Form990
Click to see attachment
Department of the Treasury
Internal Revenue Service
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung benefit trust or private foundation)

MediumBullet The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0047
2010
Open to Public Inspection
A For the calendar year, or tax year beginning 01-01-2010 and ending 12-31-2010
BCheck if applicable:
CName of organization
ST CLARE HEALTH CARE FOUNDATION INC
 
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
477 N LINDBERGH
 
Room/suite
City or town, state or country, and ZIP + 4
ST LOUIS, MO63141
D Employer identification number

43-1940683
E Telephone number

G Gross receipts $ 487,639
F Name and address of principal officer:
SR MARY JEAN RYAN
477 N LINDBERGH
ST LOUIS,MO63141
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
WWW.SSMHC.COM
H(a)
Is this a group return for
affiliates?
H(b)
Are all affiliates included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet0928
K Form of organization:
 
L Year of formation: 2000
M State of legal domicile: WI
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: FUNDRAISING FOR ST. CLARE HOSPITAL AND HEALTH SERVICES
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) .... 3 16
4 Number of independent voting members of the governing body (Part VI, line 1b) .... 4 15
5 Total number of individuals employed in calendar year 2010 (Part V, line 2a) ... 5 0
6 Total number of volunteers (estimate if necessary) .... 6 39
7a Total unrelated business revenue from Part VIII, column (C), line 12 .. 7a 0
b Net unrelated business taxable income from Form 990-T, line 34 .. 7b 0
Revenues; Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 322,403 395,821
9 Program service revenue (Part VIII, line 2g) ......... 0 0
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... -41,824 91,818
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 0 0
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 280,579 487,639
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 351,054 156,807
14 Benefits paid to or for members (Part IX, column (A), line 4) .... 0 0
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10) 0 53,500
16a Professional fundraising fees (Part IX, column (A), line 11e).... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet53,500    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f).... 52,924 18,839
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 403,978 229,146
19 Revenue less expenses. Subtract line 18 from line 12...... -123,399 258,493
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............ 2,216,401 2,618,392
21 Total liabilities (Part X, line 26)............ 34,000 42,500
22 Net assets or fund balances. Subtract line 21 from line 20 ..... 2,182,401 2,575,892
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title.
Paid Preparer's Use Only Preparer's
signatureBig Right Arrow 		Date
right pointing bullet image Preparer’s taxpayer identification number
(see instructions)
Firm’s name (or yours
if self-employed),
address, and ZIP + 4Big Right Arrow




 		EIN right pointing bullet image
Phone no. right pointing bullet image
May the IRS discuss this return with the preparer shown above? (see instructions) .........
For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2010)
Form 990 (2010)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III . . . . . . . . . .
1
Briefly describe the organization’s mission: THROUGH OUR EXCEPTIONAL HEALTH CARE SERVICES, WE REVEAL THE HEALING PRESENCE OF GOD.
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ....................
If “Yes,” describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services? ..........................
If “Yes,” describe these changes on Schedule O.
4
Describe the exempt purpose achievements for each of the organization’s three largest program services by expenses.
Section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 156,807 including grants of $ 156,807 ) (Revenue $   )
SEE SCHEDULE O.
4b (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4c (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4d Other program services. (Describe in Schedule O.)
(Expenses $   including grants of $   ) (Revenue $   )
4e Total program service expensesMediumBullet$ 156,807
Form 990 (2010)
Form 990 (2010)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If “Yes,” complete Schedule AClick to see attachment.....................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors? Click to see attachment........
2
Yes
 
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part I..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities? If “Yes,” complete Schedule C,
Part II.........................
4
 
No
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If “Yes,” complete Schedule C, Part III........................
5
 
 
6
Did the organization maintain any donor advised funds or any similar funds or accounts where donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If “Yes,” complete
Schedule D, Part IClick to see attachment.......................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas or historic structures? If “Yes,” complete Schedule D, Part IIClick to see attachment...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If “Yes,” complete Schedule D, Part III Click to see attachment....................
8
 
No
9
Did the organization report an amount in Part X, line 21; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If “Yes,”
complete Schedule D, Part IVClick to see attachment...................
9
 
No
10
Did the organization, directly or through a related organization, hold assets in term, permanent,or quasi-endowments? If “Yes,” complete Schedule D, Part VClick to see attachment
10
Yes
 
11
If the organization’s answer to any of the following questions is ‘Yes,’ then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable:
a
Did the organization report an amount for land, buildings, and equipment in Part X, line10? If “Yes,” complete Schedule D, Part VI.Click to see attachment
11a
 
No
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VII.Click to see attachment
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIII.Click to see attachment
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part IX.Click to see attachment
11d
 
No
e
Did the organization report an amount for other liabilities in Part X, line 25? If “Yes,” complete Schedule D, Part X.Click to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If “Yes,” complete Schedule D, Part X.Click to see attachment
11f
Yes
 
12a
Did the organization obtain separate, independent audited financial statements for the tax year? If “Yes,” complete Schedule D, Parts XI, XII, and XIII Click to see attachment
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If “Yes,” and if the organization answered ‘No’ to line 12a, then completing Schedule D, Parts XI, XII, and XIII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, and program service activities outside the United States? If “Yes,” complete Schedule F, Part I.........
14b
 
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the U.S.? If “Yes,” complete Schedule F, Part II..
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the U.S.? If “Yes,” complete Schedule F, Part III..
16
 
No
17
Did the organization report a total of more than $15,000, of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If “Yes,” complete Schedule G, Part I
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If “Yes,” complete Schedule G, Part II..........
18
 
No
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If “Yes,” complete Schedule G, Part III...................
19
 
No
Form 990 (2010)
Form 990 (2010)
Page 4
Part IV
Checklist of Required Schedules (continued)
20a
Did the organization operate one or more hospitals? If “Yes,” complete Schedule H.....
20a
 
No
b
Did the organization attach its audited financial statement to this return? Note: All Form 990 filers that operate one or more hospitals must attach audited financial statements. .....
20b
 
 
21
Did the organization report more than $5,000 of grants and other assistance to governments and organizations in the United States on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II.. Click to see attachment
21
Yes
 
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III..... Click to see attachment
22
 
No
23
Did the organization answer “Yes” to Part VII, Section A, questions 3, 4, or 5, about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If “Yes,” complete Schedule J................ Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer questions 24b–24d and complete Schedule K. If “No,” go to line 25................
24a
 
No
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
 
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
 
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
 
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If “Yes,” complete Schedule L, Part I......
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I................
25b
 
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highly compensated employee, or disqualified person outstanding as of the end of the organization’s tax year? If “Yes,” complete Schedule L,
Part II...........................
26
 
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor, or a grant selection committee member, or to a person related to such an individual? If “Yes,” complete Schedule L, Part III...............
27
 
No
28
Was the organization a party to a business transaction with one of the following parties? (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If “Yes,” complete Schedule L, Part IV .........................
28a
 
No
b
A family member of a current or former officer, director, trustee, or key employee? If “Yes,”
complete Schedule L, Part IV...................
28b
 
No
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or owner? If “Yes,” complete Schedule L, Part IV..
28c
 
No
29
Did the organization receive more than $25,000 in non-cash contributions? If “Yes,” complete Schedule MClick to see attachment
29
Yes
 
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M............ Click to see attachment
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If “Yes,” complete Schedule N,
Part I........................... Click to see attachment
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If “Yes,” complete Schedule N, Part II.......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If “Yes,” complete Schedule R, Part I........ Click to see attachment
33
 
No
34
Was the organization related to any tax-exempt or taxable entity? If “Yes,” complete Schedule R, Parts II, III, IV, and V, line 1..................... Click to see attachment
34
Yes
 
35
Is any related organization a controlled entity within the meaning of section 512(b)(13)? .....
35
 
No
a
Did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If “Yes,” complete Schedule R, Part V, line 2... Click to see attachment
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If “Yes,” complete Schedule R, Part V, line 2........... Click to see attachment
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If “Yes,” complete Schedule R, Part VIClick to see attachment
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11 and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2010)
Form 990 (2010)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V . . . . . . . . . .
Yes
No
1a
Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable. .......
1a
0
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable.
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
 
 
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax Statements filed for the calendar year ending with or within the year covered by this return .....................
2a
0
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?

Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file. (see instructions)
2b
 
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?.............................
3a
 
No
b
If “Yes,” has it filed a Form 990-T for this year? If “No,” provide an explanation in Schedule O.....
3b
 
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account or securities account)?.......................
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If “Yes” to line 5a or 5b, did the organization file Form 8886-T? ........
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible?..........
6a
 
No
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
 
No
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
 
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?..........................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?...................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?...............
7h
 
 
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?................
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?.........
9a
 
 
b
Did the organization make a distribution to a donor, donor advisor, or related person?......
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them.) ........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year.
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. All 501(c)(29) organizations must list in Schedule O each state in which they are licensed to issue qualified health plans, the amount of reserves required by each state, and the amount of reserves the organization allocated to each state.
13a
 
 
b
Enter the aggregate amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans.
13b
 
c
Enter the aggregate amount of reserves on hand.
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
 
b
If "Yes," has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O..
14b
 
 
Form 990 (2010)
Form 990 (2010)
Page 6
Part VI
Governance, Management, and Disclosure For each “Yes” response to lines 2 through 7b below, and for a “No” response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI . . . . . . . . . .
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year ..............
1a
16
b
Enter the number of voting members included in line 1a, above, who are independent .................
1b
15
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
 
No
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? ..
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed?
4
 
No
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Does the organization have members or stockholders? ................
6
Yes
 
7a
Does the organization have members, stockholders, or other persons who may elect one or more members of the governing body? .........................
7a
Yes
 
b
Are any decisions of the governing body subject to approval by members, stockholders, or other persons? ..
7b
Yes
 
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .........................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ............
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If “Yes,” provide the names and addresses in Schedule O .....
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal
Revenue Code.)
Yes
No
10a
Does the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If “Yes,” does the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with those of the organization? ....
10b
 
 
11a
Has the organization provided a copy of this Form 990 to all members of its governing body before filing the form?
11a
Yes
 
b
Describe in Schedule O the process, if any, used by the organization to review the Form 990. .....
12a
Does the organization have a written conflict of interest policy? If “No,” go to line 13.......
12a
Yes
 
b
Are officers, directors or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ...........................
12b
Yes
 
c
Does the organization regularly and consistently monitor and enforce compliance with the policy? If “Yes,” describe in Schedule O how this is done ....................
12c
Yes
 
13
Does the organization have a written whistleblower policy? ...............
13
Yes
 
14
Does the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
Yes
 
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes" to line a or b, describe the process in Schedule O. (See instructions.)
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
 
No
b
If “Yes,” has the organization adopted a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and taken steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
 
 
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
WI
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you make these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how), the organization makes its governing documents, conflict of interest policy, and financial statements available to the public.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization: MediumBullet
RON MICKELSON
FIN SUPERVISOR 707 FOURTEENTH
ST BARABOO,WI53913
(608) 356-1420
Form 990 (2010)
Form 990 (2010)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response to any question in this Part VII . . . . . . . . . .
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation, and current key employees. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

RoundBullet List all of the organization’s current key employees, if any. See instructions for definition of "key employee."
RoundBullet List the organization’s five current highest compensated employees (other than an officer, director, trustee or key employee)
who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the
organization and any related organizations.

