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 |
||||||
Calendar year
(or fiscal year beginning in)
![]() |
(a) 2020 | (b) 2021 | (c) 2022 | (d) 2023 | (e) 2024 | (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) 2020 | (b) 2021 | (c) 2022 | (d) 2023 | (e) 2024 | (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) 2020 | (b) 2021 | (c) 2022 | (d) 2023 | (e) 2024 | (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) 2020 | (b) 2021 | (c) 2022 | (d) 2023 | (e) 2024 | (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) |
||||
| 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 | ||||
| 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 2024 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-2024 |
(iii) Distributable Amount for 2024 |
|
|---|---|---|---|---|
| 1 Distributable amount for 2024 from Section C, line 6 | ||||
|
2
Underdistributions, if any, for years prior to 2024 (reasonable cause required-- explain in Part VI).
See instructions. |
||||
| 3 Excess distributions carryover, if any, to 2024: | ||||
| a From 2019....... | ||||
| b From 2020....... | ||||
| c From 2021....... | ||||
| d From 2022....... | ||||
| e From 2023....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2024 distributable amount | ||||
|
i
Carryover from 2019 not applied (see instructions) |
||||
| j Remainder. Subtract lines 3g, 3h, and 3i from line 3f. | ||||
| 4Distributions for 2024 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2024 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from line 4. | ||||
|
5
Remaining underdistributions for years prior to 2024, 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 2024. 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 2025. Add lines 3j and 4c. |
||||
| 8 Breakdown of line 7: | ||||
| a Excess from 2020..... | ||||
| b Excess from 2021..... | ||||
| c Excess from 2022..... | ||||
| d Excess from 2023..... | ||||
| e Excess from 2024..... | ||||
| Facts And Circumstances Test |
|---|
| Return Reference | Explanation |
|---|
| Software ID: | |
| Software Version: |
| Return Reference | Explanation |
|---|---|
| FORM 990, PART VI, SECTION B, LINE 11B | A DRAFT FORM 990 IS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM, WHICH IS THEN REVIEWED BY THE CEO AND CFO; ADJUSTMENTS ARE MADE, AS NECESSARY. THE COMPLETE FORM 990 IS THEN PROVIDED AND REVIEWED WITH THE ENTIRE GOVERNING BODY PRIOR TO FILING WITH THE IRS. |
| FORM 990, PART VI, SECTION B, LINE 12C | THE ORGANIZATION HAS A CONFLICT OF INTEREST POLICY. UNDER THE POLICY "INTERESTED PERSONS" INCLUDE ANY DIRECTOR, PRINCIPAL OFFICER, OR MEMBER OF A COMMITTEE WITH GOVERNING BOARD DELEGATED POWERS WHO HAS A DIRECT OR INDIRECT FINANCIAL INTEREST, DIRECTLY OR INDIRECTLY, THROUGH BUSINESS, INVESTMENT, OR FAMILY: 1) OWNERSHIP OR INVESTMENT INTEREST IN ANY ENTITY WITH WHICH THE CORPORATION HAS A TRANSACTION OR ARRANGEMENT 2) A COMPENSATION ARRANGEMENT WITH THE ORGANIZATION OR WITH ANY ENTITY OR INDIVIDUAL WITH WHICH THE CORPORATION HAS A TRANSACTION OR ARRANGEMENT, OR 3) A POTENTIAL OWNERSHIP OR INVESTMENT INTEREST IN, OR COMPENSATION ARRANGEMENT WITH ANY ENTITY OR INDIVIDUAL WITH WHICH THE CORPORATION IS NEGOTIATING A TRANSACTION OR ARRANGEMENT. THE ORGANIZATION REGULARLY AND CONSISTENTLY MONITORS AND ENFORCES COMPLIANCE WITH THE