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Home My WebLink About8.1 Axis Community Hlth Attch 14 . !!J ". I! "'l CITY OF DUBLIN Fiscal Year 2008-2009 RECEIVED CITY OF DUBLIN JAN 2 5 zoo~ COY MANAGER'S OffiCE COMMUNITY GRo~~IORGANIZATION APPLICATION FOR FUNDS C6 AGB'NCY NAME,Z Pk8POSlt Q.Tft"GRAl\1N~MI:: WOMEN'lS FUNIJ_O,AMOUNT SECTION 2 Page 1 of 16 A77~H-m &NT I'-/- . !!J ". ItIilJ l! "l CITY OF DUBLIN Fiscal Year 2008-2009 A~~LICATI(tN F'(}iR FUNDS 1. Please select Qpeexpell'Se category: x Ca~ital [J Operating 2. Applicaut In'forma;tion: OrganiZiE1tioEfAgency Warne: Axis q~Im!Jl;w.B;~fll~ ,{,~:<: MailingA.ess: 4361 Rai1rQ~A ~~',e Street Address: same as above Ci1iY: ~leaslll1ton State:;CA '~i';tij.566 Sue;C~ml1>ton Chief Executive Officer WtlJrk'hcme SCOl1'lpton@axisheaIth.org Email James;r~~ Board PlreSiijet),l 925- 734-65 Work Phone .}~ ames@hacieIlda.org. Email Please list the Primary Project Contact Persoll:who would be able to ansWer questions about this application and project/program during the fundmg li>eriod. Carol Beddome Contact Person for ProjectlProgtam. D.~v~l~pmert;t Pi,t;ector JbbTitle 925-201-6068 Work Phone cbeddome@axishealth.org Email 925-417-1503 Fax Federal Tax Identification No. (required) 94-2232394 City of Dublin Business License No. (required) application is il'l. J9foeess \OfQllr SECTION 2 Page 2 of 16 L iii1 A r. 'V""lllil! "l City of Dublin Fiscal Year 2008-2009 Application for Funds 3. Proposed Project/ProgramIn.fGr'matioll (Do not describe Organization.) Axis Community Hea),this$eeking;$25,Odd.tp sUPPott'ofth~qClnstruqti()nofa Women's Health Clinic at Axis' s Ra11r()adl\'Vi~nue sitewhicl1 will c()pve:rta 1 ,400sq;Uare foot office space into a three-examination room obstetrical suite. The t0tal estimated budget for this project is $511,076. Amount/of Funds Requested: $ 25;~tl~) (MaxiUlum $2~,OQO)"er project.) PropO$edPr():jectIProgra.i_:..~.n 's/.e~I."'iQinit Proposed Proj.ectIP'FQgram Date($'~* ;I~ 074'0 11 <(j)~ mo. yr. , -,': .,.'::.,. ,::,.,' Pl$se note:Ci1lY Co.~i~ Grant F~~;;ar~~is~~u_~OJ;);~teimbursement'basis. If your Agency m~dsa 100% disi~~~~e~~~t1lle'_Si~g;~FtheFiscal Year, please indicate this .1pd,0w:and please p~~~e)j;ust.ati.():n for this need. o Ag;~n;~yi$rell~e.sting 100% disb'!sement,atthebeginni.;of the Fiscal Year. msele .ct.iniJthi '. :8.0. ption, pleatc...........,'...'.P...................r...........o....vide.j;....:.....:....,....t........l......fi.. ..Catl...;o.'.'............................ he blank space.... .b..<clo. w. . ", ...........^co... ',',' ',. '.',_.<....".. .. ,""-" .. ',- '" 'c",' -:'" ;-' x Agency is not requesting 1 00% disb~~eJ,1lent at the ~~l!linning of the Fiscal Year. If selec$ing this Optioll, please prov;t~the:Q,sell1ency that reimbjJI'sementswil1 be submitted to the Ci1lY,in tliebJank space/oelow; e.g., monthly, quarterly, at project completion, etc. Will submit invoices monthly as pF(}j.gct eX:pen$es occm-. SECTION 2 Page 3 of 16 l>. il .. r. City of Dublin Fiscal Year 2008-2009 Application for Funds a. How would the requested funds be used? · Describe, in detail, the PROJ,>OSEI),;RROJECTIPROGRAM (not the Agency). Axis Community Health is seeking $25>,0'00 in support or ~" c<iJnstmction of a women's clinic at Axis's Railroa€i;A venue site. ThisprQjectinv6lves the conversion of an existing office are~{Suite A~ to cIlmc~1 space thatwill$>>pport Axis's rapidly growing prenatal care program..'ll1e e$timat~aproject totali$,,1~511 ,07Y~~$323,835 construction, $17,250 sprinkler syst!IDl, $4,875 pennits/fee, $75,~~~>.fee$~)1it5,525 equipment and furnishings and $44,649 prQject contingenc,:;estimat~d~~>~~I~l o~t b. H6wWOuld... ~~"kOIl>S.)~.~~T.~O~M: addre$san unmet community need and i.rovetb,~qUhtfty)6f;;'i!fe for DublinreSi<len(~~ '~is1Jhis project/program needed? Axis is thte sole proviaer of prenatal servicesforlocalt.e.sidents who are indigentancl ~*d. Fpr the past:1._5o~l~ai(~Pt$'Wet'~.\,)kt~;,a~~ss ValleyCare Medical C~n~f<\),r a:~Ji\rery services. TI~'necessitated an agre~~nt with Alta B~tes Sll1\t11Il'lt Medic~ Center in Berketey to ~~~our p~~nts deliv.~'their babies there. Access to Alta Bates was difficult for our patients. ">'Qa~ third of C). patients do nQt have cars ,and many others have just Olle cartosh~e amongS'~W~J!~>families. A11facedciifficulties getting to Berkeley duriqg <?ommuteJJo~~''W'hfle,:thiswas'll'Clt'a sati~factoryflI1'angement, it was the '~.-_::r- :');:.->' ..,: best we were able to arrCl:IliefOr o~ p~tiellts. In 2004, Dr. Michael Bleecker, a local obstetrician, took on a new partner, Dr. Scott Eaton. This partnership allowed Dr. Bleecker to expand his services. Axis's prenatal patients have been the beneficiaries of this new partnership, as Dr. Eaton and Dr. Bleecker are now providing prenatal services at our clinics in partnership with our obstetrical nurse SECTION 2 Page 4 of 16 L jiI ,;t Ii !!J " l! "l practitioner. This partnership has allowed our patients to deliver their babies locally at ValleyCare and has resulted in rapid growth in our prenatal program. 19% of all of deliveries at ValleyCare are Axis's patients. Our visit statistics demonstrate this growing need for prenatal services for low income residents: Prenatalservices for.low income,..~ID~f$'e()j~iti6~1..i~~portance in our community. In the document Healthy People 2010~ine U.S. Offiee:ofDis~~'$e Prevention and Health ProJi)!lotionestablished ~~t";;s'taWll~ps'.athave~ee;rJ:impl~~lQ;ted nationwide. these staDd2i$'ds:{are based the dise 'ldhood ;im1nunizations~~~~ity~ am\imi ~~lt-t,t mortality. Dublin meets:tHenati,.:;~;~dards in.~~J~'Ve~f,)ategory with tne excePtion of low birth weights. the estab1islil~s:tandara.. is thatfe~et than 5% of :a:ewboms should be in the "lawt>irth weight"category~les~,~~~ 5<m~s";~;;~~');i~l,a rate~#;9%, Caucasilll1 women in Dublin are meeting thisis:md~'Thedatais:notat~;9sM'iefbr non-whitelDubfin re$i~ts: 8.2% of Hispanics lll1t7.7%of A~ians are d~tiwering low birth weight babies (Alamg~eo1DJ$y!!)elect HealthfJ;)itl@ators, 12;'(04). Because birth weight is the most important~dicator of 'predicting the c~ces forslilTVival and for healthy growth and development (U.$.lDept;.ofH~th and Him_Services, Healtbf Peopl~, Wovember 2004), this data is troubling. F acttilrs fiat l~d to 16wblrth weig}lt_dude'premattlre births, maternal smoking, drug and alcohol u~e, po~erty,poor nutrition, young maternal age, and low education attainment (Centerfor)Jisease Control,MMW:Rc, 1999). Prenatal care has a proven impact on mitigating these factors and bringing about positive birth outcomes. Axis's prenatal program is comprehensive and includes: (1) assistance in enrolling in a publicly-supported health plan (which also provides immediate medical coverage for SECTION 2 Page 5 of 16 L ill "" Ii !!ill!.! "ll newborns), (2) health education and nutritional counseling, (3) supplemental food through our WIC program, (4) drug and alcohol services, as appropriate, and (5) prenatal and post partum medical care. As the indigent and uninsured population grows in Dublin and the Tri~ Valley as a whole, our prenatal program has grown as \Y'(;(11"."Weiiare;n6w.,QJ.U ()f clinical space to meet this growing need. This project willc6iivertl,4(1f::)sqiJ;lare feet of ofiice,,space into a clinical area that will include three additional examination rOOIllS. It will also create a separate waiting..Joom for prenatal pati.ents, which i~, prefera:bleto haviI1g themeSp,;;u-e the, waiting Jioom with our general medicalpatie1\ts, man,y ()~>whom are iij;~;~M.g0.'4itional cliilicfJ,1 space Wll also be used for other gynecological services, inclutlll!;g ff;lIDiJypl~l1g, cancer detection services, and our bre,l:lSt cancer detection progr..The_'~ti~n<:){ the$~ three examination rooms will also iIlCr~aSe, our clftpacity to provid~i.edicaJ care for lowi,mcome Dublin residents by more than especially {or adultpreventi;~e sl!}~es;i~I;;ije ' '~:$,/iBy increasi!Jll;~. our capaci1lY, we will be able to morejilly l,J~~tthe gfoMI'!sneed for l11eai9al ililc0me fam.iliesinour c01')1mumty. ..,~a~!tlocumenta'1~,~~ 'PIl{)JECT/PROGBllll~!PI :@;~ed"for this PQQYOSED y:{}m'a.a't~ · Healthy People 201 (}:; · ~,lameda.County Select~~~th Indicator~,2004; '..'iJ.S. D~PartineIlt ofHealth,._.Hl]~~;Services, Healthy People, Wovember 2004; · Center for Disease Control, MMWR, 1999; · Tri- Valley Needs Assessment, May 2003. SECTION 2 Page 6 of 16 .. iii1 A. Ii !!:J r I! .. City of Dublin Fiscal Year 2008-2009 Application for Funds d. Specify the PROPOSE:QJ?R~9Et;tmf{()G:lt:ttMl!>QJllllation to be served. ,,-" ",.-/,>. .,-"..:,",' .,..". ~y> ::::,: :(' This project targetsthe!.OO (20,,'Dublin%r~sidents) ~bw injQ#ie pre~ant women who come to Axis for prenatal care each year. It willalsoprev:ide incrga~ed,;spaoe fQ~the 1,000 women (100 Dublin llesidents) whQl.lSe our wonlelt'si~~;fllth services~chyear. This project will also incre~eour overall q,apacity at our o~Ay.~ltliil~qlinic site by 30%. Weourrent1y pro'fide R).~4i9~~fvices for 10 ,1,200 DubliIl>resi~ents) between our two sites. the addition of',:~e ex::um.natidnrooms:t:Jj,our Pleasantonsite will ailow us to se~e an additional 2,OQl~~is'~~I4_bl~ r~~d~_) av.~::$ite. Upon proj,ect icompl'etion we :amauaIQasis. at this site on an 2j%of our patientsarechildren'.~~r:tie a;~~ Q;e~~lV'~f.!Ild 75%,o'$'the adults we serve are wOi\lenofchildbearing.~.%iO~]~utj!patie:s.ts.are;)j,t!!-:e.1'1t1"'8peaking, with the maj.ori1lY ofth~se~$4~)geing Spanish- our adult pati~lltsiaree~lQyed, nearJy~lare .ong the '~worki or."i:~I"have ily income that liS less that$24,850 for a f~'~ydifour (PIlJD "extreme oW"), an~)!''Vo have an income between $24,851 and $41,400 for a faJ1.lliilyoffQu:r;~ "very:l~~"~. 97% of ourprepatalpatients fall into the "high risk" category duetji)!C~Tpli1~te~~~i~ati'for?:b~t7~~al:i}isto~es, anemia, poverty and poor nutrition.Q~spi~ tq,~se rfks'actqrs, justiJto of1ourpa.mel.'l;t;s!experience obstetrical """":,.:'_'u. .,.:"') .:,-<>':.: ';'::-:_:_::_' -.'.-,'.,----:/-c:-<.-,.., .:., :':':':,,-,;:':' ,";< complications. This compMe~Jonati~p.al rat.es that rangefcQm 10 - 30% for high risk pregnancies. e. Projects/programs must be evaluated to determine if they are being carried out efficiently and if project/program goals are being met. Please describe how you plan to monitor your project/program's success and impact. SECTION 2 Page 7 of 16 L i01 A Ii ~ 1111 II" I!! ~ The objectives of this project are to expand our capacity to provide medical care for low income Tri- Valley residents, as well as to increase the availability of services for high risk pregnant women. These objectives will be met by completing a capital project at our Pleasanton site which will convert a 1,400 sq. ft. office space into a three-examination room obstetrical suite. The project will be eValuat.ed on several levels including: (1) the physical completion of the project withinthe~esta1:i'llished bw@getandtimeline, (2) the increase in the number of low income pregnan~ wome.t;l we serve, and (J') the increase in the number of low income Dublinr~sitietlts!\:we can aCc\?mmoQate,atow:Ple~at)tqli1'cllQ.ic ~te. Thisproj ect will allow us to explll1~:$t1rp17enatarcaE~,rogram, which is the Tri -Valley's only prenatal program for low Qat)ome WOmell./Pttolic l1:e~th data consistently demonstrates the~ost..e. ffi... ectiveness.o.. f......!p.............,...r.......~.eJla.....tal..........".;...:..}~~.....!....................e.......................Th.......,.....'.i. e......t......o.........,.....t.. al....................c.........o........s.......t. .!....~.....)~!.mn...'......,.'..!...................... e...........r-Ill.,........>.p......,......n.......th........ s of prena. +a1. Oaretat Axis .... ... ... . .... ...................... >< .< .... ..>>>i;"/>' ................. ... .. .... . .. .. av~rages$l ~OOO per'~1li,ent. 9fltQof}~~\pa'~n~}fj;~ve f~'I0fableiol1;tcomes thatdo'llotrequire additional medis~~~me form9~~.~;t).Jlewb(,)J;;;J,l.Pr.~.~t WOmen who do not have prenatal cane ~drt:heir .ants);Ji1~lr~a c.o~ij~~n rate that'_g~s.fr.G}ltl.lO~ 30%. For som.e women ana. infants, ther~.~mplications ophj,c an~!~~~~~itate.!eX!traor~ary medical care th@t can oost $500,OO~"or more iJlliiuit!1iate artum P.(:)'(l. Some.ofthese infantsface lifelong ph,.si~~t.;jiffj.