPTm
IP TimezonePDIPTimezoneCd
Filing License TypePFilingLicenseTypeCd
At Submission Creation Device Id09D358876ECFCAFBA6DD6B2528C44D39FD12853FAtSubmissionCreationDeviceId
At Submission Filing Device Id09D358876ECFCAFBA6DD6B2528C44D39FD12853FAtSubmissionFilingDeviceId
FieldValueIRS element (for citing)
Tax2016TaxYr
Build TS2021-01-29 14:40:06ZBuildTS

Form 990 IRS990

FieldValueIRS element (for citing)
Principal OfficerANTHONY BRETTPrincipalOfficerNm

US Address USAddress

FieldValueIRS element (for citing)
Address Line12135 New Walkertown RoadAddressLine1Txt
CityWinstonSalemCityNm
State AbbreviationNCStateAbbreviationCd
ZIP27101ZIPCd
FieldValueIRS element (for citing)
Gross Receipts$2,121,244GrossReceiptsAmt
Group Return For AffiliatesfalseGroupReturnForAffiliatesInd
Organization501c3Yes (X)Organization501c3Ind
Website AddressWWW.CCCForsyth.orgWebsiteAddressTxt
Type Of Organization CorpYes (X)TypeOfOrganizationCorpInd
Formation1980FormationYr
Legal Domicile StateNCLegalDomicileStateCd
Activity Or MissionTo provide free on-site medical and dental care to low-income families.ActivityOrMissionDesc
Voting Members Governing Body23VotingMembersGoverningBodyCnt
Voting Members Independent23VotingMembersIndependentCnt
Total Employee26TotalEmployeeCnt
Total Volunteers400TotalVolunteersCnt
Total Gross UBI$0TotalGrossUBIAmt
PY Contributions Grants$1,811,231PYContributionsGrantsAmt
CY Contributions Grants$2,094,684CYContributionsGrantsAmt
CY Program Service Revenue$0CYProgramServiceRevenueAmt
PY Investment Income$27PYInvestmentIncomeAmt
CY Investment Income-$270CYInvestmentIncomeAmt
PY Other Revenue$40,207PYOtherRevenueAmt
CY Other Revenue$26,550CYOtherRevenueAmt
PY Total Revenue$1,851,465PYTotalRevenueAmt
CY Total Revenue$2,120,964CYTotalRevenueAmt
CY Grants And Similar Paid$0CYGrantsAndSimilarPaidAmt
CY Benefits Paid To Members$0CYBenefitsPaidToMembersAmt
PY Salaries Comp Emp Bnft Paid$815,172PYSalariesCompEmpBnftPaidAmt
CY Salaries Comp Emp Bnft Paid$771,281CYSalariesCompEmpBnftPaidAmt
CY Total Prof Fndrsng Expns$0CYTotalProfFndrsngExpnsAmt
CY Total Fundraising Expense$19,384CYTotalFundraisingExpenseAmt
PY Other Expenses$982,053PYOtherExpensesAmt
CY Other Expenses$1,485,228CYOtherExpensesAmt
PY Total Expenses$1,797,225PYTotalExpensesAmt
CY Total Expenses$2,256,509CYTotalExpensesAmt
PY Revenues Less Expenses$54,240PYRevenuesLessExpensesAmt
CY Revenues Less Expenses-$135,545CYRevenuesLessExpensesAmt
Total Assets BOY$784,664TotalAssetsBOYAmt
Total Assets EOY$649,193TotalAssetsEOYAmt
Total Liabilities BOY$48,643TotalLiabilitiesBOYAmt
Total Liabilities EOY$42,802TotalLiabilitiesEOYAmt
Net Assets Or Fund Balances BOY$736,021NetAssetsOrFundBalancesBOYAmt
Net Assets Or Fund Balances EOY$606,391NetAssetsOrFundBalancesEOYAmt
MissionTo provide free on-siteMissionDesc
Significant New Program SrvcfalseSignificantNewProgramSrvcInd
Significant ChangefalseSignificantChangeInd
Expense$2,087,243ExpenseAmt
DescCOMMUNITY CARE CENTER OF FORSYTH COUNTY, INC. IS A FREE MEDICAL CLINIC FOR FAMILIES WHO EARN LESS THAN 200% OF THE FEDERAL PROVERTY LEVEL AND ARE NOT ELIGIBLE FOR GOVERNMENT PROGRAMS AND HAVE NO MEDICAL INSURANCE. THE CENTER PROVIDES FREE ON-SITE MEDICAL AND DENTAL CARE TO LOW-INCOME FAMILIES, AS THE SOLE PROGRAM.Desc
Total Program Service Expenses$2,087,243TotalProgramServiceExpensesAmt
Described In Section501c3Yes (true)DescribedInSection501c3Ind
Schedule B RequiredYes (true)ScheduleBRequiredInd
Political Campaign ActyfalsePoliticalCampaignActyInd
Lobbying ActivitiesfalseLobbyingActivitiesInd
Subject To Proxy TaxfalseSubjectToProxyTaxInd
Donor Advised FundfalseDonorAdvisedFundInd
Conservation EasementsfalseConservationEasementsInd
Collections Of ArtfalseCollectionsOfArtInd
Credit CounselingfalseCreditCounselingInd
Temp Or Permanent EndowmentsYes (true)TempOrPermanentEndowmentsInd
Report Land Building EquipmentYes (true)ReportLandBuildingEquipmentInd
Report Investments Other SecfalseReportInvestmentsOtherSecInd
Report Program Related InvstfalseReportProgramRelatedInvstInd
