GIRDWOOD HEALTH CLINIC: Form 990, tax year 2011
View the entire original 990 at ProPublica ↗
- Organization
- GIRDWOOD HEALTH CLINIC (EIN 90-0622646)
- Tax period
- 2011-12-22 to 2011-12-31
- Filed
- 2012-11-07
- IRS object ID
- 201213129349301216
- Schema version
- 2011v1.2
- 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
| Field | Value | IRS element (for citing) |
|---|---|---|
| Timestamp | 2012-11-07T08:43:49-09:00 | Timestamp |
| Tax Period End Date | 2011-12-31 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
Preparer Firm Business Name PreparerFirmBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | White and Associates CPA | BusinessNameLine1 |
Preparer Firm US Address PreparerFirmUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO Box 772165 | AddressLine1 |
| City | Eagle River | City |
| State | AK | State |
| ZIP Code | 99577 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2011-12-22 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 900622646 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Girdwood Health Clinic Inc | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | GIRD | NameControl |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO Box 1130 | AddressLine1 |
| City | Girdwood | City |
| State | AK | State |
| ZIP Code | 99587 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | Mary Jo Thill | Name |
| Title | President | Title |
| Date Signed | 2012-11-06 | DateSigned |
| Authorize Third Party | false | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | Sharon K White CPA | Name |
| Phone | 9075619599 | Phone |
| Date Prepared | 2012-11-07 | DatePrepared |
| Self Employed | X | SelfEmployed |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2011 | TaxYear |
| Build TS | 2016-02-24 21:20:13Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Initial Return | X | InitialReturn |
| Gross Receipts | 23101 | GrossReceipts |
| Group Return For Affiliates | false | GroupReturnForAffiliates |
| Organization501c3 | X | Organization501c3 |
| Web Site | www.girdwoodhealthclinic.org | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 2011 | YearFormation |
| State Legal Domicile | AK | StateLegalDomicile |
| Activity Or Mission Description | provide expanded quality health care to residents and visitors of the area without regard to ability to pay operation of a sustainable nonprofit community health clinic | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 13 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 13 | NbrIndependentVotingMembers |
| Total Nbr Employees | 3 | TotalNbrEmployees |
| Total Nbr Volunteers | 13 | TotalNbrVolunteers |
| Total Gross UBI | 0 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | 0 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Current Year | 7793 | ContributionsGrantsCurrentYear |
| Program Service Revenue CY | 15308 | ProgramServiceRevenueCY |
| Investment Income Current Year | 0 | InvestmentIncomeCurrentYear |
| Other Revenue Current Year | 0 | OtherRevenueCurrentYear |
| Total Revenue Current Year | 23101 | TotalRevenueCurrentYear |
| Grants And Similar Amnts CY | 0 | GrantsAndSimilarAmntsCY |
| Benefits Paid To Members CY | 0 | BenefitsPaidToMembersCY |
| Salaries Etc Current Year | 1950 | SalariesEtcCurrentYear |
| Total Prof Fundrsng Exp CY | 0 | TotalProfFundrsngExpCY |
| Total Fundrsng Exp Current Year | 1214 | TotalFundrsngExpCurrentYear |
| Other Expenses Current Year | 6097 | OtherExpensesCurrentYear |
| Total Expenses Current Year | 8047 | TotalExpensesCurrentYear |
| Revenues Less Expenses CY | 15054 | RevenuesLessExpensesCY |
| Total Assets EOY | 151270 | TotalAssetsEOY |
| Total Liabilities EOY | 136216 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances EOY | 15054 | NetAssetsOrFundBalancesEOY |
| Mission Description | provide expanded quality health care to residents and visitors of the area without regard to ability to pay operation of a sustainable nonprofit community health clinic | MissionDescription |
| Significant New Program Services | false | SignificantNewProgramServices |
| Significant Change | false | SignificantChange |
| Expense | 5233 | Expense |
| Revenue | 15308 | Revenue |
| Description | Successfully obtained nonprofit status and began providing services on a sliding fee scale | Description |
| Total Program Service Expense | 5233 | TotalProgramServiceExpense |
| Described In501 C3 | true | DescribedIn501C3 |
| Schedule B Required | false | ScheduleBRequired |
| Political Activities | false | PoliticalActivities |
| Lobbying Activities | false | LobbyingActivities |