~eg,!as~el1,1ft~t~q_\:_i1y long-term medical care and$};,Jpport. This project will alSOa1h'liW us to incr~~pp.r .a:city to proviatmedical care for all patients at our Pleasanton site. Public health data consistently demonstrates the cost-effectiveness of community clinic services as well, as c~inicsmake ongoingIl1edical.care available to those who do not otherwise~y~ aES~ss'ito I1edi~al care. Her example, a patient who has asthma who is treated at a communitycnnic,..i.tec,~iy~$QfigQiIlgpreventive medications and health education, which results in fewer and less serious asthma, attacks. An average visit at Axis is $155, while a typical emergency room visit for an acute asthma attack is $1,500. These savings are far greater when heart attacks and strokes can be prevented. F or uninsured SECTION 2 Page 8 of 16 Ii. iii1 ~ r. '!J ,. l!! "II patients, hospitalization and emergency room visits ultimately end up being a cost that is born by the general public. Axis has a comprehensive Quality Assurance program which tracks all aspects of the services we provide. We also collaborate with the Community Health Center Network, which is a consortium of coJIHfiunity clinics il1l Alameda Qount~, tl1evaluate the quality and outcomes of our me<:ii~f:ll services,. Asa result of<>1U" q;uaijty ass~ance activities, we have documented a cOl1iplicatl~ ra~<>fJust 3 % ,~ong our (jt?stetri~al pati~n.ts. This rate compa,t;~s favor~ply wlt};llthe 10 - 30%;i~~mp1ic~p rate in the '{J,S.for s;i1nila,t; populations. This success of ourprogtam also 1;l@~Na po~itiV'~H;pPa~'9n our commtu:ri1lY, as the net cost of care is mitllmizet!l and resident y ~jt~1t~t,~~ty cY~!tife. f. Specify numbers or clients serveca h:yag~.c)Z,_l1~)Z'PROP.S:ED PROJECTIPROGRAM: SECTION 2 Page 9 of 16 h. '" A Iii !!J J" l!! ~ City of Dublin Fiscal Year 2008-2009 Application for Funds 5. Financial Information - Operating Budget Oontracted Seryices/Profe$'sional Fees Occupanq~, @onsumable Su~,~~eg; Travel and Transportation JltJ'luipment ~ent.ain.rm:rfe:e Outreach afil'tl?romotlou Printing Pu~ti:q,ations I_tWanc:e/fees/ duesf~~'Ord ~~ ek~d~ hon ConsmuC6orlVRe'1lalJilitation PermitsalIttFe,es Design Furnishing/Equipmerft Fire Sprinkler System Project contingency @lO% roject construction costs TOTAL o $25,525 $,,17,250 $44,~49' $(j,610,312 $32~1,8!~:~ $4,_7 ~.: $75,0(~0 $25,525 $17,250 $44,649 $511,076 $25,000 Bud2et Notes: The HGA architectural firm (formerly The Thistlethwaite Architectural Group) will provide all project design services and has completed an initial project plan (see attachments). The Thistlethwaite Group designed Axis's adult medical clinic (a City of SECTION 2 Page 10 of 16 lo.. ill !!J '" L iil L! "l Pleasanton CDBG project that was completed in 1990) and our pediatric clinic (another City of Pleasanton CDBG project, completed in 1999). This fIrm specializes in medical facilities in the Bay Area, including projects at John Muir Hospital in Walnut Creek and Eden Medical Center in Castro Valley. This proposal includes a detailed c~st esti~~efor co~tructionA~oststhat was provided by the Nelson T. Lewis COl;lstruc'€i~p Company. This."estimf!;t:(;: was based upon Davis-Bacon wages for all project constm~tion cgmponents. Costs~~t~~lPng the neW clinic space were based upon our actufll experience as we complete.. clinic expaJi>.sion pFoj,ect in 2006. We ha~e'extensiv~'experience with\v'a,vis-:a:a~on reql.l:ireme_ through our past CDBG}M'ojects. SECTION 2 Page 11 of 16 .Ii Ii !!J ,. I!! ""l City of Uublin Fiscal Year 2008-2009 Application for Funds b. Revenue Budget o $5:15,Q.': $1 ,3 ~,7!,13 3 ,500 $20,000 $61,424 $669 434i , """ $1,6,000 $'1:6 $1,6n,Q,Opo' "/. ..$38,QQO $1~2,266 $100,000 $25,000 $224,315 $6,536,680 $100,000 $25,000 $24,315 $511,076 * All current contracts will be up for renewal 7/1/08; we have no indication that any of our contracts will be decreased and/or not renewed. SECTION 2 Page 12 of 16 4.. Ii !J r t.. ii1 ~ ~ City of Dublin Fiscal Year 2008-2009 ApplicanonforFunds 6. General Agency Information o Past grantappliQ~ts~~ycheck thiS';,~~e_f~~U of compl~tirtgn,m 6 (/il"d) if the progratnJorgaaizati.onal descripti~~wonfile Ci1lY is correct~a current. a. List all years that Organiza.~11 has pre:vrously.recei'Ve<lCity of Dublin funding (not COlil1l1nu.rrl1lY Developm~nt Bel. Grant - CDBG). Wofuriding history to4'litte: b. Describe the populati.on( s' setwed{ib~ the Orgamza:1lion. AxisQurrent~iY I1>rovideSi.~diCal.> ....... .,Z7lte tn)~~~~1ql~~~~~S~~~~~. An additio~al 2,000 residents :(!:larti~ipate in Axis~~:;_an'lllc~:lollJJro~~\~d:!!_~~.~\lhealth services,i$l42,eOO others participate in Axis's WIC nl.$'itionprogram. Those who ~e. s~Jwed by~xis are the w~~~p.g familie~(ofthe Tri-Valley. The maj0rity of the families areel11ployed'in lOQaJ:s~rvice indU~$~ileluding hot~ls~d restaurants, landscaping and agricultural businesses. N:[ianyare employedl:>ysmalflocal businesses that do not have the resources to provide health in~lll1ce f.(\)r theiremploy;ees or thei,t; e'tJ!lployees' families. 74% of the medical patients have a familyincome'thans less than 100% of U.S. poverty standards ($20,652 for a family of four). An additional 24% of the patients have a family income that is between 101 and 200% of poverty levels ($20,653 - $41,304 for a family of four). 25% of those served by Axis are children under the age of twelve. SECTION 2 Page 13 of 16 A r. !J J L If' I! '"'l 62% of the medical patients are non-English-speaking, with Spanish being the predominant language. 54% of the patients live in Livermore, 29% live in Pleasanton and 8% live in Dublin. The remaining 9% reside in surrounding rural areas. c. Describe all the services the OrgamZ:i:ltionc:yr.rently provides to Dublin residents. In the past year, Dublin resiElefits made In(;)rei;tl1an 1 Q,Q190 visits"to .Axis, including: · 2,55Qme$cal vistts · 350 teen drugandialcohol · 1,700 adult drug and alcoho,l:"isits . 1,175 EJUI class visits . .,. 3@,O domestic · 3,000 WIC nutrition pro$'. visits · 750 eli;~bility dli.healtllt~ll:l1llll1ceemol_eJilt~is~ce"isits d. Has }rour agen er previ please specify in w~t,! the City 0fl!>ublin? If yes, reGeiv:~d'each year. No, this is our first time for request for funding. SECTION 2 Page 14 of 16 A r. !J P' City of Dublin Fiscal Year 2008-2009 Application for Funds 7. Required Attachments: ter A enc oti,~ach ~,ft"~ followiqg is rt:,f[U,ired,yevClIl with tnultiple proj ects/p.rograJDs sub )ted. o Applications withQut the following docurg.~Il~';~11!,!!Q! be reviewetl for funding. o Please label attachmeuts: A. B. C. etc. o A. Names of Gove~j~g B()'a:r~;,i_t1" curt!~:mt Board officers. ,t!l ::8. ,. Current · Cl eJPJECllPRtJ.,A_, ping revenue. luaesthe PROPOSED o C.Mostr~.t,;auditt~~rtQr tax ret~,(if(J,Rpli9~~1~1. o D. ~~~~~tion, lette Bo~Qrganizat · B6a:Jl~Or roval wras@rap,te~. -,"--,'-'-"-": -.:/,:< -'.___: -.' ::::',.' --:'/0 t!l E.' Organization's c~l:f'i.cate of insurance sbJ.~wing coverage for liability and workers' compe.tion. Q F. AppHc;ation V erifie~~n DeclaratiqJ.\\'i'ignature Page, . Q G. Signed affidavit form from,e~~collaboratin,g:ag~ncynamed in proposed Pl1ojectlprogtiam pima (if aRRlicable). Q H. Copy, 6r I~'S 14etter.(T)f ll.etemnination!indicating tax exempt status. SECTION 2 Page 15 of 16 L iii1 A r. -A-.J..fvc '^~ V-t Axis Community Health Board of Directors 2007 t!!.m! Position/Committees Phone E-Mail Bert Brook Chair (hm) (925) 846-0789 bertbrook@comcast.net 852 Castlewood Place Finance Pleasanton, CA 94566 Foundation Donald Odell Vice Chair (hm) (925) 254-5926 dodell@mcnicholslaw.com McNichols, Randick, O'Dea & Tooliatos Long Range (wk) (925) 460-3700 5000 Hopyard Road Pleasanton, CA 94588 Mark Eaton Secltreasurer (hm) (925) 373-9249 markleaton@comcast.net 2109 Fourth Street Finance (wi<) (925) 373-3455 Livermore, CA 94550 Thelma Fones (hm) (925) 443-7320 tfones@livermore.k12.ca.us Livermore School District (wi<) (925) 454-5596 750 Del Mar Avenue Livermore, CA 94550 Michael Fraser, Chief of Police Goverance (hm) (925) 846-8847 mfraser@ci.oleasanton.ca.us Pleasanton Police Department (wi<) (925) 931-5100 4833 Bemal Avenue Pleasanton, CA 94566 L. James Ghilardi Govemance (hm) (925) 484-2449 volvosao@aol.com Arroyo Counseling (wi<) (925) 462-0220 4713 First Street, #250 Pleasanton, CA 94566 Ted Kaye, Ph.D. Goverance (hm) (925) 417-1201 tkave@lasoositascolleae.edu Las Positas College Foundation (wi<) (925) 424-1010 4131 Garibaldi Place Pleasanton, CA 94566 Farzana (Farzi) Najeeb. Foundation (hm) (925) 399-5131 farzinaieeb@vahoo.com 9302 BenzonDrive Marketing Pleasanton, CA 94588 James Paxon, General Manager Long Range (hm) (510) 524-0679 iames@hacienda.ora Hacienda Owners Association (wi<) (925) 734-6510 4473 Willow Road, Suite 105 Pleasanton, CA 94588 Rebecca Silva, Executive Director (hm) (510) 487-7769 rsilva@caoeheadstart.ora CAPElHeadstart (wi<) (925) 443-9380 34864 Rumford (home address) Union City, CA 94587 Jeri Steiger (hm) (925) 484-3699 oizzarob@aol.com 3819 Vineyard, #68 (wi<) (925) 846-2520 Pleasanton, CA 94566 Jorge Suarez (hm) (831) 770-6478 iorae@oceanmist.com Ocean Mist (wi<) (925) 314-0578 311 South Branciforte Avenue Santa Cruz, CA 95062 Laura Torres (hm) (925) 294-4144 Itores@livermore.k12.ca.us Marylin Avenue School (wi<) (925) 606-4724 4804 Marcella Court (home address) Livermore, CA 94550 Aida White (hm) (925) 455-4708 awhite@caoeheadstart.ora CAPE/Headstart (wi<) (925) 443-3434 6125 Augusta Way (home address) Livermore, CA 94550 ~"'~ u~ AXIS COMMUNITY HEALTH FY 2007- 2008 CONSOLIDATED BUDGET SUMI\IIARY Behavioral Medical Clinic Health WIC Total REVENUE: PUBLIC SUPPORT CONTRACTS State 65,000 515,000 580,000 County 1,401,396 746,858 2,148,254 Local 25,000 25,000 TOTAL CONTRACTS 1,491,396 746,858 515,000 2,753,254 Foundations 68,300 1,000 69,300 Donations 137,500 3,000 140,500 Other 75,100 75,100 TOTAL PUBLIC SUPPORT 1,772,296 750,858 515,000 3,038,154 BILLED-PATIENT/CLIENT FEES BCEDP 1,500 1,500 CHCN-CAP 360,000 360,000 CHOP 3,500 3,500 CPSP 378,000 . 378,000 Full Fees 51,200 51,200 Medi-Cal 1,260,000 40,000 1,300,000 Medi-Care 38,000 38,000 SOFP 150,000 150,000 Anger MgmntlDV 37,000 37,000 Assessment & Eval 800 800 City Programs 7,000 7,000 DOT 5,000 5,000 Drug Testing 1,000 1,000 DUI Fees 325,700 325,700 EAP 500 500 Private Insurance/Patient Fees - 199,300 199,300 lOP 110,000 110,000 OP 20,000 20,000 TOTAL PATIENT/CLIENT FEES 2,242,200 746,300 0 2,988,500 TOTAL REVENUE 4,014,496 1,497,158 515,000 6,026,654 EXPENSES: DIRECT PERSONNEL 2,769,544 880,369 359,016 4,008,930 CONTRACTED SERVICES 155,070 32,086 20,900 208,056 OCCUPANCY 141,579 67 ;970 41 ,450 250,999 CONSUMABLE SUPPLIES 359,000 41,450 30,250 430,700 OTHER 143,448 98,469 19,090 261,007 TOTAL DIRECT EXPENSES 3,568,642 1,120,344 470,707 5,159,692 <I:; INDIRECT -. PERSONNEL 458,559 245,795 ,~o, 700 ' 735,055 CONTRACTED SERVICES 8,679 3,673 .8,700 21,052 OCCUPANCY 18,522 10,250 0 28,772 CONSUMABLE SUPPLIES 17,300 8,550 2,300 28,150 OTHER 35,446 15,686 1,750 52,883 TOTAL INDIRECT EXPENSES . 538,507 283,955 43,450 865,912 TOTAL EXPENSES 4,107,148 1,404,299 514,157 6,025,604 NET OPERATING INCOME (LOSS) Before Depreciation) {92,652 92,859 843 1,050 ~/Cu::-Vt~ '0 Ll .a c ~ill'lf:;lil~:~il~. ~.~ &O~~i~~~j~l~ I Ntl! iil~il. !!i~C'.!. 8 g;.~ 0.. S" ~ I' -I ~)( 5 ,to) ~ i i )( I i IG C5 8 g ,- w · . ::7 · ,to)~. tl 2~ttl. ~ 31l 28 8 !ia; i R3- i I: ~8~i~.O~ ~Ii I i! -;!t~.,to)I~g. OJ. i~ N~li~)(~! I ~ _(,to)~. + ." m .- ... ~ 01 ~ .... N .. j\)- 0 ~ ~ ... ~ 8 ... ... N .. N en . . i i N :.. ~ ! 8 01 ~ i ~ ~ ~ ~. en i = i :s . i I ! .- "n a r ~. .. ~ it ar i. aJn& all 1.1 ,., 1 I ~ 'NELSON. T.' LEWIS' CONSTRUCTION COMPANY, INC. (I LICENSE NO. 195866 GENERAL CONTRACTOR COMMERCIAl. . INDUSIRlAl · RESIDENTIAl. February 9, 2006 Thistlethwaite Architectural Group 355 Bryant Street, Suite 210 San Francisco, CA 94107 ' Fax: (415) 227-9839 AtteDtiOD: Refennee: Subject: Mr. David TIaist1etInvaite AxisHeaItIacare Building Additio. ill Pleasa.toa BaiIdiag Additio. Portio. Oaly Budget Dear Mr. Thistlethwiute: . We are pleased to submit a budget for the building addition portion only of the referenced project {see the attached Exhibit" A j. The same exclusions and clarifications from the last proposal apply to this budget as well. We look forward to discussing our proposal in greater detail. Sincerely, Enclosure ~~~ fEB - 9 ZOO6 GeoffMassa COO cc: Henry Uyehara. Axis Community Health doclbidslaxis healthcare building addition portion only in pleasanton budget #2 25001 O'NeD Avenue · MaIlIng Address P.O. Box 637 · Hayward. CA 94543-0637. · (510) 581-3362 · Fax (510) 727-9171 " BUDGET RECAP EXHIBIT "A" Axis Health building addition - Pleasanton spec # W~C:I 11.e GENERALCCI DITIONS 118 SUPERVISION 117 PUNCH LIST 102 STAKING 208 SOFT DEMOLITION 220 EARTHWORK & PAVING " 250 SITE CONCRETE 300 BUILOINGCONCRETE 550 MISC. · METAL 610 CARPENTRY AND FRAMING 650 CABINETRY no INSULATION 750 ROOFING . ASPHALT SHINGLE no SHEET METAL 790 CAUlKING 810 DOORS. FRAMES &'HARD. 880 GlASS,GLAXING & STORE. 