Report Other AssetsYes (true)ReportOtherAssetsInd
Report Other LiabilitiesfalseReportOtherLiabilitiesInd
Include FIN48 FootnotefalseIncludeFIN48FootnoteInd
Independent Audit Fincl StmtYes (true)IndependentAuditFinclStmtInd
Consolidated Audit Fincl StmtfalseConsolidatedAuditFinclStmtInd
School OperatingfalseSchoolOperatingInd
Foreign OfficefalseForeignOfficeInd
Foreign ActivitiesfalseForeignActivitiesInd
More Than5000 K To OrgfalseMoreThan5000KToOrgInd
More Than5000 K To IndividualsfalseMoreThan5000KToIndividualsInd
Professional FundraisingfalseProfessionalFundraisingInd
Fundraising ActivitiesYes (true)FundraisingActivitiesInd
Gaming ActivitiesfalseGamingActivitiesInd
Operate HospitalfalseOperateHospitalInd
Grants To OrganizationsfalseGrantsToOrganizationsInd
Grants To IndividualsfalseGrantsToIndividualsInd
Schedule J RequiredfalseScheduleJRequiredInd
Tax Exempt BondsfalseTaxExemptBondsInd
Engaged In Excess Benefit TransfalseEngagedInExcessBenefitTransInd
PY Excess Benefit TransfalsePYExcessBenefitTransInd
Loan OutstandingfalseLoanOutstandingInd
Grant To Related PersonfalseGrantToRelatedPersonInd
Business Rln With Org MemfalseBusinessRlnWithOrgMemInd
Business Rln With Fam MemfalseBusinessRlnWithFamMemInd
Business Rln With Officer EntYes (true)BusinessRlnWithOfficerEntInd
Deductible Non Cash ContriYes (true)DeductibleNonCashContriInd
Deductible Art ContributionfalseDeductibleArtContributionInd
Terminate OperationsfalseTerminateOperationsInd
Partial LiquidationfalsePartialLiquidationInd
Disregarded EntityfalseDisregardedEntityInd
Related EntityYes (true)RelatedEntityInd
Related Organization Ctrl EntfalseRelatedOrganizationCtrlEntInd
Transaction With Control EntfalseTransactionWithControlEntInd
Activities Conducted PrtshpfalseActivitiesConductedPrtshpInd
Schedule O RequiredYes (true)ScheduleORequiredInd
IRP Document0IRPDocumentCnt
IRP Document W2 G0IRPDocumentW2GCnt
Backup Wthld ComplianceYes (true)BackupWthldComplianceInd
Employee26EmployeeCnt
Employment Tax Returns FiledYes (true)EmploymentTaxReturnsFiledInd
Unrelated Bus Incm Over LimitfalseUnrelatedBusIncmOverLimitInd
Foreign Financial AccountfalseForeignFinancialAccountInd
Prohibited Tax Shelter TransfalseProhibitedTaxShelterTransInd
Taxable Party NotificationfalseTaxablePartyNotificationInd
Nondeductible ContributionsfalseNondeductibleContributionsInd
Quid Pro Quo ContributionsfalseQuidProQuoContributionsInd
Form8282 Property Disposed OffalseForm8282PropertyDisposedOfInd
Rcv Fnds To Pay Prsnl Bnft CntrctfalseRcvFndsToPayPrsnlBnftCntrctInd
Pay Premiums Prsnl Bnft CntrctfalsePayPremiumsPrsnlBnftCntrctInd
Indoor Tanning ServicesfalseIndoorTanningServicesInd
Info In Schedule O Part VIYes (X)InfoInScheduleOPartVIInd
Governing Body Voting Members23GoverningBodyVotingMembersCnt
Independent Voting Member23IndependentVotingMemberCnt
Family Or Business RlnfalseFamilyOrBusinessRlnInd
Delegation Of Mgmt DutiesYes (true)DelegationOfMgmtDutiesInd
Change To Org DocumentsfalseChangeToOrgDocumentsInd
Material Diversion Or MisusefalseMaterialDiversionOrMisuseInd
Members Or StockholdersfalseMembersOrStockholdersInd
Election Of Board MembersfalseElectionOfBoardMembersInd
Decisions Subject To ApprovafalseDecisionsSubjectToApprovaInd
Minutes Of Governing BodyYes (true)MinutesOfGoverningBodyInd
Minutes Of CommitteesYes (true)MinutesOfCommitteesInd
Officer Mailing AddressfalseOfficerMailingAddressInd
Local ChaptersfalseLocalChaptersInd
Form990 Provided To Gvrn BodyfalseForm990ProvidedToGvrnBodyInd
Conflict Of Interest PolicyYes (true)ConflictOfInterestPolicyInd
Annual Disclosure Covered PrsnYes (true)AnnualDisclosureCoveredPrsnInd
Regular Monitoring EnfrcfalseRegularMonitoringEnfrcInd
Whistleblower PolicyYes (true)WhistleblowerPolicyInd
Document Retention PolicyYes (true)DocumentRetentionPolicyInd
Compensation Process CEOYes (true)CompensationProcessCEOInd
Compensation Process OtherYes (true)CompensationProcessOtherInd
Investment In Joint VenturefalseInvestmentInJointVentureInd
Own WebsiteYes (X)OwnWebsiteInd
Upon RequestYes (X)UponRequestInd

