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.") .. | 1,464,075 | 1,836,089 | 3,709,973 | 1,567,254 | 596,177 | 9,173,568 |
| 2 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.... | ||||||
| 3 | The value of services or facilities furnished by a governmental unit to the organization without charge.. | ||||||
| 4 | Total. Add lines 1 through 3 | 1,464,075 | 1,836,089 | 3,709,973 | 1,567,254 | 596,177 | 9,173,568 |
| 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).. | 1,345,781 | |||||
| 6 | Public support. Subtract line 5 from line 4. | 7,827,787 | |||||
Calendar year
(or fiscal year beginning in) ![]() |
(a) 2016 | (b) 2017 | (c) 2018 | (d) 2019 | (e) 2020 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 7 | Amounts from line 4.. | 1,464,075 | 1,836,089 | 3,709,973 | 1,567,254 | 596,177 | 9,173,568 |
| 8 | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources... | 17,498 | 1,470 | 1,194 | 2,080 | 0 | 22,242 |
| 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.).. | 220,462 | 195,334 | 270,071 | 24,069 | 106,616 | 816,552 |
| 11 | Total support. Add lines 7 through 10 | 10,012,362 | |||||
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.") . | ||||||
| 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) 2016 | (b) 2017 | (c) 2018 | (d) 2019 | (e) 2020 | (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 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) |
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| 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 |
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| 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, PART VI, SECTION A, LINE 4 | THE GOVERNING DOCUMENTS WERE AMENDED UPON ACQUISITION TO REFLECT CHILDREN'S HEALTHCARE OF CALIFORNIA (CHC) AS THE SOLE MEMBER. |
| FORM 990, PART VI, SECTION A, LINE 6 | THE SOLE MEMBER OF PROVIDENCE SPEECH AND HEARING CENTER (PSHC) IS CHC. |
| FORM 990, PART VI, SECTION A, LINE 7A | THE SOLE MEMBER, CHC, HAS THE POWERS DETAILED IN LINE 7B. |
| FORM 990, PART VI, SECTION A, LINE 7B | THE APPROVAL OF THE MEMBER SHALL BE REQUIRED WITH RESPECT TO ANY OF THE FOLLOWING ACTIONS: (1) CHANGING THE PURPOSES AND POWERS OF PSHC; (2) OBLIGATING PSHC TO UNDERTAKE ANY CAPITAL EXPENDITURE IN EXCESS OF $5,000,000; (3) ADOPTING PSHC'S ANNUAL OPERATING AND CAPITAL BUDGETS; (4) ADOPTING A LONG-TERM CAPITAL BUDGET; (5) BUYING, SELLING, LEASING, MORTGAGING, PLEDGING, OR OTHERWISE HYPOTHECATING ANY REAL PROPERTY; (6) INCURRING ANY INDEBTEDNESS IN EXCESS OF $5,000,000; (7) OBLIGATING PSHC TO ACT AS GUARANTOR WITH RESPECT TO ANY DEBT OF ANY PERSON OR OTHER ENTITY; (8) ACCEPTING ANY DONATION WHICH IS CONDITIONED UPON PSHC'S UNDERTAKING ANY UNBUDGETED CAPITAL EXPENDITURE IN EXCESS OF $5,000,000 OR ANY UNBUDGETED EXPENDITURE IN EXCESS OF $5,000,000; (9) ENTERING INTO ANY CONTRACT WHICH INVOLVES THE FOLLOWING: (A) ANY FINANCIAL OBLIGATION ON THE PART OF PSHC IN AN AMOUNT IN EXCESS OF $5,000,000 OR (B) ANY PURPOSE OR ACTIVITY WHICH IS OUTSIDE THE SCOPE OF PSHC'S ORDINARY COURSE OF BUSINESS. (10) INVOLVING PSHC IN ANY MERGER, ACQUISITION, CORPORATE RESTRUCTURING, OR FORMAL AFFILIATION; (11) INVOLVING PSHC AS A MEMBER, SHAREHOLDER, OR PARTNER IN ANY NEW CORPORATION, PARTNERSHIP, OR OTHER LEGAL ENTITY; (12) DISSOLVING PSHC; (13) ENTERING INTO ANY TRANSACTION INVOLVING THE SALE, CONVEYANCE, EXCHANGE, TRANSFER OR OTHER DISPOSITION OF ALL OR SUBSTANTIALLY ALL OF PSHC'S ASSETS; (14) AMENDING PSHC'S ARTICLES OF INCORPORATION; (15) ADOPTING NEW BYLAWS OR AMENDING EXISTING BYLAWS. |
