Department of the Treasury Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. See separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
MCV ASSOCIATED PHYSICIANS
Employer identification number
54-1581185
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization?
................
11g(i)
No
(ii)
a family member of a person described in (i) above?
......................
11g(ii)
No
(iii)
a 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
No
h
Provide the following information about the supported organization(s).
(i) Name of supported organization
(ii) EIN
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions))
(iv) Is the organization in col. (i) listed in your governing document?
(v) Did you notify the organization in col. (i) of your support?
(vi) Is the organization in col. (i) organized in the U.S.?
(vii) Amount of support?
Yes
No
Yes
No
Yes
No
(1)
VCU SCHOOL OF MEDICINE
546001758
02
Yes
2,017,142
Total
2,017,142
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the
organization failed to qualify under Part III. If the organization fails to
qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3
The value of services or facilities furnished by a governmental unit to the organization without charge..
4
Total. Add lines 1 through 3..
5
The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included
on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6
Public Support. Subtract line 5 from line 4.
Section B. Total Support
Calendar year(or fiscal year beginning in)
(a) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(f) Total
7
Amounts from line 4..
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
9
Net income from unrelated business activities, whether or not the business is regularly carried on..
10
Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..
11
Total support (Add lines 7 through 10).
12
Gross receipts from related activities, etc. (See instructions.)
..................
12
13
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here..........................................
Section C. Computation of Public Support Percentage
14
Public Support Percentage for 2010 (line 6 column (f) divided by line 11 column (f))
.........
14
15
Public Support Percentage for 2009 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2011.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
......................
b
33 1/3% support test—2010.
If the organization did not check the box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2011.
If the organization did not check a box on line 13, 16a, or 16b and line 14
is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported
organization
..................................................
b
10%-facts-and-circumstances test—2010.
If the organization did not check a box on line 13, 16a, 16b, or 17a and line
15 is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported organization
..............................................
18
Private Foundation
If the organization did not check a box on line 13, 16a, 16b, 17a or 17b, check this box and see
instructions
...................................................
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization
failed to qualify under Part II. If the organization fails to qualify under
the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2
Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
6
Total. Add lines 1 through 5.
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
b
Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c
Add lines 7a and 7b..
8
Public Support (Subtract line 7c from line 6.)
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(f) Total
9
Amounts from line 6...
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
13
Total support (Add lines 9, 10c, 11 and 12.).
14
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public Support Percentage for 2011 (line 8 column (f) divided by line 13 column (f))
.........
15
16
Public support percentage from 2010 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2011 (line 10c column (f) divided by line 13 column (f))
......
17
18
Investment income percentage from 2010 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2011.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3% and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
..........
b
33 1/3% support tests—2010.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
....
20
Private Foundation
If the organization did not check a box on line 14, 19a or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 4
Part IV
Supplemental Information.
Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
Explanation
Schedule A (Form 990 or 990-EZ) 2011
Additional Data
Software ID:
Software Version:
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
MCV ASSOCIATED PHYSICIANS
Employer identification number
54-1581185
Identifier
Return Reference
Explanation
FORM 990, PART VI, LINES 6 AND 7A
THE SELECTION PROCESS FOR THE GOVERNING BODY OF MCV PHYSICIANS IS AS FOLLOWS: THE CHAIRS OF EACH SCHOOL OF MEDICINE CLINICAL DEPARTMENT SHALL RECOMMEND APPOINTMENT OF THE FOUR DEPARTMENTAL CHAIR DIRECTORS TO THE CORPORATE MEMBER. THE FULL-TIME FACULTY OF THE SCHOOL OF MEDICINE SHALL RECOMMEND TO THE CORPORATE MEMBER APPOINTMENT OF THE FOUR FACULTY DIRECTORS WHO ARE NOT DEPARTMENTAL CHAIRS. THE PRESIDENT AND EXECUTIVE DIRECTOR OF THE CORPORATION SHALL RECOMMEND THREE INDEPENDENT DIRECTORS TO THE BOARD OF DIRECTORS; THE BOARD, AFTER CONSIDERATION OF THE RECOMMENDATIONS FROM THE PRESIDENT AND EXECUTIVE DIRECTOR, SHALL RECOMMEND THREE INDEPENDENT DIRECTORS TO THE CORPORATE MEMBER. ALL RECOMMENDATIONS FOR APPOINTED DIRECTORS SHALL BE SUBMITTED TO THE CORPORATE MEMBER BY THE PRESIDENT OF THE CORPORATION, FOLLOWING NOTIFICATION OF THE RECOMMENDATIONS TO THE CEO/VCUHS AND THE DEAN. AFTER CONSIDERATION OF THE RECOMMENDATIONS, THE CORPORATE MEMBER SHALL APPOINT DIRECTORS TO THE BOARD, FOR TERMS OF SERVICE CONSISTENT WITH THE PROVISIONS OF THESE BYLAWS.
FORM 990, PART VI, LINE 7B
MCV PHYSICIANS BOARD OF DIRECTORS DECISIONS ARE SUBJECT TO APPROVAL OF THE CORPORATE MEMBER, VIRGINIA COMMONWEALTH UNIVERSITY HEALTH SYSTEM AUTHORITY.
