167 Pg 6 Form Department of the Treasury Internal Revenue Servie A B I J K Ativities & Governane Revenue Expenses Net Assets or Fund Balanes enefit trust or private foundation) The organization may have to use a opy of this return to satisfy state reporting requirements. For the 011 alendar year, or tax year eginning0/01/11, and ending 0/0/1 Chek if appliale: Address hange Name hange Initial return Terminated 990 Amended return Appliation pending Tax-exempt status: Wesite: Form of organization: Part I 1 C Name of organization F Doing Business As Return of Organization Exempt From Inome Tax Under setion 01(), 7, or 97(a)(1) of the Internal Revenue Code (exept lak lung Numer and street (or P.O. ox if mail is not delivered to street address) City or town, state or ountry, and ZIP + Name and address of prinipal offier: Summary 01() 97(a)(1) or 7 Briefly desrie the organization's mission or most signifiant ativities: 16aProfessional fundraising fees (Part I, olumn (A), line 11e)............................... Total fundraising expenses (Part I, olumn (D), line )....................... 0........ 17 Other expenses (Part I, olumn (A), lines 11a 11d, 11f e)............................ 18 Total expenses. Add lines 1 17 (must equal Part I, olumn (A), line )............... 19 Revenue less expenses. Sutrat line 18 from line 1..................................... Room/suite H(a) H() D E Telephone numer G Gross reeipts$ OMB No. 1-7 011 Open to Puli Inspetion Employer identifiation numer Is this a group return for affiliates? Chek this ox if the organization disontinued its operations or disposed of more than % of its net assets. 6 Numer of voting memers of the governing ody (Part VI, line 1a)............................................ Numer of independent voting memers of the governing ody (Part VI, line 1).............................. Total numer of individuals employed in alendar year 011 (Part V, line a).................................. Total numer of volunteers (estimate if neessary)............................................................. 6 7a Total unrelated usiness revenue from Part VIII, olumn (C), line 1........................................... Net unrelated usiness taxale inome from Form 990-T, line.............................................. 7a 7 Prior Year 8 9 10 11 1 1 1 1 0 1 Part II 10 F AVENUE Yes Are all affiliates inluded? Yes If "No," attah a list. (see instrutions)........................................................................................................................................................ REGARDLESS OF ABILITY TO PAY.............................................................................................................................................................................................................................................................................................................. Contriutions and grants (Part VIII, line 1h)................................................ Program servie revenue (Part VIII, line g)................................................ Investment inome (Part VIII, olumn (A), lines,, and 7d).............................. Other revenue (Part VIII, olumn (A), lines, 6d, 8, 9, 10, and 11e)................... Total revenue add lines 8 through 11 (must equal Part VIII, olumn (A), line 1)....... Grants and similar amounts paid (Part I, olumn (A), lines 1 )......................... Benefits paid to or for memers (Part I, olumn (A), line )............................... Salaries, other ompensation, employee enefits (Part I, olumn (A), lines 10)....... Total assets (Part, line 16)................................................................ Total liailities (Part, line 6).............................................................. Net assets or fund alanes. Sutrat line 1 from line 0................................. Signature Blok CHIRICAHUA COMMUNITY HEALTH CENTERS DOUGLAS AZ 8607 GARY MCPHERRAN 10 F AVENUE DOUGLAS AZ 8607 01()() ( ) (insert no.)............................................................................ Beginning of Current Year 86-081898 0-6-681 11,896,101 WWW.CCHCI.ORG H() Group exemption numer Corporation Trust Assoiation Other L Year of formation: 199 M State of legal domiile: AZ TO PROVIDE QUALITY, EFFICIENT PRIMARY HEALTH CARE TO ALL IN COCHISE COUNTY, Current Year Under penalties of perjury, I delare that I have examined this return, inluding aompanying shedules and statements, and to the est of my knowledge and elief, it is true, orret, and omplete. Delaration of preparer (other than offier) is ased on all information of whih preparer has any knowledge. 10 10 06 0 No No 0 0 6,187,8,08,16,1, 6,78,68 16 1 6,8,16 11,67,1 11,896,101 0 0 0 0 6,79, 7,907,66 0 0,1,88,87,616 10,06,17 11,781,7 1,1, 11,89 End of Year 8,,1 8,71,09 1,91,797,68,06 6,088,6 6,0, Sign Here Paid Preparer Use Only Signature of offier BETTY PIPER Type or print name and title PRESIDENT Print/Type preparer's name Preparer's signature Date Chek if PTIN self-employed Firm's name FESTER & CHAPMAN PC Firm's EIN 86-09 RACHEL R. LOCKE, CPA RACHEL R. LOCKE, CPA 0/08/1 P 88 N HAYDEN RD STE SCOTTSDALE, AZ 88-6 Phone no. 60-6-077 Firm's address May the IRS disuss this return with the preparer shown aove? (see instrutions)..................................................... For Paperwork Redution At Notie, see the separate instrutions. Date Yes No Form 990 (011)
Form 990 (011) Page Part III Statement of Program Servie Aomplishments 1 Briefly desrie the organization's mission: Did the organization undertake any signifiant program servies during the year whih were not listed on the prior Form 990 or 990-EZ?......................................................................................................... If "Yes," desrie these new servies on Shedule O. Did the organization ease onduting, or make signifiant hanges in how it onduts, any program servies?........................................................................................................................... If "Yes," desrie these hanges on Shedule O. Desrie the organization's program servie aomplishments for eah of its three largest program servies, as measured y expenses. Setion 01()() and 01()() organizations and setion 97(a)(1) trusts are required to report the amount of grants and alloations to others, the total expenses, and revenue, if any, for eah program servie reported. a (Code:........ ) (Expenses $.......................... inluding grants of$......................... ) (Revenue $.......................... ) ) $.......................... (Revenue ) inluding grants of$......................... ) (Expenses $.......................... (Code:........ (Code:........ $.......................... inluding grants of$......................... ) ) (Expenses $.......................... ) (Revenue. d Other program servies. (Desrie in Shedule O.) (Revenue ) $ (Expenses ) inluding grants of$ $ e Total program servie expenses Form 990 (011) No Yes Yes No Chek if Shedule O ontains a response to any question in this Part III............................................ CHIRICAHUA COMMUNITY HEALTH CENTERS86-081898 TO PROVIDE QUALITY, EFFICIENT PRIMARY HEALTH CARE TO ALL IN COCHISE COUNTY, REGARDLESS OF ABILITY TO PAY. 8,67,087 CCHC PROVIDES PRIMARY HEALTH CARE SERVICES TO SPECIALIZED GROUPS IN SOUTHEASTERN ARIZONA. THE SERVICE AREA IS DESIGNATED AS AN UNDERSERVED AND HEALTH PROVIDER SHORTAGE AREA. 8,67,087 167 Pg 7
167 Pg 8 Form 990 (011) 1 6 7 8 9 10 11 1a 1 1a Part IV a d e f Cheklist of Required Shedules Is the organization desried in setion 01()() or 97(a)(1) (other than a private foundation)? If Yes, omplete Shedule A............................................................................................................... Is the organization required to omplete Shedule B, Shedule of Contriutors (see instrutions)?.............................. Did the organization engage in diret or indiret politial ampaign ativities on ehalf of or in opposition to andidates for puli offie? If Yes, omplete Shedule C, Part I................................................................ Setion 01()() organizations. Did the organization engage in loying ativities, or have a setion 01(h) eletion in effet during the tax year? If "Yes," omplete Shedule C, Part II..................................................... Is the organization a setion 01()(), 01()(), or 01()(6) organization that reeives memership dues, assessments, or similar amounts as defined in Revenue Proedure 98-19? If "Yes," omplete Shedule C, Part III.............................................................................................................................. Did the organization maintain any donor advised funds or any similar funds or aounts for whih donors have the right to provide advie on the distriution or investment of amounts in suh funds or aounts? If Yes, omplete Shedule D, Part I................................................................................................ Did the organization reeive or hold a onservation easement, inluding easements to preserve open spae, the environment, histori land areas, or histori strutures? If Yes, omplete Shedule D, Part II.............................. Did the organization maintain olletions of works of art, historial treasures, or other similar assets? If Yes, omplete Shedule D, Part III...................................................................................................... Did the organization report an amount in Part, line 1; serve as a ustodian for amounts not listed in Part ; or provide redit ounseling, det management, redit repair, or det negotiation servies? If Yes, omplete Shedule D, Part IV...................................................................................................... Did the organization, diretly or through a related organization, hold assets in temporarily restrited endowments, permanent endowments, or quasi-endowments? If Yes, omplete Shedule D, Part V.......................... If the organization's answer to any of the following questions is Yes, then omplete Shedule D, Parts VI, VII, VIII, I, or as appliale. Did the organization otain separate, independent audited finanial statements for the tax year? If Yes, omplete Shedule D, Parts I, II, and III................................................................................................. Was the organization inluded in onsolidated, independent audited finanial statements for the tax year? If "Yes," and if the organization answered "No" to line 1a, then ompleting Shedule D, Parts I, II, and III is optional..................... Is the organization a shool desried in setion 170()(1)(A)(ii)? If Yes, omplete Shedule E................................ Did the organization maintain an offie, employees, or agents outside of the United States?.................................... Did the organization have aggregate revenues or expenses of more than $10,0 from grantmaking, fundraising, usiness, investment, and program servie ativities outside the United States, or aggregate foreign investments valued at $1,0 or more? If Yes, omplete Shedule F, Parts I and IV................................ 1 Did the organization report on Part I, olumn (A), line, more than $,0 of grants or assistane to any organization or entity loated outside the United States? If Yes, omplete Shedule F, Parts II and IV........................ 16 Did the organization report on Part I, olumn (A), line, more than $,0 of aggregate grants or assistane to individuals loated outside the United States? If Yes, omplete Shedule F, Parts III and IV................................ 17 Did the organization report a total of more than $1,0 of expenses for professional fundraising servies on Part I, olumn (A), lines 6 and 11e? If Yes, omplete Shedule G, Part I (see instrutions)................................... 18 Did the organization report more than $1,0 total of fundraising event gross inome and ontriutions on Part VIII, lines 1 and 8a? If "Yes," omplete Shedule G, Part II................................................................. 19 Did the organization report more than $1,0 of gross inome from gaming ativities on Part VIII, line 9a? If "Yes," omplete Shedule G, Part III............................................................................................. 0a Did the organization operate one or more hospital failities? If Yes, omplete Shedule H..................................... If Yes to line 0a, did the organization attah a opy of its audited finanial statements to this return?......................... CHIRICAHUA COMMUNITY HEALTH CENTERS86-081898 Did the organization report an amount for land, uildings, and equipment in Part, line 10? If "Yes," omplete Shedule D, Part VI...................................................................................................... Did the organization report an amount for investments other seurities in Part, line 1 that is % or more of its total assets reported in Part, line 16? If "Yes," omplete Shedule D, Part VII............................................ Did the organization report an amount for investments program related in Part, line 1 that is % or more of its total assets reported in Part, line 16? If "Yes," omplete Shedule D, Part VIII........................................... Did the organization report an amount for other assets in Part, line 1 that is % or more of its total assets reported in Part, line 16? If "Yes," omplete Shedule D, Part I............................................................... Did the organization report an amount for other liailities in Part, line? If "Yes," omplete Shedule D, Part............. Did the organization's separate or onsolidated finanial statements for the tax year inlude a footnote that addresses the organization's liaility for unertain tax positions under FIN 8 (ASC 70)? If "Yes," omplete Shedule D, Part.......... 1 6 7 8 9 10 11a 11 11 11d 11e 11f 1a 1 1 1a 1 1 16 17 18 19 0a 0 Yes Page No Form 990 (011)
167 Pg 9 Form 990 (011) Page Part IV CHIRICAHUA COMMUNITY HEALTH CENTERS86-081898 Cheklist of Required Shedules (ontinued) 1 Did the organization report more than $,0 of grants and other assistane to any government or organization in the United States on Part I, olumn (A), line 1? If Yes, omplete Shedule I, Parts I and II................................. Did the organization report more than $,0 of grants and other assistane to individuals in the United States on Part I, olumn (A), line? If "Yes," omplete Shedule I, Parts I and III...................................................... Did the organization answer Yes to Part VII, Setion A, line,, or aout ompensation of the organization's urrent and former offiers, diretors, trustees, key employees, and highest ompensated employees? If "Yes," omplete Shedule J........................................................................................ a Did the organization have a tax-exempt ond issue with an outstanding prinipal amount of more than $1,0 as of the last day of the year, that was issued after Deemer 1,? If Yes, answer lines through d and omplete Shedule K. If No, go to line...................................................................... Did the organization invest any proeeds of tax-exempt onds eyond a temporary period exeption?......................... Did the organization maintain an esrow aount other than a refunding esrow at any time during the year to defease any tax-exempt onds?................................................................................................ d Did the organization at as an on ehalf of issuer for onds outstanding at any time during the year?......................... a Setion 01()() and 01()() organizations. Did the organization engage in an exess enefit transation with a disqualified person during the year? If Yes, omplete Shedule L, Part I................................................ Is the organization aware that it engaged in an exess enefit transation with a disqualified person in a prior year, and that the transation has not een reported on any of the organization's prior Forms 990 or 990-EZ? If "Yes," omplete Shedule L, Part I............................................................................................... 6 Was a loan to or y a urrent or former offier, diretor, trustee, key employee, highly ompensated employee, or disqualified person outstanding as of the end of the organization s tax year? If Yes, omplete Shedule L, Part II............ 7 Did the organization provide a grant or other assistane to an offier, diretor, trustee, key employee, sustantial ontriutor or employee thereof, a grant seletion ommittee memer, or to a % ontrolled entity or family memer of any of these persons? If Yes, omplete Shedule L, Part III......................................... 8 Was the organization a party to a usiness transation with one of the following parties (see Shedule L, Part IV instrutions for appliale filing thresholds, onditions, and exeptions): a A urrent or former offier, diretor, trustee, or key employee? If "Yes," omplete Shedule L, Part IV.......................... A family memer of a urrent or former offier, diretor, trustee, or key employee? If "Yes," omplete Shedule L, Part IV................................................................................................................. An entity of whih a urrent or former offier, diretor, trustee, or key employee (or a family memer thereof) was an offier, diretor, trustee, or diret or indiret owner? If Yes, omplete Shedule L, Part IV............................. 9 Did the organization reeive more than $,0 in non-ash ontriutions? If Yes, omplete Shedule M.................... 0 Did the organization reeive ontriutions of art, historial treasures, or other similar assets, or qualified onservation ontriutions? If Yes, omplete Shedule M....................................................................... 1 Did the organization liquidate, terminate, or dissolve and ease operations? If Yes, omplete Shedule N, Part I................................................................................................................................ Did the organization sell, exhange, dispose of, or transfer more than % of its net assets? If "Yes," omplete Shedule N, Part II....................................................................................................... Did the organization own 1% of an entity disregarded as separate from the organization under Regulations setions 01.7701- and 01.7701-? If Yes, omplete Shedule R, Part I..................................................... Was the organization related to any tax-exempt or taxale entity? If Yes, omplete Shedule R, Parts II, III, IV, and V, line 1.................................................................................................................... a Did the organization have a ontrolled entity within the meaning of setion 1()(1)?......................................... Did the organization reeive any payment from or engage in any transation with a ontrolled entity within the meaning of setion 1()(1)? If Yes, omplete Shedule R, Part V, line.................................................... 6 Setion 01()() organizations. Did the organization make any transfers to an exempt non-haritale related organization? If Yes, omplete Shedule R, Part V, line............................................................... 7 Did the organization ondut more than % of its ativities through an entity that is not a related organization and that is treated as a partnership for federal inome tax purposes? If Yes, omplete Shedule R, Part VI.............................................................................................................................. 8 Did the organization omplete Shedule O and provide explanations in Shedule O for Part VI, lines 11 and 19? Note. All Form 990 filers are required to omplete Shedule O.............................................................. 1 a d a 6 7 8a 8 8 9 0 1 a 6 7 8 Yes No Form 990 (011)
