Form VA Form 10-10073 VA Form 10-10073 NPC Annual Report Template

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Overview

1. Instructions
2. NPC Certification
3. Board of Directors
4. Revenues
5. Expenses
6. Financial Position
7. Gov. Funding >$25K
8. Non-Gov Funding >$25K
9. Payees >$50K
10. Accomplishments
11. Edu Activities
12. Budget & Other

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Sheet 1: 1. Instructions

The VA Nonprofit Program Office (NPPO) is responsible for collecting and compiling the Annual

Reports to VA from all of the VA Affiliated Nonprofit Research and Education Corporations

(NPCs). If you have questions or concerns regarding the Excel Workbook used to compile this

Report or the submission instructions, please call or email Kimberly Collins, NPPO Director.

Phone: (202) 731-6973

Email: [email protected]

GENERAL INSTRUCTIONS

1. This information is being collected primarily for the purpose of compiling the NPC Annual Report

to Congress. Congress mandated a combined Annual Report so that it could get information

about the entire NPC program on a consolidated basis nationwide. The combined NPC Annual

Report to Congress is also used by top level VA managers to assess the program's progress,

by the NPCs themselves to gauge their individual standing in relation to the entire group of

NPCs, and by organizations and individuals outside the government that have an interest in

the NPCs. Also, very importantly, the information submitted is used by the VA executives and

the NPPO to carry out some of the VA Secretary's oversight duties and responsibilties.

2. The NPC Annual Reports are needed by VA to accomplish its duties and responsibilities to report

to Congress, to provide needed information to senior VA executives, conduct some of the

oversight for the NPCs, and to aid the NPCs in accomplishing their fundamental objective of

providing support to VA research and education.

3. All NPCs must respond annually by submitting their NPC Annual Reports. Normally, the reports

will be prepared by the NPC's Executive Director, Chief Executive Officer, Chief Financial Officer,

Controller or other person with equivalent authority, ability and access to the required financial

and other information.

4. NPPO estimates that it will take an average of 3-1/2 hours to prepare this Report.

However, because of the huge size disparities in the NPCs and other factors peculiar to some

of the NPCs, more or less time may be needed. If you would like to comment upon the estimated

burden of preparing this Report, please contact Kimberly Collins, NPPO Administrator, at

(202) 731-6973 or [email protected].

5. As noted above, this Annual Report is mandatory for all NPCs, regardless of size and whether

they are active or not. Each NPC will be responsible for submitting this Annual Report as long

as it is not properly, legally dissolved.

6. VA and NPPO do not and cannot assure confidentiality or privacy of any of the information

submitted in this Report. The information in this Report is required for and will be included in

VA's NPC Annual Report to Congress, which is required by statute and is a public document.

7. The Congress requires detailed listings of all NPC payees greater than $50,000. This may

require the listing of payments to employees. If the NPC regards this as "sensitive"

information, then we suggest that employee numbers, not names, be used in the listing.

NPPO does not regard any other information submitted in this Report to be of a sensitive

nature.

8. Under the Paperwork Reduction Act, VA may not conduct or sponsor, and you are not

required to respond to a collection of information unless it displays a valid Office of

Management and Budget (OMB) number, or is being collected from fewer than ten

persons (entities) in a twelve month period.

SPECIFIC INSTRUCTIONS

9. Both the preparation and filing of this Report are by electronic means.

10. On or before June 1, please submit your NPC Annual Report form in Excel format by email to

[email protected].

11. Print out the NPC Certification page (Tab 2), sign the Certification, and create a PDF of the NPC

Certification page only.

