Attach to Form 990 or Form 990-EZ.
Go to
www.irs.gov/Form990 for instructions and 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 |
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Calendar year (or fiscal year beginning in) ![]() |
(a) 2015 | (b) 2016 | (c) 2017 | (d) 2018 | (e) 2019 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") .. | 919,311 | 1,568,925 | 1,685,104 | 1,863,805 | 6,037,145 | |
| 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 | 919,311 | 1,568,925 | 1,685,104 | 1,863,805 | 6,037,145 | |
| 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).. | 2,278,456 | |||||
| 6 | Public support. Subtract line 5 from line 4. | 3,758,689 | |||||
Calendar year
(or fiscal year beginning in) ![]() |
(a) 2015 | (b) 2016 | (c) 2017 | (d) 2018 | (e) 2019 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 7 | Amounts from line 4.. | 919,311 | 1,568,925 | 1,685,104 | 1,863,805 | 6,037,145 | |
| 8 | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources... | 52 | 304 | 583 | 315 | 1,254 | |
| 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 | 6,038,399 | |||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2015 | (b) 2016 | (c) 2017 | (d) 2018 | (e) 2019 | (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) 2015 | (b) 2016 | (c) 2017 | (d) 2018 | (e) 2019 | (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 2019 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-2019 |
(iii) Distributable Amount for 2019 |
|
|---|---|---|---|---|
| 1 Distributable amount for 2019 from Section C, line 6 | ||||
|
2
Underdistributions, if any, for years prior to 2019 (reasonable cause required-- explain in Part VI). See instructions. |
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| 3 Excess distributions carryover, if any, to 2019: | ||||
| a From 2014....... | ||||
| b From 2015....... | ||||
| c From 2016....... | ||||
| d From 2017....... | ||||
| e From 2018....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2019 distributable amount | ||||
|
i
Carryover from 2014 not applied (see instructions) |
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| j Remainder. Subtract lines 3g, 3h, and 3i from 3f. | ||||
| 4Distributions for 2019 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2019 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from 4. | ||||
|
5
Remaining underdistributions for years prior to 2019, if any. Subtract lines 3g and 4a from line 2. If the amount is greater than zero, explain in Part VI. See instructions. |
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|
6
Remaining underdistributions for 2019. Subtract lines 3h and 4b from line 1. If the amount is greater than zero, explain in Part VI. See instructions. |
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|
7 Excess distributions carryover to 2020. Add lines 3j and 4c. |
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| 8 Breakdown of line 7: | ||||
| a Excess from 2015..... | ||||
| b Excess from 2016..... | ||||
| c Excess from 2017..... | ||||
| d Excess from 2018..... | ||||
| e Excess from 2019..... | ||||
| Facts And Circumstances Test |
|---|
| Return Reference | Explanation |
|---|---|