920 LATH & PLASTER 925 DRYWALL 96S FLOORING 990 PAINTING 1052 RREEXnN.&CABINETS 1080 TOIlET ACCESSORIES 154C1 PLUMBING' 1580 HVAC 1650 ELECTRICAl I RARY FENCE INSURANCE FINAL CLEAN-UP PLANS SUB NTL NTL NTL NTL NTL NTL NTL NTL NTL NTL NTL NTL REGMG NTL NTL NTL NTL NAVA NTL NTL NTL NTL NTL NTL NTl NTL NTL NTl NTL NTL SUBTOTAL PERM~ESib15% CONTINGENCY t& 10% BID '''!" , ' 23 BID 17.658 44.935 4,603 2,459 7,750 9.047 2,973 27,299 744 38,437 7.380 2,990 6.196 2,766 744 4.196 1.487 7.930 11,3n 3,073 5,204 520 669 17,on 11,153 15.291 1.239 1.239 794 1,863 259,088 38.880 25.907 323,835 . ' ~ ~~'~~~~~.:'-?'~:'.~~2".~'.:..14 ~~~.~: . "~"';f'.,::-:. .,.....:......~~~. ~ ~ I I , ~:~ j! I I! I f I :11 ~ .; . i i! ~ ! t~ I i I:: .11111 ill ~I ii II n; U~I~~~~~lnti, I; .;..; '~ : ~hr i !! . I ; 1 9 I I. :.1 I J [[ I II ~I . J I I I i , I I . r ! i I 'I .1 .Ii I ---~----------------------------------------- 4.....-::= ~- -- ... 2S ~1~.'IXlIl'-Il',,~llt f.f lilt: 'rlt.:'b~.llI" IIH~lIlal RPo'/Hll" S'".". ' .. The organization may have to use a copy of this return to satisfy state reporting reQullel11ents. A For the 2005 calendar year. or tax ear beginning 7/01 . 2005, and endin 6/30 B Cile<:h ,I ;1\)1,1,(:(,1)18' D Employer Identification Number o A.r.l""oscl',IIiV,; Pi~s~~~~e AXI S COMMUNITY HEALTH, INC. I Ir'liltne'I,(,"g,; ~ir;~~t 4361 RAILROAD AVE., STE 8 ~ 111,1,,11 ,,,llIlI' SP~~ifiC PLEASANTON I CA 94566 - 6652 instruc. Flllflllt..:lIIIU tions. Alllem!eej lellul]. . A",,,,,",,, '''''''''' . S"tion S01 (oX') "goo;",tiO", 00' 4947(,)(1) "'e,,mp1 charitable trusts must attach a completed Schedul e A {Form 990 or 990.EZ). G Web site: ~ WWW.AXISHEALTH. ORG t:, FOfn~90 MT I Go(L... V lIN ,c.. v '- . \",.00"" Return of Organization Exem pt from Income Tax Under section 501(c), 527, or 4947(a)(1)of the Internal Revenue Code . (except black lung benefit trust 0 r private foundation) 94-2232394 E Telephone number OMB No 1545.0047 2005 Open to Public Inspection , 2006 E ~~~~~~ting Ott"'lef f$pe'cllyj IIJo- H ,mdl :lie 11013ppilcable 10 sect,o'l 527 org3/l1z31,ons H (a) Is tillS a g,ollp let",,, lOt "~llIale'?. 0 Yo.s H (b) If 'Yes.' ent", nllllllie,1 01 aHiI"lIes ~ H (C) Are all atf.llales ,"clueled? . (II 'No.' allacll a lis!. See 11151111cllon5.) Organization type (check only one) . . 3'" (mserl no.) K Check here ~ if the organization's gross receipts are normally not 1110re than $25.000. The organization need not file a return with the IR~; but if the organization chooses to ftle a return, be sure to file a complete return. Some states require a complete return. 527 I Group Exemplion Number. .. ~ M Check" if the orgaillzatlon IS not reqUired Gross receipts: Add lines 6b. 8b, 9b, and lOb to line 12.. ~ 6,130,407. to attach Schedule B (Form 990, 990.EZ, or 99Q.PF). Revenue, Ex enses, and Chan es in Net Assets or Fund Balances (See Instructions) Contributions, gifts, grants, and similal,ilmounts received: a Direct public support. . . . . , , . ' . . . . b Indirect public support. . c Government contnbutlons (grants) . . . . . . . .. . . d Total (add lines $ 3 294 057 $ 1a tllrOllgh lc) (cash r" noncash ) . . 2 Program service revenue including government fees and contracts (from Part VII, line 93). , . 3 Membership dues and assessments. . . . . ' . . . , . . . . . . . . 4 Interest on savings and temporary cash investments. , . .. .. .. ... . 5 Dividends and Interest from securities. . . . . . . . , . . . . . . . . . . . . . . 6a Gross rents. . . b Less: rental expenses. . . . . . . . . . c Net rental Income or (loss) (subtract line 6b from line 6a) 7 Other Investment income (describe. . ~ H (d) Is this a separate ,ell"n !tleel by an organization coveled by a glOup luling' 1 a 181,856. 1b 1c 3,112,201. 1d 2 3 4 5 6a 6b R E V E N U E (A) Securjties (B) Other 8 a Gross amount frol11 sales of assets other than, inventory... .......... bLess: cost or other basis and sales expenses. . c Galll or (loss) (attach schedule). . . , . . . . . . . . . . . . . . . . . . d Net gain or (loss) (combine line Bc, columns (A) and (8)) . . 9 Special events and actlvilies (attach schedule). If any amount IS from gaming, check here, a Gross revenue (not including $ of .contributions reported on line 1a). .......... b Less: direct expenses otller than fundraising expenses. c Net Income or (loss) frol11 special events (subtract line 9b from line 9a) . 10 a Gross sales of Inventory, less returns and allowances b Less: cost of goods sold, . c Gross proht or (loss) from sales of Inventory (attach schedule) (subtract IlIle lOb fromlll1e lOa) 11 Other revenue (from Part VII. line 103) . 12 Total revenue (add lines 1 d, 2. 3. 4. 5, 6c. 7. 3d. 9c, 10c. and 11) . 13 Program services (from line 44. column (8)) 14 Management and general (from line 44. column (e)l 15 Fundralslng (from Ime 44. colull1n (D)) 16 Payments to affiliates (attach schedule) 17 Total expenses (add lines 16 and 44, column (A)) . A 18 Excess or (defiCit) for the yeal (subtract line 17 frol11 IlIle 12) N s 19 Net assets or fund balances at beginning of year (from line 73, column (A)). E s T ~ 20 Other changes In net assets or fund balances (attach explanation). s 21 Net assets or fund balances at end of yeal (combine Itnes 18. 19, and 20). BAA For Privacy Act and Paperwork ReductionAct Notice, see the separate instructions. 8a Bb 8c .., . ~O 9a 9b lOa -lOb E X P E N 5 E 5 10c 11 12 13 14 15 16 17 18 19 20 21 SEE STATEMENT.l TEEA0109L 02103/06 [Rj No ONe DYes No 3,294,057. 2,750,905. 3,184. 6c 7 Bd 9c 82/26l. 6,130,407. 5/278,089. 597,469. 5,875,558. 254,B49. 1,300,986. 379,469. 1/935/304. Form 990 (2005) "Form990(20OS) AXIS COMMUNITY HEALTH, INC. 94-2232394 Pa e2 Part II Statement of Fu nctional Expenses AUorganlzallons must complete column (A). Columns (B), (C), and (D) are required for seclion 501 (c)(3) and (4) organizations and section 494 7(a)(1) nonexempt charitable trusts i)llt optional for others Do not Include amounts reported on Ime tA)lotal (8) Program (C) Management (D) Fundraislng 6b. 8b. 9b. lOb, or 16 of Part /. services and general 22 Grant and allucatlon. (all sell) (cash $ non.cash $ ) If thiS amount Includes "'0 foreign grants, check here 22 23 Spec!llc aSSIStance to IncllVlCllIa!s (atl sell) 23 24 Benefits palcl to Oilormenlbers (att sell) 24 25 CompensatIOn of officers, (IireCtors, etc 25 176.975. 176,975. O. O. 26 Otlleu;alarles and wages. 26 2,856,658. 2,363,243. 493,415. 27 . Pension plan contributions. 27 28 Otller employee benefits 28 404,453. 365,735. 38,718. 29 Payroll taxes 29 , 30 Professional fundralslng fees 30 31 Accounting fees. , 31 32 Legal fees. 32 33 Supplies. .. "... 33 no, 841 . 110,502. 339. 34 Telephone. . 34 65,758. 65,758. 35 Postage and shipping. 35 30,434. 30,093. 34l. 36 Occupancy, 36 151,402. 149,122. . 2.280. . . ... . 37 Equipment rental and maintenance. . . 37 118.726. 117,150. 1,576. 38 PrinUngand publications, . . ... , .". . 38 39 Travel. 39 27,544.. 27 269. 275. 40 Conferences, conventions, and meetings. . .. , 40 41 interest . .. ' ",. ,. 41 42 DepreCiation, deple\ion. ete (attach schedule) . 42 140,417. 99,713. 40,704. 43 Other expenses not covered above (itemize): aSEE STATEMENT 2 43a 1 792,350. 1,772,529. 19,82l. ------------------ b 43b ------------------ c 43c ------------------ d 43d ------------------ e 43e ------------------- f 43f ------------------ 9______------------ 43q 44 Total functional expenses. Add lines 22 throu~h 43. (Orgal1lzatlons completing columns (B) . (D , 5,875,558. 5, 278 , 089 . 597,469. O. carry tliese totals to IlI1es 13 . 15) . . . . . . . , '. ' 44 Joint Costs. Check. "'-0 if you are following SOP 98.2. Are any loint costs trom a combined educational campaign and tundralslng solicitation reported in (8) Program services? . . . "'0 Yes IZJ No If 'Yes,'enter (i) the aggregate amount of these joint costs $ ; (ii) the amount allocated to Program services $ ; (Hi) the amount allocated to Management and general $ ; and (iv) tile amount allocated to Fundraislng $ BAA Form 990 (20D5) TEE~.0102L 11101105 "" Form 990 (2005) AXIS COMMUNITY HEALTH, INC. 94-2232394 . Page 3 /Part JIl ' I Statement of Program Service Accomplishments Form 990 IS available for pul)IIC inspection and, for some people, serves as the primary or sole source of Information about a parlicular organlzalion. How the public perceives an organization in SLICh cases may be determined by the information presented on ItS return, Therefore, please make sure the return IS complete and accurate and fully desGrlbes, In Part III, the organization's programs and accomplishments, Wllat IS the organization's prllllary exempt purpose?" SEE STATEMENT 3 Program Service Expenses All organizations must desCllbe their exempt purpose ach1e7ements Tn-a ciear and conCise mahner. State iiie- numbel:-of (Re(~';'~~Z~~:z;?,~I;;:t;:,t'(1 ~lients served, [)ublicatlons Issued, etc. DISCUSS achievements that are not measurable, (S€<ctlon 501 ic)(3) and (4) organ, 4947(a)(1) hllsts I)lll Izatlons ancl 4947(a)(1) nonexempt chaf'ltable trusts mLlst also enter the amount of grants and allocations to others,) opt,on,i1to, Olllm,) aJ~~}1~~~~~~i_________________________________________, ---------------~-------------~------------------------. (Grants and allocations b $ ) If thiS amount Includes foreign grants, check here, ~ 5,278,089. -----~------------------------------~---------------_. c~----------------_--------___________~---------------. ^ .-- . (Grants and allocations $ ) If thiS amount includes forel n grants, check here " ~ c ---------~------------~-------~--.--------------------. (Grants and allocations $ d ) If thts amount includes forei n rants, check here" ~ --~---------------------------------------------------. (Grants and allocatiOnS $ e Other program services. . , . , , , , , ' , (Grants and allocations $ ) If thiS amount inCludes foreign rants, check here., ~ fTotal of Program Service Expenses (should equal line 44, column (8), Program services)""""" BAA ) If this amount includes foreign grants. check here. ~ 5,278,089. Form ~90 (2005) TEEI',0103L 10/\4!05 . L Form 990 (2005) AXIS COMMUNITY HEALTH, INC. [Part IV . I Balance Sheets (See Instructions) 94-2232394 Page 4 Note: Where reqwred, attached schedules and amounts within the descflption (A) (8) column should be for end.of.year amolmts only. Beginning of year Enel of year 45 Cash - non'lnterest.beanng, 171,684. 45 269,116. 46 Savings and temporary cash Investments, ' 446,453. 46 337 , 0 3 0 . 47 a Accounts receivable, 47a 970,414. b Less: allowance for doubtful accounts, 47b 252,767. 471,338. 47c 717,647. 48a Pledges receivable 48a b Less: allowance for doubtful accounts, 48b ~ 48c 49 Grants receivable, .... . .,. . 137,886. 49 320,310. A 50 Receivables from officers, directors, trustees, and key s employees (attach schedule) , . . . . . . .. 1~1 al .... . 50 s E 51 a Other notes & loans receivable (attach sch). . . . . . T S b Less: allowance for doubtful accounts. . . . '." . 51 b 51 c 52 InventOries for sale or use. . . , ' .... . . .'. .. , ... . .... . .... . ,.., '.. 52 53 Prepaid expenses and deferred charges, , ' , . .... . ...... . ,. . 3,700. 53 9,568. 54 Investments - securities (attach schedule) . . , ' ... . ~O CastO FMV 54 5Sa Investments - land, buildings, & equipment: basis 5Sa bLess: accumulated depreciation (attach schedule) , '" . .... . . , , . . .'. ,. , '. . 55b 55c 56 Investments - other (attach schedule) . . , . .,....., . ....' . " . """"'" . " -, 56 57a Land, buildings, and equipment: basis., . . . . . '. , 57a 3,011,490. b Less: accumulated depreciation 1,309,016. 1,456,660. 1,702,,474. (attach schedule) ,. .",.... S.TATEMENT. ' 5 , 57b 57c 58 Other assets (describe .. ).. 58 59 Total assets (must equal line 74). Add lines 45 through 58 , ' . . , . . . . . . . . .' , . , . . 2,687, 721. 59 3,356,145. 60 Accounts payable and accrued expenses. ' . , ".,..,.,. ..., ....... ., ,.., . 650,207. 60 676,439. L 61 Grants payable. .. ..",.... ,..... . , . . . , . . .. , ,.., . .., . ..,. . ..,.. ,- 61 I A 62 Deferred revenue, ... . .,.....,.. . ,....-. . ...,. . ,.. , . , . , . , .. . ,.." . '. ,. , 62 B I 63 Loans from officers, directors, trustees, and key employees (attach schedule), . . . , ' ...., , ... ,... 63 L I 64a Tax-exempt bond liabilities (attach schedule) , .., , ' .' .,. . ....,. , " , 64a T 710,325. 718,199, I b Mortgages and other notes payable (attach schedule). . .SEE, STATEMENT .6.. ., .. 64b E 26,203. s 65 Other liabilities (describe .., SEE STATEMENT 7 ). 65 26,203. .. , 66 Total liabilities. Add lines 60 through 65. . , ." . .. ., ... , ..... . ,. , 1,386,735. 