-
TIN:
Form
990-PF
Department of the Treasury
Internal Revenue Service
Return of Private Foundation
or Section 4947(a)(1) Trust Treated as Private Foundation
Do not enter social security numbers on this form as it may be made public.
Go to
www.irs.gov/Form990PF
for instructions and the latest information.
OMB No. 1545-0052
20
19
Open to Public Inspection
For calendar year 2019, or tax year beginning
11-01-2019
, and ending
10-31-2020
Name of foundation
POTOMAC HEALTH FOUNDATION
Number and street (or P.O. box number if mail is not delivered to street address)
2296 OPITZ BLVD NO 200
Room/suite
City or town, state or province, country, and ZIP or foreign postal code
WOODBRIDGE
,
VA
22191
A Employer identification number
52-1340920
B
Telephone number (see instructions)
(703) 523-0620
C
If exemption application is pending, check here
G
Check all that apply:
Initial return
Initial return of a former public charity
Final return
Amended return
Address change
Name change
D 1.
Foreign organizations, check here.............
2
. Foreign organizations meeting the 85%
test, check here and attach computation ...
E
If private foundation status was terminated
under section 507(b)(1)(A), check here .......
H
Check type of organization:
Section 501(c)(3) exempt private foundation
Section 4947(a)(1) nonexempt charitable trust
Other taxable private foundation
F
If the foundation is in a 60-month termination
under section 507(b)(1)(B), check here .......
I
Fair market value of all assets at end
of year (from Part II, col. (c),
line 16)
$
109,559,427
J
Accounting method:
Cash
Accrual
Other (specify)
(Part I, column (d) must be on cash basis.)
Part I
Analysis of Revenue and Expenses
(The total of amounts in columns (b), (c), and (d) may not necessarily equal the amounts in column (a) (see instructions).)
(a)
Revenue and
expenses per
books
(b)
Net investment
income
(c)
Adjusted net
income
(d)
Disbursements
for charitable
purposes
(cash basis only)
1
Contributions, gifts, grants, etc., received (attach schedule)
544,463
2
Check
.............
3
Interest on savings and temporary cash investments
395
395
4
Dividends and interest from securities
...
6,087,323
6,394,539
5a
Gross rents
............
b
Net rental income or (loss)
6a
Net gain or (loss) from sale of assets not on line 10
1,895,064
b
Gross sales price for all assets on line 6a
54,416,365
7
Capital gain net income (from Part IV, line 2)
...
1,895,064
8
Net short-term capital gain
.........
9
Income modifications
...........
10a
Gross sales less returns and allowances
b
Less: Cost of goods sold
....
c
Gross profit or (loss) (attach schedule)
.....
11
Other income (attach schedule)
.......
126,688
0
12
Total.
Add lines 1 through 11
........
8,653,933
8,289,998
13
Compensation of officers, directors, trustees, etc.
139,739
20,961
118,778
14
Other employee salaries and wages
......
143,416
0
89,833
15
Pension plans, employee benefits
.......
59,463
12,487
46,976
16a
Legal fees (attach schedule)
.........
b
Accounting fees (attach schedule)
.......
52,034
0
52,034
c
Other professional fees (attach schedule)
....
667,734
625,149
42,585
17
Interest
...............
18
Taxes (attach schedule) (see instructions)
...
33,633
0
0
19
Depreciation (attach schedule) and depletion
...
2,582
0
20
Occupancy
..............
34,506
0
0
21
Travel, conferences, and meetings
.......
4,229
0
4,229
22
Printing and publications
..........
23
Other expenses (attach schedule)
.......
104,835
513
75,567
24
Total operating and administrative expenses.
Add lines 13 through 23
..........
1,242,171
659,110
430,002
25
Contributions, gifts, grants paid
.......
5,168,290
5,181,821
26
Total expenses and disbursements.
Add lines 24 and 25
6,410,461
659,110
5,611,823
27
Subtract line 26 from line 12:
a
Excess of revenue over expenses and disbursements
2,243,472
b
Net investment income
(if negative, enter -0-)
7,630,888
c
Adjusted net income
(if negative, enter -0-)
...
For Paperwork Reduction Act Notice, see instructions.
Cat. No. 11289X
Form
990-PF
(2019)
Form 990-PF (2019)
Page
2
Part II
Balance Sheets
Attached schedules and amounts in the description column
should be for end-of-year amounts only. (See instructions.)
Beginning of year
End of year
(a)
Book Value
(b)
Book Value
(c)
Fair Market Value
1
Cash—non-interest-bearing
.............
2
Savings and temporary cash investments
.........
129,873
147,069
147,069
3
Accounts receivable
48,100
Less: allowance for doubtful accounts
62,555
48,100
48,100
4
Pledges receivable
450,803
Less: allowance for doubtful accounts
47,757
450,803
450,803
5
Grants receivable
.................
6
Receivables due from officers, directors, trustees, and other
disqualified persons (attach schedule) (see instructions)
.....
7
Other notes and loans receivable (attach schedule)
Less: allowance for doubtful accounts
8
Inventories for sale or use
..............
9
Prepaid expenses and deferred charges
..........
85,835
32,480
32,480
10a
Investments—U.S. and state government obligations (attach schedule)
0
5,000,000
5,000,000
b
Investments—corporate stock (attach schedule)
.......
52,521,193
54,402,407
54,402,407
c
Investments—corporate bonds (attach schedule)
.......
36,451,613
31,122,223
31,122,223
11
Investments—land, buildings, and equipment: basis
Less: accumulated depreciation (attach schedule)
12
Investments—mortgage loans
.............
13
Investments—other (attach schedule)
..........
22,024,114
18,354,737
18,354,737
14
Land, buildings, and equipment: basis
49,098
Less: accumulated depreciation (attach schedule)
47,490
3,190
1,608
1,608
15
Other assets (describe
)
16
Total assets
(to be completed by all filers—see the
instructions. Also, see page 1, item I)
111,326,130
109,559,427
109,559,427
17
Accounts payable and accrued expenses
..........
209,788
207,187
18
Grants payable
.................
1,383,718
1,370,187
19
Deferred revenue
.................
20
Loans from officers, directors, trustees, and other disqualified persons
21
Mortgages and other notes payable (attach schedule)
......
22
Other liabilities (describe
)
183,484
144,293
23
Total liabilities
(add lines 17 through 22)
.........
1,776,990
1,721,667
Foundations that follow FASB ASC 958, check here
and complete lines 24, 25, 29 and 30.
24
Net assets without donor restrictions
...........
109,549,140
107,837,760
25
Net assets with donor restrictions
............
Foundations that do not follow FASB ASC 958, check here
and complete lines 26 through 30.
26
Capital stock, trust principal, or current funds
........
27
Paid-in or capital surplus, or land, bldg., and equipment fund
28
Retained earnings, accumulated income, endowment, or other funds
29
Total net assets or fund balances
(see instructions)
.....
109,549,140
107,837,760
30
Total liabilities and net assets/fund balances
(see instructions)
.
111,326,130
109,559,427
Part III
Analysis of Changes in Net Assets or Fund Balances
1
Total net assets or fund balances at beginning of year—Part II, column (a), line 29 (must agree with end-of-year figure reported on prior year’s return)
...............
1
109,549,140
2
Enter amount from Part I, line 27a
.....................
2
2,243,472
3
Other increases not included in line 2 (itemize)
3
0
4
Add lines 1, 2, and 3
..........................
4
111,792,612
5
Decreases not included in line 2 (itemize)
5
3,954,852
6
Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 29
.
6
107,837,760
Form
990-PF
(2019)
Form 990-PF (2019)
Page
3
Part IV
Capital Gains and Losses for Tax on Investment Income
(a)
List and describe the kind(s) of property sold (e.g., real estate,
2-story brick warehouse; or common stock, 200 shs. MLC Co.)
(b)
How acquired
P—Purchase
D—Donation
(c)
Date acquired
(mo., day, yr.)
(d)
Date sold
(mo., day, yr.)
1 a
PUBLICLY TRADED SECURITIES - SEI ACCT # 17100
2020-10-30
b
c
d
e
(e)
Gross sales price
(f)
Depreciation allowed
(or allowable)
(g)
Cost or other basis
plus expense of sale
(h)
Gain or (loss)
(e) plus (f) minus (g)
a
54,416,365
52,521,301
1,895,064
b
c
d
e
Complete only for assets showing gain in column (h) and owned by the foundation on 12/31/69
(l)
Gains (Col. (h) gain minus
col. (k), but not less than -0-)
or
Losses (from col.(h))
(i)
F.M.V. as of 12/31/69
(j)
Adjusted basis
as of 12/31/69
(k)
Excess of col. (i)
over col. (j), if any
a
1,895,064
b
c
d
e
2
Capital gain net income or (net capital loss)
If gain, also enter in Part I, line 7
If (loss), enter -0- in Part I, line 7
2
1,895,064
3
Net short-term capital gain or (loss) as defined in sections 1222(5) and (6):
If gain, also enter in Part I, line 8, column (c) (see instructions). If (loss), enter -0-
in Part I, line 8
...................
