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 (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 | |||||
| (A)
MOUNTAINLANDS COMMUNITY HEALTH CENTER |
870515716 | 7 | No | 639,500 | 0 | |
| (B)
ODYSSEY HOUSE INC OF UTAH |
870292487 | 7 | No | 33,200 | 0 | |
| (C)
WASATCH MENTAL HEALTH |
450531249 | 9 | No | 32,865 | 0 | |
| (D)
PEOPLE'S HEALTH CLINIC |
870638042 | 7 | No | 23,670 | 0 | |
| (E)
POLIZZI FOUNDATION |
571241243 | 9 | No | 33,960 | 0 | |
| (F)
FAMILY COUNSELING SERVICE |
870271413 | 7 | No | 25,000 | 0 | |
| (G)
INTERMOUNTAIN SPECIALIZED ABUSE TREATMENT CENTER |
870414241 | 9 | No | 18,925 | 0 | |
| (H)
INTERNATIONAL RESCUE COMMITTEE |
135660870 | 7 | No | 20,050 | 0 | |
| (I)
UTAH HEALTH & HUMAN RIGHTS PROJECT |
203901845 | 7 | No | 29,744 | 0 | |
| (J)
VOLUNTEERS OF AMERICA UTAH |
943008720 | 7 | No | 37,488 | 0 | |
| (K)
WORK ACTIVITY CENTER |
870255186 | 7 | No | 25,872 | 0 | |
| (L)
UTAH AIDS FOUNDATIONS |
870455172 | 7 | No | 28,684 | 0 | |
| (M)
JEWISH FAMILY SERVICE |
870227089 | 7 | No | 21,146 | 0 | |
| (N)
FOURTH STREET CLINIC |
870569356 | 7 | No | 237,532 | 0 | |
| (O)
THE ROAD HOME |
870212465 | 7 | No | 14,185 | 0 | |
| (P)
MALIHEH FREE CLINIC |
202313461 | 7 | No | 22,598 | 0 | |
| (Q)
COMMUNITY HEALTH CONNECT |
651260998 | 7 | No | 17,974 | 0 | |
| (R)
CHILDREN'S SERVICE SOCIETY OF UTAH |
870212451 | 7 | No | 35,640 | 0 | |
| (S)
SALT LAKE DONATED DENTAL SERVICES |
870482710 | 9 | No | 25,872 | 0 | |
| (T)
THE CHILDREN'S CENTER |
876114073 | 7 | No | 35,200 | 0 | |
| (U)
MIDTOWN COMMUNITY HEALTH CENTER INC |
870540039 | 7 | No | 385,000 | 0 | |
| (V)
COMMUNITY HEALTH CENTERS INC |
742412898 | 7 | No | 1,355,000 | 0 | |
| (W)
SOUTHWEST UTAH COMMUNITY HEALTH CENTER |
352163112 | 9 | No | 150,000 | 0 | |
| (X)
IHC HEALTH SERVICES INC |
942854057 | 3 | No | 1,418,080 | 0 | |
| Total 24 | 4,667,185 | 0 | ||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2011 | (b) 2012 | (c) 2013 | (d) 2014 | (e) 2015 | (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) 2011 | (b) 2012 | (c) 2013 | (d) 2014 | (e) 2015 | (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) 2011 | (b) 2012 | (c) 2013 | (d) 2014 | (e) 2015 | (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.) | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2011 | (b) 2012 | (c) 2013 | (d) 2014 | (e) 2015 | (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 VI.) .. | ||||||
| 13 | Total support. (Add lines 9, 10c, 11, and 12.).. | ||||||
| Section A - Adjusted Net Income | (A) Prior Year |
(B) Current Year (optional) |
||||
| 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 | ||||
| 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 2015 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-2015 |
(iii) Distributable Amount for 2015 |
|
|---|---|---|---|---|
|
1
Distributable amount for 2015 from Section C, line 6 |
||||
|
2
Underdistributions, if any, for years prior to 2015 (reasonable cause required--see instructions) |
||||
| 3 Excess distributions carryover, if any, to 2015: | ||||
| a | ||||
| b | ||||
| c | ||||
| d From 2013....... | ||||
