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
2012
Open to Public Inspection
Name of the organization
DISTRICT 6 HEALTH CARE LEARNING CENTER
Employer identification number
81-0348449
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 supported organization?
................
11g(i)
(ii)
A family member of a person described in (i) above?
......................
11g(ii)
(iii)
A 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
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 monetary support
Yes
No
Yes
No
Yes
No
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 2
Part II
Support Schedule for Organizations Described in Sections 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) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
10,500
10,000
9,250
11,096
40,846
2
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
0
3
The value of services or facilities furnished by a governmental unit to the organization without charge..
0
4
Total. Add lines 1 through 3
10,500
10,000
9,250
11,096
40,846
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)..
0
6
Public support. Subtract line 5 from line 4.
40,846
Section B. Total Support
Calendar year
(or fiscal year beginning in)
(a) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(f) Total
7
Amounts from line 4..
10,500
10,000
9,250
11,096
40,846
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
5,821
4,684
3,045
1,937
15,487
9
Net income from unrelated business activities, whether or not the business is regularly carried on..
0
10
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
0
11
Total support (Add lines 7 through 10).
56,333
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 2012 (line 6, column (f) divided by line 11, column (f))
.........
14
0 %
15
Public support percentage for 2011 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2012.
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—2011.
If the organization did not check a 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—2012.
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—2011.
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) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 3
Part III
Support Schedule for Organizations Described in Section 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) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(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) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(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 2012 (line 8, column (f) divided by line 13, column (f))
.........
15
16
Public support percentage from 2011 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2012 (line 10c, column (f) divided by line 13, column (f))
......
17
18
Investment income percentage from 2011 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2012.
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—2011.
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) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 4
Part IV
Supplemental Information.
Complete this part to provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and 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) 2012
Additional Data
Software ID:
12000229
Software Version:
2012v2.0
-
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
2012
Open to Public Inspection
Name of the organization
DISTRICT 6 HEALTH CARE LEARNING CENTER
Employer identification number
81-0348449
Identifier
Return Reference
Explanation
Form 990, Part VI, Line 19
Form 990, Part VI, Line 19: Other Organization Documents Publicly Available
No documents available to the public.
Form 990, Part VI, Line 15a
Form 990, Part VI, Line 15a: Compensation Review & Approval Process - CEO, Top Management
MANAGEMENT REVIEWS EXECUTIVE DIRECTOR PERFORMANCE BASED ON BUDGET PERFORMANCE, ATTENDANCE, AND GENERAL CONDITIONS. COMPENSATION IS ADJUSTED FOR COST OF LIVING, PERFORMANCE BASED ADJUSTMENTS, AND MARKET CONDITIONS IN THE REGION.
Form 990, Part VI, Line 12c
Form 990, Part VI, Line 12c: Explanation of Monitoring and Enforcement of Conflicts
ANNUAL REVIEW AND UPDATING OF CONFLICT OF INTEREST FORMS BY EACH BOARD MEMBER
Form 990, Part VI, Line 11b
Form 990, Part VI, Line 11b: Form 990 Review Process
ORGANIZATION WAS PROVIDED WITH COMPLETED FORM 990 AND AN ELECTRONIC SUBMISSION APPROVAL FORM. UPON REVIEW AND APPROVAL OF THE COMPLETED FORM 990 BY MANAGEMENT, THE ORGANIZATION SIGNED THE ELECTRONIC SUBMISSION FOR AND PRESENTED TO THE ERO FOR FILING.
