Attach to Form 990 or Form 990-EZ.
Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
| (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 listed in your governing document? | (v) Amount of monetary support (see instructions) | (vi) Amount of other support (see instructions) | |
|---|---|---|---|---|---|---|
| Yes | No | |||||
| Total | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (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. | ||||||
Calendar year
(or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (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 VI.).. | ||||||
| 11 | Total support Add lines 7 through 10. | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") . | 382,000 | 549,206 | 931,206 | |||
| 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...... | 572,000 | 286,000 | 858,000 | |||
| 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. | 954,000 | 835,206 | 1,789,206 | |||
| 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. | 0 | |||||
| c | Add lines 7a and 7b.. | 0 | |||||
| 8 | Public support (Subtract line 7c from line 6.) | 1,789,206 | |||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | 954,000 | 835,206 | 1,789,206 | |||
| 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 VI.) .. | ||||||
| 13 | Total support. (Add lines 9, 10c, 11, and 12.).. | 954,000 | 835,206 | 1,789,206 | |||
| Section A - Adjusted Net Income | (A) Prior Year |
(B) Current Year (optional) |
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| 1 | Net short-term capital gain | 1 | ||||
| 2 | Recoveries of prior-year distributions | 2 | ||||
| 3 | Other gross income (see instructions) | 3 | ||||
| 4 | Add lines 1 through 3 | 4 | ||||
| 5 | Depreciation and depletion | 5 | ||||
| 6 | Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions) | 6 | ||||
| 7 | Other expenses (see instructions) | 7 | ||||
| 8 | Adjusted Net Income (subtract lines 5, 6 and 7 from line 4) | 8 | ||||
| Section B - Minimum Asset Amount | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year): | 1 | ||||
| a | Average monthly value of securities | 1a | ||||
| b | Average monthly cash balances | 1b | ||||
| c | Fair market value of other non-exempt-use assets | 1c | ||||
| d | Total (add lines 1a, 1b, and 1c) | 1d | ||||
| e | Discount claimed for blockage or other factors (explain in detail in Part VI): | |||||
| 2 | Acquisition indebtedness applicable to non-exempt use assets | 2 | ||||
| 3 | Subtract line 2 from line 1d | 3 | ||||
| 4 | Cash deemed held for exempt use. Enter 1-1/2% of line 3 (for greater amount, see instructions). | 4 | ||||
| 5 | Net value of non-exempt-use assets (subtract line 4 from line 3) | 5 | ||||
| 6 | Multiply line 5 by .035 | 6 | ||||
| 7 | Recoveries of prior-year distributions | 7 | ||||
| 8 | Minimum Asset Amount (add line 7 to line 6) | 8 | ||||
| Section C - Distributable Amount | Current Year | |||||
| 1 | Adjusted net income for prior year (from Section A, line 8, Column A) | 1 | ||||
| 2 | Enter 85% of line 1 | 2 | ||||
| 3 | Minimum asset amount for prior year (from Section B, line 8, Column A) | 3 | ||||
| 4 | Enter greater of line 2 or line 3 | 4 | ||||
| 5 | Income tax imposed in prior year | 5 | ||||
| 6 | Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions) | 6 | ||||
| 7 | Check here if the current year is the organization's first as a non-functionally-integrated Type III supporting organization (see instructions) | |||||
| Section D - Distributions | Current Year | |
|---|---|---|
| 1 Amounts paid to supported organizations to accomplish exempt purposes | ||
