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 | |||||
| (A)
DELTA DENTAL OF IOWA |
420959302 | 10 | Yes | 0 | 0 | |
|
Total 1
|
0 | 0 | ||||
Calendar year
(or fiscal year beginning in)
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(a) 2017 | (b) 2018 | (c) 2019 | (d) 2020 | (e) 2021 | (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) 2017 | (b) 2018 | (c) 2019 | (d) 2020 | (e) 2021 | (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) 2017 | (b) 2018 | (c) 2019 | (d) 2020 | (e) 2021 | (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) 2017 | (b) 2018 | (c) 2019 | (d) 2020 | (e) 2021 | (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 on 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) |
||||
| 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) |
||||
| 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 2021 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-2021 |
(iii) Distributable Amount for 2021 |
|
|---|---|---|---|---|
| 1 Distributable amount for 2021 from Section C, line 6 | ||||
|
2
Underdistributions, if any, for years prior to 2021 (reasonable cause required-- explain in Part VI). See instructions. |
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| 3 Excess distributions carryover, if any, to 2021: | ||||
| a From 2016....... | ||||
| b From 2017....... | ||||
| c From 2018....... | ||||
| d From 2019....... | ||||
| e From 2020....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2021 distributable amount | ||||
|
i
Carryover from 2016 not applied (see instructions) |
||||
| j Remainder. Subtract lines 3g, 3h, and 3i from line 3f. | ||||
| 4Distributions for 2021 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2021 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from line 4. | ||||
|
5
Remaining underdistributions for years prior to 2021, 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 2021. Subtract lines 3h and 4b from line 1. If the amount is greater than zero, explain in Part VI. See instructions. |
||||
|
7 Excess distributions carryover to 2022. Add lines 3j and 4c. |
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| 8 Breakdown of line 7: | ||||
| a Excess from 2017..... | ||||
| b Excess from 2018..... | ||||
| c Excess from 2019..... | ||||
| d Excess from 2020..... | ||||
| e Excess from 2021..... | ||||
| Facts And Circumstances Test |
|---|
| Return Reference | Explanation |
|---|---|
| SCHEDULE A, PART 1, LINE 12G, COLUMN V: | DELTA DENTAL OF IOWA'S MISSION IS TO STRENGTHEN AND TRANSFORM THE HEALTH AND SMILES OF THE PEOPLE WE SERVE. AN AMOUNT IS SET ASIDE EACH YEAR TO FUND THIS MISSION. THE AMOUNT IS DETERMINED BY THE PERFORMANCE AND FINANCIAL STRENGTH OF DELTA DENTAL. AFTER THE AUDITED FINANCIALS ARE COMPLETE, THE AMOUNT IS PAID TO THE FOUNDATION. THE FOUNDATION IS A SEC. 501(C)(3) ORGANIZATION AND IS A