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)
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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)
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(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) |
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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 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) |
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| 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. |
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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 |
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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, BOX C, DOING BUSINESS AS: | CHILDREN'S WISCONSIN - PRIMARY CARE |
| FORM 990, PART V, LINE 1A | THE ORGANIZATION DID NOT FILE ANY FORMS 1099 DURING THE TAXABLE YEAR. ALTHOUGH THE ORGANIZATION DID RETAIN INDEPENDENT CONTRACTORS, THE COMPENSATION AMOUNTS OWED TO SUCH CONTRACTORS WERE PROCESSED AND PAID BY A RELATED ENTITY, CHILDREN'S HOSPITAL OF WISCONSIN, INC. ("CHW"), WITH APPROPRIATE INTERCOMPANY ARRANGEMENTS BETWEEN THE ORGANIZATION AND CHW. THE FORMS 1099 FOR SUCH PAYMENTS WERE ISSUED BY CHW, AS THE ENTITY THAT PROCESSED AND MADE THE PAYMENTS TO THE INDEPENDENT CONTRACTORS. |
| FORM 990, PART VI, SECTION A, LINE 2 | BUSINESS RELATIONSHIPS EXIST BETWEEN THE FOLLOWING BOARD MEMBERS: TROY AND LEVY, AND TROY AND JARZEMBOWSKI. |
| FORM 990, PART VI, SECTION A, LINE 6 | THE ORGANIZATION HAS A SOLE CORPORATE MEMBER WHICH IS CHILDREN'S HOSPITAL AND HEALTH SYSTEM, INC. (CHHS). |
| FORM 990, PART VI, SECTION A, LINE 7A | CHHS, THE SOLE CORPORATE MEMBER OF THE ORGANIZATION, ELECTS THE ORGANIZATION'S GOVERNING BODY. |
| FORM 990, PART VI, SECTION A, LINE 7B | THE SOLE CORPORATE MEMBER, CHHS, HAS CERTAIN RESERVE POWERS OVER THE CORPORATION, INCLUDING AMENDMENT OF THE ARTICLES OF INCORPORATION AND BYLAWS; APPROVAL OF MERGER, CONSOLIDATION OR THE CREATION OF ANY SUBSIDIARIES BY THE CORPORATION; AND APPROVAL OF THE ANNUAL BUDGET AND ANY DEBT. THE PRESIDENT AND CHIEF EXECUTIVE OFFICER OF CHHS SELECTS THE PRESIDENT. |
| FORM 990, PART VI, SECTION B, LINE 11B | THE FORM 990 OF CMG WAS REVIEWED BY THE AUDIT AND COMPLIANCE COMMITTEE OF CHHS BOARD OF DIRECTORS, AND PRIOR TO FILING, A COPY WAS PROVIDED TO ALL DIRECTORS OF CMG. |
| FORM 990, PART VI, SECTION B, LINE 12C | ANNUALLY, ALL MEMBERS OF THE BOARD OF DIRECTORS, OFFICERS AND KEY EMPLOYEES ARE REQUESTED TO SUBMIT A CONFLICT OF INTEREST DISCLOSURE TO THE DIRECTOR OF CORPORATE COMPLIANCE. THE COMPLIANCE DEPARTMENT MONITORS AND PERIODICALLY REVIEWS TRANSACTIONS BETWEEN THE ORGANIZATION AND BOARD MEMBERS OR ENTITIES WITH WHICH THEY ARE AFFILIATED. |
