FREE CLINIC OF POWHATAN: Form 990, tax year 2011

View the entire original 990 at ProPublica ↗

Organization
FREE CLINIC OF POWHATAN (EIN 26-1275136)
Tax period
2011-01-01 to 2011-12-31
Filed
2012-05-23
IRS object ID
201241449349300104
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

FieldValueIRS element (for citing)
Timestamp2012-05-23T08:36:41-05:00Timestamp
Tax Period End Date2011-12-31TaxPeriodEndDate

Preparer Firm PreparerFirm

Preparer Firm Business Name PreparerFirmBusinessName

FieldValueIRS element (for citing)
Business Name Line1RICHARD W MCMINN III CPA PLLCBusinessNameLine1

Preparer Firm US Address PreparerFirmUSAddress

FieldValueIRS element (for citing)
Address Line13229 ANDERSON HWY STE 100AddressLine1
CityPOWHATANCity
StateVAState
ZIP Code231397340ZIPCode
FieldValueIRS element (for citing)
Return Type990ReturnType
Tax Period Begin Date2011-01-01TaxPeriodBeginDate

Filer Filer

FieldValueIRS element (for citing)
EIN261275136EIN

Name Name

FieldValueIRS element (for citing)
Business Name Line1FREE CLINIC OF POWHATAN INCBusinessNameLine1
FieldValueIRS element (for citing)
Name ControlFREENameControl
Phone8043796484Phone

US Address USAddress

FieldValueIRS element (for citing)
Address Line12364 HUGUENOT TRAILAddressLine1
CityPOWHATANCity
StateVAState
ZIP Code23139ZIPCode

Officer Officer

FieldValueIRS element (for citing)
NameCONNIE MOSLOWName
TitleEXECUTIVE DIRECTORTitle
Phone8043796484Phone
Date Signed2012-05-18DateSigned
Authorize Third PartytrueAuthorizeThirdParty

Preparer Preparer

FieldValueIRS element (for citing)
NameRICHARD W MCMINNIII CPAName
Phone8045986662Phone
Date Prepared2012-05-18DatePrepared
Self EmployedXSelfEmployed
FieldValueIRS element (for citing)
Tax Year2011TaxYear
Build TS2016-02-24 21:20:13ZBuildTS

Form 990 IRS990

FieldValueIRS element (for citing)
Name Of Principal Officer PersonCONNIE MOSLOWNameOfPrincipalOfficerPerson

Address Principal Officer US AddressPrincipalOfficerUS

FieldValueIRS element (for citing)
Address Line12364 HUGUENOT TRAILAddressLine1
CityPOWHATANCity
StateVAState
ZIP Code23139ZIPCode
FieldValueIRS element (for citing)
Gross Receipts150026GrossReceipts
Group Return For AffiliatesfalseGroupReturnForAffiliates
Organization501c3XOrganization501c3
Web SiteWWW.FREECLINICOFPOWHATAN.ORGWebSite
Type Of Organization CorporationXTypeOfOrganizationCorporation
Year Formation2007YearFormation
Activity Or Mission DescriptionTO PROVIDE MEDICAL AND DENTAL SERVICES TO THOSE NOT ABLE TO PURCHASE THESE SERVICES THROUGH OTHER AVENUESActivityOrMissionDescription
Nbr Voting Members Governing Body15NbrVotingMembersGoverningBody
Nbr Independent Voting Members15NbrIndependentVotingMembers
Total Nbr Employees3TotalNbrEmployees
Total Nbr Volunteers25TotalNbrVolunteers
Total Gross UBI0TotalGrossUBI
Contributions Grants Prior Year282249ContributionsGrantsPriorYear
Contributions Grants Current Year150026ContributionsGrantsCurrentYear
Program Service Revenue CY0ProgramServiceRevenueCY
Investment Income Current Year0InvestmentIncomeCurrentYear
Other Revenue Current Year0OtherRevenueCurrentYear
Total Revenue Prior Year282249TotalRevenuePriorYear
Total Revenue Current Year150026TotalRevenueCurrentYear
Grants And Similar Amnts CY0GrantsAndSimilarAmntsCY
Benefits Paid To Members CY0BenefitsPaidToMembersCY
Salaries Etc Current Year32056SalariesEtcCurrentYear
Total Prof Fundrsng Exp CY0TotalProfFundrsngExpCY
Total Fundrsng Exp Current Year0TotalFundrsngExpCurrentYear
Other Expense Prior Year92293OtherExpensePriorYear
Other Expenses Current Year139629OtherExpensesCurrentYear
Total Expenses Prior Year92293TotalExpensesPriorYear
Total Expenses Current Year171685TotalExpensesCurrentYear
Revenues Less Expenses Prior Year189956RevenuesLessExpensesPriorYear
Revenues Less Expenses CY-21659RevenuesLessExpensesCY
Total Assets BOY261522TotalAssetsBOY
Total Assets EOY238986TotalAssetsEOY
Total Liabilities BOY1192TotalLiabilitiesBOY
Total Liabilities EOY315TotalLiabilitiesEOY
Net Assets Or Fund Balances BOY260330NetAssetsOrFundBalancesBOY
Net Assets Or Fund Balances EOY238671NetAssetsOrFundBalancesEOY
Info In Schedule O Part IIIXInfoInScheduleOPartIII
Mission DescriptionTO PROVIDE MEDICAL AND DENTAL SERVICES TO THOSE NOT ABLE TO PURCHASE THESE SERVICES THROUGH OTHER AVENUESMissionDescription
Significant New Program ServicesfalseSignificantNewProgramServices
Significant ChangefalseSignificantChange
Expense35714Expense
DescriptionORGANIZATION FACILITATES THE AVAILABILITY OF MEDICAL AND DENTAL SERVICES TO THE RESIDENTS OF POWHATAN, VIRGINIA THAT DO NOT HAVE THE RESOURCES TO GET THE SERVICES ELSEWHERE.Description