TYPE 1 SUPPORTING ORGANIZATION UNDER SEC. 509(A)(3). IT IS THE RESPONSIBILITY OF THE FOUNDATION TO DISTRIBUTE THE MONIES CONSISTENT WITH ITS MISSION AND FOUNDING DOCUMENTS. THE MISSION OF THE FOUNDATION IS TO STRENGTHEN AND TRANSFORM THE HEALTH AND SMILES OF ALL IOWANS. THE FOUNDATION WILL PROVIDE FUNDS TO OTHER SEC. 501(C)(3) ORGANIZATIONS, GOVERNMENTS, OR ACADEMIC INSTITUTIONS THROUGH THEIR GRANTS PROGRAM THAT ALIGN WITH THE PROJECTS OF ORAL HEALTH, ORAL AND OVERALL HEALTH INTEGRATION AND OVERALL HEALTH. THE AMOUNT CONTRIBUTED TO THE FOUNDATION IN 2021 WAS $5,600,000. |
| SCHEDULE A, PART IV, LINE 3B: | DELTA DENTAL OF IOWA HAS PROVIDED A COPY OF THEIR 501(C)(4) IRS DETERMINATION LETTER AND HAS COMPLETED THE PROFORMA PUBLIC SUPPORT CALCULATIONS FOR THE APPLICABLE YEARS. DURING THE CURRENT YEAR, DELTA DENTAL OF IOWA MET THE PUBLIC SUPPORT TEST REQUIREMENTS. DELTA DENTAL OF IOWA FOUNDATION HAS A FORMAL POLICY APPROVED BY THE BOARD TO ANNUALLY CONFIRM THAT DELTA DENTAL OF IOWA HAS MAINTAINED ITS SUPPORTED ORGANZATION STATUS AS A 501(C)(4) AND HAS SATISIFIED THE PUBLIC SUPPORT TESTS UNDER SECTION 509(A)(2) OF THE INTERNAL REVENUE CODE. |
| SCHEDULE A, PART IV, LINE 3C: | ALL GRANTEES THAT RECEIVE FUNDS FROM THE DELTA DENTAL OF IOWA FOUNDATION ARE REQUIRED TO COMPLETE AN OUTCOMES REPORT WITHIN 30 DAYS OF COMPLETION OF THE PROJECT. FOR GRANTEES UNDER $25,000, THIS INCLUDES INFORMATION SUCH AS NUMBER OF INDIVIDUALS SERVICED, CHALLENGES, OPPORTUNITIES AND LESSONS LEARNED. FOR GRANTEES THAT RECEIVE OVER $25,000 AN EVALUATION PLAN IS DEVELOPED IN COORDINATION WITH THE GRANTEE AND THE FOUNDATION SPECIFIC TO THE PROJECT AND TO ALIGN WITH A CORE SET OF INDICATORS OF SUCCESS. IN ADDITION, GRANTEES OVER $50,000 PRESENT TO THE DELTA DENTAL OF IOWA FOUNDATION BOARD AT THE COMPLETION OF THE PROJECT. GRANTEES MAY REQUEST A ONE TIME EXTENSION TO SPEND DOWN ANY UNUSED FUNDS, BUT IT MUST BE FOR THE SAME PROJECT OTHERWISE THEY FUNDS ARE REQUIRED TO BE RETURNED. ANY CHANGE FROM THE INITIAL REQUEST FOR FUNDS REQUIRES A WRITTEN REQUEST AND APPROVAL. |
| 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 2 | J. RUSSELL HAD A GOVERNMENT PROGRAM RELATED BUSINESS RELATIONSHIP WITH BOARD MEMBER T. RODGERS IN 2021. J. CHAFFIN HAD A GOVERNMENT PROGRAM RELATED BUSINESS RELATIONSHIP WITH BOARD MEMBER T. RODGERS IN 2021. S. HECKENLAIBLE HAD A GOVERNMENT PROGRAM RELATED BUSINESS RELATIONSHIP WITH BOARD MEMBER T. RODGERS IN 2021. T. RODGERS HAD BUSINESS RELATIONSHIPS WITH L. CURRY, H. COWEN, D. CAPLAN, N. EGBUONYE, J. RUSSELL, S. HECKENLAIBLE, AND J. CHAFFIN IN 2021. L. CURRY HAD A BUSINESS RELATIONSHIP WITH T. RODGERS IN 2021. D. CAPLAN HAD A BUSINESS RELATIONSHIP WITH H. COWEN, K. JONES, AND T. RODGERS IN 2021. H. COWEN HAD A BUSINESS RELATIONSHIP WITH T. RODGERS AND D. CAPLAN IN 2021. N. EGBUONYE HAD A BUSINESS RELATIONSHIP WITH T. RODGERS IN 2021. |