| FORM 990, PART VI, SECTION B, LINE 11B | THE CEO, CFO, THE CHAIRMAN OF THE FINANCE COMMITTEE AND MEMBERS WILL HAVE REVIEWED THE COMPLETED FORM 990 FOR COMPLETENESS AND ACCURACY PRIOR TO ITS SUBMISSION TO THE INTERNAL REVENUE SERVICE. IN ADDITION, A COPY OF THE COMPLETED AND REVIEWED FORM 990 WILL BE SUBMITTED TO EACH BOARD MEMBER PRIOR TO THE SCHEDULED BOARD MEETING FOR REVIEW AND APPROVAL PRIOR TO ITS SUBMISSION TO THE INTERNAL REVENUE SERVICE. |
| FORM 990, PART VI, SECTION B, LINE 12C | THE BOARD OR DESIGNATED COMMITTEE REVIEWS ANY CONFLICTS PRESENTED BY INTERESTED PARTIES. ALL BOARD MEMBERS SHALL COMPLETE A CONFLICT OF INTEREST STATEMENT AND BE RESPONSIBLE FOR UPDATING PERTINENT INFORMATION TO REFLECT APPLICABLE CHANGES. THE STATEMENT WILL BE RETAINED IN THE PSHC DATABASE AND BE MADE AVAILABLE FOR REVIEW UPON REQUEST OF THE BOARD PRESIDENT, EXECUTIVE DIRECTOR, OR ANY AUTHORIZED AUDITING ENTITY. |
| FORM 990, PART VI, SECTION B, LINE 15 | ON AN ANNUAL BASIS THE PERSONNEL COMMITTEE OF THE BOARD OF DIRECTORS REVIEWS AND SUBMITS SALARY RECOMMENDATIONS FOR THE CEO AND OTHER TOP MANAGEMENT POSITIONS OF THE COMPANY TO THE BOARD OF DIRECTORS FOR APPROVAL. IN DETERMINING APPROPRIATE SALARY RECOMMENDATIONS, THE PERSONNEL COMMITTEE USES COMMUNITY SURVEYS AND A NATIONAL DATABASE TO DETERMINE COMPENSATION. IN ADDITION, ANNUAL SURVEYS ARE CONDUCTED BASED UPON AVAILABLE NATIONAL, STATE, AND LOCAL MARKET DATA FOR EACH POSITION WITHIN THE COMPANY. |
| FORM 990, PART VI, SECTION C, LINE 19 | WE MAKE OUR GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICIES AND FINANCIAL INFORMATION AVAILABLE TO THE GENERAL PUBLIC UPON REQUEST EITHER THROUGH OUR WEBSITE OR IN PERSON. |
| FORM 990, PART XII, LINE 2 | CHANGE OF OVERSIGHT OR SELECTION PROCESS THE ORGANIZATION HAS AN AUDIT COMMITTEE THAT ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THE OVERSIGHT PROCESS OR SELECTION PROCESS HAS NOT CHANGED DURING THE YEAR. BELOW ARE THE DUTIES AND MEMBERSHIP CRITERIA OF THE AUDIT COMMITTEE: DUTIES: - RECOMMENDS ACCOUNTING FIRM RETENTION AND TERMINATION - NEGOTIATES THE ACCOUNTING FIRM'S COMPENSATION - CONFERS WITH THE ACCOUNTING FIRM TO ASSURE FINANCIAL AFFAIRS ARE IN ORDER - DETERMINES WHETHER TO ACCEPT THE AUDIT - APPROVES PERFORMANCE NON-AUDIT SERVICES TO BE PROVIDED BY ACCOUNTING FIRM - REPORTS AUDIT FINDINGS TO BOARD OF DIRECTORS - ENSURES THAT AUDIT RECOMMENDATIONS ARE ADEQUATELY AND TIMELY IMPLEMENTED BY STAFF MEMBERSHIP: - CHAIRPERSON MAY NOT BE A FINANCE COMMITTEE MEMBER - FINANCE COMMITTEE MEMBERS MUST COMPRISE LESS THAN 50% OF MEMBERSHIP - MAY INCLUDE NON BOARD OF DIRECTOR MEMBERS - NO MEMBER OF STAFF, INCLUDING MANAGEMENT - NO PERSON WITH A MATERIAL FINANCIAL INTEREST IN AN ENTITY DOING BUSINESS WITH PROVIDENCE SPEECH AND HEARING CENTER |
| FORM 990, PART XI, LINE 9: | VALUATION CHANGE UPON ACQUISITION 6,731,858. |
| Software ID: | |
| Software Version: |