2023-11-03T13:28:35-05:00 2022-12-31 410746749 CLIFTONLARSONALLEN LLP 10700 NORTHUP WAY SUITE 200 BELLEVUE WA 98004 990 2022-01-01 853172690 AVIVA QALICB AVIV 5416729596 150 NE KENNETH FORD DRIVE ROSEBURG OR 97470 LEAH WOODS PRESIDENT 5416729596 2023-10-31 1 LEAH WOODS 999009999 0 KURT BENNION CPA P01469618 4252506100 2023-10-31 3 AAL1 IAL1 2022 2023-04-26 12:10:37Z LEAH WOODS 150 NE KENNETH FORD DRIVE ROSEBURG OR 97470 556628 0 X N/A X 2020 OR TO BENEFIT AND CARRY OUT THE PURPOSES FOR AVIVA HEALTH (UMPQUA COMMUNITY HEALTH CENTER, INC.). 3 2 0 2 0 0 7164912 316143 0 0 64132 40485 0 -912644 7229044 -556016 0 0 0 0 0 0 0 0 0 726605 266669 726605 266669 6502439 -822685 22992439 22394157 16490000 16590000 6502439 5804157 AVIVA QALICB IS ORGANIZED AND OPERATES EXCLUSIVELY FOR THE BENEFITS AND TO CARRY OUT THE PURPOSES FOR UMPQUA COMMUNITY HEALTH CENTER (DBA: AVIVA HEALTH). 0 0 190719 0 200000 AVIVA QALICB WAS FORMED IN DECEMBER 2020, IN CONJUNCTION WITH THE NEW MARKETS TAX CREDIT FINANCING TRANSACTION THAT CLOSED ON DECEMBER 2020. AVIVA QALICB HOLDS THE AVIVA HEALTH ROSEBURG CLINIC BUILDING AND UNDERLYING LAND AS ASSETS AND LEASES THE BUILDING TO COMMUNITY ORGANIZATIONS AND OTHER ENTITIES FOR PERFORMANCE, GATHERING, REHEARSAL, MEETING AND OFFICE SPACE. 190719 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 X 3 2 0 0 0 0 0 1 0 1 1 0 0 1 1 1 1 1 1 0 0 0 OR X LEAH WOODS 5416729596 150 NE KENNETH FORD DRIVE ROSEBURG OR 97470 LEAH WOODS PRESIDENT 1.00 49.00 X X 0 157471 22854 BETTY KAY TAMM SECRETARY 1.00 0.00 X X 0 0 0 MICAH WATTERS BOARD MEMBER 1.00 0.00 X 0 0 0 0 157471 22854 0 0 1 0 0 316143 316143 40485 40485 200000 1112644 -912644 -912644 -912644 -556016 -912644 0 40485 X 46675 46675 29443 168 29275 162616 162616 8910 8910 MEDICAL SUPPLIES 19025 19025 266669 190719 75950 0 101000 248850 8594203 1199442 21858954 913089 14297236 20945865 22992439 22394157 100000 16490000 16490000 16490000 16590000 X 6502439 5804157 6502439 5804157 22992439 22394157 -822685 124403 0 X 0 0 0 X X X 1 AVIVA HEALTH 931070304 7 1 1379313 0 1 1379313 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 X 1 1 PART IV, SECTION D, LINE 3: THE CFO OF UMPQUA COMMUNITY HEALTH CENTER (DBA: AVIVA HEALTH) IS THE PRESIDENT OF THE BOARD OF DIRECTORS OF AVIVA QALICB. AS ONE OF THREE BOARD MEMBERS, THE BOARD PRESIDENT IS IN THE MINORITY AND, THEREFORE, DOES NOT CONTROL THE BOARD OF DIRECTORS. HOWEVER, AS ONE OF ONLY THREE BOARD MEMBERS AND AS THE PRESIDENT OF THE BOARD, THE CFO HAS A SIGNIFICANT VOICE IN ALL DECISIONS MADE BY THE BOARD OF DIRECTORS, INCLUDING INVESTMENT DECISIONS AND OTHER DECISIONS DIRECTING THE USE OF AVIVA QALICB'S INCOME AND ASSETS AT ALL TIMES DURING THE YEAR. PART IV, SECTION E, LINE 2A: AVIVA QALICB'S ACTIVITIES CONSIST ENTIRELY OF