NPC Annual Report Template Instructions 2011 by jG7GtM6s

VIEWS: 8 PAGES: 17

									                                       NPC Annual Report Template
                                              Instructions
                                                  2011
     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 Administrator:

                                             Phone:     (202) 731-6973

                                              Email: kimberly.collins@va.gov


                                         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 five 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 kimberly.collins@va.gov.
     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.
     9.    Both the preparation and filing of this Report are by electronic means.


OMB 2900-XXXX
Approval expiration 12/31/XX                             Tab 1
                                      NPC Annual Report Template
                                             Instructions
                                                 2011
                                      SPECIFIC INSTRUCTIONS
     10. On or before June 1, please submit your NPC Annual Report form in Excel format by email to
         paula.floyd@va.gov.

     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 - 2011 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 2011 - 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.




OMB 2900-XXXX
Approval expiration 12/31/XX                            Tab 1
                                                       NPC Annual Report Template
                                                           NPC Certification
                                                                 2011

            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)             N/A - No Management Letter Issued
                       Auditor's Management Letter (PDF)              N/A - No Education Activities
                       Educational Activities List
                       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


OMB 2900-XXXX
Approval expiration 12/31/XX                                               Tab 2
                                                        NPC Annual Report
                                                         Board of Directors
                                                               2011

List members of the board of directors as of May 1, 2012

0

                                                                                 NPC Office Held (Chair,
                                                                              President, Secretary, Treasurer,
           Statutory Board Members                                     Name              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




    OMB 2900-XXXX
    Approval expiration 12/31/XX                               Tab 3
                                                          NPC Annual Report
                                                              Revenues
                                                                2011

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.

                          0

Revenue                                                                                                            Refer to IRS Form 990

                              Research        Education           General             Total                         Form 990           Form 990EZ

Government Funding                                                               $             -    Total = Part VIII, Line 1d            Part I, Line 2
Received                                                                                                    + Line 1e                   Include ONLY
                                                                                                            + (Column A) Line 2g       amounts for Fees
                                                                                                            include ONLY amounts         and contracts -
                                                                                                            for Fees and contracts -       Government
                                                                                                            government
Non-Government Funding                                                                         -    Total = Part VIII, Lines 1 a,b,c   Part I, Line 1 + 2
Received                                                                                                    &f                         MINUS amounts
                                                                                                            + (Column A) Line 2g       included for Fees
                                                                                                            MINUS amounts                 and contracts -
                                                                                                            included for Fees and            government
                                                                                                            contracts - government
Interest, Dividend &                                                                           -    Total = Part VIII (Column A),          Part I, Line 4
Other Investment Income                                                                                     Line 3
                                                                                                            + Line 4
Other Misc. Revenue (do                                                                        -    Total = Part VIII (Column A),      Part I, Line 3 + 5
not include IPA                                                                                             Lines 5, 6d, 7d, 8c, 9c,           through 8
reimbursements or Gov. or                                                                                   10c, & 11e
Non-Gov. Funding)
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!




   OMB 2900-XXXX
   Approval expiration 12/31/XX                                        Tab 4
                                                                                                              NPC Annual Report
                                                                                                                  Expenses
                                                                                                                    2011




Instructions:
Enter expenses in the cells shaded yellow. Totals will calculate automatically.


    0

        IRS Form 990 Part IX Statement of                                                    (B) Program services                   (C)
                                                                                                                                                 (D)
              Functional Expenses                                 (A) Total                                                     Management
                                                                                                                                              Fundraising
                                                                                                                                and General
                                                                                  Research        Education         Total                                           Comments
1       Grants and other assistance to governments       1                                                                                                  1
        and organization in the U.S. See Part IV, line
        21                                                                    -
2       Grants and other assistance to individuals in    2                                                                                                  2
        the U.S., See Part IV, line 22                                        -                                             -
3       Grants and other assistance to governments,      3                                                                                                  3
        organizations and individuals outside the U.S.
        See Part IV, lines 15 and 16                                          -                                             -
4       Benefits paid to or for members                  4                    -                                             -                               4
5       Compensation of current officers, directors,     5                                                                                                  5
        trustees, and key employees                                           -                                             -
6       Compensation not included above, to              6                                                                                                  6
        disqualified persons (as defined under section
        4958(f)(1)) and persons decribed in section
        4958(c)(3)(B)                                                         -                                             -
7       Other salaries and wages                         7                    -                                             -                               7
8       Pension plan contributions (include section 401 8                                                                                                   8
        (k) and section 403 (b) employer contributions
                                                                              -                                             -
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          18                                                                                                 18 Includes reimbursement for costs for any federal, state, or local
   for any federal, state, or local public officials                                                                                                           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)




         OMB 2900-XXXX
         Approval expiration 12/31/XX                                                                                  Tab 5
                                                                                                       NPC Annual Report
                                                                                                           Expenses
                                                                                                             2011