3
Part V
Qualification Under Section 4940(e) for Reduced Tax on Net Investment Income
(For optional use by domestic private foundations subject to the section 4940(a) tax on net investment income.)
If section 4940(d)(2) applies, leave this part blank.
Was the foundation liable for the section 4942 tax on the distributable amount of any year in the base period?
Yes
No
If "Yes," the foundation does not qualify under section 4940(e). Do not complete this part.
1
Enter the appropriate amount in each column for each year; see instructions before making any entries.
(a)
Base period years Calendar
year (or tax year beginning in)
(b)
Adjusted qualifying distributions
(c)
Net value of noncharitable-use assets
(d)
Distribution ratio
(col. (b) divided by col. (c))
2018
5,641,599
107,583,852
0.052439
2017
5,562,672
110,334,651
0.050416
2016
4,850,615
106,530,115
0.045533
2015
5,247,271
98,321,142
0.053369
2014
4,980,260
100,254,131
0.049676
2
Total
of line 1, column (d)
.....................
2
0.251433
3
Average distribution ratio for the 5-year base period—divide the total on line 2 by 5.0, or by the number of years the foundation has been in existence if less than 5 years
......
3
0.050287
4
Enter the net value of noncharitable-use assets for 2019 from Part X, line 5
......
4
107,760,260
5
Multiply line 4 by line 3
......................
5
5,418,940
6
Enter 1% of net investment income (1% of Part I, line 27b)
...........
6
76,309
7
Add lines 5 and 6
........................
7
5,495,249
8
Enter qualifying distributions from Part XII, line 4
,.............
8
5,611,823
If line 8 is equal to or greater than line 7, check the box in Part VI, line 1b, and complete that part using a 1% tax rate. See the Part VI instructions.
Form
990-PF
(2019)
Form 990-PF (2019)
Page
4
Part VI
Excise Tax Based on Investment Income (Section 4940(a), 4940(b), 4940(e), or 4948—see instructions)
1a
Exempt operating foundations described in section 4940(d)(2), check here
and enter “N/A" on line 1.
Date of ruling or determination letter:
(attach copy of letter if necessary–see instructions)
b
Domestic foundations that meet the section 4940(e) requirements in Part V, check
1
76,309
here
and enter 1% of Part I, line 27b
...................
c
All other domestic foundations enter 2% of line 27b. Exempt foreign organizations enter 4% of Part I, line 12, col. (b)
2
Tax under section 511 (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-)
2
0
3
Add lines 1 and 2
...........................
3
76,309
4
Subtitle A (income) tax (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-)
4
0
5
Tax based on investment income.
Subtract line 4 from line 3. If zero or less, enter -0-
.....
5
76,309
6
Credits/Payments:
a
2019 estimated tax payments and 2018 overpayment credited to 2019
6a
94,308
b
Exempt foreign organizations—tax withheld at source
......
6b
c
Tax paid with application for extension of time to file (Form 8868)
...
6c
0
d
Backup withholding erroneously withheld
...........
6d
0
7
Total credits and payments. Add lines 6a through 6d
..............
7
94,308
8
Enter any
penalty
for underpayment of estimated tax.
Check here
if Form 2220 is attached.
8
0
9
Tax due.
If the total of lines 5 and 8 is more than line 7, enter
amount owed
.......
9
10
Overpayment.
If line 7 is more than the total of lines 5 and 8, enter the
amount overpaid
...
10
17,999
11
Enter the amount of line 10 to be:
Credited to 2020 estimated tax
17,999
Refunded
11
0
Part VII-A
Statements Regarding Activities
1a
During the tax year, did the foundation attempt to influence any national, state, or local legislation or did
Yes
No
it participate or intervene in any political campaign?
....................
1a
No
b
Did it spend more than $100 during the year (either directly or indirectly) for political purposes? (see Instructions
for definition)
.................................
1b
No
If the answer is "Yes" to
1a
or
1b,
attach a detailed description of the activities and copies of any materials
published or distributed by the foundation in connection with the activities.
c
Did the foundation file
Form 1120-POL
for this year?
.....................
1c
No
d
Enter the amount (if any) of tax on political expenditures (section 4955) imposed during the year:
(1)
On the foundation.
$
0
(2)
On foundation managers.
$
0
e
Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed
on foundation managers.
$
0
2
Has the foundation engaged in any activities that have not previously been reported to the IRS?
.......
2
No
If "Yes," attach a detailed description of the activities.
3
Has the foundation made any changes, not previously reported to the IRS, in its governing instrument, articles
of incorporation, or bylaws, or other similar instruments?
If "Yes," attach a conformed copy of the changes
....
3
No
4a
Did the foundation have unrelated business gross income of $1,000 or more during the year?
........
4a
No
b
If "Yes," has it filed a tax return on
Form 990-T
for this year?
...................
4b
5
Was there a liquidation, termination, dissolution, or substantial contraction during the year?
.........
5
No
If "Yes," attach the statement required by General Instruction T.
6
Are the requirements of section 508(e) (relating to sections 4941 through 4945) satisfied either:
By language in the governing instrument, or
By state legislation that effectively amends the governing instrument so that no mandatory directions
that conflict with the state law remain in the governing instrument?
................
6
Yes
7
Did the foundation have at least $5,000 in assets at any time during the year?
If "Yes," complete Part II, col. (c),
and Part XV.
.................................
7
Yes
8a
Enter the states to which the foundation reports or with which it is registered (see instructions)
VA
b
If the answer is "Yes" to line 7, has the foundation furnished a copy of Form 990-PF to the Attorney
General (or designate) of each state as required by General Instruction G?
If "No," attach explanation
.
8b
Yes
9
Is the foundation claiming status as a private operating foundation within the meaning of section 4942(j)(3)
or 4942(j)(5) for calendar year 2019 or the taxable year beginning in 2019? See the instructions for Part XIV.
If "Yes," complete Part XIV
.............................
9
No
10
Did any persons become substantial contributors during the tax year?
If "Yes," attach a schedule listing their names
and addresses.
...............................
10
No
Form
990-PF
(2019)
Form 990-PF (2019)
Page
5
Part VII-A
Statements Regarding Activities
(continued)
11
At any time during the year, did the foundation, directly or indirectly, own a controlled entity within the
meaning of section 512(b)(13)? If "Yes," attach schedule. See instructions
.............
11
No
12
Did the foundation make a distribution to a donor advised fund over which the foundation or a disqualified person had
advisory privileges? If "Yes," attach statement. See instructions
.................
12
No
13
Did the foundation comply with the public inspection requirements for its annual returns and exemption application?
13
Yes
Website address
WWW.POTOMACHEALTHFOUNDATION.ORG
14
The books are in care of
SUSIE LEE
Telephone no.
(703) 523-0620
Located at
2296 OPITZ BOULEVARD SUITE 200
WOODBRIDGE
VA
ZIP+4
22191
15
Section 4947(a)(1) nonexempt charitable trusts filing Form 990-PF in lieu of
Form 1041
—check here
.........
and enter the amount of tax-exempt interest received or accrued during the year
........
15
16
At any time during calendar year 2019, did the foundation have an interest in or a signature or other authority over
Yes
No
a bank, securities, or other financial account in a foreign country?
.................
16
No
See the instructions for exceptions and filing requirements for FinCEN Form 114. If "Yes", enter the name of the foreign
country
Part VII-B
Statements Regarding Activities for Which Form 4720 May Be Required
File Form 4720 if any item is checked in the "Yes" column, unless an exception applies.
Yes
No
1a
During the year did the foundation (either directly or indirectly):
(1)
Engage in the sale or exchange, or leasing of property with a disqualified person?
Yes
No
(2)
Borrow money from, lend money to, or otherwise extend credit to (or accept it from)
a disqualified person?
......................
Yes
No
(3)
Furnish goods, services, or facilities to (or accept them from) a disqualified person?
Yes
No
(4)
Pay compensation to, or pay or reimburse the expenses of, a disqualified person?
Yes
No
(5)
Transfer any income or assets to a disqualified person (or make any of either available
for the benefit or use of a disqualified person)?
...............
Yes
No
(6)
Agree to pay money or property to a government official? (
Exception.
Check "No"
if the foundation agreed to make a grant to or to employ the official for a period
after termination of government service, if terminating within 90 days.)
.......
Yes
No
b
If any answer is "Yes" to 1a(1)–(6), did
any
of the acts fail to qualify under the exceptions described in Regulations
section 53.4941(d)-3 or in a current notice regarding disaster assistance? See instructions
........
1b
No
Organizations relying on a current notice regarding disaster assistance check here
........
c
Did the foundation engage in a prior year in any of the acts described in 1a, other than excepted acts,
that were not corrected before the first day of the tax year beginning in 2019?