167 Pg 10 Form 990 (011) Part V 1a a a a a 6a 7 a d e f g h 8 9 a 10 a 11 a 1a Statements Regarding Other IRS Filings and Tax Compliane Chek if Shedule O ontains a response to any question in this Part V........................................... Enter the numer reported in Box of Form 1096. Enter -0- if not appliale................... 1a Enter the numer of Forms W-G inluded in line 1a. Enter -0- if not appliale................ 1 Did the organization omply with akup withholding rules for reportale payments to vendors and reportale gaming (gamling) winnings to prize winners?......................................................................... Enter the numer of employees reported on Form W-, Transmittal of Wage and Tax Statements, filed for the alendar year ending with or within the year overed y this return.... a 06 If at least one is reported on line a, did the organization file all required federal employment tax returns?..................... Note. If the sum of lines 1a and a is greater than 0, you may e required to e-file (see instrutions) Did the organization have unrelated usiness gross inome of $1,0 or more during the year?................................ If Yes, has it filed a Form 990-T for this year? If No, provide an explanation in Shedule O.................................. At any time during the alendar year, did the organization have an interest in, or a signature or other authority over, a finanial aount in a foreign ountry (suh as a ank aount, seurities aount, or other finanial aount)?........................................................................................................................... If Yes, enter the name of the foreign ountry:................................................................................. See instrutions for filing requirements for Form TD F 90-.1, Report of Foreign Bank and Finanial Aounts. Was the organization a party to a prohiited tax shelter transation at any time during the tax year?............................ Did any taxale party notify the organization that it was or is a party to a prohiited tax shelter transation?.................... If Yes to line a or, did the organization file Form 8886-T?................................................................... Does the organization have annual gross reeipts that are normally greater than $1,0, and did the organization soliit any ontriutions that were not tax dedutile?............................................................... If Yes, did the organization inlude with every soliitation an express statement that suh ontriutions or gifts were not tax dedutile?...................................................................................................... Organizations that may reeive dedutile ontriutions under setion 170(). Did the organization reeive a payment in exess of $7 made partly as a ontriution and partly for goods and servies provided to the payor?............................................................................................... If Yes, did the organization notify the donor of the value of the goods or servies provided?................................... Did the organization sell, exhange, or otherwise dispose of tangile personal property for whih it was required to file Form 88?........................................................................................................ If Yes, indiate the numer of Forms 88 filed during the year................................ 7d Did the organization reeive any funds, diretly or indiretly, to pay premiums on a personal enefit ontrat?................. Did the organization, during the year, pay premiums, diretly or indiretly, on a personal enefit ontrat?..................... If the organization reeived a ontriution of qualified intelletual property, did the organization file Form 8899 as required?.. If the organization reeived a ontriution of ars, oats, airplanes, or other vehiles, did the organization file a Form 1098-C? Sponsoring organizations maintaining donor advised funds and setion 09(a)() supporting organizations. Did the supporting organization, or a donor advised fund maintained y a sponsoring organization, have exess usiness holdings at any time during the year?....................................................... Sponsoring organizations maintaining donor advised funds. Did the organization make any taxale distriutions under setion 966?........................................................ Did the organization make a distriution to a donor, donor advisor, or related person?.......................................... Setion 01()(7) organizations. Enter: Initiation fees and apital ontriutions inluded on Part VIII, line 1............................ 10a Gross reeipts, inluded on Form 990, Part VIII, line 1, for puli use of lu failities......... 10 Setion 01()(1) organizations. Enter: Gross inome from memers or shareholders.................................................... 11a Gross inome from other soures (Do not net amounts due or paid to other soures against amounts due or reeived from them.).................................................... 11 Setion 97(a)(1) non-exempt haritale trusts. Is the organization filing Form 990 in lieu of Form 101?................. If Yes, enter the amount of tax-exempt interest reeived or arued during the year.......... 1 1 Setion 01()(9) qualified nonprofit health insurane issuers. a Is the organization liensed to issue qualified health plans in more than one state?............................................. Note. See the instrutions for additional information the organization must report on Shedule O. Enter the amount of reserves the organization is required to maintain y the states in whih CHIRICAHUA COMMUNITY HEALTH CENTERS86-081898 the organization is liensed to issue qualified health plans....................................... Enter the amount of reserves on hand............................................................ 1a Did the organization reeive any payments for indoor tanning servies during the tax year?..................................... If "Yes," has it filed a Form 70 to report these payments? If "No," provide an explanation in Shedule O...................... Yes Page Form 990 (011) 1 1 16 0 1 a a a 6a 6 7a 7 7 7e 7f 7g 7h 8 9a 9 1a 1a 1a 1 No