CONFLICT OF INTEREST POLICY BY THE FOLLOWING PROCEDURES: (A) DUTY TO DISCLOSE. IN CONNECTION WITH ANY ACTUAL OR POSSIBLE CONFLICTS OF INTEREST, AN INTERESTED PERSON MUST DISCLOSE THE EXISTENCE OF HIS OR HER POTENTIAL CONFLICT OF INTEREST AND ALL MATERIAL FACTS TO THE BOARD AND MEMBERS OF COMMITTEES WITH BOARD-DELEGATED POWERS CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT. (B) DETERMINING WHETHER A CONFLICT OF INTEREST EXISTS. AFTER DISCLOSURE OF THE POTENTIAL CONFLICT OF INTEREST AND ALL MATERIAL FACTS, AND AFTER ANY DISCUSSION WITH THE INTERESTED PERSON, HE OR SHE SHOULD LEAVE THE BOARD OR COMMITTEE MEETING WHILE THE DETERMINATION OF A CONFLICT OF INTEREST IS DISCUSSED AND VOTED UPON. THE REMAINING BOARD OR COMMITTEE MEMBERS SHOULD DECIDE IF A CONFLICT OF INTEREST EXISTS. (C) PROCEDURES FOR ADDRESSING THE CONFLICT OF INTEREST: 1. AN INTERESTED PERSON MAY MAKE A PRESENTATION AT THE BOARD OR COMMITTEE MEETING, BUT AFTER SUCH PRESENTATION, HE/SHE WILL LEAVE THE MEETING DURING THE DISCUSSION OF, AND THE VOTE ON, THE POTENTIAL CONFLICT OF INTEREST. 2. THE CHAIR OF THE BOARD OR COMMITTEE, IF APPROPRIATE, APPOINTS A DISINTERESTED PERSON OR COMMITTEE TO INVESTIGATE ALTERNATIVES TO THE POTENTIAL CONFLICT OF INTEREST. 3. AFTER EXERCISING DUE DILIGENCE, THE BOARD MAKES A FINAL DETERMINATION ON THE POTENTIAL CONFLICT OF INTEREST. (D) VIOLATIONS OF THE CONFLICTS OF INTEREST POLICY: 1. IF THE BOARD OR COMMITTEE HAS REASONABLE CAUSE TO BELIEVE THAT A MEMBER HAS FAILED TO DISCLOSE ACTUAL OR POSSIBLE CONFLICTS OF INTEREST, IT SHOULD INFORM THE MEMBER OF THE BASIS FOR SUCH BELIEF AND AFFORD THE MEMBER AN OPPORTUNITY TO EXPLAIN THE ALLEGED FAILURE TO DISCLOSE. 2. IF, AFTER HEARING THE RESPONSE OF THE MEMBER AND MAKING SUCH FURTHER INVESTIGATION AS MAY BE WARRANTED IN THE CIRCUMSTANCES, THE BOARD OR COMMITTEE DETERMINES THAT THE MEMBER HAS IN FACT FAILED TO DISCLOSE AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, IT TAKES APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION. (E) ANNUAL STATEMENTS: EACH DIRECTOR, PRINCIPAL OFFICER, AND MEMBER OF A COMMITTEE WITH BOARD-DELEGATED POWERS ANNUALLY SIGNS A STATEMENT, WHICH AFFIRMS THAT SUCH PERSON: (A) HAS RECEIVED A COPY OF THE CONFLICTS OF INTEREST POLICY; (B) HAS READ AND UNDERSTANDS THE POLICY; (C) HAS AGREED TO COMPLY WITH THE POLICY; AND (D) UNDERSTANDS THAT THE CORPORATION IS A CHARITABLE ORGANIZATION AND THAT IN ORDER TO MAINTAIN ITS FEDERAL TAX EXEMPTION IT MUST ENGAGE PRIMARILY IN ACTIVITIES, WHICH ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. (F) PERIODIC REVIEWS: TO ENSURE THAT THE CORPORATION OPERATES IN A MANNER CONSISTENT WITH ITS CHARITABLE PURPOSES AND THAT IT DOES NOT ENGAGE IN ACTIVITIES THAT COULD JEOPARDIZE ITS STATUS AS AN ORGANIZATION EXEMPT FROM FEDERAL INCOME TAX, PERIODIC REVIEWS ARE CONDUCTED. THE PERIODIC REVIEWS, INCLUDES THE FOLLOWING SUBJECTS: (1) WHETHER COMPENSATION ARRANGEMENTS AND BENEFITS ARE REASONABLE AND ARE THE RESULTS OF ARM'S-LENGTH BARGAINING. (2) WHETHER ACQUISITIONS OF PHYSICIAN PRACTICES AND OTHER PROVIDER SERVICES RESULT IN INUREMENT OR IMPERMISSIBLE PRIVATE BENEFIT. (3) WHETHER PARTNERSHIP AND JOINT VENTURE ARRANGEMENTS AND ARRANGEMENTS WITH MANAGEMENT SERVICE ORGANIZATIONS AND PHYSICIAN HOSPITAL ORGANIZATIONS CONFORM TO WRITTEN POLICIES, ARE PROPERLY RECORDED, REFLECT REASONABLE PAYMENTS FOR GOODS AND SERVICES, FURTHER THE CORPORATION'S CHARITABLE PURPOSES, AND DO NOT RESULT IN INUREMENT OR IMPERMISSIBLE PRIVATE BENEFIT. (4) WHETHER AGREEMENTS TO PROVIDE HEALTHCARE AND AGREEMENTS WITH OTHER HEALTHCARE PROVIDERS, EMPLOYEES, AND THIRD-PARTY PAYORS FURTHER THE CORPORATION'S CHARITABLE PURPOSES AND DO NOT RESULT IN INUREMENT OR IMPERMISSIBLE PRIVATE BENEFIT. |
