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, PART VI, SECTION A, LINE 6 | MEMBERS MUST BE EITHER (I) NONPROFIT, CHARITABLE ORGANIZATIONS WHICH ARE EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE OF 1986, AS AMENDED, AND WHICH ARE LICENSED BY THE STATE OF ARIZONA TO OPERATE AN ACUTE CARE HOSPITAL OR WHICH OWN OR CONTROL ANY NONPROFIT, CHARITABLE ORGANIZATION WHICH IS SO LICENSED; OR (II) NONPROFIT, CHARITABLE ORGANIZATIONS WHICH ARE EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE OF 1986, AS AMENDED, THAT PROVIDES FUNDS FOR THE DELIVERY OF CHARITABLE HEALTH CARE SERVICES. THE INITIAL MEMBERS WERE TUCSON MEDICAL CENTER (TMC) AND UNIVERSITY MEDICAL CENTER (UMC). TMC AND BANNER UMC ARE EQUAL MEMBERS, EACH ENTITLED TO ONE VOTE ON MATTERS ACTED UPON BY THE MEMBERS. SQUARE AND COMPASS CHILDREN'S CLINIC (S&C) IS NOT A MEMBER OF THE CORPORATION BUT PARTICIPATES AS A PHILANTHROPIC STAKEHOLDER OF THE CORPORATION IN ACCORDANCE WITH THE BYLAWS. |
| FORM 990, PART VI, SECTION A, LINE 7A | PER THE BYLAWS, THERE SHALL BE NO FEWER THAN 9 VOTING DIRECTORS. 2 DIRECTORS SHALL BE APPOINTED BY S&C; 2 DIRECTORS SHALL BE APPOINTED BY TMC; AND 2 DIRECTORS SHALL BE APPOINTED BY BANNER UMC. THE 6 DIRECTORS APPOINTED BY S&C, TMC AND BANNER UMC ARE REFERRED TO AS THE ORGANIZING DIRECTORS. THE PRESIDENT OF THE CCRS CLINIC MEDICAL STAFF OR A MEMBER OF THE MEDICAL STAFF DESIGNATED BY THE PRESIDENT SHALL BE APPOINTED A DIRECTOR BY THE ORGANIZING DIRECTORS. A PHYSICIAN MEMBER OF THE CCRS CLINIC MEDICAL STAFF WHO IS ENGAGED IN THE PRIVATE PRACTICE OF MEDICINE IN PIMA COUNTY, ARIZONA AND WHO IS NOT A FULL-TIME FACULTY MEMBER OF THE UNIVERSITY OF ARIZONA COLLEGE OF MEDICINE AND ALSO IS NOT EMPLOYED BY ANY ORGANIZATION AFFILIATED WITH THE COLLEGE OF MEDICINE SHALL BE SELECTED AND APPOINTED A DIRECTOR BY THE ORGANIZING DIRECTORS. A PHYSICIAN MEMBER OF THE CCRS CLINIC MEDICAL STAFF WHO IS A FULL-TIME FACULTY MEMBER OF THE UNIVERSITY OF ARIZONA COLLEGE OF MEDICINE SHALL BE SELECTED AND APPOINTED A DIRECTOR BY THE ORGANIZING DIRECTORS. EACH OF THE FOREGOING 9 DIRECTORS SHALL HAVE A SINGLE AND EQUAL VOTE ON THE BOARD OF DIRECTORS. ADDITIONAL PERSONS MAY BE SELECTED TO SERVE ON THE BOARD OF DIRECTORS IF APPROVED BY 2/3 OF THE DIRECTORS ENTITLED TO VOTE AND MUST INCLUDE THE CONSENT OF 1 DIRECTOR APPOINTED BY S&C, TMC AND BANNER UMC. |
