Polk County Medical Association — Form 990EZ, tax year 2012

View Polk County Medical Association on 990iQ →
Form990-EZ
Click to see attachment
Department of the Treasury
Internal Revenue Service
Short Form
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code
(except black lung benefit trust or private foundation)
bullet Sponsoring organizations of donor advised funds, organizations that operate one or more hospital facilities, and certain controlling organizations as defined in section 512(b)(13) must file Form 990 (see instructions).
All other organizations with gross receipts less than $200,000 and total assets less than $500,000 at the end of the year may use this form.
bulletThe organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-1150
2012
Open to Public
Inspection
A
For the 2012 calendar year, or tax year beginning 01-01-2012, and ending 12-31-2012
B
Check if applicable:
C Name of organization
POLK COUNTY MEDICAL ASSOCIATION
 
Number and street (or P. O. box, if mail is not delivered to street address)4315 HIGHLAND PARK BLVD STE B
ROOM/SUITE 111Room/suite
City or town, state or country, and ZIP + 4 LAKELAND, FL33813
D Employer identification number

59-6137315
E Telephone number

(863) 644-4051
F Group Exemption
Number. . bullet  
G Accounting Method: Other (specify) bullet   H Check bulletI Website:bulletWWW.POLKCOUNTYDOCTORS.COMJ Tax-exempt status(check only one)—( 6) bullet(insert no.) or
K Check bullet A Form 990-EZ or Form 990 return is not required though Form 990-N (e-postcard) may be required (see instructions). But if the organization chooses to file a return, be sure to file a complete return.
L Add lines 5b, 6c, and 7b, to line 9 to determine gross receipts. If gross receipts are $200,000 or more, or if total assets (Part II, line 25, column (B) below) are $500,000 or more, file Form 990 instead of Form 990-EZ . . . . . . . bullet $ 125,176
Part I
Revenue, Expenses, and Changes in Net Assets or Fund Balances (see the instructions for Part I)Check if the organization used Schedule O to respond to any question in this Part I...................
VerticalRevenue 1 Contributions, gifts, grants, and similar amounts received............... 1 94,771
2 Program service revenue including government fees and contracts ............ 2  
3 Membership dues and assessments...................... 3  
4 Investment income........................... 4 138
5a Gross amount from sale of assets other than inventory........ 5a  
b Less: cost or other basis and sales expenses........... 5b  
c Gain or (loss) from sale of assets other than inventory (Subtract line 5b from line 5a) ...... 5c  
6 Gaming and fundraising events
a Gross income from gaming (attach Schedule G if greater than $15,000) . 6a  
b Gross income from fundraising events (not including $   of contributions
from fundraising events reported on line 1) (attach Schedule G if the
sum of such gross income and contributions exceeds $15,000) 6b  
c Less: direct expenses from gaming and fundraising events....... 6c  
d Net income or (loss) from gaming and fundraising events (add lines 6a and 6b and subtract line 6c) 6d  
7a Gross sales of inventory, less returns and allowances........ 7a  
b Less: cost of goods sold................. 7b  
c Gross profit or (loss) from sales of inventory (Subtract line 7b from line 7a) ......... 7c  
8 Other revenue (describe in Schedule O) ..................... 8 30,267
9 Total revenue. Add lines 1, 2, 3, 4, 5c, 6d, 7c, and 8.............. Bullet 9 125,176
VerticalExpenses 10 Grants and similar amounts paid (list in Schedule O) ................. 10  
11 Benefits paid to or for members........................ 11  
12 Salaries, other compensation, and employee benefits................ 12 50,210
13 Professional fees and other payments to independent contractors............ 13 2,517
14 Occupancy, rent, utilities, and maintenance................... 14 17,523
15 Printing, publications, postage, and shipping................... 15 5,683
16 Other expenses (describe in Schedule O) .................... 16 21,312
17 Total expenses. Add lines 10 through 16 ................. Bullet 17 97,245
VerticalNetAssets 18 Excess or (deficit) for the year (Subtract line 17 from line 9)............ 18 27,931
19 Net assets or fund balances at beginning of year (from line 27, column (A)) (must agree with
end-of-year figure reported on prior year’s return)................ 19 94,154
20 Other changes in net assets or fund balances (explain in Schedule O) .......... 20  
21 Net assets or fund balances at end of year. Combine lines 18 through 20.........Bullet 21 122,085
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 10642I Form 990-EZ (2012)
Form 990-EZ (2012)
Page 2
Part IIBalance Sheets (see the instructions for Part II)Check if the organization used Schedule O to respond to any question in this Part II.................

