efile Public Visual Render
Submission Date - 2012-08-14
TIN: 26-3159849
Form
990-EZ
Department of the Treasury
Internal Revenue Service
Short Form
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code
(except black lung benefit trust or private foundation)
Sponsoring organizations of donor advised funds, organizations that operate one or more hospital facilities, and certain controlling organizations as defined in section 512(b)(13) must file Form 990 (see instructions).
All other organizations with gross receipts less than $200,000 and total assets less than $500,000 at the end of the year may use this form.
The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-1150
20
10
Open to Public
Inspection
A
For the 2010 calendar year, or tax year beginning
10-01-2010
, and ending
09-30-2011
B
Check if applicable:
Address change
Name change
Initial return
Terminated
Amended return
Application pending
C
Name of organization
FLETCHER ALLEN HEALTH CARE FOUNDATION INC
Number and street (or P. O. box, if mail is not delivered to street address)
111 COLCHESTER AVE
Room/suite
City or town, state or country, and ZIP + 4
BURLINGTON
,
VT
05401
D Employer identification number
26-3159849
E
Telephone number
(802) 847-5959
F
Group Exemption
Number.
.
G
Accounting method:
Cash
Accrual
Other (specify)
H
Check
required to attach Schedule B
(Form 990, 990-EZ, or 990-PF).
I Website:
WWW.FLETCHERALLEN.ORG/ABOUT/FOUNDATION
J Tax-Exempt status
(check only one)
501(c)(3)
501(c)
(
)
(insert no.)
4947(a)(1)
or
527
K
Check
if the organization is not a section 509(a)(3) supporting organization
and
its gross receipts are normally
not
more than
$50,000.
A Form 990-EZ or Form 990 return is not required though Form 990-N (e-postcard) may be required (see instructions). But if the
organization chooses to file a return, be sure to file a complete return.
L
Add lines 5b, 6c, and 7b, to line 9 to determine gross receipts; If gross receipts are $200,000 or more, or if total assets (Part II, line 25, column (B) below) are $500,000 or more,
file Form 990 instead of Form 990-EZ.
.
.
$
0
Part I
Revenue, Expenses, and Changes in Net Assets or Fund Balances
(See the instructions for Part I.)
Check if the organization used Schedule O to respond to any question in this Part I
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1
Contributions, gifts, grants, and similar amounts received
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1
2
Program service revenue including government fees and contracts
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2
3
Membership dues and assessments
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3
4
Investment income
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4
5a
Gross amount from sale of assets other than inventory
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5a
b
Less: cost or other basis and sales expenses
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5b
c
Gain or (loss) from sale of assets other than inventory (Subtract line 5b from line 5a)
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5c
6
Gaming and fundraising events
a
Gross income from gaming (attach Schedule G if greater than $15,000)
6a
b
Gross income from fundraising events (not including $
of contributions from fundraising events reported on line 1) (attach Schedule G if the sum of such gross income and contributions exceed $15,000)
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c
Less: direct expenses from gaming and fundraising events
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6c
d
Net income or (loss) from gaming and fundraising events (Add lines 6a and 6b and subtract line 6c)
6d
7a
Gross sales of inventory, less returns and allowances
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7a
b
Less: cost of goods sold
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7b
c
Gross profit or (loss) from sales of inventory (Subtract line 7b from line 7a)
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7c
8
Other revenue (describe in Schedule O)
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8
9
Total revenue.
Add lines 1, 2, 3, 4, 5c, 6d, 7c, and 8
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9
10
Grants and similar amounts paid (list in Schedule O)
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10
11
Benefits paid to or for members
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11
12
Salaries, other compensation, and employee benefits
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12
0
13
Professional fees and other payments to independent contractors
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13
14
Occupancy, rent, utilities, and maintenance
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14
15
Printing, publications, postage, and shipping
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15
16
Other expenses (describe in Schedule O)
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16
17
Total expenses.