12. In an email to the NPPO, please attach the following items in the format indicated in parenthesis:

a. Completed NPC Annual Report Template workbook including Tab 12 (Excel only)

b. Signed Certification page (only) at Tab 2 (PDF)

c. Independent Audtiors' Report (PDF)

d. Audited Financial Statements (PDF)

e. Independent Auditors' Mangement Letter(s) (PDF)

f. IRS Form 990 or Form 990EZ with all schedules (PDF)

13. In the "Subject" line of your email, please indicate your city and state first and then the item(s)

you are submitting: For example: "Subject: Columbia, MO - 2012 NPC Annual Report"

14. If the attached files are too large to send in one email, then please submit multiple emails with a

notation in the email "Subject" line. For example: "Subject: Columbia, MO - Independent

Auditors' Report and Audited Financial Statements for 2012 - 1 of 2"

15. Please double check to see that your Total Assets, Total Liabilities, Total Revenues and Total

Expenses figures agree exactly with the corresponding amounts shown on your Form 990 or

990 EZ tax return. Also, please be sure you have completed all of the worksheets, including

"Accomplishments" (Tab 10) and "Budget and Other" (Tab 12). The information on Tab 12

is very important for VA's budgeting and reporting of budget information to the OMB. The

other information at Tab 12 is necessary for senior VA executives and NPPO to evaluate your

NPC's progress, financial condition, and operations.

16. NPPO will send you an email acknowledging your submission and NPPO's acceptance of

your NPC Annual Report as soon as it has made a preliminary review of the Report's

completeness and accuracy.

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Sheet 2: 2. NPC Certification

Instructions:
Only enter information in the cells shaded yellow. All other fields will populate automatically from data on subsequent worksheets.
Exact Name of Corporation
per Articles of Incorporation:
Primary Affiliated VAMC:
Other Affiliated VAMC(s):
Executive Director Name:
	Phone:
	Fax:
	Email:
This corporation engages in:
		Research		Research & Education				Education Only
Audit Type:	A133		GAGAS				GAAS
If no audit this year, date of last audit:
Total Revenue			$-
	(See VHA Handbook 1200.17, Appendix A to determine audit requirements.)
Revenues and Expenditures
	a.	Government funding received for research						$-
	b.	Government funding received for education						$-
	c.	Non-Government funding received for research						$-
	d.	Non-Government funding received for education						$-
	e.	Salary expenditure for research staff						$-
	f.	Salary expenditure for education staff						$-
	g.	Salary expenditure for corporate administrative staff						$-
	h.	Total expenditure for research						$-
	i.	Total expenditure for education						$-
	j.	Travel expenditure for research						$-
	k.	Travel expenditure for education						$-
The following required items are included as attachments - all documents must be submitted electronically:
	Independent Auditors' Report (PDF)					N/A - Revenue <$100,000 or 3 Yr Grace Period
	Audited Financial Statements (PDF)
	Auditor's Management Letter (PDF)					N/A - No Management Letter Issued
	Educational Activities List					N/A - No Education Activities
	Lists of Funding Sources >$25,000
	List of Payees >$50,000
	List of Major Accomplishments - Minimum 3
	IRS Form 990 with all Schedules (PDF)
I certify that each NPC director, officer and employee has been trained about the NPC's conflict
of interest policy in accordance with VHA Handbook 1200.17, and has acknowledged underestanding of the policy,
agreed to comply with the policy and submitted a conflict of interest disclosure form in accordance with said policy.
	Executive Director Signature							Date
I certify that all new NPC board members, including statutory VA directors, and all new executive
directors, officers and key employees have taken internal controls training within 90 days of assuming
their roles.
	Executive Director Signature							Date

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Sheet 3: 3. Board of Directors

List members of the board of directors as of May 1, 2013
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Statutory Board Members	Name	NPC Office Held (Chair, President, Secretary, Treasurer, etc., if any)
Medical Center Director or equivalent
Chief of Staff or equivalent
Associate Chief of Staff for Research or equivalent
Associate Chief of Staff for Education or equivalent
Outside Board Member 1
Outside Board Member 2
Others	Name