.............
1c
No
2
Taxes on failure to distribute income (section 4942) (does not apply for years the foundation was a private
operating foundation defined in section 4942(j)(3) or 4942(j)(5)):
a
At the end of tax year 2019, did the foundation have any undistributed income (lines 6d
and 6e, Part XIII) for tax year(s) beginning before 2019?
.............
Yes
No
If "Yes," list the years
20
,
20
,
20
,
20
b
Are there any years listed in 2a for which the foundation is
not
applying the provisions of section 4942(a)(2)
(relating to incorrect valuation of assets) to the year’s undistributed income? (If applying section 4942(a)(2)
to
all
years listed, answer "No" and attach statement—see instructions.)
..............
2b
c
If the provisions of section 4942(a)(2) are being applied to
any
of the years listed in 2a, list the years here.
20
,
20
,
20
,
20
3a
Did the foundation hold more than a 2% direct or indirect interest in any business enterprise at
any time during the year?
......................
Yes
No
b
If "Yes," did it have excess business holdings in 2019 as a result of
(1)
any purchase by the foundation
or disqualified persons after May 26, 1969;
(2)
the lapse of the 5-year period (or longer period approved
by the Commissioner under section 4943(c)(7)) to dispose of holdings acquired by gift or bequest; or
(3)
the lapse of the 10-, 15-, or 20-year first phase holding period?
(Use Schedule C, Form 4720, to determine
if the foundation had excess business holdings in 2019.)
..................
3b
4a
Did the foundation invest during the year any amount in a manner that would jeopardize its charitable purposes?
4a
No
b
Did the foundation make any investment in a prior year (but after December 31, 1969) that could jeopardize its
charitable purpose that had not been removed from jeopardy before the first day of the tax year beginning in 2019?
4b
No
Form
990-PF
(2019)
Form 990-PF (2019)
Page
6
Part VII-B
Statements Regarding Activities for Which Form 4720 May Be Required
(continued)
5a
During the year did the foundation pay or incur any amount to:
Yes
No
(1)
Carry on propaganda, or otherwise attempt to influence legislation (section 4945(e))?
Yes
No
(2)
Influence the outcome of any specific public election (see section 4955); or to carry
on, directly or indirectly, any voter registration drive?
.............
Yes
No
(3)
Provide a grant to an individual for travel, study, or other similar purposes?
Yes
No
(4)
Provide a grant to an organization other than a charitable, etc., organization described
in section 4945(d)(4)(A)? See instructions
................
Yes
No
(5)
Provide for any purpose other than religious, charitable, scientific, literary, or
educational purposes, or for the prevention of cruelty to children or animals?
.....
Yes
No
b
If any answer is "Yes" to 5a(1)–(5), did
any
of the transactions fail to qualify under the exceptions described in
Regulations section 53.4945 or in a current notice regarding disaster assistance? See instructions
......
5b
Organizations relying on a current notice regarding disaster assistance check here
.........
c
If the answer is "Yes" to question 5a(4), does the foundation claim exemption from the
tax because it maintained expenditure responsibility for the grant?
..........
Yes
No
If "Yes," attach the statement required by Regulations section 53.4945–5(d).
6a
Did the foundation, during the year, receive any funds, directly or indirectly, to pay premiums on
a personal benefit contract?
.....................
Yes
No
b
Did the foundation, during the year, pay premiums, directly or indirectly, on a personal benefit contract?
....
6b
No
If "Yes" to 6b, file Form 8870.
7a
At any time during the tax year, was the foundation a party to a prohibited tax shelter transaction?
Yes
No
b
If "Yes", did the foundation receive any proceeds or have any net income attributable to the transaction?
....
7b
8
Is the foundation subject to the section 4960 tax on payment(s) of more than $1,000,000 in remuneration or
excess parachute payment during the year?
.................
Yes
No
Part VIII
Information About Officers, Directors, Trustees, Foundation Managers, Highly Paid Employees,
and Contractors
1
List all officers, directors, trustees, foundation managers and their compensation. See instructions
(a)
Name and address
(b)
Title, and average
hours per week
devoted to position
(c)
Compensation
(If not paid, enter
-0-)
(d)
Contributions to employee benefit plans and deferred compensation
(e)
Expense account,
other allowances
SUSIE LEE
EXECUTIVE DIRECTOR
40.00
142,110
29,843
815
2296 OPITZ BOULEVARD SUITE 200
WOODBRIDGE
,
VA
22191
MARION M WALL
CHAIR
4.00
0
0
0
2296 OPITZ BOULEVARD SUITE 200
WOODBRIDGE
,
VA
22191
CAROL S SHAPIRO MD
VICE-CHAIR
4.00
0
0
0
2296 OPITZ BOULEVARD SUITE 200
WOODBRIDGE
,
VA
22191
R MICHAEL SORENSEN
TREASURER
3.00
0
0
0
2296 OPITZ BOULEVARD SUITE 200
WOODBRIDGE
,
VA
22191
WAYNE MALLARD
SECRETARY
2.00
0
0
0
2296 OPITZ BOULEVARD SUITE 200
WOODBRIDGE
,
VA
22191
HOWARD L GREENHOUSE
DIRECTOR
1.00
0
0
0
2296 OPITZ BOULEVARD SUITE 200
WOODBRIDGE
,
VA
22191
SARAH PITKIN PHD
DIRECTOR
1.00
0
0
0
2296 OPITZ BOULEVARD SUITE 200
WOODBRIDGE
,
VA
22191
WILLIAM M MOSS
DIRECTOR
1.00
0
0
0
2296 OPITZ BOULEVARD SUITE 200
WOODBRIDGE
,
VA
22191
SAM HILL EDD
DIRECTOR
1.00
0
0
0
2296 OPITZ BOULEVARD SUITE 200
WOODBRIDGE
,
VA
22191
MEGAN PERRY
DIRECTOR
1.00
0
0
0
2296 OPITZ BOULEVARD SUITE 200
WOODBRIDGE
,
VA
22191
2
Compensation of five highest-paid employees (other than those included on line 1—see instructions). If none, enter “NONE."
(a)
Name and address of each employee paid more than $50,000
(b)
Title, and average
hours per week
devoted to position
(c)
Compensation
(d)
Contributions to
employee benefit
plans and deferred
compensation
(e)
Expense account,
other allowances
ERIN MATTHEWS THOMAS
SR. PROGRAM OFFICER
40.00
90,002
18,900
1,018
2296 OPITZ BLVD SUITE 200
WOODBRIDGE
,
VA
22191
Total
number of other employees paid over $50,000
...................
0
Form
990-PF
(2019)
Form 990-PF (2019)
Page
7
Part VIII
Information About Officers, Directors, Trustees, Foundation Managers, Highly Paid Employees,
and Contractors
(continued)
3
Five highest-paid independent contractors for professional services (see instructions). If none, enter "NONE".
(a)
Name and address of each person paid more than $50,000
(b)
Type of service
(c)
Compensation
SEI GLOBAL INSTITUTIONAL GROUP
INVESTMENT MANAGEMENT
625,227
1 FREEDOM VALLEY DRIVE
OAKS
,
PA
19456
Total
number of others receiving over $50,000 for professional services
.............
0
Part IX-A
Summary of Direct Charitable Activities
List the foundation’s four largest direct charitable activities during the tax year. Include relevant statistical information such as the number of organizations and other beneficiaries served, conferences convened, research papers produced, etc.
Expenses
1
2
3
4
Part IX-B
Summary of Program-Related Investments
(see instructions)
Describe the two largest program-related investments made by the foundation during the tax year on lines 1 and 2.
Amount
1
2
All other program-related investments. See instructions.
3
Total.
Add lines 1 through 3
.........................
0
Form
990-PF
(2019)
Form 990-PF (2019)
Page
8
Part X
Minimum Investment Return
(All domestic foundations must complete this part. Foreign foundations, see instructions.)
1
Fair market value of assets not used (or held for use) directly in carrying out charitable, etc.,
purposes:
a
Average monthly fair market value of securities
...................
1a
109,195,452
b
Average of monthly cash balances
.......................
1b
205,827
c
Fair market value of all other assets (see instructions)
................
1c
0
d
Total
(add lines 1a, b, and c)
.........................
1d
109,401,279
e
Reduction claimed for blockage or other factors reported on lines 1a and
1c (attach detailed explanation)
.............
1e
0
2
Acquisition indebtedness applicable to line 1 assets
..................
2
0
3
Subtract line 2 from line 1d
.........................
3
109,401,279
4
Cash deemed held for charitable activities. Enter 1 1/2% of line 3 (for greater amount, see
instructions)
.............................
4
1,641,019
5
Net value of noncharitable-use assets.
Subtract line 4 from line 3. Enter here and on Part V, line 4
5
107,760,260
6
Minimum investment return.
