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
MENTAL HEALTH AMERICA - OF NORTHERN CALIFORNIA
Employer identification number
94-1476949
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.") ....
864,574
908,497
1,545,787
2,443,900
2,522,973
8,285,731
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
864,574
908,497
1,545,787
2,443,900
2,522,973
8,285,731
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.
8,285,731
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..
864,574
908,497
1,545,787
2,443,900
2,522,973
8,285,731
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
39
15
33
36
33
156
9
Net income from unrelated business activities, whether or not the business is regularly carried on..
10
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
11
Total support (Add lines 7 through 10).
8,285,887
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
100.000 %
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
0 %
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
0 %
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:
12000057
Software Version:
12.19.1011.1
-
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
MENTAL HEALTH AMERICA - OF NORTHERN CALIFORNIA
Employer identification number
94-1476949
Identifier
Return Reference
Explanation
Form 990, Part III, Line 4d Program Service Expenses 139,011, Grants and allocations 0, Revenue 158,794 MHAC GRANTS WLLNESS WORKS IS WORKPLACE MENTAL HEALTH PROGRAM THAT SEEKS TO REDUCE MENTAL HEALTH STIGMA AND PROMOTE MENTAL WELLNESS IN THE WORKPLACE THROUGH CORPORATE TRINING. WELLNESS WORKS IS BASED ON THE CANADIAN AWARD WINNING mENTAL hEALTH wORKS CURRICULUM DEVELOPED BY THE CANADIAN MENTAL HEALTHE ASSOCIATION. WELLNESS WORKS IS FUNDED THROUGH THE MENTAL HEALTH SERVICES ACT PROP 63, DESIGNED EXCLUSIVELY FOR EMPLOIYERS AS TE STATES LEADING GOTO RESOURCES FOR EDUCATRION, TRAINING AND CONSULTING TO ADDRESS MENTAL HEALTH SERVICES IN THE WORKPLACE.
Form 990, Part III, Line 4d Program Service Expenses 133,909, Grants and allocations 0, Revenue 114,550 LGBTQ GRANT THE LGBTQ REDUCING DISPARITIES PROJECCT OFFERS LGBTQ CLIENTS, FAMILY MEMBERS AND ALLIES, THE OPPORTUNITY TO PARTICIPATE IN COMMUNITY-BASED RESEARCH OFFERING COMMUNITY-DEFINED RECOMMENDATIONS, AIMED AT REDUCING DISPARITIES AFFECCTING LGBTQ MENTAL HEALTH. A PARTNERSHIP BETWEEN CA LGBTQ HEALTH AND HUMAN SERVICES NETWORK, EQUALITY CALIFORNIA INSTITUTE AND MENTAL HEALTH AMERICAN OF NORTHERN CALIFORNI. FND BY THE CA DEPT OF MENTAL HEALTH THRU MHSA.
Form 990, Part III, Line 4d Program Service Expenses 70,933, Grants and allocations 0, Revenue 86,720 CALAVERAS COUNTY GRANT PEERS PROVIDE SUPPORT TO CLIENTS WITHIN THE FULL SERVICE PARTNERSHI PROGRAM TO DECREASE ISOLATION, AND IMPROVE SOCIALIZATION. PEER PARTNERS ASSIST CLIENTS TOWARDS IMPROVING THEIR NATURAL SUPPORTS, LINKAGE WITH COMMUNITY RESOURCES, SOCIALIZATION, TRANSPORTATION, AND IMPROVING WELLNESS.
Form 990, Part III, Line 4d Program Service Expenses 29,123, Grants and allocations 0, Revenue 30,748 CALIFORNIA ENDOWMENT GRANT - HEALTHY LEADERSHIP SUPPORT FOR LGBTQ YOUTH PROMOTES A SAFE AND HEALTHY ENVIRONMENT FOR LGBTQ YOUTH TO WORK TOWARDS IMPROVING EXPERIENCE OF OTHER LGBTQ YOUTH LIVING IN SOUTH SACRAMENTO. THROUGH THIS PROGRAM WE HAVE DEVELOPED A SACRAMENTO YOUTH PRIDE COALITION TO DEVELOP SAFER SPACES BY PROVIDING LGBTQ AFFIRMING TRAINING THROUGHOUT THE BHC AREA. THIS PROGRAM ALSO PROVIDES YOUTH ON THE SYPC WITH MENTORHSIP AND LEADERSHIP TRAINING. OUR HOPE IS TO WORK TOWARDS CREATING A SAFER ENVIRONMENT NOT ONLY FOR LGBTQ YOUTH BUT ALL YOUTH LIVING, WORKING AND PLAYING IN THIS AREA.