| FORM 990, PART VI, SECTION B, LINE 15 | BLESSING COMMUNITY HEALTH CENTER'S BOARD OF DIRECTORS HAS A PROCESS FOR REVIEWING AND APPROVING THE COMPENSATION OF THE CHIEF EXECUTIVE OFFICER AND OTHER OFFICERS AND KEY EMPLOYEES ON A REGULAR BASIS TO DETERMINE IT IS FAIR AND REASONABLE WITH THE GOAL OF RETAINING EMPLOYEES AT COMPENSATION LEVELS WITHIN APPROPRIATE MARKET RANGE. THE PROCESS FOR DETERMINING THE COMPENSATION PAID TO THE CEO INCLUDES THE APPROVAL OF THE COMPENSATION ARRANGEMENT IN ADVANCE, BY THE BOARD OF DIRECTORS, WITH ALL PERSONS WITH A CONFLICT OF INTEREST ABSTAINING FROM THE BOARD'S DELIBERATION AND DISCUSSION. THE BOARD REVIEWS DATA OF COMPARABLE COMPENSATION FOR SIMILARLY QUALIFIED NONPROFIT EXECUTIVES AT SIMILARLY SITUATED ENTITIES. THE DOCUMENTATION OF THE BOARD INCLUDES THE TERMS OF THE TRANSACTION AND THE DATE OF APPROVAL, THE MEMBERS WHO WERE PRESENT DURING THE DEBATE AND VOTE ON THE TRANSACTION, A DESCRIPTION OF THE COMPARABLE DATA AND HOW IT WAS OBTAINED, AND DOCUMENTATION OF THE BASIS FOR THE DETERMINATION. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICIES AND THE FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. |
| FORM 990, PART IX, LINE 11G | SECURITY EXPENSES: PROGRAM SERVICE EXPENSES 245. MANAGEMENT AND GENERAL EXPENSES 6. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 251. BILLING SERVICES: PROGRAM SERVICE EXPENSES 5,308. MANAGEMENT AND GENERAL EXPENSES 126. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 5,434. MEDICAL SERVICES: PROGRAM SERVICE EXPENSES 850. MANAGEMENT AND GENERAL EXPENSES 20. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 870. CREDENTIALING SERVICES: PROGRAM SERVICE EXPENSES 896. MANAGEMENT AND GENERAL EXPENSES 21. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 917. ANSWERING SERVICES: PROGRAM SERVICE EXPENSES 2,994. MANAGEMENT AND GENERAL EXPENSES 71. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,065. OTHER CONSULTING FEES: PROGRAM SERVICE EXPENSES 83,562. MANAGEMENT AND GENERAL EXPENSES 4,476. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 88,038. OTHER PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 10,340. MANAGEMENT AND GENERAL EXPENSES 554. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 10,894. CONTRACTOR: PROGRAM SERVICE EXPENSES 89,361. MANAGEMENT AND GENERAL EXPENSES 2,127. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 91,488. JANITORIAL EXPENSE: PROGRAM SERVICE EXPENSES 4,888. MANAGEMENT AND GENERAL EXPENSES 116. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 5,004. RECRUITMENT SERVICES: PROGRAM SERVICE EXPENSES 116. MANAGEMENT AND GENERAL EXPENSES 3. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 119. |
| FORM 990, PART IX, LINE 24E | STAFF DEVELOPMENT: PROGRAM SERVICE EXPENSES 14. MANAGEMENT AND GENERAL EXPENSES 1. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 15. |
| Software ID: | |
| Software Version: |