CONSTRUCTING AND MAINTAINING A BUILDING THAT IS LEASED SOLELY TO UMPQUA COMMUNITY HEALTH CENTER (DBA: AVIVA HEALTH). AVIVA QALICB WAS CREATED AS PART OF A NEW MARKETS TAX CREDIT ARRANGEMENT THAT WILL ULTIMATELY RESULT IN THE TRANSFER OF THE BUILDING AND RELATED OPERATIONS TO AVIVA HEALTH. THE BUILDING FURTHERS AVIVA HEALTH'S MISSION OF PROVIDING HEALTHCARE SERVICES TO MEDICALLY UNDERSERVED INDIVIDUALS IN OUR COMMUNITY BY PROVIDING A MODERN FACILITY THROUGH WHICH THESE SERVICES CAN BE PROVIDED. AVIVA QALICB REMAINS RESPONSIVE TO AVIVA HEALTH THROUGH THE BOARD PRESIDENT'S DUAL POSITION AS CFO OF AVIVA HEALTH. THE BOARD PRESIDENT CAN CALL BOARD MEETINGS AND RAISE ISSUES AS NEEDED BY AVIVA HEALTH. PART IV, SECTION E, LINE 2B: AVIVA QALICB'S ACTIVITIES CONSIST ENTIRELY OF CONSTRUCTING AND MAINTAINING A BUILDING THAT IS LEASED SOLELY TO UMPQUA COMMUNITY HEALTH CENTER (DBA: AVIVA HEALTH). IF NOT FOR THE EXISTENCE OF AVIVA QALICB, THE FACILITY COULD HAVE BEEN ACQUIRED AND/OR CONSTRUCTED DIRECTLY BY AVIVA HEALTH. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 684970 684970 20716202 879686 19836516 457782 33403 424379 20945865 0 0 0 0 0 0 0 0 0 LEAH WOODS PRESIDENT 0 157423 0 0 0 48 0 4708 0 18146 0 180325 0 0 PART I, LINE 3 THE PRESIDENT'S COMPENSATION IS SET BY UMPQUA COMMUNITY HEALTH CENTER (DBA: AVIVA HEALTH), THE SUPPORTED ORGANIZATION. A COMPENSATION SURVEY OR STUDY WAS USED BY AVIVA HEALTH TO SET THE PRESIDENT'S COMPENSATION. FORM 990, PART VI, SECTION A, LINE 7A ONE BOARD MEMBER MUST BE THE CFO OF UMPQUA COMMUNITY HEALTH CENTER (DBA: AVIVA HEALTH), THE SUPPORTED ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 11B PRIOR TO FILING, THE FORM 990 WAS REVIEWED BY THE BOARD OF DIRECTORS OF UMPQUA COMMUNITY HEALTH CENTER (DBA: AVIVA HEALTH) AND COPIES WERE PROVIDED TO AVIVA QALICB'S BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION'S CONFLICT OF INTEREST POLICY COVERS THE BOARD OF DIRECTORS. IF A BOARD MEMBER HAS A POTENTIAL CONFLICT, THEY ARE REQUIRED TO DISCLOSE THAT TO THE REST OF THE BOARD MEMBERS. A TRANSACTION INVOLVING A CONFLICT MAY BE AUTHORIZED BY MAJORITY VOTE OF THE BOARD MEMBERS WHO DO NOT HAVE CONFLICTS. FORM 990, PART VI, SECTION B, LINE 15 ALL COMPENSATION DECISIONS ARE MADE BY UMPQUA COMMUNITY HEALTH CENTER (DBA: AVIVA HEALTH), THE SUPPORTED ORGANIZATION. FORM 990, PART VI, SECTION C, LINE 19 THE FINANCIAL STATEMENTS AND GOVERNING DOCUMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G OTHER SERVICES: PROGRAM SERVICE EXPENSES 168. MANAGEMENT AND GENERAL EXPENSES 29,275. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 29,443. UMPQUA COMMUNITY HEALTH CENTER 150 NE KENNETH FORD DRIVE ROSEBURG OR 97470 931070304 HEALTH CARE OR 501(C)(3) LINE 7 N/A 0 0 0 0 1 0 0 0 0 0 0 0 0 1 1 1 1 0 0 0