FORM 990, PART VI, LINE 11
THE FINANCIAL INFORMATION IS PROVIDED TO KPMG BY THE MCV PHYSICIANS CONTROLLER. KPMG PREPARES THE FORM 990 AND RETURNS THE COMPLETED FORM 990 TO MCV PHYSICIANS FOR REVIEW. THE CONTROLLER OF MCV PHYSICIANS REVIEWS THE FORM 990 TO ENSURE IT IS COMPLETE AND ACCURATE. THE CONTROLLER WILL REVIEW THE FORM 990 WITH THE EXECUTIVE DIRECTOR OF MCV PHYSICIANS. UPON COMPLETING THE REVIEW WITH THE EXECUTIVE DIRECTOR, THE GOVERNING BODY OF MCV PHYSICIANS IS PROVIDED WITH A COPY OF FORM 990 BEFORE IT IS FILED WITH THE IRS.
FORM 990, PART VI, LINE 12C
VCU HEALTH SYSTEM POLICY 2104.01 - TERMS OF EMPLOYMENT CONTAINS THE HEALTH SYSTEM'S POLICY REGARDING CONFLICTS OF INTEREST IN SECTION I. ALSO, VCU HEALTH SYSTEM IS REQUIRED TO PARTICIPATE IN THE COMMONWEALTH'S STATEMENT OF ECONOMIC INTEREST PROCESS. IN THE PROCESS, EACH EMPLOYEE AT THE DIRECTOR OR ABOVE LEVEL PLUS EMPLOYEES OF COMPLIANCE, AUDIT AND PROCUREMENT ARE REQUIRED TO SUBMIT TO CINDY EARNHARDT, VCUHS DIRECTOR OF AUDIT & COMPLIANCE SERVICES, ON AN ANNUAL BASIS THE COMMONWEALTH'S STATEMENT OF ECONOMIC INTEREST. CINDY EARNHARDT, ALONG WITH THE HEALTH SYSTEM GENERAL COUNSEL, REVIEWS THESE FORMS TO DETERMINE WHETHER THERE ARE ANY POTENTIAL CONFLICTS NOTED. WHEN DEVIATIONS FROM POLICY HAVE BEEN NOTED CINDY EARNHARDT WORKS WITH SENIOR MANAGEMENT TO REMEDIATE THE SITUATION. THESE FORMS ARE THEN SUBMITTED TO THE SECRETARY OF THE COMMONWEALTH. VCU HEALTH SYSTEM'S PARTICIPATION IN THIS PROCESS IS MANDATED BY THE ENABLING LEGISLATION FOR THE HEALTH SYSTEM.
FORM 990, PART VI, LINES 15a and 15b
THE COMPENSATION FOR THE SENIOR LEVEL ADMINISTRATORS, SALARY AND ANY BONUS IS SET BY DR. SHELDON RETCHIN AS THE CEO OF THE HEALTH SYSTEM. THIS IS CONSISTENT WITH THE REQUIREMENTS ESTABLISHED IN THE BYLAWS OF VCUHS. DR. RETCHIN TRADITIONALLY CONDUCTS A 360 DEGREE EVALUATION OF ALL SENIOR LEVEL ADMINISTRATORS. THIS INFORMATION IS THEN USED ALONG WITH A REVIEW OF THEIR PERFORMANCE AND OF THEIR ACHIEVEMENT OF GOALS FOR THE YEAR. DR. RETCHIN THEN MEETS IN EXECUTIVE SESSION WITH THE VCUHS BOARD OF DIRECTORS TO DISCUSS THE MATTER.
FORM 990, PART VI, LINE 19
THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS FOR MCV PHYSICIANS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST.
FORM 990, PART XI, LINE 5
OTHER CHANGES IN NET ASSETS CONSISTS OF THE FOLLOWING: UNREALIZED LOSS ON INVESTMENTS $(982,771) ------------ OTHER CHANGES IN NET ASSETS $(982,771)
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:MITCHELL S ANSCHER TITLE:BD MEMBER DEPT CHAIR HOURS:16
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:LENORE M BUCKLEY TITLE:BD MEMBER PROFESSOR HOURS:8
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:JEROME F STRAUSS TITLE:BD MEMBER DEAN HOURS:25
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:Ananda K Pandurangi TITLE:Board member & Div Chair HOURS:11
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:JOHN D WARD TITLE:Bd Member PRESIDENT HOURS:7
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:HARINDER S DHINDSA TITLE:BD MEMBER ASSOC PROF HOURS:1
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:ANTON J KUZEL TITLE:BD MEMBER & DEPT CHAIR HOURS:48
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:ANN S FULCHER TITLE:BD MEMBER DEPT CHAIR HOURS:10
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:LAURIE J LYCKHOLM TITLE:BD MEMBER & PROFESSOR HOURS:16
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:BRUCE K RUBIN TITLE:BD MEMBER & DEPT CHAIR HOURS:18
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:John F Butterworth TITLE:Chair HOURS:12
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:JOHN E NESTLER TITLE:INTERIM DEPT CHAIR HOURS:31
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:David A Lanning TITLE:Assoc. Professor HOURS:2
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:Jeffrey H Haynes TITLE:Professor HOURS:2
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:Marc P Posner TITLE:Div. Chair HOURS:10
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:BRUCE E MATHERN TITLE:ASSOC PROFESSOR HOURS:4
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:Claudio Oiticica TITLE:Assoc. Professor HOURS:2
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.