| FORM 990, PART VI, SECTION A, LINE 7B | CERTAIN DECISIONS OF THE BOARD OF DIRECTORS ARE ""MEMBER DECISIONS AND MUST BE APPROVED BY UNANIMOUS AGREEMENT OF THE ORGANIZING DIRECTORS ENTITLED TO VOTE. MEMBER DECISIONS INCLUDE THE FOLLOWING ACTIONS: 1. THE AMENDMENT OF THE ARTICLES OF INCORPORATION OR BYLAWS; 2. THE ACQUISITION OR CREATION OF ANY SUBSIDIARY OR CONTROLLED CORPORATION; 3. THE MERGER OR CONSOLIDATION OF THE CORPORATION WITH ANOTHER CORPORATION, OR THE ENTERING INTO ANY JOINT VENTURE, PARTNERSHIP, LIMITED LIABILITY COMPANY, OR OTHER BUSINESS VENTURE WITH A THIRD PARTY; 4. THE DISSOLUTION OR LIQUIDATION OF THE CORPORATION; 5. THE EXPENDITURE OF ANY FUNDS IN EXCESS OF THOSE PREVIOUSLY APPROVED IN THE CAPITAL AND OPERATING BUDGETS OF THE CORPORATION; 6. THE ENTERING INTO ANY LOAN, INDEBTEDNESS, GUARANTY, SECURITY INTEREST, MORTGAGE, SURETY, HYPOTHECATION; 7. THE DISPOSITION OF ANY ASSETS IN EXCESS OF SUCH MONETARY SUM AS THE MEMBERS MAY DETERMINE FROM TIME TO TIME TO ANY PERSON OTHER THAN TO THE MEMBERS OR A SUBSIDIARY OF THE MEMBERS; 8. THE APPOINTMENT OF AN INDEPENDENT AUDITOR OR HIRING OF INDEPENDENT COUNSEL; 9. THE APPROVAL OF THE ANNUAL OPERATING AND CAPITAL BUDGETS AND ANY MATERIAL OR SUBSTANTIAL MODIFICATION OR AMENDMENT THEREOF; AND 10. THE SELECTION, REMOVAL OR REPLACEMENT OF A BOARD MEMBER. |
| FORM 990, PART VI, SECTION B, LINE 11B | FORM 990 IS REVIEWED BY THE CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER. AFTER THE FORM IS REVIEWED BY THE CEO AND CFO, A COPY IS PROVIDED TO THE ENTIRE BOARD PRIOR TO FILING. |
| FORM 990, PART VI, SECTION B, LINE 12C | THE ORGANIZATION MONITORS CONFLICTS ANNUALLY BY REQUIRING EACH BOARD MEMBER TO FILL OUT A DISCLOSURE FORM. ANY DETERMINATION OF CONFLICT IS MADE BY THE BOARD PRESIDENT AND/OR VICE PRESIDENT. THE CONFLICT OF INTEREST POLICY COVERS ALL OF THE BOARD OF DIRECTORS AND A SEPARATE POLICY EXISTS FOR EMPLOYEES AND CONTRACTORS. IF THERE IS A CONFLICT THE BOARD WILL DECIDE WHETHER THE PERSON OR PEOPLE WITH THE CONFLICT WILL BE INCLUDED IN THE VOTE. IF IT IS DETERMINED THAT THEY SHOULD NOT VOTE ON THE MATTER, THEN THEY WILL BE EXCLUDED FROM THE VOTE. |
| FORM 990, PART VI, SECTION B, LINE 15 | A COMPENSATION COMMITTEE WAS CREATED FOR THE CEO'S SALARY. INFORMATION WAS OBTAINED IN THE FORM OF A SALARY SURVEY BY THIS COMMITTEE. THEY THEN DECIDED ON CURRENT SALARY BASED ON THE DATA OBTAINED. THE CEO SALARY WAS LAST DETERMINED IN 2017. NEITHER THE CEO NOR ANY EMPLOYEE PARTICIPATES IN THE COMPENSATION COMMITTEE. THE COO POSITION WAS HIRED IN 2015. INFORMATION WAS OBTAINED FROM THE MEDICAL GROUP MANAGEMENT ASSOCIATION AND THE ARIZONA COUNCIL OF HUMAN SERVICES. SALARY.COM WAS UTILIZED FOR COMPARABILITY. A SIMILAR PROCESS WAS DONE FOR THE CFO POSITION IN 2014. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. |
| Software ID: | |
| Software Version: |