| SUPPLEMENTAL INFORMATION | SGHC IS CLASSIFIED AS AN ORGANIZATION THAT NORMALLY RECEIVES A SUBSTANTIAL PART OF ITS SUPPORT FROM A GOVERNMENTAL UNIT OR FROM THE GENERAL PUBLIC AS DESCRIBED IN SECTION 170(B)(1)(A)(VI). ALTHOUGH SGHC IS NOT REQUIRED TO MEET THE PUBLIC SUPPORT TEST WITHIN THE FIRST FIVE YEARS AS A SECTION 501(C)(3) ORGANIZATION, THE TEST HAS BEEN MET FOR THIS FISCAL YEAR. EFFECTIVE OCTOBER 16, 2018, THE SGHC RECEIVED THE FEDERALLY QUALIFIED HEALTH CENTER LOOK-ALIKE DESIGNATION. SGHC'S VISION INCLUDES THE DEVELOPMENT AND IMPLEMENTATION OF A COMPREHENSIVE PLAN PROVIDING FOR THE COMMUNITYS PHYSICAL HEALTH, MENTAL HEALTH, SPIRITUAL HEALTH, AND ENVIRONMENTAL AND ECONOMIC NEEDS, WITH ATTENTION TO WOMEN AND CHILDREN. PRIOR TO 2019, DHI, AN UNRELATED ORGANIZATION, AGREED TO COVER THE LOSSES INCURRED BY SGHC ON AN ANNUAL BASIS. BEGINNING 2019, NEW FOUND COMMUNITY FOUNDATION, INC., A PUBLICLY SUPPORTED 501(C)(3) UNRELATED ORGANIZATION UNDER IRC SECTION 170(B)(1)(A)(IV), AGREED TO COVER THE LOSSES THE PHYSICIANS INCURRED. SGHC CURRENTLY WOULD QUALIFY AS A PUBLIC CHARITY UNDER 509(A)(2). |
| 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 - ORGANIZATION'S MISSION | TO PROVIDE, AT THE DIRECTION OF OUR MEDICAL STAFF, A UNIFORM LEVEL OF SUCH HIGH-QUALITY CURATIVE AND PALLIATIVE HEALTH CARE AND DIAGNOSTIC SERVICES AS ARE WITHIN OUR SCOPE OF SERVICES TO ALL WHO SEEK OUR AID, REGARDLESS OF THEIR ABILITY TO PAY, AND TO REFER THOSE WHOSE NEEDS CANNOT BE MET WITHIN OUR SCOPE OF SERVICES TO OTHER QUALIFIED AND COMPETENT PROVIDERS OF CARE, WHILE STRIVING CONTINUOUSLY TO IMPROVE THE QUALITY OF CARE AND SERVICE, AND PREPARING ALWAYS TO EVOLVE AS AN ORGANIZATION AS THE NATURE OF HEALTH CARE IN THE NATION AND OUR GEOGRAPHIC LOCALITY CHANGES. |
| FORM 990, PART V | PART V LINE 1A - NUMBER OF 1099S ISSUED FORM 1099S FOR INDEPENDENT CONTRACTORS WERE ISSUED BY DONALSONVILLE HOSPITAL, INC. (DHI), AN UNRELATED ORGANIZATION, ON BEHALF OF SGHC. PRIOR TO FY 2019, DHI COMMITTED TO COVERING ANY OPERATIONAL LOSS UNTIL SGHC COULD OBTAIN GOVERNMENT FUNDING AS A FEDERALLY QUALIFIED HEALTHCARE CLINIC. |
| FORM 990, PART VI | SOUTHWEST GEORGIA HEALTHCARE CLINICS, INC. (SGHC) ENTERED INTO A STAFFING SERVICE AGREEMENT DATED JULY 26, 2017 WITH DONALSONVILLE HOSPITAL, INC. (DHI) TO PROVIDE EMPLOYEES FOR SGHC. UNDER THE TERMS OF THE AGREEMENT, SALARIES AND WAGES WILL BE REIMBURSED BY SGHC. PRIOR TO 2019, DHI AGREED TO COVER THE LOSSES INCURRED BY SGHC ON AN ANNUAL BASIS UNTIL SUCH TIME AS SGHC OBTAINS FEDERAL APPROVAL AND FUNDING AS A FEDERALLY QUALIFIED HEALTHCARE CLINIC (FQHC). BEGINNING 2019, NEW FOUND COMMUNITY FOUNDATION, INC. AGREED TO COVER THE LOSSES THE PHYSICIANS INCURRED. |
| FORM 990, PAGE 6, PART VI, LINE 8B | THE ORGANIZATION DOES NOT HAVE ANY COMMITTEES WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. |
| FORM 990, PAGE 6, PART VI, LINE 11B | THE INDEPENDENT ACCOUNTING FIRM THAT PREPARES THE FORM 990 (BASED UPON INFORMATION PROVIDED BY THE ORGANIZATION) PROVIDES A COPY OF THE RETURN TO BE REVIEWED BY MANAGEMENT. MANAGEMENT PERFORMS A DETAILED REVIEW WHICH CONSISTS OF REVIEWING THE FINANCIAL DATA, THE NARRATIVES DISCLOSED, AND OTHER FACTS PRESENTED ON THE RETURN. UPON REVIEW, THE FORM 990 AND RELATED SCHEDULES ARE PROVIDED TO ALL BOARD MEMBERS FOR REVIEW AND FEEDBACK. ONCE THE FORM 990 IS REVIEWED BY ALL APPLICABLE PARTIES, A COPY OF THE FINAL VERSION IS PROVIDED TO ALL MEMBERS OF THE GOVERNING BODY PRIOR TO FILING WITH THE IRS. |