Books In Care Of Detail BooksInCareOfDetail

FieldValueIRS element (for citing)
PersonJAMES T ROBINSONPersonNm
Phone3367601235PhoneNum

US Address USAddress

FieldValueIRS element (for citing)
Address Line12135 New Walkertown RdAddressLine1Txt
CityWinston SalemCityNm
State AbbreviationNCStateAbbreviationCd
ZIP27101ZIPCd
FieldValueIRS element (for citing)
No Listed Persons CompensatedYes (X)NoListedPersonsCompensatedInd

Form990 Part VII Section A Form990PartVIISectionAGrp (23 entries)

TitleTitleTxtAverage Hours Per WeekAverageHoursPerWeekRtIndividual Trustee Or DirectorIndividualTrusteeOrDirectorIndReportable Comp From OrgReportableCompFromOrgAmtReportable Comp From Rltd OrgReportableCompFromRltdOrgAmtOther CompensationOtherCompensationAmtOfficerOfficerInd
DR WILLIAM M SATTERWHITE JR
Director0.00Yes (X)$0$0$0
JAMES T ROBINSON
Secretary/Treasurer/Executive Director0.00Yes (X)$0$0$0Yes (X)
DR CARL S PHIPPS
Director0.00Yes (X)$0$0$0
MARK MEYER DDS
Director0.00Yes (X)$0$0$0
MICHAEL CLEMENTS
Director0.00Yes (X)$0$0$0
DR ERNESTO DE LA TORRE
Director0.00Yes (X)$0$0$0
ANN FLYNT
Director0.00Yes (X)$0$0$0
KATHY KENNEDY
Director0.00Yes (X)$0$0$0
WARD B MILLER
Board Chair0.00Yes (X)$0$0$0Yes (X)
DR ROBERT V FORD
Director0.00Yes (X)$0$0$0
DAVID L MOUNT
Director0.00Yes (X)$0$0$0
ANTHONY H BRETT
Director0.00Yes (X)$0$0$0
SYLVIA OBERLE
Director0.00Yes (X)$0$0$0
DR R TED TOBORG
Director0.00Yes (X)$0$0$0
JULIA H FLOYD
Director0Yes (X)
DONNA FARRAR
Director0Yes (X)
MICHELLE MARTINEZ
Director0Yes (X)
FELIPE VILLALON
Director0Yes (X)
ANNE SLOWEY
Director0Yes (X)
CAROLYN BREESE
Director0Yes (X)
LUCINDA JONES
Director0Yes (X)
GREGORY G HOLTHUSEN MD
Director0Yes (X)
SILVIA V NILSEN
Vice Chair0Yes (X)Yes (X)
FieldValueIRS element (for citing)
Former Ofcr Employees ListedfalseFormerOfcrEmployeesListedInd
Total Comp Greater Than150 KfalseTotalCompGreaterThan150KInd
Compensation From Other SrcsfalseCompensationFromOtherSrcsInd

Contractor Compensation ContractorCompensationGrp

Contractor Name ContractorName

Business Name BusinessName

FieldValueIRS element (for citing)
Business Name Line1Robinson Association Mgmt Svcs IncBusinessNameLine1Txt

Contractor Address ContractorAddress

US Address USAddress

FieldValueIRS element (for citing)
Address Line12135 New Walkertown RoadAddressLine1Txt
CityWinstonSalemCityNm
State AbbreviationNCStateAbbreviationCd
ZIP27101ZIPCd
FieldValueIRS element (for citing)
ServicesManagement CompanyServicesDesc
Compensation$130,000CompensationAmt
FieldValueIRS element (for citing)
Cntrct Rcvd Greater Than100 K1CntrctRcvdGreaterThan100KCnt
Federated Campaigns$202,746FederatedCampaignsAmt
Fundraising$74,365FundraisingAmt
Government Grants$135,968GovernmentGrantsAmt
All Other Contributions$1,681,605AllOtherContributionsAmt
Noncash Contributions$1,051,532NoncashContributionsAmt
Total Contributions$2,094,684TotalContributionsAmt

Investment Income InvestmentIncomeGrp

FieldValueIRS element (for citing)
Total Revenue Column$10TotalRevenueColumnAmt
Exclusion$10ExclusionAmt