167 Pg 11 Form 990 (011) Page 6 Part VI Governane, Management, and Dislosure For eah "Yes" response to lines through 7 elow, and for a "No" response to line 8a, 8, or 10 elow, desrie the irumstanes, proesses, or hanges in Shedule O. See instrutions. Chek if Shedule O ontains a response to any question in this Part VI............... Setion A. Governing Body and Management 1a 6 7a 8 a 9 Setion C. Dislosure Enter the numer of voting memers of the governing ody at the end of the tax year....................... 1a If there are material differenes in voting rights among memers of the governing ody, or if the governing ody delegated road authority to an exeutive ommittee or similar ommittee, explain in Shedule O. Enter the numer of voting memers inluded in line 1a, aove, who are independent...................... 1 10 Did any offier, diretor, trustee, or key employee have a family relationship or a usiness relationship with any other offier, diretor, trustee, or key employee?............................................................................. Did the organization delegate ontrol over management duties ustomarily performed y or under the diret supervision of offiers, diretors, or trustees, or key employees to a management ompany or other person?.................. Did the organization make any signifiant hanges to its governing douments sine the prior Form 990 was filed?............ Did the organization eome aware during the year of a signifiant diversion of the organization s assets?..................... Did the organization have memers or stokholders?............................................................................. 6 Did the organization have memers, stokholders, or other persons who had the power to elet or appoint one or more memers of the governing ody?.................................................................................... 7a Are any governane deisions of the organization reserved to (or sujet to approval y) memers, stokholders, or persons other than the governing ody?......................................................................... 7 Did the organization ontemporaneously doument the meetings held or written ations undertaken during the year y the following: The governing ody?............................................................................................................... Eah ommittee with authority to at on ehalf of the governing ody?........................................................... Is there any offier, diretor, trustee, or key employee listed in Part VII, Setion A, who annot e reahed at the organization s mailing address? If Yes, provide the names and addresses in Shedule O................................. Setion B. Poliies (This Setion B requests information aout poliies not required y the Internal Revenue Code.) 10a Did the organization have loal hapters, ranhes, or affiliates?................................................................. If Yes, did the organization have written poliies and proedures governing the ativities of suh hapters, affiliates, and ranhes to ensure their operations are onsistent with the organization's exempt purposes?.................... 11a Has the organization provided a omplete opy of this Form 990 to all memers of its governing ody efore filing the form?. Desrie in Shedule O the proess, if any, used y the organization to review this Form 990. 1a 1 1 1 a 16a 17 18 19 0 CHIRICAHUA COMMUNITY HEALTH CENTERS86-081898 Did the organization have a written onflit of interest poliy? If No, go to line 1............................................... Were offiers, diretors, or trustees, and key employees required to dislose annually interests that ould give rise to onflits? Did the organization regularly and onsistently monitor and enfore ompliane with the poliy? If Yes, desrie in Shedule O how this was done........................................................................................ Did the organization have a written whistlelower poliy?......................................................................... Did the organization have a written doument retention and destrution poliy?................................................. Did the proess for determining ompensation of the following persons inlude a review and approval y independent persons, omparaility data, and ontemporaneous sustantiation of the delieration and deision? The organization s CEO, Exeutive Diretor, or top management offiial......................................................... Other offiers or key employees of the organization............................................................................... If Yes to line 1a or 1, desrie the proess in Shedule O (see instrutions). Did the organization invest in, ontriute assets to, or partiipate in a joint venture or similar arrangement with a taxale entity during the year?.............................................................................................. If Yes, did the organization follow a written poliy or proedure requiring the organization to evaluate its partiipation in joint venture arrangements under appliale federal tax law, and take steps to safeguard the organization s exempt status with respet to suh arrangements?................................................................ List the states with whih a opy of this Form 990 is required to e filed Setion 610 requires an organization to make its Forms 10 (or 10 if appliale), 990, and 990-T (Setion 01()()s only) availale for puli inspetion. Indiate how you made these availale. Chek all that apply. Own wesite Another's wesite Upon request Desrie in Shedule O whether (and if so, how), the organization made its governing douments, onflit of interest poliy, and finanial statements availale to the puli during the tax year. State the name, physial address, and telephone numer of the person who possesses the ooks and reords of the organization: JEANNE BUTLER 1066 HIGHWAY 191 10 8a 8 9 10a 10 11a 1a 1 1 1 1 1a 1 16a 16 Yes Yes.............................................................................. EL FRIDA AZ 8610 0-6-681 AZ No No Form 990 (011)