Form 990, Part III, Line 4d Program Service Expenses 24,238, Grants and allocations 0, Revenue 32,505 ALL OTHER GRANTS - YHID INCLUDES CAL STIGMA PROGRAM, SPEAKERS BURUEAU, OUTREACH FAMILY VOICE, MENTAL HEALTH-CENTRAL VALLEY AND SAN JOAQUIN PROGRAMS.
Form 990 Part III Line 4d MHAC GRANTS EXPENSES 139,011 REVENUES 158,794 WELLNESS WORKS IS A WORKPLACE MENTAL HEALTH PROGRAM THAT SEEKS TO REDUCE MENTAL HEALTH STIGMA AND PROMOTE MENTAL WELLNESS IN THE WORKPLACE THROUGH CORPORATE TRAINING. WELLNESS WORKS IS BASED ON THE CANADIAN AWARD-WINNING MENTAL HEALTH WORKS CURRICULUM DEVEOPED BY THE CANADIAN MENTAL HEALTH ASSOCIATION. WELLNESSWORKS IS FUNDED THROUGH THE MENTAL HEALTH SERVICES ACT PROP 63, DESIGFNED EXCLUSIVELY FOR EMPLOYERS AS THE STATES LEADING GO TO RESOURCE FOR EDUCAITON, TRAINING AND CONSULTING TO ADDRESS MENTAL HEALTH SERVICES IN THE WORKPLACE.
Form 990 Part III Line 4d LGBTQ STATEWIDE GRANT EXPENSES 133,909 REVENUES114,550 THE LGBTQ REDUCING DISPARITIES PROJECT OFFERS LGBTQ CLIENTS, FAMILIY MEMBERS AND ALLIES, THE OPPORTUNITY TO PARTICIPATE IN COMMUNITY-BASED RESEARCH OFFERING COMMUNITY-DEFINED RECOMMENDATIONS, AIMED AT REDUCING DISPARIIES AFFECTING LGBTQ MENTAL HEALTH. A PARTNERSHIP BETWEEN CA LGBT HEALTH AND HUMAN SERVICES NETWORK, EQUALITY CALIFONIA INSTUTE AND MENTAL HEALTH AMERICA OF NORTHERN CALIFORNIA. FUNDED BY THE CA DEPT OF MENTAL HEALTH THROUGH MHSA.
Form 990 Part III Line 4d CALAVERAS COUNTY GRANT EXPENSES 70,933 REVENUES86,720 PEERS PROVIDE SUPPORT TO CLIENTS WITHIN THE FULL SERVICE PARTNERSHIP PROGRAM TO DECREASE ISOLATION, AND IMPROVE SOCIALIZATION. PEER PARTNERS ASSIST CLIENTS TOWARDS IMPROVING THEIR NATURAL SUPPORTS, LIKAGE WITH COMMUNITY RESOURCES, SOCIALIZATION, TRANSPORTATION, AND IMPROVING WELLNESS.
Form 990 Part III Line 4d CALIFORNIA EDOWMENT EXPENSES 29,123 REVENUES 30,748 HEALTHY LEADERSHIP SUPPORT FOR LGBTQ YOUTH PROMOTES A SAFE AND HEALTHY ENVIRONMENT FOR LGBTQ YOUTH TO WORK TOWARDS IMPROVING THE EXPERIENCE OF OTHER LGBTQ YOUTH LIVING IN SOUTH SACRAMENTO. THROUGH THIS PROGRAM WE HAVE DEVELOPED A SACRAMENTO YOUTH PRIDE COALITION TO DEVELOPE SAFER SPACES BY PROVIDING LGBTQ AFFIRMING TRAINING THROUGHOUT THE BHC AREA. THIS PROGRAM ALSO PROVIDES YOUTH ON THE SYC WITH MENTORSHIP AND LEADERSHIP TRAINING. OUR HOPE IS TO WORK TOWARDS CREATRING A SAFTER ENVIRONMENT NOT ONLY FOR LBGTQ YOUTH BUT ALL YOUTH LIVING, WORKING AND PLAYING IN THIS AREA.
Form 990 Part III Line 4d ALL OTHERS GRANTS EXPENSES 15,466 REVENUES 32,505 THIS INCLUDES GRANTS FROM CAL STIGMA, SPEAKERS BUREAU, OUTREACH FAMILY VOICE, MENAL HEALTH-CENTRAL VALLEY AND SAN JOAQUIN COUNTY.
Form 990 Part V Section Section B Line 11b Reviewed by the board in a meeting for questions and comments.
Form 990 Part VI Section Section B Line 12a, 12b,12c Reviewed and presented annually for reminder.
Form 990 Part VI Section Section C Line 19 Available upon request, and also available on the website.
Form 990 Part XII Line 20c Full Board reviews the audit report, and ssumes role as audit committee.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.