Form990
Click to see attachment
Department of the Treasury
Internal Revenue Service
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)

MediumBullet The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0047
2010
Open to Public Inspection
A For the calendar year, or tax year beginning 07-01-2010 and ending 06-30-2011
BCheck if applicable:
CName of organization
MERCY MEDICAL FOUNDATION
 
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
1301 15th Avenue West
 
Room/suite
City or town, state or country, and ZIP + 4
Williston, ND58801
D Employer identification number

45-0381803
E Telephone number

G Gross receipts $ 5,080,928
F Name and address of principal officer:
MATTHEW GRIMSHAW
1301 15th Avenue West
Williston,ND58801
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
HTTP://BUILDINGMERCY.ORG/FOUNDATION
H(a)
Is this a group return for
affiliates?
H(b)
Are all affiliates included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet0928
K Form of organization:
 
L Year of formation: 1984
M State of legal domicile: ND
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: MERCY MEDICAL FOUNDATION SERVES AS THE FUNDRAISING ARM OF MERCY MEDICAL CENTER AND COORDINATES GIFTS OF ENERGY, TALENTS, AND FINANCIAL RESOURCES TO BUILD HEALTHIER COMMUNITIES IN OUR REGION.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) .... 3 12
4 Number of independent voting members of the governing body (Part VI, line 1b) .... 4 8
5 Total number of individuals employed in calendar year 2010 (Part V, line 2a) ... 5 0
6 Total number of volunteers (estimate if necessary) .... 6 100
7a Total unrelated business revenue from Part VIII, column (C), line 12 .. 7a -16
b Net unrelated business taxable income from Form 990-T, line 34 .. 7b 0
Revenues; Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 1,577,076 4,791,793
9 Program service revenue (Part VIII, line 2g) ......... 0 24,000
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 176,530 67,437
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 78,531 169,313
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 1,832,137 5,052,543
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 161,808 478,067
14 Benefits paid to or for members (Part IX, column (A), line 4) .... 0 0
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10) 0 0
16a Professional fundraising fees (Part IX, column (A), line 11e).... 33,863 32,306
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet49,362    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f).... 62,669 75,248
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 258,340 585,621
19 Revenue less expenses. Subtract line 18 from line 12...... 1,573,797 4,466,922
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............ 5,455,382 10,649,054
21 Total liabilities (Part X, line 26)............ 51,879 347,260
22 Net assets or fund balances. Subtract line 21 from line 20 ..... 5,403,503 10,301,794
Part II
Signature Block
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) .........
For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2010)
Form 990 (2010)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III . . . . . . . . . .
1
Briefly describe the organization’s mission: THE ORGANIZATION'S MISSION IS TO NURTURE THE HEALING MINISTRY OF THE CHURCH BY BRINGING IT NEW LIFE, ENERGY AND VIABILITY IN THE 21ST CENTURY. FIDELITY TO THE GOSPEL URGES US TO EMPHASIZE HUMAN DIGNITY AND SOCIAL JUSTICE AS WE MOVE TOWARD THE CREATION OF HEALTHIER COMMUNITIES.
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ....................
If “Yes,” describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services? ..........................
If “Yes,” describe these changes on Schedule O.
4
Describe the exempt purpose achievements for each of the organization’s three largest program services by expenses.
Section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 484,848 including grants of $ 478,067 ) (Revenue $ 24,000 )
SEE SCHEDULE O
4b (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4c (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4d Other program services. (Describe in Schedule O.)
(Expenses $   including grants of $   ) (Revenue $   )
4e Total program service expensesMediumBullet$ 484,848
Form 990 (2010)
Form 990 (2010)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If “Yes,” complete Schedule AClick to see attachment.....................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors? Click to see attachment........
2
Yes
 
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part I..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities? If “Yes,” complete Schedule C,
Part II.........................
4
 
No
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If “Yes,” complete Schedule C, Part III........................
5
 
 
6
Did the organization maintain any donor advised funds or any similar funds or accounts where donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If “Yes,” complete
Schedule D, Part I.......................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas or historic structures? If “Yes,” complete Schedule D, Part II...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If “Yes,” complete Schedule D, Part III Click to see attachment....................
8
Yes
 
9
Did the organization report an amount in Part X, line 21; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If “Yes,”
complete Schedule D, Part IV...................
9
 
No
10
Did the organization, directly or through a related organization, hold assets in term, permanent,or quasi-endowments? If “Yes,” complete Schedule D, Part V
10
 
No
11
If the organization’s answer to any of the following questions is ‘Yes,’ then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable:
a
Did the organization report an amount for land, buildings, and equipment in Part X, line10? If “Yes,” complete Schedule D, Part VI.Click to see attachment
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VII.Click to see attachment
11b
Yes
 
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIII.
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part IX.
11d
 
No
e
Did the organization report an amount for other liabilities in Part X, line 25? If “Yes,” complete Schedule D, Part X.Click to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If “Yes,” complete Schedule D, Part X.Click to see attachment
11f
Yes
 
12a
Did the organization obtain separate, independent audited financial statements for the tax year? If “Yes,” complete Schedule D, Parts XI, XII, and XIII
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If “Yes,” and if the organization answered ‘No’ to line 12a, then completing Schedule D, Parts XI, XII, and XIII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, and program service activities outside the United States? If “Yes,” complete Schedule F, Part I.........
14b
 
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the U.S.? If “Yes,” complete Schedule F, Part II..
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the U.S.? If “Yes,” complete Schedule F, Part III..
16
 
No
17
Did the organization report a total of more than $15,000, of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If “Yes,” complete Schedule G, Part IClick to see attachment
17
Yes
 
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If “Yes,” complete Schedule G, Part II.......... Click to see attachment
18
Yes
 
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If “Yes,” complete Schedule G, Part III...................
19
 
No
Form 990 (2010)
Form 990 (2010)
Page 4
Part IV
Checklist of Required Schedules (continued)
20a
Did the organization operate one or more hospitals? If “Yes,” complete Schedule H.....
20a
 
No
b
Did the organization attach its audited financial statement to this return? Note: All Form 990 filers that operate one or more hospitals must attach audited financial statements. .....
20b
 
 
21
Did the organization report more than $5,000 of grants and other assistance to governments and organizations in the United States on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II.. Click to see attachment
21
Yes
 
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III.....
22
 
No
23
Did the organization answer “Yes” to Part VII, Section A, questions 3, 4, or 5, about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If “Yes,” complete Schedule J................ Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer questions 24b–24d and complete Schedule K. If “No,” go to line 25................
24a
 
No
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
 
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
 
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
 
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If “Yes,” complete Schedule L, Part I......
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I................
25b
 
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highly compensated employee, or disqualified person outstanding as of the end of the organization’s tax year? If “Yes,” complete Schedule L,
Part II...........................
26
 
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor, or a grant selection committee member, or to a person related to such an individual? If “Yes,” complete Schedule L, Part III...............
27
 
No
28
Was the organization a party to a business transaction with one of the following parties? (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If “Yes,” complete Schedule L, Part IV .........................
28a
 
No
b
A family member of a current or former officer, director, trustee, or key employee? If “Yes,”
complete Schedule L, Part IV...................
28b
 
No
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or owner? If “Yes,” complete Schedule L, Part IV..
28c
 
No
29
Did the organization receive more than $25,000 in non-cash contributions? If “Yes,” complete Schedule M
29
 
No
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M............
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If “Yes,” complete Schedule N,
Part I...........................
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If “Yes,” complete Schedule N, Part II.......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If “Yes,” complete Schedule R, Part I........
33
 
No
34
Was the organization related to any tax-exempt or taxable entity? If “Yes,” complete Schedule R, Parts II, III, IV, and V, line 1..................... Click to see attachment
34
Yes
 
35
Is any related organization a controlled entity within the meaning of section 512(b)(13)? .....
35
Yes
 
a
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,” complete Schedule R, Part V, line 2... Click to see attachment
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If “Yes,” complete Schedule R, Part V, line 2...........
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If “Yes,” complete Schedule R, Part VI
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11 and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2010)
Form 990 (2010)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V . . . . . . . . . .
Yes
No
1a
Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable. .......
1a
1
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable.
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
Yes
 
2a
Enter the number of employees reported 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 .....................
2a
0
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?

Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file. (see instructions)
2b
 
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?.............................
3a
 
No
b
If “Yes,” has it filed a Form 990-T for this year? If “No,” provide an explanation in Schedule O.....
3b
 
 
4a
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 or securities account)?.......................
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If “Yes” to line 5a or 5b, did the organization file Form 8886-T? ........
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible?..........
6a
 
No
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
 
No
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
 
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?..........................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?...................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?...............
7h
 
 
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?................
8
 
No
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?.........
9a
 
 
b
Did the organization make a distribution to a donor, donor advisor, or related person?......
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them.) ........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year.
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. All 501(c)(29) organizations must list in Schedule O each state in which they are licensed to issue qualified health plans, the amount of reserves required by each state, and the amount of reserves the organization allocated to each state.
13a
 
 
b
Enter the aggregate amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans.
13b
 
c
Enter the aggregate amount of reserves on hand.
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
 
b
If "Yes," has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O..
14b
 
 
Form 990 (2010)
Form 990 (2010)
Page 6
Part VI
Governance, Management, and Disclosure For each “Yes” response to lines 2 through 7b below, and for a “No” response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI . . . . . . . . . .
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year ..............
1a
12
b
Enter the number of voting members included in line 1a, above, who are independent .................
1b
8
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
 
No
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? ..
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed?
4
 
No
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Does the organization have members or stockholders? ................
6
Yes
 
7a
Does the organization have members, stockholders, or other persons who may elect one or more members of the governing body? .........................
7a
Yes
 
b
Are any decisions of the governing body subject to approval by members, stockholders, or other persons? ..
7b
Yes
 
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .........................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ............
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If “Yes,” provide the names and addresses in Schedule O .....
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal
Revenue Code.)
Yes
No
10a
Does the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If “Yes,” does the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with those of the organization? ....
10b
 
 
11a
Has the organization provided a copy of this Form 990 to all members of its governing body before filing the form?
11a
Yes
 
b
Describe in Schedule O the process, if any, used by the organization to review the Form 990. .....
12a
Does the organization have a written conflict of interest policy? If “No,” go to line 13.......
12a
Yes
 
b
Are officers, directors or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ...........................
12b
Yes
 
c
Does the organization regularly and consistently monitor and enforce compliance with the policy? If “Yes,” describe in Schedule O how this is done ....................
12c
Yes
 
13
Does the organization have a written whistleblower policy? ...............
13
Yes
 
14
Does the organization have a written document retention and destruction policy? .........
14
 
No
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
Yes
 
b
Other officers or key employees of the organization ................
15b
 
No
If "Yes" to line a or b, describe the process in Schedule O. (See instructions.)
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
 
No
b
If “Yes,” has the organization adopted a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and taken steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
 
 
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
ND
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you make these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how), the organization makes its governing documents, conflict of interest policy, and financial statements available to the public.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization: MediumBullet
Kerry Monson
1301 15th Avenue West
Williston,ND58801
(701) 774-7408
Form 990 (2010)
Form 990 (2010)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response to any question in this Part VII . . . . . . . . . .
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation, and current key employees. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

RoundBullet List all of the organization’s current key employees, if any. See instructions for definition of "key employee."
RoundBullet List the organization’s five current highest compensated employees (other than an officer, director, trustee or key employee)
who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the
organization and any related organizations.

RoundBullet List all of the organization’s former officers, key employees, or highest compensated employees who received more than $100,000
of reportable compensation from the organization and any related organizations.

