2016-11-11T09:05:18-06:00 2015-12-31 010494526 BAKER NEWMAN & NOYES LLC 650 ELM STREET SUITE 302 MANCHESTER NH 03101 990 2015-01-01 020489150 Northeast Delta Dental Foundation NORT 6032231000 PO Box 2002 Concord NH 033022002 THOMAS RAFFIO President & CEO 6032231000 2016-11-02 1 E Drew Cheney P00182972 8002447444 2016-11-02 2015 2017-02-10 21:41:12Z Thomas Raffio PO Box 2002 Concord NH 033022002 818146 0 X www.nedelta.com X 1996 NH Promote dental health and education in northern New England 10 10 0 15 0 0 257282 673586 0 0 281807 94968 0 0 539089 768554 258429 324738 0 0 0 0 0 0 0 8152 8750 266581 333488 272508 435066 4094668 4253065 0 25000 4094668 4228065 To promote dental health and education in northern New England 0 0 219019 219019 Dental Equipment and Supplies: Cash donations to 29 nonprofit dental clinics to purchase dental equipment and supplies to serve patients who cannot afford dental care. 62000 62000 Oral Health Education Programs and Public Policy Development: Cash donations to 11 organizations to sponsor oral health education programs. Donations of printed materials and supplies to schools, nonprofit dental clinics, and other organizations to provide oral health education programs. 43719 43719 In-School Programs for Children: Cash donations to 9 organizations to sponsor in-school education programs on fluoride rinse or sealants for children. 324738 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 X 10 10 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 0 0 0 0 0 NH X Kathleen B Walker 6032231000 c/o One Delta Drive Concord NH 033022002 X Paul A Averill DDS Director 0.50 X 0 0 0 Michael Degnan Director 0.50 X 0 0 0 Demitroula Kouzounas DMD Director 0.50 X 0 0 0 Suzanne M McDowell Director 0.50 X 0 0 0 Barry C Saltz DDS Director 0.50 X 0 0 0 Eleanor H Vien Secretary 1.00 X 0 0 0 Terence A Wardrop Director 0.50 X 0 0 0 Melvin J Severance III Chair & Director 0.50 X X 0 0 0 Thomas Raffio President & Director 2.00 X X 0 0 0 Kathleen B Walker Treasurer & Director 6.00 X X 0 0 0 Jennifer L McGrath Assistant Treasurer 4.00 X 0 0 0 0 0 0 0 0 0 0 0 19249 654337 673586 70076 70076 65000 40108 24892 24892 24892 9484 19249 9484 0 768554 0 0 94968 324738 324738 2500 2500 6175 6175 State of NH filing fees 75 75 333488 324738 8750 0 1269744 321036 157600 566600 2667324 3365429 4094668 4253065 25000 0 25000 X 3905852 4089249 188816 138816 4094668 4228065 4094668 4253065 435066 -301669 0 X 0 0 0 X 650579 648757 416998 259782 679490 2655606 650579 648757 416998 259782 679490 2655606 2343088 312518 83382 60763 66294 78082 70076 358597 3014203 0.10370 0.10740 X The Organization meets the "facts and circumstances" test for the following reasons:- Through its activities, the Organization regularly and continuously benefits many thousands of members of the general public.- The Organization encourages donations from the general public through the website of Northeast Delta Dental (a group of nonprofit organizations) and through other means.- The Organization's Board does not represent any narrow interests and is committed to representing all of the citizens of northern New England who are most in need of dental care assistance. Part II, Section A, Line 1 Line 1 includes $2,500 as a very conservative estimate of the amount of annual in-kind non-cash contributions which are not included on the organization's books. These contributions are support from the general public. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 4078143 566600 -206701 216814 4221228 3977210 157600 87457 144124 4078143 3449410 167500 482357 122057 3977210 2820677 401900 332044 105211 3449410 2642281 405200 -130207 96597 2820677 0.96710 0.00000 0.03290 0 0 0 Part V, Line 4: To help ensure that the Foundation can continue to promote dental health and education in Northern New England Golf Tournament 26973 17489 9484 7787 1697 26973 17489 9484 7787 1697 9484 0 1 Access Health dba Leavitt's Mill Free Health Center PO Box 47 Bar Mills ME 04004 010757566 501(c)(3) 5000 Dental Supplies Ammonoosuc Community Health Services 25 Mount Eustis Road Littleton NH 03561 510137745 501(c)(3) 10000 Dental Equipment Catholic Charities MaineJesse Albert Dental Center PO Box 10660 Portland ME 04104 010280225 501(c)(3) 5000 Dental Equipment Champlain Valley Head StartEarly Head Start Champlain Valley Office of Economic Opportunity 255 South Champlain Str Burlington VT 05402 030216837 501(c)(3) 32000 Tooth Tutor Program Children's Oral Health Program Portland Public Health & Human Services 1600 Forest Avenue Portland ME 042407291 016000032 501(c)(3) 9500 Dental Equipment Community Clinical Services PO Box 7291 Lewiston ME 04243 010409788 501(c)(3) 5256 Portable Dental