RoundBullet List all of the organization’s former officers, key employees, or highest compensated employees who received more than $100,000
of reportable compensation from the organization and any related organizations.

RoundBullet List all of the organization’s former directors or trustees that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organizations compensated any current or former officer, director, or trustee.
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (check all that apply) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(1) ALAN LANGETEIG
DIRECTOR AND PRESIDENT
 1.00 X   X       0 0 0
(2) ANTHONY KUJAWA PHD
DIRECTOR AND VICE PRES
 1.00 X   X       0 0 0
(3) BONNIE SAUEY
DIRECTOR & SECRETARY
 1.00 X   X       0 0 0
(4) KIM KALEPP
DIRECTOR & TREASURER
 1.00 X   X       0 0 0
(5) SANDRA ANDERSON
HOSPITAL PRESIDENT
 1.00 X   X       0 320,096 104,226
(6) JON BERNANDER
DIRECTOR
 1.00 X           0 0 0
(7) LUANNE LUEBKE DREGNE
DIRECTOR
 1.00 X           0 0 0
(8) KATE FITZWILLIAMS
DIRECTOR
 1.00 X           0 0 0
(9) WILLIAM GREENHALGH
DIRECTOR
 1.00 X           0 0 0
(10) ERICH HERBST MD
DIRECTOR
 1.00 X           0 0 0
(11) CHRISTINA HOOK MD
DIRECTOR
 1.00 X           0 0 0
(12) DIANE JACOBSON
DIRECTOR
 1.00 X           0 0 0
(13) MARY KLINGENMEYER
DIRECTOR
 1.00 X           0 0 0
(14) NANCY O'DONNELL
DIRECTOR
 1.00 X           0 0 0
(15) ARNOLD UTZINGER DDS
DIRECTOR
 1.00 X           0 0 0
(16) JOEY VAN DINTER
DIRECTOR
 1.00 X           0 0 0
(17) KERI OLSON
FOUNDATION DIRECTOR
 20.00     X       0 65,256 27,817
Form 990 (2010)
Form 990 (2010)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (check all that apply) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(18) JUNE PICKETT
ASST SECRETARY
 1.00     X       0 220,736 182,149
























1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 0 606,088 314,192
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 in reportable compensation from the organizationMediumBullet0
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If “Yes,” complete Schedule J for such individual .............
3
 
No
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person .....
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 in compensation from the organization MediumBullet0
Form 990 (2010)
Form 990 (2010)
Page 9
Part VIII
Statement of Revenue
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, gifts, grants and other similar amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c  
d Related organizations...1d 19,550
e Government grants (contributions)1e  
f All other contributions, gifts, grants, and
similar amounts not included above1f 		376,271
g Noncash contributions included in lines 1a-1f:$ 66,405
h Total. Add lines 1a-1f.......MediumBullet 395,821
Program Service Revenue Business Code
2a
b
c
d
e
f All other program service revenue .        
g Total. Add lines 2a–2f........MediumBullet  
Other Revenue 3 Investment income (including dividends, interest
and other similar amounts).....MediumBullet 66,139     66,139
4 Income from investment of tax-exempt bond proceeds..MediumBullet        
5 Royalties............MediumBullet        
(i) Real (ii) Personal
6a Gross Rents    
b Less: rental expenses    
c Rental income or (loss)    
d Net rental income or (loss).......MediumBullet        
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory 25,679  
b Less: cost or other basis and sales expenses    
c Gain or (loss) 25,679  
d Net gain or (loss)..........MediumBullet 25,679     25,679
8a Gross income from fundraising events (not including
$  
of contributions reported on line 1c). See Part IV, line 18 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from fundraising events..MediumBullet      
9a Gross income from gaming activities.
See Part IV, line 19 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from gaming activities...MediumBullet        
10a Gross sales of inventory, less
returns and allowances .
a  
b Less: cost of goods sold ..b  
c Net income or (loss) from sales of inventory..MediumBullet        
Miscellaneous Revenue Business Code
11a            
b            
c            
d All other revenue ....        
e Total. Add lines 11a–11d ......MediumBullet  
12 Total revenue. See Instructions....MediumBullet 487,639 0 0 91,818
Form 990 (2010)
Form 990 (2010)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A) but are not required to complete columns (B), (C), and (D).
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII. 		(A)
Total expenses 		(B)
Program service expenses 		(C)
Management and general expenses 		(D)
Fundraising expenses
1 Grants and other assistance to governments and organizations in the U.S. See Part IV, line 21 156,807 156,807
2 Grants and other assistance to individuals in the U.S. See Part IV, line 22    
3 Grants and other assistance to governments, organizations, and individuals outside the U.S. See Part IV, lines 15 and 16    
4 Benefits paid to or for members    
5 Compensation of current officers, directors, trustees, and key employees .... 53,500     53,500
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....        
7 Other salaries and wages        
8 Pension plan contributions (include section 401(k) and section 403(b) employer contributions) ....        
9 Other employee benefits .......        
10 Payroll taxes ...........        
11 Fees for services (non-employees):        
a Management ......        
b Legal .........        
c Accounting ...........        
d Lobbying ...........        
e Professional fundraising. See Part IV, line 17..    
f Investment management fees ...... 18,839   18,839  
g Other ..........        
12 Advertising and promotion ....        
13 Office expenses .......        
14 Information technology ......        
15 Royalties ..        
16 Occupancy ...........        
17 Travel ............        
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ......        
19 Conferences, conventions, and meetings ....        
20 Interest ...........        
21 Payments to affiliates .......        
22 Depreciation, depletion, and amortization .....        
23 Insurance ..............        
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.)
a
b
c
d
e
f All other expenses        
25 Total functional expenses. Add lines 1 through 24f 229,146 156,807 18,839 53,500
26 Joint costs. Check here MediumBullet if following
SOP 98-2 (ASC 958-720). Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation 		       
Form 990 (2010)
Form 990 (2010)
Page 11
Part X Balance Sheet
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash—non-interest-bearing ..........   1 74,833
2 Savings and temporary cash investments ....... 81,234 2 101,316
3 Pledges and grants receivable, net ......... 63,121 3 29,690
4 Accounts receivable, net ......... 25,201 4 25,201
5 Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L ..........   5  
6 Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
Schedule L ..........   6  
7 Notes and loans receivable, net .............   7  
8 Inventories for sale or use ..............   8  
9 Prepaid expenses and deferred charges ............   9  
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a  
b Less: accumulated depreciation. ..... 10b     10c  
11 Investments—publicly traded securities .......... 2,046,845 11 2,387,352
12 Investments—other securities. See Part IV, line 11 ......   12  
13 Investments—program-related. See Part IV, line 11 ..   13  
14 Intangible assets .........   14  
15 Other assets. See Part IV, line 11 ...........   15  
16 Total assets. Add lines 1 through 15 (must equal line 34)... 2,216,401 16 2,618,392
Liabilities 17 Accounts payable and accrued expenses .   17  
18 Grants payable ..........   18  
19 Deferred revenue ..........   19  
20 Tax-exempt bond liabilities ..........   20  
21 Escrow or custodial account liability. Complete Part IV of Schedule D..   21  
22 Payables to current and former officers, directors, trustees, key
employees, highest compensated employees, and disqualified
persons. Complete Part II of Schedule L..........   22  
23 Secured mortgages and notes payable to unrelated third parties ..   23  
24 Unsecured notes and loans payable to unrelated third parties ....   24  
25 Other liabilities. Complete Part X of Schedule D..... 34,000 25 42,500
26 Total liabilities. Add lines 17 through 25..... 34,000 26 42,500
Net Assets or Fund Balance Organizations that follow SFAS 117, check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets ..... 1,111,186 27 1,262,415
28 Temporarily restricted net assets ..... 136,767 28 115,408
29 Permanently restricted net assets ..... 934,448 29 1,198,069
Organizations that do not follow SFAS 117, check here MediumBullet and complete lines 30 through 34.
30 Capital stock or trust principal, or current funds .....   30  
31 Paid-in or capital surplus, or land, building or equipment fund .....   31  
32 Retained earnings, endowment, accumulated income, or other funds   32  
33 Total net assets or fund balances ..... 2,182,401 33 2,575,892
34 Total liabilities and net assets/fund balances ..... 2,216,401 34 2,618,392
Form 990 (2010)
Form 990 (2010)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI . . . . . . . . . .
1
Total revenue (must equal Part VIII, column (A), line 12) . . .
1
487,639
2
Total expenses (must equal Part IX, column (A), line 25) . . . . .
2
229,146
3
Revenue less expenses. Subtract line 2 from line 1 . . . .
3
258,493
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) . .
4
2,182,401
5
Other changes in net assets or fund balances (explain in Schedule O) . . . .
5
134,998
6
Net assets or fund balances at end of year. Combine lines 3, 4, and 5 (must equal Part X, line 33, column (B)) . . . . . .
6
2,575,892
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII . . . . . . . . . .
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?..
2a
 
No
b
Were the organization’s financial statements audited by an independent accountant?........
2b
Yes
 
c
If “Yes,” to 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant?
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O............................
2c
Yes
 
d
If “Yes” to line 2a or 2b, check a box below to indicate whether the financial statements for the year were issued on a separate basis, consolidated basis, or both:
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133? ................
3a
 
No
b
If “Yes,” did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits. ..
3b
 
 
Form 990 (2010)
Additional Data


Software ID:  
Software Version:  
Form 990, Special Condition Description:
Special Condition Description
SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service
Public Charity Status and Public Support

Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
right arrow Attach to Form 990 or Form 990-EZ. right arrow See separate instructions.
OMB No. 1545-0047
2010
Open to Public
Inspection
Name of the organization
ST CLARE HEALTH CARE FOUNDATION INC
 
Employer identification number

43-1940683
Part I
Reason for Public Charity Status (All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
f
g
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization? ................
11g(i)
 
 
(ii) a family member of a person described in (i) above? ......................
11g(ii)
 
 
(iii) a 35% controlled entity of a person described in (i) or (ii) above? ................
11g(iii)
 
 
h
(i)
Name of supported organization 		(ii)
EIN 		(iii)
Type of organization (described on lines 1- 9 above or IRC section (see instructions)) 		(iv)
Is the organization in col. (i) listed in your governing document? 		(v)
Did you notify the organization in col. (i) of your support? 		(vi)
Is the organization in col. (i) organized in the U.S.? 		(vii)
Amount of support?
Yes No Yes No Yes No
Total                  

