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. | 0 | |||||
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.") . | 157,939 | 214,827 | 1,851,837 | 5,535,947 | 41,445,636 | 49,206,186 |
| 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 | 34,736,475 | 34,673,755 | 36,493,516 | 40,080,369 | 5,943,377 | 151,927,492 |
| 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 | 34,894,414 | 34,888,582 | 38,345,353 | 45,616,316 | 47,389,013 | 201,133,678 |
| 7a | Amounts included on lines 1, 2, and 3 received from disqualified persons | 400 | 400 | 800 | |||
| 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.. | 400 | 400 | 800 | |||
| 8 | Public support. (Subtract line 7c from line 6.) | 201,132,878 | |||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2017 | (b) 2018 | (c) 2019 | (d) 2020 | (e) 2021 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | 34,894,414 | 34,888,582 | 38,345,353 | 45,616,316 | 47,389,013 | 201,133,678 |
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | 5,291 | 8,187 | 7,451 | 4,692 | 668 | 26,289 |
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | 0 | |||||
| c | Add lines 10a and 10b. | 5,291 | 8,187 | 7,451 | 4,692 | 668 | 26,289 |
| 11 | Net income from unrelated business activities not included on line 10b, whether or not the business is regularly carried on. | 0 | |||||
| 12 | Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.) .. | 0 | |||||
| 13 | Total support. (Add lines 9, 10c, 11, and 12.).. | 34,899,705 | 34,896,769 | 38,352,804 | 45,621,008 | 47,389,681 | 201,159,967 |
| 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: | 21013554 |
| Software Version: | 21.0.5.0 |
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 | Board director Wilford A. Cardon and Board director Craig A. Cardon are related, as defined by the IRS definition of a relative. |
| Form 990, Part VI, Section A, Line 3 | The filing organization contracted with one of its related organizations, COPA Health, Inc. COPA, for management and programmatic services medical staff services. COPA provides the CEO and CFO for the filing organization and they were paid 36,742 and 16,017 by COPA respectively during the fiscal year for the services they provided to the filing organization. As COPA and the filing organization are related organizations, the 2021 calendar year related party compensation and benefits for the CEO and CFO are reported on Form 990, Part 7, Section A, columns E F, and Sch J, Part II, row ii of line 1 2. |
| Form 990, Part VI, Section A, Line 6 7a | COPA Health, Inc COPA is the sole member of the filing organization. Under this arrangement, the full Board of Directors and officers of COPA act as the full Board of Directors and officers for the filing organization. |
| Form 990, Part VI, Section A, Line 7b | The following acts require approval from the Membership Body 1 Amendments to the Organizations Operating Agreement, 2 Sale or Disposition of substantially all of the assets, 3 Assignment for the benefit of creditors, file a voluntary petition in bankruptcy or consent to appointment of a receiver for the Organization, 4 Approval of a plan of merger or consolidation, 5 Contract or agreement with any Member, Interest Holder or Affiliate Member, 6 Acquisition or sale of real property, 7 Borrowing money from any lender or Member in excess of 50,000, 8 Issuance of further Membership Interests, 9 Decisions that affect the tax liability of the Organization or Members as well as any elections that would affect the Organization or Members, 10 Institution of fringe benefits for Organization employees, 11 Distributions to Members except as otherwise provided, 12 Expanding into new business area such as providing different products or services that exceed 5 of the amount set forth in the budget or any line thereof, and 13 Adoption or Modification of the annual budget. |
| Form 990, Part VI, Section B, Line 11b | Copies of the 990 and all related schedules are sent to the Board of Directors for review after being reviewed and approved by the Audit Committee. Any questions the Board might have are directed back to the Chief Financial Officer. The 990 is then discussed at a full board meeting and approved by the Board of Directors. |
| Form 990, Part VI, Section B, Line 12c | Enforcing agency policy on conflicts of interest is the responsibility of the Enterprise Risk, Audit, and Finance Committee of the Board of Directors. This committee dedicates one meeting per year to 1 Ensure all conflict of interest statements have been received, 2 Ensure conflicts are fully understood and implications discussed and disposition agreed upon, 3 Ensure that board members with conflicts, if any, follow policy with respect to voting on matters that they may have a conflict with, and 4 Recommend enhancements to existing forms, policies, and training related to conflicts of interest. |
| Form 990, Part VI, Section B, Line 15 | The Organization does not currently have any paid officers or employees. However, a compensation policy is in place that would require the Board as a whole, as the Executive Committee, to review the compensation of all officers by comparing their compensation to compensation of individuals in like positions, in like organizations using Form 990, compensation studies, and other available data. The Board or Committee would then approve any changes in compensation based on this information. |
| Form 990, Part VI, Section C, Line 19 | The Organization will provide in a timely manner, copies of all policies, procedures, annual financial audits, and Forms 990 when requested in writing or in person. |
| Form 990, Part XI, Line 11g | Other Contract Services were for programmatic services medical staff services, interpreters and temporary personnel paid to COPA Health, Inc., a related nonprofit, and other contractors. |
| Form 990, Part XII, Line 2c | The Board of Directors has an Enterprise Risk, Audit, and Finance Committee that is tasked to oversee the consolidated financial statement audit and select the independent auditor. There have been no changes to the selection and oversight process from the prior year. |
| Software ID: | 21013554 |
| Software Version: | 21.0.5.0 |