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
2011
Open to Public Inspection
Name of the organization
AULTMAN HEALTH FOUNDATION
Employer identification number
34-1445390
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)
AULTMAN HOSP
340714538
03
Yes
Yes
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) 2011
Schedule A (Form 990 or 990-EZ) 2011
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) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(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) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(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—2011.
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—2010.
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—2011.
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—2010.
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) 2011
Schedule A (Form 990 or 990-EZ) 2011
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) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(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) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(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 2011 (line 8 column (f) divided by line 13 column (f))
.........
15
16
Public support percentage from 2010 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2011 (line 10c column (f) divided by line 13 column (f))
......
17
18
Investment income percentage from 2010 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2011.
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—2010.
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) 2011
Schedule A (Form 990 or 990-EZ) 2011
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
AULTMAN HEALTH FOUNDATION (AHF) WAS FORMED TO HANDLE THE OVERALL MANAGEMENT FOR AULTMAN HOSPITAL (AH) AND AHF'S SUBSIDIARIES. THIS STRUCTURE IS COMMON TO MANY HEALTH CARE SYSTEMS. AHF PERFORMS ACTIVITIES THAT DIRECTLY AND INDIRECTLY IMPACT AH. SPECIFICALLY IDENTIFYING THOSE EXPENSES RELATED TO AH WOULD BE DIFFICULT TO QUANTIFY. AS SUCH, AHF HAS NOT REPORTED ANY DIRECT EXPENSES ON SCHEDULE A PART I. THERE IS A CLOSE WORKING RELATIONSHIP BETWEEN AHF AND AH AND SUBSTANTIAL RESOURCES OF AHF ARE COMMITTED TO FURTHERING THE AH MISSION.
Schedule A (Form 990 or 990-EZ) 2011
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
2011
Open to Public Inspection
Name of the organization
AULTMAN HEALTH FOUNDATION
Employer identification number
34-1445390
Identifier
Return Reference
Explanation
PROGRAM SERVICE ACCOMPLISHMENTS
PART III LINE 4D
OTHER EXPENSES INCURRED ARE IN SUPPORT OF AULTMAN HEALTH FOUNDATION'S PURPOSE TO "LEAD OUR COMMUNITY TO IMPROVED HEALTH."
OTHER IRS FILINGS AND TAX COMPLIANCE
PART V, LINE 1A
AULTMAN HEALTH FOUNDATION'S EMPLOYEES ARE PAID BY A COMMON PAYMASTER. AULTMAN HEALTH FOUNDATION IS THE PARENT COMPANY WITH THE FOLLOWING SUBSIDIARIES: AULTMAN DEVELOPMENT INSTITUTE THE AULTMAN FOUNDATION AULTMAN HOSPITAL NORTH CANTON MEDICAL RESOURCES, INC AULTCARE CORPORATION MCKINLEY LIFE INSURANCE COMPANY WEST TUSCARAWAS PROPERTY MANAGEMENT, LLC MCKINLEY ASSURANCE SPC AULTRA ADMINISTRATIVE GROUP PART VI, SECTION A, LINE 1B EDWARD J ROTH III IS A PAID EMPLOYEE OF THE ORGANIZATION. RICK L HAINES, CHRISTOPHER E REMARK, MILAN R DOPIRAK MD, AND PRABHCHARAN P GILL MD ARE PAID EMPLOYEES OF A RELATED ORGANIZATION. PART VI, SECTION A, LINE 2 JOHN SIRPILLA AND THEODORE BOYD ARE BOARD MEMBERS OF AULTMAN HEALTH FOUNDATION AND AULTMAN HOSPITAL AND HAVE A BUSINESS RELATIONSHIP. R CLINT ZOLLINGER ESQ AND SHEILA MARKLEY BLACK ESQ ARE BOARD MEMBERS OF AULTMAN HEALTH FOUNDATION AND AULTMAN HOSPITAL AND HAVE A BUSINESS RELATIONSHIP. BRIAN BELDEN AND WILLIAM BELDEN ARE BOARD MEMBERS OF THE AULTMAN HEALTH FOUNDATION AND AULTMAN HOSPITAL AND HAVE A FAMILY RELATIONSHIP. T STEPHEN GREGORY AND LISA WARBURTON-GREGORY ARE BOARD MEMBERS OF THE AULTMAN HEALTH FOUNDATION AND AULTMAN HOSPITAL AND HAVE A FAMILY RELATIONSHIP.
