ETENDED TO NOVEMBER 16, 015 OMB. 155-007 Return of Orgniztion Exempt From Inome Tx Form 990 Under setion 501(), 57, or 97()(1) of the Internl Revenue Code (exept privte foundtions) 01 Deprtment of the Tresury Internl Revenue Servie Do not enter soil seurity numers on this form s it my e mde puli. Informtion out Form 990 nd its instrutions is t www.irs.gov/form990. Open to Puli Inspetion A For the 01 lendr yer, or tx yer eginning nd ending B Chek if C Nme of orgniztion D Employer identifition numer pplile: Address hnge Nme hnge COLORADO DENTAL SERVICE, INC. Doing usiness s DELTA DENTAL OF COLORADO 8-05687 Initil return Numer nd street (or P.O. ox if mil is not delivered to street ddress) Room/suite E Telephone numer Finl return/ 58 SO. ULSTER STREET 800 (800)-0860 terminted City or town, stte or provine, ountry, nd ZIP or foreign postl ode G Gross reeipts $ 65,06,91. Amended return DENVER, CO 807 H() Is this group return Applition F Nme nd ddress of prinipl offier: KATHRYN ANN PAUL for suordintes? ~~ pending SAME AS C ABOVE H() Are ll suordintes inluded? I Tx-exempt sttus: 501()() 501() ( 0 ) (insert no.) 97()(1) or 57 If "," tth list. (see instrutions) J Wesite: WWW.DELTADENTALCO.COM H() Group exemption numer K Form of orgniztion: Corportion Trust Assoition Other L Yer of formtion: 1958 M Stte of legl domiile: CO Prt I Summry 1 Briefly desrie the orgniztion s mission or most signifint tivities: TO IMPROVE THE ORAL HEALTH OF THE COMMUNITIES WE SERVE. Ativities & Governne Revenue Expenses Net Assets or Fund Blnes Sign Here 5 6 8 9 10 11 1 1 1 15 Chek this ox if the orgniztion disontinued its opertions or disposed of more thn 5% of its net ssets. Numer of voting memers of the governing ody (Prt VI, line 1) Numer of independent voting memers of the governing ody (Prt VI, line 1) ~~~~~~~~~~~~~~ Totl numer of individuls employed in lendr yer 01 (Prt V, line ) ~~~~~~~~~~~~~~~~ Net unrelted usiness txle inome from Form 990-T, line 16 Professionl fundrising fees (Prt I, olumn (A), line 11e) ~~~~~~~~~~~~~~ Totl fundrising expenses (Prt I, olumn (D), line 5) 0. true, orret, nd omplete. Delrtion of preprer (other thn offier) is sed on ll informtion of whih preprer hs ny knowledge. Signture of offier DAVID ANDREW BEAL, CFO AND TREASURER Type or print nme nd title ~~~~~~~~~~~~~~~~~~~~ Totl numer of volunteers (estimte if neessry) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 7 Totl unrelted usiness revenue from Prt VIII, olumn (C), line 1 ~~~~~~~~~~~~~~~~~~~~ Contriutions nd grnts (Prt VIII, line 1h) ~~~~~~~~~~~~~~~~~~~~~ Progrm servie revenue (Prt VIII, line g) ~~~~~~~~~~~~~~~~~~~~~ Investment inome (Prt VIII, olumn (A), lines,, nd 7d) ~~~~~~~~~~~~~ Other revenue (Prt VIII, olumn (A), lines 5, 6d, 8, 9, 10, nd 11e) ~~~~~~~~ Totl revenue - dd lines 8 through 11 (must equl Prt VIII, olumn (A), line 1) Grnts nd similr mounts pid (Prt I, olumn (A), lines 1-) Benefits pid to or for memers (Prt I, olumn (A), line ) ~~~~~~~~~~~ ~~~~~~~~~~~~~ Slries, other ompenstion, employee enefits (Prt I, olumn (A), lines 5-10) ~~~ = = 5 6 7 7 Prior Yer Current Yer 0. 0. 99,76,09. 9,571,076.,866,67. 8,8,58. 5,768. 5,0. 0,18,99. 7,859,890.,55,0.,75,69. 6,588,1. 87,088,65. 1,9,61. 1,55,80. 0. 0. Print/Type preprer s nme Preprer s signture Dte Chek PTIN if Pid TODD A. JACKSON self-employed P000967 Preprer Firm s nme MCGLADREY LLP Firm s EIN -0715 Use Only Firm s ddress 801 NICOLLET MALL, SUITE 1100 9 9MINNEAPOLIS, MN 550 Phone no. 61--00 My the IRS disuss this return with the preprer shown ove? (see instrutions) 001 11-07-1 LHA For Pperwork Redution At tie, see the seprte instrutions. Form 990 (01) Dte 15 11 1 0 5,0. 0. 17 Other expenses (Prt I, olumn (A), lines 11-11d, 11f-e) ~~~~~~~~~~~~~ 0,567,90.,5,18. 18 Totl expenses. Add lines 1-17 (must equl Prt I, olumn (A), line 5) ~~~~~~~ 01,060,187. 9,60,15. 19 Revenue less expenses. Sutrt line 18 from line 1,088,1. 8,55,575. Beginning of Current Yer End of Yer 0 Totl ssets (Prt, line 16) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 10,850,. 11,011,707. 1 Totl liilities (Prt, line 6) ~~~~~~~~~~~~~~~~~~~~~~~~~~~ 6,055,01. 1,87,6. Net ssets or fund lnes. Sutrt line 1 from line 0 77,79,8. 81,19,81. Prt II Signture Blok Under penlties of perjury, I delre tht I hve exmined this return, inluding ompnying shedules nd sttements, nd to the est of my knowledge nd elief, it is
Form (Rev. Jnury 01) Deprtment of the Tresury Internl Revenue Servie File y the due dte for filing your return. See instrutions. File seprte pplition for eh return. Informtion out Form 8868 nd its instrutions is t www.irs.gov/form8868. If you re filing for n Automti -Month Extension, omplete only Prt I nd hek this ox ~~~~~~~~~~~~~~~~~~~ If you re filing for n Additionl (t Automti) -Month Extension, omplete only Prt II (on pge of this form). Do not omplete Prt II unless you hve lredy een grnted n utomti -month extension on previously filed Form 8868. Eletroni filing (e-file). You n eletronilly file Form 8868 if you need -month utomti extension of time to file (6 months for orportion required to file Form 990-T), or n dditionl (not utomti) -month extension of time. You n eletronilly file Form 8868 to request n extension Personl Benefit Contrts, whih must e sent to the IRS in pper formt (see instrutions). For more detils on the eletroni filing of this form, visit www.irs.gov/efile nd lik on e-file for Chrities & nprofits. Prt I Automti -Month Extension of Time. Only sumit originl (no opies needed). A orportion required to file Form 990-T nd requesting n utomti 6-month extension - hek this ox nd omplete Prt I only ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ All other orportions (inluding 110-C filers), prtnerships, REMICs, nd trusts must use Form 700 to request n extension of time to file inome tx returns. Enter filer s identifying numer Type or print 8868 Applition for Extension of Time To File n Exempt Orgniztion Return OMB. 155-1709 of time to file ny of the forms listed in Prt I or Prt II with the exeption of Form 8870, Informtion Return for Trnsfers Assoited With Certin Nme of exempt orgniztion or other filer, see instrutions. Numer, street, nd room or suite no. If P.O. ox, see instrutions. 58 SO. ULSTER STREET, NO. 800 City, town or post offie, stte, nd ZIP ode. For foreign ddress, see instrutions. DENVER, CO 807 Employer identifition numer (EIN) or COLORADO DENTAL SERVICE, INC. 8-05687 Soil seurity numer (SSN) Enter the Return ode for the return tht this pplition is for (file seprte pplition for eh return) ~~~~~~~~~~~~~~~~~ 0 1 Applition Is For Form 990 or Form 990-EZ Form 990-BL Form 70 (individul) Form 990-PF Form 990-T (se. 01() or 08() trust) 1 Return Code 01 0 0 0 05 Applition Form 990-T (trust other thn ove) 06 Form 8870 GREG VOCHIS The ooks re in the re of 58 SO. ULSTER STREET, NO. 800 - DENVER, CO 807 Telephone. 