Form990-EZ
Click to see list of attachments
Department of the Treasury
Internal Revenue Service
Short Form
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)
bullet Sponsoring organizations of donor advised funds, organizations that operate one or more hospital facilities, and certain controlling organizations as defined in section 512(b)(13) must file Form 990 (see instructions).
All other organizations with gross receipts less than $200,000 and total assets less than $500,000 at the end of the year may use this form.
bulletThe organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-1150
2010
Open to Public
Inspection
A
For the 2010 calendar year, or tax year beginning 01-01-2010, and ending 12-31-2010
B
Check if applicable:
C Name of organization
ST MARY'S - GOOD SAMARITAN INC
 
Number and street (or P. O. box, if mail is not delivered to street address)477 N LINDBERGH BLVD
  Room/suite
City or town, state or country, and ZIP + 4 ST LOUIS, MO63141
D Employer identification number

36-4170833
E Telephone number

(618) 436-8000
F Group Exemption
Number. . bullet  
G Accounting method: Other (specify) bullet   H Check bulletI Website:bulletHTTP://WWW.SSMHC.COMJ Tax-Exempt status(check only one)—Click to see attachment(   ) bullet(insert no.) or
K Check bullet A Form 990-EZ or Form 990 return is not required though Form 990-N (e-postcard) may be required (see instructions). But if the organization chooses to file a return, be sure to file a complete return.
L Add lines 5b, 6c, and 7b, to line 9 to determine gross receipts; If gross receipts are $200,000 or more, or if total assets (Part II, line 25, column (B) below) are $500,000 or more, file Form 990 instead of Form 990-EZ.. . bullet $ 24,600
Part IRevenue, Expenses, and Changes in Net Assets or Fund Balances (See the instructions for Part I.) Check if the organization used Schedule O to respond to any question in this Part I . . . . . . . .
VerticalRevenue 1 Contributions, gifts, grants, and similar amounts received . . . . . . . . . 1  
2 Program service revenue including government fees and contracts . . . . . . . 2 24,600
3 Membership dues and assessments . . . . . . . . . . . . . . 3  
4 Investment income . . . . . . . . . . . . . . . . . . 4  
5a Gross amount from sale of assets other than inventory . . . . 5a  
b Less: cost or other basis and sales expenses . . 5b  
c Gain or (loss) from sale of assets other than inventory (Subtract line 5b from line 5a) . . 5c  
6 Gaming and fundraising events
a Gross income from gaming (attach Schedule G if greater than $15,000) 6a  
b Gross income from fundraising events (not including $   of contributions from fundraising events reported on line 1) (attach Schedule G if the sum of such gross income and contributions exceed $15,000) . . . . . . .
c Less: direct expenses from gaming and fundraising events . . . 6c  
d Net income or (loss) from gaming and fundraising events (Add lines 6a and 6b and subtract line 6c) 6d  
7a Gross sales of inventory, less returns and allowances . . . . 7a  
b Less: cost of goods sold . . . . . . . . . . 7b  
c Gross profit or (loss) from sales of inventory (Subtract line 7b from line 7a) . . . . . . 7c  
8 Other revenue (describe in Schedule O) . . . . . . . . . 8  
9 Total revenue. Add lines 1, 2, 3, 4, 5c, 6d, 7c, and 8 . . . . . . . . . 9 24,600
VerticalExpenses 10 Grants and similar amounts paid (list in Schedule O) . . . . . . . . 10  
11 Benefits paid to or for members . . . . . . . . . . . . . . . 11  
12 Salaries, other compensation, and employee benefits . . . . . . . . . . . 12  
13 Professional fees and other payments to independent contractors . . . . . . . . 13  
14 Occupancy, rent, utilities, and maintenance . . . . . . . . . . . . . 14  
15 Printing, publications, postage, and shipping . . . . . . . . . . . . 15  
16 Other expenses (describe in Schedule O) . . . . . . . . . . 16 75,821
17 Total expenses. Add lines 10 through 16 . . . . . . . . . . . . 17 75,821
VerticalNetAssets 18 Excess or (deficit) for the year (Subtract line 17 from line 9) . . . . . . . . . 18 -51,221
19 Net assets or fund balances at beginning of year (from line 27, column (A)) (must agree with
end-of-year figure reported on prior year’s return) . . . . . . . . . . . 19 -613
20 Other changes in net assets or fund balances (explain in Schedule O) . . . . . . . 20 51,834
21 Net assets or fund balances at end of year. Combine lines 18 through 20 . . . . . Bullet 21 0
Part IIBalance Sheets Check if the organization used Schedule O to respond to any question in this Part II. . . . . . . . .

