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.
Attach to Form 990 or Form 990-EZ. See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
CLARIAN TRANSPLANT INSTITUTE INC
Employer identification number
13-4350599
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
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(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
Provide the following information about the supported organization(s).
(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.") ....
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..
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)..
6
Public Support. Subtract line 5 from line 4.
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..
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
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).
12
Gross receipts from related activities, etc. (See instructions.)
..................
12
13
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here..........................................
Section C. Computation of Public Support Percentage
14
Public Support Percentage for 2010 (line 6 column (f) divided by line 11 column (f))
.........
14
15
Public Support Percentage for 2009 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2010.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
......................
b
33 1/3% support test—2009.
If the organization did not check the box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2010.
If the organization did not check a box on line 13, 16a, or 16b and line 14
is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported
organization
..................................................
b
10%-facts-and-circumstances test—2009.
If the organization did not check a box on line 13, 16a, 16b, or 17a and line
15 is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported organization
..............................................
18
Private Foundation
If the organization did not check a box on line 13, 16a, 16b, 17a or 17b, check this box and see
instructions
...................................................
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.") .
1,112,690
258,000
300,181
1,491,141
3,162,012
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......
1,650,001
9,050,000
9,821,150
9,854,903
30,376,054
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.
2,762,691
9,308,000
10,121,331
11,346,044
33,538,066
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.
1,622,366
2,587,025
2,547,514
1,715,928
8,472,833
c
Add lines 7a and 7b..
1,622,366
2,587,025
2,547,514
1,715,928
8,472,833
8
Public Support (Subtract line 7c from line 6.)
25,065,233
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...
2,762,691
9,308,000
10,121,331
11,346,044
33,538,066
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
772
651
1,423
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
772
651
1,423
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.).
2,763,463
9,308,651
10,121,331
11,346,044
33,539,489
14
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public Support Percentage for 2010 (line 8 column (f) divided by line 13 column (f))
.........
15
16
Public support percentage from 2009 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2010 (line 10c column (f) divided by line 13 column (f))
......
17
18
Investment income percentage from 2009 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2010.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3% and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
..........
b
33 1/3% support tests—2009.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
....
20
Private Foundation
If the organization did not check a box on line 14, 19a or 19b, check this box and see instructions
.....
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:
-
TIN:
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.
Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
CLARIAN TRANSPLANT INSTITUTE INC
Employer identification number
13-4350599
Identifier
Return Reference
Explanation
Part VI, Section A - Governing Body and Management
Line 1B - Number of Voting Members that are Independent
Clarian Transplant Institute, Inc. is part of a multi-entity hospital system controlled by Indiana University Health, Inc., a 501(c)(3) exempt organization whose board is comprised of voting members, of which substantially all are independent community members.
Part VI, Section A - Governing Body and Management
Line 2 - Family or Business Relationships
Norman G. Tabler, Jr. and John Fitzgerald, M.D. serve on the Board of Directors of Clarian Health Plans, Inc., Clarian Health Risk Retention Group, Inc. and IUH Assurance, Ltd. (f/k/a CHA Assurance, Ltd.). Additionally, Norman G. Tabler, Jr. is an Officer of these organizations. No additional compensation is provided for their service.
Part VI, Section A - Governing Body and Management
Lines 6, 7A and 7B - Members or Stockholders
Line 6: The sole member of Clarian Transplant Institute, Inc. ("CTI") is Indiana University Health, Inc. ("IU Health"), formerly known as Clarian Health Partners, Inc., a 501(c)(3) tax-exempt hospital. Line 7A: The control and management of the affairs of CTI is vested in a Board of Directors of twelve (12) members, subject to the limitation that the Board shall never be reduced to less than three (3) nor increased to more than thirteen (13) Directors. IU Health, as the sole member of CTI, elects three (3) Directors on the Board while the remaining directors are elected according to their designation as follows: - Chief Medical Officer of IU Health; - Chief Medical Officer of University Hospital of IU Health; - Chief Medical Officer of CTI; - Chief Operating Officer of CTI; - President and Chief Executive Officer of Methodist Hospital and University Hospital of IU Health; - Chairman of the Department of Medicine of the Indiana University School of Medicine ("IUSOM"); - Chairman of the Department of Surgery of the IUSOM Line 7B: The Board of Directors may not undertake certain actions without the prior approval of IU Health, as the sole member. Actions that require prior approval include the following: - Authorization of any merger, consolidation, reorganization, sale or transfer of all or substantially all of the assets of CTI; - Authorization of any plan of dissolution of CTI, any liquidating distribution of CTI's assets or other action related to the dissolution or liquidation of CTI; - Authorization of any voluntary declaration of bankruptcy of CTI; - The amendment, repeal, revision or adoption of changes to the organizational documents of CTI; - Authorization of the consolidation of any entity with, or acquisition of any entity by CTI; - Authorization of any agreement to act as primary obligor, or to serve as a guarantor, surety or co-obligor with respect to the indebtedness of any other party, to borrow amounts from third-party lenders or to loan money to any person or entity; - Approval of strategic plans and amendments; - Authorization of any pledge of, or grant of any security interest or mortgage in, or otherwise encumber, any tangible assets in excess of an appropriate monetary threshold, other than in the ordinary course of business or pursuant to an approved budget or strategic plan; - Approval of any management agreement for the management of all or a substantial part of CTI's operations; or - Authorization of the establishment or acquisition by CTI of any subsidiaries, affiliates or joint venture arrangements or the acquisition by CTI of the stock or other equity interest or substantially all the assets of any other business or entity.
