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
SOUTHERN TIER INDEPENDENCE CENTER INC
Employer identification number
16-1204347
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.") ....
1,824,684
1,609,736
2,006,173
1,700,322
2,000,839
9,141,754
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
1,824,684
1,609,736
2,006,173
1,700,322
2,000,839
9,141,754
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.
9,141,754
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..
1,824,684
1,609,736
2,006,173
1,700,322
2,000,839
9,141,754
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
13,094
12,930
8,455
4,052
4,386
42,917
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.)..
76,756
5,929
6,745
89,430
11
Total support (Add lines 7 through 10).
9,274,101
12
Gross receipts from related activities, etc. (see instructions)
..................
12
27,315,307
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
98.570 %
15
Public support percentage for 2012 Schedule A, Part II, line 14
...............
15
95.500 %
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
SOUTHERN TIER INDEPENDENCE CENTER INC
Employer identification number
16-1204347
Return Reference
Explanation
FORM 990, PART III, LINE 2
STIC IS CONTRACTED THROUGH NYS DOH TO PROVIDE IN PERSON ASSITANCE AND NAVIGATION SERVICES TO INDIVIDUALS, FAMILIES, AND SMALL BUSINESSES ENROLLING IN HEALTH INSURANCE THROUGH THE NEW YORK STATE OF HEALTH INSURANCE MARKETPLACE, FORMERLY KNOWN AS THE HEALTH BENEFITS EXCHANGE. THROUGH THE MARKETPLACE, NEW YORKERS WILL BE ABLE TO COMPARE HEALTH INSURANCE OPTIONS AND ENROLL IN HEALTH INSURANCE COVERAGE THROUGH AN ON-LINE PORTAL BEGINNING OCTOBER 1, 2013. THIS WILL INCLUDE THOSE PURCHASING A QUALIFIED HEALTH PLAN AND ALSO INDIVIDUALS THAT QUALIFY FOR MEDICAID AND CHP USING THE MAGI LEVELS. STIC HAS FIFTEEN FULL-TIME AND TWO PART-TIME NAVIGATORS ASSIGNED TO PROVIDE IN PERSON ASSISTANCE IN TIOGA, STEUBEN, ALLEGHANY, CHEMUNG, SCHUYLER, TOMPKINS CORTLAND, CHENANGO, AND SCHOHARIE COUNTIES. OUR NAVIGATORS WILL MEET WITH PEOPLE AND HELP THEM GO THROUGH THE PROCESS OF CHOOSING AND ENROLLING IN A HEALTH PLAN THAT MEETS THEIR NEEDS. ADDITIONALLY, WE WILL EXPLAIN THE ESTIMATED TAX CREDITS THAT ARE AVAILABLE. WE EXPECT TO ENROLL AT LEAST 60 INDIVIDUALS PER MONTH INTO A HEALTH INSURANCE PLAN INITIALLY. THIS NUMBER MAY CHANGE IN RESPONSE TO DEMAND FOR ASSISTANCE. IN ADDITION TO SEEING PEOPLE AT OUR MAIN SITE IN TIOGA COUNTY, WE WILL ALSO BE DOING ENROLLMENTS AT EIGHT OTHER COUNTY LOCATIONS.
FORM 990, PART VI, SECTION B, LINE 11
PAULA BARTLOW INITIALLY REVIEWS THE FORM 990 THEN IT GOES BEFORE THE MEMBERS OF THE BOARD. THE MEMBERS OF THE BOARD VOTE TO EITHER APPROVE OR DISAPPROVE THE 990.