RoundBullet List all of the organization’s former directors or trustees that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organizations compensated any current or former officer, director, or trustee.
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (check all that apply) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(1) FATHER RAYMOND AYDT
BOARD MEMBER
 1 X           0 20,807 1,816
(2) JAMES AGRE
BOARD MEMBER
 1 X           0 0 0
(3) DOUGLAS CROSBY
VICE CHAIR
 1 X   X       0 0 0
(4) LAVINA DOMAGALA
BOARD MEMBER
 1 X           0 0 0
(5) GREG EVERSON
BOARD MEMBER
 1 X           0 0 0
(6) NANCY HOFFELT
BOARD MEMBER
 1 X           0 0 0
(7) MERRI MORADIAN
BOARD MEMBER
 1 X           0 0 0
(8) MARK MCGINLEY
SECRETARY/TREASURER
 1 X   X       0 0 0
(9) WARREN SUNDET
EX-OFFICIO
 1 X           0 73,695 12,852
(10) MELANIE STILLWELL
CHAIR
 1 X   X       0 0 0
(11) CARMELITA SKURDAL
BOARD MEMBER
 1 X           0 2,765 0
(12) BRETT VIBETO
BOARD MEMBER
 1 X           0 420,420 26,805
(13) DENNIS GOEBEL
FORMER PRESIDENT/CEO
 1           X 0 174,357 24,986
(14) MATTHEW GRIMSHAW
PRESIDENT/CEO
 1     X       0 122,906 16,229
(15) KERRY MONSON
CFO
 1     X       0 148,187 24,068




Form 990 (2010)
Form 990 (2010)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (check all that apply) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;


























1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 0 963,137 106,756
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 in reportable compensation from the organizationMediumBullet0
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If “Yes,” complete Schedule J for such individual .............
3
Yes
 
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person .....
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 in compensation from the organization MediumBullet0
Form 990 (2010)
Form 990 (2010)
Page 9
Part VIII
Statement of Revenue
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, gifts, grants and other similar amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c 79,624
d Related organizations...1d 7,725
e Government grants (contributions)1e  
f All other contributions, gifts, grants, and
similar amounts not included above1f 		4,704,444
g Noncash contributions included in lines 1a-1f:$  
h Total. Add lines 1a-1f.......MediumBullet 4,791,793
Program Service Revenue Business Code
2a RENTAL INCOME FROM RELATED ORGANIZATIONS 900,099 24,000 24,000    
b
c
d
e
f All other program service revenue . 0 0 0 0
g Total. Add lines 2a–2f........MediumBullet 24,000
Other Revenue 3 Investment income (including dividends, interest
and other similar amounts).....MediumBullet 76,668   -16 76,684
4 Income from investment of tax-exempt bond proceeds..MediumBullet 0      
5 Royalties............MediumBullet 0      
(i) Real (ii) Personal
6a Gross Rents    
b Less: rental expenses    
c Rental income or (loss) 0 0
d Net rental income or (loss).......MediumBullet 0      
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory    
b Less: cost or other basis and sales expenses 9,231  
c Gain or (loss) -9,231 0
d Net gain or (loss)..........MediumBullet -9,231     -9,231
8a Gross income from fundraising events (not including
$ 79,624
of contributions reported on line 1c). See Part IV, line 18 ...
a 64,812
b Less: direct expenses ...b 19,154
c Net income or (loss) from fundraising events..MediumBullet 45,658   45,658
9a Gross income from gaming activities.
See Part IV, line 19 ...
a 12,450
b Less: direct expenses ...b  
c Net income or (loss) from gaming activities...MediumBullet 12,450     12,450
10a Gross sales of inventory, less
returns and allowances .
a  
b Less: cost of goods sold ..b  
c Net income or (loss) from sales of inventory..MediumBullet 0      
Miscellaneous Revenue Business Code
11a MINERAL ACRE PRODUCTION/LEASE 900,099 111,205     111,205
b            
c            
d All other revenue .... 0 0 0 0
e Total. Add lines 11a–11d ......MediumBullet 111,205
12 Total revenue. See Instructions....MediumBullet 5,052,543 24,000 -16 236,766
Form 990 (2010)
Form 990 (2010)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A) but are not required to complete columns (B), (C), and (D).
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII. 		(A)
Total expenses 		(B)
Program service expenses 		(C)
Management and general expenses 		(D)
Fundraising expenses
1 Grants and other assistance to governments and organizations in the U.S. See Part IV, line 21 478,067 478,067
2 Grants and other assistance to individuals in the U.S. See Part IV, line 22 0  
3 Grants and other assistance to governments, organizations, and individuals outside the U.S. See Part IV, lines 15 and 16 0  
4 Benefits paid to or for members 0  
5 Compensation of current officers, directors, trustees, and key employees .... 0      
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .... 0      
7 Other salaries and wages 0      
8 Pension plan contributions (include section 401(k) and section 403(b) employer contributions) .... 0      
9 Other employee benefits ....... 0      
10 Payroll taxes ........... 0      
11 Fees for services (non-employees):        
a Management ...... 0      
b Legal ......... 0      
c Accounting ........... 0      
d Lobbying ........... 0      
e Professional fundraising. See Part IV, line 17.. 32,306 32,306
f Investment management fees ...... 0      
g Other .......... 33,742 3,658 30,084  
12 Advertising and promotion .... 0      
13 Office expenses ....... 5,025 503 1,256 3,266
14 Information technology ...... 0      
15 Royalties .. 0      
16 Occupancy ........... 21,375 397 18,396 2,582
17 Travel ............ 240   240  
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ...... 0      
19 Conferences, conventions, and meetings .... 0      
20 Interest ........... 0      
21 Payments to affiliates ....... 0      
22 Depreciation, depletion, and amortization ..... 1,435   1,435  
23 Insurance .............. 0      
24 Other expenses. Itemize expenses not covered above. (Expenses grouped together and labeled miscellaneous may not exceed 5% of total expenses shown on line 25 below.)
a DUES & SUBSCRIPTIONS 357 357    
b
c
d
e
f All other expenses 13,074 1,866 0 11,208
25 Total functional expenses. Add lines 1 through 24f 585,621 484,848 51,411 49,362
26 Joint costs. Check here MediumBullet if following
SOP 98-2 (ASC 958-720). Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation 		0      
Form 990 (2010)
Form 990 (2010)
Page 11
Part X Balance Sheet
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash—non-interest-bearing ..........   1  
2 Savings and temporary cash investments ....... 512,138 2 728,481
3 Pledges and grants receivable, net ......... 1,038,588 3 4,930,225
4 Accounts receivable, net ......... 24,821 4 4,648
5 Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L ..........   5  
6 Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
Schedule L ..........   6  
7 Notes and loans receivable, net .............   7  
8 Inventories for sale or use ..............   8  
9 Prepaid expenses and deferred charges ............   9  
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 385,334
b Less: accumulated depreciation. ..... 10b 204,209 182,560 10c 181,125
11 Investments—publicly traded securities ..........   11  
12 Investments—other securities. See Part IV, line 11 ...... 3,451,178 12 4,525,227
13 Investments—program-related. See Part IV, line 11 ..   13 0
14 Intangible assets ......... 31,224 14 31,224
15 Other assets. See Part IV, line 11 ........... 214,873 15 248,124
16 Total assets. Add lines 1 through 15 (must equal line 34)... 5,455,382 16 10,649,054
Liabilities 17 Accounts payable and accrued expenses . 6,039 17 9,300
18 Grants payable ..........   18  
19 Deferred revenue ..........   19  
20 Tax-exempt bond liabilities ..........   20  
21 Escrow or custodial account liability. Complete Part IV of Schedule D..   21  
22 Payables to current and former officers, directors, trustees, key
employees, highest compensated employees, and disqualified
persons. Complete Part II of Schedule L..........   22  
23 Secured mortgages and notes payable to unrelated third parties ..   23  
24 Unsecured notes and loans payable to unrelated third parties ....   24  
25 Other liabilities. Complete Part X of Schedule D..... 45,840 25 337,960
26 Total liabilities. Add lines 17 through 25..... 51,879 26 347,260
Net Assets or Fund Balance Organizations that follow SFAS 117, check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets ..... 2,642,566 27 2,828,522
28 Temporarily restricted net assets ..... 1,970,803 28 6,683,138
29 Permanently restricted net assets ..... 790,134 29 790,134
Organizations that do not follow SFAS 117, check here MediumBullet and complete lines 30 through 34.
30 Capital stock or trust principal, or current funds .....   30  
31 Paid-in or capital surplus, or land, building or equipment fund .....   31  
32 Retained earnings, endowment, accumulated income, or other funds   32  
33 Total net assets or fund balances ..... 5,403,503 33 10,301,794
34 Total liabilities and net assets/fund balances ..... 5,455,382 34 10,649,054
Form 990 (2010)
Form 990 (2010)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI . . . . . . . . . .
1
Total revenue (must equal Part VIII, column (A), line 12) . . .
1
5,052,543
2
Total expenses (must equal Part IX, column (A), line 25) . . . . .
2
585,621
3
Revenue less expenses. Subtract line 2 from line 1 . . . .
3
4,466,922
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) . .
4
5,403,503
5
Other changes in net assets or fund balances (explain in Schedule O) . . . .
5
431,369
6
Net assets or fund balances at end of year. Combine lines 3, 4, and 5 (must equal Part X, line 33, column (B)) . . . . . .
6
10,301,794
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII . . . . . . . . . .
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?..
2a
 
No
b
Were the organization’s financial statements audited by an independent accountant?........
2b
Yes
 
c
If “Yes,” to 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant?
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O............................
2c
Yes
 
d
If “Yes” to line 2a or 2b, check a box below to indicate whether the financial statements for the year were issued on a separate basis, consolidated basis, or both:
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133? ................
3a
 
No
b
If “Yes,” did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits. ..
3b
 
 
Form 990 (2010)
Additional Data


Software ID: 10000128
Software Version: v2010.1.0
Form 990, 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
MERCY MEDICAL FOUNDATION
 
Employer identification number

45-0381803
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) MERCY MEDICAL CENTER
  		450231183 3 Yes   Yes   Yes   380,577
Total                 380,577

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
 
Explanation
 
 
 
 
Schedule A (Form 990 or 990-EZ) 2010

Additional Data


Software ID: 10000128
Software Version: v2010.1.0
Schedule B
(Form 990, 990-EZ,
or 990-PF)
Department of the Treasury
Internal Revenue Service
Schedule of Contributors
Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
OMB No. 1545-0047
2010
Name of organization
MERCY MEDICAL FOUNDATION
 
Employer identification number

45-0381803
Organization type (check one):
Filers of:
Section:
Form 990 or 990-EZ





Form 990-PF




Check if your organization is covered by the General Rule or a Special Rule.  
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.
General Rule—
Special Rules
......................... Arrow Bullet   $    
Caution. An Organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2 of its Form 990, or check the box in the heading of its
Form 990-EZ, or on line 2 of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).
For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.
Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2010)

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)
Page 1 of 1 of Part I
Name of organization
MERCY MEDICAL FOUNDATION
  		Employer identification number

45-0381803
Part I
Contributors (see Instructions)
     
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
RESTRICTED
RESTRICTED
 

     
RESTRICTED
RESTRICTED  
RESTRICTED, RESTRICTED   RESTRICTED

$RESTRICTED




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)
Page 1 of 1 of Part II
Name of organization
MERCY MEDICAL FOUNDATION
  		Employer identification number

45-0381803
Part II
Noncash Property (see Instructions)
     
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)
Page 1 of 1 of Part III
Name of organization
MERCY MEDICAL FOUNDATION
  		Employer identification number

45-0381803
Part III
Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
aggregating more than $1,000 for the year. (Complete columns (a) through (e) and the following line entry.)
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet $  
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Additional Data


Software ID: 10000128
Software Version: v2010.1.0
SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11, or 12.
SchDMd Bullet Attach to Form 990. SchDMd Bullet See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
MERCY MEDICAL FOUNDATION
 
Employer identification number

45-0381803
Part I
Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.
(a) Donor advised funds (b) Funds and other accounts
1 Total number at end of year .......    
2 Aggregate contributions to (during year) ...    
3 Aggregate grants from (during year) ...    
4 Aggregate value at end of year .......    
5
Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............
6
Did the organization inform all grantees, donors, and donor advisors in writing that grant funds may be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit. ...................................
Part II
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
Complete lines 2a–2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.
Held at the End of the Year
a Total number of conservation easements ....................... 2a  
b Total acreage restricted by conservation easements .................. 2b  
c Number of conservation easements on a certified historic structure included in (a) ..... 2c  
d Number of conservation easements included in (c) acquired after 8/17/06 ........ 2d  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the taxable year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................
6
Staff and volunteer hours devoted to monitoring, inspecting and enforcing conservation easements during the year SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year SchDMd Bullet $  
8
Does each conservation easement reported on line 2(d) above satisfy the requirements of section
170(h)(4)(B)(i) and 170(h)(4)(B)(ii)? ....................................
9
In Part XIV, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.
1a
If the organization elected, as permitted under SFAS 116, not to report in its revenue statement and balance sheet works of
art, historical treasures, or other similar assets held for public exhibition, education or research in furtherance of public service,
provide, in Part XIV, the text of the footnote to its financial statements that describes these items.
b
If the organization elected, as permitted under SFAS 116, to report in its revenue statement and balance sheet works of art,
historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service,
provide the following amounts relating to these items:
(i)
Revenues included in Form 990, Part VIII, line 1 ........................SchDMd Bullet $ 0
(ii)
Assets included in Form 990, Part X ..............................SchDMd Bullet $ 12,000
2
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 relating to these items:
a
Revenues included in Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 52283D
Schedule D (Form 990) 2010

