Annual Filing for Charitable Organizations Form C HAR500 I New York State Department of Law (Office of the Attorney General) Charities Bureau - Registration Section 120 Broadway New York, NY 10271 http://www.charitiesnys.com 010 ..d CIIAR 006) 2 0 10 Open to Pu Inspectii 1. General Information a. For the fiscal year beginning (rnm!ddlyyyy) I/I b. Check if applicable for NYS: El El / 2 0 1 0 and ending (mmlddlyyyy) FLf 3 /1 0 c. Name of organization I'y, Address change d. Fed, employer ID no. (EIN) (lilt ltltltltltlttt) 4'+' 2 e. NY State registration no. (##-##-##) Name change — & — - Initial filing E3 Final filing 0 Amended filing O NY registration pending Number and street (or P.O. box If mall not delivered to Street address) Roomisulte f. Telephone number S4 L+CO '" •"° City or town, state or country and zip + 4 ____________ tDC\ W\P 02(L (I 7 LI. .0 U 0 g. Email htY* cocLC .0 2. Certification - Two Signatures Required We certify under penalties of peljury that we reviewed this report, including all attachments, and to the best of our knowledge and belief, they are true, correct and complete In accordance with the laws of the State of New York applicable to this report. I I 'ka jr .ex C.E a. President or Authorized Officer b. Chief Financial Officer or Treas. Printed Name > Title 12-2-1- 11 3LklU? Slhdature Printed Name Date Title Date 3. Annual Report Exemption Information a. Article 7-A annual report exemption (Article 7-A registrants and dual registrants) Check if total contributions from NY State (including residents, foundations, corporations, government agencies, etc.) did not exceed $25,000 and the organization did not engage a professional fund raiser (PFR) or fund raising counsel (FRC).to solicit contributions during this fiscal year. NOTE: An organization may claim this exemption if no PFR or FRC was used and either: 1) it received an allocation from a federated fund, United Way or incorporated community appeal and contributions from other sources did not exceed $25,000 or 2) it received all or substantially all of its contributions from one government agency to which it submitted an annual report similar to that required by Article 7-A. b. EPTL annual report exemption (EPTL registrants and dual registrants) Check ' 0 if gross receipts did not exceed $25,000 and assets (market value) did not exceed $25,000 at any time during this fiscal year. For EPTL or Article-7A registrants claiming the annual report exemption under the one law under which they are registered and for dual registrants claiming the annual report exemptions under both laws, simply complete part 1 (General Information), part 2 (Certification) and part 3 (Annual Report Exemption Information) above. Do not submit a fee, do not complete the following schedules and do not submit any attachments to this form. 4. Article 7-A Schedules If you did not check the Article 7-A annual report exemption above, complete the following for this fiscal year: a. Did the organization use a professional fund raiser, fund raising counsel or commercial co-venturer for fund raising activity in NY State? . . * If "Yes", complete Schedule 4a. b. Did the organization receive government contributions (grants)? .......................................................... • If "Yes", complete Schedule 4b. 0 YesjNo Yes*E No 5. Fee Submitted: See last page for summary of fee requirements. Indicate the filing fee(s) you are submitting along with this form: a. Article 7-A filing fee ................................................$ ___ Submit only one check or money order for the b. EPTL filing fee .................................................... $ c. Total fee ........................................................ $ total fee, payable to "NYS Department of Law" 6. Attachments - For organizations that are not claiming annual report exemptions under both laws, see last page for required attachments -,-- 1 CHAR500 - 2010 I Schedule 4a: Professional Fund Raisers (PFR), Fund Raising Counsels (FRC), Commercial Co-Venturers (CCV) If you checked the box in question 4.a. on page 1, complete the following schedule for each PFR, FRC or CCV that the organization engaged for fund raising activity in NY State: 1. Type of fund raising professional (FRP): Professional fund raiser .......................................................................................... Fund raising counsel ............................................................................................ Commercial co-venturer .......................................................................................... 2. 0 0 0 Name of FRP: Number and street (or P.O. box if mail is not delivered to street address): City or town, state or country and zip + 4: 3. FRP telephone number: 4. Services provided by FRP (provide description): 5. Compensation arrangement with FRP (provide description): 6. Dates of contract ................................................ through (mm/dd/yyyy) (mm/dd/yyyy) 7. Amount paid to FRP .........................................................................$ 8. If services were provided by a CCV, did the CCV provide the charitable organization with the interim report(s) required by § 173-a. 3 of the Executive Law? CHARSOO - 2010 Schedule 4b: Government Contributions (Grants) If you checked the box in question 4.b. on page 1 complete the following schedule for each government contribution (grant). Use additional copies of this page if necessary to list each government contribution (grant) separately. Government Agency Name Grant Amount (LM) $Z l 01 Total Government Contributions (Grants),$ 2i1Q cii 9 CHAR500 -20 5. Fee Instructions The filing fee depends on the organization's Registration Type. For details on Registration Type and filing fees, see the Instructions for Form CHAR500. Organization's Registration Type Fee Instructions Calculate the Article 7-A filing fee using the table in part a below. The EPTL filing fee is $0. • Article 7-A EPTL Dual a) Calculate the EPTL filing fee using the table in part b below. The Article 7-A filing fee is $0. Calculate both the Article 7-A and EPTL filing fees using the tables in parts a and b below. Add the Article 7-A and EPTL filing fees together to calculate the total fee. Submit a jgq check or money order for the total fee. Article 7-A filing fee I Total Support & Revenue Article 7-A Fee b) more than $250,000 $25 up to $250,000 * $10 * Any organization that contracted with or used the services of a professional fund raiser (PFR) or fund raising counsel (FRC) during the reporting period must pay an Article 7-A filing fee of $25, regardless of total support and revenue. EPTL filing fee EPTL Fee Net Worth at End of Year $25 Less than $50,000 $50 $50,000 or more, but less than $250,000 $250,000 or more, but less than $1,000,000 $100 $1,000,000 or more, but less than $10,000,000 $250 $10,000,000 or more, but less than $50,000,000 $750 $1500 $50,000,000 or more 6. Attachments - Document Attachment Check-List Check the boxes for the documents you are attaching. For All Filers Filing Fee Single check or money order payable to 'NYS Department of Law" Copies of Internal Revenue Service Forms .{IRS Form 990 El All required schedules (including 0 0 Schedule B) El IRS Form 990-T 0 IRS Form 990-EZ All required schedules (including Schedule B) IRS Form 990-T Additional Article 7-A Document Attachment Requirement Indypendent Accountant's Report IY!' Audit Report (total support & revenue more than $250,000) o Review Report (total support & revenue $100,001 to $250,000) El 4 No Accountant's Report Required (total support & revenue not more than $100,000) CHAR500 - 2010 0 IRS Form 990-PF 0 All required schedules (including Schedule B) 0 IRS Form 990-T COPY OF ripen RECEIVED JAN 10 2012 NYS OFFICE OF THE ATTOHIIEY GENERAL CHARITIES BUREAU Form IRS e-f!ieSlgnature AuThorizatIon for an Exempt Organization 8879-E0 For calendar year2O1O,or fiscal year beginning ---------,ÔI0, 0MB No. 1545-1878 end endg -------,20 - - - - Do not send to the IRS. Keep for your records. 'See Instructions on back. D.pwtrn.n* of th. Treasury Internal Revenue S.Mce Name of exempt organization 2010 Employer Identification number ET Name end title of officer JULIE FEDER, CFO Type of Return and Return information '(Whole Dollars Only) FDL Check the box for the return for which you are using this Form 8879-E0 and enter the Applicable amount, if any, from ;the return. if you check the box ph line le, '2a, 3a,, 4a, Or .a, below, and the amount on that line for the return being filed with this (do not enter -0-). But, if you entered form was blank, then 1eave line lb. 2b, 3b, 4b, or 5b, Whichever is applicable, blank -0-on the return, then enter O-'on the applicable line below. Do not complete- more than I line In Part I; 173699351. lb b Total revOnuO, if any (Fo'rm 990, Part VIII, column (A), line 12) , . Ia Form 990 check here b Total revenue, If any (Form 996EZ, line 9) ...........2b 2a Form 990-EZ check here ... . 3b b TOtal tax (Form 1120-POL, line 22) 3a Form 1120-POL check here line 5) • 4b b Tax based on Investment income (Form 9907PF,'PartVI 4a Form 990-PF check here lo, 1 ....fib 913 Balance Due (Form 8868, Part I, line 3c or Part II, line 8c 5a Form 8868 check here •ai. Declaration and Signature Authorization of Officer Under penalties of perjury, I declare that lam an officer of the above organization and that 1 have examined a copy of the organizOtion's 2010 electronic return and accompanying schedules and statements and to the best of 'my knowledge and belief, they are true, correct, and complete. I further declare that the amount in Part I above is t he amount shown on the copy of the organization's electronic return. I consent to allow my intermediate service provider, transmitter, or electronic return originator (ERO) to send the organization's return to the IRS and to receive from the IRS (a) an acknowledgement of receipt or reason for rejection of ithe transmission, (b) the reason for any delay In processing the return or refund, and (c) the date of any refund. If applicable, I authorize the U.S. Treasury and Its designated Financial Agent to initiate an electronic funds withdrawal '(direCt' debit) entry to the 'financial institution account Indicated In the tax preparation 'software for payment of the brani±ation's federal takes owed on this return, and the financial Institution to debit the entry to this account. To revoke a payment, I must contact the U.S. Treasury Financial Agent at 1-888-3534537 no later than 2 business days prior to the payment (settlement) date. I'also authorize the 'financial institutions involved In the processing of the electronic payment 'of taxes to receive confidential information necessary to answer InquirieS and resolve issues related to the payment. I have selected a personal identification number (PIN) as my signature for the organization's electrOnic return and, if applicable, the organization's consnt to electrOniC ftfnds withdrawal. Officer's PIN: check one box only I 'authorize BKD, LLP , to enter my PN , _0 2 1 2 7 as my,signature Enter five numbers, but do not enter all zeros ERO firm name on the organization's tax year 2010 electronically filed rOtufn. If I have indicated within this return that a copy 'of the return is being filed with a state agency(ies) regulating charities as part of the IRS Fed/State program, I also 'authorize the aforOmeñtiOned EROto entermy PIN on the return's disclosure consent Screen. El As an 'otfcer of the organization, I will enter my PIN as my signature on the 'organization's tax year :2010 electronIcally filed return. if I have indicated within this return that 'a copy of the return is being filed With a state 'agency(Ies) regulating charities is part of the IRS Fed/State program, I will enter my, PIN on the return's disclosure consent screen. ERO's EF1N!PIN. Enter your six-digit electronic filing Identification number (EFIN) followed by your five-digit self-seleCted PIN. 1110 '1 5 5 '7 2 2 0 3 do not inter all zeros I certify that the 'above numeric entry Is my PIN, which is my. 'signature on the 2010 electronically filed return for the organization Indicated above. 