(See the instructions for Part II.)(A) Beginning of year(B) End of year
22Cash, savings, and investments . . . . . . . . . .
18,600
22
21,800
23Land and buildings . . . . . . . . . . . . .
 
23
 
24Other assets (describe in Schedule O) . . . . . .
5,000
24
2,800
25Total assets . . . . . . . . . . . . . .
23,600
25
24,600
26
Total liabilities (describe in Schedule O) . . . . .
24,213
26
24,600
27Net assets or fund balances (line 27 of column (B) must agree with line 21) .
-613
27
0
For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 10642I Form 990-EZ (2010)
Form 990-EZ (2010)
Page 2
Part IIIStatement of Program Service Accomplishments Check if the organization used Schedule O to respond to any question in this Part III . Expenses
(Required for section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts; optional for others.)
What is the organization's primary exempt purpose? IMPROVE ACCESS TO HEALTH CARE & IMPROVE HEALTH IN OUR COMMUNITIES.
Describe what was achieved in carrying out the organization's exempt purposes. In a clear and concise manner, describe the services provided, the number of persons benefited, and other relevant information for each program title.
28 THE ORGANIZATION PROVIDES HOSPITALS AND PHYSICIANS WITH THE RESOURCES TO COORDINATE MANAGED CARE. DURING 2010, THERE WERE 123 PARTICIPATING PHYSICIANS. FORM 990-EZ, PART III 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 EMPLOYEES 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. ST. MARY'S - GOOD SAMARITAN, INC. IS COMMITTED TO THE PURPOSE OF ENABLING ITS ENTITIES, ST MARY'S HOSPITAL IN CENTRALIA, IL AND GOOD SAMARITAN REGIONAL HEALTH CENTER IN MOUNT VERNON, IL, TO PROVIDE ACCESS TO QUALITY HEALTH CARE SERVICES TO ALL PERSONS IN THE SOUTHERN ILLINOIS REGION REGARDLESS OF THEIR ABILITY TO PAY. THROUGH ITS GOVERNANCE, OPERATION AND ADMINISTRATION, ST MARY'S - GOOD SAMARITAN, INC. HELPS TO MEET THE COMMUNITY NEEDS IDENTIFIED BY EACH HOSPITAL IN AN ECONOMIC AND EFFICIENT MANNER. THE LEADERS OF ST. MARY'S - GOOD SAMARITAN, INC. PARTICIPATE IN COMMUNITY ORGANIZATIONS WHICH ENABLE THEM TO IDENTIFY COMMUNITY NEEDS. ALL SSMHC FACILITIES WILL STRIVE TO PROVIDE EXCEPTIONAL HEALTH CARE SERVICES TO ALL PERSONS IN NEED REGARDLESS OF THEIR ABILITY TO PAY. ALL BILLING AND COLLECTION POLICIES AND PRACTICES WILL REFLECT THE MISSION AND VALUES OF SSMHC, INCLUDING OUR SPECIAL CONCERN FOR PEOPLE WHO ARE POOR AND VULNERABLE. SSMHC FACILITIES OFFER DISCOUNTS FOR HOSPITAL SERVICES TO ALL UNINSURED PERSONS. SELF-PAY DISCOUNTS APPLY TO EVERYONE WHO DOES NOT HAVE HEALTH INSURANCE, NO MATTER THEIR ABILITY TO PAY. SSMHC WILL APPLY ITS CHARITY CARE POLICIES FAIRLY AND CONSISTENTLY. EACH PERSON WILL BE TREATED AS AN INDIVIDUAL WITH SPECIFIC NEEDS FOR ASSISTANCE WITHOUT