Enter 5% of line 5
..................
6
5,388,013
Part XI
Distributable Amount
(see instructions) (Section 4942(j)(3) and (j)(5) private operating foundations and certain foreign organizations check here
and do not complete this part.)
1
Minimum investment return from Part X, line 6
....................
1
5,388,013
2a
Tax on investment income for 2019 from Part VI, line 5
......
2a
76,309
b
Income tax for 2019. (This does not include the tax from Part VI.)
...
2b
c
Add lines 2a and 2b
............................
2c
76,309
3
Distributable amount before adjustments. Subtract line 2c from line 1
............
3
5,311,704
4
Recoveries of amounts treated as qualifying distributions
................
4
126,687
5
Add lines 3 and 4
............................
5
5,438,391
6
Deduction from distributable amount (see instructions)
.................
6
0
7
Distributable amount
as adjusted. Subtract line 6 from line 5. Enter here and on Part XIII, line 1
...
7
5,438,391
Part XII
Qualifying Distributions
(see instructions)
1
Amounts paid (including administrative expenses) to accomplish charitable, etc., purposes:
a
Expenses, contributions, gifts, etc.—total from Part I, column (d), line 26
..........
1a
5,611,823
b
Program-related investments—total from Part IX-B
..................
1b
0
2
Amounts paid to acquire assets used (or held for use) directly in carrying out charitable, etc.,
purposes
...............................
2
3
Amounts set aside for specific charitable projects that satisfy the:
a
Suitability test (prior IRS approval required)
....................
3a
b
Cash distribution test (attach the required schedule)
.................
3b
4
Qualifying distributions.
Add lines 1a through 3b. Enter here and on Part V, line 8, and Part XIII, line 4
4
5,611,823
5
Foundations that qualify under section 4940(e) for the reduced rate of tax on net investment
income. Enter 1% of Part I, line 27b. See instructions
.................
5
76,309
6
Adjusted qualifying distributions.
Subtract line 5 from line 4
..............
6
5,535,514
Note:
The amount on line 6 will be used in Part V, column (b), in subsequent years when calculating whether the foundation qualifies for
the section 4940(e) reduction of tax in those years.
Form
990-PF
(2019)
Form 990-PF (2019)
Page
9
Part XIII
Undistributed Income
(see instructions)
(a)
Corpus
(b)
Years prior to 2018
(c)
2018
(d)
2019
1
Distributable amount for 2019 from Part XI, line 7
5,438,391
2
Undistributed income, if any, as of the end of 2019:
a
Enter amount for 2018 only
.......
4,414,068
b
Total for prior years:
20
,
20
,
20
0
3
Excess distributions carryover, if any, to 2019:
a
From 2014
......
b
From 2015
......
c
From 2016
......
d
From 2017
......
e
From 2018
......
f
Total
of lines 3a through e
........
0
4
Qualifying distributions for 2019 from Part
XII, line 4:
$
5,611,823
a
Applied to 2018, but not more than line 2a
4,414,068
b
Applied to undistributed income of prior years
(Election required—see instructions)
.....
0
c
Treated as distributions out of corpus (Election
required—see instructions)
........
0
d
Applied to 2019 distributable amount
.....
1,197,755
e
Remaining amount distributed out of corpus
0
5
Excess distributions carryover applied to 2019.
0
0
(If an amount appears in column (d), the
same amount must be shown in column (a).)
6
Enter the net total of each column as
indicated below:
a
Corpus. Add lines 3f, 4c, and 4e. Subtract line 5
0
b
Prior years’ undistributed income. Subtract
line 4b from line 2b
..........
0
c
Enter the amount of prior years’ undistributed
income for which a notice of deficiency has
been issued, or on which the section 4942(a)
tax has been previously assessed
......
0
d
Subtract line 6c from line 6b. Taxable amount
—see instructions
...........
0
e
Undistributed income for 2018. Subtract line
4a from line 2a. Taxable amount—see
instructions
.............
0
f
Undistributed income for 2019. Subtract
lines 4d and 5 from line 1. This amount must
be distributed in 2020
..........
4,240,636
7
Amounts treated as distributions out of
corpus to satisfy requirements imposed by
section 170(b)(1)(F) or 4942(g)(3) (Election may
be required - see instructions)
.......
0
8
Excess distributions carryover from 2014 not
applied on line 5 or line 7 (see instructions)
...
0
9
Excess distributions carryover to 2020.
Subtract lines 7 and 8 from line 6a
......
0
10
Analysis of line 9:
a
Excess from 2015
....
b
Excess from 2016
....
c
Excess from 2017
....
d
Excess from 2018
....
e
Excess from 2019
....
Form
990-PF
(2019)
Form 990-PF (2019)
Page
10
Part XIV
Private Operating Foundations
(see instructions and Part VII-A, question 9)
1a
If the foundation has received a ruling or determination letter that it is a private operating
foundation, and the ruling is effective for 2019, enter the date of the ruling
.......
b
Check box to indicate whether the organization is a private operating foundation described in section
4942(j)(3)
or
4942(j)(5)
2a
Enter the lesser of the adjusted net
income from Part I or the minimum
investment return from Part X for each
year listed
..........
Tax year
Prior 3 years
(e) Total
(a)
2019
(b)
2018
(c)
2017
(d)
2016
b
85% of line 2a
.........
c
Qualifying distributions from Part XII,
line 4 for each year listed
.....
d
Amounts included in line 2c not used directly
for active conduct of exempt activities
..........
e
Qualifying distributions made directly
for active conduct of exempt activities.
Subtract line 2d from line 2c
....
3
Complete 3a, b, or c for the
alternative test relied upon:
a
“Assets" alternative test—enter:
(1)
Value of all assets
......
(2)
Value of assets qualifying
under section 4942(j)(3)(B)(i)
b
“Endowment" alternative test— enter 2/3
of minimum investment return shown in
Part X, line 6 for each year listed
...
c
“Support" alternative test—enter:
(1)
Total support other than gross
investment income (interest,
dividends, rents, payments
on securities loans (section
512(a)(5)), or royalties)
....
(2)
Support from general public
and 5 or more exempt
organizations as provided in
section 4942(j)(3)(B)(iii)
....
(3)
Largest amount of support
from an exempt organization
(4)
Gross investment income
Part XV
Supplementary Information (Complete this part only if the foundation had $5,000 or more in
assets at any time during the year—see instructions.)
1
Information Regarding Foundation Managers:
a
List any managers of the foundation who have contributed more than 2% of the total contributions received by the foundation
before the close of any tax year (but only if they have contributed more than $5,000). (See section 507(d)(2).)
b
List any managers of the foundation who own 10% or more of the stock of a corporation (or an equally large portion of the
ownership of a partnership or other entity) of which the foundation has a 10% or greater interest.