Client Note 2 - SCHEDULE N SUPPLEMENTDISTRICT 6 HEALTH CARE LEARNING CENTERFINAL DISTRIBUTION OF ASSETSOCTOBER 1, 2012-JANUARY 31, 2013MT Department of Justice-Office of Consumer Protection Record Number 12-7629MT Secretary of State Articles of Dissolution Filing Number D040723-1320185Cash Assets$58,612.15 to Yellowstone Health Partnership, Check #9803, Issued Dec.21, 2012$5,057.03 to Mrachek Popp and Associates PC Trust. Cashiers check, issued February 14, 2013. This is the money remaining in the checking account of District 6 Health Care Learning Center on January 31, 2013. This amount will be in a trust at Mrachek, Popp and Associates (certified public accounts) for the preparation of the final tax return and preparation of the 2012 W2s, state and federal reporting. Any money left will be distributed to the Yellowstone Health Partnership.St. Vincent DePaul - Office furniture and equipment as follows:Black leather office ChairCorner white laminate and metal computer deskKodak slide projectorElectric TypewriterFile DividerMiscellaneous office suppliesPaper cutterOverhead projectorFloor mat2 side office chairsCatholic Social Services - Office furniture and equipment as follows:Apartment size refrigerator3 shelf walnut book caseOak DeskCouchCopy MachineYellowstone Health Partnership - Office furniture and equipment as follows:Intellectual property copyright Basic X-ray TechniquesLaptop computer and PowerPoint projector35 DVDs for workshop trainingOverhead projectorCartAudiovisual materials35 DVDs for professional training to McCone County Health Center, Circle, MT2 DVDs for professional training to RiverStone Health, Rural Schools Program120 DVD for professional training to Roundup Memorial Healthcare, Roundup, MT
Client Note 1 - SCHEDULE N SUPPLEMENT:The District 6 Health Care Learning Center Board has been discussing the future of District 6 Health Care Learning Center for the last several years. At our Annual Board meeting of May 3, 2011, a discussion was held regarding different dissolution options and direction was given to the Executive Committee to proceed. At the Executive Committee meeting of July 18, 2011 Kristianne Wilson and Tim Russell were appointed to represent the board and pursue dissolution options for D6HCLC.There has been a search for a nonprofit - educational partner which most closely meets the mission of District 6 Health Care Learning Center (Guided by state and IRS regulations for the dissolution of a nonprofit organization). The mission statement of Eastern Montana-Area Health Education Center, contracted by RiverStone Health, most closely aligns with our mission. Eastern Montana-Area Health Education Center mission states;-Benefiting the rural and underserved communities-Serve as a resource of health information-Provide technical assistance on healthcare-related issues-Help implement education and training for health professionals-Encourage recruitment and retention of health professionals in rural areasWe recognize that our closure will be a hardship for our Basic X-ray Workshop clients throughout Montana and the surrounding states. Transfer of our workshop assets and reserves to Eastern Montana-Area Health Education Center would ensure the continuation of these workshops.Our dissolution is discussed in our Articles of Incorporation which states:In the event the existence of the corporation shall for any reason be terminated, all funds of the corporation shall, after the payment of its liabilities, be distributed exclusively to the qualified Internal Revenue Code tax exempt charitable institutions actively participating in and financially supporting the Health care Learning Center for purposes as selected by the Board of Directors.The time line for our dissolution plan is as follows:May 21, 2012- Dissolution Plan to be presented at the Annual Board Meeting. Plan must include where our assets will be going-assets must go to a nonprofit organization and designated for education. Plan must be voted on by the Board and member votes recorded. After District 6 Health Care Learning Center Board approval the Dissolution Plan will be sent to State of Montana Attorney General. The Attorney Generals office has 20 days to review plan and disbursement of assets. We cannot disburse any of the assets until after we receive approval from the Attorney Generals office.July 1, 2012- Disbursement of office equipment and materials. We plan that it will take approximately two months. Review of office files and destroy unnecessary documents-Retain required documents. Copyright transfer. Notice to MT Board of Rad Tech, North Dakota State Department of Health, ASRT-CEU approval. Actively publicize closure. Notify Liability Carrier (30 day advance notice). Payroll liabilities and Workers Compensation. Take requests and disburse all AV materials and office supplies. Final tax return (this will be the last thing to be completed). Submit final W-2(Will be done in November by Executive Director or Mrachek, Popp &Associates).September, 2012- We would like to offer the Basic X-ray Class and limited permit continuing education classes before we close our doors. Since the Executive Director would be working on closure, at the same time we could provide these two programs one more time. This would give Eastern Montana-Area Health Education Center time to develop procedures. This would also help prevent any hardship for rural facilities requiring training. On September 30 District 6 Health Care Learning Center would be officially closed.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.