66 1,420,84l. N Organizatiol1s-.that follow SFAS 117, check here .. " ~ and complete lines 67 E through 69 and lines 73 and 74. T A 67 Unrestricted. . .... ..,... . .",... , ,. , ....... . .., ,., . , , . . . . . . , , , . , .. 1,300,986. 67 1,885,304. ~ 68 Temporarily restricted, ....... . . , . . . . . . . . . , . . . ... . .,. . ,.", . .... . 68 50,000. E T 69 Permanently restricted, . . ' , . .. . ......,. , ..... ,. . . '. . "", , .. ' ., . 69 s 0 Organizations that do not follow SFAS 117, check here .. o and complete lines R F' 70 through 74, u 70 Capital stock, trust pl'lncipal, or current funds, 70 N . . . . . 0 71 Paid-in or capital surplus. or land. building. and equipment fLlnd 71 B ' . A 72 Retained earnings. endowment. accumulated income, or other funds 72 L ..., . A' N 73 Total net assets orfund balances (add lines 67 through 69 or lines 70 through c 1,935,304. E 72: column (A) must equal line 19: column (B) must equal line 21) , 1,300,986. 73 s 74 Total liabilities and net assets/fund balances. Add lines 66 and 73. " 2,687,721. 74 3,356,145. ~~ BAA Form 990 (2005) TEEAO1 04L 10l17i05 .I. Form 990 (2005) AXIS COMMUNITY 'HEALTH, INC. 94-2232394 IPartIV.A IRecondliation of Revenue per Audited Financial Statements with Revenue perReturn (See instructions.) , , . Page 5 a Total revenue; gallls. and other support per audited financial statements b Amounts Included on line a but not on Part I. IlIle 12: 1 Net unrealized gains on Investments, . 2Donatecl servlces'and use of facilities. 3 Recoveries of prior year grants 4 Ottler(speclfy): a 6,130,407. bl b2 b3 - - - - - - - - - -.- - - - - - -. - - - - - - -.-.~. ,- - - - b4 c d Add'1tne~.bl through b4.. Subtract line b from line a . Amounts Included on Part I ,line 12, but not on line a: 1 Investment expenses not Included on Part I ,line 6b . 20ther (specify) b c 6,130,407. dl d2 d ~ e 6,130,407. er Return a Total expenses and losses per audited finanCial statements. bAmounts included on line a but not on Part I, line 17: 1 Donated sel'vices and use of facilities. . . . . . . . , . b 1 2Prior year adjustments reported on Part I, line 20. . b2 3Losses reported on Part I, line 20.. b3 40ther (specify): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ a 5,875,558. --~--~-----------------------~'-------- b4 Add lines bl through b4. , . . . , . . . . . . c Subtract line b from line a , . . . . . . . ' . . . . . d Amounts included on Part I, line 17, but not on line a: 1 Investment expenses not included on Part I, line 6b. . 20ther (specify): b c 5,875,558. dl --------------------~~---------------- d2 Add lines dl and d2. . . . . . . . . . . . . . . . . ' . .. . . . . . . . . . . . d Total ex enses (Part I, line 17). Add lines c and d..............,..... .....,....,............... ~ e 5,875,558. Part V-A Current Officers, Directors, Trustees, and Key Employees (List each person who was an officer, director, trustee, or key employee at any time during the year even If they were, not compensated.) (See the instructions.) (8) Title and average hours (C) Compensalron (0) Contflbutions to (E) Expense per week devoted (if not paid, employee benefit account and other to positron enter -0-) plans and deferred allowances compensation plans (A) Name and address SEE STATEMENT 8 176,975. 1,373. o. BAA TEEA0105L 10/17/05 Form 990 (2005) . ; i, Form 990 (2005) AXIS COMMUNITY HEALTH, INC. Part V-A Current Officers, Directors, Trustees, and Ke Em 10 ees (continLled! .75aEnler the totJI num/Jerol officers, cilrectors, ami trustees permitted to vote on org3111ZJII011 I)uslness as boanl meetll1gs. ~ J.~ _ _ _ _ _ _ _ __ b Are any officers, directors, trustees, or key employees listed m Form 990, Part V.A, or Ilighest compensated employees listed In Schedule A, Part I, or hlgllest compensated profeSSional andothel Independent contractors listed In Schedule A, Part II.A or 11.8, related to each other thl'ough family or bUSiness relalionshlps? If 'Yes,' attacll a statement that Identifies tile IndiViduals and explainS the relatlonshlp(s), c Do any officers, clirectors, trustees, or key employees listed tr1 form 990, Part V.A, or highest compensated employees listed In Schedule A, Part I, 01 ~lIghest compensated professional and other Inclependent contractors listed In Schedule A, Part II.A or 11.8, receive compensation from any other organizations, whetller tax exempt 01 taxable, that are related to this organization through common superVISion or common control? . ,. .. , Note. Related organizations Include section 509(a)(3) supporting organizations, If 'Yes,' attach a statement that identifies the IndiViduals, explainS the relationship between tillS organization and the other organlzation(s), and descnbes the compensatIOn arrangements, Including amounts paid to each indiVidual by each related organizatIOn d Does the or anlzal10n have a written conflict of Interest policy? . , 75d X Part V-B Former Officers, Directors, Trustees, and Key Employees That Received Compensation or Other Benefits (If any former officer, director, trustee, or key employee received compensation or other benefits (deSCribed below) during, the year, list that person below and enter the amount of compensation or other benefits In the appropriate column, See the Instructions,) 94-2232394 Page 6 Yes No 75b X. 75c x (A) Name and address " (B) Loans and Advances (C) Compensation (0) Contributions to employee benefit plans and deferred compensation plans O. (E) Expense account and other allowances NONE ------------------------ o. o. o. ----------------------~- . ' , ,~:-. , -------~------~--------- , "Part VI I Other Information (See the instructions.) 80 a Is the organizalion related (other than by association With a stateWide or nalionwide organization) through common membership, governing bodies, trustees, officers, etc, to any other exempt or nonexempt organization? b If 'Yes,' ef1ter the name of the organization ~~LA_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ and clleck whether It IS D exempt or 0 nonexempt. 81 a Enter dllect and Irldll'eel political expenditures, (See line 81 Instructions.), . . ..1 81 al 0 . b Old the olganlzallon file Form 1120-POL for this year? . .. . , 81 b X I Yes No 76 X I 77 X I 78a X I 78b N A I 79 X I 80a xl 76 Did tbl; organization engage in any activity not previously reported to the IRS? If 'Yes,' attach a detailed description of each activity. . . . , , , , , , , ' , , . . , , , , . . . . . , ,. ",. . . , , , . , , , n Were any changes made in the organiZing or governing documents but not reported to the IRS?, ,. ,',"" . , . If 'Yes,' attach a conformed copy of the changes. 78a Did the organization have unrelated busllless gross income of $1 ,000 or more during the year covered by this return? . b If 'Yes,' has It filed a tax return on Form 990-T for this year? . .. .."".."""."."".,. . , 79 Was there a liquidation, . dissolution, termination, or substaRtlal contractIOn during the year? If 'Yes,' attach a statement. , , . . . . , . BAA Form 990 (2005) TEEAO 1 O&L 11103105 94-2232394 B2 a Old the organization receive clonated services or the use of malenals, equipment, or tacilitles at no charge or at , substantially less than tail' rental value?, , " , , , " , , ,,' " "" " """,', , , " " ' , b It 'Yes,' you may Indicate the ,value of these Items here, Do not Inclucle this all10unt as revenue In Part I or as an expense tn Part II (See Instrucltons In Part III,) B2b 83 a Old the organlzalion comply with the public inspection requirements tor reiurns ami exemption applications? b Old tile organization comply With the'.$tsclosLlre I'equlrements relating to quid pi 0 quo contnbutlons? B4a Old the organization SOliCit any contnbutlons or gifts that were not tax deductible? b If 'Yes,' did the ol~anlzatlon Include With every soliCitation an express statement that such contribLJtlons or gifts were not tax deductible, "", ,,"", , ", " '" ", ",' ,,', " , ' """ " "" ' , , 85 501 (c)(4) , (5), or (6) organizations, a Were substariliallyall dues nondeductible by members?" ",J.i< b Old the organrzation make only tn.house 10bbYln'gexpenditures ot $2,000 or less? If 'Yes' was answered to either 85a or 85b, do not complete 85c tllrough 85h below unless the organizatIOn received a waiver tor proxy tax owed for the prior year, ' Page 7 Yes No 82a x N/A 83a X 83 b N A 84a X 84b N A 8Sa N A 8Sb N A 'c Dues, assessments, and similar amounts trom members, 85e d Section 162(e) lobbYing and political expenditures, 8Sd e Aggregate nondeduc\.\J:lle amOLlnt of section 6033(e)(1)(A) dues notices" ' , , , " , , , , , 85e f Taxable amount of lobbying and political expenditures (line 85d less 85e) 85f 9 Does the organization elect to pay the section 6033(e) tax on the amount on line 85P , h If section 6033(e)(1 )(A) dues nottces were sent, does the organization agree to adcl the amount on line 8S! to Its reasonable estimate of dues allocable 10 nondeductible lobbYing and political expenditures for the follOWing tax year?, , . 86 501 (c)(7) organizations, Enter: a Iniliation fees and C'spitalcontribulions included on line 12 , , , " , , . , , . " ., , , , " . , , , , , " , , , , . " , , , 86a b Gross receipts, included on line 12, for public use of club facilities.". 8Gb 87 501 (c) (7 2) organizations, Enter: a Gross income from members or shareholders, 87 a b Gross income from other sources, (Do not net amounts~e or paid to other sources against amounts due or received from them,} " " , , , , . , , , ,. 87b N/A 88 At any time during the year, did the organization own a 50% or greater interest in a taxable corporation or partnership, or an entity disregarded as 'separate from the organization under Regulations sections 301.7701-2 and 301.7701-37 If 'Yes,'complete Part IX. . . , , , , , , . . 88 X 89l! SOl (c)(3) organizations, Enter: Amount of tax imposed on the organization during the year under: section 4911 .._________.Q.:... ; section 4912" _________.9~ ; section4955.._________.9~ b 501 (c)(3) and 507 (c)(4) organizations, Did the organization engage in any seclion4958 excess benefit transaction during the year or did it become ,aware of an excess benefit transaction from a prior year? If 'Yes,' attach a statement explaining each transaction, , , . . , . , . . , , , , , , . , , ' . , . . , ., ,."".,'.,'.""",..,."",.",.".."""...."...'..,'. 89 b X, c Enter: Amount of tax Imposed on the organization managers or disqualified persons during the year under sections 4912,4955, and 4958"" "",.""",.,.. ,. ., ,. ."',..",.".", d Enter: Amount of tax on line 89c, above, reimbursed by the organization, :' 90 a List the states with which a copy of this return is filed" CA. , b Number of employees employed In the pay period thahntiud~ 'M;rCh 12: 2005($; in;t~ct,~n;,)~ ~ ~ ~.~ ,-.~.~.~ .~-1-90 b1- - -"84" 91 a The books are In care of .. _Rl'Ih. ,!.~W_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _.. Telephone number" J.? ~- J.Q!' -_6.9 ~ 7_ _ _ _ _ _ __ 'Located at .. 31~1_ MI_LBQ@_~VJ:l.JlIE..!_~T_L~,_f~E_A~~N.JQ!i J!:_ _ _ _ _ _ ____.. ZIP + 4 .. Jlj~6_6.:~652 Yes No X ... ... b At any time during the calendar year, did the organization have an Interest III or a signatLlre or other authority over a financial account in a foreign country (such as a bank account. securities account. or other financial account)?, , . , , ' , If 'Yes,' enter the name of the foreign country. " ... _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ __ _ _ _ _ __ _ _ _ __ See the Instructions for exceptions and filing requirements tor Form TO F 90-22.1, Report of Foreign Bank and Financial Statements c At any tllne during the calendar year, did the organization mallltain an office outside of the United States? If 'Yes,' enter the name ot the foreign country., ... _ _ _ _ _ _ _ _ _ _ ~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 92 SectIOn 4947(a)(I) nonexempt chao table trusts filing Form 990 In lieu of Form 7047 -Check here, and enter the amount of tax-exempt Interest received or accrued dUring the tax year. , ' ,;.: 92 BAA TEEA0107L 02103/06 N/A N/A N/A N/A 85 N A 8Sh N A N/A N/A N/A o. o. 91 b 91 e X N/A "'0 N/A Form 990 (2005) AXIS COMMUNITY HEALTH INC. 94-2232394 Part I Compensation of the Five Highest Paid Employees Other Than Officers, Directors, and Trustees (See Instructions. List each one. If there are none, enter 'None.') (a) Name and address of each (b) Title and average employee pcud more hours per week than $50.000 devoted to position 4; SCHEDULE A (Form 990 or 990.EZ) Organization Exempt Under Section 501 (c)(3) (Except Private Foundation) and Section 501 (e), 501(1), sOl(k), 501(n), or 4947(a)(1) Nonexempt Charitable Trust Supplementary Information - (See separate instructions.) .. MUST be completed by the above organizations and attached to their Form 990 or 990.EZ. c.'