| Donor Advised Funds | false | DonorAdvisedFunds |
| Conservation Easements | false | ConservationEasements |
| Collections Of Art | false | CollectionsOfArt |
| Credit Counseling | false | CreditCounseling |
| Term Or Permanent Endowments | false | TermOrPermanentEndowments |
| Report Land Bldg Equip | true | ReportLandBldgEquip |
| Report Invest Oth Securities | false | ReportInvestOthSecurities |
| Report Prog Rel Invest | false | ReportProgRelInvest |
| Report Other Assets | false | ReportOtherAssets |
| Report Other Liabilities | false | ReportOtherLiabilities |
| Report Fin48 Footnote | false | ReportFin48Footnote |
| Independent Audit Financial Stmt | false | IndependentAuditFinancialStmt |
| Consolidated Audit Financial Stmt | false | ConsolidatedAuditFinancialStmt |
| School | false | School |
| Foreign Office | false | ForeignOffice |
| Foreign Activities | false | ForeignActivities |
| More Than5000 K To Organizations | false | MoreThan5000KToOrganizations |
| More Than5000 K To Individuals | false | MoreThan5000KToIndividuals |
| Professional Fundraising | false | ProfessionalFundraising |
| Fundraising Activities | false | FundraisingActivities |
| Gaming | false | Gaming |
| Hospital | false | Hospital |
| Grants To Organizations | false | GrantsToOrganizations |
| Grants To Individuals | false | GrantsToIndividuals |
| Schedule J Required | false | ScheduleJRequired |
| Tax Exempt Bonds | false | TaxExemptBonds |
| Excess Benefit Transaction | false | ExcessBenefitTransaction |
| Prior Excess Benefit Transaction | false | PriorExcessBenefitTransaction |
| Loan To Officer Or DQP | false | LoanToOfficerOrDQP |
| Grant To Related Person | false | GrantToRelatedPerson |
| Bsnss Rltnshp With Organization | true | BsnssRltnshpWithOrganization |
| Bsnss Rltnshp Thru Family Member | false | BsnssRltnshpThruFamilyMember |
| Officer Entity With Bsnss Rltnshp | false | OfficerEntityWithBsnssRltnshp |
| Deductible Non Cash Contributions | false | DeductibleNonCashContributions |
| Deductible Contributions Of Art | false | DeductibleContributionsOfArt |
| Terminated | false | Terminated |
| Partial Liquidation | false | PartialLiquidation |
| Disregarded Entity | false | DisregardedEntity |
| Related Entity | false | RelatedEntity |
| Related Org Controlled Entity | false | RelatedOrgControlledEntity |
| Transaction Related Entity | false | TransactionRelatedEntity |
| Transfers To Exempt Non Chrtbl Org | false | TransfersToExemptNonChrtblOrg |
| Activities Conducted Partnership | false | ActivitiesConductedPartnership |
| Schedule O Required | true | ScheduleORequired |
| Number Forms Transmitted With1096 | 0 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Compliance With Backup Witholding | true | ComplianceWithBackupWitholding |
| Number Of Employees | 3 | NumberOfEmployees |
| Employment Tax Returns Filed | true | EmploymentTaxReturnsFiled |
| Unrelated Business Income | false | UnrelatedBusinessIncome |
| Foreign Financial Account | false | ForeignFinancialAccount |
| Prohibited Tax Shelter Trans | false | ProhibitedTaxShelterTrans |
| Taxable Party Notification | false | TaxablePartyNotification |
| Non Deductible Contributions | false | NonDeductibleContributions |
| Quid Pro Quo Contributions | false | QuidProQuoContributions |
| Form8282 Property Disposed Of | false | Form8282PropertyDisposedOf |
| Funds To Pay Premiums | false | FundsToPayPremiums |
| Premiums Paid | false | PremiumsPaid |
| Excess Business Holdings | false | ExcessBusinessHoldings |
| Taxable Distributions | false | TaxableDistributions |
| Distribution To Donor | false | DistributionToDonor |
| Indoor Tanning Services | false | IndoorTanningServices |
| Info In Schedule O Part VI | X | InfoInScheduleOPartVI |
| Nbr Voting Governing Body Members | 13 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 13 | NumberIndependentVotingMembers |
| Family Or Business Relationship | false | FamilyOrBusinessRelationship |
| Delegation Of Management Duties | false | DelegationOfManagementDuties |
| Changes To Organizing Docs | false | ChangesToOrganizingDocs |
| Material Diversion Or Misuse | false | MaterialDiversionOrMisuse |
| Members Or Stockholders | false | MembersOrStockholders |
| Election Of Board Members | false | ElectionOfBoardMembers |
| Decisions Subject To Approval | false | DecisionsSubjectToApproval |
| Minutes Of Governing Body | true | MinutesOfGoverningBody |
| Minutes Of Committees | true | MinutesOfCommittees |
| Officer Mailing Address | false | OfficerMailingAddress |
| Local Chapters | false | LocalChapters |
