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) 2018 | (b) 2019 | (c) 2020 | (d) 2021 | (e) 2022 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") .. | 1,918,171 | 1,535,203 | 55,267 | 4,546 | 0 | 3,513,187 |
| 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 | 1,918,171 | 1,535,203 | 55,267 | 4,546 | 3,513,187 | |
| 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) .. | 59,818 | |||||
| 6 | Public support. Subtract line 5 from line 4. | 3,453,369 | |||||
Calendar year
(or fiscal year beginning in)
![]() |
(a) 2018 | (b) 2019 | (c) 2020 | (d) 2021 | (e) 2022 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 7 | Amounts from line 4.. | 1,918,171 | 1,535,203 | 55,267 | 4,546 | 3,513,187 | |
| 8 | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources... | 141,200 | 326,892 | 51,013 | 219,391 | 289,703 | 1,028,199 |
| 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.).. | 167,095 | 171,066 | 338,161 | |||
| 11 | Total support. Add lines 7 through 10 | 4,879,547 | |||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2018 | (b) 2019 | (c) 2020 | (d) 2021 | (e) 2022 | (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) 2018 | (b) 2019 | (c) 2020 | (d) 2021 | (e) 2022 | (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 2022 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-2022 |
(iii) Distributable Amount for 2022 |
|
|---|---|---|---|---|
| 1 Distributable amount for 2022 from Section C, line 6 | ||||
|
2
Underdistributions, if any, for years prior to 2022 (reasonable cause required-- explain in Part VI).
See instructions. |
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| 3 Excess distributions carryover, if any, to 2022: | ||||
| a From 2017....... | ||||
| b From 2018....... | ||||
| c From 2019....... | ||||
| d From 2020....... | ||||
| e From 2021....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2022 distributable amount | ||||
|
i
Carryover from 2017 not applied (see instructions) |
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| j Remainder. Subtract lines 3g, 3h, and 3i from line 3f. | ||||
| 4Distributions for 2022 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2022 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from line 4. | ||||
|
5
Remaining underdistributions for years prior to 2022, 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 2022. 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 2023. Add lines 3j and 4c. |
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| 8 Breakdown of line 7: | ||||
| a Excess from 2018..... | ||||
| b Excess from 2019..... | ||||
| c Excess from 2020..... | ||||
| d Excess from 2021..... | ||||
| e Excess from 2022..... | ||||
| 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 - EXPLANATION | ON OCTOBER 14, 2020, THE BOARD OF DIRECTORS ADOPTED A PLAN OF DISSOLUTION FOR THE ORGANIZATION. THE PLAN OF DISSOLUTION WAS PROVIDED TO THE STATE OF TENNESSEE ATTORNEY GENERAL AS REQUIRED BY TENNESSEE CODE ANNOTATED SECTION 48-64-103. ON FEBRUARY 14, 2022, THE ATTORNEY GENERAL ("AG")OF TENNESSEE ADVISED, UPON REVIEW OF THE PLAN OF DISSOLUTION, NO ACTION WOULD BE TAKEN BY THE AG'S OFFICE. THE ORGANIZATION IS IN THE PROCESS OF FINALIZING THE DISSOLUTION AND EXPECTS TO COMPLETE DISSOLUTION IN 2024 AND WILL INFORM THE AG WHEN COMPLETED IN ACCORDANCE WITH THE STATUTE. |
| FORM 990, PART III, LINE 3 | ON OCTOBER 14, 2020, THE INSTITUTE'S BOARD OF DIRECTORS VOTED TO DISSOLVE THE ORGANIZATION, AND IT ADOPTED A PLAN OF DISSOLUTION. A COPY OF THE ACTION OF DIRECTORS WITHOUT A MEETING, ALONG WITH THE PLAN OF DISSOLUTION, HAS PREVIOUSLY BEEN INCLUDED IN THE 2021 FORM 990. ACCORDINGLY, THERE ARE NO CONTRIBUTION REVENUES OR PROGRAM EXPENSES FOR THE YEAR ENDED DECEMBER 31, 2022. |
| FORM 990 - PART IV, QUESTION 8 | AS DISCLOSED IN PREVIOUSLY FILED TAX RETURNS, THE ORGANIZATION MAINTAINED A COLLECTION OF ART AND ANTIQUES AND ACCOUNTED FOR THOSE ASSETS IN ACCORDANCE WITH FINANCIAL ACCOUNTING STANDARDS BOARD'S ACCOUNTING STANDARD CODIFICATION 958-605, NOT FOR PROFIT REVENUE RECOGNITION, WHEREBY THE RECEIPT OF THE ART WORK WAS NOT ACCOUNTED FOR AS A CONTRIBUTION. DURING THE DISSOLUTION PROCESS AS DESCRIBED IN SCHEDULE O, EXPLANATION, THE ORGANIZATION HAD THE ARTWORK APPRAISED AND THE VALUE OF THE COLLECTION WAS SIGNIFICANTLY LESS THAN EXPECTED. ACCORDINGLY, THE COLLECTION WAS SOLD AT THE APPRAISED VALUE, ALONG WITH OTHER NONCAPITALIZED ASSETS, AND THE PROCEEDS WILL BE USED IN THE SAME MANNER AS OTHER ASSETS IN THE DISSOLUTION PROCESS. |