For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year(or fiscal year beginning in) (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .... 279,193 187,627 299,230 322,403 395,821 1,484,274
2 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......            
3 The value of services or facilities furnished by a governmental unit to the organization without charge..            
4 Total. Add lines 1 through 3.. 279,193 187,627 299,230 322,403 395,821 1,484,274
5 The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..           371,363
6 Public Support. Subtract line 5 from line 4.           1,112,911
Section B. Total Support
Calendar year(or fiscal year beginning in) (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total
7 Amounts from line 4.. 279,193 187,627 299,230 322,403 395,821 1,484,274
8 Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. 49,641 59,159 68,051 56,307 66,139 299,297
9 Net income from unrelated business activities, whether or not the business is regularly carried on..            
10 Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..            
11 Total support (Add lines 7 through 10).           1,783,571
12
12
 
13
Section C. Computation of Public Support Percentage
14
14
62.400 %
15
15
50.920 %
16a
b
17a
b
18
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2)
(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year(or fiscal year beginning in) (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .            
2 Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......            
3 Gross receipts from activities that are not an unrelated trade or business under section 513..            
4 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...            
5 The value of services or facilities furnished by a governmental unit to the organization without charge..            
6 Total. Add lines 1 through 5.            
7a Amounts included on lines 1, 2, and 3 received from disqualified persons...            
b Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.            
c Add lines 7a and 7b..            
8 Public Support (Subtract line 7c from line 6.)            
Section B. Total Support
Calendar year (or fiscal year beginning in) (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total
9 Amounts from line 6...            
10a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..            
b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.            
c Add lines 10a and 10b.            
11 Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.            
12 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)            
13 Total support (Add lines 9, 10c, 11 and 12.).            
14
Section C. Computation of Public Support Percentage
15
15
 
16
16
 
Section D. Computation of Investment Income Percentage
17
17
 
18
18
 
19a
b
20
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 4
Part IV
Supplemental Information. Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
 
Explanation
 
 
 
 
Schedule A (Form 990 or 990-EZ) 2010

Additional Data


Software ID:  
Software Version:  
Schedule B
(Form 990, 990-EZ,
or 990-PF)
Department of the Treasury
Internal Revenue Service
Schedule of Contributors
Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
OMB No. 1545-0047
2010
Name of organization
ST CLARE HEALTH CARE FOUNDATION INC
 
Employer identification number

43-1940683
Organization type (check one):
Filers of:
Section:
Form 990 or 990-EZ





Form 990-PF




Check if your organization is covered by the General Rule or a Special Rule.  
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.
General Rule—
Special Rules
......................... Arrow Bullet   $    
Caution. An Organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2 of its Form 990, or check the box in the heading of its
Form 990-EZ, or on line 2 of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).
For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.
Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2010)

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)
Page 1 of 1 of Part I
Name of organization
ST CLARE HEALTH CARE FOUNDATION INC
  		Employer identification number

43-1940683
Part I
Contributors (see Instructions)
     
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
RESTRICTED
RESTRICTED
 

     
RESTRICTED
RESTRICTED  
RESTRICTED, RESTRICTED   RESTRICTED

$RESTRICTED




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)
Page 1 of 1 of Part II
Name of organization
ST CLARE HEALTH CARE FOUNDATION INC
  		Employer identification number

43-1940683
Part II
Noncash Property (see Instructions)
     
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)
Page 1 of 1 of Part III
Name of organization
ST CLARE HEALTH CARE FOUNDATION INC
  		Employer identification number

43-1940683
Part III
Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
aggregating more than $1,000 for the year. (Complete columns (a) through (e) and the following line entry.)
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet $  
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Additional Data


Software ID:  
Software Version:  
SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11, or 12.
SchDMd Bullet Attach to Form 990. SchDMd Bullet See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
ST CLARE HEALTH CARE FOUNDATION INC
 
Employer identification number

43-1940683
Part I
Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.
(a) Donor advised funds (b) Funds and other accounts
1 Total number at end of year .......    
2 Aggregate contributions to (during year) ...    
3 Aggregate grants from (during year) ...    
4 Aggregate value at end of year .......    
5
Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............
6
Did the organization inform all grantees, donors, and donor advisors in writing that grant funds may be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit. ...................................
Part II
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
Complete lines 2a–2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.
Held at the End of the Year
a Total number of conservation easements ....................... 2a  
b Total acreage restricted by conservation easements .................. 2b  
c Number of conservation easements on a certified historic structure included in (a) ..... 2c  
d Number of conservation easements included in (c) acquired after 8/17/06 ........ 2d  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the taxable year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................
6
Staff and volunteer hours devoted to monitoring, inspecting and enforcing conservation easements during the year SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year SchDMd Bullet $  
8
Does each conservation easement reported on line 2(d) above satisfy the requirements of section
170(h)(4)(B)(i) and 170(h)(4)(B)(ii)? ....................................
9
In Part XIV, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.
1a
If the organization elected, as permitted under SFAS 116, not to report in its revenue statement and balance sheet works of
art, historical treasures, or other similar assets held for public exhibition, education or research in furtherance of public service,
provide, in Part XIV, the text of the footnote to its financial statements that describes these items.
b
If the organization elected, as permitted under SFAS 116, to report in its revenue statement and balance sheet works of art,
historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service,
provide the following amounts relating to these items:
(i)
Revenues included in Form 990, Part VIII, line 1 ........................SchDMd Bullet $  
(ii)
Assets included in Form 990, Part X ..............................SchDMd Bullet $  
2
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 relating to these items:
a
Revenues included in Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 52283D
Schedule D (Form 990) 2010

Schedule D (Form 990) 2010
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
Using the organization’s accession and other records, check any of the following that are a significant use of its collection
items (check all that apply):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIV.
5
During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........
Part IV
Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b
If "Yes," explain the arrangement in Part XIV and complete the following table:
Amount
c Beginning balance ................................. 1c  
d Additions during the year .............................. 1d  
e Distributions during the year ............................. 1e  
f Ending balance ................................... 1f  
2a
Did the organization include an amount on Form 990, Part X, line 21? .....................
b
If “Yes,” explain the arrangement in Part XIV.
Part V
Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
(a)Current Year (b)Prior Year (c)Two Years Back (d)Three Years Back (e)Four Years Back
1a Beginning of year balance .... 1,971,430 1,687,925 2,061,990
b Contributions ........ 312,760 135,436 78,318
c Investment earnings or losses ... 199,340 237,889 -285,074
d Grants or scholarships .....      
e Other expenditures for facilities
and programs ........ 		66,489 89,820 167,309
f Administrative expenses ....      
g End of year balance ...... 2,417,041 1,971,430 1,687,925
2
Provide the estimated percentage of the year end balance held as:
a
Board designated or quasi-endowment: SchDMd Bullet50.400 %
b
Permanent endowment: SchDMd Bullet49.600 %
c
Term endowment: SchDMd Bullet  
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) unrelated organizations ........................
3a(i)
Yes
 
(ii) related organizations ........................
3a(ii)
 
No
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
 
 
4
Describe in Part XIV the intended uses of the organization's endowment funds.
Part VI
Investments—Land, Buildings, and Equipment. See Form 990, Part X, line 10.
Description of investment (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .................      
b Buildings ................        
c Leasehold improvements ............        
d Equipment ................        
e Other .................        
Total. Add lines 1a-1e. (Column (d) should equal Form 990, Part X, column (B), line 10(c).)........SchDMdBullet 0
Schedule D (Form 990) 2010

Schedule D (Form 990) 2010
Page 3
Part VII
Investments—Other Securities. See Form 990, Part X, line 12.
(a) Description of security or category
(including name of security)		 (b)Book value (c) Method of valuation:
Cost or end-of-year market value
(1)Financial derivatives    
(2)Closely-held equity interests    
Other








Total. (Column (b) should equal Form 990, Part X, col.(B) line 12.)Small Bullet  
Part VIII
Investments—Program Related. See Form 990, Part X, line 13.
(a) Description of investment type (b) Book value (c) Method of valuation:
Cost or end-of-year market value








Total. (Column (b) should equal Form 990, Part X, col.(B) line 13.)Small Bullet  
Part IX
Other Assets. See Form 990, Part X, line 15.
(a) Description (b) Book value








Total. (Column (b) should equal Form 990, Part X, col.(B) line 15.)...........Small Bullet  
Part X
Other Liabilities. See Form 990, Part X, line 25.
1.(a) Description of Liability (b) Amount
Federal Income Taxes  
DUE TO AFFILIATE 42,500








Total. (Column (b) should equal Form 990, Part X, col.(B) line 25.)Small Bullet 42,500
2. Fin 48 (ASC 740) Footnote. In Part XIV, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC740).
Schedule D (Form 990) 2010