1 confirm that I am submitting this return In accordance with the requirements of Pub. 4163, Modernized :e-File (MeF) Information for Authorized IRS c-fife Providers for Business Returns. ER0.s signature __4t ' ' Date jo. 11/14/2011 ERO Must Retain This Form - See Instructions Do Not'SUbmit This Form To the IRS Unless Requested To Do So For Paperwork 'Reduction Act Notice, see back of form. Form 8879-E0' (201C) TT OE t676Z 4,3cs K92$ 11/15/2011 :44:06 P4 V 10-8.2 637 PAE 1 Form OMB No. 1545-0047 9 9 0 Return of Organization Exempt From Income Tax Department of the Treasury internal Revenue Service 2010 Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung benefit trust or private foundation) The organization may have to use a copy of this return to satisfy state reporting requirements. A For the 2010 calendar year, or tax year beginning , 2010, and endinq 20 D Employer Identification number C Name of organization B CheckCappiicable CLINTON HEALTH ACCESS INITIATIVE, INC. Address Name change Doing Business As Number and street (or P.O. box if mail is not delivered to street address) Initial return 383 DORCHESTER AVE 11111 change Terminated ATended re Application E Telephone number Room/suite 400 1(617) 774-0110 City or town, state or country, and ZIP + 4 G Gross receipts $ 173, 699, 351. H(a) is this a group return for YesX No BOSTON, MA 02127 F Name and address of principal officer IRA C. MAGAZ INER pending 383 DORCHESTER _AVE_ BOSTON,_MA_02127 I Tax-exempt status: I X I 501(cX3) ( insert no.) I ) I I 501(c) ( I 4947(1 J Webslte: WWW. CLINTONHEALTHACCESS. ORG K Form of organization: I X I Corporation I I 27-1414646 I Trust I I Association affiliates? H(b) Are all affiliates included? or I Other 1 Yes No if "NO." attach a list (see instructions) 1527 H(c) Group exemption number I L Year of formation: 20091 M State of legal domicile: AR Briefly describe the organizations mission or most significant activities: SUPPORT GOVERNMENTS TO BUILD AND STRENGTHEN INTEGRATED HEALTH SYSTEMS IN THE DEVELOPING -WORLD —AND — EXPAND— ACCESS— TO HIGH—QUALITY CARE AND TREATMENT FOR HIV/AIDS, MALARIA AND OTHER — DISEASES - a, C., C Oa 2 Check this box if the organization discontinued its operations or disposed of more than 25% of its net assets. 3 Number of voting members of the governing body (Part VI, line 1 a) a, 4 Number of independent voting members of the governing body (Part VI, line ib) > 5 Total number of individuals employed in calendar year 2010 (Part V, line 2a) 6 Total number of volunteers (estimate if necessary) 7a Total gross unrelated business revenue from Part VIII, column (C), line 12 7a b Net unrelated business taxable income from Form 990-T, line 34 7b Prior Year I , 8 Contributions and grants (Part VIII, line ih) 0. 9 Program service revenue (Part VIII, line 2g) 0. 10 investment income (Part VIII, column (A), lines 3, 4, and 7d) 0. 11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, bc, and lie) 0. - 12 Total revenue - add lines 8 through 11 (must equal Part VIII, column (A), line 12) 0. 13 Grants and similar amounts paid (Part IX, column (A), lines 1-3) 0. 14 Benefits paid to or for members (Part IX, column (A), line 4) 0. ,. 15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5-10) 0. an 16 a Professional fundraising fees (Part IX, column (A), line lie) 0. ---750,653 b Total fundraising expenses (Part IX, column (D), line 25) 17 Other expenses (Part IX, column (A), lines ha-bid, ilf-24f) 0. 18 Total expenses. Add lines 13-17 (must equal Part IX, column (A), line 25) 0. 19 Revenue less expenses. Subtract line 18 from line 12 0. —Th Beginning of Current Year 0 CD 06 7. 3. 281. 54. C., Current Year 173,513,413. 0. 185,938. 0. 173,699,351. 8,906,335. 0. 29,961,992. 2,760. 139, 684, 009. 178,555, 096. —4,855,745. End of Year 20 Total assets (Part X, line 16) 0. 113,424,316. . 21 Total liabilities (Part X, line 26) 98,202,001. 0. 22 Net assets or fund balances. Subtract line 21 from line 20 0. 15,222,315. Signature Block Under penalties of pel)ury, 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 Signature of officer Type or print name and title Print/Type preparer's name selfemployed Firni'sEIN e 44-0160260 Phone no. 501-372-1040 Paid Preparer BKD, LLP Use Firm's name Firm'saddress . P.O. BOX 3667 LITTLE ROCK, AR 72203-3667 May the IRS discuss this return with the preparer shown above? (see instructions) [ )jes No I Form 990 (2010) For Paperwork Reduction Act Notice, see the separate instructions. JSA OE1010 1.000 1743CS K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 2 27-1414646 Form 99O(2010) Page 1fl1ll1 Statement of Program Service Accomplishments Check if Schedule 0 contains a response to any question in this Part Ill ........................ I Ei1 Briefly describe the organizations mission: ATTACHMENT 1 2 Did the organization undertake any significant program services during the year which were not listed on the prior Form 990 or 990-EZ?Yes ENo If "Yes," describe these new services on Schedule 0. 3 Did the organization cease conducting, or make significant changes in how it conducts, any program services? .Yes No If "Yes," describe these changes on Schedule 0. 4 Describe the exempt purpose achievements for each of the organization's three largest program services by expenses. Section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported. 4a (Code: 4b (Code: (Expenses $ 108,868,409. including grants of $ 108,868,409. ) (Revenue $ (Expenses $ 12,114,902. including grants of $ 12,114,902. ) (Revenue $ 0. RURAL IN A SELECTED NUMBER OF COUNTRIES CHAI WORKS TO STRENGTHEN NATIONAL HEALTH SYSTEMS IN ORDER TO PROVIDE HIGH—QUALITY AFFORDABLE HEALTH CARE TO THOSE IN RURAL COMMUNITIES AND POOR TOWNSHIPS. IN ETHIOPIA, MALAWI, TANZANIA, AND PAPUA NEW GUINEA, WE WORK WITH THE GOVERNMENT TO IMPROVE TARGETED ASPECTS OF THEIR HEALTHCARE SYSTEMS, SUCH AS HUMAN RESOURCES, SUPPLY CHAIN, OPTIMAL SERVICE DELIVERY AND THE COLLECTION OF DATA TO BETTER INFORM SUCCESS OF TARGETED INTEVENTIONS. 4c (Code:)(Expenses$ 8,297,724including grants of$ 8,297,724. )(Revenue$ 0. PEDS CHAI'S PEDIATRIC PROGRAM IS FOCUSED ON EXPANDING ACCESS TO HIGH QUALITY TESTING AND TREATMENT SERVICES FOR HIV—EXPOSED AND —INFECTED CHILDREN ACROSS 10+ HIGH — BURDEN COUNTRIES IN AFRICA AND ASIA. 4d Other program services. (Describe in Schedule 0.) (Expenses$ 42,369,414. including grants of$ 4e Total program service expenses lio. 171, 650, 449. 0. ) ( Revenue $ 0. Form 990 (2010) JSA 0E1020 1.000 1743CS K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 3 Form 990 Page 3 27-1414646 Schedules Yes No Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If "Yes," I complete Schedule A .................................................. 2 Is the organization required to complete Schedule B, Schedule of Contributors? (see instructions) 3 Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If "Yes, "complete Schedule C, Part! 4 Section 501(c)(3) organizations. Did the organization engage in lobbying activities, or have a section 501(h) election in effect during the tax year? If "Yes, "complete Schedule C, Part II 5 Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If "Yes," complete Schedule C, PartII! I X ........................... ...................... 3 x 4 x .......................................................... 5 6 Did the organization maintain any donor advised funds or any similar funds or accounts where donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If "Yes," complete Schedule D, Part! ............................................... 7 Did the organization receive or hold a conservation easement, including easements to preserve open space, the environment, historic land areas, or historic structures? If "Yes, "complete Schedule D, Part!! 8 Did the organization maintain collections of works of art, historical treasures, or other similar assets? If "Yes," complete Schedule D, Part Ill .......... .............................................. 6 X 7 x 8 X 9 x 10 X 9 Did the organization report an amount in Part X, line 21; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If "Yes," complete Schedule D, Part IV .............................................. Did the organization, directly or through a related organization, hold assets in term, permanent, or 10 quasi-endowments? If "Yes, "complete Schedule D, Part V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . If the organization's answer to any of the following questions is "Yes," then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable. a Did the organization report an amount for land, buildings, and equipment in PartX, line 10? If "Yes,"complete 11 Schedule D, Part VI ................................................... ................. ................. .......................... b Did the organization report an amount for investments—othersecurities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If "Yes, "complete Schedule D, Part VII c Did the organization report an amount for investments-program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If "Yes, "complete Schedule D, Part VIII d Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If "Yes, "complete Schedule 0, Part IX e Did the organization report an amount for other liabilities in Part X, line 25? If "Yes, "complete Schedule D, Part X f Did the organization's separate or consolidated financial statements for the tax year include a footnote that addresses the organization's liability for uncertain tax positions under FIN 48 (ASC 740)? If "Yes, "complete Schedule 0, PartX ...... 12a Did the organization obtain separate, independent audited financial statements for the tax year? If "Yes," ....................................... ............ 13 Is the organization a school described in section 170(b)(1)(A)(ii)? .......... 14 a Did the organization maintain an office, employees, or agents outside of the United States? ............. complete Schedule 0, Parts XI, XII, and XIII b Was the organization included in consolidated, independent audited financial statements for the tax year? ha X lib X lic X lid X X hf 12a X 12b 13 14a X If "Yes, "and if the organization answered "No" to line 12a, then completing Schedule 0, Parts Xl, XII, and XIII is optional If "Yes," complete Schedule E b Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, and program service activities outside the United States? If "Yes, "complete Schedule F, Parts land IV. 15 Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the United States? If "Yes, "complete Schedule F, Parts!! and IV ....... 16 Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the United States? If "Yes, "complete Schedule F, Parts III and IV 17 Did the organization report a total of more than $15,000 of expenses for professional fundraising services ........... (see instructions) ........... 18 Did the organization report more than $15,000 total of fundraising event gross income and contributions on ............................ 19 Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? .......................................... ................. 20 a Did the organization operate one or more hospitals? X X 14b X 15 X 16 X on Part IX, column (A), lines 6 and lie? If "Yes, "complete Schedule G, Part I 17 X Part VIII, lines lc and 8a? If "Yes,"complete Schedule G, Part II 18 X If "Yes, "complete Schedule G, Part III 19 0a X X If "Yes, "complete Schedule H b If "Yes" to line 20a, did the organization attach its audited financial statements to this return? Note. Some Form 120b1 Form 990 (2010) JSA 0E1021 1.000 1743CS K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 4 Form 990 (2010) IIIL'I Checklist of 22-1414646 Page 4 Schedules Yes No Did the organization report more than $5,000 of grants and other assistance to governments and organizations in the United States on Part IX, column (A), line 1? If "Yes,"complete Schedule!, Parts/and!!............ Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If "Yes, "complete Schedule!, Parts! and II! ...................... Did the organization answer "Yes" to Part VII, Section A, line 3, 4, or 5 about compensation of the organization's current and former officers, directors, trustees, key employees, and highest compensated 21 22 23 employees? If "Yes, "complete Schedule J ....................................... 24 a Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If "Yes, "answer lines 24b through 24d and complete Schedule K. If "No, "go to line 25 .............................. b Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception? Did the organization maintain an escrow account other than a refunding escrow at any time during the year C to defease any tax-exempt bonds? ........................................... d Did the organization act as an "on behalf of' issuer for bonds outstanding at any time during the year? 25 a Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? lf"Yes,"complete Schedule L, Part! ................... b Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization's prior Forms 990 or 990-EZ? If "Yes, "complete Schedule L, Part /........................................... Was a loan to or by a current or former officer, director, trustee, key employee, highly compensated employee, or disqualified person outstanding as of the end of the organization's tax year? If "Yes, "complete Schedule L, Part!! Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor, or a grant selection committee member, or to a person related to such an individual? 26 27 X 21 X 22 X 23 X 24a 24b 24c 24d 25a X 25b X 26 X X If "Yes, "complete Schedule L, Part I/I .......................................... 27 Was the organization a party to a business transaction with one of the following parties (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions): X a A current or former officer, director, trustee, or key employee? If "Yes," complete Schedule L, Part/V........ 28a b A family member of a current or former officer, director, trustee, or key employee? If "Yes," complete X Schedule L, Part/V.................................................... 28b An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) C was an officer, director, trustee, or direct or indirect owner? If "Yes, "complete Schedule L, Part IV ......... 28c X X 29 Did the organization receive more than $25,000 in non-cash contributions? If "Yes," complete Schedule M 29 Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified 30 conservation contributions? If "Yes, "complete Schedule M .............................. REMM Did the organization liquidate, terminate, or dissolve and cease operations? If "Yes," complete Schedule N, 31 28 Part/ ........................................................... Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If "Yes," complete Schedule N, Part/I............................................... 32 Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If "Yes, "complete Schedule R, Part!..................... Was the organization related to any tax-exempt or taxable entity? If "Yes," complete Schedule R, Parts II, /111 33 34 IV, and V, line l ..................................................... 35 Is any related organization a controlled entity within the meaning of section 512(b)(13)? a Did the organization receive any payment from or engage in any transaction with a If "Yes," complete Schedule R, controlled entity within the meaning of section 512(b)(13)? Part V, line ............................................. LIlYes 36 IIIIlNo 36 X 37 x Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If "Yes," complete Schedule R, PartVI .......................................................... 38 MOMM Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If "Yes, "complete Schedule R, Part V, line 2 ........................... 37 Sol Jul Jul Did the organization complete Schedule 0 and provide explanations in Schedule 0 for Part VI, lines 11 and 38 1 X Form 990 (2010) JSA 001030 1.000 1743CS K925 11/15/2011 1:44:06 P1 V 10-8.2 66337 PAGE 5 Page 27-1414646 Form 9SO(2010) 1na'I Statements Regarding Other IRS Filings and Tax Compliance Check if Schedule 0 contains a response to any q uestion in this Part V ....................... LI1 33 I a Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable ........... b Enter the number of Forms W-2G included in line I a. Enter -0- if not applicable . c Did the organization comply with backup withholding rules for reportable payments to vendors and X reportable gaming (gambling) winnings to prize winners? ................................ Yes No ......... Ia lb 0 Ic 2a Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax 281 2a Statements, filed for the calendar year ending with or within the year covered by this return b If at least one is reported on line 2a, did the organization file all required federal employment tax returns? Note. If the sum of lines la and 2a is greater than 250, you may be required to e-file. (see instructions) 3a Did the organization have unrelated business gross income of $1,000 or more during the year? b If 'Yes," has it filed a Form 990-T for this year? If "No," provide an explanation in Schedule 0 4a 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)? SEE SCHEDULE b If "Yes," enter the name of the foreign country: See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts. 5a Was the organization a party to a prohibited tax shelter transaction at any time during the tax year? b Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction? c If "Yes," to line 5a or 5b, did the organization file Form 8886-T? 6a Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible? b If "Yes," did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible? 7 Organizations that may receive deductible contributions under section 170(c). a Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor? b If "Yes," did the organization notify the donor of the value of the goods or services provided" c Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282? I 7d I d If "Yes," indicate the number of Forms 8282 filed during the year e Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract? f Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract? g If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?. h If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C? 8 Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year? 9 Sponsoring organizations maintaining donor advised funds. a Did the organization make any taxable distributions under section 4966? b Did the organization make a distribution to a donor, donor advisor, or related person? 10 Section 501(c)(7) organizations. Enter: IOa a Initiation fees and capital contributions included on Part VIII, line 12 lOb . . . b Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities II Section 501(c)(12) organizations. Enter: ha a Gross income from members or shareholders b Gross income from other sources (Do not net amounts due or paid to other sources lIb against amounts due or received from them.) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041? 12a Section 4947(a)(I) b If "Yes," enter the amount of tax-exempt interest received or accrued during the year I 12b I 13 Section 501(c)(29) qualified nonprofit health Insurance issuers. a Is the organization licensed to issue qualified health plans in more than one state? Note. Seethe instructions for additional information the organization must report on Schedule 0. b Enter the amount of reserves the organization is required to maintain by the states in which .......13b the organization is licensed to issue qualified health plans 13c c Enter the amount of reserves on hand 14a Did the organization receive any payments for indoor tanning services during the tax year? h If "Yes" has it filed a Form 720 to recort these oavments? If "No." orovide an exolanafion in Schedule 0 ...... 2b .......... ............. 3a 3b ......................................................... 4a ............................ .......................... .............................................. X X X 'I, mom III ........................................... ............ ..................................... MMM ................ Rol MME ....................... ............... ........................... ............................ .................. ................................ ............. 0E1040 1.00 1743CS K925 11/15/2011 1:44:06 PM V 10-8.2 66337 X Form 990 (2010) PAGE 6 Form 990 (2010) Page 27-1414646 each "Yes" response to lines 2 through 7b below, and for a "No" response to line 8a, 8b, or I Ob below, describe the circumstances, processes, or changes in Schedule 0. See instructions. •1'AI Governance, Management, and Disclosure For Check if Schedule 0 contains a response to any question in this Part VI ................ overnina bod y an Yes No ......Ia ...... lb la Enter the number of voting members of the governing body at the end of the tax year b Enter the number of voting members included in line I a, above, who are independent 2 Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? 3 Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? 4 Did the organization make any significant changes to its governing documents since the prior Form 990 was filed? 5 Did the organization become aware during the year of a significant diversion of the organization's assets'? ..... 6 Does the organization have members or stockholders? 7a Does the organization have members, stockholders, or other persons who may elect one or more members of the governing body? . b Are any decisions of the governing body subject to approval by members, stockholders, or other persons? 8 Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following: a The governing body? b Each committee with authority to act on behalf of the governing body? 9 Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization's mailing address? If "Yes," provide the names and addresses in Schedule 0 Section B. Policies (This Section B reauests information about oo!icies not reauired b y the Internal Revenue . ................................ ................................................. ................................................... 2 X 3 X 4 5 6 x x 7a 7b X X X 8a X 8b X x 9 ode) Yes No lOa Does the organization have local chapters, branches, or affiliates'? .......................... b If "Yes," does the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with those of the organization'? 11 a Has the organization provided a copy of this Form 990 to all members of its governing body before filing the form'? ........................................................... b Describe in Schedule 0 the process, if any, used by the organization to review this Form 990. 12a Does the organization have a written conflict of interest policy? If "No," go to line 13 b Are officers, directors or trustees, and key employees required to disclose annually interests that could give rise to conflicts'? ..................................................... C Does the organization regularly and consistently monitor and enforce compliance with the policy? If "Yes," describe in Schedule 0 how this is done 13 Does the organization have a written whistleblower policy'? .............................. 14 Does the organization have a written document retention and destruction policy? 15 Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision? a The organization's CEO, Executive Director, or top management official b Other officers or key employees of the organization If "Yes" to line 15a or 15b, describe the process in Schedule 0. (See instructions.) 16a Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? b If "Yes," has the organization adopted a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and taken steps to safeguard the organization's exem pt status with respect to such arrangements? .......... ................ ........................................ .......................................... lOa X 10b ha X 12a X 12b X 12c X 13 X 14 X 15a 15b X X 16a X ure 17 18 List the states with which a copy of this Form 990 is required to be filed Section 6104 requires an organization to make its Forms 1023 (or 1024 if applicable), 990, and 990-T (501 (c)(3)s only) v ilable for public ins e ion. Indicate how you mak these available. Check all that apply. Own website Another's website I X I Upon request 19 Describe in Schedule 0 whether (and if so, how), the organization makes its governing documents, conflict of interest policy, and financial statements available to the public. 20 State the name, physical address, and telephone number of the person who possesses the books and records of the organization: P ___________________ 617-774-0110 Form 990 (2010) JSA 0E10421.000 1743CS 1(925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 7 27-1414646 Form 99O(2010) 0a'1ii Page Compensation of Officers, Directors, Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors Check if Schedule 0 contains a response to any question in this Part VII .....................liii Employees, and Highest Compensated Employees Section A. Officers, Directors, Trustees, Key la Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization's tax year. • List all of the organization's current officers, directors, trustees (whether individuals or organizations), regardless of amount of compensation. Enter -0- in columns (D), (E), and (F) if no compensation was paid. • List all of the organization's current key employees, if any. See instructions for definition of "key employee." • List the organization's five current highest compensated employees (other than an officer, director, trustee, or key employee) who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the organization and any related organizations. • List all of the organization's former officers, key employees, and highest compensated employees who received more than $100,000 of reportable compensation from the organization and any related organizations. • List all of the organization's former directors or trustees that received, in the capacity as a former director or trustee of the organization, more than $10,000 of reportable compensation from the organization and any related organizations. List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest compensated employees; and former such persons. Check this box if neither the organization nor any related organization compensated any current officer, director, or trustee. (A) (B) Name and Title (C) Position (check at that apply) Average hours per 0 5 s a i '8 week '< 60 ' CD (describe a hours for related CD . 