TIN:
SCHEDULE A
(Form 990)
Department of the Treasury
Internal Revenue Service
(Form 990)
Department of the Treasury
Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. Go to
www.irs.gov/Form990 for instructions and the latest information.
OMB No. 1545-0047
2022
Open to Public
Inspection
Inspection
Name of the organization
Kaua'i Medical Clinic
Employer identification number
99-0326099
99-0326099
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions.
The organization is not a private foundation because it is: (For lines 1 through 12, check only one box.)
1
2
3
4
5
6
7
8
9
10
11
12
a
b
c
d
e
f
Enter the number of supported organizations
...............................
g
Provide the following information about the supported organization(s).
| (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 |
||||||
For Paperwork Reduction Act Notice, see the Instructions for
Form 990 or 990-EZ.
Form 990 or 990-EZ.
Cat. No. 11285F
Schedule A (Form 990) 2022
Schedule A (Form 990) 2022
Page 2
Part II
Support Schedule for Organizations Described in
Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization failed to qualify under the tests listed below, please complete Part III.)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization failed to qualify under the tests listed below, please complete Part III.)
| 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 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) 2018 | (b) 2019 | (c) 2020 | (d) 2021 | (e) 2022 | (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 | ||||||
12
12
13
First 5 years.
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section
501(c)(3) organization, check this box and stop here
........................................
Section C. Computation of Public Support Percentage
14
14
15
15
16a
33 1/3% support test—2022.
If the organization did not check the box on line 13, and line 14 is 33
1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization .......................
and stop here. The organization qualifies as a publicly supported organization .......................
b
33 1/3% support test—2021.
If the organization did not check a box on line 13 or 16a, and line 15 is 33
1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization .....................
box and stop here. The organization qualifies as a publicly supported organization .....................
17a
10%-facts-and-circumstances test—2022.
If the organization did not check a box on line 13, 16a, or 16b, and line 14
is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and
stop here. Explain in Part VI how the organization meets the "facts-and-circumstances" test.
The organization qualifies as a publicly supported organization
............
b
10%-facts-and-circumstances test—2021.
If the organization did not check a box on line 13, 16a, 16b, or 17a, and line 15 is 10% or more,
and if the organization meets the "facts-and-circumstances" test, check this box and
stop here. Explain in Part VI how the organization meets the "facts-and-circumstances" test.
The organization qualifies as a publicly supported organization
............
18
Private foundation.
If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions .....................................................
instructions .....................................................
Schedule A (Form 990) 2022
Schedule A (Form 990) 2022
Page 3
Part III
Support Schedule for Organizations Described in
Section 509(a)(2)
(Complete only if you checked the box on line 10 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)
(Complete only if you checked the box on line 10 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)
| 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.).. | ||||||
14
First 5 years.
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section
501(c)(3) organization, check this box and stop here.................................................
Section C. Computation of Public
Support Percentage
15
15
16
16
Section D. Computation of Investment
Income Percentage
17
17
18
18
19a
33 1/3% support
tests-2022.
If the organization did not check the box on line 14, and line 15 is more than 33
1/3%, and line 17 is not more than
33 1/3%, check this box and stop here. The organization
qualifies as a publicly supported organization
.......
b
33 1/3% support tests—2021.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33
1/3% and line 18 is not more than 33
1/3%, check this box and stop here. The organization qualifies
as a publicly supported organization
.....
20
Private foundation.
If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions
....
Schedule A (Form 990) 2022
Schedule A (Form 990) 2022
Page 4
Part IV
Supporting Organizations
(Complete only if you checked a box on line 12 of Part I. If you checked box 12a, of Part I, complete
Sections A and B. If you checked box 12b, of Part I, complete Sections A and C. If you checked box 12c, of
Part I, complete Sections A, D, and E. If you checked box12d, of Part I, complete Sections A and D, and
complete Part V.)
Section A. All Supporting Organizations
Yes
No
1
Are all of the organization’s supported organizations listed by name in the organization’s governing documents?
If "No," describe in Part VI how the supported organizations are designated. If designated by class or purpose,
describe the designation. If historic and continuing relationship, explain.
If "No," describe in Part VI how the supported organizations are designated. If designated by class or purpose,
describe the designation. If historic and continuing relationship, explain.
1
2
Did the organization have any supported organization that does not have an IRS determination of status under section 509(a)(1) or (2)? If "Yes," explain in Part VI how the organization determined that the supported organization was
described in section 509(a)(1) or (2).