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Sheet 4: 4. Revenues

Instructions:
Enter Revenue amounts in the cells shaded yellow. Totals will calculate automatically.
Check the figures in the Total column to see that they match the referenced 990 entries.
Expense & ratio fields populate with entries/calculations from data on the Expenses tab.
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Revenue						Refer to IRS Form 990
	Research	Education	General	Be sure computed totals are consistent with amounts reported on IRS Form 990 Total			Form 990	Form 990EZ
Government Funding Received				$-		Total =	Part VIII, Line 1d + Line 1e + (Column A) Line 2g include ONLY amounts for Fees and contracts - government	Part I, Line 2 Include ONLY amounts for Fees and contracts - Government
Non-Government Funding Received				-		Total =	Part VIII, Lines 1 a,b,c & f + (Column A) Line 2g MINUS amounts included for Fees and contracts - government	Part I, Line 1 + 2 MINUS amounts included for Fees and contracts - government
All interest, dividend and other investment income should be reported in the General Column. Interest, Dividend & Other Investment Income				-		Total =	Part VIII (Column A), Line 3 + Line 4	Part I, Line 4
Other Misc. Revenue (do not include IPA reimbursements or Gov. or Non-Gov. Funding)				-		Total =	Part VIII (Column A), Lines 5, 6d, 7d, 8c, 9c, 10c, & 11e	Part I, Line 3 + 5 through 8
Total Revenue	$0	$0	$0	$0		Total =	Part I, Line 12	Part I, Line 9
Expenses
Total Management and General Expenses			$-	$-
Total Fundraising Expenses			$-	$-
Total Program Expenses	-	-		-
Total Expenses				$0
Ratio of Admin/Program Expenses				#DIV/0!

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Sheet 5: 5. Expenses

Instructions:
Enter expenses in the cells shaded yellow. Totals will calculate automatically.
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	IRS Form 990 Part IX Statement of Functional Expenses		(A) Total	(B) Program services			(C) Management and General	(D) Fundraising
				Research	Education	Total					Comments
1	Grants and other assistance to governments and organization in the U.S. See Part IV, line 21	1	-			-				1
2	Grants and other assistance to individuals in the U.S., See Part IV, line 22	2	-			-				2
3	Grants and other assistance to governments, organizations and individuals outside the U.S. See Part IV, lines 15 and 16	3	-			-				3
4	Benefits paid to or for members	4	-			-				4
5	Compensation of current officers, directors, trustees, and key employees	5	-			-				5
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons decribed in section 4958(c)(3)(B)	6	-			-				6
7	Other salaries and wages	7	-			-				7
8	Pension plan contributions (include section 401 (k) and section 403 (b) employer contributions	8	-			-				8
9	Other employee benefits	9	-			-				9
10	Payroll taxes	10	-			-				10
11	Fees for services (non-employees):	11	-			-				11	Fees for services paid to non-employees, independent contractors
a	Management	a	-			-				a
b	Legal	b	-			-				b	Legal fees by outside firms or individuals.
c	Accounting	c	-			-				c
d	Lobbying	d	-			-				d
e	Professional fundraising. See Part IV, line 17	e	-			-				e
f	Investment management fees	f	-			-				f	Investment counseling and portfolio management, i.e. monthly account service fees.
g	Other	g	-			-				g
12	Advertising and promotion	12	-			-				12
13	Office expenses	13	-			-				13
14	Information technology	14	-			-				14
15	Royalties	15	-			-				15
16	Occupancy	16	-			-				16
17	Travel	17	-			-				17	Total travel expenses, i.e. fares, mileage allowances, and automobile expenses, meals and lodging, and per diem payments.
18	Payments of travel or entertainment expenses for any federal, state, or local public officials	18	-			-				18	Includes reimbursement for costs for any federal, state, or local public officials (as determined under section 4946 ( c ) and their family members under section 4946 (d)
19	Conferences, conventions, and meetings	19	-			-				19	Do not include air or ground transportation, lodging or per diem; those should be reported as Travel expenses (Line 17 or 18)
			(A) Total	(B) Program services			(C) Management and General	(D) Fundraising
				Research	Education	Total
20	Interest	20	-			-				20
21	Payments to affiliates	21	-			-				21
22	Depreciation, depletion, and amortization	22	-			-				22
23	Insurance	23	-			-				23
24	Other expenses -- Itemize expenses not covered above (Expenses grouped together and labeled miscellaneous may not exceed 5% of total expenses shown on line 25 below)	24	-			-				24	Those items not reportable on lines 1-23.
a	Subcontracts	a	-			-				a
b	Permits, fees and taxes	b	-			-				b
c	Inter institutional agreements and transfers	c	-			-				c
d	Dues and subscriptions	d	-			-				d
e	Research study costs (other than office expenses)	e	-			-				e
			-			-
			-			-
			-			-
			-			-
			-			-
			-			-
f	All other expenses	f	-			-				f
25	Total functional expenses. Add lines 1 through 24f	25	-	-	-	-	-	-		25
26	Joint Costs. Check if following SOP 98-2. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation	26	-			-				26
			#DIV/0!	#DIV/0!
	Recap (no entries required):
	Compensation		0	0	0	0	0	0
	Travel		0	0	0	0	0	0
	Other		0	0	0	0	0	0
	Total		0	0	0	0	0	0