| FORM 990, PART VI, SECTION A, LINE 2 | THE CURRENT VOTING MEMBERS OF THE INSTITUTE'S BOARD HAVE A BUSINESS RELATIONSHIP AS THE AFOREMENTIONED VOTING MEMBERS ARE OWNERS, OFFICERS OR EMPLOYEES UNDER THEIR RELATED ENTITY AS FOLLOWS: WEST CLINIC, PLLC DR. BRADLEY G. SOMER DR. KURT W. TAUER DR. TODD TILLMANNS METHODIST LEBONHEUR HEALTHCARE DR. MICHAEL UGWUEKE DR. KATHLEEN FORBES UNIVERSITY OF TENNESSEE HEALTH SCIENCE CENTER DR. DAVID SHIBATA DR. SCOTT STROME DR. NEIL HAYES THE OCTOBER 14, 2020, ACTION BY DIRECTORS APPOINTED THREE BOARD MEMBERS, DR. FORBES, DR. STROME, AND DR. TILLMANS, AS MEMBERS OF THE DISSOLUTION COMMITTEE, AND GAVE THEM PLENARY AUTHORITY TO WIND DOWN THE AFFAIRS OF THE INSTITUTE THROUGH ITS COMPLETE LIQUIDATION PER THE PLAN OF DISSOLUTION. |
| FORM 990, PART VI, SECTION A, LINE 7A | ELECTION OF MEMBERS AND THEIR RIGHTS TO THE BOARD OF THE INSTITUTE ARE APPOINTED EQUALLY BY METHODIST LEBONHEUR HEALTHCARE, UNIVERSITY OF TENNESSEE HEALTH SCIENCE CENTER, AND WEST CLINIC, PLLC. |
| FORM 990, PART VI, SECTION A, LINE 7B | THE BOARD OF DIRECTORS ELECTED A DISSOLUTION COMMITTEE TO HANDLE ACTIVITIES, GOVERNANCE AND OPERATIONS OF THE INSTITUTE AS DESCRIBED IN SCHEDULE O, EXPLANATION. |
| FORM 990, PART VI, SECTION A, LINE 8A | AS DESCRIBED IN SECTION O, THE BOARD OF DIRECTORS ELECTED A DISSOLUTION COMMITTEE TO HANDLE ALL OF THE ACTIVITIES OF THE ORGANIZATION INCLUDING GOVERNANCE AND OPERATIONS. ACCORDINGLY, THE BOARD DID NOT MEET DURING 2022. THE DISSOLUTION COMMITTEE MET DURING CALENDAR YEAR 2022 AND FORMAL MINUTES WERE MAINTAINED. |
| FORM 990, PART VI, SECTION B, LINE 11B | THE BOARD OF DIRECTORS ELECTED A DISSOLUTION COMMITTEE TO HANDLE ACTIVITIES, GOVERNANCE AND OPERATIONS OF THE INSTITUTE FOR 2022. THE DISSOLUTION COMMITTEE WILL REVIEW AND PROVIDE COMMENTS OR SUGGESTED CHANGES AND APPROVE THE FORM 990 BEFORE FILING. |
| FORM 990, PART VI, SECTION B, LINE 12C | POLICIES ADOPTED BY THE ORGANIZATION PRIOR TO THE INITIATION OF THE DISSOLUTION PROCESS, REQUIRE ANNUAL DISCLOSURE FORMS FOR ANY POTENTIAL CONFLICTS OF INTEREST FROM ALL BOARD MEMBERS. AS DISCLOSED IN SCHEDULE O, THE ORGANIZATION'S DISSOLUTION COMMITTEE IS RESPONSIBLE FOR GOVERNANCE AND OPERATIONS. THE DISSOLUTION COMMITTEE IS AWARE OF THE CONFLICT OF INTEREST POLICY AND MONITORS ITS COMPLIANCE. |
| FORM 990, PART VI, SECTION B, LINE 15 | DURING THE YEAR ENDED 2022, THE ORGANIZATION HAD NO EMPLOYEES. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE INSTITUTE HAS ALL OF THE REQUIRED PUBLIC DISCLOSURE DOCUMENTS, INCLUDING FORMS 990 AND 1023 AND THE INTERNAL REVENUE SERVICE LETTER VERIFYING THE APPROVAL OF THE INSTITUTE'S TAX EXEMPT STATUS IN A SEPARATE BINDER MARKED OPEN FOR PUBLIC INSPECTION. |
| FORM 990 - PART VI, SECTION A, QUESTION 8A | THE OCTOBER 14, 2020, ACTION BY DIRECTORS APPOINTED THREE BOARD MEMBERS, DR. FORBES, DR. STROME, AND DR. TILLMANS, AS MEMBERS OF THE DISSOLUTION COMMITTEE AS OF DECEMBER 31, 2022, WITH AUTHORITY TO COMPLETE THE LIQUIDATION OF THE ORGANIZATION PER THE PLAN OF DISSOLUTION. THEREFORE, THE FULL BOARD IS NO LONGER TAKING AN ACTIVE PART WITH RESPECT TO THE INSTITUTE'S DISSOLUTION AND TERMINATION ACTIVITIES. THE DISSOLUTION COMMITTEE DID MAINTAIN MINUTES OF ALL MEETINGS. |
| FORM 990, PART VIII - STATEMENT OF REVENUE AND PART XI - STATEMENT OF FUNCT | THE ABOVE REFERENCED SECTIONS OF THE INSTITUTE'S TAX RETURNS REFLECT ONLY INVESTMENT INCOME, GAIN FROM THE SALE OF SECURITIES, AND ONLY GENERAL AND ADMINISTRATIVE EXPENSES INCURRED DURING THE DISSOLUTION PROCESS AS DESCRIBED IN SCHEDULE O AND THROUGHOUT THE RETURN. THE INSTITUTE HAS NOT SOLICITED CONTRIBUTIONS IN 2022 AND HAS INCURRED NO PROGRAM EXPENSES FOR 2022. |
| FORM 990, PART XI, LINE 9: | GAIN FROM DISPOSITION OF NON-DEPRECIABLE ASSETS 29,580. |
| Software ID: | |
| Software Version: |