REGARD TO PAYMENT. SSMHC EMBRACES ITS RESPONSIBILITY TO SERVE THE COMMUNITIES IN WHICH WE PARTICIPATE BY ESTABLISHING SOUND BUSINESS PRACTICES. CHARITY CARE IS PROVIDED TO PATIENTS BASED ON A SLIDING SCALE FOR HOUSEHOLD INCOMES UP TO FOUR TIMES THE FEDERAL POVERTY LEVEL. PATIENTS WHOSE HOUSEHOLD INCOME IS NO MORE THAN TWO TIMES THE FEDERAL POVERTY LEVEL ARE ELIGIBLE FOR FREE HOSPITAL SERVICES. IN ADDITION, AN EXCEPTION TO THE SLIDING SCALE IS PROVIDED FOR A PATIENT'S BALANCE DUE IF THE AMOUNT IS TOO LARGE TO BE REASONABLY PAID THROUGH AN INSTALLMENT PLAN OVER FOUR YEARS GIVEN THE FAMILY INCOME AND EXPENSES. EACH ENTITY PROVIDING MEDICAL SERVICES SHALL PROVIDE INFORMATION TO THE PUBLIC REGARDING ITS CHARITY CARE POLICIES AND THE QUALIFICATION REQUIREMENTS FOR EACH OF ITS FACILITIES. WHEN STANDARD SYSTEM NOTICES AND COMMUNICATIONS REGARDING CHARITY CARE ARE AVAILABLE, THESE MUST BE USED. MODIFICATIONS TO THE STANDARD MAY BE MADE TO COMPLY WITH STATE AND LOCAL LAWS, AS WELL AS REFLECT CULTURALLY SENSITIVE TERMINOLOGY FOR THE POLICY. ALL NOTICES WILL BE EASY TO UNDERSTAND BY THE GENERAL PUBLIC, CULTURALLY APPROPRIATE AND AVAILABLE IN THOSE LANGUAGES THAT ARE PREVALENT IN THE COMMUNITY. THEY WILL PROVIDE INFORMATION ABOUT: THE PATIENT'S RESPONSIBILITY FOR PAYMENT, THE AVAILABILITY OF FINANCIAL ASSISTANCE FROM PUBLIC PROGRAMS AND ENTITY CHARITY CARE AND PAYMENT ARRANGEMENTS, THE ENTITY'S CHARITY POLICY AND APPLICATION PROCESS, AND WHOM TO CONTACT TO GET ADDITIONAL INFORMATION OR FINANCIAL COUNSELING. THE FOLLOWING TYPES OF NOTICES TO THE PUBLIC SHALL BE PROVIDED: SIGNS IN THE EMERGENCY DEPARTMENT, OUTPATIENT AND INPATIENT REGISTRATION AND PUBLIC WAITING AREAS, BROCHURES OR FLIERS AT TIME OF REGISTRATION AND AVAILABLE IN THE FINANCIAL COUNSELING AREAS, NOTICES SENT WITH OR ON PATIENT BILLS OR COMMUNICATIONS SENT TO PATIENTS AND GUARANTORS RELATED TO MEDICAL SERVICES AND APPLICATIONS PROVIDED TO UNINSURED PATIENTS AT THE TIME OF REGISTRATION. THE APPLICATION FOR CHARITY CARE, TOGETHER WITH ANY INSTRUCTIONS, MUST CLEARLY STATE THE POLICIES REGARDING CHARITY CARE, INCLUDING EXCLUDED SERVICES, ELIGIBILITY CRITERIA AND DOCUMENTATION REQUIREMENTS. INFORMATION ABOUT THE ENTITY'S CHARITY POLICIES WILL ALSO BE PROVIDED TO PUBLIC AGENCIES. ST MARY'S - GOOD SAMARITAN, INC. SUPPORTS TWO SSMHC HOSPITALS THAT EACH OPERATE AN EMERGENCY ROOM THAT IS OPEN TO ALL PERSONS REGARDLESS OF ABILITY TO PAY, HAVE AN OPEN MEDICAL STAFF WITH PRIVILEGES AVAILABLE TO ALL QUALIFIED PHYSICIANS IN THE AREA, HAVE A GOVERNING BODY IN WHICH INDEPENDENT PERSONS REPRESENTATIVE OF THE COMMUNITY COMPRISE A MAJORITY, ENGAGE IN THE TRAINING AND EDUCATION OF HEALTH CARE PROFESSIONALS, AND PARTICIPATE IN MEDICAID, MEDICARE, CHAMPUS, TRICARE, AND/OR OTHER GOVERNMENT-SPONSORED HEALTH CARE PROGRAMS. ADDITIONAL INFORMATION REGARDING SSMHC'S 2010 COMMUNITY BENEFIT REPORT CAN BE FOUND AT WWW.SSMHC.COM. FORM 990EZ, PART V, LINE 45A:ST. MARY'S - GOOD SAMARITAN, INC. DID ENGAGE IN TRANSACTIONS WITH CONTROLLED ENTITIES DURING THE YEAR ENDED DECEMBER 31, 2010; HOWEVER, THE TOTAL AMOUNTS OF THE EACH CATEGORY OF TRANSACTION WITH EACH CONTROLLED ENTITY DID NOT EXCEED $50,000.