70-89-715 Fx. Is For Return Code Form 990-T (orportion) 07 Form 101-A Form 70 (other thn individul) Form 57 Form 6069 If the orgniztion does not hve n offie or ple of usiness in the United Sttes, hek this ox~~~~~~~~~~~~~~~~~ If this is for Group Return, enter the orgniztion s four digit Group Exemption Numer (GEN). If this is for the whole group, hek this ox. If it is for prt of the group, hek this ox nd tth list with the nmes nd EINs of ll memers the extension is for. I request n utomti -month (6 months for orportion required to file Form 990-T) extension of time until AUGUST 15, 015, to file the exempt orgniztion return for the orgniztion nmed ove. The extension is for the orgniztion s return for: lendr yer01 or tx yer eginning, nd ending. 08 09 10 11 1 If the tx yer entered in line 1 is for less thn 1 months, hek reson: Initil return Finl return Chnge in ounting period If this pplition is for Forms 990-BL, 990-PF, 990-T, 70, or 6069, enter the tenttive tx, less ny nonrefundle redits. See instrutions. If this pplition is for Forms 990-PF, 990-T, 70, or 6069, enter ny refundle redits nd estimted tx pyments mde. Inlude ny prior yer overpyment llowed s redit. Blne due. Sutrt line from line. Inlude your pyment with this form, if required, y using EFTPS (Eletroni Federl Tx Pyment System). See instrutions. Cution. If you re going to mke n eletroni funds withdrwl (diret deit) with this Form 8868, see Form 85-EO nd Form 8879-EO for pyment instrutions. LHA For Privy At nd Pperwork Redution At tie, see instrutions. Form 8868 (Rev. 1-01) 81 05-01-1 $ $ $ 0. 0. 0.
Form 990 (01) COLORADO DENTAL SERVICE, INC. 8-05687 Prt III Sttement of Progrm Servie Aomplishments 1 Chek if Shedule O ontins response or note to ny line in this Prt III Briefly desrie the orgniztion s mission: DELTA DENTAL OF COLORADO (DDCO) WAS FORMED AS A 501(C)() ORGANIZATION IN ORDER TO IMPROVE THE ORAL HEALTH OF THE COMMUNITIES IT SERVES. BECAUSE PEOPLE WITH DENTAL INSURANCE OVER TIME HAVE BETTER ORAL HEALTH OUTCOMES, DELTA DENTAL OF COLORADO DEVOTES ITSELF TO PROVIDING HIGH Did the orgniztion undertke ny signifint progrm servies during the yer whih were not listed on the prior Form 990 or 990-EZ? If "," desrie these new servies on Shedule O. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion ese onduting, or mke signifint hnges in how it onduts, ny progrm servies? ~~~~~~ If "," desrie these hnges on Shedule O. Desrie the orgniztion s progrm servie omplishments for eh of its three lrgest progrm servies, s mesured y expenses. Setion 501()() nd 501()() orgniztions re required to report the mount of grnts nd llotions to others, the totl expenses, nd Pge revenue, if ny, for eh progrm servie reported. ( Code: ) ( Expenses $ 19,765,16. inluding grnts of $ ) ( Revenue $ 9,571,076. ) PROVISION OF RISK AND SELF-FUNDED PLANS TO SUBSCRIBERS. DELTA DENTAL OF COLORADO DEVOTES ITSELF TO ITS MISSION OF IMPROVING THE ORAL HEALTH OF COLORADO S PEOPLE. BECAUSE PEOPLE WITH DENTAL INSURANCE ARE OVER TWICE AS LIKELY TO VISIT A DENTIST REGULARLY, DELTA DENTAL OF COLORADO WORKS HARD TO MAKE DENTAL INSURANCE AS AFFORDABLE AND ACCESSIBLE AS POSSIBLE, AND TO THAT END, INSURES OVER 1,100,000 PEOPLE IN COLORADO. THE REVENUE GENERATED IS USED TO FUND THE COMMUNITY BENEFIT EFFORTS DESCRIBED IN LINE B. 5,50,000.,75,69. COMMUNITY BENEFIT PROGRAMS ( Code: ) ( Expenses $ inluding grnts of $ ) ( Revenue $ ) BECAUSE DENTAL INSURANCE IS NOT POSSIBLE FOR EVERYONE, DELTA DENTAL OF COLORADO DEVOTES SIGNIFICANT RESOURCES AND MONEY TO PROVIDING DENTAL SERVICES AND DENTAL HYGIENE INFORMATION TO AS A MANY PEOPLE AS POSSIBLE; PARTICULARLY THOSE UNDERSERVED POPULATIONS, WHERE ORAL DISEASE IS MORE PREVALENT. TO THAT END, DELTA DENTAL OF COLORADO, OVER THE PAST TWELVE YEARS, HAS DEVOTED 55% OF ITS NET GAIN TO ITS COMMUNITY BENEFIT PROGRAM AND THE DELTA DENTAL OF COLORADO FOUNDATION. IN 01, DELTA DENTAL OF COLORADO DONATED $,00,000 TO THE DELTA DENTAL OF COLORADO FOUNDATION. IT ALSO SPENT $1,5,69 ON A NUMBER OF INITIATIVES THROUGH ITS COMMUNITY BENEFIT PROGRAM. THESE PROGRAMS ( Code: ) ( Expenses $ inluding grnts of $ ) ( Revenue $ ) d e 00 11-07-1 Other progrm servies (Desrie in Shedule O.) ( Expenses $ inluding grnts of $ ) ( Revenue $ ) Totl progrm servie expenses 5,67,16. SEE SCHEDULE O FOR CONTINUATION(S) Form 990 (01)
Form 990 (01) COLORADO DENTAL SERVICE, INC. 8-05687 Prt IV Cheklist of Required Shedules 1 5 6 7 8 9 10 11 1 1 15 16 17 18 19 d e f 0 Is the orgniztion desried in setion 501()() or 97()(1) (other thn privte foundtion)? If "," omplete Shedule A~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Is the orgniztion required to omplete Shedule B, Shedule of Contriutors? ~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion engge in diret or indiret politil mpign tivities on ehlf of or in opposition to ndidtes for puli offie? If "," omplete Shedule C, Prt I ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Setion 501()() orgniztions. Did the orgniztion engge in loying tivities, or hve setion 501(h) eletion in effet during the tx yer? If "," omplete Shedule C, Prt II ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Is the orgniztion setion 501()(), 501()(5), or 501()(6) orgniztion tht reeives memership dues, ssessments, or similr mounts s defined in Revenue Proedure 98-19? If "," omplete Shedule C, Prt III ~~~~~~~~~~~~~~ Did the orgniztion mintin ny donor dvised funds or ny similr funds or ounts for whih donors hve the right to provide dvie on the distriution or investment of mounts in suh funds or ounts? If "," omplete Shedule D, Prt I Did the orgniztion reeive or hold onservtion esement, inluding esements to preserve open spe, the environment, histori lnd res, or histori strutures? If "," omplete Shedule D, Prt II~~~~~~~~~~~~~~ Did the orgniztion mintin olletions of works of rt, historil tresures, or other similr ssets? If "," omplete Shedule D, Prt III ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion report n mount in Prt, line 1, for esrow or ustodil ount liility; serve s ustodin for mounts not listed in Prt ; or provide redit ounseling, det mngement, redit repir, or det negotition servies? If "," omplete Shedule D, Prt IV ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion, diretly or through relted orgniztion, hold ssets in temporrily restrited endowments, permnent endowments, or qusi-endowments? If "," omplete Shedule D, Prt V ~~~~~~~~~~~~~~~~~~~~~~~~ If the orgniztion s nswer to ny of the following questions is "," then omplete Shedule D, Prts VI, VII, VIII, I, or s pplile. Did the orgniztion