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 | |||||
| Total | ||||||
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.) .... | 21,287,630 | 24,787,244 | 17,621,348 | 24,189,609 | 26,424,071 | 114,309,902 |
| 2 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf....... | 0 | |||||
| 3 | The value of services or facilities furnished by a governmental unit to the organization without charge.. | 0 | |||||
| 4 | Total. Add lines 1 through 3 | 21,287,630 | 24,787,244 | 17,621,348 | 24,189,609 | 26,424,071 | 114,309,902 |
| 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).. | 79,008,091 | |||||
| 6 | Public support. Subtract line 5 from line 4. | 35,301,811 | |||||
Calendar year
(or fiscal year beginning in) ![]() |
(a) 2011 | (b) 2012 | (c) 2013 | (d) 2014 | (e) 2015 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 7 | Amounts from line 4.. | 21,287,630 | 24,787,244 | 17,621,348 | 24,189,609 | 26,424,071 | 114,309,902 |
| 8 | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources... | 1,354,252 | -411,907 | 679,101 | 831,171 | 873,451 | 3,326,068 |
| 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.).. | 0 | |||||
| 11 | Total support. Add lines 7 through 10. | 117,635,970 | |||||
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) |
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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) |
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| 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): |
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| 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 |
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|
2
Underdistributions, if any, for years prior to 2015 (reasonable cause required--see instructions) |
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| 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) |
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| 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) |
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|
6
Remaining underdistributions for 2015. Subtract lines 3h and 4b from line 1 (if amount greater than zero, see instructions) |
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|
7 Excess distributions carryover to 2016. Add lines 3j and 4c. |
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| 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 Sch A Part II Line 17a | There are two requirements that FHC must fulfill in order to satisfy the Facts-and-Circumstances Test set forth in Treas. Reg. 1.170A-9T(f)(3)(ii). First, FHC must derive at least 10 percent of its support from governmental units or from direct or indirect contributions from the general public, or a combination of both. By receiving over 25 percent of its support from the government units and the public, FHC has satisfied this requirement. Second, FHC must maintain a continuous and bonafide fundraising program or carry on programs designed to attract support from governmental units or other public charities described in IRC Section 170(b)(1)(A)(i) through (vi). FHC does maintain a concerted and bonafide grant writing and application program as the major part of its fundraising efforts. FHC's activities directly benefit the medically underserved in a large area of northern Wisconsin, which permits FHC to receive substantial governmental support. FHC also maintains a close relationship with Marshfield Clinic, a non-profit that is exempt from tax under IRC section 501(c)(3) and classified as a public charity under IRC section 170(b)(1)(A)(iii). Marshfield Clinic provides a substantial portion of FHC's support in recognition of the need to provide health care services to the poor in Marshfield Clinic's extensive service area. The following additional facts and circumstances further demonstrates that FHC is properly classified as a publicly supported organization under IRC section 509(a)(1) and 170(b)(1)(A)(vi): 1) Charity Care: FHC is a community health center program. In collaboration with Marshfield Clinic, FHC offers a discounted prepaid health care services program that provides low income individuals with doctor visits, prescription drugs, and dental care. 2) Governing Body: FHC's governing body consists of 10 voting members who uniquely represent the public's health care interests. the majority of FHC's board members represent individuals being served in terms of demographic factors such as race, ethnicity, and sex. 3)Breadth Support Sources: The overwhelming majority of FHC's support is derived from other public charities and Federal and State government. 4) Broad Appeal to the Public: FHC's programs appeal to a broad spectrum of the public and its health care needs. FHC's services directly provide for the benefit of the general public on a continuing basis. |
