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) 2016 | (b) 2017 | (c) 2018 | (d) 2019 | (e) 2020 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") .. | ||||||
| 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 | ||||||
| 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).. | ||||||
| 6 | Public support. Subtract line 5 from line 4. | ||||||
Calendar year
(or fiscal year beginning in) ![]() |
(a) 2016 | (b) 2017 | (c) 2018 | (d) 2019 | (e) 2020 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 7 | Amounts from line 4.. | ||||||
| 8 | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources... | ||||||
| 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 | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2016 | (b) 2017 | (c) 2018 | (d) 2019 | (e) 2020 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") . | 150,901 | 150,901 | ||||
| 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 | 9,995 | 9,995 | ||||
| 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 | 160,896 | 160,896 | ||||
| 7a | Amounts included on lines 1, 2, and 3 received from disqualified persons | 40,201 | 40,201 | ||||
| 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.. | 40,201 | 40,201 | ||||
| 8 | Public support. (Subtract line 7c from line 6.) | 120,695 | |||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2016 | (b) 2017 | (c) 2018 | (d) 2019 | (e) 2020 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | 160,896 | 160,896 | ||||
| 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.).. | 160,896 | 160,896 | ||||
| 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 0.015 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 0.035 | 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 | 1 | |
|
2
Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity |
2 | |
| 3 Administrative expenses paid to accomplish exempt purposes of supported organizations | 3 | |
| 4 Amounts paid to acquire exempt-use assets | 4 | |
| 5 Qualified set-aside amounts (prior IRS approval required - provide details in Part VI) | 5 | |
| 6 Other distributions (describe in Part VI). See instructions | 6 | |
| 7Total annual distributions. Add lines 1 through 6. | 7 | |
|
8
Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions |
8 | |
| 9 Distributable amount for 2020 from Section C, line 6 | 9 | |
| 10 Line 8 amount divided by Line 9 amount | 10 | |
| Section E - Distribution Allocations (see instructions) |
(i) Excess Distributions |
(ii) Underdistributions Pre-2020 |
(iii) Distributable Amount for 2020 |
|
|---|---|---|---|---|
| 1 Distributable amount for 2020 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 2020: | ||||
| a From 2015....... | ||||
| b From 2016....... | ||||
| c From 2017....... | ||||
| d From 2018....... | ||||
| e From 2019....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2020 distributable amount | ||||
|
i
Carryover from 2015 not applied (see instructions) |
||||