report n mount for lnd, uildings, nd equipment in Prt, line 10? If "," omplete Shedule D, Prt VI ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion report n mount for investments - other seurities in Prt, line 1 tht is 5% or more of its totl ssets reported in Prt, line 16? If "," omplete Shedule D, Prt VII ~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion report n mount for investments - progrm relted in Prt, line 1 tht is 5% or more of its totl ssets reported in Prt, line 16? If "," omplete Shedule D, Prt VIII ~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion report n mount for other ssets in Prt, line 15 tht is 5% or more of its totl ssets reported in Prt, line 16? If "," omplete Shedule D, Prt I ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion report n mount for other liilities in Prt, line 5? If "," omplete Shedule D, Prt ~~~~~~ Did the orgniztion s seprte or onsolidted finnil sttements for the tx yer inlude footnote tht ddresses the orgniztion s liility for unertin tx positions under FIN 8 (ASC 70)? If "," omplete Shedule D, Prt ~~~~ Did the orgniztion otin seprte, independent udited finnil sttements for the tx yer? If "," omplete Shedule D, Prts I nd II ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Ws the orgniztion inluded in onsolidted, independent udited finnil sttements for the tx yer? If "," nd if the orgniztion nswered "" to line 1, then ompleting Shedule D, Prts I nd II is optionl ~~~~~ Is the orgniztion shool desried in setion 170()(1)(A)(ii)? If "," omplete Shedule E ~~~~~~~~~~~~~~ 1 Did the orgniztion mintin n offie, employees, or gents outside of the United Sttes? ~~~~~~~~~~~~~~~~ Did the orgniztion hve ggregte revenues or expenses of more thn $10,000 from grntmking, fundrising, usiness, investment, nd progrm servie tivities outside the United Sttes, or ggregte foreign investments vlued t $100,000 or more? If "," omplete Shedule F, Prts I nd IV ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion report on Prt I, olumn (A), line, more thn $5,000 of grnts or other ssistne to or for ny foreign orgniztion? If "," omplete Shedule F, Prts II nd IV ~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion report on Prt I, olumn (A), line, more thn $5,000 of ggregte grnts or other ssistne to or for foreign individuls? If "," omplete Shedule F, Prts III nd IV ~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion report totl of more thn $15,000 of expenses for professionl fundrising servies on Prt I, olumn (A), lines 6 nd 11e? If "," omplete Shedule G, Prt I ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion report more thn $15,000 totl of fundrising event gross inome nd ontriutions on Prt VIII, lines 1 nd 8? If "," omplete Shedule G, Prt II ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion report more thn $15,000 of gross inome from gming tivities on Prt VIII, line 9? If "," omplete Shedule G, Prt III ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion operte one or more hospitl filities? If "," omplete Shedule H ~~~~~~~~~~~~~~~~ If "" to line 0, did the orgniztion tth opy of its udited finnil sttements to this return? 1 5 6 7 8 9 10 11 11 11 11d 11e 11f 1 1 1 1 1 15 16 17 18 19 0 Pge 0 Form 990 (01) 00 11-07-1
Form 990 (01) COLORADO DENTAL SERVICE, INC. 8-05687 Prt IV Cheklist of Required Shedules (ontinued) 1 6 7 8 9 0 1 6 7 8 d 5 Setion 501()(), 501()(), nd 501()(9) orgniztions. Did the orgniztion engge in n exess enefit trnstion with disqulified person during the yer? If "," omplete Shedule L, Prt I ~~~~~~~~~~~~~~~~ Did the orgniztion report more thn $5,000 of grnts or other ssistne to ny domesti orgniztion or domesti government on Prt I, olumn (A), line 1? If "," omplete Shedule I, Prts I nd II ~~~~~~~~~~~~~~ Did the orgniztion report more thn $5,000 of grnts or other ssistne to or for domesti individuls on Prt I, olumn (A), line? If "," omplete Shedule I, Prts I nd III ~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion nswer "" to Prt VII, Setion A, line,, or 5 out ompenstion of the orgniztion s urrent nd former offiers, diretors, trustees, key employees, nd highest ompensted employees? If "," omplete Shedule J ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion hve tx-exempt ond issue with n outstnding prinipl mount of more thn $100,000 s of the lst dy of the yer, tht ws issued fter Deemer 1, 00? If "," nswer lines through d nd omplete Shedule K. If "", go to line 5 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion invest ny proeeds of tx-exempt onds eyond temporry period exeption? ~~~~~~~~~~~ Did the orgniztion mintin n esrow ount other thn refunding esrow t ny time during the yer to defese ny tx-exempt onds? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion t s n "on ehlf of" issuer for onds outstnding t ny time during the yer? ~~~~~~~~~~~ Is the orgniztion wre tht it engged in n exess enefit trnstion with disqulified person in prior yer, nd tht the trnstion hs not een reported on ny of the orgniztion s prior Forms 990 or 990-EZ? If "," omplete Shedule L, Prt I ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion report ny mount on Prt, line 5, 6, or for reeivles from or pyles to ny urrent or former offiers, diretors, trustees, key employees, highest ompensted employees, or disqulified persons? If "," omplete Shedule L, Prt II ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion provide grnt or other ssistne to n offier, diretor, trustee, key employee, sustntil ontriutor or employee thereof, grnt seletion ommittee memer, or to 5% ontrolled entity or fmily memer of ny of these persons? If "," omplete Shedule L, Prt III ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Ws the orgniztion prty to usiness trnstion with one of the following prties (see Shedule L, Prt IV instrutions for pplile filing thresholds, onditions, nd exeptions): A urrent or former offier, diretor, trustee, or key employee? If "," omplete Shedule L, Prt IV ~~~~~~~~~~~ A fmily memer of urrent or former offier, diretor, trustee, or key employee? If "," omplete Shedule L, Prt IV ~~ An entity of whih urrent or former offier, diretor, trustee, or key employee (or fmily memer thereof) ws n offier, diretor, trustee, or diret or indiret owner? If "," omplete Shedule L, Prt IV~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion reeive more thn $5,000 in non-sh ontriutions? If "," omplete Shedule M ~~~~~~~~~ Did the orgniztion reeive ontriutions of rt, historil tresures, or other similr ssets, or qulified onservtion ontriutions? If "," omplete Shedule M ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion liquidte, terminte, or dissolve nd ese opertions? If "," omplete Shedule N, Prt I ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion sell, exhnge, dispose of, or trnsfer more thn 5% of its net ssets? If "," omplete Shedule N, Prt II ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion own 100% of n entity disregrded s seprte from the orgniztion under Regultions setions 01.7701- nd 01.7701-? If "," omplete Shedule R, Prt I ~~~~~~~~~~~~~~~~~~~~~~~~ Ws the orgniztion relted to ny tx-exempt or txle entity? If "," omplete Shedule R, Prt II, III, or IV, nd Prt V, line 1 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 5 Did the orgniztion hve ontrolled entity within the mening of setion 51()(1)? ~~~~~~~~~~~~~~~~~~ If "" to line 5, did the orgniztion reeive ny pyment from or engge in ny trnstion with ontrolled entity within the mening of setion 51()(1)? If "," omplete Shedule R, Prt V, line ~~~~~~~~~~~~~~~~~~~ Setion 501()() orgniztions. Did the orgniztion mke ny trnsfers to n exempt non-hritle relted orgniztion? If "," omplete Shedule R, Prt V, line ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion ondut more thn 5% of its tivities through n entity tht is not relted orgniztion nd tht is treted s prtnership for federl inome tx purposes? If "," omplete Shedule R, Prt VI ~~~~~~~~ Did the orgniztion omplete Shedule O nd provide explntions in Shedule O for Prt VI, lines 11 nd 19? te. All Form 990 filers re required to omplete Shedule O 1 d 5 5 6 7 8 8 8 9 0 1 5 5 6 7 Pge 8 Form 990 (01) 00 11-07-1
Form 990 (01) COLORADO DENTAL SERVICE, INC. 8-05687 Pge 5 Prt V Sttements Regrding Other IRS Filings nd Tx Compline Chek if Shedule O ontins response or note to ny line in this Prt V 1 Enter the numer reported in Box of Form 1096. Enter -0- if not pplile ~~~~~~~~~~~ 1 17 Enter the numer of Forms W-G inluded in line 1. Enter -0- if not pplile ~~~~~~~~~~ 1 0 Did the orgniztion omply with kup withholding rules for reportle pyments to vendors nd reportle gming If t lest one is reported on line, did the orgniztion file ll required federl employment tx returns? ~~~~~~~~~~ te. If the sum of lines 1 nd is greter thn 50, you my e required to e-file (see instrutions) ~~~~~~~~~~~ 7 Orgniztions tht my reeive dedutile ontriutions under setion 170(). Did the orgniztion reeive pyment in exess of $75 mde prtly s ontriution nd prtly for goods nd servies provided to the pyor? 8 9 10 11 1 d e f g h 1 Sponsoring orgniztions mintining donor dvised funds. Did donor dvised fund mintined y the Sponsoring orgniztions mintining donor dvised funds. Setion 501()(7) orgniztions. Enter: Setion 501()(1) orgniztions. Enter: 1 Setion 97()(1) non-exempt hritle trusts. Is the orgniztion filing Form 990 in lieu of Form 101? (gmling) winnings to prize winners? Enter the numer of employees reported on Form W-, Trnsmittl of Wge nd Tx Sttements, filed for the lendr yer ending with or within the yer overed y this return ~~~~~~~~~~ Did the orgniztion hve unrelted usiness gross inome of $1,000 or more during the yer? ~~~~~~~~~~~~~~ If "," hs it filed Form 990-T for this yer? If "," to line, provide n explntion in Shedule O ~~~~~~~~~~ At ny time during the lendr yer, did the orgniztion hve n interest in, or signture or other uthority over, finnil ount in foreign ountry (suh s nk ount, seurities ount, or other finnil ount)?~~~~~~~ If "," enter the nme of the foreign ountry: J See instrutions for filing requirements for FinCEN Form 11, Report of Foreign Bnk nd Finnil Aounts (FBAR). 5 Ws the orgniztion prty to prohiited tx shelter trnstion t ny time during the tx yer? ~~~~~~~~~~~~ Did ny txle prty notify the orgniztion tht it ws or is prty to prohiited tx shelter trnstion? ~~~~~~~~~ If "," to line 5 or 5, did the orgniztion file Form 8886-T? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 6 Does the orgniztion hve nnul gross reeipts tht re normlly greter thn $100,000, nd did the orgniztion soliit ny ontriutions tht were not tx dedutile s hritle ontriutions? If "," did the orgniztion inlude with every soliittion n express sttement tht suh ontriutions or gifts were not tx dedutile? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "," did the orgniztion notify the donor of the vlue of the goods or servies provided? Setion 501()(9) qulified nonprofit helth insurne issuers. te. See the instrutions for dditionl informtion the orgniztion must report on Shedule O. Did the orgniztion reeive ny pyments for indoor tnning servies during the tx yer? ~~~~~~~~~~~~~~~~ If "," hs it filed Form 70 to report these pyments? If "," provide n explntion in Shedule O ~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion sell, exhnge, or otherwise dispose of tngile personl property for whih it ws required to file Form 88? ~~~~~~~~~~~~~~~ If "," indite the numer of Forms 88 filed during the yer ~~~~~~~~~~~~~~~~ Did the orgniztion reeive ny funds, diretly or indiretly, to py premiums on personl enefit ontrt? Did the orgniztion, during the yer, py premiums, diretly or indiretly, on personl enefit ontrt? 7d 10 10 11 11 1 1 1 ~~~~~~~ ~~~~~~~~~ If the orgniztion reeived ontriution of qulified intelletul property, did the orgniztion file Form 8899 s required? ~ If the orgniztion reeived ontriution of rs, ots, irplnes, or other vehiles, did the orgniztion file Form 1098-C? sponsoring orgniztion hve exess usiness holdings t ny time during the yer? ~~~~~~~~~~~~~~~~~~~ Did the sponsoring orgniztion mke ny txle distriutions under setion 966? Did the sponsoring orgniztion mke distriution to donor, donor dvisor, or relted person? Initition fees nd pitl ontriutions inluded on Prt VIII, line 1 ~~~~~~~~~~~~~~~ Gross reeipts, inluded on Form 990, Prt VIII, line 1, for puli use of lu filities ~~~~~~ Gross inome from memers or shreholders ~~~~~~~~~~~~~~~~~~~~~~~~~~ Gross inome from other soures (Do not net mounts due or pid to other soures ginst mounts due or reeived from them.) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "," enter the mount of tx-exempt interest reeived or rued during the yer ~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~ Is the orgniztion liensed to issue qulified helth plns in more thn one stte? ~~~~~~~~~~~~~~~~~~~~~ Enter the mount of reserves the orgniztion is required to mintin y the sttes in whih the orgniztion is liensed to issue qulified helth plns ~~~~~~~~~~~~~~~~~~~~~~ Enter the mount of reserves on hnd~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 1 1 5 5 5 6 6 7 7 7 7e 7f 7g 7h 8 9 9 1 1 1 1 Form 990 (01) 005 11-07-1 5