|
2
Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity |
||
| 3 Administrative expenses paid to accomplish exempt purposes of supported organizations | ||
| 4 Amounts paid to acquire exempt-use assets | ||
| 5 Qualified set-aside amounts (prior IRS approval required) | ||
| 6 Other distributions (describe in Part VI). See instructions | ||
| 7Total annual distributions. Add lines 1 through 6. | ||
|
8
Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions |
||
| 9 Distributable amount for 2014 from Section C, line 6 | ||
| 10 Line 8 amount divided by Line 9 amount | ||
| Section E - Distribution Allocations (see instructions) |
(i) Excess Distributions |
(ii) Underdistributions Pre-2014 |
(iii) Distributable Amount for 2014 |
|
|---|---|---|---|---|
|
1
Distributable amount for 2014 from Section C, line 6 |
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|
2
Underdistributions, if any, for years prior to 2014 (reasonable cause required--see instructions) |
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| 3 Excess distributions carryover, if any, to 2014: | ||||
| a From 2009.......X | ||||
| b From 2010.......X | ||||
| c From 2011.......X | ||||
| d From 2012.......X | ||||
| e From 2013....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2014 distributable amount | ||||
|
i
Carryover from 2009 not applied (see instructions) |
||||
| j Remainder. Subtract lines 3g, 3h, and 3i from 3f. | ||||
| 4Distributions for 2014 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2014 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from 4. | ||||
|
5
Remaining underdistributions for years prior to 2014, if any. Subtract lines 3g and 4a from line 2 (if amount greater than zero, see instructions) |
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|
6
Remaining underdistributions for 2014. Subtract lines 3h and 4b from line 1 (if amount greater than zero, see instructions) |
||||
|
7 Excess distributions carryover to 2015. Add lines 3j and 4c. |
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| 8 Breakdown of line 7: | ||||
| a From 2010.......X | ||||
| b From 2011.......X | ||||
| c From 2012.......X | ||||
| d From 2013....... | ||||
| e From 2014....... | ||||
| Facts And Circumstances Test |
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| Return Reference | Explanation |
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| Software ID: | |
| Software Version: |
Attach to Form 990 or 990-EZ.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at| Return Reference | Explanation |
|---|---|
| FORM 990, PART III, LINE 2 | HEALTH HOMES CARE COORDINATION INITIATIVE: SUPPORTS HIGH RISK/HIGH UTILIZERS OF MEDICAID TO IMPROVE HEALTH AND HEALTH CARE OUTCOMES AND REDUCE COSTS. FAMILY ASSESSMENT RESPONSE (FAR) INITIATIVE: IS A CHILD PROTECTIVE SERVICES ALTERNATIVE TO INVESTIGATIONS OF LOW TO MODERATE RISK REPORTS OF CHILD MALTREATMENT, WHICH SUPPORTS FAMILY RESILIENCE AND CHILD SAFETY. H3 (HEALTH, HOUSING AND HOMELESSNESS) PROJECT: SEEKS TO REDUCE RE-HOSPITALIZATIONS AND IMPROVE HEALTH OUTCOMES FOR MEDICALLY VULNERABLE HOMELESS INDIVIDUALS BY FINDING SUITABLE HOUSING AND PROVIDING WRAPAROUND CLIENT SERVICES TO SUPPORT WELL-BEING. |
| FORM 990, PART VI, SECTION A, LINE 3 | WITH RESPECT TO URGENT ACTION: THE EXECUTIVE COMMITTEE IS REQUIRED TO AND SHALL EXERCISE AT SUCH TIME ALL POWERS OF THE BOARD IN THE MANGEMENT OF THE BUSINESS AND AFFAIRS OF THE ORGANIZATION, EXCEPT AS DESIGNATED BY WASHINGTON LAW MUST BE UNDERTAKEN BY THE ENTIRE BOARD OR THAT THE BOARD ITSELF HAS DESIGNATED AS NOT SUBJECT TO AMENDMENT, ALTERATION OR REPEAL BY THE COMMITTEE. COMPOSITION OF THE EXECUTIVE COMMITTEE IS AT LEAST 4 BOARD MEMBERS (CHAIR, VICE CHAIR, SECRETARY AND TREASURER) AND MAY ALSO INCLUDE THE IMMEDIATE PAST CHAIR IF STILL SERVING. OTHER BOARD MEMBERS MAY BE APPOINTED AT THE DISCRETION OF THE BOARD. |