~,:p(tl\llh~n( 01 lIh.' Tf'::':l:i.tilv lid6/1\;-11 Re....enllc St:'l \lILe ' Ni1U1C (,I.th€: ',)1 gi:ifllZiiltOl1 Employe, identification number (c) Compensation (d) Contributions to employee tJeneflt plans ami deferred compensation _~E~_~T~t~M~~~l~____________ 432,225. 18,694. Total number of other employees paid over $50.000. . , , . , , , . . , , . . . , . , . . . .. ;. ~ 11 Part II - A Compensation of the Five Highest Paid Independent Contractors for Professional Services (See instructions, List each one (whether individuals or firms). If there are none. enter 'N9nEii.J (il) Name and address of each independent contractor paid more than $50,000 (b) TYI"e of service JBI~~L~Y_~~~~~~~OQt~l~~__________________ 1133 EAST STANLEY # 205 LIVERMORE, CA 94550 MEDICAL SERVICES OMS No 1545.0047 2005 (e) Expense account and other allowances o. (c) COlJJpensation 77,000. Total number of others receiving over $50.000 for professional services. . . . ~ 0 Part II '- B Compensation of the Five Highest Paid Independent Contractors for Other Services (List each contractor who performed services other than professional services" whether individuals or firms. If there are none. enter 'None,' See instructions.) (a) Name and address of each Independent contractor paid more than $50.000 (b) Type of service jJ..9~E_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Total number of olller contractors recel\lIng over $50.000 for other services . ~ 0 BAA For Paperwork Reduction Act Notice, see the Instructions for Form 990 and Form 990.EZ. (c) Compensation TEEA0401 L OSi09105 Schedule A (Form 990 or 990.EZ) 2005 Schedule A (Form 990 or 990-EZ) 2005 AXIS COMMUNITY HEALTH, INC_ lpart III I Statements About Activities (See instructions.) 94-2232394 OWing the year has the organization attempted to Influence national. state. or localleglslalion. including any attempt to Influence public opinIon on a legislative matter or referendum? If 'Yes,' enter the total expenses palel or Incurred In connection with the lobbYing activitIes. ~$ N I A (Must equal amounts on lIne 38. ParlVI-A, or line i of Part VI-B.) Organizations thatmacle an electIon under sectIon 501 (h) by ftllng Form 5758 must complete Part VI-A. Other organizations checking 'Yes' must complete Part VI-B AND attach a statement giving a detatled desCtlptlon of tile lobbYIng actiVities. ' 2 During the year. has Ule organization. either elllecUy 01 IndllecUy, engagecllll any of the follOWing acts W.lUl any substantial contril)utors. Irustees, directors. officers, creators. key employees. or members of their famtlles, or with any taxable organizatIOn wllh which any SUCll pel:son is afftllated as an officer. director. trustee, malorlty owner. or pllnclpal beneficiary? (If the answer to any question is 'Yes.' attach a detifill/ed statement explainmg the tr?Jnsactions.) a Sale. exchange. or leaSing of pl'operty? ' 2a 2b 2c 2d X 2e . 3a 3b 3c 4a 4b b Lending of money 01 other extension of credit?, c Furnishing of goods, serVices, or facilities? SEE FORM 990, PART V d Payment of compensation (or payment or reimbursement of expenses if more than $1 ,OOO)?, . e Transfer of any part of ItS income Or assets?, ., , .. . . . .. . . 3a Do you make grants for scholarships, fellowships, student loans, etc? (If 'Yes,' attach an explanation of how you determine that recipients qualify to receivep<ayments,). b Do you have a section 403(b) annuity plan for your employees? . . . . c Dunng the year, did the organizalion receive a contnbution of qualified real property interest under section 170(h)? . . 4a Did you maintain any separate account for participating donors where donors have the right to prOVide "dvice on the use or distribution of funds? . . . . , .' . . . . . . . . . . b Do you provide credit counseling, debt management, credit repair, or debt n oliation services.? . I Part IV l Reasonfor Non-Private Foundation Status (See, instructions.) Pa e 2 Yes No x x x X x x X X X X The organization is not a pnvate foundation because it is: (Please check only ONE applicabte box.) 5 ~ A church, convention of churches, or associatIon of churches.. Section l70(b)(1 )(A)(i). 6 A school. SectIon 170(b)(1 )(A)(ii). (Also complete Part V.) 7' A hospital or a cooperative hospital service organization. Section 170(b)(1 )(A)(iii). . 8 A Federal, state, or local government or governmental unit. Section 170(b)(1 )(A)(v). 9 A m,di" , "",,,h "g,,'z,',oo op,,,,,d '0 "o,UOO"oo wilh, ho'pit" 'Seo"dn 170(b)(l )(A)(I"). Eo',dh, Ii"p""" nom" O'ly, and state ~ , 10 0 An organizatio; ;P~-~ed fo~the-b-;n~fii bf~ ~oli;g; ~ ~~v;r;;ty ;;-w-;;d ~;-op;ated by-a g;;-v;r~;e~t;j ~nit-S-;cti;-; 7O(b)(l~(A)0v). (Also complete the Support Schedule in Part IV-A.) 11 a ~ An organization that normally receives a substanlial part of ItS support from a governmental unit or from the general public. Section 170(b)(1)(A)(vi). (Also complete the Support Schedule in Part IV-A.) ,11 bOA community trust. Seclion 170(b)(1)(A)(vi). (Also complete the Support Schedule In Part IV-A.) 12 0 An organization that normally receives: (1) more than 33-113% of ItS support from contributions, memberShip fees, and gross receipts from activities related to its chal'ltable, etc, functions - subject to c,ertalll exceptions, and (2) no more than 33-1/3% of Its support from gross investment Income and unrelated bUSiness taxable IIlcome (less secllon 511 tax) from businesses acquired by the organization after JLJIle 30, 1,975. See section 509(a)(2). (Also complete the Supp.ort Schedule In Part IV-A.) 13 ,0 An organization that is not controlled by any disqualified persons (other than foundation managers) and supports organizations descl'lbedin: (1) Irnes 5 through 12 above; or (2) section 501 (c) (4) , (5). or (5), ,if they meet the test of section 509(a)(2). Check the box tl1at describes the type of supporting organization: .. 0 Type 1 o Type 2 nType 3 _ Provide the following mformatlon about the supported organizations. (See Instructions.) (a) Name(s) of supported olganlzatlon(s) (b) Line number from above 14 BAA n " ' I I An organizatIon organized and operated to test tOI public safety. Section 509(a)(4) (See instructions.) TEEA0402L OSf09i05 Schedule A (Form 990 or Form 990-EZ) 2005 19 Net Income from unrelated business activities not Included In line 18. . 20 Tax revenues levied for the QrganizatiQn's benefit and erther pa~tQitor expended Qn its behalf, ., . . , . . . .. ... 21 The value Qf services or facilities furnished to the organization by a governmental . unit withQut charge. Do nQt include the value Qf services Qr facilities generally furnished to the public without charge. . . 22 Other income. Attach a schedule. DQ nQt include gain or (loss) from sale of Capital assets SEE. STMT..1.1 65,489. 2,138. 1,002. 23 TQtaloflines15throu h22.. 5,336,943. 4,492,849. 5,346,066. 24 Line 23 minus line 17.. 2,999,725. 2,301,545. 2,724,297. 25 E'nter1%ofline23. 53,369. 44,928. 53,461. 26 Organizations described on lines 10 or 11: a Enter 2% of amount in column (e), line 24. . . . . . . . b Prepare a list for your records to show the name of and amount contributed by each person (other than. a governmental unit or publicly supported organizatIOn) whose total gifts 101',2001 through 2004 exceeded the amount shown in line 26a, Do not file this list with your return. Enter the total of all these excess amounts. . . ~ 26 b c Total support for sectiQn 509(a)(1) test: Enter line 24, column (e). . . . . . . . . . . . ~ 26c 10, 865, 973. d Add: Amounts from column (e) for lines: 18 14,395. 19 22 92, 8 5 9 . 26 b e Public support (line 26c minus line 26d total) . . . f Public su ort ercenta e line 26e (numerator) divided b line 26c (denominator)) . 27 Organizations described on line 12: N/ A a For amounts included in lines 15,16, and 17 that were received from a 'disqualified person,' prepare a list for your records to show the name of, and total amounts received in each year from, each 'disqualified person.' Do not file this list with your return. Enter the sum of such amounts for each year: (2004) _ _ _ _ _ _ _ _ _ _ _ _ (2003) _ _ _ _ _ _ _ _ _ _ _ _ (2002) _ _ _ _ _ _ _ _ _ _ _ _ (2001) _ _ _ _ _ _ _ _ _ _ _ __ bFaI' any amollnt included In line 17 that was received from each person (other !llan 'disqualified persons'), prepare a list for your records to show the name of, and amount received fOl each year, tliat was more than the larger of (1) the amount on line 25 for the year or (2) $5,000. (Include in the list organizalionsdescribed In lines 5 lhrougll 11 b, as well as Individuals.) Do not file this list with your return. After computlllg tile difference between the amount received and the larger amount described In (1) or (2), entel' the sum of these differences (the excess amounts) .for each year: (2004) _ _ _ _ _ _ _ _ _ _ _ _ (2003) _ _ _ _ _ _ _ _ _ _ _ _ (2002) _ _ _ _ _ _ _ _ _ _ _ _ (2001) _ _ _ _ _ _ _ _ _ _ _ _ _ c Add: Amounts from column (e) for lines: 15 17 20 Schedule A (Form 990 or 990,EZ) 2005 AXIS COMMUNITY HEALTH, INC, 94-2232394 IPartlV-A ISupport Schedule (Complete only ifyoLl checked a box on line 10,11. or 12.) Usecashmethodolaccounting, Note: 'y'ou 1113 use the worksheet In the instructIOns for convertlf1Q from the accrual to the cash method of accounting. Calendar year (or fiscal year (a) (b) (c) (d) beginning in). .. .... . . ~ 2004 2003 2002 2001 15 GiftS. grants. and contributions received, (Do not Include unusual grants. See line 28,) . 16 Memberslllpfees received. 2,932,147. 2,815,793. 2,299,124. 2,711,655. 17 Gr05s receipts tram admiSSions, mercllanchse sold or services per/ollnecl, or furnishing 01 faCilities In any activity that IS relatecl to tile organization's cllarltable, etc, purpose. 18 Gross IIlcome from Interest. diVidends, amounts received from payments on seCUi'ltles loans (section 512(a)(5)), rents, royalties, and llnrelated bUSIl1es5 taxable Income (less section 511 taxes) from busl/lesses acquired by the organ, Izatlon after JllWif30, 1975. 2,337,218. 2,191,304. 2,621,769. 1,652,001. 11,640. 383. 2,089. 283. 24,230. 4,492,407. 2,840 406. 44,924. ~ 26a 26d ~ 26e ~ 26f 16 21 27c 27d ~ 27e and line 27b total. . Page 3 (e) Total 1 0 , '7 58, 71 9 . 0, 8,802,292. 14,395. o. o. o. 92, 859. 19,668,265. 10,865,973. 217,319. 107,254. 10,758,719. 99.01 % ,d Add: Line 27a total e Public support (line 27c total IT1I1lUS line 27d total). f Total support for section 509(a)(2) test: Enter amount from line 23, column (e). .. ~27f 9 Public support percentage (line 27e (numerator) divided byline 27f (denominator)). . ~ 27 % h Investment income ercenta e (line 18, column (e) (numerator) divided b line 271 (denominator ~ 27h % 28 Unusual Grants: For an organization described In hne 10, 11, or 1.2 that received any unusual grants during 2001 through 2004, prepare a list for YOllr records to show. fOl each year. the name of the contributor, the date and amount of the grant. and a brief description of the nature of tile grant Do not file this list with your return. Do not Include tllese grants In line 15. BAA TEEA0403L 02/03.'06 Schedule A (Form 990 or 990.EZ) 2005 ~ Schedule A (Form 990 or 990-EZ) 2005 AXIS COMMUNITY HEALTH, I NC. Private School Questionnaire (See instructions,) (To be completed ONLY by schools that checked the box on line 6 in Part IV) 94-2232394 Page 4 N/A Yes No 29 Does tile organization have a raCially nondiscriminatory policy toward stu dents by statement in its charter, bylaws, other goverlllng I/lstrument. or in a resolution of Its governing I)ocly?, , ", " , , ' ,',',' ' , 29 30 Does the organization Include a statement of Its raCially nondiSCrIminatory pOlicy toward students In all ItS l)rocl'1ures, catalogues, anel othel written communications With the public dealing With student admiSSions, programs. and scholarsl'1lps? , 30 31 Has tI'1e orgal'1lzation publlclzecl Its raCially nondlscl'lmlnatory pOlicy through newspaper or broadcast media during the pellodotsolicltatlon tor students. or during the registration pel'lod if It has no soliCitation program, in a way that makes the policy known to all parts of the general community It serves? , 31 If 'Yes,' please describe; if 'No,' please explain, (It you need more space. attach a separate statement.) --------------------------------------------------------- -------------------------------------.