08 CD 09DCOflS ATTACHMENT 3 In schedule 0) __LIIWILLIAM _J CLINTON --DIRECTOR AND OFFICER __(21BRUCE --DIRECTOR GO (D) (E) (F) Reportable compensation from the organization (W-2/1099-MISC) Reportable compensation from related organizations (W-2/1 099-MISC) Estimated amount of other compensation from the organization and related organizations 6 0' 9 0. 276,2981 32,245. 0.1 01 0. 0.1 01 0. 0.1 01 0. OJ 01 0. 0 0 X 132,604. 0 X 74,569. 0 1 IX 89,249. 0 1 IX 78,654.1 01 12.870. 0. OMMMIM 'HI' 'HI' Emil Emil __L3't DIRECTOR (41PAULFARR DIRECTOR __C5jSTEPHEN_LEWIS --DIRECTOR (6)LYN TALIENTO J DIRECTOR I 1.00 X L7IIRAMAGAZINER CEO/VICE CHAIRMAN 50.00 X (8jANILSONI CHIEF EXECUTIVE OFFICER 50.00 - (91RANDALLWALTHER ACTING CHIEF FINANCIAL OFFICER 50.00 itO1D CHIEF EXECUTIVE OFFICER I 50.00 1tUCJ!DE J CHIEF FINANCIAL OFFICER I 50.00 0 X 14,828. 12,267. 7,684. 5.820. 50.00 X - 125,481. 0 20,968. 50.00 X - 123,192. 0 8,180. 50.00 X - 120,273. 0 15,252. I 50.00 _1.612JSA-------------------- J DIRECTOR OF BUDGET & REPORTING I 50.00 X - 115,615. 0 10,843. X1- 111,569.1 0 19,180* REG MEDICAL OFFICER, SE ASIA it31E EXECUTIVE VP, HIV/AIDS 1t4i------------------------ EXECUTIVE VP, ACCESS PROGRAMS _11.51INDER EXEC VP ACCESS PROGRAMS Form 990 (2010) JSA 0E1041 1.000 1743CS K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 8 Form 990 Section A. Officers (A) Name and title and H (B) Average hours per week (describe hours for related organizations in Schedule 0) (C) Position R3 CL CL a I gI o- — I 21 ,, I eck all that ap 0 31 S c ca .' $n o o 3 I CD CD I I CD 27-1414646 lest Compensated Employee, (D) (E) Reportable Reportable compensation compensation from from related the organizations organization (W-211 099-MISC) (W-211099-MISC) a, CD C. 8 (F) Estimated amount of other compensation from the organization and related organizations (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28) 971,206. 276,298 lb Sub-total 1111. c Total from continuation sheets to Part VII, Section A ............. pod Total (add lines lb and lc) 971,206. 276,298 2 Total number of individuals (including but not limited to those listed above) who received more than $100,000 in reportable compensation from the organization 16 160,137. 160,137. Yes No 3 Did the organization list any former officer, director or trustee, key employee, or highest compensated - employee on line 1 a? If "Yes, "complete Schedule J for such individual ...........................3 - X 4 For any individual listed on line la, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If "Yes," complete Schedule J for such individual ............................................................ 4 - X 5 Did any person listed on line la receive or accrue compensation from any unrelated organization or individual5 - X for services rendered to the organization? If "Yes, "complete Schedule J for such person Section B. Independent Contractors I Complete this table for your five highest compensated independent contractors that received more than $100,000 of com pensation from the oroanization. (A) (B) (C) Name and business address Description of services Compensation DR. PETER BARRON KALK BAY CAPE TOWN SF CONSULTING 209, 000. 2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 in compensation from the organization 0 . 1 Form 990 (2010) JsA 0E1050 1.000 1743CS K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 9 27-1414646 Form 990 (A) Total revenue (B) Related or exempt function revenue 9 (C) Unrelated business revenue (D) Revenue excluded from tax under sections 512, 513, or 514 la Federated campaigns . b Membership dues c Fundraising events ......... d Related organizations ........ e Government grants (contributions) . . All other contributions, gifts, grants, and similar amounts not Included above g Noncash contributions included in lines la-if: $ h Total. Add lines la-If ..........JJ cm -E C) m oe .0 . o Oc .......... Business Code C 2a b 0) C., C d e f All other program service revenue U) E CS C) 0 3 Investment income (including dividends, interest, and other similar amounts) 4 Income from investment of tax-exempt bend proceeds 5 Royalties (i) Real (ii) Personal ................... .......... I I 6a Gross Rents ......... b Less: rental expenses c Rental income or (loss) d Net rental income or (loss) ................. 7a Gross amount from sales of assets other than inventory b Less: cost or other basis and sales expenses c Gain or ....... d Net gain or (loss) (loss) (i) Securities (ii) Other ._____________ ..................... 8a Gross income from fundraising events (not including $ of contributions reported on line lc). See Part IV, line 18 . . . . . . . . . . . a b Less: direct expenses . . . . . . . . . . b C Net income or (loss) from fundraising events ........ 9a Gross income from gaming activities. See Part IV, line l9 . . . . . . . . . . . a b Less: direct expenses . . . . . . . . . . b c Net income or (loss) from gaming activities ......... ba Gross sales of inventory, less returns and allowances . . . . . . . . . a b Less: cost of goods sold . . . . . . . . . b c Net income or (loss) from sales of inventory ......... Miscellaneous Revenue I Business Code ha b C ............. d All other revenue e Total. Add lines ila-lld 12 Total rventJ p pp instrt,rftir,n Form 990 (2010) JSA 0E1051 2.000 1743CS K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 10 27-1414646 Form 99O(2010) Page 10 IThi( Statement of Functional Expenses Section 501(c) (3) and 501(c) (4) organizations must complete all columns. other organizations must complete column (A) but are not required to complete columns (B), (C), and (D). (A) (B) (C) (D) Do not include amounts reported on lines 6b, Total expenses Program service Management and Fundraising 7b, 8b, 9b, and lOb of Part VIII. expenses general expenses expenses All 1 Grants and other assistance to governments and organizations in the U.S. See Part IV, line 21 . 1,959,340. 2 Grants and other assistance to individuals in the U.S. See Part IV, line 22 0. 3 Grants and other assistance to governments, organizations, and individuals outside the U.S. See Part IV, lines 15 and 16 .6,946, 1,959,340. 995. 6, 946, 995. 0. 4 Benefits paid to or for members 5 Compensation of current officers, directors, trustees, and key employees ............ 428,545. 6 Compensation not Included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) 7 Other salaries and wages . . . . . . . . . . . . 0. 428,545. 0. 22,455,634. 3,354,263. 555,059. 2,686,538. 431,169. 50,784. 65,223. 75,498. 42,727. 1,980. 410. 0. 2,760. 0. 26,364,956. 8 Pension plan contributions (include section 401(k) and section 403(b) employer contributions) 0. ............. .................... 3 , 168 , 491. 9 Other employee benefits 0. 10 Payroll taxes 11 Fees for services (non-employees): a Management .................... 0. 108,360. b Legal . . . . . . . . . . . . . . . . . . . . . 77 , 478. c Accounting .0. d Lobbying .................... 2,760. e Professional fundralsing services. See Part IV, line 17 f Investment management fees 0. ...................... 3 , 28616,, 451. 030. ............ 681 , 520. .................11,510,682. ..................... 1,996,315. 7 ...................... , 489 , 920. g Other 12 Advertising and promotion 13 Office expenses 14 Information technology . . . . . . . . . . . . . 15 Royalties 16 Occupancy . . . . . . . . . . . . . . . . . . 17 Travel 18 Payments of travel or entertainment expenses for any federal, state, or local public officials , 3,035,454. 988. 1,496,144. 1,288,709. 230,203. 0. 172,490. 207,043. 20,794. 15,042. 12,886. 14,930. 1,767,057. 6,975,693. 229,258. 453,741. 0. 60,486. 3,359,804. 6,995. 147. 0. 512, 695. 0. 110, 640, 089. 7,540,196. 0. 487. 0. 1,456. 1,357,087. 171, 650, 449. 82,398. 6, 153, 994. 15,899. 750, 653. 0. 0. 3,366,946. 19 Conferences, conventions, and meetings 0. 20 Interest 0. 21 Payments to affiliates 512, 695. 22 Depreciation, depletion, and amortization . . 23 Insurance ...................0. ..................... 24 Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 241. If line 24f amount exceeds 10% of line 25, column (A) amount, list line 241 expenses on Schedule 0.) 640, 089. 7,542,139. aQL]l.AP-----------------------110, b DIRECT— PROGRAM EXPENDITURES __ C• d . e. I All other expenses ------------------ 1,455,384. 178, 555, 096. 25 Total functional expenses. Add lines I through 241 26 Joint Costs. Check here L.J if following SOP 98-2 (ASC 958-720). Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation Form 990 (2010) 1743CS K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 11 27-1414646 Form 99O(2010) Page 11 Balance Sheet (A) Beginning of year .....................Cash - non-interest-bearing I ..................0.2 2 Savings and temporary cash investments 3 Pledges and grants receivable, net 0.3 ...4 Accounts receivable, net 0.4 5 Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L .5 6 (B) End of year 5,757,920. 7,827,100. 491,366. Receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(cX9) voluntary employees' beneficiary organizations (see instructions) 6 .- 7 Notes and loans receivable, net .8 Inventories for sale or use .9 Prepaid expenses and deferred charges .....................lOa Land, buildings, and equipment: cost or 2,626,250. other basis. Complete Part VI of Schedule D lOa b Less: accumulated depreciation ........... lOb 1,533, 692. 11 Investments - publicly traded securities ......................12 Investments - other securities. See Part IV, line 11 ................13 Investments - program-related. See Part IV, line 11 ...............14 Intangible assets .................................. 0 .15 15 Other assets. See Part IV, line 11 .........................— 16 Total assets. Add lines 1 through 15 (must equal line 34) 17 Accounts payable and accrued expenses .....................18 Grants payable ...................................19 Deferred revenue .................................20 Tax-exempt bond liabilities ............................21 Escrow or custodial account liability. Complete Part IV of Schedule D 22 Payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified persons.-j Complete Part II of Schedule L ..........................23 Secured mortgages and notes payable to unrelated third parties ........24 Unsecured notes and loans payable to unrelated third parties .......... 0 25 Other .25 liabilities. Complete Part X of Schedule D ................— 26 Total liabilities. Add lines 17 through 25 Organizations that follow SFAS 117, check here [2L] and complete lines 27 through 29, and lines 33 and 34. 27 Unrestricted net assets ..............................28 Temporarily restricted net assets .........................29 Permanently restricted net assets .........................and Organizations that do not follow SFAS 117, check here U. complete lines 30 through 34. 30 Capital stock or trust principal, or current funds .................31 Paid-in or capital surplus, or land, building, or equipment fund .........< 32 Retained earnings, endowment, accumulated income, or other funds . 33 Total net assets or fund balances ........................ 34 Total liabilities and net assets/fund balances .................. 0.1 9 0.10c 11 12 13 14 0.16 0.17 18 0.19 20 21 I 439,200. 1,092,558. 97,816,172. 113,424,316. 8,625,614. 82,881,932. 22 23 24 0.26 El 0.27 0.28 29 6,694,455. 98,202,001. -3,711,550. 18,933,865. 30 15,222,315. 113, 424, 316. Form 990 (2010) JSA 0E1053 1.000 1743CS K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 12 27-1414646 Page Form9SO(2010) 12 IW4i Reconciliation of Net Assets Check if Schedule 0 contains a response to any question in this Part XI ........................X Total revenue (must equal Part VIII, column (A), line 12) .......................... I 2 Total expenses (must equal Part IX, column (A), line 25) .......................... Revenue less expenses. Subtract line 2 from line 1 3 Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) 4 5 Other changes in net assets or fund balances (explain in Schedule 0) Net assets or fund balances at end of year. Combine lines 3, 4, and 5 (must equal Part X, line 33, 6 column (B)) 173, 699,351. 