Schedule D (Form 990) 2010
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
Using the organization’s accession and other records, check any of the following that are a significant use of its collection
items (check all that apply):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIV.
5
During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........
Part IV
Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b
If "Yes," explain the arrangement in Part XIV and complete the following table:
Amount
c Beginning balance ................................. 1c  
d Additions during the year .............................. 1d  
e Distributions during the year ............................. 1e  
f Ending balance ................................... 1f  
2a
Did the organization include an amount on Form 990, Part X, line 21? .....................
b
If “Yes,” explain the arrangement in Part XIV.
Part V
Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
(a)Current Year (b)Prior Year (c)Two Years Back (d)Three Years Back (e)Four Years Back
1a Beginning of year balance ....      
b Contributions ........      
c Investment earnings or losses ...      
d Grants or scholarships .....      
e Other expenditures for facilities
and programs ........ 		     
f Administrative expenses ....      
g End of year balance ......      
2
Provide the estimated percentage of the year end balance held as:
a
Board designated or quasi-endowment: SchDMd Bullet  
b
Permanent endowment: SchDMd Bullet  
c
Term endowment: SchDMd Bullet  
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) unrelated organizations ........................
3a(i)
 
 
(ii) related organizations ........................
3a(ii)
 
 
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
 
 
4
Describe in Part XIV the intended uses of the organization's endowment funds.
Part VI
Investments—Land, Buildings, and Equipment. See Form 990, Part X, line 10.
Description of investment (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .................   177,525 177,525
b Buildings ................   168,654 168,626 28
c Leasehold improvements ............       0
d Equipment ................   39,155 35,583 3,572
e Other .................       0
Total. Add lines 1a-1e. (Column (d) should equal Form 990, Part X, column (B), line 10(c).)........SchDMdBullet 181,125
Schedule D (Form 990) 2010

Schedule D (Form 990) 2010
Page 3
Part VII
Investments—Other Securities. See Form 990, Part X, line 12.
(a) Description of security or category
(including name of security)		 (b)Book value (c) Method of valuation:
Cost or end-of-year market value
(1)Financial derivatives 0  
(2)Closely-held equity interests 0  
(3)Other
(A) ANNUITY TRUSTS 		35,000 F

(B) CHI OIP - FIXED INCOME 		1,281,655 F

(C) CHI OIP - EQUITY SECURITIES 		2,148,234 F

(D) CHI OIP - MONEY MARKET 		1,060,338 F





Total. (Column (b) should equal Form 990, Part X, col.(B) line 12.)Small Bullet 4,525,227
Part VIII
Investments—Program Related. See Form 990, Part X, line 13.
(a) Description of investment type (b) Book value (c) Method of valuation:
Cost or end-of-year market value








Total. (Column (b) should equal Form 990, Part X, col.(B) line 13.)Small Bullet  
Part IX
Other Assets. See Form 990, Part X, line 15.
(a) Description (b) Book value








Total. (Column (b) should equal Form 990, Part X, col.(B) line 15.)...........Small Bullet  
Part X
Other Liabilities. See Form 990, Part X, line 25.
1.(a) Description of Liability (b) Amount
Federal Income Taxes 0
DUE TO AFFILIATES 337,960








Total. (Column (b) should equal Form 990, Part X, col.(B) line 25.)Small Bullet 337,960
2. Fin 48 (ASC 740) Footnote. In Part XIV, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC740).
Schedule D (Form 990) 2010

Schedule D (Form 990) 2010
Page 4
Part XI Reconciliation of Change in Net Assets from Form 990 to Financial Statements
1 Total revenue (Form 990, Part VIII, column (A), line 12) .................... 1 5,039,529
2 Total expenses (Form 990, Part IX, column (A), line 25) ..................... 2 557,010
3 Excess or (deficit) for the year. Subtract line 2 from line 1 ............. 3 4,482,519
4 Net unrealized gains (losses) on investments .......................... 4 419,772
5 Donated services and use of facilities ............................. 5  
6 Investment expenses ................................... 6  
7 Prior period adjustments .................................. 7 -4,000
8 Other (Describe in Part XIV) ................................. 8 0
9 Total adjustments (net). Add lines 4 - 8 ............................. 9 415,772
10 Excess or (deficit) for the year per financial statements. Combine lines 3 and 9 ......... 10 4,898,291
Part XII Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1 Total revenue, gains, and other support per audited financial statements ....... 1  
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains on investments .......... 2a  
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIV): ............ 2d 0
e Add lines 2a through 2d ..................... 2e 0
3 Subtract line 2e from line 1..................... 3 0
4 Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b . 4a  
b Other (Describe in Part XIV): ........... 4b 0
c Add lines 4a and 4b....................... 4c 0
5 Total Revenue. Add lines 3 and 4c. (This should equal Form 990, Part I, line 12.) ...... 5 0
Part XIII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1 Total expenses and losses per audited financial statements ............. 1  
2 Amounts included on line 1 but not on Form 990, Part IX, line 25:
a Donated services and use of facilities .......... 2a  
b Prior year adjustments .............. 2b  
c Other losses ................ 2c  
d Other (Describe in Part XIV): ............ 2d 0
e Add lines 2a through 2d...................... 2e 0
3 Subtract line 2e from line 1..................... 3 0
4 Amounts included on Form 990, Part IX, line 25, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b .. 4a  
b Other (Describe in Part XIV): ............ 4b 0
c Add lines 4a and 4b....................... 4c 0
5 Total expenses. Add lines 3 and 4c. (This should equal Form 990, Part I, line 18.) ...... 5 0
Part XIV
Supplemental Information
Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X; Part XI, line 8; Part XII, lines 2d and 4b; and Part XIII, lines 2d and 4b. Also complete this part to provide any additional information.
Identifier Return Reference Explanation
Collections of art - description of collections Schedule D, Part III, Line 4 THE ORGANIZATION'S COLLECTION OF ART CONSISTS OF ONE PAINTING THAT WAS DONATED IN 2005, WHICH IS HELD FOR PUBLIC EXHIBITION.
FIN 48 (ASC 740) footnote Schedule D, Part X, Line 2 MERCY MEDICAL FOUNDATION'S FINANCIAL INFORMATION IS INCLUDED IN THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS OF CATHOLIC HEALTH INITIATIVES (CHI), A RELATED ORGANIZATION. CHI'S FIN 48 (ASC 740) FOOTNOTE FOR THE YEAR ENDED JUNE 30, 2011 READS AS FOLLOWS: "CHI IS A TAX-EXEMPT COLORADO CORPORATION AND HAS BEEN GRANTED AN EXEMPTION FROM FEDERAL INCOME TAX UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. CHI OWNS CERTAIN TAXABLE SUBSIDIARIES AND ENGAGES IN CERTAIN ACTIVITIES THAT ARE UNRELATED TO ITS EXEMPT PURPOSE AND THEREFORE SUBJECT TO INCOME TAX. AS OF JUNE 30, 2011, CHI HAS CURRENT NET DEFERRED TAX ASSETS OF $2.1 MILLION AND A NONCURRENT NET DEFERRED TAX LIABILITY OF $5.4 MILLION RELATED TO THESE TAXABLE ACTIVITIES. MANAGEMENT REVIEWS ITS TAX POSITIONS ANNUALLY AND HAS DETERMINED THAT THERE ARE NO MATERIAL UNCERTAIN TAX POSITIONS THAT REQUIRE RECOGNITION IN THE CONSOLIDATED FINANCIAL STATEMENTS."
Schedule D (Form 990) 2010

Additional Data


Software ID: 10000128
Software Version: v2010.1.0




SCHEDULE G
(Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Supplemental Information Regarding
Fundraising or Gaming Activities
Complete if the organization answered "Yes" to Form 990, Part IV, lines 17, 18, or 19,
or if the organization entered more than $15,000 on Form 990-EZ, line 6a.
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
MERCY MEDICAL FOUNDATION
 
Employer identification number

45-0381803
Part I
Fundraising Activities. Complete if the organization answered "Yes" to Form 990, Part IV, line 17.
1
Indicate whether the organization raised funds through any of the following activities. Check all that apply.
a e
b f
c g
d
2a
Did the organization have a written or oral agreement with any individual (including officers, directors, trustees
or key employees listed in Form 990, Part VII) or entity in connection with professional fundraising services?
b
If “Yes,” list the ten highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is
to be compensated at least $5,000 by the organization. Form 990-EZ filers are not required to complete this table.
(i) Name and address of individual
or entity (fundraiser) 		(ii) Activity (iii) Did fundraiser have custody or control of contributions? (iv) Gross receipts
from activity 		(v) Amount paid to
(or retained by)
fundraiser listed in
col. (i) 		(vi) Amount paid to
(or retained by)
organization
Yes No
 
CORDELL G DICK CPA CFRE CONSULTING
6640 N STAR ACRES RD
 
BISMARCK, ND58503 		FUNDRAISING CONSULTING FOR CAPITAL CAMPAIGN   No 409,312 32,306 377,006
Total .................right arrow 409,312 32,306 377,006
3
List all states in which the organization is registered or licensed to solicit funds or has been notified it is exempt from registration or licensing.
ND
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50083H
Schedule G (Form 990 or 990-EZ) 2010
Schedule G (Form 990 or 990-EZ) 2010
Page 2
Part II
Fundraising Events. Complete if the organization answered "Yes" to Form 990, Part IV, line 18, or reported more than $15,000 on Form 990-EZ, line 6a. List events with gross receipts greater than $5,000.
(a) Event #1

COMMUNITY SALE
(event type) 		(b) Event #2

HACKFEST
(event type) 		(c) Other Events

  
(total number) 		(d) Total Events
(Add col. (a) through col. (c))
VerticalRevenue 1 Gross receipts . . . 120,116 24,320   144,436
2 Less: Charitable
contributions . . . 		62,120 17,504   79,624
3 Gross income (line 1
minus line 2) . . . 		57,996 6,816 0 64,812
VerticalDirectExpenses 4 Cash prizes . . .       0
5 Non-cash prizes . .   866   866
6 Rent/facility costs . .   4,179   4,179
7 Food and beverages . .   1,347   1,347
8 Entertainment . . .       0
9 Other direct expenses . 11,212 1,550   12,762
10 Direct expense summary. Add lines 4 through 9 in column (d) ........... right arrow 19,154
11 Net income summary. Combine lines 3 and 10 in column (d)............ right arrow 45,658
Part III
Gaming. Complete if the organization answered "Yes" to Form 990, Part IV, line 19, or reported more than $15,000 on Form 990-EZ, line 6a.
VerticalRevenue (a) Bingo (b) Pull tabs/Instant
bingo/progressive bingo 		(c) Other gaming (d) Total gaming (Add col. (a) through col. (c))
1 Gross revenue . . . .        
VerticalDirectExpenses 2 Cash prizes . . . .        
3 Non-cash prizes . . .        
4 Rent/facility costs . . .        
5 Other direct expenses . .        
6 Volunteer labor . . .
 