Chair Concord Dental Sealant Coalition PO Box 1062 Concord NH 03301 262799313 501(c)(3) 6500 School-Based Dental Program Concord Hospital Trust 250 Pleasant Street Concord NH 03301 222594672 501(c)(3) 20000 Benefactors Circle - Dental Clinic Dancing with the Dentists Inc 202 US Route 1 Falmouth ME 04105 463017043 501(c)(3) 5000 Fundraising Event Dental Lifeline Network of NH (Donated Dental Services) 1800 15th Street Suite 100 Denver CO 80202 846129064 501(c)(3) 15000 Program Support Easter Seals NH 555 Auburn Street Manchester NH 03103 020272825 501(c)(3) 5000 Dental Clinic Support Families First Health of the Greater Seacost 100 Campus Drive Suite 12 Portsmouth NH 03801 222757341 501(c)(3) 8000 Program Support Frisbie Memorial Hospital 11 Whitehall Road Rochester NH 03867 020222131 501(c)(3) 6500 School-Based Dental Program Good Neighbor Health Clinic & Red Logan Dental Clinic 70 North Main Street White River Junction VT 05001 030346949 501(c)(3) 6000 Program Support and Dental Supplies Goodwin Community Health 311 Route 108 Somersworth NH 03878 020304203 501(c)(3) 8500 Dental Equipment Harbor Homes 45 High Street Nashua NH 03060 020351932 501(c)(3) 10000 Dental Clinic Kennebec Family Dentistry 269 Water Street Augusta ME 04330 263322306 501(c)(3) 5000 Dental Equipment Leland and Gray Union Middle and High School PO Box 128 Townshend VT 05353 030220993 Government 6900 Dental Referral Program Lunder-Dineen Education Alliance of Maine a program of Mass Gen Hospital PO Box 1505 Bangor ME 044021505 900656139 501(c)(3) 5000 Oral Health Education Program MaineHealth 110 Free Street Portland ME 04101 010431680 501(c)(3) 8000 From the First Tooth Maine Community Foundation 245 Main Street Ellsworth ME 04605 010391479 501(c)(3) 50000 Local Oral Health Initiatives in Maine Maine Health Access Foundation 150 Capitol Street Suite 4 Augusta ME 04330 010535144 501(c)(3) 5000 Maine Oral Health Funders Consultant Merrimack County Nursing Program 325 Daniel Webster Highway Boscawen NH 03303 026000546 501(c)(3) 5000 Dental Equipment Open Door Clinic 100 Porter Drive Middlebury VT 05753 030359531 501(c)(3) 6520 Dental Equipment and Software South Royalton SchoolHealthHub 223 South Windsor Street South Rovalton VT 05068 030370825 501(c)(3) 5000 School-Based Dental Program Springfield Medical Care Systems 25 Ridgewood Road Springfield VT 05156 030284813 501(c)(3) 5000 Dental Equipment United Way of Windham County PO Box 617 Brattleboro VT 05301 036003074 501(c)(3) 5000 Free Adult Dental Care Day University of VT College of Dental Medicine (FKA Fletcher Allen Healthcare) 111 Colchester Avenue Burlington VT 05401 030219309 501(c)(3) 8500 General Practice Dental Residency Program Windsor Hospital Corp dba Mt Ascutney Hospital 289 County Road Windsor VT 05089 030183721 501(c)(3) 5347 Windsor Smiles - School-Based Dental Program 29 0 Part I, Line 2: Donation recipients are required to send a report annually detailing how the money was spent, using statistics of patients served, utilization of machinery, or other specifics. These reports are monitored by the Foundation Treasurer who tracks the receipt of the annual reports. Form 990, Part VI, Section A, line 6 The Foundation has three members: Delta Dental Plan of New Hampshire, Inc.; Delta Dental Plan of Vermont, Inc.; and Maine Dental Services Corporation. All three members are tax-exempt under Internal Revenue Code Section 501(c)(4). Form 990, Part VI, Section A, line 7a The members elect the Foundation's Board of Directors. Form 990, Part VI, Section A, line 7b In addition to electing the Board of Directors, the members have the power to remove directors, repeal or change bylaws by 2/3rd member vote (Board has primary authority to amend bylaws), and to dissolve the Corporation by 2/3rd member vote. Form 990, Part VI, Section B, line 11 The Form 990 is reviewed in detail by key finance employees of Northeast Delta Dental. A final draft is presented to the Board before the Form 990 is filed. Form 990, Part VI, Section B, line 12c A copy of the conflict of interest policy is distributed annually to all officers, directors, and the management team. All are required to report any conflicts and sign, date, and return the policy, whether or not a conflict exists, to confirm compliance. General Counsel reviews the returned policies and reports the results to the entire Board of Directors. Board members are asked to provide updates of any changes that may occur between their annual conflict of interest filings. Form 990, Part VI, Section C, line 19 Upon request, Northeast Delta Dental Foundation makes its governing documents, conflict of interest policy, or financial statements available to the public.