178,555,096. —4,855,745. 0. 20, 078, 060. 15,222,315. Check if Schedule 0 contains a response to any question in this Part XII Other Accrual Accounting method used to prepare the Form 990: [II] Cash If the organization changed its method of accounting from a prior year or checked "Other," explain in Schedule 0. 2a Were the organization's financial statements compiled or reviewed by an independent accountant? b Were the organization's financial statements audited by an independent accountant? C If "Yes" to line 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant? If the organization changed either its oversight process or selection process during the tax year, explain in Schedule 0. d If "Yes" to line 2a or 2b, check a box below to indicate whether the financial statements for the year were issued on a separate basis, consolidated basis, or both: Consolidated basisBoth consolidated and separate basis Separate basis 2a 2b X X' 2c X 1111 3a As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-i 33? b If "Yes," did the organization undergo the required audit or audits? If the organization did not undergo the reauired audit or audits. exDlain wh y in Schedule 0 and describe any steos taken to underrio such audits. lx 3a1 I 3b1 Form 990 (2010) JSA 0E1054 1.000 1743CS 1<925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 13 SCHEDULE A (Form 990 or 990-EZ) 0MB No. 1545-0047 Public Charity Status and Public Support Complete if the organization is a section 501(c)(3) organization or section 4947(a)(1) nonexempt charitable trust Department of the Treasury Internal Revenue Service Name of the organization See separate instructions. Attach to Form 990 or Form 990-EZ. Employer identification number 27-1414646 CLINTON HEALTH ACCESS INITIATIVE, INC. 1 •ii 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 11, check only one box.) A church, convention of churches, or association of churches described in section 170(b)(1)(A)(i). I A school described in section 170(b)(1)(A)(ii). (Attach Schedule E.) 2 A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii). 3 A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the 4 hospital's name, city, and state: An organization operated for the benefit of a college or university owned or operated by a governmental unit described in 5 section 170(b)(1)(A)(iv). (Complete Part II.) 6A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v). 7 X An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 170(b)(1)(A)(vi). (Complete Part II.) A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.) 8 9 An organization that normally receives: (1) more than 331/3 % of its support from contributions, membership fees, and gross receipts from activities related to its exempt functions - subject to certain exceptions, and (2) no more than 331/3% of its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part Ill.) An organization organized and operated exclusively to test for public safety. See section 509(a)(4). 10 11 An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box that describes the type of supporting organization and complete lines lie through 11 h. Type Ill - Other Type Ill - Functionally integrated d c Type II Type I b a By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified e persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). If the organization received a written determination from the IRS that it is a Type I, Type II, or Type III supporting f organization, check this box Since August 17, 2006, has the organization accepted any gift or contribution from any of the g following persons? Yes No (i) A person who directly or indirectly controls, either alone or together with persons described in (ii) .llg(I) and (iii) below, the governing body of the supported organization? .11g(II) (ii) A family member of a person described in (i) above? .11g(III) (iii) A 35% controlled entity of a person described in (i) or (ii) above? Provide the following information about the supported organization(s). h Ej 0 LII LII (i) Name of supported organization (ii) EIN (iii) Type of organization (described on lines 1-9 above or IRC section (see instructions)) (iv) is the organization in cot. (I) listed in Yes Total For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ. I No (v) Did you notify the organization In cot. (i) of your support? Yes I No (vi) Is the organization In col. (I) organized In the U.S.? Yes I No (vii) Amount of support Schedule A (Form 990 or 990-EZ) 2010 JSA 0E1210 3.000 1743CS K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 14 27-1414646 Schedule A (Form 990 or 990-EZ) 2010 Page 2 IThIII 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 Ill. If the organization fails to qualify under the tests listed below, please complete Part Ill.) Section A. Public SuDDort (a) 2006 Calendar year (or fiscal year beginning in) (c) 2008 (b)2007 (d) 2009 (e)2010 (1) Total I Gifts, grants, contributions, and membership fees received. (Do not include any 'unusual grants.") ...... 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. Section B. Total Support Calendar year (or fiscal year beginning In) " (a) 2006 (b) 2007 (c) 2008 (d) 2009 2010 Total 7 Amounts from line 4 8 Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources................. 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 IV.) ........... 64,830,942. 11 Total support Add lines 7 through lo . 12 I 12 Gross receipts from related activities, etc. (see instructions) ........................... 13 First five 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 Public support percentage for 2010 (line 6, column (f) divided by line 11, column (f)) % ........14 1 15 Public support percentage from 2009 Schedule A, Part II, line 14 ....................15 % 16a 33113 % support test - 2010. If the organization did not check the box on line 13, and line 14 is 331/3 % or more, check this box and stop here. The organization qualifies as a publicly supported organization .................... 33113 % support test - 2009. If the organization did not check a box on line 13 or 16a, and line 15 is 331/3 % or more, check this box and stop here. The organization qualifies as a publicly supported organization ................. 17a 10%-facts-and-circumstances test -2010. 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 IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported organization ............................................................. Bo. L---j b 10%-facts-and-circumstances test - 2009. 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 IV how the organzation 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 14 LII Li Li instructions .............................................................. Schedule A (Form 990 or 990 .EZ) 2010 J5A 0E1220 1.000 1743CS K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 15 Schedule A (Form 990 or 990-EZ) 2010 27-1414646 Page 3 1fl1Il1 Support Schedule for Organizations Described in Section 509(a)(2) (Complete only if you checked the box on line 9 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.) Section A. Public Support (a) 2006 Calendar year (or fiscal year beginning in) 00, 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 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total I - 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 I 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 ................ ............ Calendar year (or fiscal year beginning in) ............ _____________ _____________ (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (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 l0a and l0b 11 Net income from unrelated business activities not included in line lOb, 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 IV.) _____________ 13 Total support. (Add lines 9, lOc, 11, and 12.) 14 First five 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 Su pp ort Percentage 15 Public support percentage for 2010 (line 8, column (f) divided by line 13, column () 16 Public support percentage from 2009 Schedule A, Part Ill, line 15 Section D. Computation of Investment Income Percentage 15 16 % ........... 17 Investment income percentage for 2010 (line lOc, column (f) divided byline 13, column () 17 % 18 Investment income percentage from 2009 Schedule A, Part III, line 17 .18 % 19a 33113% support tests - 2010. If the organization did not check the box on line 14, and line 15 is more than 331/3 %, and line 17 is not more than 331/3 %, check this box and stop here. The organization qualifies as a publicly supported organization b 331/3% support tests -2009. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 331/3%, and line 18 is not more than 331/3 %, 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 JSA - Schedule A (Form 990 or 990-EZ) 2010 0E1221 1.000 1743C5 K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 16 27-1414646 Page 4 Schedule A (Form 990 or 990-EZ) 2010 I1IL'I Supplemental Information. Complete this part to provide the explanations required by Part II, line 10; Part II, line 17a or 17b; or Part Ill, line 12. Also complete this part for any additional information. (See instructions). UNUSUAL GRANTS SCHEDULE A, PART II, SECTION A, LINE 1 UNUSUAL GRANTS - $108,868,409 Schedule A (Form 990 or 990-EZ) 2010 JSA 0E1225 2.000 1743CS K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 17 SCHEDULE D (Form 990) OMB No. 1545-0047 Supplemental Financial Statements Department of the Treasury Name of the organization 2010 Complete if the organization answered "Yes," to Form 990, Part IV, line 6, 7, 8, 9, 10, 11, or 12. See separate instructions. Attach to Form 990. Employer Identification number CLINTON HEALTH ACCESS INITIATIVE, INC. 27-1414646 Organizations Maintaining Donor Advised Funds or Other Similar Funds or AccountsComplete if the organization answered "Yes" to Form 990, Part IV, line 6. (a) Donor advised funds (b) Funds and other accounts I I 2 3 4 5 6 Total number at end of year ........... Aggregate contributions to (during year) ...... Aggregate grants from (during year) Aggregate value at end of year ......... Did the organization inform all donors and donor advisors in writing that the assets held in donor advised funds are the organization's property, subject to the organization's exclusive legal control? Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other "r nea rnnfrrinr, imnQrmicchl nrkifo hQn,fif'? "-'"a " i"-' "-'-'-"- i-' •"•'- .-'-• "-j' ..-. . LII Yes LIINo ._-. Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7. IThIII Pu ose(s) of conservation easements held by the organization (check all thg tply). i Preservation of an historically important land area Preservation of land for public use (e.g., recreation or education) Preservation of a certified historic structure Protection of natural habitat Preservation of open space 2 Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year. - Held at the End of the Tax Year a Total n'umber of conservation easements ............................____________________________ b Total acreage restricted by conservation easements ......................_____________________________ c Number of conservation easements on a certified historic structure included in (a) d Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register .......................... it. Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during the 3 tax year lio__________________ Number of states where property subject to conservation easement is located Io__________________ 4 Does the organization have a written policy regarding the periodic monitoring, inspection, handling of 5 violations, and enforcement of the conservation easements it holds? ....................... LI Yes No Staff and volunteer hours devoted to monitoring, inspecting, and enforcing conservation easements during the year 6 LI 7 Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B) (i) and 170(h)(4)(B)(ii)? LIII Yes In Part XIV, describe how the organization reports conservation easements in its revenue and expense statement, and 9 balance sheet, and include, if applicable, the text of the footnote to the organization's financial statements that describes the organization's accounting for conservation easements. Ifl1llI Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets. Complete if the organization answered "Yes" to Form 990, Part IV, line 8. 