Form 990 (01) COLORADO DENTAL SERVICE, INC. 8-05687 Pge 6 Prt VI Governne, Mngement, nd Dislosure For eh "" response to lines through 7 elow, nd for "" response to line 8, 8, or 10 elow, desrie the irumstnes, proesses, or hnges in Shedule O. See instrutions. Chek if Shedule O ontins response or note to ny line in this Prt VI Setion A. Governing Body nd Mngement 1 Enter the numer of voting memers of the governing ody t the end of the tx yer ~~~~~~ If there re mteril differenes in voting rights mong memers of the governing ody, or if the governing 5 6 8 9 Is there ny offier, diretor, trustee, or key employee listed in Prt VII, Setion A, who nnot e rehed t the orgniztion s miling ddress? If "," provide the nmes nd ddresses in Shedule O Setion B. Poliies (This Setion B requests informtion out poliies not required y the Internl Revenue Code.) 1 1 1 15 16 exempt sttus with respet to suh rrngements? Setion C. Dislosure 17 List the sttes with whih opy of this Form 990 is required to e filed J NONE 18 19 0 ody delegted rod uthority to n exeutive ommittee or similr ommittee, explin in Shedule O. Enter the numer of voting memers inluded in line 1, ove, who re independent ~~~~~~ persons other thn the governing ody? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion ontemporneously doument the meetings held or written tions undertken during the yer y the following: Desrie in Shedule O the proess, if ny, used y the orgniztion to review this Form 990. Did the orgniztion hve written onflit of interest poliy? If "," go to line 1 ~~~~~~~~~~~~~~~~~~~~ Were offiers, diretors, or trustees, nd key employees required to dislose nnully interests tht ould give rise to onflits? ~~~~~~ Did the orgniztion regulrly nd onsistently monitor nd enfore ompline with the poliy? If "," desrie in Shedule O how this ws done ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ for puli inspetion. Indite how you mde these ville. Chek ll tht pply. Own wesite Another s wesite Upon request Other (explin in Shedule O) 006 11-07-1 Did ny offier, diretor, trustee, or key employee hve fmily reltionship or usiness reltionship with ny other offier, diretor, trustee, or key employee? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion delegte ontrol over mngement duties ustomrily performed y or under the diret supervision of offiers, diretors, or trustees, or key employees to mngement ompny or other person? ~~~~~~~~~~~~~~ Did the orgniztion mke ny signifint hnges to its governing douments sine the prior Form 990 ws filed? ~~~~~ Did the orgniztion eome wre during the yer of signifint diversion of the orgniztion s ssets? ~~~~~~~~~ Did the orgniztion hve memers or stokholders? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 7 Did the orgniztion hve memers, stokholders, or other persons who hd the power to elet or ppoint one or more memers of the governing ody? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Are ny governne deisions of the orgniztion reserved to (or sujet to pprovl y) memers, stokholders, or The governing ody? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Eh ommittee with uthority to t on ehlf of the governing ody? 1 1 ~~~~~~~~~~~~~~~~~~~~~~~~~~ 10 Did the orgniztion hve lol hpters, rnhes, or ffilites? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "," did the orgniztion hve written poliies nd proedures governing the tivities of suh hpters, ffilites, nd rnhes to ensure their opertions re onsistent with the orgniztion s exempt purposes? ~~~~~~~~~~~~~ 11 Hs the orgniztion provided omplete opy of this Form 990 to ll memers of its governing ody efore filing the form? Did the orgniztion hve written whistlelower poliy? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion hve written doument retention nd destrution poliy? ~~~~~~~~~~~~~~~~~~~~~~ Did the proess for determining ompenstion of the following persons inlude review nd pprovl y independent persons, omprility dt, nd ontemporneous sustntition of the deliertion nd deision? The orgniztion s CEO, Exeutive Diretor, or top mngement offiil Other offiers or key employees of the orgniztion ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "" to line 15 or 15, desrie the proess in Shedule O (see instrutions). ~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the orgniztion invest in, ontriute ssets to, or prtiipte in joint venture or similr rrngement with txle entity during the yer? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "," did the orgniztion follow written poliy or proedure requiring the orgniztion to evlute its prtiiption in joint venture rrngements under pplile federl tx lw, nd tke steps to sfegurd the orgniztion s Setion 610 requires n orgniztion to mke its Forms 10 (or 10 if pplile), 990, nd 990-T (Setion 501()()s only) ville Desrie in Shedule O whether (nd if so, how) the orgniztion mde its governing douments, onflit of interest poliy, nd finnil sttements ville to the puli during the tx yer. Stte the nme, ddress, nd telephone numer of the person who possesses the orgniztion s ooks nd reords: GREG VOCHIS - 70-89-715 58 SO. ULSTER STREET, NO. 800, DENVER, CO 807 6 15 11 5 6 7 7 8 8 9 10 10 11 1 1 1 1 1 15 15 16 16 Form 990 (01)
Form 990 (01) COLORADO DENTAL SERVICE, INC. 8-05687 Pge 7 Prt VII Compenstion of Offiers, Diretors, Trustees, Key Employees, Highest Compensted Employees, nd Independent Contrtors Chek if Shedule O ontins response or note to ny line in this Prt VII Setion A. List ll of the orgniztion s urrent offiers, diretors, trustees (whether individuls or orgniztions), regrdless of mount of ompenstion. Enter -0- in olumns (D), (E), nd (F) if no ompenstion ws pid. List ll of the orgniztion s urrent key employees, if ny. See instrutions for definition of "key employee." List the orgniztion s five urrent highest ompensted employees (other thn n offier, diretor, trustee, or key employee) who reeived reportle ompenstion (Box 5 of Form W- nd/or Box 7 of Form 1099-MISC) of more thn $100,000 from the orgniztion nd ny relted orgniztions. List ll of the orgniztion s former offiers, key employees, nd highest ompensted employees who reeived more thn $100,000 of reportle ompenstion from the orgniztion nd ny relted orgniztions. List ll of the orgniztion s former diretors or trustees tht reeived, in the pity s former diretor or trustee of the orgniztion, more thn $10,000 of reportle ompenstion from the orgniztion nd ny relted orgniztions. List persons in the following order: individul trustees or diretors; institutionl trustees; offiers; key employees; highest ompensted employees; nd former suh persons. 