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
ST LUKES EPISCOPAL HOSPITAL SELF SLEH SELF INSURANCE TRUST
Employer identification number
76-6046296
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)
No
(ii)
a family member of a person described in (i) above?
......................
11g(ii)
No
(iii)
a 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
No
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
(1)
ST LUKES EPISCOPAL HOSPITAL
741161938
03
Yes
Yes
Yes
87,782
Total
87,782
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.") .
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
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
ST LUKES EPISCOPAL HOSPITAL SELF SLEH SELF INSURANCE TRUST
Employer identification number
76-6046296
Identifier
Return Reference
Explanation
FORM 990, PART IV, QUESTION 12 & 12a; FORM 990, PART XI, QUESTION 2d
CHECK LIST OF REQUIRED SCHEDULES; FINANCIAL STATEMENTS AND REPORTING
DID THE ORGANIZATION OBTAIN SEPARATE, INDEPENDENT AUDITED FINANCIAL STATEMENTS FOR THE TAX YEAR? WAS THE ORGANIZATION INCLUDED IN COnSOLIDATED, INDEPENDENT AUDITED FINANCIAL STATEMENT FOR THE TAX YEAR? ST. LUKE'S EPISCOPAL HEALTH SYSTEM CORPORATION AND ITS RELATED ENTITIES WERE AUDITED AS A CONSOLIDATED GROUP IN ACCORDANCE WITH GAAP. THUS, THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS DO NOT PROVIDE INDIVIDUAL ENTITY BY ENTITY REPORTING FOR CALENDAR YEAR 2010.
FORM 990, PART V, QUESTION 1 AND 2a
STATEMENTS REGARDING OTHER IRS FILINGS AND TAX COMPLIANCE
ENTER THE NUMBER REPORTED IN BOX 3 OF FORM 1096, ANNUAL SUMMARY AND TRANSMITTAL OF U.S. INFORMATION RETURNS. ST. LUKE'S EPISCOPAL HEALTH SYSTEM CORPORATION REMITS ALL VENDORS PAYMENTS AND ISSUES FORM 1099 ON BEHALF OF ITS RELATED ORGANIZATIONS. INDIVIdual ENTITIES OF ST. LUKE'S EPISCOPAL HEALTH SYSTEM CORPORATION DO NOT FILE FORMS 1096 FOR THIS REASON. ENTER THE NUMBER OF EMPLOYEES ENTERED 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. SLEH SELF INSURANCE TRUST had no employees in 2010. therefore, NO FORM W-3 OR 941S WERE FILED.
FORM 990, PART VI, SECTION A, QUESTION 6,7a AND 7b
SECTION A: GOVERNING BODY AND MANAGEMENT
DOES THE ORGANIZATION HAVE MEMBERS OR STOCKHOLDERS? SLEH SELF INSURANCE TRUST DOES NOT HAVE A "GOVERNING BOARD", INSTEAD, IT IS ADMINISTERED BY ITS FINANCE MANAGERS WHO ACT AT THE DIRECTION OF ST. LUKE'S EPISCOPAL HOSPITAL. DOES THE ORGANIZATION HAVE MEMBERS, STOCKHOLDERS, OR OTHER PERSONS THAT MAY ELECT ONE OR MORE MEMBERS OF THE GOVERNING BODY? THE SLEH SELF INSURANCE TRUST'S FINANCE MANAGERS ARE APPOINTED BY THE BOARD OF DIRECTORS OF ST. LUKE'S EPISCOPAL HOSPITAL. ARE ANY DECISIONS OF THE GOVERNING BODY SUBJECT TO APPROVAL BY MEMBERS, STOCKHOLDERS, OR OTHER PERSONS? ST. LUKE'S EPISCOPAL HOSPITAL AND THE SLEH SELF INSURANCE TRUST SHARE COMPLETE COMMON CONTROL. THE BOARD OF DIRECTORS OF ST. LUKE'S EPISCOPAL HOSPITAL ULTIMATELY CONTROLS ST. LUKE'S EPISCOPAL HOSPITAL AND THE SLEH SELF INSURANCE TRUST, THROUGH ITS POWER TO APPOINT AND REMOVE THOSE CHARGED WITH RESPONSIBILITY FOR THE DAILY OPERATIONS OF BOTH ORGANIZATIONS.
FORM 990, PART VI, SECTION B, QUESTION 11 & 11a
SECTION B: POLICIES
HAS THE ORGANIZATION PROVIDED A COPY OF THE FORM 990 TO ALL MEMBERS OF ITS GOVERNING BODY BEFORE FILING THE FORM? DESCRIBE IN SCHEDULE O THE PROCESS, IF ANY, USED BY THE ORGANIZATION TO REVIEW THIS FORM 990. SLEH SELF INSURANCE TRUST'S FORM 990 WAS PREPARED BY THE TAX DEPARTMENT OF ST. LUKE'S EPISCOPAL HEALTH SYSTEM CORPORATION, a related entity, UTILIZING INFORMATION PROVIDED BY SLEH SELF INSURANCE TRUST'S FUND MANAGERS. COLLABORATIVE REVIEW OF THE RETURN BY one of THE ORGANIZATION'S finance managers AND THE St. luke's episcopal health system corporation's tax director was conducted, and the return was made available to the all of the finance managers before filing.