8 El No la If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIV, the text of the footnote to its financial statements that describes these items. b If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts relating to these items: (i) Revenues included in Form 990, Part VIII, line I $_____________ (ii) Assets included in Form 990, Part $_____________ If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the 2 following amounts required to be reported under SFAS 116 (ASC 958) relating to these items: a Revenues included in Form 990, Part VIII, line I $_____________ ..................................... 10, $ b Assets included in Form 990, Part X Schedule D (Form 990) 2010 For Paperwork Reduction Act Notice, see the Instructions for Form 990. ............................. ................................... ............................... JSA 0E1268 1.000 1743CS K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 21 27-1414646 Schedule D (Form 9SO)2010 Page 2 .muff-organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets(continued) 3 Using the organizations acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply): Public exhibition Loan or exchange programs a d Scholarly research Other b e Preservation for future generations C 4 Provide a description of the organization's collections and explain how they further the organization's exempt purpose in Part xlv. 5 During the year, did the organization solicit or receive donations of art, historical treasures, or other similar assets to be sold to raise funds rather than to be maintained as part of the organization's collection? Yes Liii No WA Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990, Part IV, line 9, or reported an amount on Form 990, Part X, line 21. F] la Is the organization an agent, trustee, custo than or other intermediary for contributions or other assets not included on Form 990, Part X? ............................................. Yes 7 No b If "Yes," explain the arrangement in Part XI V and complete the following table: Amount c Beginning balance ...................................Ic d Additions during the year ...............................Id e Distributions during the year .............................. le f Ending balance ..................................... if ________ 2a Did the organization include an amount on Form 990, Part X, line 21 ? ...................... Li Yes Li No b If "Yes," explain the arrangement in Part XI V. i1VI Endowment Funds. Complete if organization answered "Yes" to Form 990, Part IV, line 10. I la b C d e f g 2 a b C 3a b 4 (a) Current year I (b) Prior year I (c) Two years back I (d) Three years back Beginning of year balance . Contributions ........... Net investment earnings, gains, and losses............. Grants or scholarships ...... Other expenditures for facilities and programs ........... Administrative expenses ..... End of year balance ........ Provide the estimated percentage of the y ear end balance held as: Board designated or quasi-endowment - % Permanent endowment % Term endowment % Are there endowment funds not in the pos session of the organization that are held and administered for the organization by: (i) unrelated organizations ............................................... (ii) related organizations ................................................ If "Yes" to 3a(ii), are the related organizati ons listed as required on Schedule R? Describe in Part XIV the intended uses oft he organization's endowment funds. Land, Buildings, and Eguipment.See Form 990, Part X, line 10. I (e) Four years back Yes No 3a(i) 3a(ii) 3b Iff Description of investment (a) Cost or other basis (investment) I (b) Cost or other basis (other) I Land ..................... b Buildings .................. c Leasehold improvements .......... 88,781.1 d Equipment ................. 2,537,469.1 e Other Total. Add lines Ia through le. (Column (d) must Form 990. Part X. column (B). line (c) Accumulated depreciation (d) Book value la 88,781 1,444,911 0. 1,092.558. 1,092,558. Schedule D (Form 990) 2010 JSA 0E1269 1.000 1743CS K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 22 27-1414646 Schedule (Form 990) 2010 3 Ifli&'1lU Investments - Other Securities. See Form 990, Part X, (a) Description of security or category (including name of security) (b) Book value (C) Method of valuation: Cost or end-of-year market value (1) Financial derivatives ..................______________ (2) Closely-held equity interests ..............______________ (3) Other (A) (B) (C) (D) (E) (F) (G) (H) Total. b) must equal Form 990, Part X, col. (B) line 12.) 10. 1 Investments - Program Related. See Form 990, Part X, Ii I (a) Description of investment type (b) Book value (c) Method of valuation: Cost or end-of-year market value 4 Total. b) must equal Form 990, Part X, cal. (B) line 13.) Other Assets. See Form 990. Part X. line 15. ) Book value 86,304,698. 11,511,474. ASSETS LIMITED AS TO USE ASSETS HELD BY AFFILIATE Total. I ) must equal Form 990, Part X, col. (B) line Other Liabilities. See Form 9 (a) Description of liability Federal income taxes DUE TO AFFILIATE 97,816,172. Part X, line 25. I (b) Amount 6,694,455. Total. (Column (b) must equal Form 990, Part X, col. (B) line 25.) 6,694,455.1 I 2. FIN 48 (ASC 740) Footnote. In Part XIV, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). JSA 0E12701.000 I Schedule D (Form 990) 2010 1743CS K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 23 27-1414646 Reconciliation of Change in Net Assets from Form 990 to Audited Financial Statements Total revenue (Form 990, Part VIII, column (A), line 12) .1 I 2 Total expenses (Form 990, Part IX, column (A), line 25) Excess or (deficit) for the year. Subtract line 2 from line I .3 3 ..........4 Net unrealized gains (losses) on investments 4 5 Donated services and use of facilities ...................................5 .............................6 Investmentexpenses 6 ................................7 7 Prior period adjustments .8 Other (Describe in Part XIV.) 8 .9 9 Total adjustments (net). Add lines 4 through 8 10 Excess or (deficit) for the year per audited financial ements.statoine Cmb l ines3 nd 9 a0 1 ji Reconciliation of Revenue per Audited Financial Statements With Revenue per Return Total revenue, gains, and other support per audited financial statements .I I 2 Amounts included on line 1 but not on Form 990, Part VIII, line 12: .2a a Net unrealized gains on investments .................21, 536,763. b Donated services and use of facilities c Recoveries of prior year grants .2c 20, 078, 060. .2d d Other (Describe in Part XIV.) ..................................e Add lines 2a through 2d Subtract line 2e from line I ..........................................3 3 4 Amounts included on Form 990, Part VIII, line 12, but not on line 1: a Investment expenses not included on Form 990, Part VIII, line 7b . b Other (Describe in Part XIV.) c Add lines 4a and 4b 4c Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) - ............5 5 flP1I1U Reconciliation of Exoenses oer Audited Financial Statements With Exoenses oer Return I Total expenses and losses per audited financial statements 2 Amounts included on line 1 but not on Form 990, Part IX, line 25: 536,763. a Donated services and use of facilities .2a b Prior year adjustments 2b 2c c Other losses d Other (Describe in Part XIV.) 2d e Add lines 2a through 2d 2e 3 Subtract line 2e from line I ......................................... 4 Amounts included on Form 990, Part IX, line 25, but not on line 1: a Investment expenses not included on Form 990, Part VIII, line 7b b Other (Describe in Part XIV.) 4b c Add lines 4a and 4b 4c Schedule D (Form 990) 2010 Page 4 173, 699,351. 178,555,096. -4,855,745. 20, 078, 060. 20, 078, 060. 15,222,315. 194,314, 174. 20, 614, 823. 173,699,351. 173,699,351. 179,091,859. 536,763. 178,555,096. 178,555,096. Information Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part Ill, lines la and 4; Part IV, lines lb and 2b; PartV, line 4; PartX, line 2; Part XI, line 8; Part XII, lines 2d and 4b; and Part XIII, lines 2d and 4b. Also complete this part to provide any additional information. 5 Total exoenses. Add lines 3 and 4c. (This must eczual Form 990. Part I. line 18.) .............. SEE PAGE 5 Schedule D (Form 990) 2010 JSA 0E1271 1.000 1743CS K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 24 27-1414646 I: 0 s Schedule (Form 990) 2010 Page 5 " upplemental Information (continued) - RECONCILIATION OF CHANGE IN NET ASSETS FORM 990, SCHEDULE D, PART XI, LINE 8 REVENUE FROM AN ENTITY INCLUDED IN THE CONSOLIDATED AND AUDITED FINANCIAL STATEMENTS BUT FILING A SEPARATE 990 - $20,078,060 REVENUE RECONCILIATION FORM 990, SCHEDULE D, PART XII, LINE 2D REVENUE FROM AN ENTITY INCLUDED IN THE CONSOLIDATED AND AUDITED FINANCIAL STATEMENTS BUT FILING A SEPARATE 990 - $20,078,060 Schedule D (Form 990) 2010 JSA 0E1226 1.000 1743CS 1<925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 25 SCHEDULE F (Form ) OMB No. 1545-0047 Statement of Activities Outside the United States Department of the Treasury Internal Revenue Service Name of the organization 2010 Complete if the organization answered "Yes" to Form 990, Part IV, line 14b, 15, or 16. Attach to Form 990. See separate instructions. Employer Identification number CLINTON HEALTH ACCESS INITIATIVE, INC. 27-1414646 Complete if the organization answered 'Yes' to General Information on Activities Outside the United States. Form 990, Part IV, line 14b. For grantmakers. Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and the selection criteria used to award the grants or assistance?EiIiJ Yes No 2 For grantmakers. Describe in Part V the organization's procedures for monitoring the use of grant funds outside the United States. 3 Activities per Region. (The following Part I, line 3 table can be duplicated if additional space is needed.) (a) Region (b) Number of offices In the region Number of employees, agents, and independent contractors in region (c) (d)Activities conducted in (e) If activity listed In (d) Is region (by type) (e.g., a program service, fundraising, programdescribe specific type of services, investments, service(s) in region grants to recipients located In the region) (f) Total expenditures for and investments In region 3a Sub-total . . . . . . . . . . . from continuation b Total sheets to Part I ....... For Paperwork Reduction Act Notice, see the Instructions for Form 990. Schedule F (Form 990) 2010 JSA 0E1274 1.000 1743CS K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 26 Schedule F(Focm 990) 2010 27-1414646 IFTilI Grants and Other Assistance to Organizations or Entities Outside the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 15, for any recipient who received more than $5,000. Check this box if no one recipient received more than $5,000 Page 2 2 Enter total number of recipient organizations listed above that are recognized as charities by the foreign country, recognized as tax-exempt by the IRS, or for which the grantee or counsel has provided a section 501 (c)(3) equivalency letter ...................... 3 Enter total number of other organizations or entities Schedule F (Form 990) 2010 JSA 0E12751.000 1743CS K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 27 27-1414646 Schedule F(Form 990)2010 Page 2 •niul. Grants and Other Assistance to Organizations or Entities Outside the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 15, for any recipient who received more than $5,000. Check this box if no one recipient received more than $5,000 2 Enter total number of recipient organizations listed above that are recognized as charities by the foreign country, recognized as tax-exempt by the IRS, or for which the grantee or counsel has provided a section 501 (c)(3) equivalency letter 3 Enter total number of other organizations or entities 10. Schedule F (Form 990) 2010 JSA 0E12751.000 1743CS K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 28 27-1414646 Grants and Other Assistance to Organizations or Entities Outside the United States. Complete if the organization answered 'Yes' to Form 990, Part IV, line 15, for any recipient who received more than $5,000. Check this box if no one recipient received more than $5,000 Schedule F(Form 990)2010 •iiiii 2 Enter total number of recipient organizations listed above that are recognized as charities by the foreign country, recognized as tax-exempt by the IRS, or for which the grantee or counsel has provided a section 501 (c)(3) equivalency letter 3 Enter total number of other organizations or entities Page 2 .LII . Schedule F (Form 990) 2010 JSA 0E12751.000 1743cs K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 29 27-1414646 Schedule F (Form 990) 2010 Page •niiU Grants and Other Assistance to Organizations or Entities Outside the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 15, for any recipient who received more than $5,000. Check this box if no one recipient received more than $5,000 2 .Lull 2 Enter total number of recipient organizations listed above that are recognized as charities by the foreign country, recognized as tax-exempt by the IRS, or for which the grantee or counsel has provided a section 501 (c)(3) equivalency letter 00.59. 