Gross Rents GrossRentsGrp

FieldValueIRS element (for citing)
Real$11,000RealAmt

Rental Income Or Loss RentalIncomeOrLossGrp

FieldValueIRS element (for citing)
Real$11,000RealAmt

Net Rental Income Or Loss NetRentalIncomeOrLossGrp

FieldValueIRS element (for citing)
Total Revenue Column$11,000TotalRevenueColumnAmt
Related Or Exempt Func Income$11,000RelatedOrExemptFuncIncomeAmt

Less Cost Oth Basis Sales Expnss LessCostOthBasisSalesExpnssGrp

FieldValueIRS element (for citing)
Other$280OtherAmt

Gain Or Loss GainOrLossGrp

FieldValueIRS element (for citing)
Other-$280OtherAmt

Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp

FieldValueIRS element (for citing)
Total Revenue Column-$280TotalRevenueColumnAmt
Related Or Exempt Func Income-$280RelatedOrExemptFuncIncomeAmt
FieldValueIRS element (for citing)
Contri Rpt Fundraising Event$74,365ContriRptFundraisingEventAmt

Other Revenue Misc OtherRevenueMiscGrp

FieldValueIRS element (for citing)
DescMisc. Revenue - RelatedDesc
Business900099BusinessCd
Total Revenue Column$15,550TotalRevenueColumnAmt
Related Or Exempt Func Income$15,550RelatedOrExemptFuncIncomeAmt
FieldValueIRS element (for citing)
Other Revenue Total$15,550OtherRevenueTotalAmt

Total Revenue TotalRevenueGrp

FieldValueIRS element (for citing)
Total Revenue Column$2,120,964TotalRevenueColumnAmt
Related Or Exempt Func Income$26,270RelatedOrExemptFuncIncomeAmt
Exclusion$10ExclusionAmt

Other Salaries And Wages OtherSalariesAndWagesGrp

FieldValueIRS element (for citing)
Total$633,103TotalAmt
Program Services$633,103ProgramServicesAmt
Management And General$0ManagementAndGeneralAmt
Fundraising$0FundraisingAmt

Other Employee Benefits OtherEmployeeBenefitsGrp

FieldValueIRS element (for citing)
Total$87,895TotalAmt
Program Services$87,895ProgramServicesAmt
Management And General$0ManagementAndGeneralAmt
Fundraising$0FundraisingAmt

Payroll Taxes PayrollTaxesGrp

FieldValueIRS element (for citing)
Total$50,283TotalAmt
Program Services$50,283ProgramServicesAmt
Management And General$0ManagementAndGeneralAmt
Fundraising$0FundraisingAmt

Fees For Services Management FeesForServicesManagementGrp

FieldValueIRS element (for citing)
Total$130,000TotalAmt
Program Services$0ProgramServicesAmt
Management And General$130,000ManagementAndGeneralAmt
Fundraising$0FundraisingAmt

Fees For Services Accounting FeesForServicesAccountingGrp

FieldValueIRS element (for citing)
Total$15,096TotalAmt
Program Services$0ProgramServicesAmt
Management And General$15,096ManagementAndGeneralAmt
Fundraising$0FundraisingAmt

Fees For Services Other FeesForServicesOtherGrp

FieldValueIRS element (for citing)
Total$10,044TotalAmt
Program Services$5,258ProgramServicesAmt
Management And General$4,786ManagementAndGeneralAmt
Fundraising$0FundraisingAmt

Advertising AdvertisingGrp

FieldValueIRS element (for citing)
Total$837TotalAmt
Program Services$837ProgramServicesAmt
Management And General$0ManagementAndGeneralAmt
Fundraising$0FundraisingAmt

Office Expenses OfficeExpensesGrp

FieldValueIRS element (for citing)
Total$53,842TotalAmt
Program Services$53,842ProgramServicesAmt
Management And General$0ManagementAndGeneralAmt
Fundraising$0FundraisingAmt

Occupancy OccupancyGrp

FieldValueIRS element (for citing)
Total$23,046TotalAmt
Program Services$23,046ProgramServicesAmt
Management And General$0ManagementAndGeneralAmt
Fundraising$0FundraisingAmt

Conferences Meetings ConferencesMeetingsGrp

FieldValueIRS element (for citing)
Total$2,962TotalAmt
Program Services$2,962ProgramServicesAmt
Management And General$0ManagementAndGeneralAmt
Fundraising$0FundraisingAmt

Depreciation Depletion DepreciationDepletionGrp

FieldValueIRS element (for citing)
Total$21,267TotalAmt
Program Services$21,267ProgramServicesAmt
Management And General$0ManagementAndGeneralAmt
Fundraising$0FundraisingAmt

Insurance InsuranceGrp

FieldValueIRS element (for citing)
Total$16,108TotalAmt
Program Services$16,108ProgramServicesAmt
Management And General$0ManagementAndGeneralAmt
Fundraising$0FundraisingAmt