 
 
7 Direct expense summary. Add lines 2 through 5 in column (d) ........... right arrow  
8 Net gaming income summary. Combine lines 1 and 7 in column (d) .......... right arrow  
9
Enter the state(s) in which the organization operates gaming activities:
a
Is the organization licensed to operate gaming activities in each of these states? ............
b
If "No," Explain:
 
10a
Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year? .....
b
If "Yes," Explain:
 
11
Does the organization operate gaming activities with nonmembers? .................
12
Is the organization a grantor, beneficiary or trustee of a trust or a member of a partnership or other entity
formed to administer charitable gaming? ...........................
Schedule G (Form 990 or 990-EZ) 2010
Schedule G (Form 990 or 990-EZ) 2010
Page 3
13
Indicate the percentage of gaming activity operated in:
a
The organization's facility ......................
13a
 
b
An outside facility ........................
13b
 
14
Provide the name and address of the person who prepares the organization's gaming/special events books and records:
Name right arrow
Address right arrow
15a
Does the organization have a contract with a third party from whom the organization receives gaming
revenue? ......................................
b
If "Yes," enter the amount of gaming revenue received by the organization right arrow $   and the
amount of gaming revenue retained by the third party right arrow $   .
c
If "Yes," enter name and address:
Name right arrow
Address right arrow
 
 
16
Gaming manager information:
Name right arrow
Gaming manager compensation right arrow $  
Description of services provided right arrow
 
17
Mandatory distributions:
a
Is the organization required under state law to make charitable distributions from the gaming proceeds to
retain the state gaming license? ............................
b
Enter the amount of distributions required under state law distributed to other exempt organizations or spent
in the organization's own exempt activities during the tax year right arrow$  
Part IV
Complete this part to provide additional information for responses to quuestion on Schedule G (see instructions.)
Identifier ReturnReference Explanation
Schedule G (Form 990 or 990-EZ) 2010
Additional Data


Software ID: 10000128
Software Version: v2010.1.0
Schedule I
(Form 990)
Department of the Treasury
Internal Revenue Service
Grants and Other Assistance to Organizations,
Governments and Individuals in the United States
Complete if the organization answered "Yes," to Form 990, Part IV, line 21 or 22.
lBullet Attach to Form 990
OMB No. 1545-0047
2010
Open to Public
Inspection
Name of the organization
MERCY MEDICAL FOUNDATION
 
Employer identification number
45-0381803
Part I
General Information on Grants and Assistance
1
Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ....................................
2
Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.
Part II
Grants and Other Assistance to Governments and Organizations in the United States. Complete if the organization answered "Yes" to
Form 990, Part IV, line 21 for any recipient that received more than $5,000. Check this box if no one recipient received more than $5,000. Use
Part IV and Schedule I-1 (Form 990) if additional space is needed ......................... lBullet
(a) Name and address of organization
or government		 (b) EIN (c) IRC Code section
if applicable		 (d) Amount of cash grant (e) Amount of non-cash
assistance		 (f) Method of valuation
(book, FMV, appraisal,
other)		 (g) Description of
non-cash assistance		 (h) Purpose of grant
or assistance
(1) MERCY MEDICAL CENTER1301 15TH AVENUE WEST
WILLISTON,ND58801 		45-0231183 501(C)(3) 380,577 0 N/A N/A MEDICAL EQUIPMENT/GENERAL PROGRAM SUPPORT
(2) CHI NATIONAL HOME CARE198 INVERNESS DRIVE WEST
ENGLEWOOD,CO80112 		45-1261716 501(C)(3) 29,189 0 N/A N/A GENERAL PROGRAM SUPPORT
(3) WILLISTON COMMUNITY BUILDERSPO BOX 2720
WILLISTON,ND58801 		26-4458181 501(C)(3) 61,726 0 N/A N/A COMMUNITY BUILDING/LOCAL PARKS


















2
Enter total number of section 501(c)(3) and government organizations ......................... Bullet Image
3
3
Enter total number of other organizations ................................ . Bullet Image
0
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50055P
Schedule I (Form 990) 2010

Schedule I (Form 990) 2010
Page 2
Part III
Grants and Other Assistance to Individuals in the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 22.
Use Schedule I-1 (Form 990) if additional space is needed.
(a)Type of grant or assistance (b)Number of
recipients		 (c)Amount of
cash grant		 (d)Amount of
non-cash assistance		 (e)Method of valuation (book,
FMV, appraisal, other)		 (f)Description of non-cash assistance













Part IV
Supplemental Information. Complete this part to provide the information required in Part I, line 2, and any other additional information.
Identifier Return Reference Explanation
Procedures for monitoring use of grant funds Schedule I, Part I, Line 2 ALL GRANT FUNDS ARE APPROVED BY THE MANAGER THAT IS IN CHARGE OF THE DEPARTMENT OR PURPOSE FOR WHICH THE FUNDS ARE RESTRICTED. THE MAJORITY OF THE DONATIONS ARE THE RESULT OF FUNDRAISERS HELD DURING THE YEAR WHERE THE PROCEEDS ARE DONATED TO OTHER COMMUNITY ORGANIZATIONS. THE DONEE ORGANIZATIONS ARE VOTED ON BY VARIOUS COMMITTEES.
Schedule I (Form 990) 2010


Additional Data


Software ID: 10000128
Software Version: v2010.1.0


Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
SchJMediumBullet Attach to Form 990. SchJMediumBullet See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
MERCY MEDICAL FOUNDATION
 
Employer identification number

45-0381803
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement orprovision of all the expenses described above? If "No," complete Part III to explain....
1b
 
 
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
officers, directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a? ....
2
 
 
3
Indicate which, if any, of the following the organization uses to establish the compensation of the
organization's CEO/Executive Director. Check all that apply.
4
During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment? ...............
4a
Yes
 
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? ........
4b
Yes
 
c
Participate in, or receive payment from, an equity-based compensation arrangement? ........
4c
 
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.
5
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization? ...........................
5a
 
No
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization? ...........................
6a
 
No
b
Any related organization? .........................
6b
 
No
If "Yes," to line 6a or 6b, describe in Part III.
7
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............
7
 
 
8
Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regs. section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................
8
 
 
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 50053T
Schedule J (Form 990) 2010

Schedule J (Form 990) 2010
Page 2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use Schedule J-1 if additional space needed.
For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.

Note. The sum of columns (B)(i)-(iii) must equal the applicable column (D) or column (E) amounts on Form 990, Part VII, line 1a.
(A) Name (B) Breakdown of W-2 and/or 1099-MISC compensation (C) Retirement and other deferred compensation (D) Nontaxable
benefits		 (E) Total of columns
(B)(i)-(D) 		(F) Compensation
reported in prior
Form 990 or
Form 990-EZ
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
(1) BRETT VIBETO (i)
(ii)		 0
398,580 		0
21,084 		0
756 		0
20,228 		0
6,577 		0
447,225 		0
0
(2) DENNIS GOEBEL (i)
(ii)		 0
0 		0
0 		0
174,357 		0
14,300 		0
10,686 		0
199,343 		0
0
(3) KERRY MONSON (i)
(ii)		 0
126,928 		0
20,834 		0
425 		0
15,997 		0
8,071 		0
172,255 		0
0













Schedule J (Form 990) 2010

Schedule J (Form 990) 2010
Page 3
Part III
Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 4c, 5a, 5b, 6a, 6b, 7, and 8. Also complete this part for any additional information.
Identifier Return Reference Explanation
Severance or change-of-control payment Schedule J, Part I, Line 4a POST-TERMINATION PAYMENTS ARE ADDRESSED IN EXECUTIVE EMPLOYMENT AGREEMENTS FOR CATHOLIC HEALTH INITIATIVES ("CHI") AND RELATED ORGANIZATIONS' EMPLOYEES AT THE LEVEL OF VICE PRESIDENT AND ABOVE, INCLUDING THE MBO CEOS. THESE EMPLOYMENT AGREEMENTS REQUIRE THAT IN ORDER FOR THE EXECUTIVE TO RECEIVE POST-TERMINATION PAYMENTS, THESE INDIVIDUALS MUST EXECUTE A GENERAL RELEASE AND SETTLEMENT AGREEMENT. POST-TERMINATION PAYMENT ARRANGEMENTS ARE PERIODICALLY REVIEWED FOR OVERALL REASONABLENESS IN LIGHT OF THE EXECUTIVE'S OVERALL COMPENSATION PACKAGE. THE FOLLOWING REPORTABLE INDIVIDUALS RECEIVED SEVERANCE PAYMENTS FROM CATHOLIC HEALTH INITIATIVES (A RELATED ORGANIZATION) DURING THE 2010 CALENDAR YEAR, AND THESE SEVERANCE PAYMENTS WERE INCLUDED IN THE INDIVIDUAL'S W-2 INCOME AND REPORTABLE COMPENSATION ON PART VII AND SCHEDULE J: DENNIS GOEBEL - $177,446
Supplemental nonqualified retirement plan Schedule J, Part I, Line 4b DURING THE 2010 CALENDAR YEAR CATHOLIC HEALTH INITIATIVES ("CHI"), A RELATED ORGANIZATION, MAINTAINED A SUPPLEMENTAL NON-QUALIFIED DEFERRED COMPENSATION PLAN FOR MBO CEOS AND OTHER CHI EMPLOYEES AT THE LEVEL OF SENIOR VICE PRESIDENT AND ABOVE. THE FOLLOWING REPORTABLE INDIVIDUALS WERE ELIGIBLE TO PARTICIPATE IN THAT PLAN: MATTHEW GRIMSHAW. DURING 2010 THE FOLLOWING CONTRIBUTIONS WERE MADE BY CHI TO THE DEFERRED COMPENSATION PLAN: MATTHEW GRIMSHAW - $8,820
METHODS USED TO ESTABLISH PRESIDENT/CEO COMPENSATION SCHEDULE J, PART I, LINE 3 COMPENSATION FOR THE TOP MANAGEMENT OFFICIAL WAS ESTABLISHED AND PAID BY CATHOLIC HEALTH INITIATIVES (CHI), A RELATED ORGANIZATION. CHI USED THE FOLLOWING TO ESTABLISH THE TOP MANAGEMENT OFFICIAL'S COMPENSATION: (1) COMPENSATION COMMITTEE; (2) INDEPENDENT COMPENSATION CONSULTANT; (3) WRITTEN EMPLOYMENT CONTRACTS; (4) COMPENSATION SURVEY OR STUDY; (5) APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE.
Schedule J (Form 990) 2010

Additional Data


Software ID: 10000128
Software Version: v2010.1.0
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
MERCY MEDICAL FOUNDATION
 
