Attach to Form 990 or Form 990-EZ.
Go to
www.irs.gov/Form990 for the latest information.
| (i) Name of supported organization | (ii) EIN | (iii) Type of organization (described on lines 1- 10 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) 2014 | (b) 2015 | (c) 2016 | (d) 2017 | (e) 2018 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") .. | 673,545 | 491,102 | 588,961 | 689,077 | 1,530,531 | 3,973,216 |
| 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 | 673,545 | 491,102 | 588,961 | 689,077 | 1,530,531 | 3,973,216 |
| 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).. | 1,103,756 | |||||
| 6 | Public support. Subtract line 5 from line 4. | 2,869,460 | |||||
Calendar year
(or fiscal year beginning in) ![]() |
(a) 2014 | (b) 2015 | (c) 2016 | (d) 2017 | (e) 2018 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 7 | Amounts from line 4.. | 673,545 | 491,102 | 588,961 | 689,077 | 1,530,531 | 3,973,216 |
| 8 | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources... | 51,152 | 48,143 | 53,901 | 54,649 | 65,689 | 273,534 |
| 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 | 4,246,750 | |||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2014 | (b) 2015 | (c) 2016 | (d) 2017 | (e) 2018 | (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) 2014 | (b) 2015 | (c) 2016 | (d) 2017 | (e) 2018 | (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 2018 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-2018 |
(iii) Distributable Amount for 2018 |
|
|---|---|---|---|---|
|
1
Distributable amount for 2018 from Section C, line 6 |
||||
|
2
Underdistributions, if any, for years prior to 2018 (reasonable cause required-- explain in Part VI). See instructions. |
||||
| 3 Excess distributions carryover, if any, to 2018: | ||||
| a From 2013....... | ||||
| b From 2014....... | ||||
| c From 2015....... | ||||
| d From 2016....... | ||||
| e From 2017....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2018 distributable amount | ||||
|
i
Carryover from 2013 not applied (see instructions) |
||||
| j Remainder. Subtract lines 3g, 3h, and 3i from 3f. | ||||
| 4Distributions for 2018 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2018 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from 4. | ||||
|
5
Remaining underdistributions for years prior to 2018, if any. Subtract lines 3g and 4a from line 2. If the amount is greater than zero, explain in Part VI. See instructions. |
||||
|
6
Remaining underdistributions for 2018. Subtract lines 3h and 4b from line 1. If the amount is greater than zero, explain in Part VI. See instructions. |
||||
|
7 Excess distributions carryover to 2019. Add lines 3j and 4c. |
||||
| 8 Breakdown of line 7: | ||||
| a Excess from 2014...... | ||||
| b Excess from 2015..... | ||||
| c Excess from 2016..... | ||||
| d Excess from 2017..... | ||||
| e Excess from 2018..... | ||||
| Facts And Circumstances Test |
|---|
| Return Reference | Explanation |
|---|
| Software ID: | |
| Software Version: |
Attach to Form 990 or 990-EZ.
Go to www.irs.gov/Form990 for the latest information.
| Return Reference | Explanation |
|---|---|
| FORM 990, PAGE 1, PART I, LINE 6 | AS A VOLUNTEER-DRIVEN NON-PROFIT ORGANIZATION, A TOTAL OF 292 INDIVIDUALS VOLUNTEERED THEIR SERVICES TO THE ANN SILVERMAN COMMUNITY HEALTH CLINIC IN FY18-19. DURING FY 18-19, THERE WERE 5,948 HOURS OF VOLUNTEER SERVICES; THE ESTIMATED VALUE OF THE VOLUNTEERS WITH SPECIALIZED SKILLS IS 508,364. THE HEALTHCARE PROFESSIONAL VOLUNTEERS INCLUDE 11 PHYSICIANS, 1 PSYCHIATRIC NURSE PRACTITIONER, 2 COUNSELORS, 1 MASSAGE/PAIN RELIEF THERAPIST, AND 10 REGISTERED NURSES PROVIDING ONSITE CARE. THERE WERE 107 MEDICAL SPECIALISTS PROVIDING CARE OFFSITE; THIS INCLUDED 15 RADIOLOGISTS, 19 CARDIOLOGISTS, AND 2 PATHOLOGISTS. IN THE DENTAL PROGRAM, OUR VOLUNTEERS INCLUDE 45 DENTISTS, 24 DENTAL HYGIENISTS, AND 2 DENTAL ASSISTANTS. THE CLINIC ALSO RECEIVED SUPPORT FROM 25 BOARD MEMBERS, 21 LANGUAGE INTERPRETERS, 13 ADVISORY COMMITTEE MEMBERS, 3 ELIGIBILITY PROCESSORS, 2 PHARMACEUTICAL APPLICATION PROCESSORS AND 10 CLERICAL ASSISTANTS. |
