2015-11-16T09:55:59-06:00 2014-12-31 521511275 RAFFA PC 1899 L STREET NW SUITE 850 WASHINGTON DC 20036 990 2014-01-01 341985248 DIVINE MERCY CARE DIVI 7039345552 11096-A LEE HIGHWAY NO 101 FAIRFAX VA 22030 JOHN T BRUCHALSKI MD CHAIRMAN & PRESIDENT 7039345552 2015-11-16 1 FRANK H SMITH P00639053 2028225000 2015-11-12 2014 2016-02-25 16:41:14Z JOHN T BRUCHALSKI MD 11096-A LEE HIGHWAY NO 101 FAIRFAX VA 22030 3416388 0 X WWW.DIVINEMERCYCARE.ORG X 2000 VA TO TRANSFORM HEARTS THROUGH HEALTHCARE. 6 5 40 49 0 0 559411 647727 2886802 2716535 284 134 -45151 -32517 3401346 3331879 0 0 0 0 2276973 2237937 0 0 125599 879207 1045040 3156180 3282977 245166 48902 754299 827672 269165 242962 485134 584710 X OUR MISSION IS TO CONVEY THE HEALING PRESENCE OF CHRIST THROUGH EXCELLENT MEDICAL CARE WHICH RESPECTS THE CONSCIENCES OF PATIENTS AND PROVIDERS, SERVES THE POOR, AND UPHOLDS THE SANCTITY OF LIFE AT ALL STAGES. WE LOVINGLY CARE FOR ALL PATIENTS, RICH OR POOR, INSURED OR UNINSURED, REGARDLESS OF FAITH TRADITION, ETHNICITY, NATIONAL ORIGIN OR BACKGROUND. 0 0 2732086 2716535 PROVIDING CULTURE OF LIFE AND CHARITABLE MEDICAL CARE, THROUGH THE TEPAYAC FAMILY CENTER LLC, TO APPROXIMATELY 15,000 WOMEN, INCLUDING INDIGENT WOMEN AND THOSE IN CRISIS PREGNANCIES. 2732086 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 25 0 1 40 1 0 0 0 0 0 1 1 0 0 0 0 X 6 5 0 0 0 0 0 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X JOHN T BRUCHALSKI MD 7039345552 11096-A LEE HIGHWAY NO 101 FAIRFAX VA 22030 JOHN T BRUCHALSKI MD CHAIRMAN & PRESIDENT 40.00 X X 232545 0 15270 ADO A MACHIDA VICE CHAIRMAN 1.00 X X 0 0 0 KATHRYN A DOHERTY PHD SECRETARY 3.00 X X 0 0 0 J PATRICK KEARNS TREASURER 1.00 X X 0 0 0 JOSEPH G COSBY MEMBER 1.00 X 0 0 0 EDWARD J GROGAN MEMBER 1.00 X 0 0 0 KAREN CASSIDY CHIEF OPER. OFFICER (UNTIL 01/2014) 60.00 X 12380 0 375 MARIE ANDERSON OB/GYN 40.00 X 229517 0 21641 DANIEL FISK OB/GYN 40.00 X 222941 0 18737 LORNA CVETKOVICH OB/GYN 40.00 X 191596 0 21713 MIRIAM PEREIRA OB/GYN 40.00 X 230267 0 15000 1119246 0 92736 5 0 1 0 0 117305 530422 24766 647727 PROFESSIONAL FEES 621110 2713115 2713115 SPEAKING EVENTS 900099 3420 3420 2716535 134 134 39000 117305 84509 -45509 -45509 TRANFERS & REBATES 900099 8506 8506 MISCELLANEOUS INCOME 900099 4486 4486 12992 3331879 2716535 0 -32383 753406 735913 7296 10197 1265616 1184076 6496 75044 10721 10121 600 93106 79152 1820 12134 115088 114942 146 2910 2667 243 67569 19714 47855 35 35 75418 69365 5789 264 9 9 130747 85685 34670 10392 11252 6004 5248 257761 209216 48545 14745 923 1485 12337 2820 2820 154 154 67565 52975 14590 236862 236862 PATIENT EXPENSES 152053 148619 3434 MISCELLANEOUS EXPENSES 18400 7209 9535 1656 STAFF COSTS 6740 5505 1235 3282977 2732086 425292 125599 238169 244333 72666 56025 37898 216777 288135 12346 27264 295364 182764 131435 112600 4552 76854 59292 1500 2125 754299 827672 251351 226454 17814 16508 269165 242962 X 464262 573115 20872 11595 485134 