| e From 2014....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2015 distributable amount | ||||
|
i
Carryover from 2010 not applied (see instructions) |
||||
| j Remainder. Subtract lines 3g, 3h, and 3i from 3f. | ||||
| 4Distributions for 2015 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2015 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from 4. | ||||
|
5
Remaining underdistributions for years prior to 2015, if any. Subtract lines 3g and 4a from line 2 (if amount greater than zero, see instructions) |
||||
|
6
Remaining underdistributions for 2015. Subtract lines 3h and 4b from line 1 (if amount greater than zero, see instructions) |
||||
|
7 Excess distributions carryover to 2016. Add lines 3j and 4c. |
||||
| 8 Breakdown of line 7: | ||||
| a | ||||
| b | ||||
| c Excess from 2013....... | ||||
| d From 2014....... | ||||
| e From 2015....... | ||||
| Facts And Circumstances Test |
|---|
| Return Reference | Explanation |
|---|---|
| FORM 990, SCHEDULE A, PART IV, SECTION A, LINE I | SUPPORTED ORGANIZATIONS OF THE FILING ENTITY ARE DESIGNATED BY CLASS IN ACCORDANCE WITH ITS ARTICLES OF INCORPORATION. THE ARTICLES STATE THAT THE PURPOSE OF THE ORGANIZATION IS CONDUCTING OR SUPPORTING ACTIVITIES FOR THE BENEFIT OF OR TO CARRY OUT THE CHARITABLE, EDUCATIONAL OR SCIENTIFIC PURPOSES OF IHC HEALTH SERVICES, INC. ONE OF THE SUPPORTED ORGANIZATIONS, IHC HEALTH SERVICES, INC., IS RELATED TO THE FILING ORGANIZATION (SEE SCHEDULE R) AND HAS HAD AN ONGOING AND HISTORIC RELATIONSHIP SINCE THE FILING ENTITY WAS ORGANIZED IN 1983. |
| FORM 990, SCHEDULE A, PART IV, SECTION A, LINE 2 | DETERMINATIONS OF 509(A)(1) OR (2) WERE BASED ON REPRESENTATIONS MADE BY THE RECIPIENT ENTITIES ON THEIR MOST RECENTLY FILED FORMS 990. |
| FORM 990 SCHEDULE A, PART IV, SECTION A, LINE 5A | AS PART OF A FORMAL GRANT APPLICATION AND REVIEW PROCESS, SEVERAL ENTITIES WERE ADDED TO/DELETED FROM THE LIST OF THE SUPPORTED ORGANIZATIONS REPORTED ON THE PRIOR YEAR RETURN. ALL OF THE NEWLY ADDED ORGANIZATIONS ARE PART OF THE CHARITABLE CLASS AS IT IS DESCRIBED IN THE ARTICLES OF INCORPORATION. DETAILS REGARDING EACH RECIPIENT ENTITY, INCLUDING THE NAME AND ADDRESS OF THE ORGANIZATION, THE AMOUNT GRANTED, AND THE BOARD-APPROVED PURPOSE OF THE GRANT, ARE REPORTED ON SCHEDULE I OF THIS RETURN. BY FORMAL RESOLUTION, THE GOVERNING BODY APPROVED THE GRANTS UNDER THE AUTHORITY OF AND IN FURTHERANCE OF THE FILING ORGANIZATION'S PURPOSES AS STATED IN THE ARTICLES OF INCORPORATION. |
| FORM 990, SCHEDULE A, PART IV, SECTION C, LINE 1 | THREE OF THE FILING ORGANIZATION'S ELEVEN BOARD MEMBERS ARE ALSO ON THE BOARD OF IHC HEALTH SERVICES, INC., THE LARGEST OF THE FILING ORGANIZATION'S SUPPORTED ORGANIZATIONS. FIVE OF THE SIX OFFICERS OF THE FILING ENTITY ARE EMPLOYEES OF THIS SUPPORTED ORGANIZATION. ADDITIONALLY, THE FILING ORGANIZATION IS HOUSED IN THE SUPPORTED ORGANIZATION'S FACILITIES, STAFFED BY ITS EMPLOYEES, AND WOULD HAVE LITTLE ABILITY TO OPERATE INDEPENDENTLY. |