2
Information Regarding Contribution, Grant, Gift, Loan, Scholarship, etc., Programs:
Check here
if the foundation only makes contributions to preselected charitable organizations and does not accept
unsolicited requests for funds. If the foundation makes gifts, grants, etc. to individuals or organizations under
other conditions, complete items 2a, b, c, and d. See instructions
a
The name, address, and telephone number or email address of the person to whom applications should be addressed:
b
The form in which applications should be submitted and information and materials they should include:
c
Any submission deadlines:
d
Any restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other
factors:
Form
990-PF
(2019)
Form 990-PF (2019)
Page
11
Part XV
Supplementary Information
(continued)
3
Grants and Contributions Paid During the Year or Approved for Future Payment
Recipient
If recipient is an individual,
show any relationship to
any foundation manager
or substantial contributor
Foundation
status of
recipient
Purpose of grant or
contribution
Amount
Name and address (home or business)
a
Paid during the year
ACTION IN COMMUNITY THROUGH SERVICE
3900 ACTS LANE
DUMFRIES
,
VA
22026
NONE
PC
COVID-19
50,000
ACTION IN COMMUNITY THROUGH SERVICE
3900 ACTS LANE
DUMFRIES
,
VA
22026
NONE
PC
SECURITY AND TRANSPORTATION
43,750
ACTION IN COMMUNITY THROUGH SERVICE
3900 ACTS LANE
DUMFRIES
,
VA
22026
NONE
PC
ANNUAL IWALK FOR ACTS 2020
2,500
ACTION IN COMMUNITY THROUGH SERVICE
3900 ACTS LANE
DUMFRIES
,
VA
22026
NONE
PC
BEHAVIORAL HEALTH TREATMENT FOR HOMELESS CLIENTS
115,138
ACTION IN COMMUNITY THROUGH SERVICE (ACTS)
3900 ACTS LANE
DUMFRIES
,
VA
22026
NONE
PC
PRINCE WILLIAM FOOD RESCUE
120,000
ALTERNATIVE PATHS TRAINING SCHOOL
2525 POINTE CENTER COURT SUITE 300
DUMFRIES
,
VA
22026
NONE
PC
ACCESS TO HEALTH-APTS SCHOOL CLINICS
19,068
AMERICAN CANCER SOCIETY
555 11TH ST NW 300
WASHINGTON
,
DC
20004
NONE
PC
RELAY FOR LIFE PRINCE WILLIAM COUNTY
5,000
BOYS AND GIRLS CLUB OF GREATER WASHINGTON
4103 BENNING RD NE
WASHINGTON
,
DC
20019
NONE
PC
CAPACITY BUILDING: BUILDING YOUTH OUTCOMES OF HEALTH
52,500
BOYS AND GIRLS CLUB OF GREATER WASHINGTON
4103 BENNING RD NE
WASHINGTON
,
DC
20019
NONE
PC
GREAT BIG KID CLUB CRUSADERS
2,500
BRAIN INJURY SERVICES
8136 OLD KEENE MILL ROAD SUIE B-102
SPRINGFIELD
,
VA
22152
NONE
PC
RECENTLY RELEASED WOMEN'S BRAIN INJURY AWARENESS AND ASSESSMENT
45,122
CAPITAL AREA FOOD BANK
4900 PUERTO RICO AVE NE
WASHINGTON
,
DC
20017
NONE
PC
YOU ARE WHAT YOU EAT
160,839
CAPITAL CARING HEALTH
3180 FAIRVIEW PARK DRIVE SUITE 500
FALLS CHURCH
,
VA
22042
NONE
PC
EXPANDING STAY AT HOME SERVICES
139,554
CATCHAFIRE
2000 P ST NW 240
WASHINGTON
,
DC
20036
NONE
PC
BRIDGING TALENT GAPS AND RESOURCES FOR NONPROFITS
115,000
COMMUNITY FOUNDATION FOR NORTHERN VIRGINIA
2940 HUNTER MILL RD SUITE 201
OAKTON
,
VA
22124
NONE
PC
COUNT THE REGION
7,500
COMMUNITY FOUNDATION FOR NORTHERN VIRGINIA
2940 HUNTER MILL RD SUITE 201
OAKTON
,
VA
22124
NONE
PC
COVID-19
100,000
CONSUMER HEALTH FOUNDATION
1400 16TH STREET NW SUITE 710
WASHINGTON
,
DC
20036
NONE
PC
REGIONAL PRIMARY CARE COALITION
7,500
COURT APPOINTED SPECIAL ADVOCATES
9384 FORESTWOOD LANE SUITE C
MANASSAS
,
VA
20110
NONE
PC
2020 EVENING UNDER THE STARS
2,500
FOOD AND FRIENDS INC
219 RIGGS ROAD NE
WASHINGTON
,
DC
20011
NONE
PC
NUTRITION SERVICES FOR SERIOUSLY ILL VIRGINIANS
17,500
GEORGE MASON UNIVERSITY
10900 UNIVERSITY BOULEVARD MS 4E5
MANASSAS
,
VA
20110
NONE
PC
MASON AND PARTNERS CLINIC - COVID-19
20,000
GEORGE MASON UNIVERSITY
10900 UNIVERSITY BOULEVARD MS 4E5
MANASSAS
,
VA
20110
NONE
PC
MULTIDISCIPLINARY PROGRAM FOR CHILDHOOD OBESITY TREATMENT AMONG LATINO COMMUNITIES
127,176
GEORGE MASON UNIVERSITY
10900 UNIVERSITY BOULEVARD MS 4E5
MANASSAS
,
VA
20110
NONE
PC
INTEGRATING SERVICES TO IMPROVE SOCIAL DETERMINANTS OF HEALTH
41,310
GEORGE MASON UNIVERSITY FOUNDATION
4400 UNIVERSITY DRIVE MS 143
FAIRFAX
,
VA
22030
NONE
PC
PHF SCHOLARSHIP AT THE COLLEGE OF HEALTH AND HUMAN SERVICES
70,000
GREATER PRINCE WILLIAM COMMUNITY HEALTH CENTER
4379 RIDGEWOOD CENTER DRIVE SUITE
102
WOODBRIDGE
,
VA
22192
NONE
PC
COVID-19
50,000
GREATER PRINCE WILLIAM COMMUNITY HEALTH CENTER
4379 RIDGEWOOD CENTER DRIVE SUITE
102
WOODBRIDGE
,
VA
22192
NONE
PC
INCREASE MEDICAL ACCESS
18,000
GREATER PRINCE WILLIAM COMMUNITY HEALTH CENTER
4379 RIDGEWOOD CENTER DRIVE SUITE
102
WOODBRIDGE
,
VA
22192
NONE
PC
BRIDGING THE BEHAVIORAL HEALTH GAP - GPWCHC/GMU PRECEPTORSHIP PIPELINE
58,500
GREATER PRINCE WILLIAM COMMUNITY HEALTH CENTER
4379 RIDGEWOOD CENTER DRIVE SUITE
102
WOODBRIDGE
,
VA
22192
NONE
PC
ENHANCED EXPANDED ACCESS-2020
180,515
GREATER PRINCE WILLIAM COMMUNITY HEALTH CENTER
4379 RIDGEWOOD CENTER DRIVE SUITE
102
WOODBRIDGE
,
VA
22192
NONE
PC
GENERAL OPERATING SUPPORT
45,000
HOUSING VIRGINIA
203 N ROBINSON STREET
RICHMOND
,
VA
23220
NONE
PC
HOUSING, HEALTH RESEARCH AND COMMUNITY ENGAGEMENT
17,500
INOVA HEALTH CARE SERVICES
2740 PROSPERITY AVENUE SUITE 200
FAIRFAX
,
VA
22031
NONE
PC
EXPANDING BEHAVIORAL HEALTH SERVICE CAPACITY IN PRINCE WILLIAM COUNTY
145,417
INSTITUTE OF PUBLIC HEALTH INNOVATION
1250 CONNECTICUT AVE NW SUITE 601
WASHINGTON
,
DC
20036
NONE
PC
HEALTH EQUITY AND THE COMMUNITY HEALTHCARE COALITION OF GREATER PRINCE WILLIAM
78,749
KOREAN AMERICAN OUTREACH GROUP
8280 WILLOW OAKS CORPORATE DRIVE
SUITE 600
FAIRFAX
,
VA
22031
NONE
PC
PREVENT STOMACH AND LIVER CANCER
17,500
LEADERSHIP PRINCE WILLIAM
9720 CAPITAL COURT SUITE 204
MANASSAS
,
VA
20110
NONE
PC
SIGNATURE PROGRAM SCHOLARSHIP FOR PEOPLE OF COLOR
16,500
LLOYD F MOSS FREE CLINIC
1301 SAM PERRY BOULEVARD
FREDERICKSBURG
,
VA
22401
NONE
PC
COVID-19
10,000
LLOYD F MOSS FREE CLINIC
1301 SAM PERRY BOULEVARD
FREDERICKSBURG
,
VA
22401
NONE
PC
COMMUNITY BRIDGE - ADDRESSING THE SOCIAL DETERMINANTS OF HEALTH
33,000
LLOYD F MOSS FREE CLINIC
1301 SAM PERRY BOULEVARD
FREDERICKSBURG
,
VA
22401
NONE
PC
GENERAL OPERATING SUPPORT
46,500
MASON & PARTNERS CLINIC (GMU)
4400 UNIVERSITY DRIVE
FAIRFAX
,
VA
22030
NONE
PC