| Form990 Provided To Governing Body | true | Form990ProvidedToGoverningBody |
| Conflict Of Interest Policy | true | ConflictOfInterestPolicy |
| Annual Disclosure Covered Persons | true | AnnualDisclosureCoveredPersons |
| Regular Monitoring Enforcement | true | RegularMonitoringEnforcement |
| Whistleblower Policy | false | WhistleblowerPolicy |
| Document Retention Policy | true | DocumentRetentionPolicy |
| Compensation Process CEO | false | CompensationProcessCEO |
| Compensation Process Other | false | CompensationProcessOther |
| Investment In Joint Venture | false | InvestmentInJointVenture |
| Upon Request | X | UponRequest |
The Books Are In Care Of TheBooksAreInCareOf
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Person | Steve Bartholomew | NamePerson |
| Telephone Number | 9077831355 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO Box 1053 | AddressLine1 |
| City | Girdwood | City |
| State | AK | State |
| ZIP Code | 99587 | ZIPCode |
Form990 Part VII Section A Form990PartVIISectionA (14 entries)
| TitleTitle | Average Hours Per WeekAverageHoursPerWeek | Individual Trustee Or DirectorIndividualTrusteeOrDirector | Reportable Comp From OrganizationReportableCompFromOrganization | Reportable Comp From Related OrgsReportableCompFromRelatedOrgs | Other CompensationOtherCompensation | OfficerOfficer | Key EmployeeKeyEmployee |
|---|---|---|---|---|---|---|---|
| Clinton Dow | |||||||
| Director | 6.00 | X | 0 | 0 | 0 | ||
| Dorinda Carter | |||||||
| Director | 3.00 | X | 0 | 0 | 0 | ||
| Eugene Bjornstad | |||||||
| Director | 4.00 | X | 0 | 0 | 0 | ||
| Karl Erickson | |||||||
| Director | 3.00 | X | 0 | 0 | 0 | ||
| Kathy Trautner | |||||||
| Director | 6.00 | X | 0 | 0 | 0 | ||
| Michelle Cosper | |||||||
| Director | 3.00 | X | 0 | 0 | 0 | ||
| Peter Preis | |||||||
| Director | 3.00 | X | 0 | 0 | |||
| Robin Ingram | |||||||
| Director | 3.00 | X | 0 | 0 | 0 | ||
| Rochelle Morris | |||||||
| Director | 3.00 | X | 0 | 0 | 0 | ||
| Amanda Snitzer | |||||||
| Sectretary | 3.00 | 0 | 0 | 0 | X | ||
| Mary Jo Thill | |||||||
| President | 8.00 | 0 | 0 | 0 | X | ||
| Steve Bartholomew | |||||||
| Treasurer | 5.00 | 0 | 0 | 0 | X | ||
| Theresa Sherwood | |||||||
| Vice President | 6.00 | 0 | 0 | 0 | X | ||
| Kerry Dorius | |||||||
| Key Employee | 60.00 | 1200 | 0 | 0 | X | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 1200 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 0 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 0 | TotalOtherCompensation |
| Number Individuals GT100 K | 0 | NumberIndividualsGT100K |
| Formers Listed | false | FormersListed |
| Total Comp GT150 K | false | TotalCompGT150K |
| Compensation From Other Sources | false | CompensationFromOtherSources |
| All Other Contributions | 7793 | AllOtherContributions |
| Total Contributions | 7793 | TotalContributions |
Program Service Revenue ProgramServiceRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | Patient Health Care | Description |
| Business Code | 621300 | BusinessCode |
| Total Revenue Column | 15308 | TotalRevenueColumn |
| Related Or Exempt Function Income | 15308 | RelatedOrExemptFunctionIncome |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | 15308 | TotalProgramServiceRevenue |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 23101 | TotalRevenueColumn |
| Related Or Exempt Function Income | 15308 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 0 | UnrelatedBusinessRevenue |
| Exclusion | $0 | ExclusionAmount |
Other Salaries And Wages OtherSalariesAndWages
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1779 | Total |
| Program Services | 1779 | ProgramServices |
Payroll Taxes PayrollTaxes
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 171 | Total |
| Program Services | 171 | ProgramServices |
Fees For Services Management FeesForServicesManagement
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1864 | Total |
| Management And General | 650 | ManagementAndGeneral |
| Fundraising | 1214 | Fundraising |
Office Expenses OfficeExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1409 | Total |
| Program Services | 1409 | ProgramServices |
Conferences Meetings ConferencesMeetings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 25 | Total |
| Program Services | 25 | ProgramServices |
Depreciation Depletion DepreciationDepletion
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1476 | Total |
| Program Services | 1476 | ProgramServices |
Insurance Insurance
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 90 | Total |