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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 I, LINE 1 | THE MISSION OF INTERMOUNTAIN COMMUNITY CARE FOUNDATION, INC. IS TO IMPROVE ACCESS TO HEALTHCARE SERVICES FOR LOW-INCOME, UNINSURED OR MEDICALLY-UNDERSERVED POPULATIONS IN UTAH AND SOUTHERN IDAHO THROUGH IDENTIFYING AND SUPPORTING EXISTING HEALTHCARE PROGRAMS THAT PROVIDE DIRECT MEDICAL, DENTAL AND MENTAL HEALTH CARE TO THESE POPULATIONS, ALONG WITH PROGRAMS THAT SUPPORT OR FACILITATE ACCESS TO HEALTHCARE SERVICES. |
| FORM 990, PART VI, SECTION A, LINE 2 | ALBERT R. ZIMMERLI / CHARLES W. SORENSON JR. MD / DANIEL G. GOMEZ- BUSINESS RELATIONSHIP (BOARD MEMBERS OF THE SELECTHEALTH BENEFIT ASSURANCE COMPANY, INC., A WHOLLY OWNED TAXABLE SUBSIDIARY OF AN AFFILIATE OF THE FILING ORGANIZATION) CHARLES W. SORENSON JR. MD / ALBERT R. ZIMMERLI / MORRIS D. LINTON / GREG MATIS / MIKELLE D. MOORE- BUSINESS RELATIONSHIP (EMPLOYER/EMPLOYEE RELATIONSHIP WITHIN IHC HEALTH SERVICES, INC., A TAX-EXEMPT SUBSIDIARY OF THE FILING ORGANIZATION'S PARENT) |
| FORM 990, PART VI, SECTION A, LINE 6 | THE SOLE MEMBER OF INTERMOUNTAIN COMMUNITY CARE FOUNDATION, INC. IS INTERMOUNTAIN HEALTH CARE, INC., A UTAH NONPROFIT CORPORATION. |
| FORM 990, PART VI, SECTION A, LINE 7A | PURSUANT TO THE APPROVED BYLAWS, THE FILING ORGANIZATION'S TRUSTEES ARE ELECTED BY THE SOLE MEMBER. |
| FORM 990, PART VI, SECTION A, LINE 7B | PURSUANT TO THE APPROVED BYLAWS, THE MEMBER EXERCISES ALL PROPERTY, VOTING, AND OTHER RIGHTS, INTERESTS AND POWERS CONFERRED UNDER LOCAL STATUTE. |
| FORM 990, PART VI, SECTION B, LINE 11 | NO REVIEW WAS OR WILL BE CONDUCTED |
| FORM 990, PART VI, SECTION B, LINE 12C | EACH OFFICER, DIRECTOR, AND TRUSTEE IS REQUIRED TO COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE AT LEAST ANNUALLY. THESE INDIVIDUALS HAVE ALSO BEEN INSTRUCTED TO UPDATE THEIR QUESTIONNAIRE INFORMATION IF THEY BECOME AWARE OF A NEW POTENTIAL CONFLICT, OR IF ANY OF THE PREVIOUSLY REPORTED INFORMATION CHANGES. THE COMPLETED QUESTIONNAIRES ARE COLLECTED AND REVIEWED BY IHC HEALTH SERVICES, INC.'S VICE PRESIDENT OF BUSINESS ETHICS AND COMPLIANCE. ANY POTENTIAL CONFLICTS ARE REVIEWED WITH APPROPRIATE PERSONNEL, WHICH MAY INCLUDE COMPLIANCE AND LEGAL PERSONNEL OF IHC HEALTH SERVICES, INC. IF AN INDIVIDUAL DISCLOSES A SITUATION THAT POSES A CONFLICT OF INTEREST, THE PRESIDENT DETERMINES IF THE SITUATION CAN BE MANAGED (SUCH AS BY RECUSAL IN DECISION-MAKING SETTINGS) OR MUST BE ELIMINATED (SUCH AS THROUGH DIVESTITURE OF THE OUTSIDE INTEREST OR REQUIRING A CHOICE BETWEEN THE INDIVIDUAL'S ROLE WITH THE FOUNDATION OR THE OUTSIDE ENTITY). |
| FORM 990, PART VI, SECTION B, LINE 15 | INTERMOUNTAIN COMMUNITY CARE FOUNDATION, INC. DID NOT COMPENSATE ANY OFFICER, DIRECTOR, TRUSTEE, OR KEY EMPLOYEE. COMPENSATION AMOUNTS LISTED ON PART VII WERE PAID BY RELATED ORGANIZATIONS AND WERE DETERMINED IN ACCORDANCE WITH ESTABLISHED IRS GUIDELINES, INCLUDING REVIEWS AND APPROVALS BY INDEPENDENT PERSONS, USE OF COMPARABLE DATA, AND CONTEMPORANEOUS SUBSTANTIATION OF DELIBERATIONS AND DECISIONS. |
| FORM 990, PART VI, SECTION C, LINE 19 | INTERMOUNTAIN COMMUNITY CARE FOUNDATION, INC. DOES NOT CURRENTLY ALLOW PUBLIC INSPECTION OF ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, OR FINANCIAL STATEMENTS. |
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