GENERAL OPERATING SUPPORT
15,000
METROPOLITAN WASHINGTON COUNCIL OF GOVERNMENTS
777 NORTH CAPITAL STREET NE SUITE
300
WASHINGTON
,
DC
20002
NONE
GOV
HOC VCU RACIAL EQUITY REPORT
2,000
MOTHER OF MERCY
230 CHURCH AVE PO BOX 676
ALBANY
,
MN
56307
NONE
PC
COVID-19
50,000
NAMI
PO BOX 1423
WOODBRIDGE
,
VA
22195
NONE
PC
LATINX MENTAL HEALTH AWARENESS
25,000
NATIONAL COALITION OF 100 BLACK WOMEN INC PRINCE WILLIAM COUNTY CHAPTER
PO BOX 1166
DUMFRIES
,
VA
22026
NONE
PC
RESPONDING AND PROTECTING MS STUDENTS, PARENTS, ADOLESCENTS, AND ADULTS
43,107
NATIONAL COALITION OF 100 BLACK WOMEN INC PRINCE WILLIAM COUNTY CHAPTER
PO BOX 1166
DUMFRIES
,
VA
22026
NONE
PC
RESPONDING & PROTECTING (RAP) MIDDLE SCHOOL STUDENTS AND PARENTS
43,200
NATIONAL KOREAN AMERICAN SERVICE & EDUCATION CONSORTIUM (NAKASEC) AND CASA
4304 EVERGREEN LN SUITE 104
ANNANDALE
,
VA
22003
NONE
PC
STRENGTHENING COMMUNITY HEALTH CARE THROUGH SERVICE AND ADVOCACY
188,119
NATIONAL KOREAN AMERICAN SERVICE & EDUCATION CONSORTIUM (NAKASEC) AND CASA
4304 EVERGREEN LN SUITE 104
ANNANDALE
,
VA
22003
NONE
PC
BUILDING POWER THROUGH HEALTH
74,852
NORTHERN VIRGINIA FAMILY SERVICE
10455 WHITE GRANITE DRIVE SUITE 100
OAKTON
,
VA
22124
NONE
PC
MENTAL HEALTH FOR FAMILIES WITH CHILDREN
30,096
NORTHERN VIRGINIA FAMILY SERVICE
10455 WHITE GRANITE DRIVE SUITE 100
OAKTON
,
VA
22124
NONE
PC
COVID-19
40,000
NORTHERN VIRGINIA FAMILY SERVICE
10455 WHITE GRANITE DRIVE SUITE 100
OAKTON
,
VA
22124
NONE
PC
MENTAL HEALTH FOR FAMILIES WITH CHILDREN
95,098
NORTHERN VIRGINIA FAMILY SERVICES (NVFS) PEDIATRIC PRIMARY CARE PROJECT (PP
10455 WHITE GRANITE DRIVE SUITE 100
OAKTON
,
VA
22124
NONE
PC
GENERAL OPERATING SUPPORT
11,500
NOVA SCRIPTSCENTRAL INC
6400 ARLINGTON BOULEVARD SUITE 120
FALLS CHURCH
,
VA
22042
NONE
PC
COVID-19
20,000
NOVA SCRIPTSCENTRAL INC
6400 ARLINGTON BOULEVARD SUITE 120
FALLS CHURCH
,
VA
22042
NONE
PC
GENERAL OPERATING SUPPORT
66,423
NUEVA VIDA INC
5225 WISCONSIN AVENUE NW SUITE 503
WASHINGTON
,
DC
20015
NONE
PC
INCREASING CANCER PREVENTION AND IMPROVING CONTINUITY OF CARE TO UNDERSERVED LATINAS IN PWC
104,799
PATHWAY HOMES
10201 FAIRFAX BOULEVARD
FAIRFAX
,
VA
22030
NONE
PC
PERMANENT SUPPORTIVE HOUSING FOR INDIVIDUALS WITH SERIOUS MENTAL ILLNESSES
175,000
POSTPARTUM SUPPORT VIRGINIA
PO BOX 7521
ARLINGTON
,
VA
22207
NONE
PC
SUPPORT FOR WOMEN EXPERIENCING POSTPARTUM DEPRESSION
53,206
PRINCE WILLIAM AREA AGENCY ON AGING
9320 MOSBY ST
MANASSAS
,
VA
20110
NONE
PC
TRAINING TO BUILD PROFESSIONAL SKILLS OF STAFF
105,000
PRINCE WILLIAM AREA FREE CLINIC
13900 CHURCH HILL DRIVE
WOODBRIDGE
,
VA
22191
NONE
PC
GENERAL OPERATING SUPPORT
38,006
PRINCE WILLIAM COUNTY PUBLIC SCHOOLS
14715 BRISTOW RD
MANASSAS
,
VA
20112
NONE
PC
EXAMINING OUR DIMENSIONS OF CULTURE TO CULTIVATE CULTURALLY RESPONSIVE LEARNING ENVIRONMENTS.
12,356
PRINCE WILLIAM DROP-IN CENTER
13184 CENTERPOINTE WAY
WOODBRIDGE
,
VA
22192
NONE
PC
OUTREACH & EDUCATION
15,450
PROJECT MEND-A-HOUSE INC
9500 TECHNOLOGY DRIVE SUITE 101
MANASSAS
,
VA
20110
NONE
PC
BUILDING FOR THE FUTURE
18,000
PROJECT MEND-A-HOUSE INC
9500 TECHNOLOGY DRIVE SUITE 101
MANASSAS
,
VA
20110
NONE
PC
HOME REPAIRS AND MODIFICATIONS FOR THOSE WHO CAN'T AFFORD THESE REPAIRS
42,000
RX PARTNERSHIP
2924 EMERYWOOD PARKWAY SUITE 300
RICHMOND
,
VA
23294
NONE
PC
GENERAL OPERATING SUPPORT
15,000
SCAN OF NORTHERN VIRGINIA
205 S WHITING STREET SUITE 205
ALEXANDRIA
,
VA
22304
NONE
PC
BUILDING RESIIENT YOUTH AND FAMILIES IN PWC
85,648
SCAN OF NORTHERN VIRGINIA
205 S WHITING STREET SUITE 205
ALEXANDRIA
,
VA
22304
NONE
PC
IMMIGRANT FAMILY REUNIFICATION: BUILDING RESILIENT YOUTH AND FAMILIES
36,706
SENTARA NORTHERN VIRGINIA MEDICAL CENTER
2300 OPITZ BOULEVARD
WOODBRIDGE
,
VA
22191
NONE
PC
GENERAL OPERATING SUPPORT
52,500
SENTARA NORTHERN VIRGINIA MEDICAL CENTER
2300 OPITZ BOULEVARD
WOODBRIDGE
,
VA
22191
NONE
PC
MOBILE HEALTH CLINIC REPLACEMENT PROJECT
166,950
SENTARA NORTHERN VIRGINIA MEDICAL CENTER
2300 OPITZ BOULEVARD
WOODBRIDGE
,
VA
22191
NONE
PC
IN-PERSON INTERPRETER
60,390
SPARK
67 E MADISON SUITE 2101
CHICAGO
,
IL
60603
NONE
PC
GENERAL OPERATIONS
1,500
STAFFORD SCHOOLS HEAD START
610 GAYLE STREET
FALMOUTH
,
VA
22405
NONE
PC
STAFFORD CHILDREN'S HEALTH INSURANCE OUTREACH PROGRAM
14,492
THE ARC OF GREATER PRINCE WILLIAM
13505 HILLENDALE DRIVE
DALE CITY
,
VA
22193
NONE
PC
VOSAC III
33,862
THE ARC OF GREATER PRINCE WILLIAM
13505 HILLENDALE DRIVE
DALE CITY
,
VA
22193
NONE
PC
INCREASE AGENCY CAPACITY TO BETTER SERVE PERSONS WHO ARE DUALLY DIAGNOSED (DD/MH)
14,512
THE ARC OF GREATER PRINCE WILLIAM
13505 HILLENDALE DRIVE
DALE CITY
,
VA
22193
NONE
PC
PURCHASE MEDICAL EQUIPMENT
175,000
THE COMMONWEALTH INSTITUTE
PO BOX 473
MAYNARD
,
MA
01754
NONE
PC
POWER-BUILDING FOR RACIAL AND HEALTH EQUITY IN THE PHF REGION AND VA
42,000
THE HOUSE INC
14001 CROWN COURT
WOODBRIDGE
,
VA
22193
NONE
PC
COVID-19
20,000
THE HOUSE INC
14001 CROWN COURT
WOODBRIDGE
,
VA
22193
NONE
PC
THE OFFICE ON YOUTH MENTAL HEALTH AND WELLNESS
202,000
THE VIRGINIA CIVIC ENGAGEMENT TABLE
1705 E MAIN ST
RICHMOND
,
VA
23223
NONE
PC
VIRGINIA COUNTS COALITION (VCC) - COMPLETE COUNT COMMITTEES
7,500
TRILLIUM DROP-IN CENTER
13184 CENTERPOINTE WAY
WOODBRIDGE
,
VA
22193
NONE
PC
MARKETING OUTREACH
36,050
VA CONSORTIUM FOR HEALTH PHILANTHROPY
112 NORTH MAIN STREET PO BOX 1606
HOPEWELL
,
VA
23860
NONE
PC
ADVOCACY FOR COMPREHENSIVE DENTAL FOR MEDICAID ENROLLED ADULTS
25,000
VIRGINIA COMMUNITY FOOD CONNECTIONS
1287 CENTRAL PARK BOULEVARD
FREDERICKSBURG
,
VA
22401
NONE
PC
IMPROVING SNAP ACCESS TO AFFORDABLE FRESH FOOD FOR COMMUNITY HEALTH
40,953
VIRGINIA COMMUNITY FOOD CONNECTIONS
1287 CENTRAL PARK BOULEVARD
FREDERICKSBURG
,
VA
22401
NONE
PC
FRESH FOOD ACCESS FOR COMMUNITY HEALTH
17,552
VIRGINIA FOUNDATION FOR COMMUNITY COLLEGE EDUCATION
101 N 14TH STREET
RICHMOND
,
VA
23219
NONE
PC
POTOMAC HEALTH FOUNDATION FELLOWS PROGRAM
125,000
VIRGINIA FUNDERS NETWORK
3409 MOORE STREET
RICHMOND
,
VA
23230
NONE
PC
PATH PARTNERSHIPS FOR SUPPORT OF VFN
10,000
VIRGINIA HEALTH CATALYST (FORMERLY VIRGINIA ORAL HEALTH COALITION)