| Program Services | 90 | ProgramServices |
Other Expenses OtherExpenses (2 entries)
| DescriptionDescription | TotalTotal | Program ServicesProgramServices | Management And GeneralManagementAndGeneral |
|---|---|---|---|
| Medical Supply | 283 | 283 | |
| Licenses and application fee | 950 | 950 |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 8047 | Total |
| Program Services | 5233 | ProgramServices |
| Management And General | 1600 | ManagementAndGeneral |
| Fundraising | 1214 | Fundraising |
Cash Non Interest Bearing CashNonInterestBearing
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | 1096 | EOY |
Accounts Receivable AccountsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | 14575 | EOY |
Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | 1575 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Buildings Equipment Basis | 57000 | LandBuildingsEquipmentBasis |
| Land Bldg Equipment Accum Deprec | 1040 | LandBldgEquipmentAccumDeprec |
Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | 55960 | EOY |
Intangible Assets IntangibleAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | 78064 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 0 | BOY |
| EOY | 151270 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | 716 | EOY |
Unsecured Notes Loans Payable UnsecuredNotesLoansPayable
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | 135500 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 0 | BOY |
| EOY | 136216 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | 15054 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 0 | BOY |
| EOY | 15054 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 0 | BOY |
| EOY | 151270 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Reconcilation Revenue Expenses | 15054 | ReconcilationRevenueExpenses |
| Reconcilation Other Changes | 0 | ReconcilationOtherChanges |
| Method Of Accounting Cash | X | MethodOfAccountingCash |
| Accountant Compile Or Review | false | AccountantCompileOrReview |
| FS Audited | false | FSAudited |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital170b1 Aiii | X | Hospital170b1Aiii |
Schedule D IRS990ScheduleD
Leasehold Improvements LeaseholdImprovements
| Field | Value | IRS element (for citing) |
|---|---|---|
| Investment Cost Or Other Basis | 10000 | InvestmentCostOrOtherBasis |
| Depreciation | 11 | Depreciation |
| Book Value | 9989 | BookValue |
Equipment Equipment
| Field | Value | IRS element (for citing) |
|---|---|---|
| Investment Cost Or Other Basis | 47000 | InvestmentCostOrOtherBasis |
| Depreciation | 1029 | Depreciation |
| Book Value | 45971 | BookValue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Land Buildings | 55960 | TotalOfBookValueLandBuildings |
Schedule L IRS990ScheduleL
Form990 Schedule L Part IV Form990ScheduleLPartIV
Name Of Interested Person NameOfInterestedPerson
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Person | Kerry Dorius | NamePerson |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Relationship | Key Employee | Relationship |
| Amount Of Transaction | 135500 | AmountOfTransaction |
| Description Of Transaction | Sale of assets | DescriptionOfTransaction |
| Sharing Of Revenues | false | SharingOfRevenues |
Form990 Schedule L Part V Form990ScheduleLPartV
| Field | Value | IRS element (for citing) |
|---|---|---|
| Identifier | 01 990 Schedule L Placeholder 4 | Identifier |
| Explanation | Business Transactions Asset Acquisition Statement under section 1060 Purchaser Girdwood Health Clinic Inc Seller Kerry L Dorius Date of Sale 12-22-2011 Total sales Price 135500 Allocation of Sales Price Class V assets 57000 Class VI and VII assets78500 A written agreement was signed by both parties which provided for an allocation of the sales price | Explanation |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (3 entries)
| IdentifierIdentifier | ExplanationExplanation |
|---|---|
| 01. Form 990 governing body review (Part VI, line 11) | The Board of Directors recieved a copy of the return have reviewed and approved the Form 990 in their regular board meeting prior to filing |
| 02. Conflict of interest policy compliance (Part VI, line 12c) | The conflict of interest policy is included in the by-laws of the organization The policy is enforced thru self-monoritoring and is reviewed and discussed regularly at board meetings |
| 03. Governing documents, etc, available to public (Part VI, line 19) | The organization makes its governing documents conflict of interest policy and financial statements available to the public by request |
Comments