-------------------- --------------------------------------------------------- ------------------------------------------_._~------------ 32 Does the organization maintain the follOWing; a Records indlcatmg the raCial composition of the student body, tawlty, and administrative staff? . . b Records documenting that scholarships and other financial assistance are awarded on a racially nondiscriminatory basis?, , , . , , , ' ." , ' . , . , , . . . ' . , " ' , , , , , , , . . c Copies of all catalogues, brochures, announcements, and other written communications to the public dealing with student admiSSions. programs, and scholarships? , , ' d Copies of all material used by the organization or on Its behalf to solicit contributions?, . 32a 32b 32c 32d .,;,.:;~, If you answered 'No' to any of the above. please explain. (If you need more space, attach a separate statement.) --------------------------------------------------------- -----~--------------------------------------------------- 33 Does the organization discriminate by race In any way with respect to: a Students' rights or privileges? , . 33a b Admissions policies? , , 33b c Employment of faculty or admllllstratlve staff?, 33c d Scholarships or other finanCial assistance? 'y, 33d e Educational policies?, , ' 33e fUse oUacilities? , . 33f 9 AthletiC programs? ' 33 h Other extracurriculcll activities?, 33h If you answered 'Yes' 10 any ot the above, please explain, (It you need more space, attach a separate statement.) --------------------------------------------------------- ----------------------------------'----------------------- ----------------------------------.----------------------- 34 a Does the organization receive any finanCial aid or assistance from a governmental agency?, , 34a b Has Ille organization's right to such aid ever been revoked or suspended? , It you answered 'Yes' to either 34a or b, please explain using an attached statement 34b 35 Does the organlza110n certify that It has complied With the applicable requirements of sections 4.01 tI'1rou~lh 4.05 of Rev Proc 75.50, 1975-2 C,B, 587. covering raCial nondisCl'lmlnatlon? It 'No,' attach an explanation.., BAA TE E.l\0404L 08/08/05 35 Schedule A (Form 990 or 990-EZ) 2005 , , Schedule A (Form 990 or 990.EZ) 2005 AXIS COMMUNITY HEALTH, INC. lPart VI.A I Lobbying Expenditures by Electing Public Charities (See Instructions,) (To be completeej ONLY by an eligible organizatIOn that filed For m 57(8) N I A anlzallon belon s to an affiliated group, Check ~ b if you cllecked 'a' and '1IInlted control' provIsions appl (a) (b) Afflliatecl group To be completed totals for ALL electing or anizatlons 94-2232394 Page 5 Check ~ a Limits on Lobbying Expenditures (The term 'expenditures' Illeans amounts paid 01 Incurred.) 36 Total lobbylflg expenditures to Iflfluence publiC opinion (grassroots lobbYing) 37 Total lobbYing expenditures to Influence a legislative bocly (dllect 10lJbYlng) 38 TotallobbYlngexpendl\LJres (add lines 35 and 37) 39 Other exempt p~1 pose expenditures. 40 Total exempt purpose expenditures (add lines 38 and 39) 41 Lobbying nontaxable amount. Enter the amount from the follOWing table If the amount on line 40 is - The lobbying nontaxable amount is - Not over $500,000 . . , ., 20% of the amount on line 40, , . ., a Over $500,000 but not over $1,000,000. .,. $100,000 plus 15% of tlle excess over $500,000 0'" 11 ,,,",1)00 001 "" ow 11,500,000 . . . . .. $175,000 plo; 10% ollh""~' '""II ,000,,," Over $1,500,000 but not over $17,000,000, "" $225,000 plus 5% oftl1e excess over $1,500,000 Over $17,000,000. . . . , " $1,000,000"..,...."..., .,.,... 42 Grassroots nontaxable amount (en1er 25% of line 41) 43 S.ubtract line 42 from line 35, Enter .0. if line .42 IS more than line 36. , . 44 Subtract line 41 from line 38, Enter -0- if line 41 is more than line 38. . Caution: If there is an amount on either line 43 or line 44, you must file Form 4720, 4 -Year Averaging Period Under Section 501(h) (Some organizations that made a section 501(h) election do not have to complete all of the five columns below, 'See the instructions for lines 45 through 50.) 36 37 38 39 40 41 42 43 44 LObbying Expenditures During 4 .Year Averaging Period Calendar year (a) (b) (c) (d) (e) (or fiscal year 2005 2004 2003 2002 Total beginning in) ~ 45 LobbYing nontaxable amount, , . . , 46 LobbYl!1g ceiling amount (150% of line 45(e)), 47 Total lobbying ex enditures..., 48 Grassroots non. taxable amount. , 49 Grassroots ceiling amount (150% oLllne 48(e)) , ' 50 Grassroots lobbying expenditures. Rart VI.B Lobbying Activity by Nonelecting Public Charities (For reporting only by organizations that did not complete Part VI-A) (See instructions.) During the year, did the organization attempt to influence national, state or local legislation, including any attempt to Influence public opinion on a legislative matter or referendum, through tile use of: a Volunteers. bPald staff or management (Include compensalion In expenses reported on lines c through h,) c Media advertisements d Mailings to members, legislators, or the public. e Publications, or published or broadcast statements. f Grants to other organizations for 101)I)Ylllg purposes. , ' g Direct contact wilh legislators. tllelr staffs. ,government offiCials, or a legislative body. h R<'lllies. clemonstratlons. seminars, conventions, speeches, lectures. or any other means i TotallolJbYll1g expendltLJreS (add IlI1es c through h.) Ii 'Yes' to any Gf tl-Ie above. also attach a statement giving a detailed descl'lptlon of the lobbYIl1Q activities. N/A Yes No Amount BAA Schedule A (Form 990 or 990.EZ) 2005 TEEA0405L 08/08105 ( I Schedule A (Form 990 or 990.EZ) 2005 AXIS COMMUNITY HEALTH, INC. 94 - 22 32 3 94 Information Regarding Transfers To and Transactions and Relationships With Noncharitable Exempt Organizations (See instructions) 51 Dlel the reporting organization directly or Indirectly engage III any of the following with any other organization described In section 501 (c) of the Code (other than section 501 (c)(3) organizations) or- In sechon 527, relating to political organizatIOns? a Transfers from the reporting organization to a noncharltal)le exempt organization of Yes No (i) Cash 51 a (i) X (ii)Other assets a (ii) X b Other transactIOns: (i) Sales or excllanges of assets with a noncharitable exempt organizatIOn, b i) . X (ii)Pwchases of assets from a nonchantable exempt organization b (ii) X . (iii)Rental of facilities, equipment. or other assets b (iii X, . (iv)Rellnbursement arrangements. b (iv) X (v)Loans or loan guarantees, b (v) X (vi)Pedormance of services or membership or fundralslng solicitations. ' b (vi) X c Sharing of facilities. equipment, mailing lists, other assets, or paid employees. , c X d If the answer to any of the above IS 'Yes,' complete the following schedule. Column (b) should always show the fem market value of the goods, other assets, or services given by thereportlng organization. If the organization received less than fair market value In any transaction or shal'lng arran ement, show In column (d) the value of the 0005. other assets. or services received: 00 M ' ~ ' ' ~ Line no. Amount Involved Name of nonchantable exempt organization Descrtptl~n of transfers, transactrons, and sharing arrangements Page 6 N/ 52 a 15 theorganlzation directly or indirectly affiliated with, or .related to, one or more tax :exBmpl organizations descl'lbed in section 501 (c) of the Code (other than section 501 (c)(3)) or In section 527?, . . . . . . . . . . . . . . . . ' Ii If. 'Yes,' com lete the followin SChedule: (a) Name of organization .. ... 0 Yes rKI No (b) Type of organization (c) Descnplion of relationship N/A BAA Schedule A (Form 990 or 990EZ) 2005 TEEA0406L 08108;05 J t. Schedule B (Form 990, 990-EZ. Or 990.PF) OMS No. 1545.0047 Schedule of Contributors Dcp(iltlllellt nt t1k~ Tte,1'i>lHY lliiL~I.llal R.;vel)1I0 SelVlli! Supplementary Information for line 1 of Form 99{l~,990.EZ and 990.PF (see instructions) 2005 Name of organization Employer identification number AXIS COMMUNITY HEALTH, INC. Organization type (check one) Filers of: Form 990 or 990.[Z 94-2232394 Section: B 501 (c)( 3 ) (enter number) org2lnlzation 4947(a)(1) nonexempt charitable trust not treated as a private foundation 527 political organlzallon Form 990-PF ~ 501 (c)(3) exempt prtvate foundatton 4947(a)(1) nonexempt ,chal'ltable trust treated as a private foundatIOn 501 (c)(3) taxable private foundation Check If your organization IS covered by the General Rule or a Special Rule. (Note: Only a section 50/(c)(7). (8). or (10) organizatIOn can check boxes for both the General Rule and a Special Rule - see instructions.) General Rule - DFor organizations filing Form 990, 990-EZ, or 990-PF that received, dUTlng the year. $5,000 or more (in money or property) from anyone contributor. (Complete Parts I and 11.) Special Rules ~ , [RJ F~r a section 501 (c) (3) organization filing Form 990. or Form 990-EZ, that met the 33-1/3% support test under Regulations sections 1.509(a).311.170A-9(e) and received from anyone contributor, durrng the year, a contribution of the greater of $5,000 or 2% of the amount on line 1 of these forms. (Comp.lete Parts I and 11.) o For a section 501 (c)(7), (8), or (10) organization filing Form 990, or Form 990-EZ, that received from anyone contrrbutor, during the year, aggregate contributions or bequests of more than $1,000 for use exclusively for religiOUS, charitable. scientific, literary. or educational purposes, or the prevention of cruelty to children or animals. (Complete Parts I, II, and III.) o For a section 501 (c)(7), (8), or ,(1 0) organization filing Form 990, or Form 990-E2, that received from anyone contributor. during the year, some contributions for use exclusively for relig,ious, charitable, etc, purposes, but these contributions did not aggregate to more than $1,000: (If this box is checked, enter here the total contributions that were received during the year for an exclusively religious, charitable. etc, purpose. Do not complete any of the Parts unless the General Rule applies to this organization because it received nonexclusively religious, charitable, etc, contributions of $5,000 or more during the year.). . . . , , , , ..., ,. ,. . . .. .. . , , . . , . ,. .. $ Caution: Organizations that are not covered by the General Rule and/or the Special Rules do not file Schedule B (Form 990, 990.EZ. or 990.PF) but they must check the box in the heading of their Form 990, Form 990-EZ, or on line 2 bf their Form 990-PF, to certify that they do not meet the filing requirements of Schedule B (Form 990, 990-EZ. or 990.PF). . BAA For Paperwork Reduction ActNotice, see the Instructions SChedule B (Form 990, 990.EZ, or 990.PF).(2005) for Form 990, Form 990-EZ, and Form 990.PF. TEEA070 1 L 02,0 \ 106 j' -~ Sclledule 8 (Form 990. 99D-EZ. or g90.PF) (2005) Name of organizatio,n AXIS COMMUNITY HEALTH, INC. I Part II Contributors (See Specific Instructions.)' (a) Number (b) Name, address, and ZIP + 4 D~~~RltiE_Nl_0J'_liE_Ab!H_ ~~~Vl~E_S_ _ _ _ _ __ _ _ _ _ _ _ _ __ 71 i X:. _ S}..:.!.... _R.QQ.M_ 2 ~ 0_ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ Sh~~~NJ.Q!....S~_~~h~______________________ (a) (b) Number Name, address, and ZIP + 4 1 2 Ab~~~~S.Q~~~~~HS~~J~~~________________ 11~1_.Q~ ~'[~.;'[____ _ __ _ __ __ _ _ __ __ __ _ _____ OM~!JQ.,_ ~~ J j ~ 1J _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (a) Number (b) Name, address, and ZIP + 4 Page 1 of 101 Part I Employer identificati6n number 94-2232394 (e) (d) Aggregate Type of contribution contributions Person B Payroll $ _____~8j.Ll3j.:. Noncash (Complete Part II if tllere IS a noncash contribution,) (e) (d) Aggregate Type of contribution contributions Person B Payroll $ __ _ J.L ~5j.L ~}J.:. Noncash (Complete Part II if there IS a noncash contribution.) (e) (d) Aggregate Type of eontributiQn contributions Person B Payroll $ _ __ _ _!7..?.LflOJ3.:. Noncash (Complete Part II if there is' a noncash contribution.) ;'*"".. 3 0 Ab?t._f~1~LQ.El'l_0J'_~EJl~i{.__BbT~___________ _____ 2.QQ.0_ ~\1B_AB~@.;~O_fQ.~E.!. _5']';_3_01_ _ __ __ ____ _ _ ___ OML~!JQ.~f~}j~~~________________________ (a) Number (a) Number (a) Number BAA (b) Name, address, and ZIP + 4 (e) Aggregate contributions (d) Type of contribution Person ' ------------------------------------- Payroll $ Noncash ~ (b) Name, address, and ZIP + 4 --------------------~~--------------- (b) Name. address, and ZIP:+- 4 TEEA0702L 08108/05 (Complete Part II if there is a noncashcontflbution.) (e) Aggregate contributions (d) Type of contribution $ Person Payroll Noncash ~ (Complete Pal'l II if there IS a noncash contribution.) (e) Aggregate contributions (d) Type of contribution Person ~ Payroll $ Noncash (Complete Part II if there IS a l10ncasll contribution.) Schedule 8 (Form g90, 9gO.EZ. or 990-PF) (2005) , , Schedule 8 (Form 990, 990.EZ, or 990.PF) (2005) Na",e'of organization Page 1 of 1 of Part II Employer identification number AXIS COMMUNITY HEALTH, INC. I Part II I Noncash Property (See Specific InsllLictlollS) 94-2232394 (a) (b) (c) (d) No. from Description of noncash property given FMV (or estimate) Date received Part I (see instructions) N/A ------------------------------ - --------- ~ - ------------------------------ - --------- " ------------------------------ - --------- ------------------------------ - --------- $ -----"------- --------- (a) , (b) (c) (d) No. from Description of noncash property given FMV (or estimate) Date received Part I (see instructions) ------------------------------- -.