| FORM 990, PAGE 2, PART III, LINE 4A | MEDICAL PROGRAM- ANN SILVERMAN COMMUNITY HEALTH CLINIC (ASCHC) WAS FOUNDED 25 YEARS AGO BY A LOCAL PHYSICIAN TO PROVIDE FREE HEALTHCARE TO THOSE IN OUR COMMUNITY WHO HAD LIMITED INCOME AND WERE UNINSURED. TODAY THE CLINIC'S MISSION REMAINS UNCHANGED, A VOLUNTEER-DRIVEN FREE CLINIC FOR UNINSURED, LOW INCOME RESIDENTS OF BUCKS COUNTY. IT PROVIDES FREE MEDICAL CARE - ACUTE, CHRONIC AND PREVENTATIVE SERVICES-AS WELL AS DIAGNOSTIC TESTING AND MEDICATION ASSISTANCE TO UNINSURED ADULTS AND CHILDREN WHO HAVE A HOUSEHOLD INCOME LESS THAN 250% OF THE FEDERAL POVERTY GUIDELINES. SINCE INCEPTION IN 1994, THE CLINIC HAS CARED FOR MORE THAN 12,824 ADULTS AND CHILDREN IN THE MEDICAL PROGRAM. IN FY 18-19, WE PROVIDED MEDICAL SERVICES TO 1,011 PATIENTS VIA 3,126 CLINIC VISITS. ASCHC CARED FOR 309 NEW PATIENTS AT OUR CLINIC LOCATED IN DONATED SPACE ON THE GROUND FLOOR OF DOYLESTOWN HOSPITAL. IN ADDITION, 1,599 MEDICAL SERVICES WERE PROVIDED BY 107 OFFSITE SPECIALISTS IN THE COMMUNITY. THE CLINIC ALSO PROCESSED 281 PRESCRIPTIONS ASSISTANCE APPLICATIONS FOR MEDICATIONS NEEDED BY 225 PATIENTS, VALUED AT 282,033. |
| FORM 990, PAGE 2, PART III, LINE 4B | DENTAL PROGRAM- THERE IS A TREMENDOUS NEED IN OUR COMMUNITY FOR DENTAL SERVICES FOR THOSE WHO ARE POOR AND HAVE NO HEALTH INSURANCE. THE ANN SILVERMAN COMMUNITY HEALTH CLINIC'S DENTAL PROGRAM USES A HYBRID MODEL, PROVIDING PREVENTIVE SERVICES ONSITE AND RESTORATIVE DENTAL CARE IN THE COMMUNITY THROUGH OUR NETWORK OF 42 VOLUNTEER DENTISTS. SINCE THE PROGRAM BEGAN IN 2002, THE CLINIC HAS PROVIDED 13,855 TREATMENT VISITS TO 3,101 ADULTS AND CHILDREN. IN FY 18-19, THE DENTAL PROGRAM SAW 478 ADULTS AND CHILDREN, AN INCREASE OF 9% OVER THE PREVIOUS FISCAL YEAR. THE TOTAL TREATMENT VISITS OF 1,377 (5% INCREASE OVER THE PREVIOUS YEAR) INCLUDES ONSITE VISITS AND 315 COMMUNITY DENTAL VISITS. IN ADDITION, IN FY 18-19, WE PROVIDED 252 DENTAL EXAMS (22% INCREASE OVER FY17-18) AND 575 DENTAL HYGIENE SERVICES (14% INCREASE OVER FY17-18). |
| FORM 990, PAGE 2, PART III, LINE 4C | SOCIAL SERVICES - THE ANN SILVERMAN COMMUNITY HEALTH CLINIC SEEKS TO PROVIDE COMPREHENSIVE, HOLISTIC AND COMPASSIONATE HEALTH CARE. NEW PATIENTS AND RETURNING PATIENTS ARE ASSESSED AND INTERVIEWED ANNUALLY TO DETERMINE THEIR ELIGIBILITY FOR CLINIC SERVICES AND TO ADDRESS THEIR CASE MANAGEMENT NEEDS SUCH AS FOOD, CLOTHING, HOUSING, AND BEHAVIORAL HEALTH SERVICES. THERE WERE 932 SOCIAL SERVICE VISITS PROVIDED BY STAFF AND VOLUNTEERS; OF THESE, 627 PEOPLE HAD ELIGIBILITY DETERMINATION VISITS. COMMUNITY RESIDENTS WERE ASSISTED IN COMPLETING APPLICATIONS FOR GOVERNMENT BENEFITS THAT INCLUDE FOOD STAMPS, ENERGY ASSISTANCE OR LOW COST INSURANCE, EVEN IF THEY ARE NOT ELIGIBLE FOR SERVICES AT OUR CLINIC. IN FY 18-19, THERE WERE 143 CASE MANAGEMENT VISITS AND 60 SOCIAL WORK TREATMENT SESSIONS. WE PROVIDED 102 BEHAVIORAL HEALTH VISITS TO CLINIC PATIENTS FOR PSYCHIATRIC MEDICATIONS, SHORT TERM THERAPY AND COUNSELING SERVICES. |
| FORM 990, PAGE 6, PART VI, LINE 11B | THE FINANCE COMMITTEE REVIEWS AND RECOMMENDS TO THE BOARD FOR APPROVAL. |
| FORM 990, PAGE 6, PART VI, LINE 12C | ORGANIZATION MAILS FORMS AS STATED IN THE BYLAWS ANNUALLY TO BOARD MEMBERS WHO SIGN FORMS AND RETURN THEM TO THE ORGANIZATION. THE BOARD CHAIRMAN ADDRESSES ANY CONFLICTS AND DETERMINES ACTION AS NEEDED. |
| FORM 990, PAGE 6, PART VI, LINE 15A | A PERFORMANCE EVALUATION IS PERFORMED ANNUALLY AND REVIEWED WITH FULL BOARD. |
| FORM 990, PAGE 6, PART VI, LINE 19 | GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST |
| FORM 990, PART XI, LINE 9 | SPECIAL EVENT EXPENSES RECLASSIFIED 1,167 SPECIAL EVENT EXPENSES RECLASSIFIED -1,167 BOOK / TAX DEPRECIATION DIFFERENCE 32,114 TOTAL 32,114 |
| Software ID: | |
| Software Version: |