Employer identification number

45-0381803
Identifier Return Reference Explanation
PROGRAM SERVICE ACCOMPLISHMENTS FORM 990, PART III, LINE 4A ORGANIZATION'S MISSION, VISION, AND TAX-EXEMPT PURPOSE: THE MISSION OF MERCY MEDICAL FOUNDATION (MMF) IS TO NURTURE THE HEALING MINISTRY OF JESUS CHRIST BY SERVING AS THE FUNDRAISING ARM OF MERCY MEDICAL CENTER, A RELATED TAX-EXEMPT ORGANIZATION, AND COORDINATING GIFTS OF ENERGY, TALENTS, AND FINANCIAL RESOURCES TO HELP BUILD HEALTHIER COMMUNITIES THROUGHOUT THE MONDAK REGION. FIDELITY TO THE GOSPEL URGES US TO EMPHASIZE HUMAN DIGNITY AND SOCIAL JUSTICE AS WE MOVE TOWARD THE CREATION OF HEALTHIER COMMUNITIES. IT IS MMF'S GOAL TO HOLD TRUE TO OUR CORE VALUES OF REVERENCE, INTEGRITY, COMPASSION, AND EXCELLENCE AND TO SUPPORT THE MISSION OF MERCY MEDICAL CENTER (A RELATED TAX-EXEMPT HOSPITAL) SO THAT TOGETHER WE CAN BUILD A HEALTHIER COMMUNITY. MERCY MEDICAL FOUNDATION HAS A FOUNDATION BOARD WHICH SERVES AS THE GOVERNING BODY FOR THE FOUNDATION. THE MAJORITY OF BOARD MEMBERS ARE INDEPENDENT PERSONS, REPRESENTATIVE OF THE COMMUNITY. MERCY MEDICAL FOUNDATION IS INCORPORATED AS A 501(C)(3), TAX-EXEMPT, CHARITABLE FOUNDATION. THE PRIMARY EXEMPT PURPOSE OF THE FOUNDATION IS TO SUPPORT THE CHARITABLE MISSION OF MERCY MEDICAL CENTER OF WILLISTON, A RELATED TAX-EXEMPT HOSPITAL, BY SOLICITING FUNDS THAT WILL BE USED FOR THE HEALTHCARE NEEDS OF RESIDENTS OF THE COMMUNITY AND SURROUNDING AREAS. QUALITATIVE DESCRIPTION OF COMMUNITY BENEFIT: THE MERCY MEDICAL FOUNDATION RAISES FUNDS THROUGH SPECIAL EVENTS, ANNUAL GIVING, MAJOR GIFTS, PLANNED GIVING, CORPORATE/FOUNDATION GRANTS AND CAPITAL CAMPAIGNS TO HELP FUND HEALTH CARE PROGRAMS AND COMMUNITY OUTREACH SERVICE OFFERED BY MERCY MEDICAL CENTER. DURING FISCAL YEAR 2011, MERCY MEDICAL FOUNDATION RAISED OVER $4.7 MILLION. MERCY MEDICAL CENTER WAS THE PRIMARY RECIPIENT OF THE FUNDS WHICH WERE USED TO SUPPORT ITS MISSION AND MINISTRY.
Classes of members or stockholders Form 990, Part VI, Section A, Line 6 THE ORGANIZATION'S SOLE CORPORATE MEMBER IS MERCY MEDICAL CENTER, A NORTH DAKOTA NONPROFIT CORPORATION.
Members or stockholders electing members of governing body Form 990, Part VI, Section A, Line 7a THE ORGANIZATION'S SOLE CORPORATE MEMBER HAS THE POWER TO APPOINT, REPLACE OR REMOVE THE MEMBERS OF THE BOARD OF DIRECTORS.
Decisions requiring approval by members or stockholders Form 990, Part VI, Section A, Line 7b THE ORGANIZATION'S SOLE CORPORATE MEMBER IS MERCY MEDICAL CENTER ("MMC"). PURSUANT TO THE ORGANIZATION'S BYLAWS, BOTH MERCY MEDICAL CENTER AND CATHOLIC HEALTH INITIATIVES ("CHI") (MMC'S SOLE CORPORATE MEMBER) HAVE RESERVED POWERS AS OUTLINED IN THE CHI GOVERNANCE MATRIX. PURSUANT TO THE GOVERNANCE MATRIX THE FOLLOWING RIGHTS ARE HELD BY THE MMC BOARD: -APPROVE MEMBERS OF THE MERCY MEDICAL FOUNDATION ("MMF") BOARD -AMENDMENT OF THE CORPORATE DOCUMENTS OF MMF -APPROVE REMOVAL OF A MEMBER OF THE GOVERNING BODY OF MMF -ADOPTION OF LONG RANGE AND STRATEGIC PLANS FOR MMF THE FOLLOWING RIGHTS ARE RESERVED TO THE CHI BOARD DIRECTLY OR THROUGH POWERS DELEGATED TO THE CHI CHIEF EXECUTIVE OFFICER: -SUBSTANTIAL CHANGE IN THE MISSION OR PHILOSOPHY OF MMF -REMOVAL OF A MEMBER OF THE GOVERNING BODY OF MMF -APPROVAL OF ISSUANCE OF DEBT BY MMF -APPROVAL OF PARTICIPATION OF MMF IN A JOINT VENTURE -APPROVAL OF FORMATION OF A NEW CORPORATION BY MMF -APPROVAL OF A MERGER INVOLVING MMF -APPROVAL OF THE SALE OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF MMF -TO REQUIRE THE TRANSFER OF ASSETS BY MMF TO CHI TO ACCOMPLISH CHI'S GOALS AND OBJECTIVES, AND TO SATISFY CHI DEBTS PURSUANT TO THE ORGANIZATION'S BYLAWS, MMC OR CHI MAY, IN EXERCISE OF THEIR APPROVAL POWERS, GRANT OR WITHHOLD APPROVAL IN WHOLE OR IN PART, OR MAY, IN ITS COMPLETE DISCRETION, AFTER CONSULTATION WITH THE BOARD AND ITS PRESIDENT AND THE CHIEF EXECUTIVE OFFICER OF THE ORGANIZATION, RECOMMEND SUCH OTHER OR DIFFERENT ACTIONS AS IT DEEMS APPROPRIATE.
Review of form 990 by governing body Form 990, Part VI, Section B, Line 11a THE CFO REVIEWS THE RETURN AND A COPY IS PROVIDED TO THE BOARD. SUBSEQUENT TO THE CFO'S REVIEW AND THE RETURN BEING PROVIDED TO THE BOARD, THE CHI TAX DEPARTMENT FILES THE RETURN WITH THE APPROPRIATE FEDERAL AGENCIES, MAKING ANY NON-SUBSTANTIVE CHANGES NECESSARY TO EFFECT E-FILING. ANY SUCH CHANGES ARE NOT RE-SUBMITTED TO THE BOARD OR CFO.
Conflict of interest policy Form 990, Part VI, Section B, Line 12c ALL EMPLOYEES, VOLUNTEERS, OFFICERS, DIRECTORS, AND TRUSTEES RECEIVE COMPREHENSIVE EDUCATION ON THE CRP PROGRAM AND CHI STANDARDS OF CONDUCT WHICH BOTH ADDRESS CONFLICT OF INTEREST, DISCLOSURE, AND REPORTING. ALL BOARD MEMBERS COMPLETE AN ANNUAL CONFLICT OF INTEREST DISCLOSURE. PRIOR TO EACH BOARD MEETING MEMBERS ARE ASKED TO DISCLOSE ANY KNOWN OR POTENTIAL CONFLICTS OF INTEREST AND ARE EXCLUDED FROM PORTIONS OR ALL OF THE MEETING AS APPROPRIATE. ALL PROJECTS ARE PUT OUT FOR BID WITH EQUAL OPPORTUNITY AFFORDED TO ALL. ALL EMPLOYEES, OFFICERS, DIRECTORS, AND TRUSTEES HAVE ACCESS TO AND ARE EDUCATED TO REPORT POTENTIAL/ACTUAL CONFLICT OF INTERESTS, ANONYMOUSLY IF THEY CHOSE. THESE REPORTS ARE SEEN BY THE CRO AT MMC AND THE REGIONAL CRO. FOLLOW-UP IS MONITORED. AN ANNUAL CRP RISK ASSESSMENT IS DONE AS WELL AS AN ANNUAL EVALUATION OF THE CRP PLAN. BOTH ARE REVIEWED AND APPROVED BY THE FULL BOARD.
Process used to establish compensation of top management official Form 990, Part VI, Section B, Line 15a THE ORGANIZATION'S PRESIDENT/CEO'S COMPENSATION IS PAID BY CHI. CHI HAS A DEFINED COMPENSATION PHILOSOPHY. BOTH THE EXECUTIVE AND NON-EXECUTIVE COMPENSATION STRUCTURES AND RANGES ARE REVIEWED ANNUALLY IN COMPARISON TO MARKET DATA. CHI USES THE HAY GROUP AS THE INDEPENDENT THIRD PARTY TO ASSESS EXECUTIVE COMPENSATION PROGRAMS AND TO ENSURE THE REASONABLENESS OF ACTUAL SALARIES AND TOTAL COMPENSATION PACKAGES. COMPENSATION OF THE SENIOR MOST EXECUTIVES IS REVIEWED ANNUALLY. THE HAY GROUP REVIEWS BOTH CASH AND TOTAL COMPENSATION FOR OVERALL REASONABLENESS, FOR ADHERENCE TO CHI'S COMPENSATION PHILOSOPHY, AND FOR COMPARABILITY TO THE NOT-FOR-PROFIT HEALTHCARE MARKET. THIS INDEPENDENT REVIEW IS DELIVERED BY HAY GROUP TO THE HR COMMITTEE OF THE CHI BOARD OF STEWARDSHIP TRUSTEES ANNUALLY AT THEIR SEPTEMBER MEETING AND MINUTES ARE SHARED WITH THE FULL BOARD AT THE DECEMBER MEETING. THE LAST REVIEW WAS SEPTEMBER 2011. IN ADDITION, IN DECEMBER 2009, HAY GROUP COMPLETED A COMPREHENSIVE REVIEW OF ALL POSITIONS AT THE LEVEL OF VICE PRESIDENT AND ABOVE TO DETERMINE AND VALIDATE APPROPRIATE COMPENSATION LEVELS.
Public Disclosure Form 990, Part VI, Section C, Line 19 THE ORGANIZATION'S FINANCIAL STATEMENTS ARE INCLUDED IN CATHOLIC HEALTH INITIATIVES' CONSOLIDATED AUDITED FINANCIAL STATEMENTS THAT ARE AVAILABLE AT WWW.CATHOLICHEALTHINIT.ORG OR AT WWW.DACBOND.ORG. THE ORGANIZATION'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT PUBLICLY AVAILABLE.
EXECUTIVE COMMITTEE COMPOSITION & AUTHORITY FORM 990, PART VI, SECTION A, LINE 1A THE EXECUTIVE COMMITTEE CONSISTS ONLY OF DIRECTORS OF THE CORPORATION AND IS COMPOSED OF THE CHAIRPERSON OF THE BOARD, THE VICE CHAIRPERSON OF THE BOARD, AND THE FOUNDATION DIRECTOR, SECRETARY, AND TREASURER, EACH OF WHOM SERVE AS EX OFFICIO VOTING MEMBERS OF THE EXECUTIVE COMMITTEE. THE EXECUTIVE COMMITTEE HAS THE POWER TO TRANSACT THE ROUTINE BUSINESS OF THE CORPORATION IN THE INTERIM PERIODS BETWEEN REGULARLY SCHEDULED MEETINGS OF THE BOARD OF DIRECTORS, PROVIDED THAT THEIR ACTIONS ARE CONSISTENT WITH ANY ACTIONS OR POLICIES OF THE BOARD OR THE CORPORATE MEMBER. ALL ACTIONS TAKEN ARE CONTEMPORANEOUSLY DOCUMENTED AND REPORTED TO THE BOARD AT THE EARLIEST MEETING.
DOCUMENT RETENTION AND DESTRUCTION POLICY FORM 990, PART VI, SECTION B, LINE 14 THE ORGANIZATION HAS A WRITTEN DOCUMENT RETENTION AND DESTRUCTION POLICY THAT IT FOLLOWS; HOWEVER, THE POLICY HAS NOT BEEN FORMALLY ADOPTED BY THE BOARD OF DIRECTORS.
PROCESS USED TO ESTABLISH COMPENSATION OF OTHER OFFICERS/KEY EMPLOYEES FORM 990, PART VI, SECTION B, LINE 15B DURING THE TAX YEAR ENDED 6/30/11, NO OTHER OFFICERS, DIRECTORS, TRUSTEES OR KEY EMPLOYEES RECEIVED COMPENSATION FROM THE ORGANIZATION. ANY EXECUTIVE COMPENSATION PAID TO OTHER OFFICERS, DIRECTORS, TRUSTEES OR KEY EMPLOYEES BY RELATED ORGANIZATIONS WAS SET BY THE RELATED ORGANIZATION'S COMPENSATION COMMITTEE UTILIZING BOTH AN INDEPENDENT CONSULTANT AND COMPARABILITY STUDIES TO DETERMINE COMPENSATION. THEREFORE, THIS QUESTION IS MORE APPROPRIATELY ANSWERED AS "N/A" BUT HAS BEEN ANSWERED "NO" IN ACCORDANCE WITH THE FORM 990 INSTRUCTIONS.
ESTIMATE OF HOURS DEVOTED TO RELATED ORGANIZATIONS FORM 990, PART VII, SECTION A, LINE 1A THE INDIVIDUALS LISTED IN PART VII THAT REPORT COMPENSATION PAID BY A RELATED ORGANIZATION DEVOTE APPROXIMATELY 60 HOURS PER WEEK TO THE RELATED ORGANIZATIONS AND RECEIVE COMPENSATION IN EXCHANGE FOR THEIR SERVICES PROVIDED.
Other changes in net assets or fund balances Form 990, Part XI, Line 5 NET UNREALIZED GAINS (LOSSES) ON INVESTMENTS - 419772; PRIOR PERIOD ADJUSTMENTS - -4000; CHANGE IN CSV OF LIFE INSURANCE - 15597;
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: 10000128
Software Version: v2010.1.0
SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBulletAttach to Form 990. MediumBullet See separate instructions.

OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
MERCY MEDICAL FOUNDATION
 
Employer identification number

45-0381803
Part I
Identification of Disregarded Entities (Complete if the organization answered "Yes" on Form 990, Part IV, line 33.)
(a)
Name, address, and EIN of disregarded entity


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Total income
(e)
End-of-year assets


 		(f)
Direct controlling
entity

















Part II
Identification of Related Tax-Exempt Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.)
(a)
Name, address, and EIN of related organization


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Exempt Code section
(e)
Public charity status
(if section 501(c)(3))

 		(f)
Direct controlling
entity

 		(g)
Section 512(b)(13) controlled organization
Yes No
(1) ALEGENT HEALTH - BERGAN MERCY HEALTH SYS

7500 MERCY ROAD

OMAHA,NE68124
47-0484764 		HEALTHCARE NE 501(C)(3) 3 CHI
 
Yes
 
(2) ALEGENT HEALTH - MERCY HOSPITAL CORNING

PO BOX 368

CORNING,IA50841
42-0782518 		HEALTHCARE IA 501(C)(3) 3 AHBMHS
 
Yes
 
(3) ALVERNA APARTMENTS

300 SE 8TH AVENUE

LITTLE FALLS,MN56345
41-1351177 		LTERM CARE MN 501(C)(3) 9 CHI
 
Yes
 
(4) APPLETREE COURT

601 OAK STREET

BRECKENRIDGE,MN56520
41-1850500 		SENIOR HOMES MN 501(C)(3) 9 SFH
 
Yes
 
(5) BISHOP DRUMM RETIREMENT CENTER

1111 6TH AVENUE

DES MOINES,IA50314
42-0725196 		LTERM CARE IA 501(C)(3) 9 CHI-IA CORP
 
Yes
 
(6) BORNEMANN HEALTHCARE CORPORATION

2500 BERNVILLE RD PO BOX 316

READING,PA19603
23-2187242 		HEALTHCARE PA 501(C)(3) 11 - Type I CHI
 
Yes
 
(7) CARRINGTON HEALTH CENTER

800 NORTH 4TH STREET

CARRINGTON,ND58421
45-0227311 		HEALTHCARE ND 501(C)(3) 3 CHI
 
Yes
 
(8) CATHOLIC HEALTH CARE FEDERATION

198 INVERNESS DRIVE WEST

ENGLEWOOD,CO80112
20-8473567 		JURIDIC PERSON CO 501(C)(3) 11 - Type I CHI
 
Yes
 
(9) CATHOLIC HEALTH INITIATIVES

198 INVERNESS DRIVE WEST

ENGLEWOOD,CO80112
47-0617373 		HEALTHCARE CO 501(C)(3) 9 CHI
 
Yes
 
(10) CATHOLIC HEALTH INITIATIVES COLORADO FOUNDATION

961 EAST COLORADO AVENUE

COLORADO SPRINGS,CO80903
84-0902211 		FUNDRAISING CO 501(C)(3) 7 CHI COLORADO
 
Yes
 
(11) CENTENNIAL MEDICAL GROUP INC

2700 STEWART PARKWAY

ROSEBURG,OR97470
90-0433062 		PHYSICIANS OR 501(C)(3) 9 MMC
 
Yes
 
(12) CHI COLORADO

188 INVERNESS DRIVE WEST

ENGLEWOOD,CO80112
84-0405257 		HEALTHCARE CO 501(C)(3) 3 CHI
 
Yes
 
(13) CHI HEALTH CONNECT AT HOME - FARGO

4816 AMBER VALLEY PARKWAY

FARGO,ND58104
27-1966847 		HEALTHCARE ND 501(C)(3) 3 CHI
 
Yes
 
(14) CHI INSTITUTE FOR RESEARCH AND INNOVATION

198 INVERNESS DRIVE WEST

ENGLEWOOD,CO80112
27-1050565 		HEALTHCARE CO 501(C)(3) 11 - Type I CHI
 
Yes
 
(15) CHI KENTUCKY INC

3900 OLYMPIC BLVD SUITE 400

ERLANGER,KY41018
20-2741651 		HEALTHCARE KY 501(C)(3) 11 - Type I CHI
 
Yes
 
(16) CHI NATIONAL FOUNDATION

198 INVERNESS DRIVE WEST

ENGLEWOOD,CO80112
27-0930004 		FUNDRAISING CO 501(C)(3) 11 - Type I CHI
 
Yes
 
(17) CHI NATIONAL HOME CARE

198 INVERNESS DRIVE WEST

ENGLEWOOD,CO80112
45-1261716 		HEALTHCARE CO 501(C)(3) 11 - Type I CHI
 
Yes
 
(18) CHI NATIONAL SERVICES

198 INVERNESS DRIVE WEST

ENGLEWOOD,CO80112
45-2532084 		HEALTHCARE CO 501(C)(3) 9 CHI
 
Yes
 
(19) CHI NEBRASKA

555 SOUTH 70TH STREET

LINCOLN,NE68510
36-3233121 		HEALTHCARE NE 501(C)(3) 11 - Type I CHI
 
Yes
 
(20) CHI-IOWA CORP

1111 6TH AVENUE

DES MOINES,IA50314
42-0680448 		HEALTHCARE IA 501(C)(3) 3 MHN
 
Yes
 
(21) CONTINUING CARE HOSPITAL

150 NORTH EAGLE CREEK DRIVE

LEXINGTON,KY40509
61-1400619 		LTACH KY 501(C)(3) 3 SJHS
 
Yes
 
(22) ENUMCLAW REGIONAL HOSPITAL ASSOCIATION

1450 BATTERSBY AVENUE

ENUMCLAW,WA98022
91-0715805 		HEALTHCARE WA 501(C)(3) 3 FHS
 
Yes
 
(23) FLAGET HEALTHCARE DBA FLAGET MEMORIAL HOSPITAL

4305 NEW SHEPHERDSVILLE ROAD

BARDSTOWN,KY40004
61-1345363 		HEALTHCARE KY 501(C)(3) 3 CHI
 
Yes
 
(24) FLAGET MEMORIAL HOSPITAL FOUNDATION INC

4305 NEW SHEPHERDSVILLE ROAD

BARDSTOWN,KY40004
56-2351341 		FUNDRAISING KY 501(C)(3) 11 - Type I FH
 
Yes
 
(25) FRANCISCAN FOUNDATION

1717 SOUTH J STREET

TACOMA,WA98405
91-1145592 		FUNDRAISING WA 501(C)(3) 9 FHS
 
Yes
 
(26) FRANCISCAN HEALTH SYSTEM FKA FRANCISCAN HEALTH SYSTEM WEST

1717 SOUTH J STREET

TACOMA,WA98405
91-0564491 		HEALTHCARE WA 501(C)(3) 3 CHI
 
Yes
 
(27) FRANCISCAN MEDICAL GROUP

1708 SOUTH YAKIMA AVENUE

TACOMA,WA98405
91-1939739 		HEALTHCARE WA 501(C)(3) 9 FHS
 
Yes
 
(28) FRANCISCAN VILLA OF SOUTH MILWAUKEE INC

3601 SOUTH CHICAGO AVENUE

SOUTH MILWAUKEE,WI53172
39-1093829 		HEALTHCARE WI 501(C)(3) 9 CHI
 
Yes
 
(29) GETTYSBURG MEDICAL CENTER

606 EAST GARFIELD AVENUE

GETTYSBURG,SD57442
46-0234354 		HEALTHCARE SD 501(C)(3) 3 SMHC
 
Yes
 
(30) GLOBAL HEALTH INITIATIVES

198 INVERNESS DRIVE WEST

ENGLEWOOD,CO80112
20-1536108 		MINISTRIES CO 501(C)(3) 11 - Type I CHI
 
Yes
 
(31) GOOD SAMARITAN COLLEGE OF NURSING & HEALTH SCIENCE

375 DIXMYTH AVE

CINCINNATI,OH45220
31-1778403 		EDUCATION KY 501(C)(3) 2 GHS
 
Yes
 
(32) GOOD SAMARITAN FOUNDATION OF CINCINNATI INC

619 OAK STREET ACCOUNTING-3 W

CINCINNATI,OH45206
31-1206047 		FUNDRAISING OH 501(C)(3) 11 - Type I GSH
 
Yes
 
(33) GOOD SAMARITAN HOSPITAL

PO BOX 1990

KEARNEY,NE68848
47-0379755 		HEALTHCARE NE 501(C)(3) 3 CHI NEBRASKA
 
Yes
 
(34) GOOD SAMARITAN HOSPITAL FOUNDATION

PO BOX 1810

KEARNEY,NE68848
47-0659443 		FUNDRAISING NE 501(C)(3) 7 GSH
 
Yes
 
(35) HEALTH SET

4200 WEST CONEJOS PLACE 436

DENVER,CO80204
84-1102943 		LOW INC.CARE CO 501(C)(3) 7 CHI COLORADO
 
Yes
 
(36) HEALTHCARE AND WELLNESS FOUNDATION

2400 ST FRANCIS DRIVE

BRECKENRIDGE,MN56520
76-0761782 		FUNDRAISING MN 501(C)(3) 11 - Type I SFMC
 
Yes
 
(37) HOSPITAL ASSOCIATION FOR ST JOSEPH HOSPITAL

7601 OSLER DRIVE

TOWSON,MD21204
52-6050777 		HEALTHCARE MD 501(C)(3) 9 SJMC
 
Yes
 
(38) HOUSE OF MERCY

1111 6TH AVENUE

DES MOINES,IA50314
42-1323808 		SHELTER IA 501(C)(3) 7 CHI-IA CORP
 
Yes
 
(39) LAKEWOOD HEALTH CENTER

600 MAIN AVENUE SOUTH

BAUDETTE,MN56623
41-0758434 		LTERM CARE MN 501(C)(3) 3 CHI
 
Yes
 
(40) LINUS OAKES INC

2700 STEWART PARKWAY

ROSEBURG,OR97470
93-0821381 		SENIOR LIVING OR 501(C)(3) 9 MMC
 
Yes
 
(41) LISBON AREA HEALTH SERVICES

905 MAIN STREET

LISBON,ND58054
82-0558836 		HEALTHCARE ND 501(C)(3) 3 CHI
 
Yes
 
(42) MEMORIAL HEALTH CARE SYSTEM FOUNDATION

2525 DE SALES AVENUE

CHATTANOOGA,TN37404
62-1839548 		FUNDRAISING TN 501(C)(3) 7 MHCS
 
Yes
 
(43) MEMORIAL HEALTH CARE SYSTEM INC

2525 DE SALES AVENUE

CHATTANOOGA,TN37404
62-0532345 		HEALTHCARE TN 501(C)(3) 3 CHI
 
Yes
 
(44) MEMORIAL HEALTH PARTNERS FOUNDATION INC

6028 SHALLOWFORD ROAD

CHATTANOOGA,TN37421
03-0417049 		HEALTHCARE TN 501(C)(3) 9 MHCS
 
Yes
 
(45) MERCY AUXILIARY OF CENTRAL IOWA

1111 6TH AVENUE

DES MOINES,IA50314
42-6076069 		AUXILIARY IA 501(C)(3) 11 - Type I CHI-IA CORP
 
Yes
 
(46) MERCY CLINICS INC

1111 6TH AVENUE

DES MOINES,IA50314
42-1193699 		PHYSICIAN IA 501(C)(3) 9 CHI-IA CORP
 
Yes
 
(47) MERCY COLLEGE OF HEALTH SCIENCES

1111 6TH AVENUE

DES MOINES,IA50314
42-1511682 		EDUCATION IA 501(C)(3) 2 CHI-IA CORP
 
Yes
 
(48) MERCY FOUNDATION OF DES MOINES IA

1111 6TH AVENUE

DES MOINES,IA50314
23-7358794 		FUNDRAISING IA 501(C)(3) 7 CHI-IA CORP
 
Yes
 
(49) MERCY FOUNDATION INC

2700 STEWART PARKWAY

ROSEBURG,OR97470
93-6088946 		FUNDRAISING OR 501(C)(3) 7 MMC
 
Yes
 
(50) MERCY HEALTH CARE FOUNDATION