(Grants $ 0) If this amount includes foreign grants, check here ...MediumBullet		 28a 75,821
29
(Grants $   ) If this amount includes foreign grants, check here ...MediumBullet 		29a
30
(Grants $   ) If this amount includes foreign grants, check here ...MediumBullet 		30a
31 Other program services (describe in Schedule O) . . . . . . . . . . . .
(Grants $   ) If this amount includes foreign grants, check here...MediumBullet		 31a
32 Total program service expenses (add lines 28a through 31a) . . . . . . . . . bullet 32 75,821
Part IVList of Officers, Directors, Trustees, and Key Employees. List each one even if not compensated. (See the instructions for Part IV.) Check if the organization used Schedule O to respond to any question in this Part IV . . . . . . . .
(a) Name and address (b) Title and average
hours per week
devoted to position		 (c) Compensation
(If not paid,
enter -0-.) 		(d) Contributions to
employee benefit plans &
deferred compensation		 (e) Expense
account and
other allowances
SR MARY JEAN RYAN FSM
477 N LINDBERGH BLVD
ST LOUIS,MO631417832
 DIRECTOR & CHAIRPERSON1.00 0 0 0
SR M CLARETTE STRYZEWSKI CSSF
3800 W PETERSON AVENUE
CHICAGO,IL62801
 DIRECTOR & VICE CHAIR1.00 0 0 0
PHILIP GUSTAFSON
400 NORTH PLEASANT
CENTRALIA,IL62801
 PRESIDENT/CEO1.00 0 0 0
JUNE L PICKETT
477 N LINDBERGH BLVD
ST LOUIS,MO63141
 SECRETARY1.00 0 0 0
CARISSA HIBBERT
400 NORTH PLEASANT
CENTRALIA,IL62801
 ASST SECRETARY1.00 0 0 0
VERLE BESANT
400 NORTH PLEASANT
CENTRALIA,IL62801
 DIRECTOR1.00 0 0 0
SR RAMONA DOMBROWSKI CSSF
3045 SOUTH 16TH STREET
MILWAOKKE,WI53215
 DIRECTOR1.00 0 0 0
D BRUCE GEARY
400 NORTH PLEASANT
CENTRALIA,IL62801
 DIRECTOR1.00 0 0 0
SAJJAN NEMANI MD
400 NORTH PLEASANT
CENTRALIA,IL62801
 DIRECTOR1.00 0 0 0
JAMES SANGER
400 NORTH PLEASANT
CENTRALIA,IL62801
 DIRECTOR1.00 0 0 0
WILLIAM P THOMPSON
477 N LINDBERGH BLVD
ST LOUIS,MO63141
 DIRECTOR1.00 0 0 0
JITENDRA TRIVEDI MD
605 N 12TH STREET
MT VERNON,IL62864
 DIRECTOR1.00 0 0 0
Form 990-EZ (2010)
Form 990-EZ (2010)
Page 3
Part VOther Information(Note the statement requirements in the instructions for Part V.)YesNo Check if the organization used Schedule O to respond to any question in this Part V . . . .
33
Did the organization engage in any activity not previously reported to the IRS? If "Yes," provide a detailed description of each activity in Schedule O ..............
33
 