007 11-07-1 Offiers, Diretors, Trustees, Key Employees, nd Highest Compensted Employees 1 Complete this tle for ll persons required to e listed. Report ompenstion for the lendr yer ending with or within the orgniztion s tx yer. Chek this ox if neither the orgniztion nor ny relted orgniztion ompensted ny urrent offier, diretor, or trustee. (A) (B) (C) (D) (E) (F) Nme nd Title Averge hours per week (list ny hours for relted orgniztions elow line) Position (do not hek more thn one ox, unless person is oth n offier nd diretor/trustee) Individul trustee or diretor Institutionl trustee Offier Key employee Highest ompensted employee Former Reportle ompenstion from the orgniztion (W-/1099-MISC) Reportle ompenstion from relted orgniztions (W-/1099-MISC) Estimted mount of other ompenstion from the orgniztion nd relted orgniztions (1) KATHRYN ANN PAUL.00 CEO/PRESIDENT.00 687,977. 0. 7,605. () DOUGLAS BERKEY - DMD, MPH, MS 5.00 CHAIR.00 8,500. 0. 956. () MARILYN E TAYLOR 5.00 VICE CHAIR.00 9,050. 0. 1. () JONATHAN M ANDERSON - DDS.00 TRUSTEE 1,750. 0. 1,97. (5) KELLY J BROUGH.00 TRUSTEE 16,000. 0.,7. (6) JOHN PAUL HOPKINS.00 TRUSTEE 18,750. 0. 0. (7) DENISE KAY KASSEBAUM - DDS, MS.00 TRUSTEE 1,000. 0. 0. (8) VICTOR LAZZARO, JR.00 TRUSTEE 0,50. 0. 669. (9) MARY NOONAN.00 TRUSTEE,550. 0. 608. (10) HASSAN SALEM.00 TRUSTEE 16,50. 0. 0. (11) DONALD S SAFER - DDS, MS.00 TRUSTEE.00 1,500. 0. 1,97. (1) GAIL SCHOETTLER - PHD.00 TRUSTEE.00 15,750. 0. 5. (1) THOMAS B SWAIN - DDS.00 TRUSTEE 0,000. 0. 0. (1) WALT VOGL - DDS.00 TRUSTEE 1,500. 0. 0. (15) MARK WEHRLE - CPA.00 TRUSTEE 1,500. 0.,995. (16) DAVID ANDREW BEAL 5.00 CFO/TREASURER 07,6. 0. 8,877. (17) LINDA MARIE ARNESON 5.00 COO/SECRETARY 7,7. 0. 1,850. 7 Form 990 (01)
Form 990 (01) COLORADO DENTAL SERVICE, INC. 8-05687 Pge 8 Prt VII Setion A. Offiers, Diretors, Trustees, Key Employees, nd Highest Compensted Employees (ontinued) (A) (B) (C) (D) (E) (F) Nme nd title Averge Position (do not hek more thn one Reportle Reportle Estimted hours per ox, unless person is oth n ompenstion ompenstion mount of week offier nd diretor/trustee) from from relted other (list ny the orgniztions ompenstion hours for orgniztion (W-/1099-MISC) from the relted (W-/1099-MISC) orgniztion orgniztions nd relted elow orgniztions line) Individul trustee or diretor Institutionl trustee Offier (18) JESSICA JEAN LAWHEAD 5.00 VICE PRESIDENT 5,79. 0.,61. (19) BARBARA BLACKBURN SPRINGER - JD.50 VICE PRESIDENT.50 199,9. 118,116. 50,590. (0) TRICIA HEMSKY 5.00 DIRECTOR OF CLIENT SERVICE 187,915. 0. 8,509. (1) LORRIE KOHLE 5.00 SENIOR SALES EECUTIVE,176. 0. 0,501. () MICHAEL OKUJI - DDS 5.00 DENTAL DIRECTOR 11,756. 0.,5. () KATHY JACOBY 5.00 DIRECTOR OF MARKETING 169,719. 0. 0,65. () ROBERT MARK THOMPSON 5.00 DIRECTOR OF SALES 81,5. 0. 5,8. Key employee Highest ompensted employee Former 1 d 008 11-07-1 Su-totl~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Totl from ontinution sheets to Prt VII, Setion A ~~~~~~~~~~ Totl (dd lines 1 nd 1) Did the orgniztion list ny former offier, diretor, or trustee, key employee, or highest ompensted employee on line 1? If "," omplete Shedule J for suh individul ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 5 Did ny person listed on line 1 reeive or rue ompenstion from ny unrelted orgniztion or individul for servies rendered to the orgniztion? If "," omplete Shedule J for suh person Setion B. Independent Contrtors 1 (A) (B) (C) Nme nd usiness ddress Desription of servies Compenstion DELTA DENTAL OF VIRGINIA 818 STARKEY ROAD SW, ROANOKE, VA 018 CLAIMS PROCESSING 1,65,675. ENCARA INC. ADVERTISING, 818 STARKEY ROAD SW, ROANOKE, VA 018 MANAGEMENT, MARKETIN 1,60,89. GREENRUBINO, 198 FAIRVIEW AVE E STE. 00, SEATTLE, WA 9810 ADVERTISING & MEDIA 97,55. BMS DIRECT INC. PRINTING, 7 MILLRACE DRIVE, LYNCHBURG, VA 50 REPRODUCTION AND POS 816,96. DELOITTE CONSULTING LLP PO BO 8717, DALLAS, T 758 STRATEGIC PLANNING 675,86. Totl numer of individuls (inluding ut not limited to those listed ove) who reeived more thn $100,000 of reportle ompenstion from the orgniztion For ny individul listed on line 1, is the sum of reportle ompenstion nd other ompenstion from the orgniztion nd relted orgniztions greter thn $150,000? If "," omplete Shedule J for suh individul~~~~~~~~~~~~~ Complete this tle for your five highest ompensted independent ontrtors tht reeived more thn $100,000 of ompenstion from the orgniztion. Report ompenstion for the lendr yer ending with or within the orgniztion s tx yer. Totl numer of independent ontrtors (inluding ut not limited to those listed ove) who reeived more thn $100,000 of ompenstion from the orgniztion 0 8,71,755. 118,116.,86. 0. 0. 0.,71,755. 118,116.,86. 5 8 Form 990 (01)
Form 990 (01) COLORADO DENTAL SERVICE, INC. 8-05687 Prt VIII Sttement of Revenue Contriutions, Gifts, Grnts nd Other Similr Amounts Progrm Servie Revenue Other Revenue 1 1 009 11-07-1 d e f g nsh ontriutions inluded in lines 1-1f: $ h 1 1 1 1d 1e e Totl. Add lines 11-11d ~~~~~~~~~~~~~~~ Totl revenue. See instrutions. 1f Totl. Add lines 1-1f Business Code SELF FUNDED PLAN PREMIUMS 511 159,6,057. 159,6,057. RISK PLAN PREMIUMS 511 158,58,57. 158,58,57. ADMINISTRATION - SELF FUNDED PLAN 598 11,085,56. 11,085,56. d PATIENT DIRECT REVENUE 511 8,189. 8,189. 5 e f g 6 d d 8 9 10 Totl. Add lines -f Misellneous Revenue Business Code 11 VISION PREMIUMS 598 5,0. 5,0. d Government grnts (ontriutions) All other ontriutions, gifts, grnts, nd similr mounts not inluded ove ~~ Pge 9 Chek if Shedule O ontins response or note to ny line in this Prt VIII (A) (B) (C) (D) Totl revenue Relted or Unrelted Revenue exluded exempt funtion usiness from tx under setions revenue revenue 51-51 Federted mpigns Memership dues ~~~~~~ ~~~~~~~~ Fundrising events ~~~~~~~~ Relted orgniztions ~~~~~~ All other progrm servie revenue ~~~~~ Investment inome (inluding dividends, interest, nd other similr mounts) ~~~~~~~~~~~~~~~~~ Inome from investment of tx-exempt ond proeeds Roylties Gross rents ~~~~~~~ Less: rentl expenses~~~ Rentl inome or (loss) ~~ Net rentl inome or (loss) 7 Gross mount from sles of ssets other thn inventory Less: ost or other sis nd sles expenses ~~~ Gin or (loss) ~~~~~~~ (i) Rel (ii) Personl (i) Seurities (ii) Other,018,67. 1,70. Net gin or (loss) Gross inome from fundrising events (not inluding $ of ontriutions reported on line 1). See Prt IV, line 18 ~~~~~~~~~~~~~ Less: diret expenses~~~~~~~~~~ Net inome or (loss) from fundrising events Gross inome from gming tivities. See Prt IV, line 19 ~~~~~~~~~~~~~ Less: diret expenses ~~~~~~~~~ Net inome or (loss) from gming tivities Gross sles of inventory, less returns nd llownes ~~~~~~~~~~~~~ Less: ost of goods sold ~~~~~~~~ Net inome or (loss) from sles of inventory All other revenue ~~~~~~~~~~~~~ 7,0,8. 1,757. 5,816,90. -87. 9,571,076.,67,81.,67,81. 5,816,10. 5,816,10. 5,0. 7,859,890. 9,571,076. 5,0. 8,8,58. 9 Form 990 (01)
