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
INDIANAPOLIS OSTEOPATHIC HOSPITAL INC
Employer identification number
35-1094734
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......
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
INDIANAPOLIS OSTEOPATHIC HOSPITAL INC
Employer identification number
35-1094734
Identifier
Return Reference
Explanation
FORM 990, PART VI, SECTION A, LINE 3
IN ACCORDANCE WITH THE MEMBER SUBSTITUTION AGREEMENT WITH COMMUNITY HEALTH NETWORK, INC. CERTAIN MANAGEMENT ROLES HAVE BEEN DELEGATED TO COMMUNITY HEALTH NETWORK, INC.
FORM 990, PART VI, SECTION A, LINE 4
EFFECTIVE AUGUST 1, 2011, THE HOSPITAL ENTERED INTO A MEMBER SUBSTITUTION AGREEMENT WITH COMMUNITY HEALTH NETWORK, INC. UNDER THE AGREEMENT, COMMUNITY BECAME THE SOLE VOTING MEMBER OF THE HOSPITAL. AS A RESULT OF THE AGREEMENT, THE HOSPITAL HAS RESTATED ITS ARTICLES OF INCORPORATION AND BYLAWS TO REFLECT THE CHANGE IN CONTROL.
FORM 990, PART VI, SECTION A, LINE 6
THE SOLE MEMBER OF THE CORPORATION SHALL BE COMMUNITY HEALTH NETWORK, INC.
FORM 990, PART VI, SECTION A, LINE 7A
THE MEMBERS OF THE BOARD OF DIRECTORS SHALL BE ELECTED FROM THE CORPORATION MEMBERSHIP AT THE ANNUAL MEETING OF THE MEMBERS TO SERVE FOR A TERM OF THREE (3) YEARS AND UNTIL THEIR SUCCESSORS ARE ELECTED AND QUALIFIED. A TERM OF OFFICE MAY BE LESS THAN THE PRESCRIBED THREE (3) YEAR TERM WHERE NECESSARY TO COMPLY WITH THE STAGGERED TERM PROVISION OF THE BYLAWS. NOMINATIONS SHALL BE MADE BY THE BOARD OF DIRECTORS NOT LESS THAN FIFTEEN (15) DAYS PRIOR TO THE ANNUAL MEETING. NO NOMINATIONS FOR DIRECTORS, EXCEPT THOSE SO MADE BY THE BOARD OF DIRECTORS, SHALL BE VOTED UPON AT THE ANNUAL MEETING UNLESS OTHER NOMINATIONS BY MEMBERS ARE MADE IN WRITING AND DELIVERED TO THE SECRETARY OF THE CORPORATION NOT LESS THAN SIXTY (60) DAYS PRIOR TO THE DATE OF THE ANNUAL MEETING. A MAJORITY VOTE SHALL CONSTITUTE ELECTION.
FORM 990, PART VI, SECTION A, LINE 7B
THE SOLE MEMBER HOLDS RESERVED POWERS WHICH ARE: APPOINTMENT OF ONE (1) CIVIC MEMBER OF THE BOARD OF DIRECTORS; APPROVAL OF CORPORATION'S THREE-YEAR STRATEGIC PLAN THAT EXPRESSES ITS PHILOSOPHY, VISION, GOALS, OBJECTIVES, AND ACTION PLANS; APPROVAL OF AMENDMENTS TO BYLAWS AND ARTICLES; APPROVAL OF ANY INDEBTNESS OR LOANS; APPROVAL OF THE FORMATION OF LEGAL ENTITIES, THE SALE, TRANSFER OR SUBSTANTIAL CHANGE IN THE USE OF ALL OR SUBSTANTIALLY ALL OF THE ASSET OF THE CORPORATION, OR THE DIVESTURE, DISSOLUTION, CLOSURE, MERGER, CONSOLIDATION OR REORGANIZATION OF THE CORPORATION; APPROVAL OF ANY DISPOSITION OF ASSETS OF THE CORPORATION AT THE TIME OF ITS DISSOLUTION; APPROVAL OF THE ANNUAL CAPITAL AND OPERATION BUDGETS; APPROVAL OF THE INDEPENDENT AUDITING FIRM FOR THE CORPORATION; APPROVAL OF EXECUTIVE AND PHYSICIAN COMPENSATION; APPROVAL OF ALL CAPITAL IMPROVEMENTS, ADDITIONS AND STRUCTURAL CHANGES TO THE PROPERTY.