Schedule D (Form 990) 2010
Page 4
Part XI Reconciliation of Change in Net Assets from Form 990 to Financial Statements
1 Total revenue (Form 990, Part VIII, column (A), line 12) .................... 1  
2 Total expenses (Form 990, Part IX, column (A), line 25) ..................... 2  
3 Excess or (deficit) for the year. Subtract line 2 from line 1 ............. 3  
4 Net unrealized gains (losses) on investments .......................... 4  
5 Donated services and use of facilities ............................. 5  
6 Investment expenses ................................... 6  
7 Prior period adjustments .................................. 7  
8 Other (Describe in Part XIV) ................................. 8  
9 Total adjustments (net). Add lines 4 - 8 ............................. 9  
10 Excess or (deficit) for the year per financial statements. Combine lines 3 and 9 ......... 10  
Part XII Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1 Total revenue, gains, and other support per audited financial statements ....... 1  
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains on investments .......... 2a  
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIV): ............ 2d  
e Add lines 2a through 2d ..................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b . 4a  
b Other (Describe in Part XIV): ........... 4b  
c Add lines 4a and 4b....................... 4c  
5 Total Revenue. Add lines 3 and 4c. (This should equal Form 990, Part I, line 12.) ...... 5  
Part XIII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1 Total expenses and losses per audited financial statements ............. 1  
2 Amounts included on line 1 but not on Form 990, Part IX, line 25:
a Donated services and use of facilities .......... 2a  
b Prior year adjustments .............. 2b  
c Other losses ................ 2c  
d Other (Describe in Part XIV): ............ 2d  
e Add lines 2a through 2d...................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part IX, line 25, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b .. 4a  
b Other (Describe in Part XIV): ............ 4b  
c Add lines 4a and 4b....................... 4c  
5 Total expenses. Add lines 3 and 4c. (This should equal Form 990, Part I, line 18.) ...... 5  
Part XIV
Supplemental Information
Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X; Part XI, line 8; Part XII, lines 2d and 4b; and Part XIII, lines 2d and 4b. Also complete this part to provide any additional information.
Identifier Return Reference Explanation
DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: ST. CLARE FOUNDATION SUPPORTS ST. CLARE HOSPITAL'S (SCH) CAPITAL NEEDS AND OTHER LOCAL HEALTH CARE PROGRAMS AS DESIGNATED BY THE FOUNDATION'S BOARD OF DIRECTORS. THE FAITH ENDOWMENT SUPPORTS CHEMICALLY DEPENDENT AND CO-DEPENDENT POPULATION SERVED BY ST. CLARE CENTER. JEAN DIEHM FUND SUPPORTS ST. CLARE HOSPITAL AUXILIARY'S SPONSORSHIP OF ANNUAL CAPITAL NEEDS AND MEDICAL EQUIPMENT FOR SCH. THE RESIDENCY TRAINING PROGRAM SUPPORTS BARABOO RURAL RESIDENCY TRAINING PROGRAM BY HELPING OFFSET COSTS FOR BOOKS, EQUIPMENT, AND DEFICITS INCURRED BY SCH IN SUPPORT OF THE PROGRAM.
DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: ST. CLARE HEALTH CARE FOUNDATION, INC.'S FINANCIAL INFORMATION IS INCLUDED IN THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS OF A RELATED ORGANIZATION, SSM HEALTH CARE (SSMHC). SSMHC EVALUATES ITS UNCERTAIN TAX POSITIONS ON AN ANNUAL BASIS. A TAX BENEFIT FROM AN UNCERTAIN TAX POSITION MAY BE RECOGNIZED WHEN IT IS MORE LIKELY THAN NOT THAT THE POSITION WILL BE SUSTAINED UPON EXAMINATION, INCLUDING RESOLUTIONS OF ANY RELATED APPEALS OR LITIGATION PROCESSES, BASED ON THE TECHNICAL MERITS. THERE HAVE BEEN NO UNCERTAIN TAX POSITIONS RECORDED IN 2010 OR 2009.
Schedule D (Form 990) 2010

Additional Data


Software ID:  
Software Version:  




Schedule I
(Form 990)
Department of the Treasury
Internal Revenue Service
Grants and Other Assistance to Organizations,
Governments and Individuals in the United States
Complete if the organization answered "Yes," to Form 990, Part IV, line 21 or 22.
lBullet Attach to Form 990
OMB No. 1545-0047
2010
Open to Public
Inspection
Name of the organization
ST CLARE HEALTH CARE FOUNDATION INC
 
Employer identification number
43-1940683
Part I
General Information on Grants and Assistance
1
Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ....................................
2
Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.
Part II
Grants and Other Assistance to Governments and Organizations in the United States. Complete if the organization answered "Yes" to
Form 990, Part IV, line 21 for any recipient that received more than $5,000. Check this box if no one recipient received more than $5,000. Use
Part IV and Schedule I-1 (Form 990) if additional space is needed ......................... lBullet
(a) Name and address of organization
or government		 (b) EIN (c) IRC Code section
if applicable		 (d) Amount of cash grant (e) Amount of non-cash
assistance		 (f) Method of valuation
(book, FMV, appraisal,
other)		 (g) Description of
non-cash assistance		 (h) Purpose of grant
or assistance
(1) ST CLARE HOSPITAL707 FOURTEENTH ST
BARABOO,WI53913 		39-1023846 501(C)(3) 123,737 15,321 BOOK GIFT IN KIND HOSPITAL ACTIVITIES
(2) ST CLARE HOSPITAL AUXILIARY707 FOURTEENTH ST
BARABOO,WI53913 		39-1023846 501(C)(3) 8,417       PURCHASE MEDICAL EQUIPMENT




















2
Enter total number of section 501(c)(3) and government organizations ......................... Bullet Image
2
3
Enter total number of other organizations ................................ . Bullet Image
 
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50055P
Schedule I (Form 990) 2010

Schedule I (Form 990) 2010
Page 2
Part III
Grants and Other Assistance to Individuals in the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 22.
Use Schedule I-1 (Form 990) if additional space is needed.
(a)Type of grant or assistance (b)Number of
recipients		 (c)Amount of
cash grant		 (d)Amount of
non-cash assistance		 (e)Method of valuation (book,
FMV, appraisal, other)		 (f)Description of non-cash assistance













Part IV
Supplemental Information. Complete this part to provide the information required in Part I, line 2, and any other additional information.
Identifier Return Reference Explanation
PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ORGANIZATION USES SEVERAL METHODS FOR MONITORING THE USE OF GRANT FUNDS. MOST GRANTS TO ORGANIZATIONS ARE MADE TO RELATED ORGANIZATIONS THAT ARE TAX EXEMPT UNDER SECTION 501(C)(3). THESE ORGANIZATIONS HAVE DEVELOPED INTERNAL CONTROL PROCEDURES FOR THE USE OF GRANT FUNDS. OTHER FUNDS ARE EITHER GRANTED FOR PRE-APPROVED PROGRAMS OR DOCUMENTATION IS REQUESTED ON A REGULAR BASIS FROM THE GRANT RECIPIENTS.
Schedule I (Form 990) 2010


Additional Data


Software ID:  
Software Version:  


Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
SchJMediumBullet Attach to Form 990. SchJMediumBullet See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
ST CLARE HEALTH CARE FOUNDATION INC
 
Employer identification number

43-1940683
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement orprovision of all the expenses described above? If "No," complete Part III to explain....
1b
 
 
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
officers, directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a? ....
2
 
 
3
Indicate which, if any, of the following the organization uses to establish the compensation of the
organization's CEO/Executive Director. Check all that apply.
4
During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment? ...............
4a
 
No
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? ........
4b
Yes
 
c
Participate in, or receive payment from, an equity-based compensation arrangement? ........
4c
 
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.
5
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization? ...........................
5a
 
No
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization? ...........................
6a
 
No
b
Any related organization? .........................
6b
 
No
If "Yes," to line 6a or 6b, describe in Part III.
7
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............
7
 
No
8
Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regs. section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................
8
 
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 50053T
Schedule J (Form 990) 2010

Schedule J (Form 990) 2010
Page 2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use Schedule J-1 if additional space needed.
For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.

Note. The sum of columns (B)(i)-(iii) must equal the applicable column (D) or column (E) amounts on Form 990, Part VII, line 1a.
(A) Name (B) Breakdown of W-2 and/or 1099-MISC compensation (C) Retirement and other deferred compensation (D) Nontaxable
benefits		 (E) Total of columns
(B)(i)-(D) 		(F) Compensation
reported in prior
Form 990 or
Form 990-EZ
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
(1) SANDRA ANDERSON (i)
(ii)		 0
280,933 		0
0 		0
39,163 		0
80,864 		0
23,362 		0
424,322 		0
0
(2) JUNE PICKETT (i)
(ii)		 0
207,649 		0
0 		0
13,087 		0
163,178 		0
18,971 		0
402,885 		0
0














Schedule J (Form 990) 2010

Schedule J (Form 990) 2010
Page 3
Part III
Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 4c, 5a, 5b, 6a, 6b, 7, and 8. Also complete this part for any additional information.
Identifier Return Reference Explanation
SUPPLEMENTAL INFORMATION PART III PART I, LINE 3: COMPENSATION TO CEO/EXECUTIVE DIRECTOR THE ORGANIZATION'S CEO IS COMPENSATED BY A RELATED ORGANIZATION THAT UTILIZED THE FOLLOWING TO DETERMINE COMPENSATION: (1) INDEPENDENT COMPENSATION CONSULTANT; (2) WRITTEN EMPLOYMENT CONTRACT; (3) COMPENSATION SURVEY OR STUDY; (4) APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. PART I, LINE 4A: SEVERANCE PLAN SSMHC HAS ADOPTED A SEVERANCE POLICY TO PROVIDE A FINANCIAL TRANSITION IN THE EVENT OF INVOLUNTARY TERMINATION WITHOUT CAUSE FOR EXECUTIVE LEVEL POSITIONS. THE AMOUNT OF THE COMPENSATION IS BASED ON THE POSITION HELD AND LENGTH OF SERVICE WITH SSMHC.SUPPLEMENTAL NONQUALIFIED RETIREMENT PLANS PART I, LINE 4B: SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN PENSION RESTORATION PLAN: SSM HEALTH CARE ("SSMHC") PROVIDES THIS SUPPLEMENTAL DEFINED BENEFIT NONQUALIFIED RETIREMENT PLAN TO ANY EMPLOYEE WHO PARTICIPATES IN THE SSMHC QUALIFIED DEFINED BENEFIT PLAN WHO EARNS OVER THE INTERNAL REVENUE SERVICE COMPENSATION LIMIT. THE PLAN "RESTORES" THE BENEFITS TO THESE EMPLOYEES THAT WOULD HAVE BEEN PROVIDED UNDER SSMHC'S QUALIFIED PLAN IF THE REGULATIONS DID NOT IMPOSE COMPENSATION LIMITS. AN INDIVIDUAL CAN TAKE A DISTRIBUTION FROM THE PLAN AT (1) AGE 65 OR OLDER IF THE INDIVIDUAL IS STILL EMPLOYED BY SSMHC OR (2) AGE 55 OR OLDER IF THE INDIVIDUAL IS NO LONGER EMPLOYED BY SSMHC. NO REPORTABLE INDIVIDUALS LISTED IN PART VII RECEIVED DISTRIBUTIONS FROM THE PLAN DURING 2010. CAPITAL ACCUMULATION PLAN: SSMHC PROVIDES THIS SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN TO EXECUTIVE LEVEL EMPLOYEES. THE ORGANIZATION CONTRIBUTED A PERCENTAGE OF THE EMPLOYEE'S BASE SALARY INTO THEIR CHOICE OF A SELECT LIST OF INVESTMENTS. THE DEPOSITS AND EARNINGS OF THE PLAN ARE OWNED BY SSMHC AND ARE TAX-DEFERRED UNTIL A DISTRIBUTION IS MADE TO THE EMPLOYEE. IN ADDITION, THE PLAN HAS SPECIAL SAFEGUARDS IN PLACE TO PROTECT THE FUNDS FROM CONTINGENCIES, OTHER THAN INSOLVENCY. FOR CONTRIBUTIONS MADE TO THE PLAN IN 2008 OR AFTER, THE DISTRIBUTION WILL OCCUR AFTER THE COMPLETION OF TWO PLAN YEARS FOR ALL EXECUTIVES THAT ARE STILL ACTIVELY EMPLOYED ON THE DISTRIBUTION DATE. ANY ACTIVE PARTICIPANT 65 YEARS OR OLDER WILL RECEIVE THE CONTRIBUTION IN THE CURRENT YEAR. THE FOLLOWING INDIVIDUALS LISTED ON PART VII OF THE FORM 990 RECEIVED DISTRIBUTIONS FROM THIS PLAN IN 2010. ALL DISTRIBUTIONS RECEIVED FROM THE PLAN IN THE CURRENT YEAR WERE INCLUDED IN THE INDIVIDUALS' TAXABLE COMPENSATION. SANDRA ANDERSON $19,017 JUNE PICKETT $ 7,123
Schedule J (Form 990) 2010