| FORM 990, PART VI, SECTION A, LINE 6 | A SINGLE MEMBER--A NONPROFIT CORPORATION WITH SOLE RIGHTS TO APPOINT ALL BOARD MEMBERS (IE, CLASS A BOARD MEMBERS). |
| FORM 990, PART VI, SECTION A, LINE 7A | A SINGLE MEMBER--A NONPROFIT CORPORATION WITH SOLE RIGHTS TO APPOINT ALL BOARD MEMBERS (IE, CLASS A BOARD MEMBERS). |
| FORM 990, PART VI, SECTION A, LINE 7B | TO AMEND THE ARTICLES OF INCORPORATION, THE BOARD OF DIRECTORS MUST ADOPT A RESOLUTION SETTING FORTH THE PROPOSED AMENDMENT AND DIRECTING THAT IT BE SUBMITTED TO A VOTE AT A MEMBER MEETING. BEFORE ARTICLES OF AMENDMENT MAY BE FILED WITH THE SECRETARY OF STATE OF THE STATE OF WASHINGTON, THE PROPOSED AMENDMENT MUST BE ADOPTED BY THE MEMBER IN ACCORDANCE WITH THE PROCEDURE SET OUT IN SECTION 24.03.165 OF THE WASHINGTON NONPROFIT CORPORATION ACT. NOTWITHSTANDING ANY OTHER PROVISION OF THESE BYLAWS, THE DIRECTORS MAY NOT ADOPT, AMEND, OR REPEAL THESE BYLAWS, OR AMEND THE ARTICLES OF INCORPORATION, IN ANY WAY THAT AFFECTS THE RIGHTS OR POWERS OF THE MEMBER, INCLUDING BY THE ADDITION OF NEW MEMBERS, WITHOUT THE PRIOR WRITTEN CONSENT OF THE MEMBER. FURTHER, THE DIRECTORS MAY NOT, WITHOUT PRIOR WRITTEN CONSENT OF THE MEMBER, ASSIGN TO ANY PARTY ANY CONTRACT TO WHICH THE CORPORATION IS A PARTY; AUTHORIZE THE SALE, LEASE, DISPOSITION, OR EXCHANGE OF THE CORPORATION'S ASSETS OTHER THAN IN THE ORDINARY COURSE OF BUSINESS; ADOPT A PLAN OF MERGER OR CONSOLIDATION, OR AUTHORIZE THE DISSOLUTION OF THE CORPORATION OR THE FILING OF ANY PETITION IN THE NATURE OF A BANKRUPTCY. |
| FORM 990, PART VI, SECTION B, LINE 11 | THE FORM 990 IS REVIEWED AT THE NEXT BOARD MEETING AFTER FILING. |
| FORM 990, PART VI, SECTION B, LINE 12C | ANNUAL DISCLOSURE STATEMENT; REVIEW BY BOARD OF MATERIAL TRANSACTIONS AND AGREEMENTS, INCLUDING DETERMINATION OF "FAIR AND REASONABLE" IF A POTENTIAL CONFLICT IS IDENTIFIED. CONFLICTED MEMBER IS NOT ALLOWED TO VOTE OR BE PRESENT FOR SUCH REVIEW AND DISCUSSION. |
| FORM 990, PART VI, SECTION B, LINE 15B | ANNUAL REVIEW BY THE EXECUTIVE COMMITTEE, INCLUDING COMPARISONS FOR LIKE POSITIONS IN OTHER NON-PROFITS. |
| FORM 990, PART VI, SECTION C, LINE 18 | FORM 990 IS AVAILABLE UPON REQUEST. |
| FORM 990, PART VI, SECTION C, LINE 19 | FINANCIAL STATEMENTS AND GOVERNING DOCUMENTS ARE GENERALLY NOT MADE AVAILABLE FOR PUBLIC INSPECTION. |
| FORM 990, PART IX, LINE 11G | SUBCONTRACTED IN-PERSON ASSISTOR SERVICES: PROGRAM SERVICE EXPENSES 415,611. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 415,611. TEMPORARY HELP, HIRING FEES AND EMPLOYMENT SCREENING: PROGRAM SERVICE EXPENSES 186. MANAGEMENT AND GENERAL EXPENSES 6,468. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 6,654. CONSULTING AND GRANTWRITING FOR VARIOUS PROGRAMS, INCLUDING PRE-ARWARD: PROGRAM SERVICE EXPENSES 6,075. MANAGEMENT AND GENERAL EXPENSES 19,772. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 25,847. BOARD CONSULTING AND DESIGN OF BOARD MATERIALS: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 7,133. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 7,133. |
| FORM 990, PART XII, LINE 12C: | THE PROCESSES AND METHODS FOR DETERMINING THE INDEPENDENT AUDITOR ARE DETERMINED BY EMPIRE HEALTH FOUNDATION AND HAVE NOT CHANGED FROM PRIOR YEARS. |
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