| j Remainder. Subtract lines 3g, 3h, and 3i from line 3f. | ||||
| 4Distributions for 2020 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2020 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from line 4. | ||||
|
5
Remaining underdistributions for years prior to 2020, 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 2020. 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 2021. Add lines 3j and 4c. |
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| 8 Breakdown of line 7: | ||||
| a Excess from 2016..... | ||||
| b Excess from 2017..... | ||||
| c Excess from 2018..... | ||||
| d Excess from 2019..... | ||||
| e Excess from 2020..... | ||||
| Facts And Circumstances Test |
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| 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-EZ, PART I, LINE 16 | EXPENSES ADVERTISING 308 BANK CHARGES 1,040 DUES AND SUBS 311 MISC 300 LICENSES 650 MEDICAL AND DENTAL SUPPLIES 7,120 MED AND DENT SUPPLIES DONATED 15,817 OFFICE 2,445 INSURANCE 3,024 NON-INVESTMENT DEPRECIATION 12,905 TOTAL 43,920 |
| FORM 990-EZ, PART I, LINE 20 | NET ASSETS UNDER LCM ACCOUNTING YEARS 132,378 |
| FORM 990-EZ, PART II, LINE 24 | 3 EXAM TABLES 0 900 LESS ACCUMULATED DEPRECIATION 0 90 2 INSTRUMENT SUPPLY STANDS 0 170 LESS ACCUMULATED DEPRECIATION 0 17 AJUSCO LAMP 0 275 LESS ACCUMULATED DEPRECIATION 0 55 PULSE OXIMETER 0 30 LESS ACCUMULATED DEPRECIATION 0 6 AED 0 750 LESS ACCUMULATED DEPRECIATION 0 150 THERMOMETER 0 75 LESS ACCUMULATED DEPRECIATION 0 15 GLUCOMETER 0 10 LESS ACCUMULATED DEPRECIATION 0 3 3 BLOOD PRESSURE BASKETS 0 30 LESS ACCUMULATED DEPRECIATION 0 10 4 STETHOSCOPES 0 240 LESS ACCUMULATED DEPRECIATION 0 48 SECA STANDUP SCALE 0 150 LESS ACCUMULATED DEPRECIATION 0 30 2 WELSH ALLEN MOUNDS 0 1,000 LESS ACCUMULATED DEPRECIATION 0 200 4 AUTO BLOOD PRESSURE CUFFS 0 200 LESS ACCUMULATED DEPRECIATION 0 40 5 MANUAL BLOOD PRESSURE CUFFS 0 250 LESS ACCUMULATED DEPRECIATION 0 50 2 WELSH ALLEN OTOSCOPE SETS 0 400 LESS ACCUMULATED DEPRECIATION 0 80 2 WELSH ALLEN CHARGERS 0 500 LESS ACCUMULATED DEPRECIATION 0 100 AUTOCLAVE 0 2,000 LESS ACCUMULATED DEPRECIATION 0 400 CAVITRON PLUS PACKAGE 0 3,960 LESS ACCUMULATED DEPRECIATION 0 330 CASSETTE STERILIZER 0 7,800 LESS ACCUMULATED DEPRECIATION 0 650 ULTRASONIC INSTRUMENT CLEANER 0 400 LESS ACCUMULATED DEPRECIATION 0 80 4 DENTAL CHAIRS W/DELIVERY SYSTEM & 0 20,800 LESS ACCUMULATED DEPRECIATION 0 2,080 8 DR./ASSISTANT CHAIRS 0 2,800 LESS ACCUMULATED DEPRECIATION 0 280 2 INTRAORAL X-RAY UNITS 0 4,000 LESS ACCUMULATED DEPRECIATION 0 800 HANDHELD X-RAY UNIT 0 400 LESS ACCUMULATED DEPRECIATION 0 80 PANORAMIC X-RAY UNIT 0 9,000 LESS ACCUMULATED DEPRECIATION 0 900 X-RAY MACHINE - BURKHART (2019) 0 3,251 LESS ACCUMULATED DEPRECIATION 0 325 ULTRASONIC HYGIENIST SCALING UNIT 0 1,000 LESS ACCUMULATED DEPRECIATION 0 200 DENTAL AIR COMPRESSOR 0 2,500 LESS ACCUMULATED DEPRECIATION 0 500 DENTAL VACUUM UNIT 0 1,000 LESS ACCUMULATED DEPRECIATION 0 200 AMALGRAM SEPARATOR 0 500 LESS ACCUMULATED