Add lines 10 through 16
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17
0
18
Excess or (deficit) for the year (Subtract line 17 from line 9)
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18
0
19
Net assets or fund balances at beginning of year (from line 27, column (A)) (must agree with
end-of-year figure reported on prior years return)
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19
0
20
Other changes in net assets or fund balances (explain in Schedule O)
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20
21
Net assets or fund balances at end of year. Combine lines 18 through 20
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21
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Part II
Balance Sheets
Check if the organization used Schedule O to respond to any question in this Part II.
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(See the instructions for Part II.)
(A)
Beginning of year
(B)
End of year
22
Cash, savings, and investments
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22
23
Land and buildings
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0
23
0
24
Other assets (describe in Schedule O)
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0
24
0
25
Total assets
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0
25
0
26
Total liabilities
(describe in Schedule O)
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0
26
0
27
Net assets or fund balances
(line 27 of column (B)
must
agree with line 21)
.
0
27
0
For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 10642I
Form
990-EZ
(2010)
Form 990-EZ (2010)
Page
2
Part III
Statement of Program Service Accomplishments
Check if the organization used Schedule O to respond to any question in this Part III
.
Expenses
(Required for section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts; optional for others.)
What is the organization's primary exempt purpose?
FUNDRAISING
Describe what was achieved in carrying out the organization's exempt purposes. In a clear and concise manner, describe the services provided, the number of persons benefited, and other relevant information for each program title.
28
THE FOUNDATION IS A NON-PROFIT, TAX EXEMPT CORPORATION ORGANIZED TO ENGAGE IN DEVELOPMENT AND FUND-RAISING ACTIVITIES EXCLUSIVELY FOR THE SUPPORT OF FLETCHER ALLEN HEALTH CARE, INC.
(Grants $
)
If this amount includes foreign grants, check here
...
28a
29
(Grants $
)
If this amount includes foreign grants, check here
...
29a
30
(Grants $
)
If this amount includes foreign grants, check here
...
30a
31
Other program services (describe in Schedule O)
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(Grants $
)
If this amount includes foreign grants, check here
...
31a
32 Total program service expenses
(add lines 28a through 31a)
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32
Part IV
List of Officers, Directors, Trustees, and Key Employees.
List each one even if not compensated. (See the instructions for Part IV.)
Check if the organization used Schedule O to respond to any question in this Part IV
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(a)
Name and address
(b)
Title and average
hours per week
devoted to position
(c)
Compensation
(If not paid,
enter -0-.)
(d)
Contributions to
employee benefit plans &
deferred compensation
(e)
Expense
account and
other allowances
MELINDA ESTES MD
111 COLCHESTER AVE
BURLINGTON
,
VT
05401
PRESIDENT
1.0
0
0
0
JOHN BRUMSTED MD
111 COLCHESTER AVE
BURLINGTON
,
VT
05401
DIRECTOR/PRESIDENT A/O 9/1/11
1.0
0
0
0
PHILIP DANIELS
111 COLCHESTER AVE
BURLINGTON
,
VT
05401
DIRECTOR
1.0
0
0
0
MARC MONHEIMER
111 COLCHESTER AVE
BURLINGTON
,
VT
05401
DIRECTOR AS OF 1/1/11
1.0
0
0
0
EMILY MORROW
111 COLCHESTER AVE
BURLINGTON
,
VT
05401
SECRETARY
1.0
0
0
0
DAVID SCHNEIDER MD
111 COLCHESTER AVE
BURLINGTON
,
VT
05401
DIRECTOR AS OF 1/1/11
1.0
0
0
0
ROGER STONE
111 COLCHESTER AVE
BURLINGTON
,
VT
05401
DIRECTOR AS OF 1/1/11
1.0
0
0
0
GLEN WRIGHT
111 COLCHESTER AVE
BURLINGTON
,
VT
05401
CHAIR
1.0
0
0
0
ROGER DESHAIES
111 COLCHESTER AVE
BURLINGTON
,
VT
05401
TREASURER
1.0
0
0
0
BRIAN BOARDMAN
111 COLCHESTER AVE
BURLINGTON
,
VT
05401
VICE CHAIR
1.0
0
0
0
JANET CARROLL
111 COLCHESTER AVE
BURLINGTON
,
VT
05401
DIRECTOR
1.0
0
0
0
MATTHEW DALY
111 COLCHESTER AVE
BURLINGTON
,
VT
05401
DIRECTOR
1.0
0
0
0
DANIELLE GILBERT-RICHARD
111 COLCHESTER AVE
BURLINGTON
,
VT
05401
DIRECTOR
1.0
0
0
0
SYLVIA MACKINNON
111 COLCHESTER AVE
BURLINGTON
,
VT
05401
DIRECTOR
1.0
0
0
0
CHRISTINE MORIARTY
111 COLCHESTER AVE
BURLINGTON
,
VT
05401
DIRECTOR
1.0
0
0
0
BRIAN WAXLER
111 COLCHESTER AVE
BURLINGTON
,
VT
05401
DIRECTOR
1.0
0
0
0
Form
990-EZ
(2010)
Form 990-EZ (2010)
Page
3
Part V
Other Information
(Note the statement requirements in the instructions for Part V.)