Activity Other ActivityOther

FieldValueIRS element (for citing)
Expense48036Expense
DescriptionORGANIZATION FACILITATES THE AVAILABILITY OF MEDICAL AND DENTAL SERVICES TO THE RESIDENTS OF POWHATAN, VIRGINIA THAT DO NOT HAVE THE RESOURCES TO GET THE SERVICES ELSEWHERE.Description
FieldValueIRS element (for citing)
Total Of Other Program Service Exp48036TotalOfOtherProgramServiceExp
Total Program Service Expense83750TotalProgramServiceExpense
Described In501 C3trueDescribedIn501C3
Schedule B RequiredtrueScheduleBRequired
Political ActivitiesfalsePoliticalActivities
Lobbying ActivitiesfalseLobbyingActivities
Subject To Proxy TaxfalseSubjectToProxyTax
Donor Advised FundsfalseDonorAdvisedFunds
Conservation EasementsfalseConservationEasements
Collections Of ArtfalseCollectionsOfArt
Credit CounselingfalseCreditCounseling
Term Or Permanent EndowmentsfalseTermOrPermanentEndowments
Report Land Bldg EquiptrueReportLandBldgEquip
Report Invest Oth SecuritiesfalseReportInvestOthSecurities
Report Prog Rel InvestfalseReportProgRelInvest
Report Other AssetsfalseReportOtherAssets
Report Other LiabilitiestrueReportOtherLiabilities
Report Fin48 FootnotefalseReportFin48Footnote
Independent Audit Financial StmtfalseIndependentAuditFinancialStmt
Consolidated Audit Financial StmtfalseConsolidatedAuditFinancialStmt
SchoolfalseSchool
Foreign OfficefalseForeignOffice
Foreign ActivitiesfalseForeignActivities
More Than5000 K To OrganizationsfalseMoreThan5000KToOrganizations
More Than5000 K To IndividualsfalseMoreThan5000KToIndividuals
Professional FundraisingfalseProfessionalFundraising
Fundraising ActivitiesfalseFundraisingActivities
GamingfalseGaming
HospitalfalseHospital
Grants To OrganizationsfalseGrantsToOrganizations
Grants To IndividualsfalseGrantsToIndividuals
Schedule J RequiredfalseScheduleJRequired
Tax Exempt BondsfalseTaxExemptBonds
Excess Benefit TransactionfalseExcessBenefitTransaction
Prior Excess Benefit TransactionfalsePriorExcessBenefitTransaction
Loan To Officer Or DQPfalseLoanToOfficerOrDQP
Grant To Related PersonfalseGrantToRelatedPerson
Bsnss Rltnshp With OrganizationfalseBsnssRltnshpWithOrganization
Bsnss Rltnshp Thru Family MemberfalseBsnssRltnshpThruFamilyMember
Officer Entity With Bsnss RltnshpfalseOfficerEntityWithBsnssRltnshp
Deductible Non Cash ContributionsfalseDeductibleNonCashContributions
Deductible Contributions Of ArtfalseDeductibleContributionsOfArt
TerminatedfalseTerminated
Partial LiquidationfalsePartialLiquidation
Disregarded EntityfalseDisregardedEntity
Related EntityfalseRelatedEntity
Related Org Controlled EntityfalseRelatedOrgControlledEntity
Transaction Related EntityfalseTransactionRelatedEntity
Transfers To Exempt Non Chrtbl OrgfalseTransfersToExemptNonChrtblOrg
Activities Conducted PartnershipfalseActivitiesConductedPartnership
Schedule O RequiredtrueScheduleORequired
Number Forms Transmitted With10960NumberFormsTransmittedWith1096
Number W2 G Included0NumberW2GIncluded
Compliance With Backup WitholdingtrueComplianceWithBackupWitholding
Number Of Employees3NumberOfEmployees
Employment Tax Returns FiledtrueEmploymentTaxReturnsFiled
Unrelated Business IncomefalseUnrelatedBusinessIncome
Foreign Financial AccountfalseForeignFinancialAccount
Prohibited Tax Shelter TransfalseProhibitedTaxShelterTrans
Taxable Party NotificationfalseTaxablePartyNotification
Non Deductible ContributionsfalseNonDeductibleContributions
Indoor Tanning ServicesfalseIndoorTanningServices
Info In Schedule O Part VIXInfoInScheduleOPartVI
Nbr Voting Governing Body Members15NbrVotingGoverningBodyMembers
Number Independent Voting Members15NumberIndependentVotingMembers
Family Or Business RelationshipfalseFamilyOrBusinessRelationship
Delegation Of Management DutiesfalseDelegationOfManagementDuties
Changes To Organizing DocsfalseChangesToOrganizingDocs
Material Diversion Or MisusefalseMaterialDiversionOrMisuse
Members Or StockholdersfalseMembersOrStockholders
Election Of Board MemberstrueElectionOfBoardMembers
Decisions Subject To ApprovalfalseDecisionsSubjectToApproval
Minutes Of Governing BodytrueMinutesOfGoverningBody
Minutes Of CommitteestrueMinutesOfCommittees
Officer Mailing AddressfalseOfficerMailingAddress
Local ChaptersfalseLocalChapters
Form990 Provided To Governing BodyfalseForm990ProvidedToGoverningBody
Conflict Of Interest PolicytrueConflictOfInterestPolicy
Annual Disclosure Covered PersonstrueAnnualDisclosureCoveredPersons
Regular Monitoring EnforcementtrueRegularMonitoringEnforcement
Whistleblower PolicyfalseWhistleblowerPolicy
Document Retention PolicyfalseDocumentRetentionPolicy
Compensation Process CEOtrueCompensationProcessCEO
Compensation Process OthertrueCompensationProcessOther
Investment In Joint VenturefalseInvestmentInJointVenture
Upon RequestXUponRequest