Other Expenses OtherExpensesGrp (4 entries)

DescDescTotalTotalAmtProgram ServicesProgramServicesAmtManagement And GeneralManagementAndGeneralAmtFundraisingFundraisingAmt
Medicines & Medical Supplies$1,107,320$1,107,320$0$0
Miscellaneous$22,972$22,972$0$0
Outside Services$0$0$0$0
Repairs$47,867$47,867$0$0

All Other Expenses AllOtherExpensesGrp

FieldValueIRS element (for citing)
Total$33,867TotalAmt
Program Services$14,483ProgramServicesAmt
Management And General$0ManagementAndGeneralAmt
Fundraising$19,384FundraisingAmt

Total Functional Expenses TotalFunctionalExpensesGrp

FieldValueIRS element (for citing)
Total$2,256,509TotalAmt
Program Services$2,087,243ProgramServicesAmt
Management And General$149,882ManagementAndGeneralAmt
Fundraising$19,384FundraisingAmt

Cash Non Interest Bearing CashNonInterestBearingGrp

FieldValueIRS element (for citing)
BOY$234,443BOYAmt
EOY$245,432EOYAmt

Savings And Temp Cash Invst SavingsAndTempCashInvstGrp

FieldValueIRS element (for citing)
BOY$9,980BOYAmt
EOY$9,983EOYAmt

Pledges And Grants Receivable PledgesAndGrantsReceivableGrp

FieldValueIRS element (for citing)
BOY$320,850BOYAmt
EOY$174,885EOYAmt

Inventories For Sale Or Use InventoriesForSaleOrUseGrp

FieldValueIRS element (for citing)
BOY$19,766BOYAmt
EOY$19,766EOYAmt

Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp

FieldValueIRS element (for citing)
BOY$9,555BOYAmt
EOY$9,039EOYAmt
FieldValueIRS element (for citing)
Land Bldg Equip Cost Or Other Bss$649,942LandBldgEquipCostOrOtherBssAmt
Land Bldg Equip Accum Deprec$586,415LandBldgEquipAccumDeprecAmt

Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp

FieldValueIRS element (for citing)
BOY$63,596BOYAmt
EOY$63,527EOYAmt

Other Assets Total OtherAssetsTotalGrp

FieldValueIRS element (for citing)
BOY$126,474BOYAmt
EOY$126,561EOYAmt

Total Assets TotalAssetsGrp

FieldValueIRS element (for citing)
BOY$784,664BOYAmt
EOY$649,193EOYAmt

Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp

FieldValueIRS element (for citing)
BOY$48,643BOYAmt
EOY$42,802EOYAmt

Total Liabilities TotalLiabilitiesGrp

FieldValueIRS element (for citing)
BOY$48,643BOYAmt
EOY$42,802EOYAmt
FieldValueIRS element (for citing)
Organization Follows SFAS117Yes (X)OrganizationFollowsSFAS117Ind

Unrestricted Net Assets UnrestrictedNetAssetsGrp

FieldValueIRS element (for citing)
BOY$437,301BOYAmt
EOY$357,529EOYAmt

Temporarily Rstr Net Assets TemporarilyRstrNetAssetsGrp

FieldValueIRS element (for citing)
BOY$298,720BOYAmt
EOY$248,862EOYAmt

Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp

FieldValueIRS element (for citing)
BOY$736,021BOYAmt
EOY$606,391EOYAmt

Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp

FieldValueIRS element (for citing)
BOY$784,664BOYAmt
EOY$649,193EOYAmt
FieldValueIRS element (for citing)
Reconcilation Revenue Expnss-$135,545ReconcilationRevenueExpnssAmt
Method Of Accounting AccrualYes (X)MethodOfAccountingAccrualInd
Accountant Compile Or ReviewfalseAccountantCompileOrReviewInd
FS AuditedYes (true)FSAuditedInd

FS Audited Basis FSAuditedBasisGrp

FieldValueIRS element (for citing)
Separate Basis Fincl StmtYes (X)SeparateBasisFinclStmtInd
FieldValueIRS element (for citing)
Audit CommitteeYes (true)AuditCommitteeInd
Federal Grant Audit RequiredfalseFederalGrantAuditRequiredInd

Schedule A IRS990ScheduleA

FieldValueIRS element (for citing)
Public Organization170Yes (X)PublicOrganization170Ind

Gifts Grants Contri Rcvd170 GiftsGrantsContriRcvd170Grp

FieldValueIRS element (for citing)
Current Tax Year Minus4 Years$2,843,824CurrentTaxYearMinus4YearsAmt
Current Tax Year Minus3 Years$2,797,513CurrentTaxYearMinus3YearsAmt
Current Tax Year Minus2 Years$2,486,738CurrentTaxYearMinus2YearsAmt
Current Tax Year Minus1 Year$1,811,231CurrentTaxYearMinus1YearAmt
Current Tax Year$1,598,777CurrentTaxYearAmt
Total$11,538,083TotalAmt