3 Enter total number of other organizations or entities ...............................................0. Schedule F (Form 990) 2010 JSA 0E12751.000 1743CS K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 30 27-1414646 Page 3 Schedule F(Form 990) 2010 •naIIu Grants and Other Assistance to Individuals Outside the United States. Complete if the organization answered 'Yes to Form 990, Part IV, line 16. Schedule F (Form 990) 2010 JSA 0E12761.000 1743CS K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 31 Page 4 Schedule F (Form 990) 2010 17F.01 Foreign Forms I Was the organization a U.S. transferor of property to a foreign corporation during the tax year? If "Yes," the organization may be required to file Form 926, Return by a U.S. Transferor of Property to a Foreign Corporation (see Instructions for Form 926) ............................... Yes 2 Did the organization have an interest in a foreign trust during the tax year? If "Yes, "the organization may be required to file Form 3520, Annual Return to Report Transactions with Foreign Trusts and Receipt of Certain Foreign Gifts, and/or Form 3520-A, Annual Information Return of Foreign Trust With a U.S. Owner (see Instructions for Forms 3520 and 3520-A) 3 Did the organization have an ownership interest in a foreign corporation during the tax year? If "Yes," the organization may be required to file Form 5471, Information Return of U.S. Persons with respect to Certain Foreign Corporations. (see Instructions for Form 5471) ..................... 4 Was the organization a direct or indirect shareholder of a passive foreign investment company or a qualified electing fund during the tax year? If "Yes, "the organization may be required to file Form 8621, Return by a Shareholder of a Passive Foreign Investment Company or Qualified Electing Fund. (see Instructions for Form 8621) 5 6 Did the organization have an ownership interest in a foreign partnership during the tax year? If "Yes," the organization may be required to file Form 8865, Return of U.S. Persons with respect to Certain Foreign Partnerships. (see Instructions for Form 8865) ......................... LNO .Yes No 1111 Yes No .Yes No [=1] Yes LNo Did the organization have any operations in or related to any boycotting countries during the tax year? If "Yes, "the organization may be required to file Form 5713, International Boycott Report (see Instructions for Form 5713) ............................................ Yes LNo Schedule F (Form 990) 2010 JSA 0E1277 1.000 1743C5 K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 32 27-1414646 CLINTON HEALTH ACCESS INITIATIVE, INC. Schedule F (Form 990) 2010 Page 5 27-1414646 I'I Supplemental Information Complete this part to provide the information required by Part I, line 2 (monitoring of funds); Part I, line 3, column (f) (accounting method); Part II, line 1 (accounting method); Part Ill (accounting method); and Part Ill, column (c) (estimated number of recipients), as applicable. Also complete this part to provide any additional information (see instructions). PROCEDURES FOR MONITORING THE USE OF GRANT FUNDS SCHEDULE F, PART I, LINE 2 MOST GRANT FUNDS ARE MAINTAINED AT HEADQUARTERS. CHAI DOES HAVE SOME IN COUNTRY, AND THEY ARE MONITORED BY THE CASH REPORTS RECEIVED AT HEADQUARTERS EACH MONTH. FOR GRANTS OUTSIDE OF THE US, EACH COUNTRY OR PROGRAM TEAM REQUESTS THEIR CASH NEEDS EACH MONTH. AFTER THE AMOUNTS ARE VERIFIED, THE HEADQUARTER'S TEAM DISBURSES THE FUNDS TO THE COUNTRY/PROGRAM TEAMS. Schedule F (Form 990) 2010 JSA 0E1502 1.000 1743CS 1(925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 33 SCHEDULE I (Form 990) Grants and Other Assistance to Organizations, Governments, and Individuals in the United States Department of the Treasury Internal Revenue Service Name of the organization 2010 Complete if the organization answered "Yes" to Form 990, Part IV, line 21 or 22. . Attach to Form 990. Employer Identification number CLINTON HEALTH ACCESS INITIATIVE, INC. 27-1414646 General Information on Grants and Assistance I Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and the selection criteria used to award the grants or assistance? .................................................. Yes 2 Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States. E:1 No 1fliIlI Grants and Other Assistance to Governments and Organizations in the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 21, for any recipient that received more than $5,000. Check this box if no one recipient received more than $5,000. Part II can be duplicated if additional space is needed I (a) Name and address of organization or government (b) EIN (c) lRcsection if applicable (d) Amount of cash grant (e) Amount of non-cash assistance (f) Method of valuation (book. FM V appraisal, (g) Description of non-cash assistance LI1 (h) Purpose of grant or assistance _LI1R1tL1(TN-----------------1.468 P0 BOX 45026 BOSTON, MA 02241-5026 ______ 472 9TH STREET OAKLAND, CA 94607 _L4)PiL 12529 COLLECTIONS CTR. DRIVE _L5 2L1ic --------------- 2033 ROUTE 130 UNIT N ______________ 1 OAK MEADOW ROAD LINCOLN, MA 01773 --------------525 BRYANT STREET, NW, SUITE 137 L81 .191 (10L (ilL____________________________ (i2L ---------------------------2 Enter total number of section 501(c)(3) and government organizations 3 Enter total number of other organizations For Paperwork Reduction Act Notice, see the Instructions for Form 990. ......................................................0_ 7. Schedule I (Form 990) (2010) JSA OE12882.cD43 K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 34 Page 2 27-1414646 Schedule I (Form 990) (2010) IThIIII Grants and Other Assistance to Individuals in the United States. Complete if the organization answered "Yes" on Form 990, Part IV, line 22. Part Ill can be duplicated if additional space is needed. (a) Type of grant or assistance (b) Number of recipients (C) Amount of I cash grant . ( d) Amount or (e) Method of valuation (book, non-cash assistance I FMV, appraisal, other) (f) Description of non-cash assistance I 5 6 7 Suoolemental Information. ComDlete this oart to Drovide the information reauired in Part I. line 2. and an y other additional information. PROCEDURES FOR MONITORING THE USE OF GRANT FUNDS SCHEDULE I, PART I, LINE 2 MOST GRANT FUNDS ARE MAINTAINED AT HEADQUARTERS. CHAI DOES HAVE SOME IN COUNTRY, AND THEY ARE MONITORED BY THE CASH REPORTS RECEIVED AT HEADQUARTERS EACH MONTH. FOR GRANTS OUTSIDE OF THE US, EACH COUNTRY OR PROGRAM TEAM REQUESTS THEIR CASH NEEDS EACH MONTH. AFTER THE AMOUNTS ARE VERIFIED, THE HEADQUARTER'S TEAM DISBURSES THE FUNDS TO THE COUNTRY/PROGRAM TEAMS. Schedule I (Form 990) (2010) JSA ,,,,,,.J,W 43 CS K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 35 Compensation Information OMB No. 1545-0047 For certain Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees Complete if the organization answered "Yes" to Form 990, Part IV, line 23. Attach to Form 990. POSee separate instructions. 2010 SCHEDULE J (Form 990) Department of the Treasury Internal Revenue Service Employer Identification number Name of the organization 27-1414646 CLINTON HEALTH ACCESS INITIATIVE, INC. Corn I Yes I No la Check the appropriate box(es) if the organization provided any of the following to or for a person listed in Form 990, Part VII, Section A, line Ia. Complete Part III to provide any relevant information regarding these items. First-class or charter travel Housing allowance or residence for personal use Travel for companions Payments for business use of personal residence Tax indemnification and gross-up payments Health or social club dues or initiation fees Discretionary spending account Personal services (e.g., maid, chauffeur, chef) b If any of the boxes on line la are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part Ill to explain......................................................... 2 Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all officers, directors, trustees, and the CEO/Executive Director, regarding the items checked in line la? 3 Indicate which, if any, of the following the organization uses to establish the compensation of the organization's CEO/Executive Director. Check all that apply. Compensation committee Written employment contract Independent compensation consultantX Compensation survey or study Form 990 of other organizations X Approval by the board or compensation committee 4 During the year, did any person listed in Form 990, Part VII, Section A, line Ia, with respect to the filing organization or a related organization: a Receive a severance payment or change-of-control payment from the organization or a related organization? b Participate in, or receive payment from, a supplemental nonqualified retirement plan? c Participate in, or receive payment from, an equity-based compensation arrangement? If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III. Only section 501(c)(3) and 501(c)(4) organizations must complete lines 5-9. For persons listed in Form 990, Part VII, Section A, line la, did the organization pay or accrue any compensation contingent on the revenues of: a The organization? b Any related organization? If "Yes" to line 5a or 5b, describe in Part III. For persons listed in Form 990, Part VII, Section A, line Ia, did the organization pay or accrue any 6 compensation contingent on the net earnings of: a The organization? b Any related organization? If "Yes" to line 6a or 6b, describe in Part III. 7 For persons listed in Form 990, Part VII, Section A, line la, did the organization provide any non-fixed payments not described in lines 5 and 6? If "Yes," describe in Part Ill 8 Were any amounts reported in Form 990, Part VII, paid or accrued pursuant to a contract that was subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe inPart Ill ........................................................ 9 If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c) ? .............................. . ........... 5 2 4a .4b .4c X X X 5a 5b X X 6a 6b X X 7 x 8 X For Paperwork Reduction Act Notice, see the Instructions for Form 990. Schedule J (Form 990) 2010 JSA 0E1290 1.000 1743CS K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 36 Page 2 27-1414646 Schedule J(Form 990)2010 IflhlU Officers, Directors, Trustees, Key Employees, and Highest Compensated EmployeesiJse duplicate copies if additional space is needed. For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII. Note. The sum of columns (B)(i)-(iii) must equal the applicable column (D) or column (E) amounts on Form 990, Part VII, line I a. (B) Breakdown of W-2 and/or 1099-MISC compensation (A) Name j BRUCE LINDSEY (c) Retirement and (D) Nontaxable benefits (F) compensation reported in prior Form 990 or Form (E) Total of columns (B)(i)-(D) iiE;--o.-o.-a.-o.-. -o - - - - - - (I) Base compensation (II) Bonus & incentive compensation 276,298. other deferred compensation (III) Other reportable compensation 0. 0. q. 15,446 16,799. 308,543. - 0. (I) 2 __ (i) 3 (i) 4 0)) 5 0)) 6 0)) 7 0) 8 0) 9 0)-- -- - 10 (i) -- ---- - 11 (i) -- - - 12 0)) -- -- - 13 0)) -- -- - 14 (i) -- - - 15 (i) Schedule J (Form 990) 2010 JSA OE1291l .43CS K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 37 Schedule J (Form 990)2010 27-1414646 Page •iiIu Supplemental Information Complete this part to provide the information, explanation, or descriptions required for Part I, lines la, lb, 4c, 5a, 5b, 6a, 6b, 7, and 8. Also complete this part for any additional information. Schedule J (Form 990) 2010 JSA 0E1505 1.000 1743CS K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 38 SCHEDULE L I (Form 990 or 990 . EZ) I Department of the Treasury Internal Revenue Service Name of the organization I OMB No. 1545-0047 Transactions With Interested Persons 1 Complete if the organization answered "Yes" on Form 990, Part IV, line 25a, 25b, 26, 27, 28a, 28b, or 28c, or Form 990-EZ, Part V, line 38a or 40b. 'Attach to Form 990 or Form 990-EZ. See se p arate instructions. Employer Identification number CLINTON HEALTH ACCESS INITIATIVE, INC. Excess Benefit Transactions (section 501 (c)(3) and section 501 (c)(4) organizations only). 