The Books Are In Care Of TheBooksAreInCareOf

FieldValueIRS element (for citing)
Name PersonCONNIE MOSLOWNamePerson
Telephone Number8043796484TelephoneNumber

Address US AddressUS

FieldValueIRS element (for citing)
Address Line12364 HUGUENOT TRAILAddressLine1
CityPOWHATANCity
StateVAState
ZIP Code23139ZIPCode
FieldValueIRS element (for citing)
No Listed Persons CompensatedXNoListedPersonsCompensated

Form990 Part VII Section A Form990PartVIISectionA (14 entries)

TitleTitleAverage Hours Per WeekAverageHoursPerWeekIndividual Trustee Or DirectorIndividualTrusteeOrDirectorOfficerOfficerReportable Comp From OrganizationReportableCompFromOrganizationReportable Comp From Related OrgsReportableCompFromRelatedOrgsOther CompensationOtherCompensation
CONNIE MOSLOW
PRESIDENT10.00XX000
JOHN CARMACK MD
VICE-PRES20.00XX000
CARSON TUCKER
SECRETARY5.00XX000
LARRY LYONS
TREASURER1.00XX000
TINA BUSTOS
DIRECTOR1.00X000
SISTER MAUREEN CARROLL
DIRECTOR1.00X000
CAROLYN BISHOP
DIRECTOR1.00X000
NANCY ALEXANDER
DIRECTOR1.00X000
INDIA COX
DIRECTOR1.00X000
RON SPEARS
DIRECTOR1.00X000
ERIC GREGORY
DIRECTOR1.00X000
ANN HOGG
DIRECTOR1.00X000
LINDA JONES
DIRECTOR1.00X000
RICHARD MCMINN III
DIRECTOR1.00X000
FieldValueIRS element (for citing)
Formers ListedfalseFormersListed
Total Comp GT150 KfalseTotalCompGT150K
Compensation From Other SourcesfalseCompensationFromOtherSources
Government Grants2380GovernmentGrants
All Other Contributions147646AllOtherContributions
Total Contributions150026TotalContributions

