2014-05-15T16:10:17-05:00 2013-06-30 910189318 MOSS ADAMS LLP 101 SECOND STREET 9TH FLOOR SAN FRANCISCO CA 94105 990 2012-07-01 680149424 CLINIC OLE FOUNDATION CLIN 7076032105 1141 PEAR TREE LANE NO 100 NAPA CA 94558 JOHN R SHAFER 7076032105 2014-05-14 1 RENIE BURBANK P00159653 4159561500 2012 2015-11-30 17:44:51Z PETER MCCREA 1141 PEAR TREE LANE NO 100 NAPA CA 94558 1059155 0 X WWW.CLINICOLE.ORG X 1987 CA FUNDRAISING & OTHER SERVICES TO SUPPORT COMMUNITY HEALTH CLINIC OLE 15 14 0 20 0 0 531474 905823 0 0 41331 30059 17257 69371 590062 1005253 550000 508350 0 0 0 112946 0 0 21301 60786 100336 610786 721632 -20724 283621 1929691 2351685 0 38480 1929691 2313205 FUNDRAISING AND OTHER SERVICES TO SUPPORT COMMUNITY HEALTH CLINIC OLE 0 0 674837 508350 FUNDRAISING SERVICES IN SUPPORT OF COMMUNITY HEALTH CLINIC OLE, A HEALTH CLINIC FOR LOW INCOME INDIVIDUALS AND OTHERS WITHOUT HEALTH INSURANCE. 674837 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 1 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 1 4 0 1 0 0 0 0 0 0 1 1 0 0 0 0 X 15 14 1 0 0 0 0 0 0 1 0 0 0 1 1 1 1 1 1 0 0 0 CA X X CYNTHIA GREGORY 7076037104 1141 PEAR TREE LANE SUITE 100 NAPA CA 94558 X PETER MCCREA 5.00 X X 0 0 0 KATHY OATES 5.00 X X 0 0 0 CYNTHIA GREGORY 5.00 X X 26532 0 0 CHRIS CAPPETO 5.00 X X 0 0 0 TANIR AMI 5.00 X 0 0 0 KARYANNE DUNCAN MD 5.00 X 0 0 0 CRISTINA SALAS-PORRAS HUDSON 5.00 X 0 0 0 DANA JOHNSON 5.00 X 0 0 0 DAN LYNCH 5.00 X 0 0 0 MARTHA MAY 5.00 X 0 0 0 JOHN SHAFER 5.00 X 0 0 0 PRISCILLA UPTON 5.00 X 0 0 0 SLOAN UPTON 5.00 X 0 0 0 TODD ZAPOLSKI 5.00 X 0 0 0 KATHY ZELAZNY 5.00 X 0 0 0 26532 0 0 0 0 0 0 0 514271 391552 25145 905823 30080 30080 3619 3640 -21 -21 -21 119633 514271 50262 69371 69371 1005253 0 0 99430 508350 508350 97628 97628 15318 15318 53541 53541 100 100 305 305 405 405 477 477 5643 5643 660 660 SPECIAL EVENT 18225 18225 BANK FEE CHARGES 10047 10047 ED SEARCH COSTS 4880 4880 SALES TAX/USE 3076 3076 2977 2977 721632 674837 25494 21301 1039432 1333208 0 890259 1018477 1929691 2351685 0 38480 0 38480 X 1929691 2313205 1929691 2313205 1929691 2351685 283621 99893 0 X 0 1 X 0 0 X X X 0 0 0 CLINIC OLE 237221695 3 1 1 1 508350 1 508350 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 PUBLICLY TRADE SECURITIES 1018477 C 1018477 X 1155408 99893 99893 1055515 -50262 -50262 1005253 771894 50262 50262 721632 0 721632 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE ORGANIZATION IS A NONPROFIT CORPORATION UNDER INTERNAL REVENUE CODE SECTION 