DEPRECIATION 0 100 4 DENTAL ROOM INSTRUMENTS 0 4,000 LESS ACCUMULATED DEPRECIATION 0 800 4 DENTAL ROOM INSTRUMENTS 0 4,000 LESS ACCUMULATED DEPRECIATION 0 800 COPY MACHINE 0 300 LESS ACCUMULATED DEPRECIATION 0 60 4 DESK CHAIRS 0 300 LESS ACCUMULATED DEPRECIATION 0 30 PAPER SHREDDER 0 100 LESS ACCUMULATED DEPRECIATION 0 20 3 FILE CABINETS 0 450 LESS ACCUMULATED DEPRECIATION 0 45 DESKTOP COMPUTER 0 500 LESS ACCUMULATED DEPRECIATION 0 100 1 DESKTOP, 8 LAPTOPS (FIREFLY 2019) 0 7,817 LESS ACCUMULATED DEPRECIATION 0 1,563 14 RECEPTION ROOM CHAIRS 0 420 LESS ACCUMULATED DEPRECIATION 0 42 3 BOOKCASES 0 90 LESS ACCUMULATED DEPRECIATION 0 9 2 TABLES 0 80 LESS ACCUMULATED DEPRECIATION 0 8 LARGE WOODEN CONF TABLE W/12 CHAIRS 0 700 LESS ACCUMULATED DEPRECIATION 0 70 CONFERENCE TABLE 0 200 LESS ACCUMULATED DEPRECIATION 0 20 REFRIGERATOR & MICROWAVE 0 160 LESS ACCUMULATED DEPRECIATION 0 32 6 SMALL TABLES 0 300 LESS ACCUMULATED DEPRECIATION 0 30 10 CHAIRS 0 300 LESS ACCUMULATED DEPRECIATION 0 30 SUPPLY SHELVING 0 250 LESS ACCUMULATED DEPRECIATION 0 25 SUPPLY SHELVING 0 250 LESS ACCUMULATED DEPRECIATION 0 25 2 FILE CABINETS SUPPLY STORAGE 0 240 LESS ACCUMULATED DEPRECIATION 0 24 PHARMACY MINI REFRIGERATOR 0 80 LESS ACCUMULATED DEPRECIATION 0 16 STACKABLE WASHER/DRYER 0 1,400 LESS ACCUMULATED DEPRECIATION 0 12 ELECTRICAL HOOKUP FOR WASHER/DRYER 0 2,449 LESS ACCUMULATED DEPRECIATION 0 20 PAINTING, SINKS, SANDBLASTING, MISC 0 3,511 LESS ACCUMULATED DEPRECIATION 0 351 PLUMBING, ETC TO OPERATE DENTAL EQUI 0 8,166 LESS ACCUMULATED DEPRECIATION 0 817 GRAYBEAL SIGNAGE 0 1,493 LESS ACCUMULATED DEPRECIATION 0 137 TOTAL 0 89,042 |
| FORM 990-EZ, PART II, LINE 26 | ACCOUNTS PAYABLE AND ACCRUED EXPENSES 0 2,584 |
| FORM 990-EZ, PART III | TO PROVIDE COMPASSIONATE, QUALITY MEDICAL AND DENTAL CARE FOR THE UNDERINSURED IN NORTH CENTRAL WASHINGTON. |
| FORM 990-EZ, PART III, LINE 28 | AS THE CASE FOR MANY ORGANIZATIONS, HOPE CARE CLINIC (HCC) WAS CLOSED FROM MARCH 16 THROUGH JULY 13, 2020 DUE TO COVID. HCC WAS ABLE TO BE OPEN FOR 35 TUESDAYS AND 11 FRIDAYS DURING 2020. HCC SERVED 272 PATIENTS DURING 2020. DENTAL SERVICES PROVIDED TO THOSE PATIENTS INCLUDED ASSESSMENTS, EXTRACTIONS AND BASIC RESTORATIVE PROCEDURES. MEDICAL SERVICES PROVIDED INCLUDED DIAGNOSIS AND TREATMENT OF URGENT MINOR INJURIES AND SCREENING FOR DIABETES AND HYPERTENSION. DURING 2020, HCC HAD 56 MEDICAL AND DENTAL PROFESSIONALS AND OFFICE SUPPORT WORKERS WHO VOLUNTEERED APPROXIMATELY 1,259 HOURS OF THEIR TIME DURING CLINIC HOURS. THE ESTIMATED VALUE OF THE PROFESSIONAL SERVICES PROVIDED WAS APPROXIMATELY 59,000 FOR THE YEAR. HCC ESTIMATES THAT IT'S 2020 FACILITY LEASE PAYMENTS OF 21,600 WERE APPROXIMATELY 1/2 OF WHAT A COMPARABLE FAIR MARKET VALUE LEASE WOULD BE. |
| Software ID: | |
| Software Version: |
| Person Name | Explanation |
|---|---|
| CAROL SEE | |
| ROGER HARRIS | |
| JIM FOSSE | |
| CAROL COSTON | |
| LINDA DIMMITT | |
| AMANDA KARSCHNICK | |
| BERNIE KOPFER | |
| VIRGINIA KERSTETTER |