Total Revenue TotalRevenue

FieldValueIRS element (for citing)
Total Revenue Column150026TotalRevenueColumn

Other Salaries And Wages OtherSalariesAndWages

FieldValueIRS element (for citing)
Total30196Total
Program Services13399ProgramServices
Management And General16797ManagementAndGeneral

Payroll Taxes PayrollTaxes

FieldValueIRS element (for citing)
Total1860Total
Program Services575ProgramServices
Management And General1285ManagementAndGeneral

Fees For Services Accounting FeesForServicesAccounting

FieldValueIRS element (for citing)
Total220Total
Management And General220ManagementAndGeneral

Fees For Services Other FeesForServicesOther

FieldValueIRS element (for citing)
Total83876Total
Program Services33849ProgramServices
Management And General50027ManagementAndGeneral

Advertising Advertising

FieldValueIRS element (for citing)
Total3352Total
Management And General3352ManagementAndGeneral

Office Expenses OfficeExpenses

FieldValueIRS element (for citing)
Total6704Total
Management And General6704ManagementAndGeneral

Information Technology InformationTechnology

FieldValueIRS element (for citing)
Total1110Total
Management And General1110ManagementAndGeneral

Conferences Meetings ConferencesMeetings

FieldValueIRS element (for citing)
Total7921Total
Program Services7921ProgramServices

Depreciation Depletion DepreciationDepletion

FieldValueIRS element (for citing)
Total788Total
Program Services788ProgramServices

Other Expenses OtherExpenses (4 entries)

DescriptionDescriptionTotalTotalProgram ServicesProgramServicesManagement And GeneralManagementAndGeneral
PRESCRIPTIONS ASSISTANCE2418924189
DUES/MEMBERSHIPS52575257
MISC22212221
DENTAL SUPPLIES18681868

All Other Expenses AllOtherExpenses

FieldValueIRS element (for citing)
Total2123Total
Program Services1161ProgramServices
Management And General962ManagementAndGeneral

Total Functional Expenses TotalFunctionalExpenses

FieldValueIRS element (for citing)
Total171685Total
Program Services83750ProgramServices
Management And General87935ManagementAndGeneral
Fundraising0Fundraising

Cash Non Interest Bearing CashNonInterestBearing

FieldValueIRS element (for citing)
BOY260434BOY
EOY236858EOY
FieldValueIRS element (for citing)
Land Buildings Equipment Basis2974LandBuildingsEquipmentBasis
Land Bldg Equipment Accum Deprec846LandBldgEquipmentAccumDeprec

Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet

FieldValueIRS element (for citing)
BOY1088BOY
EOY2128EOY

Total Assets TotalAssets

FieldValueIRS element (for citing)
BOY261522BOY
EOY238986EOY

Other Liabilities OtherLiabilities

FieldValueIRS element (for citing)
BOY1192BOY
EOY315EOY

Total Liabilities TotalLiabilities

FieldValueIRS element (for citing)
BOY1192BOY
EOY315EOY
FieldValueIRS element (for citing)
Follow SFAS117XFollowSFAS117

Unrestricted Net Assets UnrestrictedNetAssets

FieldValueIRS element (for citing)
BOY117067BOY
EOY175914EOY

Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets

FieldValueIRS element (for citing)
BOY143263BOY
EOY62757EOY

Total Net Assets Fund Balances TotalNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY260330BOY
EOY238671EOY

Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY261522BOY
EOY238986EOY
FieldValueIRS element (for citing)
Reconcilation Revenue Expenses-21659ReconcilationRevenueExpenses
Method Of Accounting CashXMethodOfAccountingCash
Accountant Compile Or ReviewtrueAccountantCompileOrReview
FS AuditedfalseFSAudited
Audit CommitteetrueAuditCommittee
Federal Grant Audit RequiredfalseFederalGrantAuditRequired

Schedule A IRS990ScheduleA

FieldValueIRS element (for citing)
Publicly Supported Org170b1 AviXPubliclySupportedOrg170b1Avi

Gifts Grants Contrib Received170 GiftsGrantsContribReceived170

FieldValueIRS element (for citing)
Current Tax Year Minus3 Years55704CurrentTaxYearMinus3Years
Current Tax Year Minus2 Years67412CurrentTaxYearMinus2Years
Current Tax Year Minus1 Year282249CurrentTaxYearMinus1Year
Current Tax Year150026CurrentTaxYear
Total555391Total

