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. Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
ORTHOPEDICS CAPITAL FOUNDATION INC
Employer identification number
27-1038452
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)
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 monetary support
Yes
No
Yes
No
Yes
No
(A)
KOSCIUSKO COUNTY COMMUNITY FOUNDATION INC
356086777
7
Yes
Yes
Yes
0
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
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) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(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) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(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. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
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 2013 (line 6, column (f) divided by line 11, column (f))
.........
14
15
Public support percentage for 2012 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2013.
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—2012.
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—2013.
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—2012.
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) 2013
Schedule A (Form 990 or 990-EZ) 2013
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) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(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) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(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 2013 (line 8, column (f) divided by line 13, column (f))
.........
15
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2013.
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—2012.
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) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 4
Part IV
Supplemental Information.
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) 2013
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.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
ORTHOPEDICS CAPITAL FOUNDATION INC
Employer identification number
27-1038452
Return Reference
Explanation
FORM 990 - ORGANIZATION'S MISSION
PART I, LINE 1 AND PART III, LINE 1 (CONTINUED)- FOR THE BENEFIT OF THE KOSCIUSKO COUNTY REGION, WE SEEK TO SUPPORT THE LONG-TERM SUSTAINABILITY AND GROWTH OF WARSAW'S ORTHOPEDIC COMMUNITY THROUGH CHARITABLE, EDUCATIONAL AND SCIENTIFIC ACTIVITIES FOCUSED ON: EDUCATION, TALENT AND WORKFORCE DEVELOPMENT, COMMUNITY ENHANCEMENT, INNOVATION AND ENTREPRENEURSHIP, TRANSPORTATION AND LOGISTICS, AND BRANDING AND AWARENESS.
FORM 990, PAGE 2, PART III, LINE 4B
ESTABLISHMENT OF AN ORTHOWORX UNIVERSITY INDUSTRY ADVISORY BOARD, WHICH NOW COUNTS NINE UNIVERSITY MEMBERS WHO ARE WORKING WITH OCF TO BETTER CONNECT INDIANA HIGHER EDUCATION RESOURCES TO THE WARSAW REGION.
FORM 990, PAGE 2, PART III, LINE 4D
OCF'S TRANSPORTATION AND LOGISTICS INITIATIVE HAS CONTINUED TO SUPPORT A BROAD EFFORT TO RESTORE PASSENGER RAIL SERVICE TO NORTHERN INDIANA AND HAS SUPPORTED THE FORMATION OF A CONSORTIUM TO RAISE AWARENESS OF THE ECONOMIC AND SAFETY BENEFITS OF IMPROVING US 30 IN NORTHERN INDIANA TO INTERSTATE- LEVEL STANDARDS.
FORM 990, PAGE 6, PART VI, LINE 8B
ORTHOPEDICS CAPITAL FOUNDATION DOES NOT HAVE ANY COMMITTEES WITH THE AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY.
FORM 990, PAGE 6, PART VI, LINE 11B
UPON COMPLETION OF THE FORM 990, AN ELECTRONIC VERSION OF THE RETURN IS DISTRIBUTED TO ALL BOARD MEMBERS. BOARD MEMBERS ARE ASKED TO REVIEW THE RETURN AND INDICATE WHETHER THEY ACCEPT OR DO NOT ACCEPT THE FORM 990 AS PRESENTED. IF ACCEPTED BY A MAJORITY OF THE BOARD, THE FORM 990 IS THEN SUBMITTED TO THE IRS. IF NOT ACCEPTED, THE FORM 990 WILL BE REVISED UNTIL ACCEPTED BY THE BOARD OF DIRECTORS.
FORM 990, PAGE 6, PART VI, LINE 12C
EACH DIRECTOR AND OFFICER ANNUALLY RECEIVES A CONFLICT OF INTEREST QUESTIONNAIRE THROUGH WHICH THEY ARE ASKED TO CONFIRM OR REPORT THE FOLLOWING: (I) THAT HE OR SHE HAS READ AND UNDERSTANDS OCF'S CONFLICT OF INTEREST POLICY (WHICH IMPOSES UPON EACH DIRECTOR AND OFFICER A CONTINUING, AFFIRMATIVE DUTY TO REPORT ANY PERSONAL OWNERSHIP, INTEREST, OR RELATIONSHIP THAT MIGHT AFFECT HIS OR HER ABILITY TO EXERCISE IMPARTIAL, ETHICAL, AND BUSINESS-BASED JUDGEMENTS IN FULFILLING RESPONSIBILITIES TO OCF); (II) THAT HE OR SHE IS IN COMPLIANCE WITH THE POLICY; (III) THAT HE OR SHE IS REPORTING (WITH HIS OR HER COMPLETED QUESTIONNAIRE) ALL ACTUAL OR POTENTIAL CONFLICTS OF INTEREST THAT ARISE AS A RESULT OF HIS OR HER ROLE WITH OCF, AND EACH POSITION THAT HE OR SHE HOLDS AS A DIRECTOR, TRUSTEE, OFFICER, OR EMPLOYEE OF ANY OTHER NONPROFIT ORGANIZATION; AND (IV) THAT HE OR SHE WILL REPORT PROMPTLY ANY CHANGES IN INFORMATION REPORTED IN HIS OR HER QUESTIONNAIRE OR IN ANY OTHER MATTERS THAT MIGHT AFFECT COMPLIANCE WITH THE POLICY. THE BOARD CHAIR COLLECTS AND REVIEWS THE QUESTIONNAIRES AS THEY ARE RETURNED AND MAKES SURE THAT ALL WHO ARE REQUIRED TO COMPLETE A CONFLICT QUESTIONNAIRE HAVE DONE SO. WHEN AN INDIVIDUAL REPORTS AN ACTUAL, POTENTIAL, OR PERCEIVED CONFLICT OF INTEREST, OCF FOLLOWS THE PROCEDURES OUTLINED IN ITS POLICY FOR DISCLOSURE OF CONFLICTS TO THE APPLICABLE BODY OF DECISION-MAKERS AND RECUSAL OF INDIVIDUAL(S) WITH CONFLICTS FROM THE DECISION-MAKING PROCESS. PURSUANT TO THE POLICY, OCF'S BOARD OF DIRECTORS IS RESPONSIBLE FOR THE OVERSIGHT OF, AND ACTION REGARDING, ALL DISCLOSURES AND/OR FAILURES TO DISCLOSE.