 0




                                                                                      (B) Program services                   (C)
                                                                                                                                          (D)
                                                           (A) Total                                                     Management
                                                                                                                                       Fundraising
                                                                                                                         and General
                                                                           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       24                                                                                                   24   Those items not reportable on lines 1-23.
   covered above (Expenses grouped together and
   labeled miscellaneous may not exceed 5% of
   total expenses shown on line 25 below)
                                                                       -                                             -
 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             e                                                                                              e
   expenses)                                                           -                                             -
                                                                       -                                             -
                                                                       -                                             -
                                                                       -                                             -
                                                                       -                                             -
                                                                       -                                             -
                                                                       -                                             -
  f All other expenses                                 f               -                                             -                                f
25 Total functional expenses. Add lines 1                                                                                                            25
    through 24f                                 25                     -              -                -             -             -             -
26 Joint Costs. Check if following SOP 98-2.                                                                                                         26
    Complete this line only if the organization
    reported in column (B) joint costs from a
    combined educational campaign and
    fundraising solicitation                    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




     OMB 2900-XXXX
     Approval expiration 12/31/XX                                                                               Tab 5
                                      NPC Annual Report
                                       Financial Position
                                             2011



   From IRS Form 990, Part I:

   Enter the figures from Column B, the "Current Year"

   Entries are required in the yellow shaded areas.

                               0

   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)   $                             -




OMB 2900-XXXX
Approval expiration 12/31/XX                     Tab 6
                                                                                      NPC Annual Report
                                                                                 Governmental Funding >$25,000
                                                                                             2011




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
A list of federal government agencies is provided to the right for your reference.                     NIOSH or NCI. Include agencies listed in green, but go up one level for agencies listed in red. Only green
Note that this page should include:                                                                    level agencies should be identified on the form.
 · 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         DHHS     Department of Health & Human Services
Values, or Paste as you normally do, then if the clipboard appears, select Match Destination                    OS         Office of the Secretary
Formatting. Alternatively, after using the Paste feature use the Format Painter to format the pasted            ACF         Administration for Children & Families
rows as the blank rows are formatted.                                                                           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




     OMB 2900-XXXX
     Approval expiration 12/31/XX                                                                  Tab 7
                                  NPC Annual Report
                           Non-Governmental Funding >$25,000
                                        2011
     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




OMB 2900-XXXX
Approval expiration 12/31/XX                     Tab 8
                                  NPC Annual Report
                           Non-Governmental Funding >$25,000
                                        2011




OMB 2900-XXXX
Approval expiration 12/31/XX             Tab 8
                                          NPC Annual Report
                                           Payees >$50,000
                                                2011
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




   OMB 2900-XXXX
   Approval expiration 12/31/XX                      Tab 9
                               NPC Annual Report
                                Payees >$50,000
                                     2011




OMB 2900-XXXX
Approval expiration 12/31/XX         Tab 9
                                          NPC Annual Report
                                         Major Accomplishments
                                                 2011

  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.
                                                                                                      0

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




OMB 2900-XXXX
Approval expiration 12/31/XX                          Tab 10
                                     NPC Annual Report
                                   Educational Activities List
                                             2011
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.
                                                                                               0

                    Educational Activities (Please limit to no more than 10)




 OMB 2900-XXXX
 Approval expiration 12/31/XX                   Tab 11
                                 NPC Annual Report
                               Educational Activities List
                                         2011




OMB 2900-XXXX
Approval expiration 12/31/XX             Tab 11
                                                   NPC Annual Report
                                                      Budget and
                                                   Other Information
                                                          2011

 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*
 0

  1. Projected or estimated data for the next three fiscal years (required by VHA and OMB for budget purporses):
                                                                                        Revenues          Expenses
     Estimated for Fiscal 2012                                                       $                $

       Estimated for Fiscal 2013                                                      $                  $

       Estimated for Fiscal 2014                                                      $                  $

  2. As of the fiscal year-end, the estimated amount of unrestricted net assets available
     for meeting administrative expenses, also known as the administrative reserve
     fund amount. It is important that funds be set aside, if possible, in a reserve
     administrative fund to allow for administrative funding for closing out grants and
     meeting other business obligations if the NPC's operations, revenues, and assets
     suffer an unavoidable downturn.                                                   $

  3. As of the fiscal year-end, the estimated number of months of administrative
     expense that the reserve fund represents. This can be estimated by dividing
     one-twevlth of the annual administrative expenses into the estimated reserve fund
     amount. Please round to the nearest whole month.

  4. Number of full-time employees at this fiscal year-end.

  5. Number of part-time employees at this fiscal year-end.

  6. Total number of employees at this fiscal year-end (total is automatically entered)              0

  7. Number of active principal investigators at this fiscal year-end.

  8. Number of active research projects at this fiscal year-end.

 *This information has been requested by VA Central Office at various points in the year.
 By gathering data at this time, the NPPO has the response when needed.




OMB 2900-XXXX
Approval expiration 12/31/XX                              Tab 12

								
To top