2
3a
Did the organization have a supported organization described in section 501(c)(4), (5), or (6)?
If "Yes," answer lines 3b and 3c below.
3a
b
Did the organization confirm that each supported organization qualified under section 501(c)(4), (5), or (6) and satisfied the
public support tests under section 509(a)(2)? If "Yes," describe in Part VI when and how the organization made the
determination.
3b
c
Did the organization ensure that all support to such organizations was used exclusively for section 170(c)(2)(B) purposes?
If "Yes," explain in Part VI what controls the organization put in place to ensure such use.
3c
4a
Was any supported organization not organized in the United States ("foreign supported organization")?
If “Yes” and if you checked box 12a or 12b in Part I, answer lines 4b and 4c below.
4a
b
Did the organization have ultimate control and discretion in deciding whether to make grants to the foreign supported
organization? If “Yes,” describe in Part VI how the organization had such control and discretion despite being controlled or
supervised by or in connection with its supported organizations.
4b
c
Did the organization support any foreign supported organization that does not have an IRS determination under sections
501(c)(3) and 509(a)(1) or (2)?
If “Yes,” explain in Part VI what controls the organization used to ensure that all support to
the foreign supported organization was used exclusively for section 170(c)(2)(B) purposes.
4c
5a
Did the organization add, substitute, or remove any supported organizations during the tax year?
If “Yes,” answer lines 5b and 5c below (if applicable). Also, provide detail in Part VI, including (i) the names and EIN numbers
of the supported organizations added, substituted, or removed; (ii) the reasons for each such action; (iii) the authority under the
organization's organizing document authorizing such action; and (iv) how the action was accomplished (such as by
amendment to the organizing document).
5a
b
Type I or Type II only. Was any added or substituted supported organization part of a class already designated in the
organization's organizing document?
5b
c
Substitutions only. Was the substitution the result of an event beyond the organization's control?
5c
6
Did the organization provide support (whether in the form of grants or the provision of services or facilities) to anyone other
than (i) its supported organizations, (ii) individuals that are part of the charitable class benefited by one or more of its
supported organizations, or (iii) other supporting organizations that also support or benefit one or more of the filing
organization’s supported organizations?
If “Yes,” provide detail in Part VI.
6
7
Did the organization provide a grant, loan, compensation, or other similar payment to a substantial contributor
(defined in section 4958(c)(3)(C)), a family member of a substantial contributor, or a 35% controlled entity
with regard to a substantial contributor? If “Yes,” complete Part I of Schedule L (Form 990) .
7
8
Did the organization make a loan to a disqualified person (as defined in section 4958) not described on line 7?
If “Yes,” complete Part I of Schedule L (Form 990).
8
9a
Was the organization controlled directly or indirectly at any time during the tax year by one or more disqualified
persons, as defined in section 4946 (other than foundation managers and organizations described in section
509(a)(1) or (2))? If “Yes,” provide detail in Part VI.
9a
b
Did one or more disqualified persons (as defined on line 9a) hold a controlling interest in any entity in which
the supporting organization had an interest? If “Yes,” provide detail in Part VI.
9b
c
Did a disqualified person (as defined on line 9a) have an ownership interest in, or derive any personal benefit
from, assets in which the supporting organization also had an interest?
If “Yes,” provide detail in Part VI.
9c
10a
Was the organization subject to the excess business holdings rules of section 4943 because of section 4943(f) (regarding certain
Type II supporting organizations, and all Type III non-functionally integrated supporting organizations)?
If “Yes,” answer line 10b below.
10a
b
Did the organization have any excess business holdings in the tax year? (Use Schedule C, Form 4720, to determine
whether the organization had excess business holdings).
10b
Schedule A (Form 990) 2022
Schedule A (Form 990) 2022
Page 5
Part IV
Supporting Organizations (continued)
Yes
No
11
Has the organization accepted a gift or contribution from any of the following persons?
a
A person who directly or indirectly controls, either alone or together with persons described on lines 11b
and 11c below, the governing body of a supported organization?
11a
b
A family member of a person described on 11a above?
11b
c
A 35% controlled entity of a person described on line 11a or 11b above?
If “Yes” to 11a, 11b, or 11c, provide detail in Part VI.
11c
Section B. Type I Supporting Organizations
Yes
No
1
Did the officers, directors, trustees, or membership of one or more supported organizations have the power to regularly appoint or
elect at least a majority of the organization’s directors or trustees at all times during the tax year?