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Sheet 6: 6. Financial Position

From IRS Form 990, Part I:
Enter the figures from Column B, the "Current Year"
Entries are required in the yellow shaded areas.
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Form 990, Page 1, Part I - Net Assets or Fund Balances -
		Current Year (Column B)
Page 1 Form 990 Line 20	Total Assets
Page 1 Form 990 Line 21	Total Liabilities
Page 1 Form 990 Line 22	Net Assets (Line 20 minus Line 21)	$-

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Sheet 7: 7. Gov. Funding >$25K

Report on this page all sources of governmental (i.e., federal, state, local) funding that total >$25,000 for the year.			DHHS funding should be broken down to the next level, e.g., CDC, NIH, but not down to the level of NIOSH or NCI. Include agencies listed in green, but go up one level for agencies listed in red. Only green level agencies should be identified on the form.
A list of federal government agencies is provided to the right for your reference.
Note that this page should include:
· Funds received from state and local governments including state universities			All other government funding sources should be reported at the highest level below.
· Pass-throughs of governmental funding; ie, subawards and subcontracts.
Formatting Note: When pasting onto this page, please use the Paste Special function and select Values, or Paste as you normally do, then if the clipboard appears, select Match Destination Formatting. Alternatively, after using the Paste feature use the Format Painter to format the pasted rows as the blank rows are formatted.			DHHS	Department of Health & Human Services
				OS	Office of the Secretary
				ACF	Administration for Children & Families
				AoA	Administration on Aging
0				AHRQ	Agency for Healthcare Research & Quality
				ATSDR	Agency for Toxic Substances & Disease Registry
Governmental Funding Sources >$25K	Amount			CDC	Centers for Disease Control & Prevention
					NIOSH	National Institute for Occupational Safety and Health
				CMS	Centers for Medicare & Medicaid Services
				FDA	Food & Drug Administration
				HRSA	Health Resources & Services Administration
				IHS	Indian Health Service
				SAMHSA	Substance Abuse & Mental Health Services Administration
				NIH	National Institutes of Health
					FIC	John E. Fogarty International Center
					NCI	National Cancer Institute
					NCCAM	National Center for Complementary and Alternative Medicine
					NCRR	National Center for Research Resources
					NCMHD	National Center on Minority Health and Health Disparities
					NEI	National Eye Institute
					NHLBI	National Heart, Lung, and Blood Institute
					NHGRI	National Human Genome Research Institute
					NIAID	National Institute of Allergy and Infectious Diseases
					NIAMS	National Institute of Arthritis and Musculoskeletal and Skin Diseases
					NIBIB	National Institute of Biomedical Imaging and Bioengineering
					NICHD	National Institute of Child Health and Human Development
					NIDCR	National Institute of Dental and Craniofacial Research
					NIDDK	National Institute of Diabetes and Digestive and Kidney Diseases
			DoD	Department of Defense
			DoE	Department of Energy
			DoL	Department of Labor
			DoI	Department of Interior
			EPA	Environmental Protection Agency
			NASA	National Aeronautics and Space Administration
			NSF	National Science Foundation
			USDA	Department of Agriculture
			VA	Department of Veterans Affairs
			Other Federal Agencies - Provide Name
			State Governmental Agencies, including Universities - Provide Name