Additional Data


Software ID:  
Software Version:  
SCHEDULE M
(Form 990)

Department of the Treasury
Internal Revenue Service
NonCash Contributions
Right pointing arrow large imageComplete if the organization answered "Yes" on Form 990, Part IV, lines 29 or 30.
Right pointing arrow large image Attach to Form 990.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
ST CLARE HEALTH CARE FOUNDATION INC
 
Employer identification number

43-1940683
Part I
Types of Property
(a)
Check if applicable 		(b)
Number of Contributions or items contributed 		(c)
Contribution amounts reported on
Form 990, Part VIII, line 1g 		(d)
Method of determining
contribution amounts
1 Art—Works of art .... X 3 548 OTHER
2 Art—Historical treasures .        
3 Art—Fractional interests ..        
4 Books and publications ..      
5 Clothing and household
goods ....... 		X 3,565 OTHER
6 Cars and other vehicles ..        
7 Boats and planes ....        
8 Intellectual property ...        
9 Securities—Publicly traded . X 1 62,292 COST OR SELLING PRICE
10 Securities—Closely held stock .        
11 Securities—Partnership, LLC,
or trust interests .... 		       
12 Securities—Miscellaneous ..        
13 Qualified conservation
contribution—Historic
structures ..... 		       
14 Qualified conservation
contribution—Other ... 		       
15 Real estate—Residential .        
16 Real estate—Commercial ..        
17 Real estate—Other ...        
18 Collectibles .....        
19 Food inventory ...        
20 Drugs and medical supplies .        
21 Taxidermy ......        
22 Historical artifacts ....        
23 Scientific specimens ..        
24 Archeological artifacts ...        
25 Other Right pointing arrow large image ( )
26 Other Right pointing arrow large image( )
27 Other Right pointing arrow large image( )
28 Other Right pointing arrow large image ( )
29
Number of Forms 8283 received by the organization during the tax year for contributions
for which the organization completed Form 8283, Part IV, Donee Acknowledgement ...
29
0
Yes
No
30a
During the year, did the organization receive by contribution any property reported in Part I, lines 1-28 that it
must hold for at least three years from the date of the initial contribution, and which is not required to be used
for exempt purposes for the entire holding period? ..................
30a
 
No
b
If "Yes," describe the arrangement in Part II.
31
Does the organization have a gift acceptance policy that requires the review of any non-standard contributions?
31
Yes
 
32a
Does the organization hire or use third parties or related organizations to solicit, process, or sell non-cash
contributions? ............................
32a
 
No
b
If "Yes," describe in Part II.
33
If the organization did not report revenues in column (c) for a type of property for which column (a) is checked,
describe in Part II.
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 51227J
Schedule M (Form 990) 2010
Schedule M (Form 990) 2010
Page 2
Part II
Supplemental Information. Complete this part to provide the information required by Part I, lines 30b,
32b, and 33. Also complete this part for any additional information.
Identifier Return Reference Explanation
METHOD FOR DETERMINING NUMBER OF CONTRIBUTORS: PART I, COLUMN (B): THE AMOUNT INCLUDED IN PART I, COLUMN B REFERS TO THE NUMBER OF CONTRIBUTORS FOR EACH TYPE OF NONCASH DONATION.
Schedule M (Form 990) 2010
Additional Data


Software ID:  
Software Version:  
SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
MediumBullet Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2010
Open to Public
Inspection
Name of the organization
ST CLARE HEALTH CARE FOUNDATION INC
 
