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
Scott & White Clinic
Employer identification number
74-2958277
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.") .
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......
270,215,559
308,925,279
352,637,733
389,814,263
429,913,747
1,751,506,581
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.
270,215,559
308,925,279
352,637,733
389,814,263
429,913,747
1,751,506,581
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
0
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.
0
c
Add lines 7a and 7b..
0
8
Public Support (Subtract line 7c from line 6.)
1,751,506,581
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...
270,215,559
308,925,279
352,637,733
389,814,263
429,913,747
1,751,506,581
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.
20,979
20,979
c
Add lines 10a and 10b.
20,979
20,979
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.).
270,215,559
308,925,279
352,658,712
389,814,263
429,913,747
1,751,527,560
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
100.000 %
16
Public support percentage from 2009 Schedule A, Part III, line 15
...............
16
100.000 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2010 (line 10c column (f) divided by line 13 column (f))
......
17
0 %
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
Scott & White Clinic
Employer identification number
74-2958277
Identifier
Return Reference
Explanation
Form 990, Part V, Line 1a: Scott & White Clinic (SWC) does not file Forms 1096 or 1099. All expenditures for goods and services, other than physician salaries and certain other salaries, are made by Scott & White Memorial Hospital, which has filed all required reporting forms.
Form 990, Part V, Line 2a: Employees of the Scott & White Healthcare system are employed by Scott & White Memorial Hospital (EIN: 74-1166904) or Scott & White Clinic (EIN: 74-2958277). This is done to achieve parity and consistency in compensation and benefits offered to employees and to reduce administration costs. Consistent with this practice, employee Form W-2's are filed by Scott & White Memorial Hospital or Scott & White Clinic. For financial reporting purposes, compensation, benefits and other employee costs are assigned to the Scott & White affiliate for which services are rendered. Oversight of and responsibility for the activities of employees are vested in the board of directors and management of the Scott & White Healthcare subsidiary to which such employees are assigned. All required employment forms have been filed by Scott & White Memorial Hospital and Scott & White Clinic.
Form 990, Part VI, Section A, line 6
Scott & White Clinic's (SWC) sole member is Scott & White Healthcare, an organization exempt from tax under IRC section 501(c)(3) and a public charity under IRC section 509(a)(3).
Form 990, Part VI, Section A, line 7b
Scott & White Clinic's (SWC) sole member is Scott & White Healthcare (EIN: 26-4532547), an organization exempt from tax under IRC section 501(c)(3) and a public charity under IRC section 509(a)(3). State statutes with respect to Texas non-profit corporations providing physician services require that all board members be physicians licensed by the Texas Medical Board who are actively engaged in the practice of medicine. Some Actions taken by the SWC Board of Directors are subject to oversight and approval of the Scott & White Healthcare Board of Trustees. The majority of the Scott & White Healthcare Board of Trustees is comprised of individuals who are representative of the community.
Form 990, Part VI, Section B, line 11
The Scott & White Clinic (SWC) Directors were each provided a copy of Form 990 prior to filing with the IRS. A meeting was held to allow the Directors to ask questions and provide feedback with respect to the information presented in the Form 990.
Form 990, Part VI, Section B, line 12c
Annually, a written questionnaire is provided to all persons identified as being subject to the Scott & White Healthcare system Conflict of Interest Policy, requesting responses to questions designed to identify potential conflicts. Responses are monitored and reviewed by system personnel and follow-ups are initiated as required. The Conflict of Interest Policy is reviewed before each board meeting or board committee meeting. Board members or persons having business with the Board are asked to identify conflicts which may arise with respect to business conducted by the Board or committee during the meeting.
Form 990, Part VI, Section B, line 15
The compensation review process is performed annually. All staff including: officers, key employees and highly compensated individuals are included in the review. The process utilizes various comparative data with respect to similar organizations. The procedures, rationale and results of the process are documented and retained. Recommended salaries and total compensation are reviewed by independent compensation consultants and approved by the Compensation Committee of the Scott & White Healthcare (SWHC) Board of Trustees. The entire SWHC Board reviews and approves the recommendations of the Compensation Committee.
Form 990, Part VI, Section C, line 19
The Scott & White Clinic (SWC) governing documents and Conflict of Interest Policy are available to the public upon request. SWC does not have separately audited financial statements, but the audited financial statements of the Scott & White Healthcare system are available at http://www.dacbond.com and upon request.
Form 990, Part VII: Average hours per week recorded in column B for the Officers, Directors, Key Employees and Highly Compensated Employees represent total hours worked for the entire Scott & White Healthcare system.
Changes in Net Assets or Fund Balances:
Form 990, Part XI, line 5:
Transfer to Captive Insurance -5,780,893. Total to Form 990, Part XI, Line 5: -5,780,893.
Form 990, Part XI, Line 2b and 2c: Results of Scott & White Clinic (SWC) operations and assets and liabilities are included in the combined financial statements of its sole member, Scott & White Healthcare. The financial statements are audited annually by an independent accounting firm selected by the Scott & White Healthcare Board of Trustees Audit Committee, which is also responsible for oversight of the audit. The Scott & White Healthcare Board of Trustees is made up of representatives of the community.
Form 990, Part IV, Line 26 and Schedule L, Part II: Scott & White Clinic entered into a loan agreement in 2004 with a physician recruited by the Clinic. The purpose of the loan was to assist the physician with relocation costs. The physician in question was elected to the Clinic's Board of Directors in 2006. Details of the note are: Borrower: W. R. Smythe, M.D. Title: Chair, Dept of Surgery; Director Original Loan Amount: $150,000 Outstanding, August 31, 2011: $64,600 Date of the Note: March 2004 Current Maturity Date: 8/31/2017 Interest Rate: 5% per annum Terms of the note were modified in 2006 and 2007, extending the note to August 31, 2017, and allowing forgiveness of annual principal and interest payments, provided the borrower remains employed by the Clinic. Annual debt forgiven per the note terms is included in the borrower's taxable compensation in the year of forgiveness. The borrower's annual compensation, including forgiveness, if any, is evaluated each year as part of the Clinic compensation review process. This loan is not reflected in the Clinic's Form 990 at Part X, Balance Sheet, as beneficial ownership of all Clinic assets is vested in Scott & White Memorial Hospital. The note receivable is reflected in the balance sheet of the Form 990 filed by Memorial Hospital.
Disclosure Statement Related to Forms 5471, Information Return of U.S. Persons With Respect to Certain Foreign Corporations, Filed on Behalf of the Taxpayer: Under the constructive ownership rules of IRC Sections 958(a) and (b). The taxpayer is required to file Forms 5471, Information Return of U.S. Persons With Respect to Certain Foreign Corporations, as a Category 5 filer with respect to certain controlled foreign corporations (CFCs). These filing requirements are or will be satisfied through the filing of Forms 5471 for these CFCs by other U.S. taxpayers identified below who have the same filing requirement. Taxpayer Name: Scott & White memorial Hospital Taxpayer Address: 2401 S. 31st Street Temple, TX 76508 Taxpayer Identification Number of U.S. tax return with which the Forms 5471 were or will be filed: 74-1166904 IRS Service Center where U.S. tax return was or will be filed: efile
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.