| FORM 990, PAGE 6, PART VI, LINE 12C | THE ORGANIZATION HAS A WRITTEN POLICY RESPECTING CONFLICTS OF INTEREST AND DISCLOSURE OF SAME. GENERALLY SPEAKING, THE POLICY REQUIRES ANY "COVERED PERSON" WHO BELIEVES HE HAS A CONFLICT OF INTEREST TO: -DISCLOSE THE EXISTENCE AND NATURE OF THE CONFLICT OF INTEREST (INCLUDING ALL FACTS KNOWN RESPECTING THE SUBJECT MATTER) TO THE CHAIRMAN OF THE BOARD; -PLAY NO PART, DIRECTLY OR INDIRECTLY, IN THE DELIBERATION OR VOTE OF THE BOARD OF DIRECTORS WITH RESPECT TO THE DETERMINATION OF WHETHER A CONFLICT OF INTEREST EXISTS; AND -RECUSE HIMSELF FROM THAT PORTION OF THE MEETING AT WHICH THE CONFLICT OF INTEREST IS DISCUSSED. THE DEFINITION OF A "COVERED PERSON" INCLUDES ALL BOARD MEMBERS, OFFICERS AND MEMBERS OF SENIOR MANAGEMENT OF THE ORGANIZATION. WHEN A COVERED PERSON DISCLOSES A POTENTIAL CONFLICT OF INTEREST TO THE BOARD CHAIRMAN, THE CHAIRMAN IS OBLIGED TO BRING THE MATTER TO THE ATTENTION OF THE FULL BOARD WHO DETERMINES WHETHER A CONFLICT OF INTEREST ACTUALLY EXISTS. IF A CONFLICT OF INTEREST EXISTS, THE TRANSACTION OR MATTER GIVING RISE TO THE CONFLICT OF INTEREST MAY NOT PROCEED UNLESS THE BOARD DETERMINES, BY A MAJORITY VOTE, THAT, DESPITE THE CONFLICT OF INTEREST, THE TRANSACTION/MATTER IS NEVERTHELESS IN THE ORGANIZATION'S BEST INTEREST AND IS FAIR AND REASONABLE TO THE ORGANIZATION. IN ADDITION TO THE REQUIREMENT TO DISCLOSE A POTENTIAL CONFLICT OF INTEREST AT THE TIME IT ARISES, EACH MUST SUBMIT ANNUALLY A 'CONFLICT AND DISCLOSURE OF INTEREST QUESTIONNAIRE'. |
| FORM 990, PAGE 6, PART VI, LINE 15A | THE BOARD OF DIRECTORS REVIEWS AND APPROVES THE COMPENSATION FOR THE CEO. THE BOARD USES COMPARABLE COMPENSATION DATA FOR SIMILARLY QUALIFIED PERSONS AT SIMILARLY SIZED ORGANIZATIONS AND SALARY SURVEYS TO DETERMINE THE COMPENSATION FOR THE CEO. THE CEO, A NONVOTING MEMBER OF THE BOARD, IS DISMISSED FROM THE MEETING DURING THE REVIEW OF HER COMPENSATION. THE LAST DETERMINATION USING COMPARABLE COMPENSATION DATA AND SALARY SURVEYS WAS IN 2016. HOWEVER, COST OF LIVING ADJUSTMENTS ARE GIVEN ANNUALLY AND ARE APPROVED BY THE BOARD. |
| FORM 990, PAGE 6, PART VI, LINE 15B | SIMILARLY THE BOARD REVIEWS AND APPROVES COMPENSATION FOR OTHER OFFICERS AND KEY EMPLOYEES OF THE ORGANIZATION. |
| FORM 990, PAGE 6, PART VI, LINE 19 | NO DOCUMENTS ARE AVAILABLE TO THE PUBLIC. |
| FORM 990, PART IX, LINE 11G | CONTRACT SERVICES 391,104 0 0 |
| FORM 990, PART XII | LINE 2C - OVERSIGHT PROCESS OF THE AUDIT AN INDEPENDENT ACCOUNTING FIRM THAT HAS BEEN APPROVED BY THE BOARD CONDUCTS THE AUDIT. MANAGEMENT PERFORMS A DETAILED REVIEW WHICH CONSISTS OF REVIEWING THE FINANCIAL DATA, THE FOOTNOTE DISCLOSURES, AND PERTINENT INFORMATION. UPON REVIEW, THE AUDITED FINANCIAL STATEMENTS AND ANY PERTINENT DATA IS PRESENTED TO THE BOARD. ONCE THE AUDIT IS REVIEWED BY ALL APPLICABLE PARTIES, A COPY OF THE FINAL VERSION IS PROVIDED TO ALL MEMBERS OF THE GOVERNING BODY. |
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