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
DYSTONIA MEDICAL RESEARCH FOUNDATION
Employer identification number
95-3378526
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) 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.") ....
2,731,455
2,494,622
2,790,859
2,899,082
2,140,332
13,056,350
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
2,731,455
2,494,622
2,790,859
2,899,082
2,140,332
13,056,350
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)..
3,869,618
6
Public support. Subtract line 5 from line 4.
9,186,732
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..
2,731,455
2,494,622
2,790,859
2,899,082
2,140,332
13,056,350
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
48,388
25,924
6,034
3,726
3,034
87,106
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.)..
16,123
8,931
10,840
5,052
7,594
48,540
11
Total support (Add lines 7 through 10).
13,191,996
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
69.640 %
15
Public support percentage for 2012 Schedule A, Part II, line 14
...............
15
72.330 %
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:
13000170
Software Version:
2013v3.1
-
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.
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
DYSTONIA MEDICAL RESEARCH FOUNDATION
Employer identification number
95-3378526
Return Reference
Explanation
Client Note 1
Client Note 1 - FORM 990PART II, LINE 42-DEPRECIATION EXPENSEPART IV, LINE 57a & 57b-FIXED ASSETS AND ACCUMULATED DEPRECIATIONDEPRECIATION IS COMPUTED ON THE STRAIGHT LINE BASIS OVER THE ESTIMATEDUSEFUL LIFES OF THE ASSETS, GENERALLY 3-5 YEARS.
Form 990, Part III, Line 4d: Other Program Services Description
OTHER PROGRAM SERVICES 4: ADVOCACY-THE DMRF PROVIDES THE STAFF AND ADMINISTRATIVE SUPPORT FOR DYSTONIA ADVOCACY NETWORK, A COLLABORATION OF FIVE DYSTONIA ORGANIZATIONS WORKING TO MEET THE POLICY NEEDS OF THE DYSTONIA COMMUNITY. FOR THE PAST seven YEARS,THE DYSTONIA ADVOCACY NETWORK HAS BEEN INSTRUMENTAL IN EDUCATING CONGRESS ABOUT THE BENEFITS OF LISTING DYSTONIA AS A CONDITION ELIGIBLE FOR STUDY ON THE DEPARTMENT OF DEFENSE (DOD) PEER-REVIEWED MEDICAL RESEARCH PROGRAM, RESULTING IN THEM MAKING THE CONDITION ELIGIBLE FOR INVESTIGATORS TO COMPETE FOR RESEARCH FUNDING. ON BEHALF OF THE FIVE DYSTONIA ADVOCACY NETWORK ORGANIZATIONS, THE DMRF UTILIZES A LEGISLATIVE CONSULTANT TO TRACK LEGISLATIVE ACTIVITIES ON CAPITOL HILL, MAINTAINS AN ADVOCACY WEBSITE, AND ELECTRONICALLY DISSEMINATES ACTION ALERTS TO STAY CONNECTED WITH KEY LEGISLATORS. THE DMRF ALSO SUPPORTS A NATIONWIDE NETWORK OF VOLUNTEER ADVOCATES WHO CONTINUALLY WORK TO EDUCATE MEMBERS OF CONGRESS ABOUT DYSTONIA AND ADVANCE THE COMMUNITY'S LEGISLATIVE AGENDA. VOLUNTEERS MEET WITH POLICYMAKERS DURING THE ANNUAL ADVOCACY DAY AND AS NEEDED THROUGHOUT THE YEAR TO ADVOCATE ON BEHALF OF THE DYSTONIA COMMUNITY ON ISSUES SUCH AS INCREASED RESEARCH FUNDING FOR THE NATIONAL INSTITUTES OF HEALTH, ACCESS TO HEALTHCARE, and appropriate, AFFORDABLE REIMBURSEMENT for dystonia treatments.
Form 990, Part VI, Line 2: Description of Business or Family Relationship of Officers, Directors, Et
SAMUEL BELZBERG IS THE SPOUSE OF FRANCES BELZBERG.FRANCES BELZBERG IS THE SPOUSE OF SAMUEL BELZBERG.ART KESSLER IS THE SON OF DENNIS AND BARBARA KESSLER.DENNIS KESSLER IS THE SPOUSE OF BARBARA KESSLER AND FATHER OF ART KESSLER.BARBARA KESSLER IS THE SPOUSE OF DENNIS KESSLER AND MOTHER OF ART KESSLER.ROSALIE LEWIS IS THE SPOUSE OF RICHARD LEWIS.RICHARD LEWIS IS THE SPOUSE OF ROSALIE LEWIS.MARK RUDOLPH IS THE SPOUSE OF DIANE RUDOLPH.DIANE RUDOLPH IS THE SPOUSE OF MARK RUDOLPH.JOHN SYMONDS IS THE SPOUSE OF KAREN ROSS.KAREN ROSS IS THE SPOUSE OF JOHN SYMONDS.