Total Calendar Year170 TotalCalendarYear170Grp

FieldValueIRS element (for citing)
Current Tax Year Minus4 Years$2,843,824CurrentTaxYearMinus4YearsAmt
Current Tax Year Minus3 Years$2,797,513CurrentTaxYearMinus3YearsAmt
Current Tax Year Minus2 Years$2,486,738CurrentTaxYearMinus2YearsAmt
Current Tax Year Minus1 Year$1,811,231CurrentTaxYearMinus1YearAmt
Current Tax Year$1,598,777CurrentTaxYearAmt
Total$11,538,083TotalAmt
FieldValueIRS element (for citing)
Public Support Total170$11,538,083PublicSupportTotal170Amt

Gross Investment Income170 GrossInvestmentIncome170Grp

FieldValueIRS element (for citing)
Current Tax Year Minus4 Years$9,180CurrentTaxYearMinus4YearsAmt
Current Tax Year Minus3 Years$15,341CurrentTaxYearMinus3YearsAmt
Current Tax Year Minus2 Years$12,903CurrentTaxYearMinus2YearsAmt
Current Tax Year Minus1 Year$3,670CurrentTaxYearMinus1YearAmt
Current Tax Year$5,915CurrentTaxYearAmt
Total$47,009TotalAmt

Other Income170 OtherIncome170Grp

FieldValueIRS element (for citing)
Current Tax Year Minus4 Years$32,706CurrentTaxYearMinus4YearsAmt
Current Tax Year Minus3 Years$34,914CurrentTaxYearMinus3YearsAmt
Current Tax Year Minus2 Years$29,290CurrentTaxYearMinus2YearsAmt
Current Tax Year Minus1 Year$40,207CurrentTaxYearMinus1YearAmt
Current Tax Year$26,270CurrentTaxYearAmt
Total$163,387TotalAmt
FieldValueIRS element (for citing)
Total Support$11,748,479TotalSupportAmt
Public Support CY1700.98210PublicSupportCY170Pct
Public Support PY1700.98090PublicSupportPY170Pct
Thirty Thr Pct Suprt Tests CY170Yes (X)ThirtyThrPctSuprtTestsCY170Ind
Public Support Total509$0PublicSupportTotal509Amt
Public Support CY5090PublicSupportCY509Pct
Investment Income CY0InvestmentIncomeCYPct

Form990 Schedule A Part VI Form990ScheduleAPartVIGrp

FieldValueIRS element (for citing)
Form And Line ReferencePt II Ln 10FormAndLineReferenceDesc
ExplanationOther Income Part II, Line 10 Description: Other Income 2012: 32706. 2013: 34914. 2014: 29290. 2015: 40207. 2016: 26270.ExplanationTxt

Schedule B IRS990ScheduleB

Contributor Information ContributorInformationGrp

FieldValueIRS element (for citing)
ContributorRESTRICTEDContributorNum

Contributor Business Name ContributorBusinessName

FieldValueIRS element (for citing)
Business Name Line1RESTRICTEDBusinessNameLine1

Contributor US Address ContributorUSAddress

FieldValueIRS element (for citing)
Address Line1RESTRICTEDAddressLine1
Address Line2RESTRICTEDAddressLine2
CityRESTRICTEDCity
StateRESTRICTEDState
ZIP CodeRESTRICTEDZIPCode
FieldValueIRS element (for citing)
Total ContributionsRESTRICTEDTotalContributionsAmt

Schedule D IRS990ScheduleD

CY Endwmt Fund CYEndwmtFundGrp

FieldValueIRS element (for citing)
Beginning Year Balance$125,234BeginningYearBalanceAmt
Investment Earnings Or Losses$5,921InvestmentEarningsOrLossesAmt
Grants Or Scholarships$5,012GrantsOrScholarshipsAmt
Administrative Expenses$1,232AdministrativeExpensesAmt
End Year Balance$124,911EndYearBalanceAmt

CY Minus1 Yr Endwmt Fund CYMinus1YrEndwmtFundGrp

FieldValueIRS element (for citing)
Beginning Year Balance$127,695BeginningYearBalanceAmt
Investment Earnings Or Losses$3,694InvestmentEarningsOrLossesAmt
Grants Or Scholarships$4,872GrantsOrScholarshipsAmt
Administrative Expenses$1,283AdministrativeExpensesAmt
End Year Balance$125,234EndYearBalanceAmt

CY Minus2 Yr Endwmt Fund CYMinus2YrEndwmtFundGrp

FieldValueIRS element (for citing)
Beginning Year Balance$120,825BeginningYearBalanceAmt
Investment Earnings Or Losses$12,903InvestmentEarningsOrLossesAmt
Grants Or Scholarships$4,792GrantsOrScholarshipsAmt
Administrative Expenses$1,241AdministrativeExpensesAmt
End Year Balance$127,695EndYearBalanceAmt