| FORM 990, PART VI, SECTION B, LINE 15 | THE COMPENSATION OF THE ORGANIZATION'S OFFICERS WAS REVIEWED AND APPROVED BY THE INDEPENDENT COMPENSATION COMMITTEE OF CHHS (THE ORGANIZATION'S CORPORATE MEMBER). WITH THE ASSISTANCE OF AN INDEPENDENT COMPENSATION CONSULTANT AND INFORMATION FROM A VARIETY OF EXTERNAL SOURCES (AS INDICATED ON SCHEDULE J), THE COMMITTEE CONFIRMED THAT TOTAL COMPENSATION AMOUNTS TO BE PAID WERE REASONABLE AND COMPARABLE TO AMOUNTS PAID BY SIMILARLY SITUATED ORGANIZATIONS. THE PROCESS FOLLOWED BY THE COMMITTEE, INCLUDING THE DATA RELIED UPON AND THE COMMITTEE'S DECISIONS, WAS THOROUGHLY AND TIMELY DOCUMENTED. COMPENSATION OF THE KEY EMPLOYEE WAS SET BY SUPERVISORY EXECUTIVES IN CONSULTATION WITH CHHS HUMAN RESOURCES LEADERS. THE PROCESS INCLUDED REVIEW BY INDEPENDENT PERSONS WHO, USING A VARIETY OF EXTERNAL SOURCES (AS INDICATED ON SCHEDULE J), CONFIRMED THAT TOTAL COMPENSATION AMOUNTS TO BE PAID WERE REASONABLE AND COMPARABLE TO AMOUNTS PAID BY SIMILARLY SITUATED ORGANIZATIONS. THE PROCESS AND DATA RELIED ON WERE THOROUGHLY AND TIMELY DOCUMENTED. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL INFORMATION OF CMG ARE AVAILABLE TO THE PUBLIC UPON REQUEST THROUGH THE CHHS MARKETING AND COMMUNICATION DEPARTMENT. |
| FORM 990, PART I, LINE 4 AND PART VI, LINE 1B | CHILDREN'S MEDICAL GROUP, INC. ("CMG") IS A WISCONSIN NONSTOCK CORPORATION. CMG IS AN AFFILIATE OF CHILDREN'S HOSPITAL AND HEALTH SYSTEM, INC. ("CHHS"), A TAX-EXEMPT WISCONSIN CORPORATION SERVING AS THE PARENT ENTITY OF AN INTEGRATED SYSTEM OF PROVIDER ORGANIZATIONS ADDRESSING THE HEALTH CARE NEEDS OF CHILDREN IN SOUTHEASTERN WISCONSIN AND SURROUNDING AREAS. AS THE CORPORATE MEMBER OF CMG, CHHS HOLDS VARIOUS RESERVE POWERS IN RELATION TO CMG, INCLUDING AUTHORITY TO APPOINT CMG'S BOARD OF DIRECTORS. THE BOARD OF DIRECTORS OF CMG CONSISTS OF CERTAIN PHYSICIANS WHO ARE EMPLOYED BY CMG, ALONG WITH REPRESENTATIVES OF CHHS'S EXECUTIVE LEADERSHIP. AS EMPLOYEES OF EITHER CMG OR CHHS, NONE OF THESE DIRECTORS MAY BE CONSIDERED "INDEPENDENT" FOR PURPOSES OF FORM 990. HOWEVER, AS ACKNOWLEDGED BY THE IRS IN ITS CPE TEXT FOR FISCAL YEAR 1997, IN A MULTI ENTITY HOSPITAL SYSTEM, THE BOARD OF A SUBSIDIARY NON-PROFIT HEALTH CARE ORGANIZATION IS CONSIDERED TO BE COMPRISED OF INDEPENDENT COMMUNITY MEMBERS IF IT IS CONTROLLED BY AN EXEMPT ORGANIZATION WHOSE BOARD IS COMPRISED OF A MAJORITY OF VOTING MEMBERS WHO ARE INDEPENDENT COMMUNITY MEMBERS. CMG MEETS THIS STANDARD BECAUSE IT IS A CONTROLLED SUBSIDIARY OF CHHS, AND CHHS'S GOVERNING BOARD INCLUDES INDEPENDENT COMMUNITY MEMBERS AS A MAJORITY THEREOF. |
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