4200 INNSLAKE DR 202
GLEN ALLEN
,
VA
23060
NONE
PC
2020 VIRTUAL VA ORAL HEALTH SUMMIT
2,500
VIRGINIA HEALTH CATALYST (VIRGINIA ORAL HEALTH COALITION)
4200 INNSLAKE DR 202
GLEN ALLEN
,
VA
23060
NONE
PC
2019 VA ORAL HEALTH SUMMIT
2,000
VIRGINIA INTERFAITH CENTER FOR PUBLIC POLICY
1716 E FRANKLIN ST
RICHMOND
,
VA
23223
NONE
PC
HEALTH CARE HOPE: EXPANDING MEDICAID THROUGH CONGREGATIONAL OUTREACH
60,000
VIRGINIA POVERTY LAW CENTER
919 E MAIN ST 610
RICHMOND
,
VA
23219
NONE
PC
ENROLL VIRGINIA - POTOMAC
198,806
VIRGINIA TECH FOUNDATION
902 PRICES FORK RD
BLACKSBURG
,
VA
24061
NONE
PC
COOKWARE FOR NUTRITION EDUCATION PROGRAM
4,000
VIRGINIANS ORGANIZED FOR INTERFAITH COMMUNITY ENGAGEMENT (VOICE)
4444 ARLINGTON BLVD
ARLINGTON
,
VA
22204
NONE
PC
CAP BLDG FOR HOUSING AND EVICTIONS RELATED TO COVID-19
25,000
VOICES FOR VIRGINIA'S CHILDREN
701 E FRANKLIN STREET SUITE 807
RICHMOND
,
VA
23219
NONE
PC
CAMPAIGN FOR CHILDREN'S MENTAL HEALTH
18,000
VOICES FOR VIRGINIA'S CHILDREN
701 E FRANKLIN STREET SUITE 807
RICHMOND
,
VA
23219
NONE
PC
EQUITABLE ACCESS TO TRAUMA-INFORMED CHILDREN'S MENTAL HEALTH SERVICES
42,000
WORKHOUSE ARTS FOUNDATION INC
9518 WORKHOUSE WAY
LORTON
,
VA
22079
NONE
PC
WORKHOUSE ARTS CENTER - MILITARY IN THE ARTS INITIATIVE
23,115
WORKHOUSE ARTS FOUNDATION INC
9518 WORKHOUSE WAY
LORTON
,
VA
22079
NONE
PC
WORKHOUSE ARTS CENTER - MILITARY IN THE ARTS INITIATIVE
53,935
YOUNG INVINCIBLES
1411 K STREET NW
WASHINGTON
,
DC
20005
NONE
PC
HEALTHY YOUNG AMERICA-NORTHERN VIRGINIA CAMPAIGN
125,000
YOUTH FOR TOMORROW
11835 HAZEL CIRCLE DRIVE
BRISTOW
,
VA
20136
NONE
PC
YFT MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES FOR THE UNDERSERVED
195,000
Total
.................................
3a
5,181,821
b
Approved for future payment
ACTION IN COMMUNITY THROUGH SERVICE
3900 ACTS LANE
DUMFRIES
,
VA
22026
NONE
PC
PRINCE WILLIAM FOOD RESCUE
36,000
ACTION IN COMMUNITY THROUGH SERVICE
3900 ACTS LANE
DUMFRIES
,
VA
22003
NONE
PC
BEHAVIORAL HEALTH TREATMENT FOR HOMELESS CLIENTS
34,500
ACTION IN COMMUNITY THROUGH SERVICE
3900 ACTS LANE
DUMFRIES
,
VA
22026
NONE
PC
SECURITY AND TRANSPORTATION
18,750
ALTERNATIVE PATHS TRAINING SCHOOL
2525 POINTE CENTER COURT SUITE 300
DUMFRIES
,
VA
22026
NONE
PC
ACCESS TO HEALTH-APTS SCHOOL CLINICS
8,172
BOYS AND GIRLS CLUB OF GREATER WASHINGTON
4103 BENNING RD NE
WASHINGTON
,
DC
20019
NONE
PC
CAPACITY BUILDING: BUILDING YOUTH OUTCOMES OF HEALTH
22,500
BRAIN INJURY SERVICES
8136 OLD KEENE MILL ROAD SUIE B-102
SPRINGFIELD
,
VA
22152
NONE
PC
RECENTLY RELEASED WOMEN'S BRAIN INJURY AWARENESS AND ASSESSMENT
19,338
CAPITAL AREA FOOD BANK
4900 PUERTO RICO AVE NE
WASHINGTON
,
DC
20017
NONE
PC
YOU ARE WHAT YOU EAT
48,000
CAPITAL CARING HEALTH
3180 FAIRVIEW PARK DRIVE SUITE 500
FALLS CHURCH
,
VA
22042
NONE
PC
EXPANDING STAY AT HOME SERVICES
59,808
FOOD AND FRIENDS INC
219 RIGGS ROAD NE
WASHINGTON
,
DC
20011
NONE
PC
NUTRITION SERVICES FOR SERIOUSLY ILL VIRGINIANS
7,500
GEORGE MASON UNIVERSITY
10900 UNIVERSITY BOULEVARD MS 4E5
MANASSAS
,
VA
20110
NONE
PC
VALE A MULTIDISCIPLINARY PROGRAM FOR CHILDHOOD OBESITY TREATMENT AMONT LATINO COMMUNITIES
38,153
GEORGE MASON UNIVERSITY FOUNDATION
4400 UNIVERSITY DRIVE MS 143
FAIRFAX
,
VA
22030
NONE
PC
PHF SCHOLARSHIP AT THE COLLEGE OF HEALTH AND HUMAN SERVICES
30,000
GREATER PRINCE WILLIAM COMMUNITY HEALTH CENTER
4379 RIDGEWOOD CENTER DRIVE SUITE
102
WOODBRIDGE
,
VA
22192
NONE
PC
ENHANCED EXPANDED ACCESS 2020
77,363
HOUSING VIRGINIA
203 N ROBINSON STREET
RICHMOND
,
VA
23220
NONE
PC
HOUSING AND HEALTH RESEARCH AND COMMUNITY ENGAGEMENT
7,500
INOVA HEALTH CARE SERVICES
2740 PROSPERITY AVENUE SUITE 200
FAIRFAX
,
VA
22031
NONE
PC
EXPANDING BEHAVIORAL HEALTH SERVICE CAPACITY IN PWC
43,626
INSTITUTE OF PUBLIC HEALTH INNOVATION
1250 CONNECTICUT AVE NW SUITE 601
WASHINGTON
,
DC
20036
NONE
PC
HEALTH EQUITY AND THE COMMUNITY HEALTHCARE COALITION OF GREATER PRINCE WILLIAM
33,749
KOREAN AMERICAN OUTREACH GROUP
8280 WILLOW OAKS CORPORATE DRIVE
SUITE 600
FAIRFAX
,
VA
22031
NONE
PC
PREVENT STOMACH AND LIVER CANCER
7,500
LLOYD F MOSS FREE CLINIC
1301 SAM PERRY BOULEVARD
FREDERICKSBURG
,
VA
22401
NONE
PC
COMMUNITY BRIDGE-ADDRESSING THE SOCIAL DETERMINANT OF HEALTH
9,000
NATIONAL COALITION OF 100 BLACK WOMEN INC PRINCE WILLIAM COUNTY CHAPTER
PO BOX 1166
DUMFRIES
,
VA
22026
NONE
PC
RESPONDING AND PROTECTING MS STUDENTS, PARENTS, ADOLESCENTS, AND ADULTS
18,474
NATIONAL KOREAN AMERICAN SERVICE & EDUCATION CONSORTIUM
4304 EVERGREEN LN SUITE 104
ANNANDALE
,
VA
22003
NONE
PC
STRENGTHENING COMMUNITY HEALTH CARE THROUGH SERVICE AND ADVOCACY
80,622
NORTHERN VIRGINIA FAMILY SERVICE
10455 WHITE GRANITE DRIVE SUITE 100
OAKTON
,
VA
22124
NONE
PC
MENTAL HEALTH FOR FAMILIES WITH CHILDREN
40,756
NUEVA VIDA INC
5225 WISCONSIN AVENUE NW SUITE 503
WASHINGTON
,
DC
20015
NONE
PC
INCREASING CANCER PREVENTION AND IMPROVING CONTINUITY OF CARE TO UNDERSERVED LATINAS IN PWC
31,500
PATHWAY HOMES
10201 FAIRFAX BOULEVARD
FAIRFAX
,
VA
22030
NONE
PC
PERMANENT SUPPORTIVE HOUSING FOR INDIVIDUALS WITH SERIOUS MENTAL ILLNESSES
52,500
POSTPARTUM SUPPORT VIRGINIA
PO BOX 7521
ARLINGTON
,
VA
22207
NONE
PC
SUPPORT FOR WOMEN EXPERIENCING POSTPARTUM DEPRESSION: WOODBRIDGE MATERNAL MENTAL HEALTH COALITION
15,900
PRINCE WILLIAM AREA AGENCY ON AGING
9320 MOSBY ST
MANASSAS
,
VA
20110
NONE
PC
TRANINGS TO BUILD PROFESSIONAL SKILLS OF STAFF
45,000
PROJECT MEND-A-HOUSE INC
9500 TECHNOLOGY DRIVE SUITE 101
MANASSAS
,
VA
20110
NONE
PC
HOME REPAIRS AND MODIFICATIONS FOR THOSE WHO CAN NOT AFFORD THESE REPAIRS THEMSELVES
18,000
SCAN OF NORTHERN VIRGINIA
205 S WHITING STREET SUITE 205
ALEXANDRIA
,
VA
22304
NONE
PC
BUILDING RESILIENT YOUTH AND FAMILIES IN PWC
36,707
SENTARA NORTHERN VIRGINIA MEDICAL CENTER
2300 OPITZ BOULEVARD
WOODBRIDGE
,
VA
22191
NONE
PC
MOBILE HEALTH CLINIC REPLACEMENT PROJECT
71,550
STAFFORD SCHOOLS HEAD START
610 GAYLE STREET
FALMOUTH
,
VA
22405
NONE
PC
STAFFORD CHILDREN'S INSURANCE OUTREACH PROGRAM
4,348
THE ARC OF GREATER PRINCE WILLIAM