Form 990 (01) COLORADO DENTAL SERVICE, INC. 8-05687 Prt I Sttement of Funtionl Expenses Setion 501()() nd 501()() orgniztions must omplete ll olumns. All other orgniztions must omplete olumn (A). Chek if Shedule O ontins response or note to ny line in this Prt I Do not inlude mounts reported on lines 6, (A) (B) (C) (D) Totl expenses Progrm servie Mngement nd Fundrising 7, 8, 9, nd 10 of Prt VIII. expenses generl expenses expenses 1 Grnts nd other ssistne to domesti orgniztions nd domesti governments. See Prt IV, line 1 ~,75,69.,75,69. 5 6 7 8 9 10 11 1 1 1 15 16 17 18 19 0 1 d e f g d Grnts nd other ssistne to domesti individuls. See Prt IV, line ~~~~~~~ Grnts nd other ssistne to foreign orgniztions, foreign governments, nd foreign individuls. See Prt IV, lines 15 nd 16 ~~~ Benefits pid to or for memers ~~~~~~~ Compenstion of urrent offiers, diretors, trustees, nd key employees ~~~~~~~~ Compenstion not inluded ove, to disqulified persons (s defined under setion 958(f)(1)) nd persons desried in setion 958()()(B) Other slries nd wges ~~~~~~~~~~ Pension pln ruls nd ontriutions (inlude setion 01(k) nd 0() employer ontriutions) Loying ~~~~~~~~~~~~~~~~~~ Professionl fundrising servies. See Prt IV, line 17 Investment mngement fees ~~~~~~~~ Other. (If line 11g mount exeeds 10% of line 5, olumn (A) mount, list line 11g expenses on Sh O.) Insurne ~~~~~~~~~~~~~~~~~ Other expenses. Itemize expenses not overed ove. (List misellneous expenses in line e. If line e mount exeeds 10% of line 5, olumn (A) e All other expenses 5 Totl funtionl expenses. Add lines 1 through e 6 Joint osts. Complete this line only if the orgniztion reported in olumn (B) joint osts from omined edutionl mpign nd fundrising soliittion. Chek here if following SOP 98- (ASC 958-70) 010 11-07-1 ~~~ Other employee enefits ~~~~~~~~~~ Pyroll txes ~~~~~~~~~~~~~~~~ Fees for servies (non-employees): Mngement ~~~~~~~~~~~~~~~~ Legl ~~~~~~~~~~~~~~~~~~~~ Aounting ~~~~~~~~~~~~~~~~~ Advertising nd promotion ~~~~~~~~~ Offie expenses~~~~~~~~~~~~~~~ Informtion tehnology ~~~~~~~~~~~ Roylties ~~~~~~~~~~~~~~~~~~ Oupny ~~~~~~~~~~~~~~~~~ Trvel ~~~~~~~~~~~~~~~~~~~ Pyments of trvel or entertinment expenses for ny federl, stte, or lol puli offiils Conferenes, onventions, nd meetings ~~ Interest ~~~~~~~~~~~~~~~~~~ Pyments to ffilites ~~~~~~~~~~~~ Depreition, depletion, nd mortiztion ~~ 87,088,65.87,088,65.,799,89.,7,99. 55,990. 7,78,78. 7,57,07. 15,576. 5,99. 5,09. 10,900. 1,88,618. 1,8,966. 7,65. 598,918. 19,. 179,675.,65,00.,100,160. 55,00. 19,9. 10,595. 5,899. 11,16. 11,16.,656.,656. 1,60,681. 1,18,77. 9,0.,056,55.,056,55. 5,78. 98,08. 17,75. 1,750,9. 1,00,9. 50,098. 591,. 7,978. 118,5. 1,50.,50. 177,000. 8,50. 16,50. 65,800. 1,588,89. 87,856. 71,97. mount, list line e expenses on Shedule O.) ~~ COMMISSIONS 5,550,691. 5,550,691. DATA PROCESSING,95,5.,6,60. 590,865. RISK SHARING PROGRAM 1,86,70. 1,86,70. POSTAGE & MAILING 1,778,8. 1,,787. 55,697. Pge 10 68,07. 68,07. 9,60,15.5,67,16.,7,169. 0. 10 Form 990 (01)
Form 990 (01) COLORADO DENTAL SERVICE, INC. 8-05687 Pge 11 Prt Blne Sheet Net Assets or Fund Blnes Liilities Assets Chek if Shedule O ontins response or note to ny line in this Prt (A) (B) Beginning of yer End of yer 1 Csh - non-interest-ering ~~~~~~~~~~~~~~~~~~~~~~~~~,7,761. 1 5,71,16. Svings nd temporry sh investments ~~~~~~~~~~~~~~~~~~ 180,76. 10,98,181. Pledges nd grnts reeivle, net ~~~~~~~~~~~~~~~~~~~~~ Aounts reeivle, net ~~~~~~~~~~~~~~~~~~~~~~~~~~ 15,51,67. 18,056,010. 5 Lons nd other reeivles from urrent nd former offiers, diretors, trustees, key employees, nd highest ompensted employees. Complete Prt II of Shedule L ~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 5 6 Lons nd other reeivles from other disqulified persons (s defined under setion 958(f)(1)), persons desried in setion 958()()(B), nd ontriuting employers nd sponsoring orgniztions of setion 501()(9) voluntry 7 employees enefiiry orgniztions (see instr). Complete Prt II of Sh L ~~ tes nd lons reeivle, net ~~~~~~~~~~~~~~~~~~~~~~~ 6 7 8 Inventories for sle or use ~~~~~~~~~~~~~~~~~~~~~~~~~~ 8 9 Prepid expenses nd deferred hrges ~~~~~~~~~~~~~~~~~~ 589,66. 9 9,510. 10 Lnd, uildings, nd equipment: ost or other sis. Complete Prt VI of Shedule D ~~~ 10 11,097,7. Less: umulted depreition ~~~~~~ 10 6,08,. 5,195,71. 10,689,500. 11 Investments - pulily trded seurities ~~~~~~~~~~~~~~~~~~~ 79,718,. 11 7,91,676. 1 Investments - other seurities. See Prt IV, line 11 ~~~~~~~~~~~~~~ 0,010. 1 0,010. 1 Investments - progrm-relted. See Prt IV, line 11 ~~~~~~~~~~~~~ 1 1 Intngile ssets ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 1 15 Other ssets. See Prt IV, line 11 ~~~~~~~~~~~~~~~~~~~~~~ 9,5. 15,0. 16 Totl ssets. Add lines 1 through 15 (must equl line ) 10,850,. 16 11,011,707. 17 Aounts pyle nd rued expenses ~~~~~~~~~~~~~~~~~~ 9,515,961. 17 10,98,897. 18 Grnts pyle ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~,68,000. 18,00,000. 19 Deferred revenue ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 1,91,17. 19,816,071. 0 Tx-exempt ond liilities ~~~~~~~~~~~~~~~~~~~~~~~~~ 0 1 Esrow or ustodil ount liility. Complete Prt IV of Shedule D ~~~~ 1 Lons nd other pyles to urrent nd former offiers, diretors, trustees, key employees, highest ompensted employees, nd disqulified persons. Complete Prt II of Shedule L ~~~~~~~~~~~~~~~~~~~~~~~ Seured mortgges nd notes pyle to unrelted third prties ~~~~~~ Unseured notes nd lons pyle to unrelted third prties ~~~~~~~~ 5 Other liilities (inluding federl inome tx, pyles to relted third prties, nd other liilities not inluded on lines 17-). Complete Prt of Shedule D ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 10,997,9. 5 1,57,58. 6 Totl liilities. Add lines 17 through 5 6,055,01. 6 1,87,6. Orgniztions tht follow SFAS 117 (ASC 958), hek here nd omplete lines 7 through 9, nd lines nd. 7 Unrestrited net ssets ~~~~~~~~~~~~~~~~~~~~~~~~~~~ 77,79,8. 7 81,19,81. 8 9 Temporrily restrited net ssets Permnently restrited net ssets ~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~ 8 9 Orgniztions tht do not follow SFAS 117 (ASC 958), hek here nd omplete lines 0 through. 0 1 Cpitl stok or trust prinipl, or urrent funds ~~~~~~~~~~~~~~~ Pid-in or pitl surplus, or lnd, uilding, or equipment fund ~~~~~~~~ 0 1 Retined ernings, endowment, umulted inome, or other funds ~~~~ Totl net ssets or fund lnes ~~~~~~~~~~~~~~~~~~~~~~ 77,79,8. 81,19,81. Totl liilities nd net ssets/fund lnes 10,850,. 11,011,707. Form 990 (01) 011 11-07-1 11