Yes
No
Check if the organization used Schedule O to respond to any question in this Part V
.
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33
Did the organization engage in any activity not previously reported to the IRS? If "Yes," provide a detailed description of each activity in Schedule O
..............
33
No
34
Were any significant changes made to the organizing or governing documents? If "Yes," attach a conformed copy of the amended documents if they reflect a change to the organizations name. Otherwise, explain the change on Schedule O (see instructions).
...................
34
No
35
If the organization had income from business activities, such as those reported on lines 2, 6a, and 7a (among others), but
not
reported on Form 990-T, explain in Schedule O why the organization did not report the income on Form 990-T.
........................
a
Did the organization have unrelated business gross income of $1,000 or more or was it a section 501(c)(4), 501(c)(5), or 501(c)(6) organization subject to section 6033(e) notice, reporting, and proxy tax requirements?
35a
No
b
If "Yes," has it filed a tax return on
Form 990-T
for this year? (see instructions)
........
35b
36
Did the organization undergo a liquidation, dissolution, termination, or significant disposition of net assets during the year? If Yes, complete applicable parts of Schedule N
.............
36
No
37a
Enter amount of political expenditures, direct or indirect, as described in the instructions.
37a
0
b
Did the organization file
Form 1120-POL
for this year?
...............
37b
No
38a
Did the organization borrow from, or make any loans to, any officer, director, trustee, or key employee
or
were
any such loans made in a prior year and still outstanding at the end of the tax year covered by this return?
38a
No
b
If Yes, complete Schedule L, Part II and enter the total amount involved
.
38b
39
Section 501(c)(7) organizations.
Enter:
a
Initiation fees and capital contributions included on line 9
......
39a
0
b
Gross receipts, included on line 9, for public use of club facilities
....
39b
0
40a
Section 501(c)(3) organizations.
Enter amount of tax imposed on the organization during the year under:
section 4911
0
; section 4912
0
; section 4955
0
b
Section 501(c)(3) and 501(c)(4) organizations.
Did the organization engage in any section 4958 excess benefit transaction during the year or did it engage in an excess benefit transaction in a prior year that has not been reported on any of its prior Forms 990 or 990-EZ? If Yes, complete Schedule L, Part I.
....
40b
No
c
Section 501(c)(3) and 501(c)(4) organizations. Enter amount of tax imposed on organization managers or disqualified persons during the year under sections 4912, 4955, and 4958
..
0
d
Section 501(c)(3) and 501(c)(4) organizations. Enter amount of tax on line 40c reimbursed by the organization
...................
0
e
All organizations.
At any time during the tax year, was the organization a party to a prohibited tax shelter transaction? If "Yes," complete Form 8886-T.
.................
40e
No
41
List the states with which a copy of this return is filed.
42a
The organization's books are in care of
ROGER DESHAIES CO FAHC
Telephone no.
(802) 847-5959
Located at
111 COLCHESTER AVE
BURLINGTON
,
VT
ZIP + 4
05401
b
At any time during the calendar year, did the organization have an interest in or a signature or other authority over a financial account in a foreign country (such as a bank account, securities account, or other financial account)?