-------- - ------------------------------- ----.....---- --------------------~---------- --------- ------------------------------- --------- $ ----------- 1-----...--- (a) (b) (c) (d) No. from Description of noncash property given FMV (or estimate) Date received Part I (see instructions) ------------------------------- --------- - ------------------------------- --------- ------------------------------- --------- ---------~------------------~-- --------- $ - - _.__._-- - -- f--------_ . (a) (b) (c) (d) No. from Description of noncash property given FMV (or estimate) D-ate received Part I (see instructions) ---~~---~---------------------- --------- - ------------------------------- --------- ------------------------------- --------- ------------------------------- --------- $ ----------- 1--------- (a) (b) (c) (d) No. frQ1T1 Description of noncash property given FMV (or estimate) Date received Part I (see instructions) ~---------------------------------------~ - ~------------------------~------ --------- ~----------------------~~------- --------- --------------------------~------------- $ ----------- f--------- (a) (b) (c) (d) No. from Description of noncash property given FMV (or estimate) Date received Part I (see instructions) , ------------------------------- --------- - --------------------------- ---- --------- --------------------------- ------------- ------------------------------- --------- $ ----------- --------- BAA Schedule B (Form 990, 990.EZ, or 990.PF) (2005) TEEA,0703L 08;08105 . , Schedule B (Form 990. 990.EZ. or 990.PF) (2005) Name' of organization Page 1 of 1 of Part III Employer identification number AXIS COMMUNITY HEALTH, INC. 94-2232394 Part III Exclusiveljt religious, charitable, etc, individual cont ributionsto section 501 (c)(7), (8), or (10) organizations aggregating more than $1,000 for the year (Complete co Is (a) through (e) and tile folloWing line entry.) F or organizatIOns completing Part III, enter total of exclusively rell QIOUS. charitable, etc, contril)utlons of $',000 or less for the year. (Entel this information once - see InstrLlctlons.) ~ $ N/A (a) (b) (c) (d) No. from Purpose of gift Useo f gift Description of how gift is held Part I .... ,', Ni~__ - - -- - - ~ -- ---~-~- ---- - - - ---- - - ------- ------ --- - -- - ----- - -. - .-- -- - -- -'--- --,-- - -- -- ----- -- ---- - ------ --'. ---- -------- ------ - -. -- - - - - - ---- ---- - -- -- --- - - ----- - - --------- ------------------ - _. (e) Transfer of gift Transferee's name, address, and ZIP +4 Relationship of transferor to transferee -- - ----- ----- --- --.----- - --- --- - - -- ---- --- -------------------. -- -- ------------ -- ------ - -- ---- - -- ---------------- ---------_. ---- ----- - - - - --------- - -- -- --- - --- ~;.,;-;~-- - - --- ----------------. (a) (b) (c) (d) No. from Purpose of gift Use of gift Description of how gift is held Part I i----- --- ------ ------'- ---- --- --- - --- ------ --------------------. - i----- --- ---- -- ------- -- ----- --- - --------- --------------------. i--------------------- ------- --- - --------- --------------------. (e) Transfer of gift Transferee's name', address, and ZIP +4 Relationship of transferor to transferee ---- ------------ ----------.---- -.--- .---------- ----------------. ---- - -- --------------- -------- - - -- ------------------------- -. --- ---- -------------------- -.-- - -;- -- ------------------------- _. (a) (b) (c) (d) No. from Purpose of gift Use of gift Description of how gift is held Part I ---- - -- - ---------..,-- ---- --- --- - - ------ -- --------------------. - ---- --- - - - - ---- ----- ------- ---- - -----.--- ------------------- -. ---- --- ------ ------- ----- -- ---- - -------- --------------------. -. (e) Transfer of gift . Transferee's name, address, and ZIP +4 Relationship of transferor to transferee ---- --- ---- ---- --- ----- -- - - - --- - -- ------ ---- ----------------. ---- --- - --- --- -- ------- -- -- - --- - -- ----- ---------------------. - --- --- -- - - -- ----- - - - -' - - - - - - --- - - - -- --- - ---- ---- - -----------. (a) (b) (c) (d) No. from Purpose of gift Use of gift Description of how gift is held Part I i---- - - -- - - - - --- - - -- -- -- - - - -- -- -- - - -- -- - - - ---- --- -- --------.-- _. - ~---- - -- - -- - - -- - - - - -- - - -- --- - - -- - - --- -- -- --- - --- -- -- -- ------ -. . - -- - - - - - - -- - - - - - - - -- -- - - - - - - - -- - - - - -- - -- ---'- --- ------ -- -- -- -. (e) Transfer of gift Transferee's name, address, and ZIP + 4 Relationship of transferor to transferee i-- - - - - -- - - - - - - -- -- - - - - - - - - -- - - -- - - - -- - --- -- - ---- - - - - -- -------. ..- -- - - -'- - - - - - - - - - - - - -- - - - - - - - - - -- - - - -- - -- - - - - - --- -- - --- ---- ---. i-- - - - - - - - - - - - - -- - -- - - --- - - - - - - -- - -- -- -- -- - -- - -- - -- - - -- ------- BAA Sclledule B (Form 990. 990.EZ, of"990.PF) (2005) TEEA0704l 08115105 t, -' ~ 2005 .;-~:. FEDERAL STATEMENTS CLIENT 500 2/08/07 AXIS COMMUNITY HEALTH, INC. STATEMENT 1 FORM 990, PART I, LINE 20 OTHER CHANGES IN NET ASSETS OR FUND BALANCES CAPITAL ADDITION STATEMENT 2 FORM 990, PART II, LINE 43 OTHER EXPENSES BAD DEBTS CAPITAL EXPENSES CONFERENCES & TRAINING CONTRACTORS FEES & DUES INSURANCE JANITORIAL SERVICES LABORATORY FEES MAINTENANCE SUPPLIES MEDICAL SUPPLIES MISCELLANEOUS EXPENSES OTHER CONTRACTED SERVICES PHARMACY ,- PROFESSIONAL SERVICES RADIOLOGY UTILITIES (A) TOTAL 126,632. 357,903. 8,339. 294,891. 37,048. 154,900. 50,348. 121,854. 7,173. 56,585. 135,501. 26,367. 252,534: 46,140. 63,189. 52,946. TOTAL $ 1,792,350. ST A TEMENT 3 '.FORM 990, PART III Q,RGANIZA TION'S PRIMARY EXEMPT PURPOSE (B) PROGRAM SERVICES 126,632. 357,903. 8,064. 294,891. 37,048. 154,523. 50,073. 121,854. 7,173. 56,585. 118,932. 24,667. 252,534. 46,140. 63,189. 52,321. $ 1,772,529. $ /'if'",.,' . $ TOTAL $ (C) MANAGEMENT & GENERAL 275. 377. 275. 16,569. 1,700. 625. 19,821. $ P AG E 1 94-2232394 11 :45AM 379,469. 379,469. (D) FUNDRAISING o. TO PROVIDE MEDICAL AND HEALTH RELATED SERVICES TO HOMELESS AND FINANCIALLY BACKWARD INDIVIDUALS. SERVICES INCLUDE ADULT AND PEDIATRIC CARE, OBSTETRICS, GYNECOLOGY, HIV TESTING, PRIMARY CARE, SENIOR SERVICES, CASE MANAGEMENT, MEDICAL CARE, MENTAL HEALTH COUNSELING, DRUG AND ALCOHOL COUNSELING, NUTRITION SERVICES AND COMMUNITY HEALTH EDUCATION. STATEMENT 4 , FORM 990, PART III, LINE A STATEMENT OF PROGRAM SERVICE ACCOMPLISHMENTS DESCRIPTION PROGRAM: GENERAL CLINIC SERVICES DESCRIPTION: MEDICAL SERVICES FOR ADULTS AND CHILDREN, INCLUDING THE INDIGENT ' ~NNUALVISITS: 24,402 PROGRAM GRANTS AND SERVICE ALLOCATIONS EXPENSES 3,750,227. ,'l 'J -~ t- 20(}5 FEDERAL STATEMENTS CLIENT 500 2/08/07 AXIS COMMUNITY HEALTH, INC. STATEMENT 4 (CONTINUED) FORM 990, PART III, LINE A STATEMENT OF PROGRAM SERVICE ACCOMPLISHMENTS GRANTS AND DESCRIPTION ' ALLOCATIONS INCLUDES FOREIGN GRANTS: NO PROGRAM: BEHAVIORAL HEALTH DESCRIPTION: DRUG, ALCOHOL, MENTAL HEALTH, DUI, DRUG COUNSELING, ANGER MANAGEMENT AND, TEEN AND MENTAL HEALTH SERVICES FOR THE"COMMUNITY ANNUAL VISITS: 35,195 INCLUDES FOREIGN GRANTS: NO PROGRAM: WIC DESCRIPTION: FOOD VOUCHER.AND NUTRITIONAL PROGRAM FOR CHILDREN, PREGNANT WOMEN AND FOR LACTATING WOMEN ANNUAL VISITS: 29,118 INCLUDES FOREIGN GRANTS: NO STATEMENT 5 FORM 990, PART IV, LINE 57 LAND, BUILDINGS, AND EQUIPMENT CATEGORY FURNITURE AND FIXTURES MACHINERY AND EQUIPMENT BUILDINGS IMPROVEMENTS LAND BASIS 644,243. $ 272,063. 1,486,776. 397,948. 210,460. 3,011,490. '$ TOTAL $ STATEMENT 6 FORM 990, PART IV, LINE 64B MORTGAGES AND OTHER NOTES PAYABLE OTHER NOTES PAYABLE LENDER'S NAME: MATURITY DATE: REPAYMENT TERMS: INTEREST RATE: SECURITY PROVIDED: BALANCE DUE: MT. DIABLO NATIONAL BANK 10/01/2010 MONTHLY INSTALLMENTS 6.50% REAL PROPERTY PAGE 2 94-2232394 11 45AM PROGRAM SERVICE EXPENSES 1,162,077. 365,785. $ O. $5,278,089. ACCUM. DEPREC. 508,800. $ 239,892. 547,750. 12,574. $ 1,309,016. $ BOOK VALUE 135,443. 32,171. 939,026. 385,374. 210,460. 1,702,474. $ 707,399. q II f! 2005 CLIENT 500 2/08/07 FEDERAL STATEMENTS AXIS COMMUNITY HEALTH, INC. STA"'fEMENT 6 (CONTINUED) FORM 990, PARTlY, LINE 64B MORTGAGES AND OTHER NOTES PAYABLE '"'^Jify OTHER NOTES PAYABLE LENDER'S NAME: MATURITY DATE: REPAYMENT TERMS: ORIGINAL AMOUNT: BALANCE DUE: STATEMENT 7 FORM 990, PART IV, LINE 65 OTHER LIABILITIES UNEMPLOYMENT RESERVE CITY OF LIVERMORE 6/01/2010 MONTHLY 14,400. STATEMENT 8 FORM 990, PART V-A LIST OF OFFICERS, DIRECTORS, TRUSTEES, AND KEY EMPLOYEES TITLE AND AVERAGE HOURS PER WEEK,DEVOTED BOARD CHAIR $ 1 NAME AND ADDRESS BERT BROOK 4361 RAILROAD AVE., STE 8 PLEASANTON, CA 94566 L. JAMES GHILARDI, MFT 4361 RAILROAD AVE., STE 8 .PLEASANTON, CA 94566 TAWNYA MONTOYA '4361 RAILROAD AVE., STE 8 PLEASANTON, CA 94566 JUDGE MAlli\ EATON 4361 RAILROAD AVE., STE 8 PLEASANTON, CA 94566 STEPHEN FLORY 4361 RAILROAD AVE., STE 8 PLEASANTON, CA 94566 MELINDA GARCIA 4361 RAILROAD AVE., STE 8 PLEASANTON, CA 94566 VICE CHAIR 1 TREASURER 1 SECRETARY 1 BOARD MEMBER 1 BOARD MEMBER 1 $ TOTAL $ ........... $ TOTAL $ COMPEN- SATION O. CONTRI- BUTION TO EBP & DC $ o. $ o. o. o. o. o. PAGE 3 94-2232394 1145AM 10,800. 718,199. 26,203. 26,203. EXPENSE ACCOUNT/ OTHER o. o. o. o. o. o. o. o. o. . O. o. n .~ .:1'", 2005 FEDERAL STATEMENTS PAGE 4 CLIENT 500 AXISCOMMUNliX HEALTH, INC. 94-2232394 2i08/07 11:45AM STATEMENT 8 (CONTINUED) FORM 990, PART V-A LIST OF OFFICERS, DIRECTORS, TRUSTEES, AND KEY EMPLOYEES TITLE AND CONTRI- EXPENSE AVERAGE HOURS COMPEN- BUTION TO ACCOUNT / NAME AND ADDRESS PER WEEK DEVOTED SATION ESP & DC OTHER BRIAN GENTRY BOARD MEMBER $ O. $ o. $ O. 4361 RAILROAD AVE., STE 8 1 PLEASANTON, CA 94566 DAVID HALPERIN BOARD MEMBER O. O. O. 4361 RAILROAD AVE., STE 8 1 PLEASANTON, CA 94566 DONALD ODELL . BOARD MEMBER O. O. O. 4361' RAILROAD AVE., STE 8 1 PLEASANTON, CA 94566 LAURA OLSON BOARD MEMBER O. O. O. 4361 RAILROAD AVE., STE 8 1 PLEASANTON, CA 94566 JAMES PAXSON BOARD MEMBER O. O. O. 4361 RAILROAD AVE., STE 8 1 PLEASANTON, CA 94566 JERI STEIGER BOARD MEMBER O. O. O. 4361 RAILROAD AVE., STE 8 1 PLEASANTON, CA 94566 RONALD GREENS PANE CEO 98,000. 1,373. O. 4361 RAILROAD AVE., STE 8 38 PLEASANTON, CA 94566 RITA LAW CONTROLLER 78,975. O. O. 4361 RAILROAD AVE., STE 8 40 PLEASANTON, CA 94566 TOTAL $ 17 6 ,975. $ I, 373. $ 0 . STATEMENT 9 FORM 990, PART VIII RELATIONSHIP OF ACTIVITIES TO THE ACCOMPLISHMENT OF EXEMPT PURPOSES LINE # 93 EXPLANATION OF ACTIVITIES TO PROVIDE GENERAL MEDICAL PEDIATRIC IMMUNIZATION AND COUNSELING SERVICES TO TARGETED POPULATION. 95 INTEREST INCOME IS USED TO SUPPORT THE ORGANIZATION'S PROGRAM EXPENSES. MISCELLANEOUS INCOME IS USED TO SUPPORT GENERAL OPERATIONS OF VARIOUS HEALTH RELATED PROGRAMS OF AXIS COMMUNITY HEALTH CENTER, INC. 103 ""..r- ,.:, 2005 FEDERAL STAT EMENTS PAGE 5 CLIENT 500 AXIS COMMUNITY HEALTH, INC. 94-2232394 11 :45AM 2/08/07 ST A TEMENT 10 SCHEDULE A, PART I COMPENSATION OF FIVE HIGHEST PAID EMPLOYEES NAME AND ADDRESS HENRY UYEHARA 4361 RAIL~OAD AVE, # 8 PLEASANTON, CA 94566 SUE COMPTON 4361 RAILROAD AVE, # 8 PLEASANTON, CA 94566 MEENA RIJHWANI 4361 RAILROAD AVE, # 8 PLEASANTON, CA 94566 SHAIDA BEHNAM 4361 RAILROAD AVE, # 8 PLEASANTON, C1\ 94566' CHARLES WHITE 4361 RAILROAD AVE, # 8 PLEASANTON,~CA 94566 TITLE & A VERAG E HOURS WORKED COMPEN- SATION 67,27 5. CONTRIBUTIO EBP & DC 3,406. EXPENSE ACCOUNT O. COO 38 ASSO. EXE. DIR 30 61,568. 3,798. o. MEDICAL DIR. 30 94,037. 2,298. o. PHYSICIAN 40 119,916. 3,096 . o. PHYSICIAN 32 89,429. 6,096 . o. TOTAL\ $ 432,225. $ 18,694. $ O. STATEMENT 11 SCHEDULE A, PART IV-A, LINE 22 OTHER INCOME DESCRIPTION .MISCELLANEOUS INCOME (A) 2004 (B) 2003 (C) 2002 (D) 2001 (El TOTAL $ 65,489. $ 2,138. $ 1,002. $ 24,230. $ 92,859. TOTAL $ 65,489. $ 2,138. $ 1,002. $ 24,230. $ 92,859. Axis Community Health Board Resolution Attachment D Board of Directors RESOLUTION The Board of Directors of Axis Community Health endorses and approves this application to the City of Dublin for support for the Women's Health Clinic. J ame Paxson, Chair ommunity Health Board of Directors Dated: f.