Form 990 (01) COLORADO DENTAL SERVICE, INC. 8-05687 Pge 1 Prt I Reonilition of Net Assets Chek if Shedule O ontins response or note to ny line in this Prt I 1 5 6 7 8 9 Totl revenue (must equl Prt VIII, olumn (A), line 1) Totl expenses (must equl Prt I, olumn (A), line 5) ~~~~~~~~~~~~~~~~~~~~~~~~~~ Revenue less expenses. Sutrt line from line 1 ~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Net ssets or fund lnes t eginning of yer (must equl Prt, line, olumn (A)) ~~~~~~~~~~ Net unrelized gins (losses) on investments Donted servies nd use of filities Investment expenses Prior period djustments ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Other hnges in net ssets or fund lnes (explin in Shedule O) ~~~~~~~~~~~~~~~~~~~ 10 Net ssets or fund lnes t end of yer. Comine lines through 9 (must equl Prt, line, olumn (B)) 10 81,19,81. Prt II Finnil Sttements nd Reporting Chek if Shedule O ontins response or note to ny line in this Prt II 1 Aounting method used to prepre the Form 990: Csh Arul Other If the orgniztion hnged its method of ounting from prior yer or heked "Other," explin in Shedule O. Were the orgniztion s finnil sttements ompiled or reviewed y n independent ountnt? ~~~~~~~~~~~~ If "," hek ox elow to indite whether the finnil sttements for the yer were ompiled or reviewed on seprte sis, onsolidted sis, or oth: Seprte sis Consolidted sis Both onsolidted nd seprte sis Were the orgniztion s finnil sttements udited y n independent ountnt? ~~~~~~~~~~~~~~~~~~~ If "," hek ox elow to indite whether the finnil sttements for the yer were udited on seprte sis, onsolidted sis, or oth: Seprte sis Consolidted sis Both onsolidted nd seprte sis If "" to line or, does the orgniztion hve ommittee tht ssumes responsiility for oversight of the udit, review, or ompiltion of its finnil sttements nd seletion of n independent ountnt?~~~~~~~~~~~~~~~ If the orgniztion hnged either its oversight proess or seletion proess during the tx yer, explin in Shedule O. As result of federl wrd, ws the orgniztion required to undergo n udit or udits s set forth in the Single Audit At nd OMB Cirulr A-1? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "," did the orgniztion undergo the required udit or udits? If the orgniztion did not undergo the required udit or udits, explin why in Shedule O nd desrie ny steps tken to undergo suh udits 1 5 6 7 8 9 7,859,890. 9,60,15. 8,55,575. 77,79,8. -,877,668. -,59. Form 990 (01) 01 11-07-1 1
SCHEDULE D OMB. 155-007 (Form 990) Complete if the orgniztion nswered "" to Form 990, Prt IV, line 6, 7, 8, 9, 10, 11, 11, 11, 11d, 11e, 11f, 1, or 1. Deprtment of the Tresury Atth to Form 990. Open to Puli Internl Revenue Servie Informtion out Shedule D (Form 990) nd its instrutions is t www.irs.gov/form990. Inspetion Nme of the orgniztion Employer identifition numer COLORADO DENTAL SERVICE, INC. 8-05687 Prt I Orgniztions Mintining Donor Advised Funds or Other Similr Funds or Aounts. Complete if the orgniztion nswered "" to Form 990, Prt IV, line 6. () Donor dvised funds () Funds nd other ounts 1 5 6 1 5 6 7 8 9 d Totl numer t end of yer ~~~~~~~~~~~~~~~ Aggregte vlue of ontriutions to (during yer) Aggregte vlue of grnts from (during yer) Aggregte vlue t end of yer (i) (ii) ~~~~ ~~~~~~ ~~~~~~~~~~~~~ Did the orgniztion inform ll donors nd donor dvisors in writing tht the ssets held in donor dvised funds re the orgniztion s property, sujet to the orgniztion s exlusive legl ontrol?~~~~~~~~~~~~~~~~~~ Did the orgniztion inform ll grntees, donors, nd donor dvisors in writing tht grnt funds n e used only for hritle purposes nd not for the enefit of the donor or donor dvisor, or for ny other purpose onferring impermissile privte enefit? Prt II Conservtion Esements. Complete if the orgniztion nswered "" to Form 990, Prt IV, line 7. Purpose(s) of onservtion esements held y the orgniztion (hek ll tht pply). Preservtion of lnd for puli use (e.g., reretion or edution) Protetion of nturl hitt Preservtion of open spe Preservtion of historilly importnt lnd re Preservtion of ertified histori struture Complete lines through d if the orgniztion held qulified onservtion ontriution in the form of onservtion esement on the lst dy of the tx yer. Totl numer of onservtion esements ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Totl rege restrited y onservtion esements ~~~~~~~~~~~~~~~~~~~~~~~~~~ Numer of onservtion esements on ertified histori struture inluded in () ~~~~~~~~~~~~ Numer of onservtion esements inluded in () quired fter 8/17/06, nd not on histori struture listed in the Ntionl Register ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ d Held t the End of the Tx Yer Numer of onservtion esements modified, trnsferred, relesed, extinguished, or terminted y the orgniztion during the tx yer Numer of sttes where property sujet to onservtion esement is loted Does the orgniztion hve written poliy regrding the periodi monitoring, inspetion, hndling of violtions, nd enforement of the onservtion esements it holds? ~~~~~~~~~~~~~~~~~~~~~~~~~ Stff nd volunteer hours devoted to monitoring, inspeting, nd enforing onservtion esements during the yer Amount of expenses inurred in monitoring, inspeting, nd enforing onservtion esements during the yer $ Does eh onservtion esement reported on line (d) ove stisfy the requirements of setion 170(h)()(B)(i) nd setion 170(h)()(B)(ii)? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ In Prt III, desrie how the orgniztion reports onservtion esements in its revenue nd expense sttement, nd lne sheet, nd inlude, if pplile, the text of the footnote to the orgniztion s finnil sttements tht desries the orgniztion s ounting for onservtion esements. Prt III Orgniztions Mintining Colletions of Art, Historil Tresures, or Other Similr Assets. Complete if the orgniztion nswered "" to Form 990, Prt IV, line 8. 1 If the orgniztion eleted, s permitted under SFAS 116 (ASC 958), not to report in its revenue sttement nd lne sheet works of rt, historil tresures, or other similr ssets held for puli exhiition, edution, or reserh in furtherne of puli servie, provide, in Prt III, the text of the footnote to its finnil sttements tht desries these items. If the orgniztion eleted, s permitted under SFAS 116 (ASC 958), to report in its revenue sttement nd lne sheet works of rt, historil tresures, or other similr ssets held for puli exhiition, edution, or reserh in furtherne of puli servie, provide the following mounts relting to these items: Revenue inluded in Form 990, Prt VIII, line 1 Assets inluded in Form 990, Prt ~~~~~~~~~~~~~~~~~~~~~~~~~~~~ $ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If the orgniztion reeived or held works of rt, historil tresures, or other similr ssets for finnil gin, provide the following mounts required to e reported under SFAS 116 (ASC 958) relting to these items: Revenue inluded in Form 990, Prt VIII, line 1 Assets inluded in Form 990, Prt Supplementl Finnil Sttements ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ $ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ $ $ 01 LHA For Pperwork Redution At tie, see the Instrutions for Form 990. Shedule D (Form 990) 01 051 10-01-1 1