501(C)(3) AND HAS BEEN GRANTED TAX-EXEMPT STATUS BY THE INTERNAL REVENUE SERVICE AND THE CALIFORNIA REVENUE AND TAXATION CODE. AS OF JUNE 30, 2013, THE ORGANIZATION HAD NO UNRECOGNIZED TAX POSITIONS OR UNCERTAIN TAX POSITIONS REQUIRING ACCRUAL. THEREFORE, NO PROVISION FOR INCOME TAXES HAS BEEN PROVIDED IN THE CONSOLIDATED FINANCIAL STATEMENTS. PART XI, LINE 4B - OTHER ADJUSTMENTS: RECLASSIFICATION SPECIAL EVENT EXPENSES TO REVENUE -50,262. PART XII, LINE 2D - OTHER ADJUSTMENTS: RECLASSIFICATION SPECIAL EVENT EXPENSES TO REVENUE 50,262. 40TH GALA 570504 451771 118733 0 13220 14977 5189 0 12069 CHILI BALL 13 63400 62500 900 0 0 3008 0 0 1799 633904 514271 119633 13220 17985 5189 13868 50262 69371 0 COMMUNITY HEALTH CLINIC OLE 1141 PEAR TREE LN STE 100 NAPA CA 94558 237221695 501(C)(3) 508350 GENERAL SUPPORT 1 X 2 15598 FMV AT CONTRIBUTION DATE X SUPPLIES 100 9547 DONOR ORGANIZATION 0 0 0 0 FORM 990, PART VI, SECTION A, LINE 2 TWO BOARD MEMBERS PRISCILLA UPTON AND SLOAN UPTON HAVE A FAMILY RELATIONSHIP FORM 990, PART VI, SECTION A, LINE 8B THE ORGANIZATION HAS NO COMMITTEES WITH THE AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11 A COPY OF THE FORM 990 AND ALL RELATED SCHEDULES AND STATEMENTS WAS PROVIDED THE BOARD BEFORE FILING IN ORDER TO ALLOW SUFFICIENT TIME FOR REVIEW AND COMMENT. FORM 990, PART VI, SECTION B, LINE 12C CONFLICT OF INTEREST STATEMENTS ARE UPDATED AND REVIEWED PERIODICALLY. FORM 990, PART VI, SECTION C, LINE 19 THE AUDITED FINANCIAL STATEMENTS, CONFLICT OF INTEREST POLICY, AND GOVERNING DOCUMENTS ARE ALL AVAILABLE UPON REQUEST. EMPLOYEES COMPENSATED BY RELATED ORGANIZATION 990, PART VII, SECTION A AND PART IX, STATEMENT OF FUNCTIONAL EXPENSES OFFICERS AND EMPLOYEES ARE EMPLOYED AND COMPENSATED BY COMMUNITY HEALTH CLINIC OLE (CHCO). CHCO REPORTS 100% OF THE INDIVIDUAL'S COMPENSATION ON W-2'S ISSUED BY CHCO UNDER THEIR FEDERAL TAX IDENTIFICATION NUMBER, 23-7221695. THERE ARE TWO EMPLOYEES ASSIGNED DUTIES TO CLINIC OLE FOUNDATION. AS A RESULT OF THESE ASSIGNMENTS, WAGE AND BENEFIT COSTS ARE REIMBURSED BY THE FOUNDATION TO CHCO. THE WAGE AND BENEFIT COSTS REIMBURSED BY THE FOUNDATION ARE REPORTED ON FORM 990, PART IX, STATEMENT OF FUNCTIONAL EXPENSES FOR THE TWO EMPLOYEES AS BEING COMPENSATED DIRECTLY FROM THE FILING. COMMUNITY HEALTH CLINIC OLE 1141 PEAR TREE LN STE 100 NAPA CA 94558 237221695 PROVIDES HEALTH CARE TO LOW INCOME AND UNINSURED RESIDENTS CA 501(C)(3) 3 N/A 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0