No
34
Were any significant changes made to the organizing or governing documents? If "Yes," attach a conformed copy of the amended documents if they reflect a change to the organization’s name. Otherwise, explain the change on Schedule O (see instructions). ...................
34
 
No
35
If the organization had income from business activities, such as those reported on lines 2, 6a, and 7a (among others), but not reported on Form 990-T, explain in Schedule O why the organization did not report the income on Form 990-T. ........................
a
Did the organization have unrelated business gross income of $1,000 or more or was it a section 501(c)(4), 501(c)(5), or 501(c)(6) organization subject to section 6033(e) notice, reporting, and proxy tax requirements?
35a
 
No
b
If "Yes," has it filed a tax return on Form 990-T for this year? (see instructions) ........
35b
 
 
36
Did the organization undergo a liquidation, dissolution, termination, or significant disposition of net assets during the year? If “Yes,” complete applicable parts of Schedule N .............
36
 
No
37a
Enter amount of political expenditures, direct or indirect, as described in the instructions. bullet
37a
0
b
Did the organization file Form 1120-POL for this year? ...............
37b
 
 
38a
Did the organization borrow from, or make any loans to, any officer, director, trustee, or key employee or were
any such loans made in a prior year and still outstanding at the end of the tax year covered by this return?
38a
 
No
b
If “Yes,” complete Schedule L, Part II and enter the total amount involved .
38b
 
39
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on line 9 ......
39a
 
b
Gross receipts, included on line 9, for public use of club facilities ....
39b
 
40a
Section 501(c)(3) organizations. Enter amount of tax imposed on the organization during the year under:
section 4911 bullet0 ; section 4912 bullet0 ; section 4955 bullet0
b
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in any section 4958 excess benefit transaction during the year or did it engage in an excess benefit transaction in a prior year that has not been reported on any of its prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I. ....
40b
 
No
c
Section 501(c)(3) and 501(c)(4) organizations. Enter amount of tax imposed on organization managers or disqualified persons during the year under sections 4912, 4955, and 4958 ..bullet0
d
Section 501(c)(3) and 501(c)(4) organizations. Enter amount of tax on line 40c reimbursed by the organization ...................bullet0
e
All organizations. At any time during the tax year, was the organization a party to a prohibited tax shelter transaction? If "Yes," complete Form 8886-T. .................
40e
 
No
41List the states with which a copy of this return is filed. bulletIL
42aThe organization's books are in care of bulletPHILIP GUSTAFSON Telephone no. bullet (618) 436-6540
Located at bullet400 N PLEASANT
CENTRALIA,IL ZIP + 4bullet62801
b
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, securities account, or other financial account)?
Yes
No
42b
 
No
If “Yes,” enter the name of the foreign country: bullet  
See the instructions for exceptions and filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
c
At any time during the calendar year, did the organization maintain an office outside of the U.S.?
42c
 
No
If “Yes,” enter the name of the foreign country: bullet  
43.......bullet
and enter the amount of tax-exempt interest received or accrued during the tax year . . . bullet43
 
44a
Did the organization maintain any donor advised funds? If "Yes", Form 990 must be completed instead of
Yes
No
Form 990-EZ.. . . . . . . . . . . . . . . . . . . .
44a
 
No
b
Did the organization operate one or more hospital facilities during the year? If ‘Yes,’ Form 990 must be completed instead of Form990-EZ. . . . . . . . .
44b
 
No
c
Did the organization receive any payments for indoor tanning services during the year? . . . . . . .
44c
 
No
d
If 'Yes' to line 44c, has the organization filed a Form 720 to report these payments? If ‘No,’ provide an explanation in Schedule O. . . . . . . . .
44d
 
 
45
Is any related organization a controlled entity of the organization within the meaning of section 512(b)(13)? If ‘Yes,’ Form 990 and Schedule R must be completed instead of Form990-EZ. . . . . . . . .
45
Yes
 
45a
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,’ Form 990 and Schedule R must be completed instead of Form990-EZ. .
45a
Yes
 
46
Did the organization engage, directly or indirectly, in political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part I. . . . . . . . . .
46
Yes
 
Form 990-EZ (2010)
Form 990-EZ (2010)
Page 4
Part VI
Section 501(c)(3) organizations and section 4947(a)(1) nonexempt charitable trusts only. All section 501(c)(3) organizations and section 4947(a)(1) nonexempt charitable trusts must answer questions 47-49b and 52. Check if the organization used Schedule O to respond to any question in this Part VI . . . . . . . .
Yes
No
47
Did the organization engage in lobbying activities? If "Yes," complete Schedule C, Part II . . . .
47
 
No
48
Is the organization a school described in section 170(b)(1)(A)(ii)? If "Yes," complete Schedule E . . .
48
 
No
49a
Did the organization make any transfers to an exempt non-charitable related organization? . . . .
49a
 
No
b
If "Yes," was the related organization a section 527 organization? . . . . . . . . .
49b
 
 
50
Complete this table for the organization's five highest compensated employees (other than officers, directors, trustees and key employees) who each received more than $100,000 of compensation from the organization. If there is none, enter "None."
(a) Name and address of each employee paid more than $100,000 (b) Title and average
hours per week
devoted to position		 (c) Compensation
 (d) Contributions to
employee benefit plans &
deferred compensation		 (e) Expense
account and
other allowances
NONE
50(f)
Total number of other employees paid over $100,000 . . . . . . . . . . . . . bullet  