CY Minus3 Yr Endwmt Fund CYMinus3YrEndwmtFundGrp

FieldValueIRS element (for citing)
Beginning Year Balance$110,917BeginningYearBalanceAmt
Contributions$25ContributionsAmt
Investment Earnings Or Losses$15,344InvestmentEarningsOrLossesAmt
Grants Or Scholarships$4,604GrantsOrScholarshipsAmt
Administrative Expenses$857AdministrativeExpensesAmt
End Year Balance$120,825EndYearBalanceAmt

CY Minus4 Yr Endwmt Fund CYMinus4YrEndwmtFundGrp

FieldValueIRS element (for citing)
Beginning Year Balance$107,167BeginningYearBalanceAmt
Investment Earnings Or Losses$9,209InvestmentEarningsOrLossesAmt
Grants Or Scholarships$4,636GrantsOrScholarshipsAmt
Administrative Expenses$823AdministrativeExpensesAmt
End Year Balance$110,917EndYearBalanceAmt
FieldValueIRS element (for citing)
Endowments Held Unrelated OrgYes (true)EndowmentsHeldUnrelatedOrgInd
Endowments Held Related OrgfalseEndowmentsHeldRelatedOrgInd

Leasehold Improvements LeaseholdImprovementsGrp

FieldValueIRS element (for citing)
Other Cost Or Other Basis$62,254OtherCostOrOtherBasisAmt
Depreciation$13,101DepreciationAmt
Book Value$49,153BookValueAmt

Equipment EquipmentGrp

FieldValueIRS element (for citing)
Other Cost Or Other Basis$581,393OtherCostOrOtherBasisAmt
Depreciation$567,690DepreciationAmt
Book Value$13,703BookValueAmt

Other Land Buildings OtherLandBuildingsGrp

FieldValueIRS element (for citing)
Other Cost Or Other Basis$6,295OtherCostOrOtherBasisAmt
Depreciation$5,624DepreciationAmt
Book Value$671BookValueAmt
FieldValueIRS element (for citing)
Total Book Value Land Buildings$63,527TotalBookValueLandBuildingsAmt

Other Assets Org OtherAssetsOrgGrp (2 entries)

DescDescBook ValueBookValueAmt
Other Assets$1,650
Funds Held in Trust - Endowment$124,911
FieldValueIRS element (for citing)
Total Book Value Other Assets$126,561TotalBookValueOtherAssetsAmt
Total Rev Etc Audited Fincl Stmt$9,027,354TotalRevEtcAuditedFinclStmtAmt
Net Unrealized Gains Invst$5,915NetUnrealizedGainsInvstAmt
Donated Services And Use Fclts$6,900,475DonatedServicesAndUseFcltsAmt
Revenue Not Reported$6,906,390RevenueNotReportedAmt
Revenue Subtotal$2,120,964RevenueSubtotalAmt
Total Revenue Per Form990$2,120,964TotalRevenuePerForm990Amt
Tot Expns Etc Audited Fincl Stmt$8,661,077TotExpnsEtcAuditedFinclStmtAmt
Donated Services Use Fclts$6,900,475DonatedServicesUseFcltsAmt
Expenses Not Reported$6,900,475ExpensesNotReportedAmt
Expenses Subtotal$1,760,602ExpensesSubtotalAmt
Total Expenses Per Form990$1,760,602TotalExpensesPerForm990Amt

Supplemental Information Detail SupplementalInformationDetail

FieldValueIRS element (for citing)
Form And Line ReferencePt V, Line 4FormAndLineReferenceDesc
ExplanationThe purpose of the endowment fund is to provide a permanent fund which may be used by the organization to support the provision of healthcare services to the medically uninsured and underserved who meet the eligibility requirement guidelines of the organization.ExplanationTxt

Schedule G IRS990ScheduleG

Fundraising Event Information FundraisingEventInformationGrp

FieldValueIRS element (for citing)
Event1DinnerEvent1Nm
Gross Receipts Event1$74,365GrossReceiptsEvent1Amt
Gross Revenue Event1$74,365GrossRevenueEvent1Amt
Food And Beverage Event1$13,340FoodAndBeverageEvent1Amt
Gross Receipts Total$74,365GrossReceiptsTotalAmt
Gross Revenue Total Events$74,365GrossRevenueTotalEventsAmt
Food And Beverage Total Events$13,340FoodAndBeverageTotalEventsAmt
Direct Expense Summary Events$13,340DirectExpenseSummaryEventsAmt
Net Income Summary$61,025NetIncomeSummaryAmt

Schedule L IRS990ScheduleL

Bus Tr Involve Interested Prsn BusTrInvolveInterestedPrsnGrp

Name Of Interested NameOfInterested

Business Name BusinessName

FieldValueIRS element (for citing)
Business Name Line1Robinson Association MgmtBusinessNameLine1Txt
FieldValueIRS element (for citing)
Relationship DescriptionOwned by Executive DirectorRelationshipDescriptionTxt
Transaction$130,000TransactionAmt
TransactionManagementTransactionDesc
Sharing Of RevenuesfalseSharingOfRevenuesInd