| FORM 990, PART VI, SECTION A, LINE 6 | THE FOUNDATION SHALL HAVE ONE MEMBER, WHICH SHALL BE DELTA DENTAL OF IOWA ("DELTA DENTAL"), A SECTION 501(C)(4) ORGANIZATION. |
| FORM 990, PART VI, SECTION A, LINE 7A | EACH DIRECTOR SHALL BE ELECTED BY THE MEMBER. IN ELECTING DIRECTORS, THE MEMBER MAY SEEK RECOMMENDATIONS FROM THE FOUNDATION'S BOARD OR A COMMITTEE OF THE BOARD. |
| FORM 990, PART VI, SECTION B, LINE 11B | THE FORM 990 AND ALL RELATED SCHEDULES WERE REVIEWED BY BOTH THE MANAGEMENT OF THE FOUNDATION AND THE BOARD OF DIRECTORS PRIOR TO FILING. THE FORM 990 WAS REVIEWED BY MANAGEMENT OF THE FOUNDATION PRIOR TO PRESENTATION TO THE BOARD OF DIRECTORS. THE MEMBERS OF THE MANAGEMENT TEAM WHO REVIEWED THE FORM 990 WERE THE PRESIDENT, SECRETARY/TREASURER, AND EXECUTIVE DIRECTOR. A COPY OF THE FORM 990 WAS PROVIDED TO ALL BOARD MEMBERS FOR REVIEW PRIOR TO FILING THE FORM 990. |
| FORM 990, PART VI, SECTION B, LINE 12C | CONSISTENT WITH ITS CONFLICT OF INTEREST POLICY, ANNUALLY THE FOUNDATION CONDUCTS A CONFLICT OF INTEREST REVIEW FOR COMPLIANCE WITH FEDERAL AND STATE LAW AND COMPANY POLICY. THE REVIEW INCLUDES ALL OFFICERS AND DIRECTORS. COMPLETED CONFLICT OF INTEREST QUESTIONNAIRES AND DISCLOSURES ARE COMPARED TO THE GROUP FOR POTENTIALLY CONFLICTING TRANSACTIONS, BUSINESS AND FAMILY RELATIONSHIPS AND AFFILIATIONS. A WRITTEN REPORT OF THE FINDINGS IS GIVEN TO THE BOARD OF DIRECTORS AND OFFICERS. THE CONFLICT OF INTEREST POLICY PROVIDES GUIDANCE ON ACTIONS AND SPECIFIC SOLUTIONS TO ADDRESS CONFLICTS WHEN THEY OCCUR. THE SOLUTIONS PROVIDED BY THE GUIDANCE ARE DISCUSSED AND DOCUMENTED IN THE BOARD OF DIRECTOR'S MEETING MINUTES. |
| FORM 990, PART VI, SECTION B, LINE 15 | THE EXECUTIVE DIRECTOR AND OFFICERS EXCLUDING THE CHAIR AND VICE CHAIR OF THE BOARD ARE EMPLOYEES OF DELTA DENTAL. DELTA DENTAL OF IOWA CHARGES THE FOUNDATION A MANAGEMENT FEE FOR THE TIME SPENT BY THE PRESIDENT, SECRETARY AND TREASURER, AND EXECUTIVE DIRECTOR. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE FOUNDATION'S ARTICLES OF INCORPORATION BECOME A MATTER OF PUBLIC RECORD WHEN THEY ARE FILED WITH THE IOWA SECRETARY OF STATE. THE FINANCIAL STATEMENTS BECOME A MATTER OF PUBLIC RECORD WHEN THEY ARE FILED AS PART OF THE FORM 990 WITH THE IRS. THE CONFLICT OF INTEREST POLICY IS NOT FILED WITH ANY AGENCY; HOWEVER, IT WOULD BE MADE AVAILABLE UPON REQUEST. ALL GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS WOULD BE MADE AVAILABLE UPON REQUEST. |
| FORM 990, PART XI, LINE 9: | RETURN OF GRANTS 4,776. |
| FORM 990, PART VI, SECTION B, LINE 13: | THE FOUNDATION DOES NOT HAVE A WHISTELEBLOWER POLICY AS IT HAS NO EMPLOYEES. THE FOUNDATION PURCHASES MANAGEMENT SERVICES FROM DELTA DENTAL. DELTA DENTAL OF IOWA HAS A WRITTEN WHISTLEBLOWER POLICY THAT ALL EMPLOYEES ARE SUBJECT TO. |
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