Form 990, Part VI, Line 11b: Form 990 Review Process
THE BOARD OF DIRECTORS HAS DELEGATED THE REVIEW OF THE FORM 990 TO THE TAX REVIEW TASK FORCE WHICH IS COMPRISED OF THE PRESIDENT, TREASURER AND CHAIRPERSON OF THE AUDIT COMMITTEE. PRIOR TO THE SIGNING AND FILING OF THE FORM 990, MANAGEMENT, OUTSIDE CPA, THE TAX REVIEW TASK FORCE AND THE INDEPENDENT ACCOUNTANT WHO PREPARES THE FORM 990 MEET TO REVIEW THE ENTIRE FORM. UPON APPROVAL BY THE TAX REVIEW TASK FORCE, THE FORM 990 IS MADE AVAILABLE TO ALL MEMBERS OF THE BOARD OF DIRECTORS FOR REVIEW, AFTER WHICH IT IS SIGNED BY THE TREASURER AND IS FILED.
Form 990, Part VI, Line 12c: Explanation of Monitoring and Enforcement of Conflicts
ON AN ANNUAL BASIS, DMRF REQUESTS WRITTEN STATEMENT OF ANY CONFLICTS FROM MEMBERS OF THE BOARD. THE BOARD PRESIDENT, ALONG WITH EXECUTIVE DIRECTOR, MONITOR AND REPORT POTENTIAL CONFLICTS TO CHAIR OF AUDIT COMMITTEE. ANY CONFLICTS THAT ARE DETERMINED TO EXIST ARE REPORTED TO THE BOARD.
Form 990, Part VI, Line 15a: Compensation Review & Approval Process - CEO, Top Management
ANNUALLY, THE DMRF BOARD PRESIDENT CONSULTS WITH THE BOARD OF DIRECTORS REGARDING THE PERFORMANCE OF THE EXECUTIVE DIRECTOR AND PREPARES A WRITTEN PERFORMANCE EVALUATION. THE BOARD PRESIDENT, AFTER CONSULTATION WITH THE BOARD, DETERMINES SALARY ACTION, IF ANY, AND MEETS WITH THE EXECUTIVE DIRECTOR TO DISCUSS THE PERFORMANCE EVALUATION. COMPARATIVE SALARY INFORMATION IS OBTAINED ABOUT ORGANIZATIONS OF SIMILAR SCOPE AND SIZE THROUGH INFORMATION FROM THE ASSOCIATION FORUM OF CHICAGOLAND AND THROUGH OTHER PUBLICLY AVAILABLE INFORMATION.
Form 990, Part VI, Line 15b: Compensation Review and Approval Process for Officers and Key Employees
NOT APPLICABLEFORM 990, PART VI, LINE 15A-COMPENSATION REVIEW & APPROVAL PROCESS FOR CE0, EXECUTIVE DIRECTOR OR TOP MANAGEMENT OFFICIALANNUALLY, THE DMRF BOARD PRESIDENT CONSULTS WITH THE BOARD OF DIRECTORS REGARDING THE PERFORMANCE OF THE EXECUTIVE DIRECTOR AND PREPARES A WRITTEN PERFORMANCE EVALUATION. THE BOARD PRESIDENT, AFTER CONSULTATION WITH THE BOARD, DETERMINES SALARY ACTION, IF ANY, AND MEETS WITH THE EXECUTIVE DIRECTOR TO DISCUSS THE PERFORMANCE EVALUATION. IF DEEMED NECESSARY BY THE BOARD, COMPARATIVE SALARY INFORMATION IS OBTAINED THROUGH CONTACTS WITH MEMBER ORGANIZATIONS OF THE NATIONAL ORGANIZATION OF RATE DISORDERS (NORD).
Form 990, Part VI, Line 19: Other Organization Documents Publicly Available
FORM 990, AUDITED FINANCIAL STATEMENTS, AND THE BOARD APPROVED ANNUAL OPERATING PLAN ARE AVAILABLE ON THE FOUNDATION'S WEBSITE. CONFLICT OF INTEREST,GOVERNING DOCUMENTS AND POLICIES ARE AVAILABLE UPON REQUEST.
FORM 990, PART V, LINE 2A-EMPLOYEES
THE NUMBER OF EMPLOYEES REPORTED ON FORM W-3 FOR 2013 WAS 9 WHICH TRANSLATES INTO 8 FULL TIME EQUIVALENTS.
FORM 990,PART VII,SECTION A-COMPENSATION
THE EXECUTIVE DIRECTOR IS OFFERED THE SAME BENEFIT PACKAGE AS ALL OTHER EMPLOYEES. CONSISTENT WITH PAST YEARS, THE EMPLOYEE BENEFITS OFFERED INCLUDE HEALTH INSURANCE, LONG-TERM DISABILITY INSURANCE, LIFE INSURANCE, PRE-TAX PARKING BENEFITS, AND 401(K) EMPLOYER MATCHING. IN ADDITION, THE FOUNDATION UNDERWRITES A MODEST DENTAL BENEFIT PLAN IN WHICH THEY REIMBURSE EMPLOYEES FOR DENTAL EXPENSES. THE COST OF PROVIDING EMPLOYEE HEALTH INSURANCE CONTINUES TO BE THE PREDOMINANT EXPENSE IN THE EMPLOYEE BENEFIT PACKAGE. OTHER COMPENSATION OF $27,943 INCLUDES $10,132 OF PRETAX CONTRIBUTIONS FOR HEALTH AND TRANSIT BENEFITS PAID BY THE EXECUTIVE DIRECTOR.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.