POLICIES
PART VI, SECTION B, LINE 11B
A DETAIL REVIEW OF THE FORM 990 IS PERFORMED BY AN INDEPENDENT CPA FIRM. AULTMAN HEALTH FOUNDATION'S FINANCE DEPARTMENT ALSO CAREFULLY REVIEWS AND ANALYZES THE TAX RETURN. THE DEPARTMENT RECONCILES THE GENERAL LEDGER AMOUNTS TO THE APPROPRIATE SCHEDULES ON THE FORM 990 AND COMPARES THOSE AMOUNTS TO THE AUDITED FINANCIAL STATEMENTS. IN ADDITION, THE FINANCE DEPARTMENT DOES A COMPARATIVE ANALYSIS TO THE PRIOR YEAR RETURN. THE ANALYSIS AND RECONCILIATION SCHEDULES ALONG WITH A COMPLETE COPY OF THE 990 ARE PROVIDED TO THE CHIEF FINANCIAL OFFICER FOR REVIEW AND APPROVAL. A COMPLETE COPY OF THE 990 IS THEN MADE AVAILABLE AT THE BOARD OF DIRECTORS MEETING PRIOR TO THE FILING DATE. THE 990 IS PRESENTED AT THE BOARD OF DIRECTORES MEETING AND A COMPLETE FINAL COPY IS EMAILED TO EACH MEMBER OF THE BOARD PRIOR TO THE FILING DATE.
POLICIES
PART VI, SECTION B, LINE 12C
THE AULTMAN HEALTH FOUNDATION'S BOARD OF DIRECTORS HAS A CONFLICT OF INTEREST POLICY. AS A RESULT OF THIS POLICY, EACH YEAR BOARD MEMBERS, OFFICERS, AND SENIOR STAFF COMPLETE A FORM DISCLOSING ANY CONFLICTS OF INTEREST THEY MAY HAVE. THE COMPLIANCE OFFICE REVIEWS THESE DISCLOSURE FORMS AND INFORMS THE BOARD CHAIRMAN, AND OTHER APPROPRIATE OFFICERS, OF NOTABLE CONFLICTS, IF ANY. THOSE WITH CONFLICTS ARE ASKED TO RECUSE THEMSELVES FROM DISCUSSIONS RELATING TO THE CONFLICT.
POLICIES
PART VI, SECTION B, LINE 15A AND 15B
THE AULTMAN HEALTH FOUNDATION AND ITS AFFILIATED ENTITIES USE THE FOLLOWING REFERENCE MATERIALS FOR THE DEVELOPMENT OF EXECUTIVE COMPENSATION: OHIO HOSPITAL ASSOCIATION (OHA), MERCER INTEGRATED HEALTH NETWORK, INCLUDING SURVEY DATA FOR BOTH HOSPITALS AND HEALTH PLANS, AND SULLIVAN COTTER AND ASSOCIATES (SCA). ADDITIONAL SOURCES OF SALARY SURVEY DATA ARE AVAILABLE FOR USE WHERE APPROPRIATE INCLUDING COMPDATASURVEYS.COM, SALARY.COM, AND CHAMPS. IN THESE CASES, THE SURVEY IS REFERENCED WHERE APPLICABLE. EXECUTIVE PERFORMANCE, WAGE RECOMMENDATIONS, AND BONUS PAYMENTS ARE REVIEWED BY THE COMPENSATION COMMITTEE OF THE AULTMAN HEALTH FOUNDATION BOARD OF DIRECTORS. THE COMPENSATION COMMITTEE OF THE AULTMAN HEALTH FOUNDATION BOARD OF DIRECTORS HAS ENGAGED SULLIVAN COTTER & ASSOCIATES, INC., AN INDEPENDENT COMPENSATION CONSULTING FIRM FOR REVIEW OF EXECUTIVE COMPENSATION PRACTICES. THE AULTMAN HEALTH FOUNDATION AND ITS AFFILIATED USES ENTITIES THE FOLLOWING REFERENCE MATERIALS FOR THE DEVELOPMENT OF PHYSICIAN COMPENSATION: MEDICAL GROUP MANAGEMENT ASSOCIATES (MGMA), AMERICAN MEDICAL GROUP ASSOCIATION (AMGA), HOSPITAL AND HEALTHCARE COMPENSATION SERVICE (HHCS) AND SULLIVAN COTTER AND ASSOCIATES (SCA). IN ADDITION TO SALARY SURVEYS, AULTMAN HOSPITAL ALSO RETAINS AN INDEPENDENT CONSULTING FIRM FOR PHYSICIANS COMPENSATION SERVICES. ALL PHYSICIAN COMPENSATION RECOMMENDATIONS ARE SENT TO THE CEO, VP OF PHYSICIAN SERVICES, COO, AND CNO FOR FINAL APPROVAL.