FORM 990, PART VI, SECTION B, QUESTION 12c
SECTION B: POLICIES
DOES THE ORGANIZATION REGULARLY AND CONSISTENTLY MONITOR AND ENFORCE COMPLIANCE WITH THE WRITTEN CONFLICT OF INTEREST POLICY? PRIMARY MONITORING OF CONFLICT OF INTEREST IS DONE THROUGH ANNUAL POLLING OF OFFICERS, DIRECTORS, AND KEY EMPLOYEES FOR POTENTIAL CONFLICTS. CONFLICT OF INTEREST SUBMISSIONS ARE REVIEWED BY THE CORPORATE COMPLIANCE OFFICER AND SENIOR COUNSEL WHO BRING ACTIONABLE ITMES TO THE BOARD. IF THE INSTITUTION DETERMINES THAT A SIGNIFICANT POSSIBILITY EXISTS THAT THERE IS A CONFLICT OF INTEREST, THE INDIVIDUALS INVOLVED WILL BE REQUIRED TO REFRAIN FROM MAKING A DECISION OR TAKING ANY ACTION UNTIL THE MATTER CAN BE FULLY INVESTIGATED AND A DECISION MADE AS TO WHETHER A CONFLICT EXISTS. IF A CONFLICT IS CONFIRMED, A PLAN FOR ALLEVIATING OR MANAGING THE CONFLICT IS IMPLEMENTED. INDIVIDUALS WITH POTENTIAL CONFLICTS MAY BE ASKED TO RECUSE AND ABSENT THEMSELVES FROM MEETINGS IN WHICH AN ALLEGED CONFLICT IS DISCUSSED IF SO DOING WOULD BETTER ASSURE THE INTEGRITY OF THE PROCESS.
FORM 990, PART VI, SECTION B, QUESTION 14
SECTION B: POLICIES
DOES THE ORGANIZATION HAVE A WRITTEN DOCUMENT RETENTION AND DESTRUCTION POLICY? ST. LUKE'S EPISCOPAL HEALTH SYSTEM CORPORATION AND RELATED ENTITIES HAVE A WRITTEN GENERAL POLICY RELATED TO DOCUMENT RETENTION AND DESTRUCTION. DOCUMENTS AND RECORDS ARE RETAINED FOR VARIOUS FEDERAL, STATE OR OTHER JURISDICTION STATUTES FOR MEDICAL OR FINANCIAL REVIEW ON A DEPARTMENT-BY-DEPARTMENT BASIS.
FORM 990, PART VI, SECTION B, QUESTION 15
SECTION B: POLICIES
DID THE PROCESS FOR DETERMINING COMPENSATION OF THE FOLLOWING PERSONS INCLUDE A REVIEW AND APPROVAL BY INDEPENDENT PERSONS, COMPARABILITY DATA, AND CONTEMPORANEOUS SUBSTANTITATION OF THE DELIBERATION AND DECISION FOR: a) THE ORGANIZATION'S CEO, EXECUTIVE DIRECTOR, OR TOP MANAGEMENT OFFICIAL? b) OTHER OFFICERS OR KEY EMPLOYEES OF THE ORGANIZATION? DESCRIBE THE PROCESS IN SCHEDULE O. SLEH SELF INSURANCE trust DOES NOT COMPENSATE ITS FINANCE MANAGERS AND RISK MANAGERS DIRECTLY, THE PARENT CORPORATION, ST. LUKE'S EPISCOPAL HEALTH SYSTEM (SLEHS) PAYS COMPENSATION FOR THE FINANCE AND RISK MANAGERS. THE SLEHS COMPENSATION COMMITTEE MEETS AS NEEDED, BUT TYPICALLY MEETS TWO TIMES PER YEAR. THIS COMMITTEE CONSISTS OF THREE OUTSIDE DIRECTORS. ITS FUNCTION IS TO MAKE RECOMMENDATIONS/DECISIONS ON SALARY AND BENEFITS FOR KEY EXECUTIVES. VARIOUS DATA ARE UTILIZED IN DECISION-MAKING INCLUDING COMPENSATION CONSULTANTS, MANAGEMENT'S LEVEL OF ACHIEVeMENT OF STIPULATED PERFORMANCE TARGETS, EXTERNAL SURVEYS, AND LOCAL MARKET CONDITIONS. PERMANENT MINUTES ARE PREPARED AND REVIEWED BY COMPENSATION COMMITTEE MEMBERS PRIOR TO THEIR RATIFICATION. THESE MINUTES ARE SUFFICIENTLY DETAILED TO PROVIDE SUBSTANTIATION OF THE DECISIONS MADE BY THE COMMITTEE WITH REGARD TO EACH KEY EXECUTIVE'S COMPENSATION AND BENEFITS. A REPORT IS MADE TO THE FULL BOARD BY THE COMPENSATION COMMITTEE CHAIR AT WHICH TIME RATIFICATION OF COMMITTEE ACTION IS VOTED BY THE BOARD.
FORM 990, PART VI, SECTION C, QUESTION 19
SECTION C: DISCLOSURE
DESCRIBE IN SCHEDULE 0 WHETHER (AND IF SO, HOW), THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. ST LUKES EPISCOPAL HEALTH SYSTEM CORPORATION AND ITS RELATED ENTITIES HAVE NOT adopted or CREATED A GENERAL POLICY PROVIDING FOR THE DISCLOSURE OF CERTAIN DOCUMENTS. IN PRACTICE, THESE DOCUMENTS HAVE BEEN MADE AVAILABLE TO THE PUBLIC UPON WRITTEN REQUEST ONLY.
Form 990, Part XI, Reconciliation of Net Assets
Line 5, Other changes in net assets or fund balances
During 2010, the finance managers of St. Luke's Episcopal Hospital Self Insurance Trust agreed to merge the remaining inactive fund balance of $87,782.00 into the supported exempt organization, St. Luke's Episcopal Hospital, in order to better manage the funds. .