13505 HILLENDALE DRIVE
DALE CITY
,
VA
22405
NONE
PC
PURCHASE MEDICAL EQUIPMENT
75,000
THE ARC OF GREATER PRINCE WILLIAM
13505 HILLENDALE DRIVE
DALE CITY
,
VA
22405
NONE
PC
VOSAC III
14,513
THE COMMONWEALTH INSTITUTE
PO BOX 473
MAYNARD
,
MA
01754
NONE
PC
POWER-BUILDING FOR RACIAL AND HEALTH EQUITY IN THE PHF REGION AND VA
18,000
THE HOUSE INC STUDENT LEADERSHIP CENTER
1400 16TH STREET NW SUITE 710
WOODBRIDGE
,
VA
22193
NONE
PC
THE OFFICE ON YOUTH MENTAL HEALTH AND WELLNESS
60,600
TRILLIUM DROP-IN CENTER
13184 CENTERPOINTE WAY
WOODBRIDGE
,
VA
22193
NONE
PC
MARKETING OUTREACH
15,450
VA CONSORTIUM FOR HEALTH PHILANTHROPY
112 NORTH MAIN STREET PO BOX 1606
HOPEWELL
,
VA
23860
NONE
PC
IMPROVING SNAP ACCESS TO AFFORDABLE FRESH FOOD FOR COMMUNITY HEALTH
17,551
VIRGINIA FOUNDATION FOR COMMUNITY COLLEGE EDUCATION
101 N 14TH STREET
RICHMOND
,
VA
23219
NONE
PC
PHF FELLOW PRGRAM
37,500
VIRGINIA INTERFAITH CENTER FOR PUBLIC POLICY
1716 E FRANKLIN ST
RICHMOND
,
VA
23223
NONE
PC
HEALTH CARE HOPE: EXPANDING MEDICAID THROUGH CONGRESSIONAL OUTREACH
18,000
VIRGINIA POVERTY LAW CENTER
919 E MAIN ST 610
RICHMOND
,
VA
23219
NONE
PC
ENROLL VIRGINIA- POTOMAC
59,642
VOICES FOR VIRGINIA'S CHILDREN
701 E FRANKLIN STREET SUITE 807
RICHMOND
,
VA
23219
NONE
PC
EQUITABLE ACCESS TO TRAUMA-INFORMED CHILDREN'S MENTAL HEALTH SERVICES
18,000
WORKHOUSE ARTS FOUNDATION INC
9518 WORKHOUSE WAY
LORTON
,
VA
22079
NONE
PC
WORKHOUSE MILITARY ARTS INITIATIVE
23,115
YOUNG INVINCIBLES
1411 K STREET NW
WASHINGTON
,
DC
20005
NONE
PC
HEALTHY YOUNG AMERICA - NOVA CAMPAIGN
37,500
YOUTH FOR TOMORROW
11835 HAZEL CIRCLE DRIVE
BRISTOW
,
VA
20136
NONE
PC
MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES FOR THE UNDERSERVED
58,500
Total
.................................
3b
1,370,187
Form
990-PF
(2019)
Form 990-PF (2019)
Page
12
Part XVI-A
Analysis of Income-Producing Activities
Enter gross amounts unless otherwise indicated.
Unrelated business income
Excluded by section 512, 513, or 514
(e)
Related or exempt
function income
(See instructions.)
1
Program service revenue:
(a)
Business code
(b)
Amount
(c)
Exclusion code
(d)
Amount
a
b
c
d
e
f
g
Fees and contracts from government agencies
2
Membership dues and assessments
....
3
Interest on savings and temporary cash
investments
...........
14
395
4
Dividends and interest from securities
....
14
6,087,323
5
Net rental income or (loss) from real estate:
a
Debt-financed property
......
b
Not debt-financed property
.....
6
Net rental income or (loss) from personal property
7
Other investment income
.....
8
Gain or (loss) from sales of assets other than
inventory
............
18
1,895,064
9
Net income or (loss) from special events:
10
Gross profit or (loss) from sales of inventory
11
Other revenue:
a
GRANT RECOVERY
126,688
b
c
d
e
12
Subtotal. Add columns (b), (d), and (e)
..
0
7,982,782
126,688
13
Total.
Add line 12, columns (b), (d), and (e)
..................
13
8,109,470
(See worksheet in line 13 instructions to verify calculations.)
Part XVI-B
Relationship of Activities to the Accomplishment of Exempt Purposes
Line No.
Explain below how each activity for which income is reported in column (e) of Part XVI-A contributed importantly to
the accomplishment of the foundation’s exempt purposes (other than by providing funds for such purposes). (See
instructions.)
11A
GRANTS PREVIOUSLY USED AS A QUALIFYING DISTRIBUTION THAT WAS LATER REFUNDED.
Form
990-PF
(2019)
Form 990-PF (2019)
Page
13
Part XVII
Information Regarding Transfers To and Transactions and Relationships With Noncharitable Exempt Organizations
1
Did the organization directly or indirectly engage in any of the following with any other organization described in section 501(c) (other than section 501(c)(3) organizations) or in section 527, relating to political organizations?
Yes
No
a
Transfers from the reporting foundation to a noncharitable exempt organization of:
(1)
Cash
...................................
1a(1)
No
(2)
Other assets
.................................
1a(2)
No
b
Other transactions:
(1)
Sales of assets to a noncharitable exempt organization
....................
1b(1)
No
(2)
Purchases of assets from a noncharitable exempt organization
..................
1b(2)
No
(3)
Rental of facilities, equipment, or other assets
.......................
1b(3)
No
(4)
Reimbursement arrangements
...........................
1b(4)
No
(5)
Loans or loan guarantees
.............................
1b(5)
No
(6)
Performance of services or membership or fundraising solicitations
................
1b(6)
No
c
Sharing of facilities, equipment, mailing lists, other assets, or paid employees
..............
1c
No
d
If the answer to any of the above is "Yes," complete the following schedule. Column
(b)
should always show the fair market value
of the goods, other assets, or services given by the reporting foundation. If the foundation received less than fair market value
in any transaction or sharing arrangement, show in column
(d)
the value of the goods, other assets, or services received.
(a)
Line No.
(b)
Amount involved
(c)
Name of noncharitable exempt organization
(d)
Description of transfers, transactions, and sharing arrangements
2a
Is the foundation directly or indirectly affiliated with, or related to, one or more tax-exempt organizations
described in section 501(c) (other than section 501(c)(3)) or in section 527?
...........
Yes
No
b
If "Yes," complete the following schedule.
(a)
Name of organization
(b)
Type of organization
(c)
Description of relationship
Sign Here
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
May the IRS discuss this return
with the preparer shown below
(see instr.)
Yes
No
Signature of officer or trustee
Date
Title
Paid Preparer Use Only
Print/Type preparer's name
Preparer's Signature
Date
Check if self-
employed
PTIN
Firm's name
Firm's EIN
Firm's address
Phone no.
Form
990-PF
(2019)
Additional Data
Software ID:
Software Version:
Form 990PF - Special Condition Description:
Special Condition Description