167 Pg 1 Form 990 (011) Part VII CHIRICAHUA COMMUNITY HEALTH CENTERS86-081898 Compensation of Offiers, Diretors, Trustees, Key Employees, Highest Compensated Employees, and Independent Contrators Chek if Shedule O ontains a response to any question in this Part VII.......................................... Setion A. Offiers, Diretors, Trustees, Key Employees, and Highest Compensated Employees 1a Complete this tale for all persons required to e listed. Report ompensation for the alendar year ending with or within the organization's tax year. List all of the organization's urrent offiers, diretors, trustees (whether individuals or organizations), regardless of amount of ompensation. Enter -0- in olumns (D), (E), and (F) if no ompensation was paid. List all of the organization's urrent key employees, if any. See instrutions for definition of "key employee." List the organization's five urrent highest ompensated employees (other than an offier, diretor, trustee, or key employee) who reeived reportale ompensation (Box of Form W- and/or Box 7 of Form 1099-MISC) of more than $1,0 from the organization and any related organizations. List all of the organization's former offiers, key employees, and highest ompensated employees who reeived more than $1,0 of reportale ompensation from the organization and any related organizations. List all of the organization s former diretors or trustees that reeived, in the apaity as a former diretor or trustee of the organization, more than $10,0 of reportale ompensation from the organization and any related organizations. List persons in the following order: individual trustees or diretors; institutional trustees; offiers; key employees; highest ompensated employees; and former suh persons. Chek this ox if neither the organization nor any related organizations ompensated any urrent offier, diretor, or trustee. (A) (B) (C) (D) (E) (F) Name and Title Average Position Reportale Reportale Estimated hours per (do not hek more than one ompensation ompensation from amount of week ox, unless person is oth an from related other (desrie hours for offier and a diretor/trustee) the organization organizations (W-/1099-MISC) ompensation from the related (W-/1099-MISC) organization organizations and related in Shedule organizations O) Individual trustee or diretor Institutional trustee Offier Key employee Highest ompensated employee Former Page 7 (1) MANNY ALVAREZ DIRECTOR 1. 0 0 0 () VICKIE............... BRAND................. VICE-PRESIDENT 1. 0 0 0 () MICHAEL................. HOLLAND............... DIRECTOR 1. 0 0 0 () ELIZABETH..................... STONER........... DIRECTOR 1. 0 0 0 () ELISA............. DE...... LA....... CRUZ...... DIRECTOR 1. 0 0 0 (6) PHILIP............... KOOP................. DIRECTOR 1. 0 0 0 (7). CARRIE............... GUSTAVSON................. TREASURER 1. 0 0 0 (8) IRENE CORNEJO DIRECTOR 1. 0 0 0 (9) LOURDEZ FERNANDEZ DIRECTOR 1. 0 0 0 (10) BETTY PIPER PRESIDENT 1. 0 0 0 (11) JENNIFER RYAN CEO 0. 10,88 0 0 (1) GARY MCPHERRAN CFO 0. 86,01 0 0 (1) STEPHEN LINDSTROM, MD MEDICAL DIRECTOR 0. 179,0 0 0 (1) JONATHAN LEE-MELK, MD MEDICAL DIRECTOR 0. 166,99 0 0 Form 990 (011)
167 Pg 1 Form 990 (011) Page 8 Setion A. Offiers, Diretors, Trustees, Key Employees, and Highest Compensated Employees (ontinued) Part VII (A) Name and title (18)................................ CHIRICAHUA COMMUNITY HEALTH CENTERS86-081898 (B) Average hours per week (desrie hours for related organizations in Shedule O) (C) Position (do not hek more than one ox, unless person is oth an offier and a diretor/trustee) Individual trustee or diretor Institutional trustee Offier Key employee Highest ompensated employee Former (D) Reportale ompensation from the organization (W-/1099-MISC) (E) Reportale ompensation from related organizations (W-/1099-MISC) (F) Estimated amount of other ompensation from the organization and related organizations (1) JACK.......... HOFFMAN,.................... MD.. PHYSICIAN 6. 11,98 0 0 (16) SHAHEDUL................... ISLAM,............. MD PHYSICIAN 0. 17,88 0 0 (17) APRIL............. ALVAREZ-CORONA,................... MD PHYSICIAN 0. 11,96 0 0 (19)................................ (0)................................ (1)................................ ()................................ ()................................ ()................................ ()................................ 1 Su-total......................................................... Total from ontinuation sheets to Part VII, Setion A........ d Total (add lines 1 and 1)..................................... 1,01,08 Total numer of individuals (inluding ut not limited to those listed aove) who reeived more than $1,0 in reportale ompensation from the organization 8 1,01,08 Did the organization list any former offier, diretor, or trustee, key employee, or highest ompensated employee on line 1a? If Yes, omplete Shedule J for suh individual.......................................................... For any individual listed on line 1a, is the sum of reportale ompensation and other ompensation from the organization and related organizations greater than $10,0? If Yes, omplete Shedule J for suh individual........................................................................................................................... Did any person listed on line 1a reeive or arue ompensation from any unrelated organization or individual for servies rendered to the organization? If Yes, omplete Shedule J for suh person....................................... Setion B. Independent Contrators 1 Complete this tale for your five highest ompensated independent ontrators that reeived more than $1,0 of ompensation from the organization. Report ompensation for the alendar year ending with or within the organization's tax year. (A) (B) Name and usiness address Desription of servies Yes No (C) Compensation Total numer of independent ontrators (inluding ut not limited to those listed aove) who reeived more than $1,0 of ompensation from the organization 0 Form 990 (011)