FORM 990, PART VI, SECTION B, LINE 11
UPON COMPLETION OF THE RETURN BY THE DIRECTOR OF FINANCE AND ACCOUNTING FIRM, AN ELECTRONIC VERSION OF THE RETURN WILL BE SENT TO THE HOSPITAL'S LEGAL COUNSEL FOR HIS REVIEW AND COMMENTS. SHOULD HE HAVE ANY ISSUES WITH THE RETURN THOSE WILL BE DISCUSSED AND ADDRESSED BY THE DIRECTOR OF FINANCE, CEO/CFO AND OUTSIDE ACCOUNTING FIRM IF NECESSARY. HARD COPIES OF THE FINAL VERSION OF OUR RETURN WILL BE DISTRIBUTED TO THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS DURING ONE OF THEIR REGULAR MONTHLY MEETINGS. AT THAT MEETING TIME WILL BE GIVEN FOR THEM TO REVIEW THE HIGH POINTS OF THE RETURN AS WELL AS ANY NEW QUESTIONS AND ANSWER ITEMS WILL BE SPECIFICALLY ADDRESSED/REVIEWED WITH THEM BY THE PRESIDENT/CEO AND/OR DIRECTOR OF FINANCE. THE 990 RETURN WILL THEN BE AN AGENDA ITEM ON THE FOLLOWING WEEK'S BOARD OF DIRECTORS MEETING, WHERE THE CHAIR OF THE BOARD AND/OR CEO/CFO WILL AGAIN REVIEW THE HIGH POINTS OF THE RETURN WITH THE WHOLE BOARD AND OFFER THE EXECUTIVE COMMITTEE'S RECOMMENDATION THAT THE RETURN BE ACCEPTED AS PREPARED. THE BOARD CHAIR WILL HAVE A HARD COPY OF THE RETURN AVAILABLE FOR INDIVIDUAL REVIEW BY THE BOARD MEMBERS IF THEY SO DESIRE.
FORM 990, PART VI, SECTION B, LINE 12C
ANNUAL CONFLICT OF INTEREST STATEMENTS ARE COLLECTED FROM THOSE IN SENSITIVE POSITIONS AND REVIEWED BY CORPORATE COMPLIANCE OFFICER AS WELL AS THE ORGANIZATION'S LEGAL COUNSEL. IF CONFLICT IS FOUND IN THOSE SATEMENTS OR IF EITHER THE CORPORATE COMPLIANCE OFFICER OR LEGAL COUNSEL BECOMES AWARE OF A CONFLICT, THEN THEY EVALUATE WHETHER THE TRANSACTION OR ARRANGEMENT IS IN WESTVIEW'S BEST INTEREST, IF THE TRANSACTION/ARRANGEMENT IS FAIR AND REASONABLE TO WESTVIEW, WHETHER THE ALTERNATIVES TO THE EXISTING TRANSACTION/ARRANGEMENT ARE ANY MORE ADVANTAGEOUS AND WHETHER THE TRANSACTION/ARRANGEMENT WAS ACCOMPLISHED IN GOOD FAITH AND USED ARM'S LENGTH BARGAINING. DEPENDING ON THE LEVEL OF THE CONFLICTING ITEM, THE ACTION MAY BE REFERRED TO THE EXECUTIVE COMPENSATION & CONFLICT COMPLIANCE COMMITTEE. SITUATIONS ARE HANDLED ON A CASE BY CASE BASIS AND WHERE CONFLICT MAY EXIST, PARTIES MAY BE ASKED TO EXCUSE THEMSELVES FROM DISCUSSION OR PARTICIPATION IN THE PARTICULAR TRANSACTION.
FORM 990, PART VI, SECTION B, LINE 15
THE EXECUTIVE COMPENSATION & CONFLICT COMPLIANCE COMMITTEE CONSISTS OF FOUR MEMBERS OF THE BOARD OF DIRECTORS WHO ARE APPOINTED BY THE CHAIRMAN OF THE BOARD FROM THE INDEPENDENT CIVIC MEMBERS OF THE BOARD. (BOARD MEMBERS WHO RECEIVE DIRECT OR INDIRECT COMPENSATION FOR SERVICES AS AN EMPLOYEE OR INDEPENDENT CONTRACTOR OR HAVE A PERSONAL FINANCIAL INTEREST IN THE AFFAIRS OF THE CORPORATION SHALL NOT BE ELIGIBLE TO BE APPOINTED TO THE EXECUTIVE COMPENSATION & CONFLICT COMPLIANCE COMMITTEE.) THIS COMMITTEE IS PROVIDED MARKET ANALYSIS, COMPARISONS AND RECOMENDATIONS FROM OUR LEGAL COUNSEL. THIS INDEPENDENT COMMITTEE SETS THE COMPENSATION LEVEL AND EMPLOYMENT TERMS FOR THE PRESIDENT/ADMINISTRATOR, CORPORATE OFFICERS, EMPLOYED PHYSICIANS, AND OTHER KEY EMPLOYEES AS DESIGNATED BY THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS. THEY ALSO REVIEW, AT LEAST ANNUALLY, TRANSACTIONS AND ARRANGEMENTS OF THE CORPORATION TO DETERMINE WHETHER COMPENSATION ARRANGEMENTS AND BENEFITS ARE REASONABLE AND ARE A RESULT OF ARM'S LENGTH NEGOTIATIONS. THEY ALSO TAKE APPROPRIATE REMEDIAL OR DISCIPLINARY ACTION WITH RESPECT TO INTERESTED PERSONS WHO VIOLATE THE CONFLICT OF INTEREST POLICY.
FORM 990, PART VI, SECTION C, LINE 19
THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC.
CHANGES IN NET ASSETS OR FUND BALANCES:
FORM 990, PART XI, LINE 5:
NET UNREALIZED LOSSES ON INVESTMENTS: -38,750. FAIR VALUE STEP UP 11,742,446. EQUITY TRANSFER FROM COMMUNITY 7,500,000. TOTAL TO FORM 990, PART XI, LINE 5: 19,203,696.
AUDIT OVERSIGHT
FORM 990, PART XI, LINE 2C
THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS AND SELECTION OF THE INDEPENDENT AUDITORS. NO PROCESSES IN REGARDS TO AUDIT OVERSIGHT HAVE CHANGED FROM THE PRIOR YEAR.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.