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.") .. | ||||||
| 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) 2015 | (b) 2016 | (c) 2017 | (d) 2018 | (e) 2019 | (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) 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 |
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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 ORGANIZATION ADDED A WHISTLEBLOWER POLICY |
| FORM 990, PART VI, SECTION A, LINE 6 | THE FOLLOWING PHYSICIANS ARE ELIGIBLE TO JOIN THE FOUNDATION AS MEMBERS - THOSE WHO: ARE MEMBERS OF THE STAFF ASSOCIATION OF RHODE ISLAND HOSPITAL (RIH) AND THE MIRIAM HOSPITAL (TMH), AND HOLD PROFESSIONAL STAFF APPOINTMENTS WITHIN THE DEPARTMENT OF EMERGENCY MEDICINE AT RIH OR THE DIVISION OF EMERGENCY MEDICINE AT TMH, AND EITHER HOLD A FACULTY APPOINTMENT IN THE BROWN UNVERSITY MEDICAL SCHOOL (BROWN) OR HAVE BEEN EMPLOYED BY THE FOUNDATION FOR LESS THAN ONE YEAR AND HAVE AGREED TO APPLY FOR A BROWN FACULTY APPOINTMENT, AND ARE APPROVED BY THE RIH CHIEF OF THE DEPARTMENT OF EMERGENCY MEDICINE AND THE FOUNDATION'S BOARD OF DIRECTORS, AND WILL BE EMPLOYED BY THE FOUNDATION TO CONDUCT THEIR PRACTICE OF MEDICINE EXCLUSIVELY ON BEHALF OF THE FOUNDATION, UNLESS OTHERWISE RECOMMENDED BY THE PRESIDENT AND APROVED BY THE BOARD, AND WILL BE BOARD CERIFIED OR BOARD ELIGIBLE IN EMERGENCY MEDICINE OR PEDIATRIC EMERGENCY MEDICINE, UNLESS OTHERWISE RECOMMENDED BY THE PRESIDENT AND APPROVED BY THE BOARD. EACH SUCH ELIGIBLE PHYSICIAN WHO HAS IN EFFECT AN EMPLOYMENT AGREEMENT WITH THE FOUNDATION SHALL BE A MEMBER OF THE FOUNDATION AS LONG AS THE EMPLOYMENT AGREEMENT IS IN A FORM APPROVED BY THE BOARD AND THE CHIEF OF EMERGENCY MEDICINE (RIH). |
| FORM 990, PART VI, SECTION A, LINE 7A | THE BOARD OF DIRECTORS SHALL BE COMPRISED OF NO MORE THAN TEN (10) VOTING DIRECTORS, COMPRISED AS FOLLOWS: (A) THE PRESIDENT OF THE CORPORATION, EX OFFICIO, WITH VOTE; (B) THE PRESIDENT AND CHIEF EXECUTIVE OFFICER OF LIFESPAN CORPORATION, A RHODE ISLAND NON-PROFIT CORPORATION WHICH IS THE SOLE MEMBER OF RIH, TMH AND OTHER NON-PROFIT HEALTH CARE PROVIDERS ("LIFESPAN CEO"), OR HIS/HER DESIGNEE, EX OFFICIO, WITH VOTE; (C) THE DEAN OF MEDICINE OF BROWN ("DEAN") OR HIS/HER PHYSICIAN DESIGNEE, EX OFFICIO, WITH VOTE; (D) UP TO SEVEN (7) CLASS A MEMBERS OF THE CORPORATION ELECTED BY THE CLASS A MEMBERS AT THEIR ANNUAL MEETING OR ANY SPECIAL MEETING HELD IN LIEU THEREOF BASED ON NOMINATIONS MADE BY THE NOMINATING COMMITTEE (EACH AN "AT-LARGE DIRECTOR"). ONE (1) AT-LARGE DIRECTOR MUST BE A PEDIATRIC EMERGENCY MEDICINE MEMBER ELECTED BY THE CLASS A MEMBERS (NOT ONLY PEDIATRICIAN MEMBERS) FROM A SLATE OF NOMINEES CONSISTING ONLY OF PEDIATRIC EMERGENCY PHYSICIANS (THE "PED.EM AT-LARGE DIRECTOR"). PEDIATRIC EMERGENCY PHYSICIAN MEMBERS MAY ALSO BE NOMINATED AND ELECTED WITHOUT LIMIT TO SERVE AS REGULAR AT-LARGE DIRECTORS. |