51
Complete this table for the organization's five highest compensated independent contractors who each received more than $100,000 of compensation from the organization. If there is none, enter "None."
(a) Name and address of each independent contractor paid more than $100,000 (b) Type of service (c) Compensation
NONE
51(d)
Total number of other independent contractors each receiving over $100,000 . . . . . . . bullet  
52
Did the organization complete Schedule A? NOTE: All Section 501(c)(3) organizations and 4947(a)(1) nonexempt charitable trusts must attach a completed Schedule A ....................
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 .........bullet
Form 990-EZ (2010)

Additional Data


Software ID:  
Software Version:  

Form 990-EZ, 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 MARY'S - GOOD SAMARITAN INC
 
Employer identification number

36-4170833
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)
 
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
(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 MARY'S HOSPITAL
  		370662580 03 Yes           0
(2) GOOD SAMARITAN REGIONAL HEALTH CENTER
  		430653587 03 Yes           0
Total                 0

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
12
 
13
Section C. Computation of Public Support Percentage
14
14
 
15
15
 
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
ST. MARY'S - GOOD SAMARITAN, INC. IS A TYPE I SUPPORTING ORGANIZATION THAT IS OPERATED EXCLUSIVELY TO SUPPORT THE OPERATIONS OF ST. MARY'S HOSPITAL AND GOOD SAMARITAN REGIONAL HEALTH CENTER, RELATED TAX-EXEMPT ORGANIZATIONS. THE AMOUNTS OF SUPPORT PROVIDED TO ST. MARY'S HOSPITAL AND GOOD SAMARITAN REGIONAL HEALTH CENTER ON SCHEDULE A, PART I, LINE 11(H)(VII) DOES NOT INCLUDE EXPENSES PAID ON BEHALF OF BUT NOT DIRECTLY TO ST. MARY'S HOSPITAL AND GOOD SAMARITAN REGIONAL HEALTH CENTER. THESE EXPENSES TOTALED $75,821 DURING THE YEAR ENDED DECEMBER 31, 2010.
Explanation
 
 
 
 
Schedule A (Form 990 or 990-EZ) 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 MARY'S - GOOD SAMARITAN INC
 
Employer identification number

36-4170833
Identifier Return Reference Explanation
OTHER EXPENSES FORM 990-EZ, PART I, LINE 16 DESCRIPTION: OFFICE EXPENSES. AMOUNT: 523. DESCRIPTION: TRAVEL. AMOUNT: 338. DESCRIPTION: INSURANCE. AMOUNT: 12,192. DESCRIPTION: LEGAL FEES. AMOUNT: 1,971. DESCRIPTION: PURCHASED SERVICES. AMOUNT: 60,681. DESCRIPTION: BANK SERVICE CHARGE. AMOUNT: 116. TOTAL TO FORM 990-EZ, LINE 16: 75,821.
OTHER CHANGES IN NET ASSETS FORM 990-EZ, PART I, LINE 20 DESCRIPTION: FUND TRANSFER - GOOD SAMARITAN REGIONAL HEALTH CENTER. AMOUNT: 25,800. DESCRIPTION: FUND TRANSFER - ST MARY'S HOSPITAL. AMOUNT: 26,034. TOTAL TO FORM 990-EZ, LINE 20: 51,834.
OTHER ASSETS FORM 990-EZ, PART II, LINE 24 DESCRIPTION: ACCOUNTS RECEIVABLE. BEG. OF YEAR AMOUNT: 5,000. END OF YEAR AMOUNT: 2,800.
OTHER LIABILITIES FORM 990-EZ, PART II, LINE 26 DESCRIPTION: DUE TO ST. MARY'S HOSPITAL. BEG. OF YEAR AMOUNT: 12,106. END OF YEAR AMOUNT: 12,300. DESCRIPTION: DUE TO GOOD SAMARITAN REGIONAL HEALTH CENTER. BEG. OF YEAR AMOUNT: 12,107. END OF YEAR AMOUNT: 12,300.
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:  

TY 2010 TransferPrsnlBnftContractsDecl
Name:
ST MARY'S - GOOD SAMARITAN INC
EIN: 36-4170833
Declaration:
THE ORGANIZATION DID NOT, DURING THE YEAR, RECEIVE ANY FUNDS, DIRECTLY,OR INDIRECTLY, TO PAY PREMIUMS ON A PERSONAL BENEFIT CONTRACT.THE ORGANIZATION, DID NOT, DURING THE YEAR, PAY ANY PREMIUMS, DIRECTLY,OR INDIRECTLY, ON A PERSONAL BENEFIT CONTRACT.