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
Northeastern Mental Health Center
Employer identification number
46-0253936
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
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.") .
112,014
102,667
258,841
152,038
570,505
1,196,065
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......
3,582,570
3,499,885
3,373,673
3,294,349
3,551,020
17,301,497
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
1,252
1,252
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.
3,694,584
3,602,552
3,632,514
3,447,639
4,121,525
18,498,814
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
0
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.
91,388
113,803
22,450
93,914
84,791
406,346
c
Add lines 7a and 7b..
91,388
113,803
22,450
93,914
84,791
406,346
8
Public support (Subtract line 7c from line 6.)
18,092,468
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...
3,694,584
3,602,552
3,632,514
3,447,639
4,121,525
18,498,814
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
2
1
586
589
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
2
1
586
589
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.)..
3,694,586
3,602,552
3,632,514
3,447,640
4,122,111
18,499,403
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
97.800 %
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
97.880 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
0 %
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
Northeastern Mental Health Center
Employer identification number
46-0253936
Return Reference
Explanation
Form 990, Part VI, Section A, line 2
KC DeBoer and Dr. John Fritz - Business Relationship
Form 990, Part VI, Section A, line 8b
Individual committees do not have the authority to act on behalf of the governing board.
Form 990, Part VI, Section B, line 11
It is NEMHC's policy that the board of directors receives a copy of the Form 990 that is filed on the organization's behalf within 30 days of it being filed with the IRS. A board resolution is required in order for the Form 990 to be filed. A copy of the Form 990 will be sent to each board member via mail or email. The CEO and CFO will review the Form 990 in detail with the finance committee.
Form 990, Part VI, Section B, line 12c
The conflict of interest policy applies to each member of the board, to each officer of Northeastern Mental Health Center, and to all persons employed by Northeastern Mental Health Center, regardless of position. Each board member, officer, and employee of Northeastern Mental Health Center shall be requested annually by Northeastern Mental Health Center to submit a disclosure statement listing all organizations with which he or she is affiliated and describing the nature of the affiliation as defined below. In the event there is any material change in the information contained in any disclosure statement, the person who submitted it shall promptly submit written notification of the change. All disclosures required under this policy and amendments thereto, if by directors, shall be directed in writing to the chair of the board, or if by employees, to the President. The chair of the board and the president shall be responsible for the administration of this policy. Issues under this policy concerning directors and officers shall be reported initially to the chair of the board for appropriate action; those concerning staff shall be referred initially to the President. Information disclosed under this policy shall be held in confidence by the persons authorized to receive and act upon it except where, in the judgment of any of such persons, the best interest of the organization requires further disclosure. This review process shall be reported annually to the board by the chair. A director or officer or a member of their immediate family who has declared or has been found to have a conflict-of-interest in any proposed transaction or other matter shall refrain from participating in consideration of the proposed transaction or other matter, unless for special reasons the Board of Directors requests information or interpretation from the person or persons involved. When such a situation presents itself, the director shall be excused from the meeting until discussion is over the matter resolved. With respect to restraint on participation by staff, the president, or, where applicable, the chair shall take such action as is necessary to assure that the transaction is completed in the best interests of Northeastern Mental Health Center without the substantive involvement of the person who has the possible conflict-of-interest. Any board member who is uncertain about possible conflict-of-interest in any matter may request the Executive Committee to determine whether a possible conflict exists; the Executive Committee shall resolve the question by majority vote. If required, the question of potential conflict might be referred to counsel for an opinion prior to the Executive Committee vote.
Form 990, Part VI, Section B, line 15a
The Personnel Committee and board shall consider the following in determining CEO compensation: - The mission of NEMHC, its responsibilities on behalf of its members, and the role of the CEO in carrying out that mission and those responsibilities, - Comparability of compensation received by CEO's of similar state-level health and social service trade or professional associations in South Dakota, community behavioral health trade or professional associations in surrounding states, - Performance goals for the CEO set by the board overall and for any particular year, - Benefit packages available to staff via NEMHC personnel policies or contract with the CEO, - The capacity of the NEMHC budget and expected revenues to support a particular compensation level, and - Any salary or compensation scale the NEMHC board may establish. Procedures - Prior to the board meeting at which the annual NEMHC budget for each fiscal year is approved, the Personnel Committee shall devote a portion of its meetings to developing a recommended total compensation figure or level for the CEO. The committee shall consider the factors outlined in the philosophy above in making its recommendation. The CEO and other staff may assist in gathering information related to this process. Deliberations of the personnel committee shall be recorded as written minutes. - In addition to the compensation factors described in the philosophy above, the recommendation for any particular year shall take into account cost-of-living and the financial condition of NEMHC. In general, total compensation shall not exceed that indicated by responsibility, performance, comparability standards, and cost-of-living but it may be less than would otherwise be indicated because of the financial condition of NEMHC and its budget. - The Personnel Committee shall provide its recommendation of CEO compensation to the NEMHC CFO in sufficient time for it to be included in the development of the annual NEMHC budget. It shall also provide its recommendation to the board prior to the meeting at which the annual NEMHC budget for the fiscal year is approved. - Prior to or during the meeting at which the NEMHC budget for the fiscal year is approved, the board shall makes its final determination of the total compensation of the CEO for that particular fiscal year based on all the considerations described in this policy. That determination shall be included in the final budget for that particular fiscal year and in IRS Form 990, audits, and other public documents. The CEO shall consider the following in determining CFO compensation: - The mission of NEMHC, its responsibilities on behalf of its members, and the role of the CFO in carrying out that mission and those responsibilities. Comparability of compensation received by CFO's of similar state-level health and social service trade or professional associations in South Dakota, community behavioral health trade or professional associations in surrounding states, - Performance goals for the CFO set by the CEO overall and for any particular year, and - The capacity of the NEMHC budget and expected revenues to support a particular compensation level. Procedures - On or before the anniversary date of the CFO, the CEO completes the CFO's performance evaluation. In addition to the compensation factors described in the philosophy above, the recommendation for an increase in any particular year shall take into account cost-of-living and the financial condition of NEMHC. In general, total compensation shall not exceed that indicated by responsibility, performance, comparability standards, and cost-of-living but it may be less than would otherwise be indicated because of the financial condition of NEMHC and its budget.
Form 990, Part VI, Section C, line 19
These documents are available upon request.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.