Employer identification number

43-1940683
Identifier Return Reference Explanation
PROGRAM SERVICE STATEMENT FORM 990, PART III, LINE 4A: SINCE IT WAS FOUNDED IN 1872 BY CATHOLIC SISTERS, SSM HEALTH CARE (SSMHC) HAS EXISTED TO MEET THE HEALTH NEEDS OF THE COMMUNITIES IT SERVES. SPONSORED BY THE FRANCISCAN SISTERS OF MARY AND HEADQUARTERED IN ST. LOUIS, MISSOURI, SSMHC OPERATES 16 HOSPITAL LOCATIONS, TWO SKILLED NURSING FACILITIES AND HOME HEALTH AGENCIES IN FOUR STATES. THE HEALTH SYSTEM EMPLOYS APPROXIMATELY 22,000 PEOPLE AND IS AFFILIATED WITH MORE THAN 5,000 PHYSICIANS. IN THE TRADITION OF ITS FOUNDING SISTERS, SSMHC STRIVES TO FULFILL ITS MISSION BY PROVIDING EXCEPTIONAL HEALTH CARE TO EVERYONE WHO COMES TO ITS HOSPITALS, REGARDLESS OF THEIR ABILITY TO PAY. IN 2010, ST. CLARE HEALTH CARE FOUNDATION SPONSORED APPROXIMATELY 40 PIECES OF MEDICAL EQUIPMENT AND OTHER NEEDS FOR ST. CLARE FACILITIES IN BARABOO, LAKE DELTON AND WISCONSIN DELLS. THE EQUIPMENT INCLUDES TWO HEMODIALYSIS MACHINES AND CRIT LINES FOR THE ST. CLARE DIALYSIS CENTER, A UROLOGY SCOPE FOR ST. CLARE HOSPITAL'S SURGERY DEPARTMENT, PORTABLE VITAL SIGN MACHINES FOR THE EMERGENCY DEPARTMENT, PORTABLE VITAL SIGN MACHINES AND A BLANKET WARMER FOR THE NEW WISCONSIN DELLS URGENT CARE CLINIC, AN UPRIGHT FITNESS BICYCLE AND WRIST OXIMETER FOR CARDIAC REHAB, A CONTINUOUS GLUCOSE MONITOR FOR THE DIABETES EDUCATION DEPARTMENT, ROLL-ON CUFFS FOR THE ANESTHESIA DEPARTMENT, A NEONATAL RESUSCITATOR FOR THE CHILDBIRTH CENTER, AND AN OCCUPATIONAL THERAPY TABLE FOR ST. CLARE MEADOWS CARE CENTER'S REHABILITATION SERVICES DEPARTMENT. IN ADDITION TO SUPPORT PROVIDED TO ST. CLARE HOSPITAL, ST. CLARE HEALTH CARE FOUNDATION SUPPORTS PROGRAMS AND ACTIVITIES THAT IMPROVE ACCESS TO HEALTH CARE AND IMPROVE HEALTH IN OUR COMMUNITIES. THROUGH ITS PATHWAYS TO WELLNESS INITIATIVE, THE FOUNDATION HAS DEVELOPED AND SPONSORED HEALTH AND WELLNESS PROGRAMS AND ACTIVITIES AS A WAY TO GIVE BACK TO THE COMMUNITY. IN 2010, THE FOUNDATION CO-SPONSORED WITH ST. CLARE HOSPITAL'S NUTRITION SERVICES DEPARTMENT "EATING FROM THE RAINBOW," A PROGRAM ABOUT EATING A RAINBOW OF FRUITS AND VEGETABLES AND GETTING ADEQUATE PHYSICAL ACTIVITY, TO THIRD GRADE STUDENTS IN THE BARABOO AND WISCONSIN DELLS SCHOOL DISTRICTS. THE ST. CLARE HEALTH CARE FOUNDATION ALSO OFFERS ANNUAL HEALTHY COMMUNITY PARTNERSHIP GRANTS TO AREA BUSINESSES AND ORGANIZATIONS THAT ARE ENGAGED IN PROJECTS THAT ADVANCE COMMUNITY HEALTH AND WELLNESS. WITH FUNDING FROM THE FOUNDATION'S ENDOWMENT, EIGHT HEALTHY COMMUNITY PARTNERSHIP GRANTS, TOTALING $6,000, WERE ISSUED IN 2010 TO: BARABOO DISTRICT AMBULANCE SERVICE - $500 FOR COMMUNITY PARAMEDIC PILL ORGANIZER DISTRIBUTION PROGRAM, BARABOO FOOD PANTRY - $500 FOR REFRIGERATORS AND FREEZERS FOR NEW PANTRY LOCATION, CENTRAL WISCONSIN COMMUNITY ACTION COUNCIL - $2,000 FOR BADGER CARE CORE PLUS RENEWAL FEES, HOPE HOUSE - $500 FOR FAITH LEADERS DOMESTIC AND SEXUAL VIOLENCE PROGRAM, SAUK COUNTY HEALTH DEPARTMENT - $1,000 FOR THE SOUTH SCHOOL DENTAL SEALANT PROGRAM, SAUK COUNTY HEALTH DEPARTMENT - $500 FOR CAR SEAT DISTRIBUTION TO QUALIFYING FAMILIES, SPIRIT LAKE WELLNESS - $500 FOR TWO PUBLIC WELLNESS PROGRAMS, AND TRINITY EPISCOPAL CHURCH - $500 FOR COMMUNITY HEART SAVER PROGRAM. IN ADDITION TO THE GRANTS, THE FOUNDATION DISTRIBUTED $2,500 TO HOME HEALTH UNITED FROM ITS HOSPICE FUND TO HELP SUSTAIN THE ST. CLARE HOSPICE HOUSE RESIDENT FUND, A CHARITY CARE FUND FOR QUALIFYING HOSPICE HOUSE PATIENTS TO HELP ASSIST THEM WITH THE ROOM AND BOARD FEES. THE FOUNDATION ALSO PROVIDED IN-KIND SUPPORT FOR THE ST. CLARE 5K WALK-RUN AND FESTIVAL OF LOVE & LIGHT, BY SPONSORING THE COST OF PROMOTIONAL LITERATURE PRINTING AND/OR DESIGN. ADDITIONAL INFORMATION REGARDING SSMHC'S COMMUNITY BENEFIT REPORT CAN BE FOUND AT WWW.SSMHC.COM.
FORM 990, PART VI, SECTION A, LINE 6   THE CORPORATE MEMBER IS SSM HEALTH CARE OF WISCONSIN, INC.
FORM 990, PART VI, SECTION A, LINE 7A   THE MEMBER HAS THE POWER TO APPOINT AND REMOVE BOARD OF DIRECTOR MEMBERS, WITH OR WITHOUT CAUSE, EXCEPT FOR THOSE WHO SERVE EX OFFICIO.
FORM 990, PART VI, SECTION A, LINE 7B   THE MEMBER HAS THE FOLLOWING POWERS: A. TO ESTABLISH AND CHANGE THE PHILOSOPHY OF THE CORPORATION B. TO APPOINT THE BOARD OF DIRECTORS, EXCEPT FOR THE DIRECTORS NAMED IN THE ARTICLES OF INCORPORATION FOR THEIR INITIAL TERM AND EXCEPT FOR ANY DIRECTOR WHO SERVES EX OFFICIO, AND TO REMOVE THE DIRECTORS WITH OR WITHOUT CAUSE C. TO APPROVE AMENDMENTS TO THE ARTICLES OF INCORPORATION OF THE CORPORATION AS PROVIDED IN THE BYLAWS D. TO APPROVE THE BYLAWS OF THE CORPORATION AND ANY AMENDMENTS THERETO E. TO APPROVE THE MERGER, CONSOLIDATION OR DISSOLUTION OF THE CORPORATION F. TO APPROVE THE SALE, CONVEYANCE, ASSIGNMENT, TRANSFER, ALIENATION, PLEDGE, ENCUMBRANCE, MORTGAGE OR LEASE OF REAL PROPERTY OR ANY INTEREST THEREIN OF THE CORPORATION IN ACCORDANCE WITH THE POLICIES APPROVED BY THE MEMBER G. TO APPROVE (I) THE ACQUISITION OF REAL PROPERTY OR ANY INTEREST THEREIN OR (II) THE ACQUISITION OF STOCK OF A CORPORATION IF, AFTER THE ACQUISITION, THE CORPORATION WILL OWN A MAJORITY OF THE VOTING STOCK OF SUCH CORPORATION, IN ACCORDANCE WITH POLICIES APPROVED BY THE MEMBER H. TO APPROVE THE SALE, TRANSFER OR OTHER DISPOSITION OF THE VOTING STOCK OF A CORPORATION IF BEFORE THE DISPOSITION THE CORPORATION OWNED A MAJORITY OF THE VOTING STOCK OF THE CORPORATION AND AFTER SUCH DISPOSITION THE CORPORATION WOULD NOT OWN A MAJORITY OF THE VOTING STOCK OF THE CORPORATION, IN ACCORDANCE WITH POLICIES APPROVED BY THE MEMBER I. TO APPROVE ANY BORROWINGS OR GUARANTEES OF THE CORPORATION IN ACCORDANCE WITH POLICIES APPROVED BY THE MEMBER J. TO ESTABLISH CENTRALIZED EMPLOYEE BENEFIT, INSURANCE, INVESTMENT, FINANCING, CORPORATE RESPONSIBILITY, PERFORMANCE ASSESSMENT AND IMPROVEMENT AND OTHER OPERATIONAL AND SUPPORT PROGRAMS, TO REQUIRE THE PARTICIPATION OF THE CORPORATION IN SUCH PROGRAMS, AND TO AUTHORIZE THE OPENING AND CLOSING OF BANK ACCOUNTS AND INVESTMENT ACCOUNTS IN THE NAME OF THE CORPORATION IN CONNECTION WITH SUCH PROGRAMS K. TO APPROVE THE ACCEPTANCE OF ANY GIFT OR CONTRIBUTION WHICH, IN CONNECTION THEREWITH, WOULD IMPOSE A CONTINUING OBLIGATION UPON THE CORPORATION, INCLUDING, WITHOUT LIMITATION, THE OBLIGATION TO PROVIDE HEALTH CARE SERVICES, PAY AN ANNUITY OR UNDERTAKE ANY OTHER OBLIGATIONS, EXCEPT AS OTHERWISE DETERMINED BY THE MEMBER PURSUANT TO POLICIES ADOPTED BY THE MEMBER AND L. TO APPROVE OR REJECT PROPOSALS FOR EXPENDITURES OR CONTRIBUTIONS IN ACCORDANCE WITH ARTICLE IX OF THE BYLAWS IN THE EVENT THE PRESIDENT OF THE HOSPITAL AND THE BOARD OF DIRECTORS DO NOT AGREE WITH RESPECT TO THE APPROVAL OF SUCH PROPOSAL.
FORM 990, PART VI, SECTION B, LINE 11   ACCOUNTING/FINANCE PERSONNEL AT EACH SSMHC (SSM HEALTH CARE SYSTEM) ENTITY, IN CONJUNCTION WITH CORPORATE FINANCE PERSONNEL, PREPARE A CHECKLIST CONTAINING INFORMATION AND SUPPORTING SCHEDULES THAT ARE USED TO PREPARE THE FORM 990. THIS CHECKLIST IS THEN REVIEWED BY A SUPERVISOR/MANAGER AND SENT TO THE CORPORATE OFFICE FOR FINAL REVIEW AND COORDINATION OF THE SYSTEM LEVEL FORM 990 INFORMATION. THE INFORMATION IS SUBMITTED TO AN OUTSIDE TAX CONSULTING FIRM WHO PREPARES AND SIGNS THE FORM 990 FROM THE SSMHC INFORMATION. PRIOR TO FINALIZING THE RETURN, A DRAFT IS SENT TO PERSONNEL AT SSMHC FOR REVIEW AND APPROVAL. UPON SSMHC FINAL APPROVAL, THE OUTSIDE PREPARER FORWARDS THE COMPLETED FORM 990 FOR THE APPROPRIATE SIGNATURES AND FILING ACTION. A COMPLETE COPY OF THE RETURN IS PROVIDED TO THE BOARD PRIOR TO FILING WITH THE IRS.
  FORM 990, PART VI, SECTION B, LINE 12C BOARD MEMBERS ARE REQUIRED TO COMPLETE A CONFLICT OF INTEREST DISCLOSURE STATEMENT ANNUALLY. THE PRESIDENT AND SECRETARY TO THE BOARD OVERSEE COMPLIANCE WITH THIS REQUIREMENT. ALL BOARD MEMBERS WITH AN IDENTIFIED CONFLICT OF INTEREST ABSTAIN FROM BOARD DISCUSSIONS AND VOTES WHEN APPLICABLE. EMPLOYEES WITH PURCHASING AUTHORITY AND/OR ABILITY TO INFLUENCE PURCHASING DECISIONS ARE ASSIGNED THE CONFLICT OF INTEREST DISCLOSURE COURSE (COI) WHICH MUST BE COMPLETED ON-LINE. PERIODICALLY THROUGH THE YEAR, THE ENTITY'S CORPORATE RESPONSIBILITY CONTACT PERSON (WITH THE HELP OF THE ENTITY'S LEARNING MANAGEMENT SYSTEM COORDINATOR) SENDS DEPARTMENT MANAGERS A LIST OF EMPLOYEES WHO HAVE NOT YET COMPLETED THEIR COI SO THEY CAN REMIND THE EMPLOYEES AND ENSURE THE EMPLOYEES HAVE TIME IN THEIR SCHEDULE TO COMPLETE THE REQUIRED COURSE. RESOLUTION OF ANY CONFLICTS THAT ARE DISCLOSED MUST BE DOCUMENTED AND KEPT ON FILE AT THE ENTITY. SUPERVISORS VERIFY REQUIRED COURSE COMPLETION PRIOR TO YEAR END.
  FORM 990, PART VI, SECTION B, LINE 15 ALL SSMHC EXECUTIVE SALARY/COMPENSATION INFORMATION IS BASED ON COMPARATIVE DATA OF SIMILAR POSITIONS IN THE MARKET. THE COMPENSATION REVIEW PROCESS IS PERFORMED BY EXTERNAL INDEPENDENT COMPENSATION CONSULTANTS. THE SAME COMPARATIVE ANALYSIS IS PERFORMED INTERNALLY FOR EMPLOYEES. THE SALARY DATA AND POTENTIAL ADJUSTMENTS FOR THE CEO OF THE SYSTEM, THE PRESIDENT/COO AND THE SENIOR VICE PRESIDENTS ARE PRESENTED TO THE SSMHC BOARD OF DIRECTORS BY THE SAME INDEPENDENT COMPENSATION CONSULTANTS TO APPROVE, DISAPPROVE OR MODIFY.
  FORM 990, PART VI, SECTION C, LINE 19 THE YEAR-END AUDITED CONSOLIDATED FINANCIAL STATEMENTS AND UNAUDITED QUARTERLY CONSOLIDATED FINANCIAL STATEMENTS FOR THE SSM HEALTH CARE SYSTEM ARE MADE AVAILABLE TO THE PUBLIC ON SSM HEALTH CARE'S WEBSITE. THE ORGANIZATION'S ARTICLES OF INCORPORATION ARE AVAILABLE UPON REQUEST TO THE WISCONSIN DEPARTMENT OF FINANCIAL INSTITUTION'S OFFICE. COPIES OF THE FORM 990 AND THE ORGANIZATION'S CONFLICT OF INTEREST POLICY ARE AVAILABLE UPON REQUEST.
RELATED ORGANIZATION COMPENSATION FORM 990, PART VII: ALL INDIVIDUALS WHO RECEIVE COMPENSATION FOR SERVICES RENDERED TO THE FILING ORGANIZATION ARE EMPLOYED AND COMPENSATED BY A RELATED ORGANIZATION. IN ADDITION, ALL COMPENSATED REPORTABLE INDIVIDUALS LISTED ON FORM 990, PART VII WORK A MINIMUM OF 40 HOURS PER WEEK FOR SSMHC RELATED ORGANIZATIONS.
CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 123,306. DONATED SERVICES AND USE OF FACILITIES: 11,692.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2010

Additional Data


Software ID:  
Software Version:  
SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBulletAttach to Form 990. MediumBullet See separate instructions.

OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
ST CLARE HEALTH CARE FOUNDATION INC
 
Employer identification number

43-1940683
Part I
Identification of Disregarded Entities (Complete if the organization answered "Yes" on Form 990, Part IV, line 33.)
(a)
Name, address, and EIN of disregarded entity


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Total income
(e)
End-of-year assets


 		(f)
Direct controlling
entity

















Part II
Identification of Related Tax-Exempt Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.)
(a)
Name, address, and EIN of related organization


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Exempt Code section
(e)
Public charity status
(if section 501(c)(3))

 		(f)
Direct controlling
entity

 		(g)
Section 512(b)(13) controlled organization
Yes No
(1) SSM HEALTH CARE CORPORATION

477 N LINDBERGH BLVD

ST LOUIS,MO63141
46-6029223 		HEALTH CARE MO 501(C)(3) LINE 11A, I FRANSISCAN SISTERS OF MARY
 
 
No
(2) SSM EMPLOYEE HEALTH CARE FUND

477 N LINDBERGH BLVD

ST LOUIS,MO63141
43-1328934 		BENEFIT PLANS MO 501(C)(9)   SSM HEALTH CARE CORPORATION
 
 
No
(3) SSMHCS LIABILITY TRUST I

477 N LINDBERGH BLVD

ST LOUIS,MO63141
43-6331003 		INSURANCE MO 501(C)(3) LINE 11A, I SSM HEALTH CARE CORPORATION
 
 
No
(4) SSM CONSOLIDATED HEALTH SERVICES

477 N LINDBERGH BLVD

ST LOUIS,MO63141
43-1473657 		HEALTH CARE MO 501(C)(3) LINE 11A, I SSM HEALTH CARE CORPORATION
 
 
No
(5) SSM POLICY INSTITUTE

477 N LINDBERGH BLVD

ST LOUIS,MO63141
43-1788151 		HEALTH CARE MO 501(C)(4)   SSM HEALTH CARE CORPORATION
 
 
No
(6) SSM PORTFOLIO MANAGEMENT CO

477 N LINDBERGH BLVD

ST LOUIS,MO63141
43-1825256 		MANAGEMENT MO 501(C)(3) LINE 11A, I SSM HEALTH CARE CORPORATION
 
 
No
(7) SSM HEALTH CARE ST LOUIS

477 N LINDBERGH BLVD

ST LOUIS,MO63141
43-1343281 		HEALTH CARE MO 501(C)(3) LINE 3 SSM HEALTH CARE CORPORATION
 
 
No
(8) SSM CARDINAL GLENNON CHILDREN'S HOSPITAL

477 N LINDBERGH BLVD

ST LOUIS,MO63141
43-0738490 		HEALTH CARE MO 501(C)(3) LINE 3 SSM HEALTH CARE ST LOUIS
 
 
No
(9) GLENNON HOSPITAL GUILD

477 N LINDBERGH BLVD

ST LOUIS,MO63141
43-1030299 		FUNDRAISING MO 501(C)(3) LINE 9 SSM CARDIAL GLENNON HOSPITAL
 
 
No
(10) CARDINAL GLENNON CHILDREN'S FOUNDATION

477 N LINDBERGH BLVD

ST LOUIS,MO63141
43-1754347 		FUNDRAISING MO 501(C)(3) LINE 7 SSM CARDIAL GLENNON HOSPITAL
 
 
No
(11) SSM DEPAUL HEALTH CENTER FOUNDATION

477 N LINDBERGH BLVD

ST LOUIS,MO63141
43-1776109 		FUNDRAISING MO 501(C)(3) LINE 7 SSM HEALTH CARE ST LOUIS
 
 
No
(12) SSM ST JOSEPH FOUNDATION

477 N LINDBERGH BLVD

ST LOUIS,MO63141
43-1591556 		FUNDRAISING MO 501(C)(3) LINE 7 SSM HEALTH CARE ST LOUIS
 
 
No
(13) ST CLARE HEALTH CENTER FOUNDATION

477 N LINDBERGH BLVD

ST LOUIS,MO63141
43-1273310 		FUNDRAISING MO 501(C)(3) LINE 7 SSM HEALTH CARE ST LOUIS
 
 
No
(14) SSM ST MARY'S HEALTH CENTER FOUNDATION

477 N LINDBERGH BLVD

ST LOUIS,MO63141
43-1552945 		FUNDRAISING OK 501(C)(3) LINE 7 SSM HEALTH CARE ST LOUIS
 
 
No
(15) SSM HEALTH CARE OF OKLAHOMA INC

477 N LINDBERGH BLVD

ST LOUIS,MO63141
73-0657693 		HEALTH CARE OK 501(C)(3) LINE 3 SSM HEALTH CARE CORPORATION
 
 
No
(16) LEE DEWEY CORPORATION

477 N LINDBERGH BLVD

ST LOUIS,MO63141
73-1279603 		MOB OK 501(C)(3) LINE 11A, I SSM HEALTH CARE OF OKLAHOMA
 
 
No
(17) ST ANTHONY HOSPITAL FOUNDATION INC

477 N LINDBERGH BLVD

ST LOUIS,MO63141
73-6104300 		FUNDRAISING WI 501(C)(3) LINE 7 SSM HEALTH CARE OF OKLAHOMA
 
 
No
(18) SSM HEALTH CARE OF WISCONSIN INC

477 N LINDBERGH BLVD

ST LOUIS,MO63141
43-0688874 		HEALTH CARE WI 501(C)(3) LINE 3 SSSM HEALTH CARE CORPORATION
 
 
No
(19) DELLS MEDICAL BUILDING INC

477 N LINDBERGH BLVD

ST LOUIS,MO63141
39-1613292 		MOB WI 501(C)(2)   SSM HEALTH CARE OF WISCONSIN
 
 
No
(20) ST MARY'S FOUNDATION INC

477 N LINDBERGH BLVD

ST LOUIS,MO63141
43-1940686 		FUNDRAISING WI 501(C)(3) LINE 7 SSM HEALTH CARE OF WISCONSIN
 
 
No
(21) ST CLARE HEALTH CARE FOUNDATION INC

477 N LINDBERGH BLVD

ST LOUIS,MO63141
43-1940683 		FUNDRAISING WI 501(C)(3) LINE 7 SSM HEALTH CARE OF WISCONSIN
 
 
No
(22) HOME HEALTH UNITED INC

4639 HAMMERSLEY ROAD

MADISON,WI53713
39-1539827 		HEALTH CARE WI 501(C)(3) LINE 9 SSM HEALTH CARE OF WISCONSIN
 
 
No
(23) HOME CARE UNITED INC

4639 HAMMERSLEY ROAD

MADISON,WI53713
39-1776340 		HEALTH CARE WI 501(C)(3) LINE 9 SSM HEALTH CARE OF WISCONSIN
 
 
No
(24) HHU XTRA CARE INC

4639 HAMMERSLEY ROAD

MADISON,WI53713
39-1705111 		HEALTH CARE WI 501(C)(3) LINE 9 SSM HEALTH CARE OF WISCONSIN
 
 
No
(25) SSM REGIONAL HEALTH SERVICES

477 N LINDBERGH BLVD

ST LOUIS,MO63141
44-0579850 		HEALTH CARE MO 501(C)(3) LINE 3 SSM HEALTH CARE CORPORATION
 
 
No
(26) ST FRANCIS HOSPITAL FOUNDATION

477 N LINDBERGH BLVD

ST LOUIS,MO63141
43-1099253 		FUNDRAISING MO 501(C)(3) LINE 7 SSM REGIONAL HEALTH SERVICES
 
 
No
(27) ST MARY'S HEALTH CENTER FOUNDATION

477 N LINDBERGH BLVD

ST LOUIS,MO63141
43-1575307 		FUNDRAISING MO 501(C)(3) LINE 11B, II SSM REGIONAL HEALTH SERVICES
 
 
No
(28) GOOD SAMARITAN REGIONAL HEALTH CENTER

477 N LINDBERGH BLVD

ST LOUIS,MO63141
43-0653587 		HEALTH CARE IL 501(C)(3) LINE 3 SSM REGIONAL HEALTH SERVICES
 
 
No
(29) ST MARY'S HOSPITAL

477 N LINDBERGH BLVD

ST LOUIS,MO63141
37-0662580 		HEALTH CARE IL 501(C)(3) LINE 3 SSM REGIONAL HEALTH SERVICES
 
 
No
(30) ST MARY'S - GOOD SAMARITAN INC

477 N LINDBERGH BLVD

ST LOUIS,MO63141
36-4170833 		HEALTH CARE IL 501(C)(3) LINE 11A, I SSM REGIONAL HEALTH SERVICES
 
 
No
(31) GOOD SAMARITAN REGIONAL HEALTH CENTER FOUNDATION

477 N LINDBERGH BLVD

ST LOUIS,MO63141
26-2884795 		FUNDRAISING IL 501(C)(3) LINE 7 ST MARY'S - GOOD SAMARITAN
 
 
No
(32) ST MARY'S HOSPITAL FOUNDATION

477 N LINDBERGH BLVD

ST LOUIS,MO63141
36-4636691 		FUNDRAISING IL 501(C)(3) LINE 7 ST MARY'S - GOOD SAMARITAN
 
 
No
(33) SSM HEALTH BUSINESSES

477 N LINDBERGH BLVD

ST LOUIS,MO63141
43-1333488 		HEALTH CARE MO 501(C)(3) LINE 3 SSM HEALTH CARE CORPORATION
 
 
No
(34) SSM HOSPICE & HOME CARE FOUNDATION

477 N LINDBERGH BLVD

ST LOUIS,MO63141
30-0012246 		FUNDRAISING MO 501(C)(3) LINE 7 SSM HEALTH BUSINESSES
 
 
No
(35) CENTRALIA MEDICAL SERVICES BLDG ASSOC

477 N LINDBERGH

ST LOUIS,MO63141
23-7408025 		HEALTH CARE IL 501(C)(3) LINE 11B, II SSM REGIONAL HEALTH SERVICES
 
 
No
(36) ST MARY'S JANESVILLE FOUNDATION INC

2901 LANDMARK PL STE 300

MADISON,WI53713
27-3439133 		FUNDRAISING WI 501(C)(3) LINE 7 SSM HEALTH CARE OF WISCONSIN
 
 
No
(37) FRANCISCAN SISTERS OF MARY

1100 BELLEVUE AVE

ST LOUIS,MO63117
43-1012492 		RELIGIOUS ORGANISATION MO 501(C)(3) LINE 1 N/A
 
No
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2010
Schedule R (Form 990) 2010
Page 2
Part III
Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.)
(a)
Name, address, and EIN of
related organization



 		(b)
Primary activity




 		(c)
Legal
domicile
(state or foreign
country)


 		(d)
Direct controlling
entity



 		(e)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(f)
Share of total income




 		(g)
Share of end-of-year
assets



 		(h)
Disproprtionate allocations?




 		(i)
Code V—UBI
amount in box 20 of
Schedule K-1
(Form 1065)
 		(j)
General or
managing
partner?