DISCLOSURE
PART VI, SECTION C, LINE 19
AULTMAN HEALTH FOUNDATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. OTHER DISCLOSURE ITEMS In January 2012, the Foundation acquired Orrville Hospital Foundation dba Dunlap Community Hospital (DCH) for approximately $5,992. Included in the purchase price is the forgiveness of the $4,752 note receivable. As a result of the agreement, the entire note receivable balance is classified as a current asset in other receivables on the consolidated balance sheets at December 31, 2011. Additionally, the Foundation has made a five year capital commitment to DCH in the amount of $7,348 to be used in conjunction with information technology, facilities, equipment, routine capital and physician and new service development. Due to the timing of the closing, the initial accounting for this acquisition has not been finalized or recorded in the Foundation's December 31, 2011 consolidated financial statements. Therefore, the estimated fair value of the acquisition components are not yet available.
STATEMENT OF REVENUE
EXPLANATION FOR LINE 3
RETURN ON INVESTMENT FROM AFFILIATE $122,349
STATEMENT OF FUNCTIONAL EXPENSES
EXPLANATION FOR LINE 11G
LTACH Patient Services 2,194,859 Personnel 86,251 Purchased Maintenance 1,750,552 Other Contracted Services 437,673 CONSULTING FEES 1,831,491 TOTAL 6,300,826
RECONCILIATION OF NET ASSETS
INTERCOMPANY TRANSFERS $68,053,155 TRANSFER OF ASSETS FROM ADI $73,781,982 NET UNREALIZED LOSSES ON INVESTMENTS ($1,254,720) AFFILIATE REVENUE ($12,315) ADJUSTMENT TO PAID IN CAPITAL &271,639 TOTAL $140,839,742
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:EDWARD J ROTH III TITLE:CEO & PRESIDENT HOURS:5
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:RICK L HAINES TITLE:DIRECTOR HOURS:54
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:CHRISTOPHER E REMARK TITLE:TREASURER HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:MILAN R DOPIRAK MD TITLE:DIRECTOR/PHYSICIAN HOURS:54
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:PRABHCHARAN P GILL MD TITLE:DIRECTOR/PHYSICIAN HOURS:54
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:EILEEN F GOOD TITLE:CEO - POST ACUTE SERVICES HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:MARK D WRIGHT TITLE:CHIEF FINANCIAL OFFICER - AHF HOURS:5
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:ELIZABETH A GETZ TITLE:CHIEF INFO. SYSTEMS OFFICER HOURS:5
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:SUSAN OLIVERA TITLE:VP HUMAN RESOURCES HOURS:5
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:RONALD R RUSNAK MD TITLE:DIRECTOR-CLINICAL INFORMATICS HOURS:50
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:TIMOTHY S REGULA TITLE:INTERNAL AUDIT COMPLIANCE HOURS:5
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:FRANCIS J SNYDER TITLE:VICE PRESIDENT HOURS:5
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:TIMOTHY M TEYNOR TITLE:VP PUBLIC POLICY HOURS:5
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.