167 Pg 1 Form 990 (011) Page 9 Part VIII Contriutions, Gifts, Grants and Other Similar Amounts Program Servie Revenue Other Revenue 1a d e f g h Statement of Revenue Federated ampaigns..... Memership dues......... Fundraising events........ Related organizations..... Government grants (ontriutions).. All other ontriutions, gifts, grants, and similar amounts not inluded aove 1a 1 1 1d 1e Nonash ontriutions inluded in lines 1a-1f: Total. Add lines 1a 1f............................. 1f 717,90 71,070 $..................... Busn. Code a........................................................................................ d e.................................................................................................................................... f All other program servie revenue........ g Total. Add lines a f............................. Investment inome (inluding dividends, interest, and other similar amounts)........................ Inome from investment of tax-exempt ond proeeds Royalties........................................... (i) Real (ii) Personal 6a Gross rents Less: rental exps. Rental in. or (loss) d Net rental inome or (loss)......................... 7a Gross amount from (i) Seurities (ii) Other sales of assets other than inventory Less: ost or other d 8a 9a 10a 11a d e 1 CHIRICAHUA COMMUNITY HEALTH CENTERS86-081898 asis & sales exps. Gain or (loss) Net gain or (loss)................................... Gross inome from fundraising events (not inluding $.................... of ontriutions reported on line 1). See Part IV, line 18.............. a Less: diret expenses......... Net inome or (loss) from fundraising events...... Gross inome from gaming ativities. See Part IV, line 19.............. Less: diret expenses......... Net inome or (loss) from gaming ativities....... Gross sales of inventory, less returns and allowanes....... a Less: ost of goods sold...... Net inome or (loss) from sales of inventory....... Misellaneous Revenue All other revenue.......................... Total. Add lines 11a 11d.......................... Total revenue. See instrutions................... a....................................................................................................................................,6, Busn. Code (A) (B) (C) (D) Total revenue Related or Unrelated Revenue exempt funtion revenue usiness revenue exluded from tax under setions 1, 1, or 1,08,16 PATIENT REVENUE 6,7,8 6,7,8 RENTAL INCOME,, 6,78,68 OTHER,16,16 1 1,16 11,896,101 6,809,67 0,01 Form 990 (011)
167 Pg 1 Form 990 (011) Part I CHIRICAHUA COMMUNITY HEALTH CENTERS86-081898 Statement of Funtional Expenses Setion 01()() and 01()() organizations must omplete all olumns. All other organizations must omplete olumn (A) ut are not required to omplete olumns (B), (C), and (D). Page 10 Do not inlude amounts reported on lines 6, 7, 8, 9, and 10 of Part VIII. 1 6 7 8 9 10 11 a d e f g 1 1 1 1 16 17 18 19 0 1 a d e 6 Chek if Shedule O ontains a response to any question in this Part I.................................................................. Grants and other assistane to governments and organizations in the U.S. See Part IV, line 1... Grants and other assistane to individuals in the U.S. See Part IV, line.............. Grants and other assistane to governments, organizations, and individuals outside the U.S. See Part IV, lines 1 and 16......... Benefits paid to or for memers........... Compensation of urrent offiers, diretors, trustees, and key employees.............. Compensation not inluded aove, to disqualified persons (as defined under setion 98(f)(1)) and persons desried in setion 98()()(B)..... Other salaries and wages................. Pension plan aruals and ontriutions (inlude setion 01(k) and 0() employer ontriutions) Other employee enefits.................. Payroll taxes.............................. Fees for servies (non-employees): Management.............................. Legal...................................... Aounting................................ Loying................................... Professional fundraising servies. See Part IV, line 17 Investment management fees............ Other...................................... Advertising and promotion................ Offie expenses........................... Information tehnology.................... Royalties.................................. Oupany................................ Travel...................................... Payments of travel or entertainment expenses for any federal, state, or loal puli offiials Conferenes, onventions, and meetings. Interest.................................... Payments to affiliates..................... Depreiation, depletion, and amortization. Insurane.................................. Other expenses. Itemize expenses not overed aove. (List misellaneous expenses in line e. If line e amount exeeds 10% of line, olumn (A) amount, list line e expenses on Shedule O.).................................................................................................................................................................................... All other expenses........................ Total funtional expenses. Add lines 1 through e... Joint osts. Complete this line only if the organization reported in olumn (B) joint osts from a omined eduational ampaign and fundraising soliitation. Chek here if following SOP 98- (ASC 98-70)............ (A) (B) (C) (D) Total expenses Program servie Management and Fundraising expenses general expenses expenses 19,68 0,089 89,79 6,,606,70,66 1,89,970 1,0,8 789,6 6,10 1,71 1,71 91,88 91,88 19,0 19,0 161,0 161,0 7,89 1,7 1,7,91 11,98 11,97,811,811 80,9 190,66 190,66 71,,01,01 SUPPLIES 1,9,67 1,1,0 61,087 CONTRACTUAL SERVICES 71,07 76,860 1,1 TELEPHONE 160,9 80,67 80,66 REPAIR & MAINTENANCE 81,89 0,97 0,98,6 110, 1,6 11,781,7 8,67,087,1,18 0 Form 990 (011)