PO BOX 368

CORNING,IA50841
42-1461064 		FUNDRAISING NE 501(C)(3) 11 - Type I AHMH
 
Yes
 
(51) MERCY HOSPITAL FOUNDATION COUNCIL BLUFFS

800 MERCY DRIVE

COUNCIL BLUFFS,IA51503
42-1178204 		FUNDRAISING IA 501(C)(3) 11 - Type I AHBMHS
 
Yes
 
(52) MERCY HOSPITAL OF DEVILS LAKE

1031 EAST SEVENTH STREET

DEVILS LAKE,ND58301
45-0227012 		HEALTHCARE ND 501(C)(3) 3 CHI
 
Yes
 
(53) MERCY HOSPITAL OF VALLEY CITY

570 CHAUTAUQUA BOULEVARD

VALLEY CITY,ND58072
45-0226553 		HEALTHCARE ND 501(C)(3) 3 CHI
 
Yes
 
(54) MERCY LIFECARE SYSTEMS

2727 MCCLELLAND BLVD

JOPLIN,MO64804
43-1305163 		PROPERTY MGMT MO 501(C)(3) 11 - Type I SJRMC
 
Yes
 
(55) MERCY MEDICAL CENTER

1301 15TH AVENUE WEST

WILLISTON,ND58801
45-0231183 		HEALTHCARE ND 501(C)(3) 3 CHI
 
Yes
 
(56) MERCY MEDICAL CENTER

2700 STEWART PARKWAY

ROSEBURG,OR97470
93-0386868 		HEALTHCARE OR 501(C)(3) 3 CHI
 
Yes
 
(57) MERCY MEDICAL CENTER - CENTERVILLE

1 ST JOSEPHS DRIVE

CENTERVILLE,IA52544
42-0680308 		HEALTHCARE IA 501(C)(3) 3 CHI-IA CORP
 
Yes
 
(58) MERCY PROFESSIONAL PRACTICE ASSOCIATES INC

1111 6TH AVENUE

DES MOINES,IA50314
42-1470935 		PHYSICIAN IA 501(C)(3) 9 CHI-IA CORP
 
Yes
 
(59) MERCY REGIONAL MEDICAL CENTER OF DURANGO

1010 THREE SPRINGS BLVD

DURANGO,CO81301
84-0405515 		HEALTHCARE CO 501(C)(3) 3 CHI
 
Yes
 
(60) MNMCH INC

220 NORTH PENNSYLVANIA

COLUMBUS,KS66725
48-1216238 		HEALTHCARE KS 501(C)(3) 3 SJRMC
 
Yes
 
(61) MT ST JOSEPH INC

3060 SE STARK STREET

PORTLAND,OR97214
93-0386870 		NURSING CARE OR 501(C)(3) 9 CHI
 
Yes
 
(62) OAKES COMMUNITY HOSPITAL

314 SOUTH 8TH STREET

OAKES,ND58474
45-0231675 		HEALTHCARE ND 501(C)(3) 3 CHI
 
Yes
 
(63) OAKES COMMUNITY HOSPITAL FOUNDATION

314 SOUTH 8TH STREET

OAKES,ND58474
71-0966606 		FUNDRAISING ND 501(C)(3) 11 - Type I OCH
 
Yes
 
(64) PUEBLO STEPUP

1925 EAST ORMAN AVE SUITE G52

PUEBLO,CO81004
84-1234295 		COMMUNITY CO 501(C)(3) 7 CHI
 
Yes
 
(65) SET OF COLORADO SPRINGS INC

825 E PIKES PEAK AVENUE BLDG 29

COLORADO SPRINGS,CO80903
84-1183335 		LTERM CARE CO 501(C)(3) 7 CHI COLORADO
 
Yes
 
(66) SAINT CLARE'S COMMUNITY CARE

66 FORD ROAD

DENVILLE,NJ07834
22-2876836 		HEALTHCARE NJ 501(C)(3) 11 - Type II SCHS
 
Yes
 
(67) SAINT CLARE''S FOUNDATION INC

66 FORD ROAD

DENVILLE,NJ07834
22-2502997 		FUNDRAISING NJ 501(C)(3) 7 SCHS
 
Yes
 
(68) SAINT CLARE''S HEALTH SERVICES INC

25 POCONO ROAD

DENVILLE,NJ07834
22-3639733 		MANAGEMENT NJ 501(C)(3) 7 CHI
 
Yes
 
(69) SAINT CLARE'S HOSPITAL

66 FORD ROAD

DENVILLE,NJ07834
22-3319886 		HEALTHCARE NJ 501(C)(3) 3 CHI
 
Yes
 
(70) SAINT ELIZABETH FOUNDATION

555 SOUTH 70TH STREET

LINCOLN,NE68510
47-0625523 		FUNDRAISING NE 501(C)(3) 7 SERMC
 
Yes
 
(71) SAINT ELIZABETH HEALTH SERVICES

555 SOUTH 70TH STREET

LINCOLN,NE68510
36-3233120 		HEALTHCARE NE 501(C)(3) 3 SERMC
 
Yes
 
(72) SAINT ELIZABETH REGIONAL MEDICAL CENTER

555 SOUTH 70TH STREET

LINCOLN,NE68510
47-0379836 		HEALTHCARE NE 501(C)(3) 3 CHI NEBRASKA
 
Yes
 
(73) SAINT FRANCIS MEDICAL CENTER

PO BOX 9804

GRAND ISLAND,NE68802
47-0376601 		HEALTHCARE NE 501(C)(3) 3 CHI NEBRASKA
 
Yes
 
(74) SAINT FRANCIS MEDICAL CENTER FOUNDATION

PO BOX 9804

GRAND ISLAND,NE68802
47-0630267 		FUNDRAISING NE 501(C)(3) 7 SFMC
 
Yes
 
(75) SAINT JOSEPH BEREA HOSPITAL FOUNDATION INC

305 ESTILL STREET

BEREA,KY40403
26-0152877 		FUNDRAISING KY 501(C)(3) 7 SJHS
 
Yes
 
(76) SAINT JOSEPH HEALTH SYSTEM INC

150 N EAGLE CREEK DR

LEXINGTON,KY40509
61-1334601 		HEALTHCARE KY 501(C)(3) 3 CHI
 
Yes
 
(77) SAINT JOSEPH LONDON FOUNDATION INC

310 EAST NINTH STREET

LONDON,KY40741
26-0438748 		FUNDRAISING KY 501(C)(3) 11 - Type I SJHS
 
Yes
 
(78) SAINT JOSEPH MEDICAL FOUNDATION INC

ONE ST JOSEPH DRIVE

LEXINGTON,KY40504
31-1539059 		PHY PRACTICES KY 501(C)(3) 3 SJHS
 
Yes
 
(79) SAINT JOSEPH MOUNT STERLING FOUNDATION INC

50 STERLING AVENUE

MOUNT STERLING,KY40353
27-2884584 		FUNDRAISING KY 501(C)(3) 7 SJHS
 
Yes
 
(80) SAINT JOSEPH'S HOSPITAL FOUNDATION

30 WEST 7TH STREET

DICKINSON,ND58601
36-3418207 		FUNDRAISING ND 501(C)(3) 11 - Type I SJHHC
 
Yes
 
(81) SAMARITAN BEHAVIORAL HEALTH

601 S EDWIN C MOSES BLVD

DAYTON,OH45408
02-0633634 		HEALTHCARE OH 501(C)(3) 3 SHP
 
Yes
 
(82) SAMARITAN HEALTH FOUNDATION

2222 PHILADELPHIA DRIVE

DAYTON,OH45406
23-7296923 		FUNDRAISING OH 501(C)(3) 7 SHP
 
Yes
 
(83) SAMARITAN HEALTH PARTNERS

2222 PHILADELPHIA DRIVE

DAYTON,OH45406
31-1107411 		HEALTHCARE OH 501(C)(3) 11 - Type I CHI
 
Yes
 
(84) ST JOSEPH HEALTH MINISTRIES

1929 LINCOLN HWY E STE 150

LANCASTER,PA17602
23-2342997 		HEALTH PA 501(C)(3) 11 - Type I CHI
 
Yes
 
(85) ST JOSEPH HEALTH MINISTRIES FOUNDATION

1929 LINCOLN HWY E STE 150

LANCASTER,PA17602
23-2605579 		FUNDRAISING PA 501(C)(3) 11 - Type I SJHM
 
Yes
 
(86) ST ANTHONY HOSPITAL

1601 SE COURT AVENUE

PENDLETON,OR97801
93-0391614 		HEALTHCARE OR 501(C)(3) 3 CHI
 
Yes
 
(87) ST ANTHONY HOSPITAL FOUNDATION

1601 SE COURT AVENUE

PENDLETON,OR97801
93-0992727 		FUNDRAISING OR 501(C)(3) 11 - Type I SA HOSPITAL
 
Yes
 
(88) ST ANTHONY'S HOSPITAL ASSOCIATION

4 HOSPITAL DRIVE

MORRILTON,AR72110
71-0245507 		HEALTHCARE AR 501(C)(3) 3 SVIMC
 
Yes
 
(89) ST CATHERINE HOSPITAL

401 EAST SPRUCE STREET

GARDEN CITY,KS67846
48-0543721 		HEALTHCARE KS 501(C)(3) 3 CHI
 
Yes
 
(90) ST CATHERINE HOSPITAL DEVELOPMENT FOUNDATION

401 EAST SPRUCE STREET

GARDEN CITY,KS67846
20-0598702 		FUNDRAISING KS 501(C)(3) 11 - Type I SCH
 
Yes
 
(91) ST DOMINIC AT ONTARIO

351 SW 9TH STREET

ONTARIO,OR97914
93-0433692 		HEALTHCARE OR 501(C)(3) 3 CHI
 
Yes
 
(92) ST FRANCIS HOME

2400 ST FRANCIS DRIVE

BRECKENRIDGE,MN56520
41-0729978 		LTERM CARE MN 501(C)(3) 9 CHI
 
Yes
 
(93) ST FRANCIS LIFE CARE CORPORATION

19 POCONO ROAD

DENVILLE,NJ07834
22-2536017 		ELDERLY CARE NJ 501(C)(3) 9 SCHS
 
Yes
 
(94) ST FRANCIS MEDICAL CENTER

2400 ST FRANCIS DRIVE

BRECKENRIDGE,MN56520
41-0695598 		HEALTHCARE MN 501(C)(3) 3 CHI
 
Yes
 
(95) ST FRANCIS OF BAKER CITY

3325 POCAHONTAS ROAD

BAKER CITY,OR97814
93-0412495 		HEALTHCARE OR 501(C)(3) 3 CHI
 
Yes
 
(96) ST JOHN'S MEDICAL GROUP

2727 MCCLELLAND BLVD

JOPLIN,MO64804
43-1882377 		PHYS PRACTICE MO 501(C)(3) 9 SJRMC
 
Yes
 
(97) ST JOHN'S MERCY REGIONAL FOUNDATION

2727 MCCLELLAND BLVD

JOPLIN,MO64804
43-1308084 		FUNDRAISING MO 501(C)(3) 7 SJRMC
 
Yes
 
(98) ST JOHN'S REGIONAL MEDICAL CENTER

2727 MCCLELLAND BLVD

JOPLIN,MO64804
44-0545809 		HEALTHCARE MO 501(C)(3) 3 CHI
 
Yes
 
(99) ST JOSEPH COMMUNITY HEALTH SERVICES

300 CENTRAL AVE SW SUITE 3000W

ALBUQUERQUE,NM87102
71-0897107 		COMMUNITY NM 501(C)(3) 11 - Type I CHI
 
Yes
 
(100) ST JOSEPH HEALTH SERVICES INC

1929 LINCOLN HWY E STE 150

LANCASTER,PA17602
20-1425375 		DENTAL CARE PA 501(C)(3) 11 - Type I SJHM
 
Yes
 
(101) ST JOSEPH HOSPITAL FOUNDATION INC

ONE ST JOSEPH DRIVE

LEXINGTON,KY40504
61-1159649 		FUNDRAISING KY 501(C)(3) 11 - Type I SJHS
 
Yes
 
(102) ST JOSEPH MEDICAL CENTER FOUNDATION

2500 BERNVILLE ROAD PO BOX 316

READING,PA19603
23-2649362 		FUNDRAISING PA 501(C)(3) 11 - Type I SJRHN
 
Yes
 
(103) ST JOSEPH MEDICAL CENTER FOUNDATION INC

7601 OSLER DRIVE

TOWSON,MD21204
52-1681044 		FUNDRAISING MD 501(C)(3) 7 SJMC
 
Yes
 
(104) ST JOSEPH MEDICAL CENTER INC

7601 OSLER DRIVE

TOWSON,MD21204
52-0591461 		HEALTHCARE MD 501(C)(3) 3 CHI
 
Yes
 
(105) ST JOSEPH MEDICAL GROUP

2500 BERNVILLE ROAD PO BOX 316