Schedule M IRS990ScheduleM

Drugs And Medical Supplies DrugsAndMedicalSuppliesGrp

FieldValueIRS element (for citing)
Non Cash CheckboxYes (X)NonCashCheckboxInd
Contribution1ContributionCnt
Noncash Contributions Rpt F990$546,075NoncashContributionsRptF990Amt
Method Of Determining RevenuesDonor ProvidedMethodOfDeterminingRevenuesTxt

Other Non Cash Contri Table OtherNonCashContriTableGrp (2 entries)

Non Cash CheckboxNonCashCheckboxIndDescDescContributionContributionCntNoncash Contributions Rpt F990NoncashContributionsRptF990AmtMethod Of Determining RevenuesMethodOfDeterminingRevenuesTxt
Yes (X)Food for Volunteers0$9,200Cost
Yes (X)Supplies1$350Cost
FieldValueIRS element (for citing)
Any Property That Must Be HeldfalseAnyPropertyThatMustBeHeldInd
Review Process Unusual NC GiftsYes (true)ReviewProcessUnusualNCGiftsInd
Third Parties UsedfalseThirdPartiesUsedInd

Schedule O IRS990ScheduleO

Supplemental Information Detail SupplementalInformationDetail (8 entries)

Form And Line ReferenceFormAndLineReferenceDescExplanationExplanationTxt
Pt VI, Line 3The organization receives management services under a board approved contract from Robinson Association Management Services, Inc. An entity owned by James T. Robinson, Executive Director.
Pt VI, Line 11bA copy of the 990 is provided to the Executive Director and Treasurer for their review prior to the return being filed. The 990 is subsequently reviewed by the finance committee.
Pt VI, Line 15aSalaries and management contracts are reviewed and recommendations made by the personnel committee which is made up of independent persons. Those recommendations then go to the finance committee for review and finally to the board for approval.
Pt VI, Line 15bSalaries and management contracts are reviewed and recommendations made by the personnel committee which is made up of independent persons. Those recommendations then go to the finance committee for review and finally to the board for approval.
Pt VI, Line 19The organization makes its governing documents, conflict of interest policy, and financial statements available to anyone that request a copy of the information.
Form 990, Part IX, Line 24eSecurity 14483. 14483. 0. 0.
Form 990, Part IX, Line 24eSpecial Event Cost 13340. 0. 0. 13340.
Form 990, Part IX, Line 24eWriteoff 6044. 0. 0. 6044.

Schedule R IRS990ScheduleR

Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp

Disregarded Entity Name DisregardedEntityName

FieldValueIRS element (for citing)
Business Name Line1Forsyth-Stokes-Davie County Medical SocietyBusinessNameLine1Txt

US Address USAddress

FieldValueIRS element (for citing)
Address Line12135 New Walkertown RoadAddressLine1Txt
CityWinstonSalemCityNm
State AbbreviationNCStateAbbreviationCd
ZIP27101ZIPCd
FieldValueIRS element (for citing)
EIN566047612EIN
Primary ActivitiesMEDICALPrimaryActivitiesTxt
Legal Domicile StateNCLegalDomicileStateCd
Exempt Code Section501 (c)(6)ExemptCodeSectionTxt
Public Charity StatusN/APublicCharityStatusTxt

Direct Controlling Entity Name DirectControllingEntityName

FieldValueIRS element (for citing)
Business Name Line1NABusinessNameLine1Txt
FieldValueIRS element (for citing)
Controlled OrganizationfalseControlledOrganizationInd
FieldValueIRS element (for citing)
Receipt Of Int Annts Rnts RyltsfalseReceiptOfIntAnntsRntsRyltsInd
Gift Grnt Or Cap Contri To Oth OrgfalseGiftGrntOrCapContriToOthOrgInd
Gift Grnt Cap Contri From Oth OrgfalseGiftGrntCapContriFromOthOrgInd
Loans Or Guarantees To Other OrgfalseLoansOrGuaranteesToOtherOrgInd
Loans Or Guarantees From Oth OrgfalseLoansOrGuaranteesFromOthOrgInd
Div Related OrganizationfalseDivRelatedOrganizationInd
Asset Sale To Other OrgfalseAssetSaleToOtherOrgInd
Asset Purchase From Other OrgfalseAssetPurchaseFromOtherOrgInd
Asset ExchangefalseAssetExchangeInd
Rental Of Facilities To Oth OrgfalseRentalOfFacilitiesToOthOrgInd
Rental Of Fclts From Oth OrgfalseRentalOfFcltsFromOthOrgInd
Perform Of Services For Oth OrgfalsePerformOfServicesForOthOrgInd
Perform Of Services By Other OrgfalsePerformOfServicesByOtherOrgInd
Sharing Of FacilitiesYes (true)SharingOfFacilitiesInd
Paid Employees SharingfalsePaidEmployeesSharingInd
Reimbursement Paid To Other OrgfalseReimbursementPaidToOtherOrgInd
Reimbursement Paid By Other OrgfalseReimbursementPaidByOtherOrgInd
Transfer To Other OrgfalseTransferToOtherOrgInd
Transfer From Other OrgfalseTransferFromOtherOrgInd

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