167 Pg 16 Form 990 (011) Page 11 Assets Liailities Net Assets or Fund Balanes Part 1 6 7 8 9 10a 11 1 1 1 1 16 17 18 19 0 1 6 7 8 9 0 1 CHIRICAHUA COMMUNITY HEALTH CENTERS86-081898 Balane Sheet Cash non-interest earing........................................................... Savings and temporary ash investments............................................ Pledges and grants reeivale, net................................................... Aounts reeivale, net.............................................................. Reeivales from urrent and former offiers, diretors, trustees, key employees, and highest ompensated employees. Complete Part II of Shedule L............................................................................ Reeivales from other disqualified persons (as defined under setion 98(f)(1)), persons desried in setion 98()()(B), and ontriuting employers and sponsoring organizations of setion 01()(9) voluntary employees' enefiiary organizations (see instrutions).............................. Notes and loans reeivale, net...................................................... Inventories for sale or use............................................................ Prepaid expenses and deferred harges............................................. Land, uildings, and equipment: ost or other asis. Complete Part VI of Shedule D........ 10a Less: aumulated depreiation..................... 10 Investments pulily traded seurities.............................................. Investments other seurities. See Part IV, line 11.................................. Investments program-related. See Part IV, line 11................................. Intangile assets...................................................................... Other assets. See Part IV, line 11.................................................... Total assets. Add lines 1 through 1 (must equal line )........................... Aounts payale and arued expenses............................................ Grants payale........................................................................ Deferred revenue..................................................................... Tax-exempt ond liailities............................................................ Esrow or ustodial aount liaility. Complete Part IV of Shedule D............... Payales to urrent and former offiers, diretors, trustees, key employees, highest ompensated employees, and disqualified persons. Complete Part II of Shedule L....................................................... Seured mortgages and notes payale to unrelated third parties.................... Unseured notes and loans payale to unrelated third parties....................... Other liailities (inluding federal inome tax, payales to related third parties, and other liailities not inluded on lines 17-). Complete Part of Shedule D......................................................................... Total liailities. Add lines 17 through............................................ Organizations that follow SFAS 117, hek here and omplete lines 7 through 9, and lines and. Unrestrited net assets............................................................... Temporarily restrited net assets..................................................... Permanently restrited net assets.................................................... Organizations that do not follow SFAS 117, hek here and omplete lines 0 through. Capital stok or trust prinipal, or urrent funds...................................... Paid-in or apital surplus, or land, uilding, or equipment fund...................... Retained earnings, endowment, aumulated inome, or other funds............... Total net assets or fund alanes..................................................... Total liailities and net assets/fund alanes......................................... (A) Beginning of year 1 6 7 8 9 10 11 1 1 1 1 16 17 18 19 0 1 7 8 9 0 1 (B) End of year 6,7 67,78 1,77,187 1,88,18 9,,69,670 66,97 16,060 1,69 7,88,687,,90,69,96,9,97,79,616 79, 8,,1 8,71,09 790,8 76,96 68,8 90,90 69,69 6,190 1,91,797 6,68,06 6,088,6 6,0, 6,088,6 6,0, 8,,1 8,71,09 Form 990 (011)
167 Pg 17 Form 990 (011) Part I Part II Chek if Shedule O ontains a response to any question in this Part II................................................... Yes No 1 Aounting method used to prepare the Form 990: Cash Arual Other If the organization hanged its method of aounting from a prior year or heked Other, explain in Shedule O. a Reoniliation of Net Assets Chek if Shedule O ontains a response to any question in this Part I.................................................... 1 Total revenue (must equal Part VIII, olumn (A), line 1)........................................................... 1 Total expenses (must equal Part I, olumn (A), line )........................................................... Revenue less expenses. Sutrat line from line 1................................................................. 6 CHIRICAHUA COMMUNITY HEALTH CENTERS86-081898 Net assets or fund alanes at eginning of year (must equal Part, line, olumn (A))........................ Other hanges in net assets or fund alanes (explain in Shedule O)............................................. Net assets or fund alanes at end of year. Comine lines,, and (must equal Part, line, olumn (B))........................................................................................................... Finanial Statements and Reporting Were the organization's finanial statements ompiled or reviewed y an independent aountant?............................ Were the organization's finanial statements audited y an independent aountant?........................................... If Yes to line a or, does the organization have a ommittee that assumes responsiility for oversight of the audit, review, or ompilation of its finanial statements and seletion of an independent aountant?................... If the organization hanged either its oversight proess or seletion proess during the tax year, explain in Shedule O. d If "Yes" to line a or, hek a ox elow to indiate whether the finanial statements for the year were issued on a separate asis, onsolidated asis, or oth: Separate asis Consolidated asis Both onsolidated and separate asis a As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit At and OMB Cirular A-1?.................................................................................... If Yes, did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Shedule O and desrie any steps taken to undergo suh audits...................... 6 a a Page 1 11,896,101 11,781,7 11,89 6,088,6 6,0, Form 990 (011)