(A) Beginning of year(B) End of year
22Cash, savings, and investments................
146,879
22
157,514
23Land and buildings....................
 
23
 
24Other assets (describe in Schedule O) ..........
5,221
24
5,008
25Total assets......................
152,100
25
162,522
26
Total liabilities (describe in Schedule O) .............
57,946
26
40,437
27Net assets or fund balances (line 27 of column (B) must agree with line 21)..
94,154
27
122,085
Part IIIStatement of Program Service Accomplishments (see the instructions for Part III) Check if the organization used Schedule O to respond to any question in this Part III . Expenses
(Required for section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts; optional for others.)
What is the organization's primary exempt purpose? THE ASSOCIATION SERVES AS AN ADVOCATE FOR PHYSICIANS AND THEIR PATIENTS TO PROMOTE HIGH STANDARDS IN MEDICAL ETHICS, PROMOTE PUBLIC HEALTH, AND TO ENHANCE THE QUALITY AND ACCESSIBILITY OF HEALTH CARE IN OUR COMMUNITIES. THE ASSOCIATION ALSO PROVIDES FREE PHYSICIAN REFERRALS AND CAN BE OF ASSISTANCE IN HELPING GROUPS SECURE A SPEAKER ON A MEDICAL TOPIC.
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. In a clear and concise manner, describe the services provided, the number of persons benefited, and other relevant information for each program title.
28 THE ASSOCIATION SERVES AS AN ADVOCATE FOR PHYSICIANS AND THEIR PATIENTS TO PROMOTE HIGH STANDARDS IN MEDICAL ETHICS, PROMOTE PUBLIC HEALTH, AND TO ENHANCE THE QUALITY AND ACCESSIBILITY OF HEALTH CARE IN OUR COMMUNITIES. THE ASSOCIATION ALSO PROVIDES FREE PHYSICIAN REFERRALS AND CAN BE OF ASSISTANCE IN HELPING GROUPS SECURE A SPEAKER ON A MEDICAL TOPIC.
(Grants $   ) If this amount includes foreign grants, check here ...MediumBullet		 28a  
29
(Grants $   ) If this amount includes foreign grants, check here ...MediumBullet 		29a
30
(Grants $   ) If this amount includes foreign grants, check here ...MediumBullet 		30a
31 Other program services (describe in Schedule O)
(Grants $   ) If this amount includes foreign grants, check here...MediumBullet		 31a
32 Total program service expenses (add lines 28a through 31a).......... bullet 32  
Part IV
List of Officers, Directors, Trustees, and Key Employees List each one even if not compensated (see the instructions for Part IV)Check if the organization used Schedule O to respond to any question in this Part IV............
(a) Name and title (b) Average
hours per week
devoted to position		 (c)Reportable compensation
(Forms W-2/1099-MISC) (if not paid, enter -0-) 		(d) Health benefits, contributions to employee benefit plans,
and deferred compensation		 (e) Estimated amount
of other compensation
JACKIE COURTNEYClick to see attachmentEXECUTIVE DI 000.00 0    
DEAN SHULL MDClick to see attachmentPRESIDENT 000.00 0    
DANIEL HAIGHT MDClick to see attachmentDIRECTOR 000.00 0    
KEVIN DORSETT MDClick to see attachmentCHAIRMAN 000.00 0    
RICHARD HAMILTON MDClick to see attachmentVICE PRESIDE 000.00 0    
RALPH NOBO MDClick to see attachmentDIRECTOR 000.00 0    
SERGIO SEOANE MDClick to see attachmentDIRECTOR 000.00 0    
ARVIND SONI MDClick to see attachmentVICE PRESIDE 000.00 0    
JAMES SANDERS MDClick to see attachmentSECRETARY/TR 000.00 0    
Form 990-EZ (2012)
Form 990-EZ (2012)
Page 3
Part V
Other Information
(Note the Schedule A and personal benefit contract statement requirements in the
instructions for Part V.) Check if the organization used Schedule O to respond to any question in this Part V.......
Yes
No
33
Did the organization engage in any significant activity not previously reported to the IRS? If "Yes," provide a detailed description of each activity in Schedule O ...................
33
 
No
34
Were any significant changes made to the organizing or governing documents? If "Yes," attach a conformed copy of the amended documents if they reflect a change to the organization’s name. Otherwise, explain the changeon Schedule O (see instructions) ..........................
34
 