~. Ubg Axis Community Health Insurance Information Attachment E Axis Community Health maintains full insurance coverage at all times (see attached Certificate of Insurance), which includes: Commercial General Liability Professional Liability Automobile Liability Workers' Compensation $1,000,000 $1,000,000 $1,000,000 $1,000,000 Certificates of current coverage will be submitted to the Ci1lY of Pleasanton as requested. ~ '^ AAtLt-d" ;- !I l!! ". ~ City of Dublin Fiscal Year 2008-2009 Application for Funds APPLICA1il(fN VERlFICA'EION' I attest that the info~ation~ntainedin,,;this"'Y"2tJ08''''iOfl2$Faat~pli~at,~n is'Q.ccurate and that the funds req!4es~g witl\inot s9Pplant any 0 . s secured;by;the91"~anization. Attachefi is Q. resolution., letter, or O~.lb~;~f,'~~Yicl.?evidence that the Board of Directors approved the application as submi~'. SUccrssMFjall~lic e required to.~ubmit a summary report; soauas possible after sub~gthe reimbEse. '< .,i~~~~~t,but nodater _ A1u~st 30,20.'9. Fa;i;Lure to subIni~~rep.,}Nt~:t~~t~jIt~.bili..r~~ funding, Si~at!rrt:;s: l ' a-"!' . t.;J t/, Date 'Ll. :2~. ZOu~ .<;::i'~\>:'''!i' Dai~e SECTION 2 Page 16 of 16 L iiI .J. Ii rrr=r~\I\ ~cr \ I Internal Revenue Service Date: July 21,2006 Department of the ~reasury P. O. Box 2508 Cincinnati, OH 45201 AXIS COMMUNITY HEALTH INC 4361 RAILROAD AVE PLEASANTON CA 94566-6611 619 Person to Contact: Ms. Wallace 31~04021 Customer Service Specialist Toll Free Telephone Number: 877 -829-5500 , Federal Identification Number: 94-2232394 . Dear Sir or Madam: This is in response to your request of July 21, 2006, regarding your organization's tax- exempt status. In December 1972 we issued a determination letter that recognized your organization as exempt from federal income tax. Our records indicate that your organization is currently exempt under section 501 (c)(3) of the Internal Revenue Code. Our records indicate that your organization is also classified as a public charity under sections 509(a)(1) and 170(b)(1)(A)(vi) of the Internal Revenue Code. Our records indicate that contributions to your organization are deductible under section 170 of the Code, and that you are qualified to receive tax deductible bequests, devises, transfers or gifts under section 2055, 2106 or 2522 of the Internal Revenue Code. If you have any questions, please call us at the telephone number shown in the heading of this letter. . .." Sincerely, ~i(.~ Janna K. Skufca, Director, TE/GE Customer Account Services CITY OF DUBLIN Finance Department 100 Civic Plaza. Dublin, CA 94568' (925) 833-6640 BUSINESS LICENSE APPLICATION Q NOTE: FEES ARE NONREFUNDABLE ~ Please Check One: ~ New Application o Home Occupation o Change of Owner o Change of Address o Change of Business Name Business Name A )(1$ ~()HI'fILAI~"Y HE~~rH I::> i-L .:r P;c. e1 ~ ,€ A /"I Bus. Start Date I "1/1 /,u().3 I Business Phone 19'?S- 5S' ..tS..lol Business Fax 19-1S- $5'6 - b~1.1{ Resale No. Corporate Name (if applicable) Business Location I / /8~o () /Jodi ~N i3J.I/L> (Cannot be P.O, Box per State of California Business & Professions Code-Section 17538.5) AI/E. ''iqs-~" Federal 10 No. State 10 No. , I{ -). ;('~1.~ tf~ tJ'$"19/tb /1./ () t:1 00 S"<t..u e~8NJ-r NIIAI.P~" T 8/:z.3/D8 Mailing Address ~ ~ /:; / /<. ,III I t..R tJA..o ;CJ t. e: A SA III r~N" t!.A- I I I ,.a;e~. State Lie. No. Emall Address I 4.,j (I. ,.~, t:l .. 4. X' I~ II e A /TIJ. ~ r~ Description of Business I 2> A' I VIAl ~ UAI~1e IN,J:'i,P8I11C e State Lie. Type Expire Date Ownership Type: ~ Corporation D Corp-Ltd Liability n Sole Proprietor C Partnership I Trust 1 st Owner Name Home Address (Cannot be P. O. Box) AXI.J (!..OH"'"N~"'Y #~t. rH . Title Driver Lie. No. Soc. Sec. No. Home Phone No. Cell/ Pager No. 2nd Owner Name Home Address (Cannot be P. O. Box) Title Driver Lie. No. Soc. Sec. No. Home Phone No. Cell/ Pager No. I Contact Name Address -5'u.c ~()MP~t>^, 'T'.j'1 1?.41 J..R 0 A-.,l:> AVe'"., t&'t.6Ao. -r".&"" Phone No. Cell/Pager No. 19~5-J(,p1.600S Annual Business License Fee - I $50 for each year starting in October Prorated Business License Fee - I for first year of operation '.. Penalty - 7% Compounded each I month application is late. Maximum $50 per year. TOTAL DUE I No. of Employees fJ .3 I Sq. Ft. of premises I I Business Hours I t;AI'I . "pJCfI Will business use/store/sell alcohol? o Yes ~ No Will business use/store/sell flammable, explosive, corrosive, hazardous materials? 0 Yes IZI No OFFICIAL USE ONLY : Application No. Amount Paid $ 'Date Paid Cash o Check No. .,.Ofl.1fc.OYisa D.APPROVED DOENIEO Comments ~ .1 declare that all of the information on this application is correct to the best of my knowledge. I certify that I will operate my business In accordance with all applicable federal, state and city laws and regulations. I understand that any false statements made are grounds for denial or revocation of my business license. ~re Of~~ntative RllvieWlnitJalS;&:Oat8 t-J..;)'~\)~ Date RETURN APPLICATION TO ABOVE ADDRESS AND MAKE CHECK PAYABLE TO CITY OF DUBLIN BUSINESS LICENSE INFORMATION AND REGISTRATION FEES Application forms are available at City Hall in the Finance Department, second floor. You can also request one by mail at the following address: City of Dublin, Finance Dept., 100 Civic Plaza, Dublin, CA 94568, or by call the following number: 925-833- 6640. All entities and persons doing business in the incorporated area of the City of Dublin (including subcontractors) are required to have a current business license. Most businesses (the primary exception being for nonprofit organizations, who still must register) pay a yearly $50 registration fee, which is prorated on a monthly basis, for the first year a business begins operation in Dublin. The Business License year begins on October 1 st and ends on September 30th. BUSINESS LICENSE FEES ARE NON-REFUNDABLE. This is the lowest fee in the Tri-Valley area for a business license. The City of Dublin only charges the amount necessary to recover its regulatory costs, and does not base its fee on the amount of gross revenue generated or staff employed by a business, as many other cities do, which often results in a substantially higher fee. . Do I throw out the Expired Business License Certificate, when I receive my new one? "NO", you will need it if you want to buy real estate or get a loan, etc., to prove you were in business those past years. The City mails you the original and we do not keep a copy. Topics that address frequently asked questions - the following represents a ti,stof frequently asked questions regarding business licenses for the City of Dublin: . Do I need a Peddlers Permit? City ordinance states if you are traveling by foot or car or any other type of conveyance, place to place or house to house, in order to conduct and/or sell product, you need to register with the Dublin Police Department for a peddlers permit and to get a business license. . How long does it take to get a license? Once you have completed your application and paid your fee, it takes approximately eight (8) weeks to receive approval from the appropriate departments in the City. Once these approvals have been received, the business license certificate is mailed to the mailing address on the application. . How do I renew my license? Renewal notices are mailed out by the City in September. Completed renewal forms are due back to the City by October 30th. Renewal notices returned to the City after this date are subject to late fees. . . Can I use my license to do business in another city? No, this license is for doing business in the incorporated area of the City of Dublin only. If you plan to do business in another city, you must contact them in order to obtain their requirements for a business license. . What types of businesses fall under the "Home Occupation" category? Are there any special requirements for a home occupation business in Dublin? A Home Occupation business is one in which the business is based out of a person's residence in Dublin. A special Home Occupation Supplemental Form must be filled out, in addition to your business license application. This form provides additional information that will assist with a prompt review of your license application. If your business location is in rented property, the Dublin Municipal Code Zoning Ordinance for Home Occupations requires the property owner's written permission prior to the issuance of a Dublin business license (Section 8.64.030.P). . How can I verify if a business operating in Dublin has a current business license? Call the Finance Department at 925-833-6640 and give them the natlle and street location of the business, and they will verify whether or not the business has a current business license. . Can I obtain a listing of businesses in Dublin? The Finance Department has a listing of businesses in Dublin that is avililable for review by the public. In addition, a person can purchase their own copy of this listing from the Finance Department for $15, payable at the time of the request. The listing will be run and available for you by the next business day. This listing can be sorted by either business name or street location and contains the business name, address, contact person and phone number. In accordance with state law, we arE!'" not authorized to give out certain information about a business, including the owner's home address and phone number. . What does it cost to replace my business license? It costs $5 to obtain a replacement copy of your business license. . Do I need to get a new business license if my business moves to another location in the city or has an ownership or name change? . If your business moves to another location within Dublin, you will need to submit a new application form and pay a prorated fee, based upon the date your business relocated. A new business license certificate will be issued. . If your business changed ownership, an application must be filled out noting the change and submitted with a $5 fee to update the business records. . If there is a business name change only, an application must be filled out noting the change submitted with a $5 fee for a new certificate. . How can I get a replacement license if I lose it? Upon request and submitting a $5 fee, a replacement license will be issued and mailed to the current business location. . Are there other agencies I need to contact prior to opening my business? A listing of some of the agencies you may need to contact prior to the opening of your business is listed below. You may also contact the Finance Department at Dublin to obtain a copy of this listing. City of Dublin Planning Department Building Department 925-833-6610 925-833-6620 Finance/Business License Fire Prevention Bureau 925-833-6640 925-833-6606 Dublin Chamber of Commerce 925-828-6200 Department of Consumer Affairs Information Center 800-952 -5210 Federal I. D. No. # 800-829-1040 Employer I. D. No. - Employment Development Dept. 888-745-3886 Fictitious Business Name - Alameda County 510-272-6363 Clerk-Recorder's Office - Hours: 8 a.m. to 5 p.m. 1106 Madison Street, Oakland, CA (exit 12th Street and turn right, go one block to 12th Street and Madison. Recorder's office is located on the left. Corrnw,ef12th Street and Madison). Sales Tax Permit/Resale License - Board of Equalization Oakland Office - Hours: 8 a.m. to 5 p.m. 510-622-4100 1515 Clay Street, #303, Oakland, CA Website Address: www.boe.ca.gov Fax 510-622-4175 Solicitor's I Peddler's Permit - Dublin Police Services 925-833-6680 800-321-2752 State Contractor's License (Oakland, CA) . General Business . Itinerant Business . Temporary Place of Sale $50.00IYear (10/1 through 9/30) $10.00/Day ($50 maximum) $10.00/Day For a new businesses starting business after October 31st of any year, the following prorated fees are used for the remaining portion of the Business License Year (10/1 through 9/30). Month Business Started Fee Due 1st Year Month Business Started Fee Due 1st Year October $50.00 April $25.00 November $45.83 May $20.83 December $41.67 June $16.67 January $37.50 July $12.50 February $33.33 August $ 8.33 March $29.17 September $ 4.17 A 7% penalty, compounded monthly, of any delinquent business registration fee shall accrue on the 30th day following the due date (up to $50.00 maximum penalty per year). Using a registration fee of $50.00 due in October, the following represents an example of the penalty due: Months Late One month Two months Three months Four months Five months Six months Penalty Due $ 3.50 $ 7.25 $11.26 $15.55 $20.14 $25.05 Months Late Seven months Eight months Nine months Ten months Eleven months Penalty Due $30.30 $35.92 $41.93 $48.37 $50.00 Maximum