FORM 990, PAGE 6, PART VI, LINE 15A
THE CEO WHO IS EMPLOYED BY ORTHOWORX, INC. (AN ORGANIZATION UNRELATED TO OCF), PROVIDES SERVICES TO OCF PURSUANT TO AN EMPLOYEE LEASE AGREEMENT WITH ORTHOWORX. THE CEO'S COMPENSATION WAS DETERMINED BY ORTHOWORX AS DESCRIBED IN ORTHOWORX'S FORM 990. THAT PROCESS (ALSO DESCRIBED IN ORTHOWORX'S FORM 990) IS AS FOLLOWS: "THE PROCESS FOR DETERMINING COMPENSATION OF THE ORGANIZATION LEADERSHIP IS GOVERNED AND APPROVED BY THE COMPENSATION COMMITTEE. THE LEADERSHIP SUBMITS A WRITTEN SELF-ASSESSMENT TO THE ORTHOWORX COMPENSATION COMMITTEE ABOUT ONE WEEK BEFORE THE MEETING AT WHICH COMPENSATION WILL BE ADDRESSED. IF INCENTIVE COMPENSATION HAS BEEN OFFERED, THE SELF-ASSESSMENT WILL INCLUDE NARRATIVE OF PERFORMANCE RESULTS COMPARED WITH THE TERMS OF THE INCENTIVE COMPENSATION. THE COMPENSATION COMMITTEE IN CONSULTATION WITH THE CEO, WILL DEVELOP A LIST OF COMPARABLES TO THE COMPENSATION OF OTHER EXECUTIVES IN SIMILAR POSITIONS AS WELL AS A COMPENSATION HISTORY FOR THE CEO. THE LIST WILL CONTAIN A MINIMUM OF THREE COMPARABLES. AT THE MEETING, THE CEO REVIEWS THE ASSESSMENT WITH THE COMMITTEE MEMBERS AND DISCUSSES ANY QUESTIONS/CONCERNS THAT MAY ARISE. THE CEO IS EXCUSED AND THE COMMITTEE DISCUSSES PERFORMANCE FURTHER AND COMES TO A CONCLUSION ON ANY CHANGES TO BE MADE TO FUTURE COMPENSATION AND PAYMENT TO BE MADE ON ANY INCENTIVE COMPENSATION. THE COMPENSATION COMMITTEE THEN REVIEWS COMPENSATION DETAIL AND DETERMINES ANY COMPENSATION ADJUSTMENT TO BE MADE. THE CHAIRMAN OF THE COMPENSATION COMMITTEE MEETS WITH THE CEO TO REVIEW THE CONCLUSIONS OF THE COMPENSATION COMMITTEE REGARDING PERFORMANCE AND COMPENSATION ADJUSTMENT AND INCENTIVE PAYMENT, IF ANY. THE COMPENSATION TERMS SHOULD BE REFLECTED IN THE MINUTES OF THE COMPENSATION COMMITTEE AND DISTRIBUTED NO LATER THAN THE NEXT MEETING OF THE BOARD OF DIRECTORS OR 60 DAYS AFTER THE DATE OF THE MEETING, AT WHICH THE COMPENSATION IS APPROVED, WHICHEVER IS LATER. THE MINUTES SHOULD REFLECT (I) THE DATE ON WHICH THE COMPENSATION WAS APPROVED, (II) THE MEMBERS OF THE COMPENSATION COMMITTEE WHO WERE PRESENT AND VOTED ON THE COMPENSATION TERMS, (III) THE COMPARABILITY DATA THAT WAS OBTAINED AND USED, AND (IV) ANY RECUSAL OR WITHDRAWAL BY A MEMBER OF THE COMPENSATION COMMITTEE WHO HAD A CONFLICT OF INTEREST WITH RESPECT TO THE COMPENSATION."
FORM 990, PAGE 6, PART VI, LINE 15B
THE ORGANIZATION HAS NO OTHER EMPLOYEES.
FORM 990, PAGE 6, PART VI, LINE 19
UPON REQUEST, ORTHOPEDICS CAPITAL FOUNDATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, FORM 1023, FORM 990S AND AUDITED FINANCIAL STATEMENTS AVAILABLE TO THE GENERAL PUBLIC.