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
ASPIRUS CLINICS INC
Employer identification number
39-1670223
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.") .
2,000,281
12,600,000
12,182,341
15,014,245
12,501,098
54,297,965
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......
53,534,680
63,629,920
102,056,655
103,852,844
100,089,915
423,164,014
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.
55,534,961
76,229,920
114,238,996
118,867,089
112,591,013
477,461,979
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
2,000,000
12,600,000
12,182,341
15,014,245
12,501,098
54,297,684
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..
2,000,000
12,600,000
12,182,341
15,014,245
12,501,098
54,297,684
8
Public support (Subtract line 7c from line 6.)
423,164,295
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...
55,534,961
76,229,920
114,238,996
118,867,089
112,591,013
477,461,979
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
1,176,416
1,213,732
1,354,871
1,306,164
1,354,043
6,405,226
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
1,176,416
1,213,732
1,354,871
1,306,164
1,354,043
6,405,226
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
4,884
4,884
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.)..
56,711,377
77,443,652
115,593,867
120,173,253
113,949,940
483,872,089
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
87.450 %
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
87.980 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
1.320 %
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
1.340 %
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
ASPIRUS CLINICS INC
Employer identification number
39-1670223
Return Reference
Explanation
FORM 990, PART VI, SECTION A, LINE 6
THE PARENT ORGANIZATION, ASPIRUS, INC. IS THE SOLE MEMBER OF THE ORGANIZATION.
FORM 990, PART VI, SECTION A, LINE 7A
SEE EXPLANATION FOR FORM 990, PART VI, LINE 7B.
FORM 990, PART VI, SECTION A, LINE 7B
THE FOLLOWING ACTIONS MUST BE APPROVED BY THE SOLE MEMBER OF THE ORGANIZATION, ASPIRUS, INC.: 1) CHANGE OR AMEND THE ARTICLES OF INCORPORATION OR BY LAWS, 2) CHANGE THE MISSION, PURPOSE, OR SCOPE OF THE CORPORATION, 3) RATIFICATION OR REMOVAL OF DIRECTORS OR OFFICERS, 4) CHANGE THE FORMULA OR METHODOLOGY FOR DETERMINING PHYSICIAN COMPENSATION, AND 5)APPROVAL OF ANNUAL OPERATING AND CAPITAL EXPENDITURE BUDGETS, STRATEGIC AND LONG RANGE PLANS.
FORM 990, PART VI, SECTION B, LINE 11
THE FORM 990 IS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM AND REVIEWED BY THE ORGANIZATION'S MANAGEMENT. THE FORM 990 IS PROVIDED TO BOARD MEMBERS FOR REVIEW AND APPROVAL PRIOR TO FILING.
FORM 990, PART VI, SECTION B, LINE 12C
BOARD MEMBERS, OFFICERS, AND KEY EMPLOYEES ARE REQUIRED TO SIGN ANNUAL CONFLICT OF INTEREST STATEMENTS AND ALL MANAGERS ARE REQUIRED TO SIGN BIANNUAL CONFLICT OF INTEREST STATEMENTS. THE ORGANIZATION'S CEO AND BOARD CHAIR REVIEW THE STATEMENTS AND HIGHLIGHT POTENTIAL CONFLICTS. THE BOARD DETERMINES ON A CASE BY CASE BASIS ANY ACTIONS REQUIRED. INDIVIDUALS ARE NOT PERMITTED TO VOTE ON ANY TRANSACTION WHERE A CONFLICT HAS BEEN DETERMINED TO EXIST. ALL CONFLICTS AND PROCEEDINGS ARE DOCUMENTED IN THE MEETING MINUTES.
FORM 990, PART VI, SECTION B, LINE 15B
FOR THE PURPOSES OF DETERMINING COMPENSATION, THE FILING ORGANIZATION, ASPIRUS CLINICS, INC. RELIED ON RELATED ORGANIZATIONS TO ESTABLISH COMPENSATION OF THE CEO AND CERTAIN OTHER OFFICERS. THE RELATED ORGANIZATIONS USED THE FOLLOWING PRACTICES FOR ESTABLISHING COMPENSATION FOR SUCH INDIVIDUALS: COMPENSATION COMMITTEE, INDEPENDENT COMPENSATION CONSULTANT, WRITTEN EMPLOYMENT CONTRACT, COMPENSATION SURVEY OR STUDY, AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. FOR OFFICERS OF ASPIRUS CLINICS, INC., THE ORGANIZATION HAD AN INDEPENDENT AUDIT FOR EXECUTIVE COMPENSATION WHICH INCLUDED BASE SALARY, INCENTIVE PLANS, AND BENEFITS FOR ALL OFFICE AND EXECUTIVE POSITIONS. THE REVIEW WAS COMMISSIONED BY THE COMPENSATION COMMITTEE OF THE BOARD AND WAS CONDUCTED BY AN INDEPENDENT CONSULTING FIRM. THE MARKET ANALYSIS WAS COMPLETED IN MARCH/APRIL OF 2013 AND PRESENTED TO THE COMPENSATION COMMITTEE OF THE BOARD IN AUGUST, 2013 FOR FINAL COMPENSATION DETERMINATION.
FORM 990, PART VI, SECTION C, LINE 19
THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, NOR ITS FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC.
FORM 990, PART VII, LINE 1A, EXPLANATION FOR HOURS WORKED:
SOME OFFICERS, DIRECTORS, AND KEY EMPLOYEES ALSO PROVIDED SERVICE TO OTHER RELATED ORGANIZATIONS OTHER THAN ASPIRUS CLINICS, INC. THESE HOURS ARE REFLECTED IN LINE 2 OF COLUMN B.
THE AUDIT COMMITTEE OF THE BOARD OF DIRECTORS OF ASPIRUS, INC., THE PARENT ORGANIZATION OF ASPIRUS CLINICS, ASSUMES THE RESPONSIBIILTY FOR THE OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS AND SELECTION OF THE INDEPENDENT ACCOUNTANT. THERE WAS NO CHANGE IN THIS PROCESS IN THE PAST YEAR.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.