| FORM 990, PART VI, SECTION A, LINE 7B | THERE WILL BE AN ANNUAL MEETING OF THE MEMBERS HELD IN THE MONTH OF DECEMBER EACH YEAR. THERE MAY ALSO BE SPECIAL MEETINGS OF THE MEMBERS, WHICH CAN BE CALLED BY THE PRESIDENT, BY THE BOARD, OR BY 2/3 VOTE OF THE MEMBERS ENTITLED TO VOTE. THERE ARE REQUIREMENTS FOR PROVIDING NOTICE OF THE MEETINGS TO THE MEMBERS. EACH MEMBER SHALL BE ENTITLED TO ONE VOTE. VACANCIES IN THE BOARD OR IN ANY CORPORATE OFFICE MAY BE FILLED BY ELECTION BY THE REMAINING DIRECTORS AT ANY REGULAR OR SPECIAL MEETING, BUT IF A VACANCY EXISTS AT THE TIME OF ANY MEMBERS MEETING, IT SHALL BE FILLED BY ELECTION AT SAID MEETING. AN AT-LARGE DIRECTOR MAY BE REMOVED FROM OFFICE WITH OR WITHOUT CAUSE AT ANY ANNUAL, REGULAR, OR SPECIAL MEETING OF MEMBERS BY VOTE OF AT LEAST 2/3 OF THE MEMBERS ENTITLED TO VOTE IN THE ELECTION OF SUCH DIRECTORS AND PRESENT IN PERSON OR BY PROXY AT A MEETING IN WHICH A QUORUM (MAJORITY) IS PRESENT, OR FOR CAUSE BY A VOTE OF A MAJORITY OF THE DIRECTORS THEN IN OFFICE AND PRESENT AT A MEETING IN WHICH A QUORUM IS PRESENT; PROVIDED, HOWEVER, THAT A DIRECTOR MAY BE REMOVED FOR CAUSE ONLY AFTER REASONABLE NOTICE AND OPPORTUNITY TO BE HEARD BEFORE THE BODY PROPOSING TO REMOVE HIM/HER. |
| FORM 990, PART VI, SECTION B, LINE 11B | THE FORM 990 IS PREPARED BY THE EXTERNAL AUDITORS AND REVIEWED BY MANAGEMENT AND THE AUDIT COMMITTEE. |
| FORM 990, PART VI, SECTION B, LINE 12C | EACH YEAR THE ORGANIZATION'S CONFLICT OF INTEREST POLICY IS PROVIDED TO ALL OFFICERS, DIRECTORS, AND KEY EMPLOYEES. THESE PEOPLE ARE ASKED TO REVIEW THE POLICY AND SIGN A STATEMENT INDICATING THAT THEY UNDERSTAND THE POLICY, HAVE REPORTED ALL POTENTIAL CONFLICTS DURING THE PAST YEAR IN ACCORDANCE WITH THE POLICY AND WILL REPORT ALL POTENTIAL CONFLICTS DURING THE COMING YEAR. ALL POTENTIAL CONFLICTS ARE EVALUATED BY THE BOARD TO DETERMINE IF A CONFLICT ACTUALLY EXISTS (AN ATTORNEY IS PRESENT AT EACH BOARD MEETING). IN THOSE INSTANCES WHERE THE POTENTIAL TRANSACTION IS A CONFLICT, THE BOARD EXAMINES THE TRANSACTION AND A VOTE IS TAKEN (WITH THOSE INVOLVED RECUSING THEMSELVES) AS TO WHETHER THE ORGANIZATION WILL ENTER INTO THE TRANSACTION. |
| FORM 990, PART VI, SECTION B, LINE 15 | AN INDEPENDENT COMPENSATION COMMITTEE CONDUCTS A PERFORMANCE REVIEW AND EVALUATION OF ALL MEMBER COMPENSATION, INCLUDING THE PRESIDENT. THIS PROCESS INVOLVES THE EVALUATION OF THE INDIVIDUAL AND A REVIEW OF COMPENSATION OF COMPARABLE POSITIONS OBTAINED FROM PUBLISHED SURVEYS OF INDUSTRY DATA. THE COMMITTEE'S DELIBERATION AND DECISION IS NOTED IN THE MINUTES OF THE MEETING. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS (ARTICLES OF INCORPORATION AND BY-LAWS, INCLUDING ITS CONFLICT OF INTEREST POLICY) AND FINANCIAL STATEMENTS AVAILABLE UPON REQUEST. THE ORGANIZATION WILL MAIL COPIES UPON REQUEST OR PROVIDE COPIES TO THOSE WHO COME TO THE ADMINISTRATIVE OFFICE DURING NORMAL BUSINESS HOURS. THE ORGANIZATION CHARGES FOR THE COPIES IN ACCORDANCE WITH IRS REGULATIONS. |
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| Software Version: |