No
35a
Did the organization have unrelated business gross income of $1,000 or more during the year from business activities (such as those reported on lines 2, 6a, and 7a, among others)? ............
35a
Yes
 
b
If "Yes," to line 35a, has the organization filed a Form 990-T for the year? If "No," provide an explanation in Schedule O
35b
Yes
 
c
Was the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization subject to section 6033(e) notice, reporting, and proxy tax requirements during the year? If "Yes," complete Schedule C, Part III
35c
 
No
36
Did the organization undergo a liquidation, dissolution, termination, or significant disposition of net assets during the year? If “Yes,” complete applicable parts of Schedule N ................
36
 
No
37a
Enter amount of political expenditures, direct or indirect, as described in the instructions. bullet
37a
 
b
Did the organization file Form 1120-POL for this year?...................
37b
 
No
38a
Did the organization borrow from, or make any loans to, any officer, director, trustee, or key employee or were
any such loans made in a prior year and still outstanding at the end of the tax year covered by this return?..
38a
 
No
b
If “Yes,” complete Schedule L, Part II and enter the total amount involved .
38b
 
39
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on line 9.......
39a
 
b
Gross receipts, included on line 9, for public use of club facilities.....
39b
 
40a
Section 501(c)(3) organizations. Enter amount of tax imposed on the organization during the year under:
section 4911 bullet   ; section 4912 bullet   ; section 4955 bullet  
b
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in any section 4958 excess benefittransaction during the year, or did it engage in an excess benefit transaction in a prior year that has not been reported on any of its prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I ......
40b
 
 
c
Section 501(c)(3) and 501(c)(4) organizations. Enter amount of tax imposed on organization managers or disqualified persons during the year under sections 4912, 4955, and 4958...bullet  
d
Section 501(c)(3) and 501(c)(4) organizations. Enter amount of tax on line 40c reimbursed by the organization...........................bullet  
e
All organizations. At any time during the tax year, was the organization a party to a prohibited tax shelter transaction? If "Yes," complete Form 8886-T ......................
40e
 
No
41List the states with which a copy of this return is filed. bullet
42aThe organization's books are in care of bulletJACKIE COURTNEY Telephone no. bullet (863) 644-4051
Located at bullet5110 S FLORIDA AVE STE 111LAKELAND,FL ZIP + 4bullet33813
b
At any time during the calendar year, did the organization have an interest in or a signature or other authority over a financial account in a foreign country (such as a bank account, securities account, or other financial account)?
Yes
No
42b
 
No
If “Yes,” enter the name of the foreign country: bullet
See the instructions for exceptions and filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
c
At any time during the calendar year, did the organization maintain an office outside the U.S.?
42c
 
No
If “Yes,” enter the name of the foreign country: bullet
43.......bullet
and enter the amount of tax-exempt interest received or accrued during the tax year....bullet43
 
Yes
No
44a
Did the organization maintain any donor advised funds during the year? If "Yes," Form 990 must be completed instead of
Form 990-EZ................................
44a
 
No
b
Did the organization operate one or more hospital facilities during the year? If "Yes," Form 990 must be completedinstead of Form 990-EZ.............................
44b
 
No
c
Did the organization receive any payments for indoor tanning services during the year?.........
44c
 
No
d
If "Yes," to line 44c, has the organization filed a Form 720 to report these payments? If "No," provide an
explanation in Schedule O ............................
44d
 
 
45a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?.........
45a
 
No
45b
Did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If "Yes," Form 990 and Schedule R may need to be completed instead of Form 990-EZ (see instructions)......................
45b
 
No
Form 990-EZ (2012)
Form 990-EZ (2012)
Page 4
Yes
No
46
Did the organization engage, directly or indirectly, in political campaign activities on behalf of or in opposition tocandidates for public office? If “Yes,” complete Schedule C, Part I. ..............
46
 
No
Part VI
Section 501(c)(3) organizations only All section 501(c)(3) organizations must answer questions 47-49b and 52, and complete the tables for lines 50 and 51 Check if the organization used Schedule O to respond to any question in this Part VI ................
Yes
No
47
Did the organization engage in lobbying activities or have a section 501(h) election in effect during the tax year? If "Yes," complete Schedule C, Part II .......................
47
 
 
48
Is the organization a school as described in section 170(b)(1)(A)(ii)? If "Yes," complete Schedule E ..
48
 
 
49a
Did the organization make any transfers to an exempt non-charitable related organization?......
49a
 
 
b
If "Yes," was the related organization a section 527 organization?................
49b
 
