2013-11-14T13:18:27-06:00 2012-12-31 010494526 BAKER NEWMAN & NOYES PO BOX 507 PORTLAND ME 04112 990 2012-01-01 020489150 Northeast Delta Dental Foundation NORT 6032231000 PO Box 2002 Concord NH 033022002 THOMAS RAFFIO 6032231000 2013-11-13 1 E Drew Cheney P00182972 2078972100 2013-11-13 2012 2016-02-24 21:20:13Z Thomas Raffio PO Box 2002 Concord NH 033022002 1027850 0 X www.nedelta.com X 1996 NH Promote dental health and education in northern New England 11 11 0 0 0 0 648079 646257 0 0 83382 41392 0 0 731461 687649 315854 357302 0 0 0 0 0 0 0 7534 4987 323388 362289 408073 325360 2919515 3535663 50000 50000 2869515 3485663 To promote dental health and education in northern New England 0 0 205400 205400 Dental equipment and supplies: cash donations to 35 nonprofit dental clinics to purchase dental equipment and supplies to serve patients who cannot afford dental care. 133617 133617 Oral health education programs and public policy development: cash donations to 8 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.Also contributed to 4 organizations to assist in oral health public policy development and to promote the importance of oral health.Also contributed to 13 organizations to fund dental residency scholarship programs. 18285 18285 Fluoride rinse and sealant programs for children: cash donations to 6 organizations to be used to provide fluoride rinse or sealants for children. These programs are usually performed in schools. 357302 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 0 0 0 0 0 0 0 0 0 X 11 11 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 0 0 0 0 0 NH X Kathleen Walker 6032231000 c/o One Delta Drive Concord NH 033022002 X MELVIN J SEVERANCE III 1.00 X X 0 0 0 KATHLEEN B WALKER 6.00 X X 0 0 0 PETER W LEBERMAN ESQ 1.00 X X 0 0 0 ELIZABETH ANDREWS 3.00 X 0 0 0 CLAYTON R ADAMS 1.00 X 0 0 0 CHARLES E BROWN 1.00 X 0 0 0 FRANCIS H LABRANCHE JR DDS 1.00 X 0 0 0 SUZANNE MCDOWELL 1.00 X 0 0 0 THOMAS RAFFIO 2.00 X X 0 0 0 DOUGLAS C TERP 1.00 X 0 0 0 ELEANOR H VIEN 2.00 X 0 0 0 TERENCE A WARDROP 1.00 X 0 0 0 0 0 0 0 0 0 0 0 21222 625035 646257 60763 60763 312181 331552 -19371 -19371 -19371 8649 21222 8649 0 687649 -19371 0 60763 357302 357302 2396 2396 1502 1502 642 642 Bank service charges 372 372 State of NH filing fees 75 75 362289 357302 4987 0 237863 231449 405200 401900 2276452 2902314 2919515 3535663 50000 50000 50000 50000 X 2680699 3296847 188816 188816 2869515 3485663 2919515 3535663 325360 290788 0 X 0 0 0 X 392355 378517 512647 650579 648757 2582855 392355 378517 512647 650579 648757 2582855 2266261 316594 62388 50649 50627 83382 60763 307809 2890664 0.10950 0.10730 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.- It encourages donations from the general public, through the website of Northeast Delta Dental (a group of nonprofit organizations) and through other means.- Its 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. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 2820677 401900 332044 105211 3449410 2642281 405200 -130207 96597 2820677 2178074 277300 278419 91512 2642281 1866113 154300 338407 100000 80746 2178074 2181578 294600 -552093 57972 1866113 0.94530 0.00000 0.05470 0 0 0 GOLF TOURNAMENT 27909 27909 6958 1691 27909 27909 6958 1691 8649 19260 1 Easter Seals NH 555 Auburn Street Manchester NH 03103 020272825 501(c)(3) 10000 Dental clinic Dental Lifeline Network of NH (Donated Dental Services) 1800 15th Street Suite 100 Denver CO 80202 846129064 501(c)(3) 10000 Program support Greater Nashua Dental Connection 31 Cross Street Nashua NH 03064 020200866 501(c)(3) 10000 Dental equipment Families First of the Greater Seacoast 100 Campus Drive Suite 12 Portsmouth NH 03801 222757341 501(c)(3) 6000 Dental supplies City of Manchester - Health Dept Fiscal Agent - Mental Health Center 401 Cypress Street Manchester NH 03103 020258994 501(c)(3) 10000 Mobile dental van repairs White Mountain Community Health Center PO Box 2800 White Mountain Highway Conway NH 03818 020275078 501(c)(3) 10000 Children's dental program Foundation for Healthy Communities - Fiscal Agent NH Dept Health Human Services 29 Hazen St Concord NH 03301 020275078 501(c)(3) 10000 3rd grade healthy smiles/healthy growth survey Maine Dental Association PO Box 215 Manchester ME 04351 271270353 501(c)(6) 15000 Workforce study St Apollonia Dental Clinic - Fiscal Agent Aroostock County Action Program PO Box 1116 Presque Isle ME 04769 010315849 501(c)(3) 10000 New operatories Maine Health Access Foundation 150 Capitol Street Suite 4 Augusta ME 04330 010535144 501(c)(3) 13700 Oral health program specialist City of Portland Children's Oral Health Program Public Health Division 1600 Forest Avenue Portland ME 04103 016000032 501(c)(3) 8000 Bright Smiles Program Penobscot Community Health Center 1048 Union Street Suite 5 Bangor ME 04401 010514750 501(c)(3) 10000 Dental residency program Eastport Health Care Inc PO Box H 30 Boynton Street Eastport ME 04631 010354589 501(c)(3) 10902 Dental equipment Community Dental (Farmington) 276 Canco Road Portland ME 04103 237129502 501(c)(3) 10000 Dental equipment Champlain Valley Head StartEarly Head Start c/o 255 South Champlain Street Burlington VT 05402 030216837 501(c)(3) 44000 Tooth Tutor Program Vermont State Dental Society 1 Kennedy Drive Suite L3 South Burlington VT 05403 222514423 501(c)(6) 15000 Diabetes project Community Health Center of Burlington 617 Riverside Avenue Burlington VT 05401 237182584 501(c)(3) 10000 Expansion of dental programs/operatories Vermont Technical College 301 Lawrence Place Williston VT 05495 030213787 13000 Dental equipment for dental hygiene dental clinic 16 2 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, 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 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.