27-1414646 Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b. 2 Enter the amount of tax imposed on the organization managers or disqualified persons during the year under section 4958 ............................................... IN. $ Enter the amount of tax, if any, on line 2, above, reimbursed by the organization 3 .............. No. $ IflIII Loans to and/or From Interested Persons. Complete if the organization answered "Yes" on Form 990, Part IV, line 26, or Form 990-EZ, Part V, line 38a. (a) Name of interested person and purpose (c) Original principal amount (d) Balance due (e) in default ?l (f) Approved (g) Written by board or agreement? committee? No Total ITh1III Grants or Assistance Benefiting Interested Persons. Complete if the organization answered "Yes" on Form 990, Part IV, line 27. For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ. Schedule L(Form 990 or 990. EZ) 2010 JSA 0E1297 1.000 1743CS K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 39 27-1414646 Page 2 Schedule L (Form 990 or 990-EZ) 2010 IflIL'I Business Transactions Involving Interested Persons. Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c. (a) Name of interested person (b) Relationship between interested person and the organization (c) Amount of transaction (d) Description of transaction (e) Sharing of organizations revenues? I No Supplemental Information Complete this part to provide additional information for responses to questions on Schedule L (see instructions). Schedule L (Form 990 or990 .EZ) 2010 0E1507 2.000 1743CS 1<925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 40 SCHEDULE 0 I (Form 990 or 990-E7) I Depaent of the Treasury Internal Revenue Service ame of the organization I Supplemental Information to Form 990 or 990-EZ Complete to provide information for responses to specific questions on Form 990 or 990-EZ or to provide any additional information. '-Attach to Form 990 or 990-EZ. OMB No. 1545-0047 2010 Employer Identification number CLINTON HEALTH ACCESS INITIATIVE, INC. 27-1414646 INTEREST IN/AUTHORITY OVER A FINANCIAL ACCOUNT IN A FOREIGN COUNTRY FORM 990, PAGE 5, PART V, LINE 4B BURUNDI, CAMBODIA, CHINA, DOMINICAN REPUBLIC, ETHIOPIA, HAITI, INDIA, INDONESIA, KENYA, LESOTHO, LIBERIA, MALAWI, MOZAMBIQUE, NIGERIA, PAPUA NEW GUINEA, RWANDA, SOUTH AFRICA, SWAZILAND, TANZANIA, UGANDA, UKRAINE, VIETNAM, ZAMBIA, AND ZIMBABWE. PROCESS TO REVIEW FORM 990 FORM 990, PAGE 6, PART VI, SECTION B, LINE 11B THE SENIOR ACCOUNTANT COLLECTS AND CONSOLIDATES THE INFORMATION WHEN THE 2010 AUDIT IS COMPLETED. THE DIRECTOR OF ACCOUNTING AND ADMINISTRATION AND CFO REVIEW THE FORM 990. THE BOARD WILL RECEIVE A COPY OF THE FINAL 990 AT A MEETING SUBSEQUENT TO FILING. PRACTICE FOR MONITORING COMPLIANCE FORM 990, PAGE 6, PART VI, SECTION B, LINE 12C THIS APPLIES TO DIRECTORS, OFFICERS, OR COMMITTEE MEMBERS AND ALL OTHERS WHO ARE PERMITTED TO VOTE AT BOARD OF DIRECTOR MEETINGS. INTERESTED PERSONS MUST DISCLOSE ANY TRANSACTION OR ARRANGEMENT WHICH RESULTS IN A CONFLICT OF INTEREST TO THE BOARD OR COMMITTEE OF WHICH THEY ARE A MEMBER. THE BOARD MEETS, REVIEWS AND DISCUSSES ANY DISCLOSED CONFLICT OF INTEREST. CHAI SHALL TAKE APPROPRIATE DISCIPLINARY ACTIONS, AS DETERMINED BY THE BOARD, WITH RESPECT TO AN INTERESTED PERSON WHO HAS VIOLATED THE CONFLICT OF INTEREST POLICY. For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990 .EZ. Schedule 0 (Form 990 or990-EZ) (2010) JSA 0E1227 2.000 1743CS K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 41 Schedule 0 (Form 990 or990-EZ) 2010 Name of the organization 2 Employer Identification number CLINTON HEALTH ACCESS INITIATIVE INC. 27-1414646 AVAILABILITY OF DOCUMENTS FORM 990, PAGE 6, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. RECONCILIATION OF NET ASSETS FORM 990, PART XI, LINE 5 REVENUE FROM AN ENTITY INCLUDED IN THE CONSOLIDATED AND AUDITED FINANCIAL STATEMENTS BUT FILING A SEPARATE 990 - $20,078,060 DELEGATED MANAGEMENT DUTIES FORM 990, PART VI, SECTION A, LINE 3 CHAI HAS A CONSULTING AGREEMENT WITH SJS ADVISORS PURSUANT TO WHICH CHAI OBTAINS THE SERVICES OF IRA C. MAGAZINER AS VICE CHAIR AND CHIEF EXECUTIVE OFFICER OF CHAI, INC. ATTACHMENT 1 FORM 990, PART III, LINE 1 - ORGANIZATION'S MISSION THE CLINTON HEALTH ACCESS INITIATIVE IS DEDICATED TO IMPROVING ACCESS TO HEALTHCARE FOR ALL INDIVIDUALS. RESIDENTS OF DEVELOPING COUNTRIES OFTEN CANNOT AFFORD AND DO NOT HAVE ACCESS TO SYSTEMS THAT PROVIDE BASIC HEALTHCARE, INCLUDING MEDICINES FOR DISEASES THAT ARE PREVENTABLE, TREATABLE OR CURABLE. THIS IS WHERE CHAI INTERVENES - BY PARTNERING WITH GOVERNMENTS AND WORKING WITH OTHER NGOS TO PROVIDE SOLUTIONS TO THE BIGGEST CHALLENGES IMPEDING EFFECTIVE HEALTHCARE IN DEVELOPING COUNTRIES. USING A BUSINESS—ORIENTED APPROACH, CHAI ENDEAVORS TO ALTER COMMODITY MARKETS TO DECREASE THE COSTS OF CARE AND TREATMENT, AS WELL AS EXPAND ACCESS TO HEALTH SERVICES. Schedule 0 (Form 990 or 990-EZ) 2010 JSA 0E1228 2.000 1743CS K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 42 2 Schedule 0 (Form 990 or 990-EZ) 2010 Name of the organization Employer Identification number CLINTON HEALTH ACCESS INITIATIVE, INC. 27-1414646 ATTACHMENT 2 FORM 990, PART III - PROGRAM SERVICE, LINE 4A UNITAID THE GOAL OF UNITAID SECOND—LINE HIV/AIDS ARV PROJECT IS TO RAPIDLY ADDRESS THE GAP BETWEEN ACCESS TO FIRST—LINE AND SECOND—LINE ANTIRETROVIRAL (ARVS) DRUGS AS A FIRST STEP TOWARDS UNIVERSAL ACCESS TO ARV TREATMENT FOR ALL PERSONS LIVING WITH HIV/AIDS, ESPECIALLY IN THE DEVELOPING COUNTRIES. THE UNITAID PEDIATRIC HIV/AIDS PROJECT WITH THE GOAL OF RAPIDLY ADDRESSING THE GAP BETWEEN PEDIATRIC AND ADULT ACCESS TO ANTIRETROVIRAL ("ARVS") DRUGS AS A FIRST STEP TOWARDS UNIVERSAL ACCESS TO TREATMENT FOR CHILDREN. ATTACHMENT 3 FORM 990, PART VII, COLUMN B - ESTIMATED AVERAGE PER WEEK NAME AND TITLE HOURS DEVOTED FOR RELATED ORGANIZATION BRUCE LINDSEY DIRECTOR 50.00 Schedule 0 (Form 990 or 990-EZ) 2010 JSA 0E1228 2.000 1743CS K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 43 SCHEDULE R (Form 990) I Department of the Treasury Internal Revenue Service I UIVID NO. i3'+OlJIJ Related Organizations and Unrelated Partnerships 1 © 10 I Complete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37. Attach to Form 990. See separate instructions. Name of the organization Employer Identification number CLINTON HEALTH ACCESS INITIATIVE, INC. 27-1414646 Identification of Disregarded Entities (Complete if the organization answered "Yes" on Form 990, Part IV, line 33.) (a) Name, address, and EIN of disregarded entity (b) Primary, activity (d) Total incorr (C) Legal domicile (state or foreign country) End-of-year assets I Direct controlling _L11________________________________________________________ _()_------------------------------------------------------______________________________________________________ -----------------------------------------------------JR----------------------------------------------------------------------------------------------------------- - Identification of Related Tax-Exempt Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.) (a) Name, address, and EIN of related organization (b) Primary activity (c) Legal domicile (state or foreign country) (d) Exempt Code section (e) Public charity status (if section 501(c)(3)) (f) Direct controlling entity (g) Section 512(b)(13) controlled entity? Yes (j) WILLIAM J CLINTON FOUNDATION 1200 PRESIDENT CLINTON AVENUE _C2) WILLIAM J CLINTON FOUNDATION UK 610 PRESIDENT CLINTON AVE 2ND (_L CLINTON GLOBAL INTIATIVE, INC. 1200 PRESIDENT CLINTON AVENUE I No 31-1580204 LITTLE ROCK, AR 72201 ECONOMIC DEV AR LITTLE ROCK, AR 72201 FUNDRAISING UK INITIATIVE AR 01 (C) (3) TA 7 NA X NA WJC FDN X hA WJC FDN X 27-1551550 LITTLE ROCK, AR 72201 01 (C) (3) ............................................. --------------------------------------------_()_ ---------------------------------------------------------------------------------------Schedule R (Form 990) 2010 For Paperwork Reduction Act Notice, see the Instructions for Form 990. JSA 1743CS K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 44 Page 2 27-1414646 Schedule R(Form 990)2010 Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes' on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.) (a) Name, address, and EIN of related organization (b) Primary activity (c) Legal domicile (state or foreign country) (d) Direct controlling entity (e) (0 Predominant Share of total income (related, ncome Income (g) Share of end-of-year assets (h) excluded from tax under sections 512-514) (I) (k) 0) General or Percentage Code V-UBI amount In box 20 managing ownership partner? of Schedule K-I - (Form 1065) - Ji)---------------------- --------------J)---------------------(4) (5) (6) JZ)_____________________ Identification of Related Organizations Taxable as a Corporation or Trust(Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.) (a) Name, address, and ElM of related organization (b) Primary activity (c) Legal domicile (state or foreign country) (d) Direct controlling entity (e) Type of entity (C corp, S corp, or trust) (f) Share of total income (g) Share of end-of-year assets (h) Percentage ownership Ji)_______________ (2) J)- .............. J4)- -------------J_)--------------J)--------------(7) Schedule R (Form 990) 2010 JSA 0E13081.000 1743CS 1(925 11/15/2011 1:44:06 P4 V 10-8.2 66337 PAGE 45 27-1414646 Schedule R (Form 99O)2010 Transactions With Related Organizations (Complete if the organization answered "Yes" to Form 990, Part IV, line 34, 35, 35a, or 36.) Note. Complete line I if any entity is listed in Parts II, Ill, or IV of this schedule. During the tax year, did the organization engage in any of the following transactions with one or more related organizations listed in Parts Il—IV? I a Receipt of (i) interest (ii) annuities (iii) royalties or (iv) rent from a controlled entity b Gift, grant, or capital contribution to other organization(s) c Gift, grant, or capital contribution from other organization(s) d Loans or loan guarantees to or for other organization(s) e Loans or loan guarantees by other organization(s) f g h I Sale of assets to other organization(s) .................................................................... Purchase of assets from other organization(s) ................................................................ Exchange of assets .............................................................................. Lease of facilities, equipment, or other assets to other organization(s) ................................................... j Lease of facilities, equipment, or other assets from other organization(s) k Performance of services or membership or fundraising solicitations for other organization(s) I Performance of services or membership or fundraising solicitations by other organization(s) m Sharing of facilities, equipment, mailing lists, or other assets ........................................................ n Sharing of paid employees .......................................................................... o Reimbursement paid to other organization for expenses p Reimbursement paid by other organization for expenses q Other transfer of cash or property to other organization(s) r Other transfer of cash or orooertv from other oraanization(s) Schedule R (Form 990) 2010 JSA 1743CS K925 11/15/2011 OE11.000 1:44:06 PM V 10-8.2 66337 PAGE 46 Page 27-1414646 Schedule R(Fotm990)2010 Unrelated Organizations Taxable as a Partnership (Complete if the organization answered 'Yes' on Form 990, Part IV, line 37.) Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships. (a) Name, address, and SIN of entity (b) Primary activity (C) Legal domicile (state or foreign country) (d) Are all partners section 501(c)(3) organizations? Yes I No (a) Share of end-of-year assets (f) Disproportionate allocations? Yes I No (g) Code V-UBI amount in box 20 of Schedule K-I (Form 1065) (h) General or managing partner? Yes I No ii)---------------------------------------------------------------------------------------------------------------------------------------------------- (4) (5) (6) -----------------------------------------------------_) -----------------------------------------------------(9) L1_0) ----------------------------------------------------£13). L1i31 ..................................................... ________________________________________________ ------------------------------------------------ Schedule R (Form 990) 2010 JSA 0E13101.000 1743CS K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 47 27-1414646 Schedule R (Form 990) 2010 Page 5 1fl1'11U Supplemental Information Complete this part to provide additional information for responses to questions on Schedule R (see instructions). Schedule R (Form 990) 2010 0E1510 1.000 - 1743CS K925 11/15/2011 1:44:06 PM V 10-8.2 66337 PAGE 48 Im JAN 10 2012 CHARITIES BUREAU FOR DEPOSIT ONLY COPY OF WITI N PAPER RECEVrfl JAN 10 2012 NYS OFFICE OFTat - CHARiTiES 6UFiiiU INEL