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Sheet 8: 8. Non-Gov Funding >$25K

Report on this page all sources of non-governmental funding that total >$25,000 for the year.
Note that this page should not include:
· Funds received from state universities (report those on the Governmental Funding page)
· Pass-throughs of governmental funding; ie, subawards and subcontracts (report those on the Governmental Funding page)
Formatting Note: When pasting onto this page, please use the Paste Special function and select Values, or Paste as you normally do. Then if the clipboard appears, select Match Destination Formatting. Alternatively, after using the Paste feature, use the Format Painter to format the pasted rows as the blank rows are formatted.
0
Non-Governmental Funding Sources >$25K	Amount

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Sheet 9: 9. Payees >$50K

Report on this page all payees (individuals and organizations) paid >$50,000 during the reporting year.
Note that this page should include:
· Individual employees paid through a Professional Employer Organization (PEO) or employee leasing firm
· Payments to PEOs only if the PEO fees are greater >$50,000
· In the case of employees, report gross wages (no fringe benefits) and use employee number, not name.
Formatting Note: When pasting onto this page, please use the Paste Special function and select Values, or Paste as you normally do, then if the clipboard appears, select Match Destination Formatting. Alternatively, after using the Paste feature use the Format Painter to format the pasted rows as the blank rows are formatted.
0
Payees >$50K	Amount

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Sheet 10: 10. Accomplishments

Report a minimum of three but not more than ten major accomplishments on this page.

If it is more convenient, you may submit a separate list as an attachment to this form.

The print area is currently set for the first three accomplishments. Adjust print area as needed.

Text will wrap and row height will grow as needed if you type directly into the cell.

If you paste into the cells you may need to adjust the row height.

Note that this page should not include specific dollar amounts.

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Major Accomplishments (Please provide at least three, but not more than ten)

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Sheet 11: 11. Edu Activities

Report on this page up to ten Educational Activities administrered by the NPC during the reporting year.

If it is more convenient, you may submit a separate list as an attachment to this form.

Text will wrap and row height will grow as needed if you type directly into the cell.

If you paste into the cells you may need to adjust the row height.

Print area may need to be changed if you want a printed copy.

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Educational Activities (Please limit to no more than 10)

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Sheet 12: 12. Budget & Other

The budgeted revenues and expense amounts are estimates based upon what is reasonably expected at the
time that the estimates are made.
An easy way to estimate the number of months in your administrative reserve amount is to divide the reserve fund
amount by 1/12 th of the total administrative expense for the year.
Budget, Administrative Reserve Fund, Employees, Investigators, and Projects*
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1.	Projected or estimated data for the next three fiscal years (required by VHA and OMB for budget purporses):
			Revenues		Expenses
	Estimated for Fiscal 2013	$		$
	Estimated for Fiscal 2014	$		$
	Estimated for Fiscal 2015	$		$
2.	If applicable, the balance in the NPC's board-designated administrative
	reserve at the end of the NPC's last completed fiscal year was….
		$
3.	If an amount is reported for #2 above, the estimatednumber of months the
	reserve could sustain the NPC's administration….
4.	Number of unique employees at this fiscal year-end
5.	Number of active principal investigators at this fiscal year-end.
6.	Number of active research projects at this fiscal year-end.
*This information has been requested by VA Central Office for use by the Office of
Management and Budget periodically each year. By gathering the data at this time,
NPPO can respond quickly to these requests.