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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 FHC IS TO IMPROVE ACCESS TO PRIMARY CARE SERVICES FOR THE MEDICALLY UNDERSERVED AND TO ENHANCE THE HEALTH OF OUR COMMUNITIES. THE PURPOSE IS TO OPERATE UNDER 42 USC SECTION 254C, WHICH SERVES MEDICALLY UNDERSERVED POPULATIONS. Form 990 Part III Line 1 The mission of FHC is to improve access to primary care services for the medically underserved and to enhance the health of our communities. The purpose of FHC is the operation of a community health center established under 42 USC section 254c and the associated regulations, which serves medically underserved populations on a not-for-profit basis. Medically underserved populations are identified by the Secretary of the U.S. Department of Health & Human Services, are defined as those who experience financial, geographic, or cultural barriers to health care. |
| Form 990 Part IV Line 24a | Family Health Center of Marshfield, Inc. (FHC) is part of the Marshfield Clinic Health System obligated group. The obligated group is responsible for outstanding financed debt obligations, however, FHC has not participated in any proceeds from the borrowings. All bond financing related to the obligated group is disclosed on the 990 of Marshfield Clinic. |
| Form 990 Part VI Line 3 | Family Health Center (FHC) has an agreement with Marshfield Clinic (Clinic) for the Clinic to provide administrative, medico-administrative, and managerial services as are reasonably necessary for efficient administration and operation of FHC's programs and according to the annual grant work plan. The cost of this agreement is included in Part IX, Line 11g. |
| Form 990 Part VI Line 11b | THE MARSHFIELD CLINIC HEALTH SYSTEM CHIEF FINANCIAL OFFICER AND THE MARSHFIELD CLINIC HEALTH SYSTEM CONTROLLER AND THE FAMILY HEALTH CENTER OF MARSHFIELD, INC DIRECTOR OF FINANCE SHALL REVIEW THE COMPLETED FORM 990. AFTER THEIR REVIEW AND PRIOR TO FILING FORM 990 WITH THE IRS, THE FINANCE DIRECTOR OF FHC WILL PROVIDE TO EACH MEMBER OF THE FHC BOARD OF DIRECTORS A DRAFT COPY OF THE FORM 990 FOR ADDITIONAL INPUT FROM THE FHC BOARD. A FINAL COPY OF THE FORM 990 AND ALL REQUIRED SCHEDULES WILL BE SHARED WITH FHC BOARD OF DIRECTORS IN ELECTONIC OR PAPER FORM PRIOR TO FILING THE RETURN. |
| Form 990 Part VI Line 12c | FHC has adopted a Conflict of Interest Policy. Each Director, Officer, Ex-Officio Board Member, and Executive Director whom are in a position to exercise substantial influence over decisions of FHC is required to annually complete and sign a disclosure statement that is part of the policy. A covered person must also disclose the existence of a potential conflict and all material facts to the governing board as soon as the person has knowledge that a potential conflict may occur. |
| Form 990 Part VI Line 15a | Executive director position. The fhc board of directors is responsible for the executive director's annual evaluation and merit changes. The fhc personnel committee conducts the process related to these activities and makes a recommendation to the full board for approval. The fhc personnel committee utilizes a human resource representative who provides them with salary survey(s) information relevant to the position. The fhc personnel committee also utilizes recommendations from the marshfield clinic health system independent compensation committee. |
| Form 990 Part VI Line 19 | Documents are available to the public by contacting the Director of Finance or the Executive Director. |
| Additional Information | Fhc provides assistance to individuals or families currently enrolled in the fhc prepaid health services program and the fhc community health access program who can show evidence of hardship case. The program fee payment assistance for the prepaid health services program is a maximum of three months per calendar year. The community health access program is a one time payment that covers a six month period. Each case is reviewed and approved by the fhc assistant director with the assistance of the fhc finance director and fhc patient assistance manager. fhc provided $1,024.00 in program fee assistance in fiscal year 2016. |
| FORM 990 PART IX LINE 11G | DESCRIPTION:PURCHASED SERVICES-PROGRAM TOTAL FEES:77894957 |
| FORM 990 PART IX LINE 11G | DESCRIPTION:PURCHASED SERVICES-MANAGEMENT TOTAL FEES:5894025 |
| FORM 990 PART IX LINE 11G | DESCRIPTION:OTHER SUPPLIES TOTAL FEES:120287 |
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