584710 754299 827672 48902 -609 51283 0 X 1 X 0 0 0 X 736826 678649 614007 598713 686727 3314922 4231248 3816177 4392426 2886802 2716535 18043188 4968074 4494826 5006433 3485515 3403262 21358110 0 0 0 21358110 1218 266 151 284 134 2053 1218 266 151 284 134 2053 3213 5129 2182 4486 15010 4969292 4498305 5011713 3487981 3407882 21375173 0.99920 0.99790 0.00010 0.00090 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: MISCELLANEOUS INCOME - 2011 AMOUNT: $ 3,213. 2012 AMOUNT: $ 5,129. 2013 AMOUNT: $ 2,182. 2014 AMOUNT: $ 4,486. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 10056 7940 2116 20557 15906 4651 264751 158918 105833 112600 DEFERRED RENT 16508 16508 3416649 -609 870 84509 84770 3331879 0 3331879 3368356 870 84509 85379 3282977 0 3282977 PART XI, LINE 2D - OTHER ADJUSTMENTS: SPECIAL EVENT EXPENSES 84,509. PART XII, LINE 2D - OTHER ADJUSTMENTS: SPECIAL EVENT EXPENSES 84,509. ANNUAL GALA 156305 117305 39000 58396 2051 3250 20812 156305 117305 39000 58396 2051 3250 20812 84509 -45509 X X X 0 0 0 0 0 0 0 0 0 JOHN T BRUCHALSKI MD CHAIRMAN & PRESIDENT 232545 0 0 0 0 0 6812 0 8458 0 247815 0 0 0 MARIE ANDERSON OB/GYN 229517 0 0 0 0 0 9508 0 12133 0 251158 0 0 0 DANIEL FISK OB/GYN 222941 0 0 0 0 0 10800 0 7937 0 241678 0 0 0 LORNA CVETKOVICH OB/GYN 191596 0 0 0 0 0 12000 0 9713 0 213309 0 0 0 MIRIAM PEREIRA OB/GYN 230267 0 0 0 0 0 14500 0 500 0 245267 0 0 0 FORM 990, PART VI, SECTION A, LINE 7A IF THE OFFICE OF ANY DIRECTOR OR DIRECTORS BECOMES VACANT, THE REMAINING DIRECTORS, THOUGH LESS THAN A QUORUM, SHALL BE AUTHORIZED TO SELECT A SUCCESSOR OR SUCCESSORS, WHO SHALL BE APPOINTED UPON THE AFFIRMATIVE VOTE OF A THREE-FOURTHS MAJORITY OF THE REMAINING DIRECTORS OF THE CORPORATION TO SERVE THE UNEXPIRED TERMS OF THE VACATED DIRECTORSHIPS. FORM 990, PART VI, SECTION B, LINE 11 THE FEDERAL FORM 990 IS PREPARED AND REVIEWED BY THE ORGANIZATION'S INDEPENDENT TAX ACCOUNTANT. THE DRAFT VERSION OF THE FEDERAL FORM 990 IS THEN SUBMITTED TO THE AUDIT REVIEW COMMITTEE, WHICH CONSISTS OF BOARD MEMBERS, FOR REVIEW AND REVISIONS PRIOR TO FILING WITH THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION'S BOARD OF DIRECTORS MEETS QUARTERLY AND DISCUSSES ANY CONFLICTS OF INTEREST AT THAT TIME. ADHERENCE TO THE WRITTEN POLICY IS CONFIRMED ANNUALLY BY THE ORGANIZATION'S INDEPENDENT AUDITORS. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION FOR THE ORGANIZATION'S CHAIRMAN, PRESIDENT, AND KEY EMPLOYEES IS REVIEWED ON AN ANNUAL BASIS BY THE COMPENSATION COMMITTEE, WHICH INCLUDES INDEPENDENT MEMBERS OF THE BOARD OF DIRECTORS. COMPENSATION IS EVALUATED IN LIGHT OF COMPARABILITY DATA FOR NORTHERN VIRGINIA. THE DELIBERATIONS AND DECISIONS OF THE INDEPENDENT COMMITTEE ARE DOCUMENTED IN THE ORGANIZATION'S MINUTES. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. TEPEYAC FAMILY CENTER LLC 11096-A LEE HIGHWAY SUITE 101 FAIRFAX VA 22030 201963116 OB/GYN SERVICES VA 3276348 616401 DIVINE MERCY CARE