Total170 Total170

FieldValueIRS element (for citing)
Current Tax Year Minus3 Years55704CurrentTaxYearMinus3Years
Current Tax Year Minus2 Years67412CurrentTaxYearMinus2Years
Current Tax Year Minus1 Year282249CurrentTaxYearMinus1Year
Current Tax Year150026CurrentTaxYear
Total555391Total
FieldValueIRS element (for citing)
Public Support Total170555391PublicSupportTotal170
Total Support555391TotalSupport
Public Support Pertcentage1701.00000PublicSupportPertcentage170
Public Support Pertcent Prior Year1.00000PublicSupportPertcentPriorYear
Thirty Three Percnt Tests CY170XThirtyThreePercntTestsCY170

Schedule B IRS990ScheduleB

Contributor Info ContributorInfo

FieldValueIRS element (for citing)
Contributor NumberRESTRICTEDContributorNumber

Contributor Name Business ContributorNameBusiness

FieldValueIRS element (for citing)
Business Name Line1RESTRICTEDBusinessNameLine1

Contributor Address US ContributorAddressUS

FieldValueIRS element (for citing)
Address Line1RESTRICTEDAddressLine1
Address Line2RESTRICTEDAddressLine2
CityRESTRICTEDCity
StateRESTRICTEDState
ZIP CodeRESTRICTEDZIPCode
FieldValueIRS element (for citing)
Aggregate ContributionsRESTRICTEDAggregateContributions

Schedule D IRS990ScheduleD

FieldValueIRS element (for citing)
Disclosed Orgs Legal ControlfalseDisclosedOrgsLegalControl
Disclosed For Charitable PurposesfalseDisclosedForCharitablePurposes
Written Policy MonitoringfalseWrittenPolicyMonitoring
Sect170h Requirements SatisfiedfalseSect170hRequirementsSatisfied
Solicited Assets For SalefalseSolicitedAssetsForSale
Agent Trustee EtcfalseAgentTrusteeEtc
Included On FSfalseIncludedOnFS
Endowments Held By Unrelated OrgsfalseEndowmentsHeldByUnrelatedOrgs
Endowments Held By Related OrgsfalseEndowmentsHeldByRelatedOrgs
Are Related Orgs Listed Schedule RfalseAreRelatedOrgsListedScheduleR

Other Land Buildings OtherLandBuildings

FieldValueIRS element (for citing)
Other Cost Or Other Basis2974OtherCostOrOtherBasis
Depreciation846Depreciation
Book Value2128BookValue
FieldValueIRS element (for citing)
Total Of Book Value Land Buildings2128TotalOfBookValueLandBuildings

Other Liabilities OtherLiabilities

FieldValueIRS element (for citing)
DescriptionOTHER LIABILITIESDescription
Amount$315Amount
FieldValueIRS element (for citing)
Total Of Amounts315TotalOfAmounts

Schedule O IRS990ScheduleO

General Explanation GeneralExplanation (7 entries)

IdentifierIdentifierReturn ReferenceReturnReferenceExplanationExplanation
ALL OTHER ACCOMPLISHMENT DESCRIPTIONFORM 990, PAGE 2, PART III, LINE 4DORGANIZATION FACILITATES THE AVAILABILITY OF MEDICAL AND DENTAL SERVICES TO THE RESIDENTS OF POWHATAN, VIRGINIA THAT DO NOT HAVE THE RESOURCES TO GET THE SERVICES ELSEWHERE.
ELECTION OF MEMBERS AND THEIR RIGHTSFORM 990, PAGE 6, PART VI, LINE 7ATHE EXECUTIVE BOARD NOMINATES DIRECTORS EVERY TWO YEARS.
ORGANIZATION'S PROCESS USED TO REVIEW FORM 990FORM 990, PAGE 6, PART VI, LINE 11BOFFICERS REVIEW ON ANNUAL BASIS
ENFORCEMENT OF CONFLICTS POLICYFORM 990, PAGE 6, PART VI, LINE 12CTHE OFFICER'S REVIEW FOR POTENTIAL CONFLICTS CONTINUOUSLY
COMPENSATION PROCESS FOR TOP OFFICIALFORM 990, PAGE 6, PART VI, LINE 15ACOMPENSATION REVIEWED ON AN ANNUAL BASIS
COMPENSATION PROCESS FOR OFFICERSFORM 990, PAGE 6, PART VI, LINE 15BCOMPENSATION REVIEWED ON AN ANNUAL BASIS
GOVERNING DOCUMENTS DISCLOSURE EXPLANATIONFORM 990, PAGE 6, PART VI, LINE 19AVAILABLE UPON REQUEST

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