 		(k)
Percentage
ownership
Yes No Yes No
(1) SSM SJ ENDOSCOPY

477 N LINDBERGH BLVD
ST LOUIS,MO63141
27-0046559 		SURGERY SERVICES MO N/A
 N/A       No     No  
(2) SSMCDI IMAGING

5775 WAYZATA BOULEVARD SUITE 400
ST LOUIS PARK,MN55416
26-3791858 		IMAGING SERVICES MO N/A
 N/A       No     No  
(3) SSM SELECT REHAB

4716 OLD GETTYSBURG ROAD
MECHANICSBURG,PA17055
26-3694972 		HEALTH CARE MO N/A
 N/A       No     No  
(4) SA MT AMB SRUG

110 N LEE
OKLAHOMA CITY,OK73103
73-1528341 		SURGERY SERVICES OK N/A
 N/A       No     No  
(5) B&J HOSPITAL

1111 N DEWEY AVE
OKLAHOMA CITY,OK73103
76-0828314 		HEALTH CARE OK N/A
 N/A       No     No  
(6) B&J MB OFF BUILD

1000 N LEE
OKLAHOMA CITY,OK73103
73-1533449 		MOB OK N/A
 N/A       No     No  
(7) B&J MANANGEMENT

1000 N LEE STREET
OKLAHOMA CITY,OK73102
36-4645813 		MANAGEMENT OK N/A
 N/A       No     No  
(8) WIITTS LLC

2901 LANDMARK PLACE SUITE 300
MADISON,WI53713
39-2016715 		MED. INF. SYSTEMS WI N/A
 N/A       No     No  
(9) SHARED IMAGING SERVICES

915 17TH STREET
PRAIRIE DU SAC,WI53578
39-1971378 		DIAG. SERVICES WI N/A
 N/A       No     No  
(10) ST CLARE IMAGING SERVICES

707 14TH STREET SUITE A
BARABOO,WI53913
20-0122365 		DIAG. SERVICES WI N/A
 N/A       No     No  
(11) MEADOW RIDGE

1402 PANKRATZ STREET SUITE 110
MADISON,WI53704
39-1991403 		ASST. LIVING WI N/A
 N/A       No     No  
(12) DEAN HEALTH HOLD

1277 DEMING WAY
MADISON,WI53717
26-1594709 		IT SERVICES WI N/A
 N/A       No     No  
(13) MV RAD THERAPY

477 N LINDBERGH BLVD
ST LOUIS,MO63141
20-1382620 		RADIATION THERAPY IL N/A
 N/A       No     No  
(14) SLEEPNEURO SO IL

477 N LINDBERGH BLVD
ST LOUIS,MO63141
20-8468195 		DIAG. SERVICES IL N/A
 N/A       No     No  
(15) SMHC SURG CO-MGMT

100 ST MARYS MEDICAL PLAZA
JEFFERSON CITY,MO65101
20-8929305 		MANAGEMENT MO N/A
 N/A       No     No  
(16) SMHC CARD CO-MGMT

100 ST MARYS MEDICAL PLAZA
JEFFERSON CITY,MO65101
20-8929381 		MANAGEMENT MO N/A
 N/A       No     No  
(17) SMHC MUSC CO-MGMT

100 ST MARYS MEDICAL PLAZA
JEFFERSON CITY,MO65101
20-8929237 		MANAGEMENT MO N/A
 N/A       No     No  
(18) CHOWSMGSI

605 N 12TH STREET
MOUNT VERNON,IL62864
37-1383861 		MOB MO N/A
 N/A       No     No  
(19) COMP CANCER CARE

477 N LINDBERGH BLVD
ST LOUIS,MO63141
20-1382727 		MOB IL N/A
 N/A       No     No  
(20) 1110 N CLASSEN BLVD LLC

110 N CLASSEN
OKLAHOMA CITY,OK73106
73-1158158 		MOB OK N/A
 N/A       No     No  
(21) M&C REALTY

1603 WENTZVILLE PARKWAY STE 121
WENTZVILLE,MO63385
62-1851447 		MOB MO N/A
 N/A       No     No  
(22) SURG CNTR MW CITY

8121 NATIONAL AVE SUITE 108
MIDWEST CITY,OK73110
23-2697171 		SURGERY SERVICES OK N/A
 N/A       No     No  
(23) SSM WELLBRIDGE

6140 GREENWOOD PLAZA BLVD
GREENWOOD VILLAGE,CO80111
43-1794814 		FITNESS CENTER MO N/A
 N/A       No     No  
(24) MIA OF ST CHARLES

132 NORTH KANSAS ST ROOM 212
EDWARDSVILLE,IL62025
42-2125740 		DIAG. SERVICES MO N/A
 N/A       No     No  
(25) MEADOW RIDGE MEMORY

1402 PANKRATZ ST SUITE 110
MADISON,WI53704
20-3163929 		HEALTH CARE WI N/A
 N/A       No     No  
(26) SSM BER-EK IMAGING

477 N LINDBERGH BLVD
ST LOUIS,MO63141
20-5039552 		IMAGING SERVICES MO N/A
 N/A       No     No  
(27) HPI-OKC LLC

14024 QUAIL POINTE DRIVE
OKLAHOMA CITY,OK73134
20-5144487 		HEALTH CARE OK N/A
 N/A       No     No  
(28) VASCULAR INSTITUTE DP

12266 DEPAUL DR SUITE 315
BRIDGETON,MO63044
20-5511708 		VASCULAR CLINIC MO N/A
 N/A       No     No  
(29) SSM SC SURG CNTR

15305 DALLAS PKWY STE 1600
ADDISON,TX75001
26-1439695 		SURGERY SERVICES MO N/A
 N/A       No     No  
(30) ST ANTHONY CARDIO SERVICES INSTITUTE

477 N LINDBERGH BLVD
ST LOUIS,MO63141
26-0646402 		MANAGEMENT OK N/A
 N/A       No     No  
(31) SSM RX EXPRESS LLC

727 N BALLAS RD
ST LOUIS,MO63141
43-1465174 		PHARMACY MO N/A
 N/A       No     No  
Part IV
Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.)
(a)
Name, address, and EIN of related organization



 		(b)
Primary activity



 		(c)
Legal domicile
(state or
foreign
country)
 		(d)
Direct controlling
entity


 		(e)
Type of entity
(C corp, S corp,
or trust)

 		(f)
Share of total income



 		(g)
Share of
end-of-year
assets

 		(h)
Percentage
ownership
(1) SSM MANAGED CARE ORGANIZATION LLC
477 N LINBERGH BLVD
ST LOUIS,MO63141
43-1708511 		HEALTH PROMOTION MO N/A
 C      
(2) FPP INC
477 N LINBERGH BLVD
ST LOUIS,MO63141
43-1465174 		HEALTH CARE MO N/A
 C      
(3) DIVERSIFIED HEALTH SERVICES CORP
477 N LINBERGH BLVD
ST LOUIS,MO63141
43-1369305 		MEDICAL EQUIPMENT MO N/A
 C      
(4) SSM CARDIO AND THORACIC SERVICES INC
477 N LINBERGH BLVD
ST LOUIS,MO63141
26-0286559 		HEALTH CARE MO N/A
 C      
(5) SSM PROPERTIES INC
477 N LINBERGH BLVD
ST LOUIS,MO63141
43-1462486 		PROPERTY SERVICES MO N/A
 C      
(6) SSM DEPAUL MEDICAL GROUP INC
477 N LINBERGH BLVD
ST LOUIS,MO63141
43-1715106 		HEALTH CARE MO N/A
 C      
(7) SSM ST CHARLES CLINIC MED GROUP INC
477 N LINBERGH BLVD
ST LOUIS,MO63141
43-0626408 		PHYSICIAN OFFICES MO N/A
 C      
(8) HEALTH FIRST PHYS MANAGEMENT
477 N LINBERGH BLVD
ST LOUIS,MO63141
73-1534336 		MEDICAL SERVICES MO N/A
 C      
(9) SSMHCS LIABILITY TRUST II
477 N LINBERGH BLVD
ST LOUIS,MO63141
81-6128118 		INSURANCE MO N/A
 C      
(10) SSM NEUROSCIENCES INC
477 N LINBERGH BLVD
ST LOUIS,MO63141
26-3413981 		HEALTH CARE MO N/A
 C      
(11) SSM MEDICAL GROUP INC
477 N LINBERGH BLVD
ST LOUIS,MO63141
43-1664107 		PHYSICIAN OFFICES MO N/A
 C      
(12) SSMHC INSURANCE COMPANY
477 N LINBERGH BLVD
ST LOUIS,MO63141
03-0310431 		INSURANCE CA N/A
 C      
(13) SSM ORTHOPEDIC INC
477 N LINBERGH BLVD
ST LOUIS,MO63141
27-1557033 		HEALTH CARE MO N/A
 C      
(14) SSM CANCER CARE INC
477 N LINBERGH BLVD
ST LOUIS,MO63141
27-1557324 		HEALTH CARE MO N/A
 C      
(15) SSM ST JOSEPH SURGERY CENTER
477 N LINDBERGH BLVD
ST LOUIS,MO63141
43-1822767 		HEALTH CARE MO N/A
 C      
(16) ST MARY'S DEAN VENTURES INC
1808 WEST BELTLINE HIGHWAY
MADISON,WI53713
39-1628491 		HEALTH CARE WI N/A
 C      
(17) SHARED MRI FACILITY INC
1104 JOHN NOLEN DRIVE
MADISON,WI53713
39-1534744 		HEALTH CARE WI N/A
 C      
Schedule R (Form 990) 2010
Schedule R (Form 990) 2010
Page 3
Part V
Transactions With Related Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35, 35A, or 36.)
Note. Complete line 1 if any entity is listed in Parts II, III or IV.
Yes
No
1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a Receipt of (i) interest (ii) annuities (iii) royalties (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .
1a
 
No
b Gift, grant, or capital contribution to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
Yes
 
c Gift, grant, or capital contribution from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c
Yes
 
d Loans or loan guarantees to or for other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1d
 
No
e Loans or loan guarantees by other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1e
 
No
f Sale of assets to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
No
g Purchase of assets from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Exchange of assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
Yes
 
i Lease of facilities, equipment, or other assets to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
 
No
j Lease of facilities, equipment, or other assets from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
 
No
k Performance of services or membership or fundraising solicitations for other organization(s) . . . . . . . . . . . . . . . . . . . . . .
1k
Yes
 
l Performance of services or membership or fundraising solicitations by other organization(s) . . . . . . . . . . . . . . . . . . . . . .
1l
 
No
m Sharing of facilities, equipment, mailing lists, or other assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1m
Yes
 
n Sharing of paid employees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1n
Yes
 
o Reimbursement paid to other organization for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
Yes
 
p Reimbursement paid by other organization for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
 
No
q Other transfer of cash or property to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
 
No
r Other transfer of cash or property from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
 
No
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of other organization 		(b)
Transaction
type(a-r) 		(c)
Amount involved 		(d)
Method of determining amount involved
(1)
(2)
(3)
(4)
(5)
(6)
Schedule R (Form 990) 2010
Schedule R (Form 990) 2010
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 37.)
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity 		(b)
Primary activity 		(c)
Legal domicile
(state or foreign
country) 		(d)
Are all
partners
section
501(c)(3)
organizations? 		(e)
Share of
end-of-year
assets 		(f)
Disproprtionate allocations? 		(g)
Code V—UBI
amount in box
20 of Schedule K-1
(Form 1065) 		(h)
General or
managing
partner?
Yes No Yes No Yes No






























Schedule R (Form 990) 2010
Schedule R (Form 990) 2010
Page 5
Part VII
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule R (see instructions).
Identifier Return Reference Explanation
Additional Data


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