If “No,” describe in Part VI how the supported organization(s) effectively operated, supervised, or controlled the
organization’s activities. If the organization had more than one supported organization, describe how the powers to appoint
and/or remove directors or trustees were allocated among the supported organizations and what conditions or restrictions, if any,
applied to such powers during the tax year.
1
2
Did the organization operate for the benefit of any supported organization other than the supported organization(s) that
operated, supervised, or controlled the supporting organization?
If “Yes,” explain in Part VI how providing such benefit
carried out the purposes of the supported organization(s) that operated, supervised or controlled the supporting
organization.
2
Section C. Type II Supporting Organizations
Yes
No
1
Were a majority of the organization’s directors or trustees during the tax year also a majority of the directors or trustees of
each of the organization’s supported organization(s)?
If “No,” describe in Part VI how control or management of the
supporting organization was vested in the same persons that controlled or managed the supported organization(s).
1
Section D. All Type III Supporting Organizations
Yes
No
1
Did the organization provide to each of its supported organizations, by the last day of the fifth month of the organization’s
tax year, (i) a written notice describing the type and amount of support provided during the prior tax year, (ii) a copy of the
Form 990 that was most recently filed as of the date of notification, and (iii) copies of the organization’s governing
documents in effect on the date of notification, to the extent not previously provided?
1
2
Were any of the organization’s officers, directors, or trustees either (i) appointed or elected by the supported organization(s)
or (ii) serving on the governing body of a supported organization?
If "No," explain in Part VI how the organization
maintained a close and continuous working relationship with the supported organization(s).
2
3
By reason of the relationship described in line 2 above, did the organization’s supported organizations have a significant voice in the
organization’s investment policies and in directing the use of the organization’s income or assets at all times during the tax year?
If "Yes," describe in Part VI the role the organization’s supported organizations played in this regard.
3
Section E. Type III Functionally-Integrated Supporting Organizations
1
Check the box next to the method that the organization used to satisfy the Integral Part Test during the year
(see instructions):
a
b
c
2
Activities Test. Answer lines 2a and 2b below.
Yes
No
a
Did substantially all of the organization’s activities during the tax year directly further the exempt purposes of the supported
organization(s) to which the organization was responsive?
If "Yes," then in Part VI identify those supported
organizations and explain how these activities directly furthered their exempt purposes, how the organization was
responsive to those supported organizations, and how the organization determined that these activities constituted
substantially all of its activities.
2a
b
Did the activities described on line 2a, above constitute activities that, but for the organization’s
involvement, one or more of the organization’s supported organization(s) would have been engaged in?
If "Yes," explain in Part VI the reasons for the
organization’s position that its supported organization(s) would have engaged in these activities but for the
organization’s involvement.
2b
3
Parent of Supported Organizations. Answer lines 3a and 3b below.
a
Did the organization have the power to regularly appoint or elect a majority of the officers, directors, or trustees of each of
the supported organizations?If "Yes" or "No", provide details in Part VI.
3a
b
Did the organization exercise a substantial degree of direction over the policies, programs and activities of each of its
supported organizations?
If "Yes," describe in Part VI. the role played by the organization in this regard.
3b
Schedule A (Form 990) 2022
Schedule A (Form 990) 2022
Page 6
Part V
Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations
1
| 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 | ||||
7
Schedule A (Form 990) 2022
Schedule A (Form 990) 2022
Page 7
| 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. |
||||
| 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) |
||||
| 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. |
||||
|
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. |
||||
|
7 Excess distributions carryover to 2023. Add lines 3j and 4c. |
||||
| 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..... | ||||
Schedule A (Form 990) (2022)
Schedule A (Form 990) 2022
Page 8
Part VI
Supplemental Information.
Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; Part III, line 12; Part IV, Section A, lines 1, 2, 3b, 3c, 4b, 4c, 5a, 6, 9a, 9b, 9c, 11a, 11b, and 11c; Part IV, Section B, lines 1 and 2; Part IV, Section C, line 1; Part IV, Section D, lines 2 and 3; Part IV, Section E, lines 1c, 2a, 2b, 3a and 3b; Part V, line 1; Part V, Section B, line 1e; Part V Section D, lines 5, 6, and 8; and Part V, Section E, lines 2, 5, and 6. Also complete this part for any additional information. (See instructions).
| Facts And Circumstances Test |
|---|
| Return Reference | Explanation |
|---|
Schedule A (Form 990) 2022
Additional Data
| Software ID: | 22016089 |
| Software Version: | 2022v5.0 |
Attach to Form 990 or 990-EZ.