Part VI, Section A - Governing Body and Management
Line 11b - Review of Form 990
Clarian Transplant Institute, Inc. has established the following process for reviewing Form 990: The Form 990 and related schedules are reviewed by the Administrative Director - Transplant Programs. After the Administrative Director - Transplant Programs approves the Form 990 and related schedules, a finalized complete Form 990 is made available to each board member on a protected intranet site prior to filing the form with the IRS. Each member is informed of the availability of the tax department to answer any questions.
Part VI, Section B - Policies
Lines 12, 13, and 14
Clarian Transplant Institute, Inc. is part of the Indiana University Health, Inc. system. As the sole member and controlling parent of Clarian Transplant Institute, Inc., Indiana University Health, Inc. and its board of directors have mandated that certain policies be followed to ensure greater standardization throughout the system. Thus, Clarian Transplant Institute, Inc.'s board of directors was not required to separately adopt the conflict of interest, whistleblower, document retention and destruction and joint venture policies because Indiana University Health, Inc.'s board had already adopted and required these policies to be followed by subsidiaries.
Part VI, Section B - Policies
Line 12C - Conflict of Interest Policy
Clarian Transplant Institute, Inc. has a Conflict of Interest Policy, the purpose of which is, to protect Clarian Transplant Institute, Inc.'s interests when it is contemplating entering into a transaction or arrangement that might benefit the private interest of an officer or director. Each employee, including those employed by related entities, officer and member of the board of directors is required to annually sign a statement which affirms that such person (1) has received a copy of the conflict of interest policy; (2) has read and understands the policy; (3) has agreed to comply with the policy; and (4) understands and acknowledges that the Corporation is a tax-exempt organization and that in order to maintain its federal tax exemption it must engage primarily in activities which accomplish one or more of its tax-exempt purposes. If an interest is disclosed, the form requires that the discloser's supervisor sign the form to indicate his/her knowledge and approval of the interest. The form then goes to Corporate Compliance. If the disclosure is by the Chief Medical Officer, it goes to the board chairman for approval. If the disclosure is by a member of the board of directors, the General Counsel/Chief Compliance Officer reviews the disclosures and determines whether to consent.
Part VI, Section C - Disclosures
Line 19 - Public Disclosure
Clarian Transplant Institute, Inc.'s Articles of Incorporation are available to the public through the Indiana Secretary of State's web-site. Clarian Transplant Institute, Inc.'s conflict of interest policy is described on Form 990, Schedule O. Clarian Transplant Institute, Inc. is a consolidated subsidiary in the consolidated financial statements for Indiana University Health, Inc. The consolidated financial statements for Indiana University Health, Inc. are available to the public through its bond filings.
Part VII, Section A
Line 1a, Column (B) - Average hours per week
Norman G. Tabler, Jr. is the Senior Vice President, General Counsel, and Secretary for Indiana University Health, Inc. and devotes 55 hours per week. David Alvar is the Administrative Director of Transplant Programs for Indiana University Health, Inc. and devotes 55 hours per week. Richard F. Graffis, M.D. is the Executive Vice President and Chief Medical Officer for Indiana University Health, Inc. and devotes 55 hours per week. John C. Kohne, M.D. is the Chief Operating Officer of Methodist Hospital for Indiana University Health, Inc. and devotes 55 hours per week. Herbert E. Cushing, M.D. is the Chief Medical Officer of University Hospital for Indiana University Health, Inc. and devotes 15 hours per week. Additionally, he is a Medical Director for Indiana University Health Care Associates, Inc. and devotes 15 hours per week. John F. Fitzgerald, M.D. is the President and Chief Executive Officer of Indiana University Health Care Associates, Inc. and devotes 55 hours per week.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.