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.) .... | 1,149,863 | 1,528,127 | 1,930,054 | 7,970,166 | 2,020,416 | 14,598,626 |
| 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 | 1,149,863 | 1,528,127 | 1,930,054 | 7,970,166 | 2,020,416 | 14,598,626 |
| 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).. | 336,886 | |||||
| 6 | Public support. Subtract line 5 from line 4. | 14,261,740 | |||||
Calendar year
(or fiscal year beginning in) ![]() |
(a) 2011 | (b) 2012 | (c) 2013 | (d) 2014 | (e) 2015 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 7 | Amounts from line 4.. | 1,149,863 | 1,528,127 | 1,930,054 | 7,970,166 | 2,020,416 | 14,598,626 |
| 8 | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources... | 54,450 | 48,403 | 15,743 | 22,319 | 23,441 | 164,356 |
| 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. | 14,762,982 | |||||
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): |
|||||
| 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 |
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| Return Reference | Explanation |
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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 III, line 3 | Healthy Steps Outreach Initiative: This initiative provided education and outreach to approximately 13,000 families in North Dakota whose children are without medical insurance, seeking to connect them to one of three free or low-cost medical assistance programs: Medicaid, Healthy Steps Children's Health Insurance Plan and Caring for Children insurance program. The 2-year grant funding program ended June 30, 2016. The CassClayAlive! program has evolved into a multi-faceted community collaboration and the activities have been incorporated into existing platforms, with funding assistance from the Foundations. A new approach to community wellness based in work sites began development through Dakota Medical Foundation in 2016 and is preparing for public launch in 2017. |
| Form 990, Part VI, Section A, line 1 | The Executive Committee will be comprised of the Chair, Vice Chair, Secretary, Treasurer, and the Chairs of: the Governance Committee, Finance/Investment Committee, Strategic Platforms Committee, and one Board Member At-Large. The Immediate Past Chair shall also serve on the Executive Committee for a one-year, nonvoting term. The Board Member At-Large shall be elected by the Board at its organizational meeting. Four (4) members of the total committee membership shall be members of the medical staff of hospitals or clinics. The Executive Committee: A. Shall be responsible for the day-to-day activities of the Foundations. B. May review actions of all Foundations' Committees, and give recommendations to the Board. C. Shall annually evaluate the performance of the President and may appoint a Compensation Subcommittee to conduct the evaluation. D. Shall set the President's annual compensation and terms of employment. E. Shall recommend to the Board a process for recruiting and selecting a President of the Foundations in the event of a vacancy in the position. F. Shall review and recommend to the Board the number and salary ranges of all staff of the Foundations. G. Shall review and may make expenditures up to and including fifty thousand dollars ($50,000) without Board approval unless otherwise specifically prohibited. |
| Form 990, Part VI, Section A, line 2 | Michael Schumacher has a business relationship, as an employee and CFO of Dakota Medical Charities (a related organization), with J. Patrick Traynor who serves as the President and is an employee of Dakota Medical Foundation, and the Board members of the Foundations pursuant to the business relationship definition per IRS guidelines. Board members include: David Clutter, M.D., Richard Vetter, M.D., Chris Kennelly, Larry Leitner, Fadel Nammour, M.D., Jane Skalsky, RN, Mike Warner, Susan Mathison, M.D., Eric Monson, Nancy Slotten, Sindy Keller, Hope Yongsmith, Seth Novak, Amanda Thomas, Robert Bakkum, David Akkerman, M.D., Curt Noyes, and Joel Haugen, M.D. |
| Form 990, Part VI, Section A, line 6 | Dakota Medical Foundation is a member organization comprised of up to 220 Members. |
| Form 990, Part VI, Section A, line 7a | The Members elect the Board of Directors annually. |
| Form 990, Part VI, Section A, line 7b | The Board of Directors may not sell, assign, commit or otherwise dispose of a significant portion of the assets of the Foundation without membership approval. Also, any amendment to the Articles of Incorporation must be approved by a majority of the directors of the corporation and at any duly held meeting of the members of the corporation by a vote of not less than two-thirds of those present or represented by proxy. |
| Form 990, Part VI, Section B, line 11 | The Form 990 is provided to all Board members for review and comment prior to filing. In addition, the filed copy is presented as an agenda item at the next scheduled Board meeting. |
| Form 990, Part VI, Section B, line 12c | Board Members and staff are annually required to review and declare conflicts. Members of the Foundations' management follow written procedures for staff conflicts. Board Members abstain from voting on any issues that create a conflict of interest. |
| Form 990, Part VI, Section B, line 15a | The President's performance and compensation are reviewed annually by the Executive Committee. The President's compensation changes are approved by the Board. The President's compensation was reviewed in December 2016 by HR Advisors, an independent human resource consulting firm engaged by the Board to establish a reasonable and competitive base compensation range. Changes to compensation in subsequent years are based on the established range, performance and inflationary changes, and compared with the Council on Foundations' annual salary surveys and other available relevant sources. Other staff compensation ranges are reviewed by the Executive Committee and/or the President and compared periodically with the Council on Foundations' salary surveys and other available relevant sources. |
| Form 990, Part VI, Section C, line 19 | The Foundations make their governing documents, conflict of interest policy and audited consolidated financial statements available to the public upon request. |
| Form 990, Part XII, Line 2c: | The Finance/Investment Committee has responsibility for oversight of the annual audit of the Foundations' consolidated financial statements and the selection of an independent accountant. The Finance/Investment Committee recommends to the Board of Directors for approval the results of the annual audit and the annual selection of the independent accountant. |
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