Yes
No
42b
No
If Yes, enter the name of the foreign country:
See the instructions for exceptions and filing requirements for
Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
c
At any time during the calendar year, did the organization maintain an office outside of the U.S.?
42c
No
If Yes, enter the name of the foreign country:
43
Section 4947(a)(1) nonexempt charitable trusts filing Form 990-EZ in lieu of
Form 1041
Check here
.......
and enter the amount of tax-exempt interest received or accrued during the tax year
.
.
.
43
44a
Did the organization maintain any donor advised funds?
If "Yes", Form 990 must be completed instead of
Yes
No
Form 990-EZ.
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44a
No
b
Did the organization operate one or more hospital facilities during the year?
If Yes, Form 990 must be completed instead of Form990-EZ
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44b
No
c
Did the organization receive any payments for indoor tanning services during the year?
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44c
No
d
If 'Yes' to line 44c, has the organization filed a Form 720 to report these payments?
If No, provide an explanation in Schedule O
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44d
45
Is any related organization a controlled entity of the organization within the meaning of section 512(b)(13)?
If Yes, Form 990 and Schedule R must be completed instead of Form990-EZ
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45
No
45a
Did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)?
If Yes, Form 990 and Schedule R must be completed instead of Form990-EZ
.
.
45a
No
46
Did the organization engage, directly or indirectly, in political campaign activities on behalf of or in opposition to candidates for public office? If Yes, complete Schedule C, Part I.
.
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46
No
Form
990-EZ
(2010)
Form 990-EZ (2010)
Page
4
Part VI
Section 501(c)(3) organizations and section 4947(a)(1) nonexempt charitable trusts only.
All section 501(c)(3) organizations and section 4947(a)(1) nonexempt charitable trusts must answer questions 47-49b and 52.
Check if the organization used Schedule O to respond to any question in this Part VI
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Yes
No
47
Did the organization engage in lobbying activities? If "Yes," complete Schedule C, Part II
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47
No
48
Is the organization a school described in section 170(b)(1)(A)(ii)?
If "Yes," complete Schedule E
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48
No
49a
Did the organization make any transfers to an exempt non-charitable related organization?
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49a
No
b
If "Yes," was the related organization a section 527 organization?
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49b
50
Complete this table for the organization's five highest compensated employees (other than officers, directors, trustees and key employees) who each received more than $100,000 of compensation from the organization. If there is none, enter "None."
(a)
Name and address of each employee paid more than $100,000
(b)
Title and average
hours per week
devoted to position
(c)
Compensation
(d)
Contributions to
employee benefit plans &
deferred compensation
(e)
Expense
account and
other allowances
NONE
50(f)
Total number of other employees paid over $100,000
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51
Complete this table for the organization's five highest compensated independent contractors who each received more than $100,000 of compensation from the organization. If there is none, enter "None."
(a)
Name and address of each independent contractor paid more than $100,000
(b)
Type of service
(c)
Compensation
51(d)
Total number of other independent contractors each receiving over $100,000
.
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52
Did the organization complete Schedule A?
NOTE:
All Section 501(c)(3) organizations and 4947(a)(1) nonexempt charitable trusts must attach a completed Schedule A
....................
Yes
No
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
2012-08-14
Signature of officer
Date
ROGER DESHAIES
TREASURER
Type or print name and title
Paid Preparer's Use Only
Preparer's
signature
PRICEWATERHOUSECOOPERS LLP
Date
Check if
self-
employed
Preparers taxpayer identification number
(See instructions)
Firms name (or yours
if self-employed),
address, and ZIP + 4
PricewaterhouseCoopers LLP
125 High Street
Boston
,
MA
02110
EIN
Phone no.
(617) 530-5000
May the IRS discuss this return with the preparer shown above? See instructions
.........
Yes
No
Form
990-EZ
(2010)
Additional Data
Software ID:
Software Version:
Form 990-EZ, Special Condition Description:
Special Condition Description