 
50
Complete this table for the organization's five highest compensated employees (other than officers, directors, trustees and key employees) who each received more than $100,000 of compensation from the organization. If there is none, enter "None."
(a) Name and title of each employee paid more than $100,000 (b) Average
hours per week
devoted to position		 (c) Reportable compensation
(Forms W-2/1099-MISC) 		(d) Health benefits, contributions to employee benefit plans, and deferred compensation (e) Estimated amount of other compensation
 
f
Total number of other employees paid over $100,000 .................bullet  

51
Complete this table for the organization's five highest compensated independent contractors who each received more than $100,000 of compensation from the organization. If there is none, enter "None."
(a) Name and address of each independent contractor paid more than $100,000 (b) Type of service (c) Compensation
 
d
Total number of other independent contractors each receiving over $100,000..........bullet  
52
Did the organization complete Schedule A? NOTE: All Section 501(c)(3) organizations and 4947(a)(1) nonexempt charitable trusts must attach a completed Schedule A ...............bullet
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title
Paid Preparer Use Only
Print/Type preparer's name
 
Preparer's signature
Date
PTIN
Firm's name bullet

Firm's EIN bullet
Firm's address bullet



Phone no.
May the IRS discuss this return with the preparer shown above? See instructions .........bullet
Form 990-EZ (2012)


Form 990-EZ, Special Condition Description:
Special Condition Description

Additional Data


Software ID:  
Software Version:  
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.
MediumBullet Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2012
Open to Public
Inspection
Name of the organization
POLK COUNTY MEDICAL ASSOCIATION
 
Employer identification number

59-6137315
Identifier Return Reference Explanation
OTHER REVENUE FORM 990-EZ, PART I, LINE 8 ENDORSEMENT INCOME 30,267 TOTAL 30,267
OTHER EXPENSES FORM 990-EZ, PART I, LINE 16 EXPENSES OFFICE 2,873 TRAVEL 1,453 CONFERENCES/MEETINGS 14,312 INSURANCE 2,460 NON-INVESTMENT DEPRECIATION 214 TOTAL 21,312
OTHER ASSETS FORM 990-EZ, PART II, LINE 24 19,613 19,613 LESS ACCUMULATED DEPRECIATION 18,936 19,149 DUE FROM P.C. MEDICAL BULLETIN 4,354 4,354 UTILITY DEPOSIT 190 190 TOTAL 5,221 5,008
OTHER LIABILITIES FORM 990-EZ, PART II, LINE 26 DEFERRED REVENUE 50,292 31,278 PAYROLL LIABILITIES 2,699 4,204 DUE TO FOUNDATION 4,955 4,955
PRIMARY EXEMPT PURPOSE FORM 990-EZ, PART III THE ASSOCIATION SERVES AS AN ADVOCATE FOR PHYSICIANS AND THEIR PATIENTS TO PROMOTE HIGH STANDARDS IN MEDICAL ETHICS, PROMOTE PUBLIC HEALTH, AND TO ENHANCE THE QUALITY AND ACCESSIBILITY OF HEALTH CARE IN OUR COMMUNITIES. THE ASSOCIATION ALSO PROVIDES FREE PHYSICIAN REFERRALS AND CAN BE OF ASSISTANCE IN HELPING GROUPS SECURE A SPEAKER ON A MEDICAL TOPIC.
FIRST ACCOMPLISHMENT FORM 990-EZ, PART III, LINE 28 THE ASSOCIATION SERVES AS AN ADVOCATE FOR PHYSICIANS AND THEIR PATIENTS TO PROMOTE HIGH STANDARDS IN MEDICAL ETHICS, PROMOTE PUBLIC HEALTH, AND TO ENHANCE THE QUALITY AND ACCESSIBILITY OF HEALTH CARE IN OUR COMMUNITIES. THE ASSOCIATION ALSO PROVIDES FREE PHYSICIAN REFERRALS AND CAN BE OF ASSISTANCE IN HELPING GROUPS SECURE A SPEAKER ON A MEDICAL TOPIC.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2012

Additional Data


Software ID:  
Software Version:  

TY 2012 CompensationExplanation
Name:
POLK COUNTY MEDICAL ASSOCIATION
EIN: 59-6137315
Person Name Explanation
JACKIE COURTNEY  
DEAN SHULL MD  
DANIEL HAIGHT MD  
KEVIN DORSETT MD  
RICHARD HAMILTON MD  
RALPH NOBO MD  
SERGIO SEOANE MD  
ARVIND SONI MD  
JAMES SANDERS MD