FORM 990, PART VI, SECTION B, LINE 12C
UPON HIRE AND/OR APPOINTMENT AND ANNUALLY THEREAFTER SOUTHERN TIER INDEPENDENCE CENTER (STIC) EMPLOYEES AND MEMBERS OF THE BOARD OF DIRECTORS ARE REQUIRED TO COMPLETE A CONFLICT OF INTEREST FORM TO APPRAISE THE BOARD PRESIDENT, EXECUTIVE DIRECTOR, HUMAN RESOURCES COORDINATOR AND PERTINENT OTHERS OF RELATIONSHIPS WITH EMPLOYEES AND STIC BOARD MEMBERS WHICH MAY CAUSE A CONFLICT OF INTEREST. INDIVIDUALS THAT MAY BE AFFECTED BY A PERSONAL RELATIONSHIP BETWEEN EMPLOYEES AND/OR BOARD MEMBERS ARE NOTIFIED SO THAT THEY MAY INFORM THE APPROPRIATE PARTY (BOARD PRESIDENT, EXECUTIVE DIRECTOR OR HUMAN RESOURCES COORDINATOR) SHOULD THE RELATIONSHIP INTERFERE WITH THEIR WORK OR THE WORK OF THE AGENCY. ADDITIONALLY, MEMBERS OF STIC'S BOARD OF DIRECTORS ARE NOTIFIED OF THE EXECUTIVE DIRECTOR'S POTENTIAL CONFLICTS OF INTERESTS. THE BOARD OF DIRECTORS APPROVES THE HIRE OF ANY INDIVIDUAL WHO HAS A PERSONAL RELATIONSHIP WITH THE EXECUTIVE DIRECTOR.
FORM 990, PART VI, SECTION B, LINE 15
COMPENSATION FOR OUR EXECUTIVE DIRECTOR AND KEY EMPLOYEES. FIRST WE REVIEW AND CONSIDER THE SALARY COMPARISONS FOR OTHER NOT FOR PROFIT EXECUTIVE DIRECTORS AND KEY EMPLOYEES IN THE SOUTHERN TIER, GATHERED ANNUALLY BY ANOTHER LOCAL NOT FOR PROFIT AS A WAGE COMPARABILITY STUDY FOR THE NOT FOR PROFIT COMMUNITY AT LARGE. SECONDLY WE REVIEW AND CONSIDER SALARY COMPENSATIONS FOR OTHER EXECUTIVE DIRECTORS AND KEY EMPLOYEES USING GUIDESTAR AND NYCON COMPENSATION REPORTS. THIRD OUR BOARD OF DIRECTORS DOES AN EXTENSIVE EMPLOYEE REVEIW OF THE EXECUTIVE DIRECTOR'S PERFORMANCE BI-ANNUALLY AND THE EXECUTIVE DIRECTOR DOES THE SAME WITH OUR KEY EMPLOYEES. ONCE THE ENTIRE ANALYSIS OF THESE THREE COMPONENTS IS COMPLETE THE BOARD OF DIRECTORS UTILIZES THE INFORMATION TO MAKE THE DETERMINATION OF MONETARY COMPENSATION. ADDITIONALLY THE BOARD APPROVES ANY CHANGES IN EMPLOYEES' SALARIES THAT ARE ABOVE AND BEYOND A COST OF LIVING INCREASE WHICH IS ALSO APPROVED BY THE BOARD WHEN REVIEWING AND ADOPTING THE AGENCY'S ANNUAL BUDGET.
FORM 990, PART VI, SECTION C, LINE 19
THE FOLLOWING STATEMENT APPEARS ON OUR WEBSITE AND IN OUR QUARTERLY NEWSLETTER (WHICH REACHED MORE THAN 2,300 INDIVIDUALS, ORGANIZATIONS, PUBLIC OFFICAL, ETC. "STIC IS A 501(C)(3) NOT FOR PROFIT CORPORATION. GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICIES AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST". ADDITIONALLY, AN ANNUAL MEETING IS HELD TO INFORM CORPORATION MEMBERS AND OTHERS FROM THE PUBLIC ABOUT THE ACTIVITIES OF STIC OVER THE YEAR INCLUDING: UPDATES ON PROGRAMS AND SERVICES; FUNDRAISING ACTIVITIES AND RESULTS; FINANCIAL AND OTHER PERTINENT INFORMATION TAKEN FROM OUR INDEPENDENT AUDITED FINANCIAL STATEMENT, ETC.
FORM 990, PART XII, LINE 2C:
FORM 990, PART XII, LINE 2C - PROCESS HAS NOT CHANGED SINCE PRIOR YEAR.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.