READING,PA19603
20-8544021 		HEALTHCARE PA 501(C)(3) 9 BHC
 
Yes
 
(106) ST JOSEPH PHYSICIAN ENTERPRISES

7601 OSLER DRIVE

TOWSON,MD21204
52-1311775 		PHYSICIANS MD 501(C)(3) 11 - Type I CHI
 
Yes
 
(107) ST JOSEPH REGIONAL HEALTH NETWORK

2500 BERNVILLE ROAD PO BOX 316

READING,PA19603
23-1352211 		HEALTHCARE PA 501(C)(3) 3 CHI
 
Yes
 
(108) ST JOSEPH'S AREA HEALTH SERVICES

600 PLEASANT AVENUE

PARK RAPIDS,MN56470
41-0695603 		HEALTHCARE MN 501(C)(3) 3 CHI
 
Yes
 
(109) ST JOSEPH'S HOSPITAL AND HEALTH CENTER

30 WEST 7TH STREET

DICKINSON,ND58601
45-0226429 		HEALTHCARE ND 501(C)(3) 3 CHI
 
Yes
 
(110) ST MARY'S HEALTHCARE CENTER

801 EAST SIOUX AVENUE

PIERRE,SD57501
46-0230199 		HEALTHCARE SD 501(C)(3) 3 CHI
 
Yes
 
(111) ST MARY'S HOSPITAL

1314 3RD AVENUE

NEBRASKA CITY,NE68410
47-0443636 		HEALTHCARE NE 501(C)(3) 3 CHI NEBRASKA
 
Yes
 
(112) ST MARY'S HOSPITAL FOUNDATION

1314 3RD AVENUE

NEBRASKA CITY,NE68410
47-0707604 		FUNDRAISING NE 501(C)(3) 7 SMH
 
Yes
 
(113) ST ROSE AMBULATORY AND SURGERY CENTER FKA CENTRAL KANSAS MEDICAL CENTER

3515 BROADWAY

GREAT BEND,KS67530
48-0543724 		SURGERY CNTR KS 501(C)(3) 3 CHI
 
Yes
 
(114) ST VINCENT FOUNDATION

TWO ST VINCENT CIRCLE

LITTLE ROCK,AR72205
51-0169537 		FUNDRAISING AR 501(C)(3) 11 - Type I SVIMC
 
Yes
 
(115) ST VINCENT INFIRMARY MEDICAL CENTER

2 ST VINCENT CIRCLE

LITTLE ROCK,AR72205
71-0236917 		HEALTHCARE AR 501(C)(3) 3 CHI
 
Yes
 
(116) ST VINCENT MEDICAL GROUP

2 ST VINCENT CIRCLE

LITTLE ROCK,AR72205
71-0830696 		HEALTHCARE AR 501(C)(3) 9 SVIMC
 
Yes
 
(117) THE COMMUNITY LIMITED CARE DIALYSIS CENTER

619 OAK STREET ACCOUNTING-3 W

CINCINNATI,OH45206
23-7419853 		DIALYSIS OH 501(C)(2) N/A GSH
 
Yes
 
(118) THE GOOD SAMARITAN HOSPITAL OF CINCINNATI OH

619 OAK STREET ACCOUNTING-3 W

CINCINNATI,OH45206
31-0537486 		HEALTHCARE OH 501(C)(3) 3 TRI-HEALTH
 
Yes
 
(119) THE MERCY HOSPITAL OF DEVILS LAKE FDN

1031 EAST SEVENTH STREET

DEVILS LAKE,ND58301
35-2367360 		FUNDRAISING ND 501(C)(3) 11 - Type I MHDL
 
Yes
 
(120) THE PHYSICIAN NETWORK

8055 O STREET SUITE 300

LINCOLN,NE68510
47-0780857 		PHYS PRACTICE NE 501(C)(3) 11 - Type I CHI NEBRASKA
 
Yes
 
(121) TOTAL HEALTHCARE

PO BOX 7021

COLORADO SPRINGS,CO80933
84-0927232 		HEALTHCARE CO 501(C)(3) 3 CHI COLORADO
 
Yes
 
(122) UNITY FAMILY HEALTHCARE

815 2ND STREET SE

LITTLE FALLS,MN56345
41-0721642 		HEALTHCARE MN 501(C)(3) 3 CHI
 
Yes
 
(123) VILLA NAZARETH INC

801 PAGE DRIVE

FARGO,ND58103
45-0226714 		LT CARE ND 501(C)(3) 9 CHI
 
Yes
 
(124) VISITING NURSE ASSOCIATION OF SAINT CLARE'S

191 WOODPORT ROAD

SPARTA,NJ07871
22-1768334 		HOME HEALTH NJ 501(C)(3) 9 SCHS
 
Yes
 
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2010
Schedule R (Form 990) 2010
Page 2
Part III
Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.)
(a)
Name, address, and EIN of
related organization



 		(b)
Primary activity




 		(c)
Legal
domicile
(state or foreign
country)


 		(d)
Direct controlling
entity



 		(e)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(f)
Share of total income




 		(g)
Share of end-of-year
assets



 		(h)
Disproprtionate allocations?




 		(i)
Code V—UBI
amount in box 20 of
Schedule K-1
(Form 1065)
 		(j)
General or
managing
partner?



 		(k)
Percentage
ownership
Yes No Yes No
(1) AUDUBON LAND COMPANY LLC

5390 N ACADEMY BLVD SUITE 300
COLORADO SPRINGS,CO80918
84-1513085 		REAL ESTATE CO THC
  		RELATED -157,673 14,390,550   No 0   No 50.1 %
(2) AVANTAS LLC

1207 SOUTH 13 STREET
OMAHA,NE68108
39-2045003 		HEALTHCARE NE AHMH
  		UNRELATED       No     No 95 %
(3) BERYWOOD OFFICE PROPERTIES LLC

400 BERYWOOD TRAIL
CLEVELAND,TN37312
62-1875199 		PHYS OFFICE TN MHCS
  		RELATED       No   Yes   63 %
(4) BLUEGRASS REGIONAL IMAGING CENTER

1218 SOUTH BROADWAY SUITE 310
LEXINGTON,KY40504
61-1386736 		DIAGNOSTIC KY SJ HOSPITAL LEX
  		RELATED       No     No 65 %
(5) CENTRAL NEBRASKA HOME CARE SERVICES

PO BOX 1146-4510 SECOND AVENUE
KEARNEY,NE68848
47-0692112 		HEALTHCARE SRVC NE HSE INC
  		RELATED -99,941 1,021,498   No -48,712 Yes   100 %
(6) CENTRAL NEBRASKA REHAB SERVICE

3004 W FAIDLEY AVE
GRAND ISLAND,NE68802
81-0653461 		PHYSICAL THERAPY NE CHI
  		RELATED 1,857,991 2,262,775   No 0   No 51 %
(7) CHI OPERATING INVESTMENT PROGRAM LP

198 INVERNESS DRIVE WEST
ENGLEWOOD,CO80112
47-0727942 		INVESTMENTS CO CHI
  		UNRELATED 139,679,805 2,069,974,790   No 371,292 Yes   100 %
(8) HEALTHCARE SUPPORT SERVICES

PO BOX 9804
GRAND ISLAND,NE68802
72-1546196 		LAUNDRY NE CHI
  		RELATED 196,124 3,913,481   No -58,436   No 100 %
(9) NORTH RIVER SURGERY CENTER LLC

2209 WILDWOOD AVENUE
SHERWOOD,AR72120
71-0799771 		AMBUL SURG CTR AR SVIMC
  		RELATED 198,313 1,758,688   No 0   No 57.45 %
(10) ORTHOCOLORADO LLC

11650 WEST 2ND PLACE
LAKEWOOD,CO80255
37-1577105 		ORTHO HOSPITAL CO THC
  		RELATED -3,249,314 10,905,384   No 0   No 60 %
(11) PENINSULA RADIATION ONCOLOGY

314 MARTIN LUTHER KING JR WAY 11
TACOMA,WA98405
87-0808610 		HEALTHCARE SRVC WA FHS
  		RELATED 131,195 3,052,504   No 0   No 60 %
(12) PENRAD IMAGING

1139 KELLY JOHNSON BLVD
COLORADO SPRINGS,CO80920
84-1072619 		MEDICAL IMAGING CO THC
  		RELATED 1,857,228 5,457,224   No 0   No 70 %
(13) RUXTON SURGICENTER LLC

8322 BELLONA AVENUE SUITE 201
BALTIMORE,MD21204
52-2095835 		SURGERY CENTER MD SJMC
  		RELATED       No   Yes   51 %
(14) SAINT JOSEPH - SCA HOLDINGS LLC

424 LEWIS HARGETT CIRCLE STE 160
LEXINGTON,KY40503
45-3801157 		OP SURGERY DE SJHS
  		RELATED 0 0   No 0   No 51 %
(15) ST ANTHONY REGIONAL MTN CANCER CENTER

4231 W 16TH AVENUE
DENVER,CO80112
37-1568013 		CANCER CENTER CO THC
  		RELATED -290,552 0   No 0   No 51 %
(16) ST FRANCIS LAND COMPANY

5390 N ACADEMY BLVD SUITE 300
COLORADO SPRINGS,CO80918
26-3134100 		REAL ESTATE CO THC
  		RELATED -180,979 14,886,022   No 0   No 51 %
(17) ST FRANCIS MEDICAL CENTER ASSOCIATES

1717 SOUTH J STREET
TACOMA,WA98405
91-1352698 		MED. OFFICE WA FHS
  		RELATED 116,948 1,652,280   No 0   No 54 %
(18) ST JOSEPH-PAML LLC

424 LEWIS HARGETT CIRCLE STE 160
LEXINGTON,KY40503
45-2116736 		MGMT SERVICES KY SJHS
  		RELATED 0 0   No 0 Yes   62.5 %
(19) SUPERIOR MEDICAL IMAGING LLC

5000 NORTH 26TH STREET
LINCOLN,NE68521
26-2884555 		OP DIAGNOSTICS NE SERMC
  		RELATED       No     No 51 %
(20) SURGERY CENTER OF LEXINGTON LLC

1451 HARRODSBURG ROAD
LEXINGTON,KY40504
62-1179539 		SURGERY CENTER DE SJHS
  		RELATED 808,840 4,236,901   No 0   No 51 %
Part IV
Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.)
(a)
Name, address, and EIN of related organization



 		(b)
Primary activity



 		(c)
Legal domicile
(state or
foreign
country)
 		(d)
Direct controlling
entity


 		(e)
Type of entity
(C corp, S corp,
or trust)

 		(f)
Share of total income



 		(g)
Share of
end-of-year
assets

 		(h)
Percentage
ownership
(1) ALTERNATIVE INSURANCE MANAGEMENT SERVICES
3900 OLYMPIC BOULEVARD SUITE 400
ERLANGER,KY41018
84-1112049 		MANAGEMENT SERVICES CO CHI
  		C CORPORATION 0 3,267,441 100 %
(2) AMERICAN NURSING CARE
1700 EDISON DRIVE
MILFORD,OH45150
31-1085414 		HOME HEALTH OH CHS
  		C CORPORATION 1,778,617 44,470,358 100 %
(3) AMERIMED INC
1700 EDISON DRIVE
MILFORD,OH45150
31-1158699 		HOME HEALTH OH ANC
  		C CORPORATION 2,395,230 11,869,657 100 %
(4) CADUCEUS MEDICAL ASSOCIATES INC
6028 SHALLOWFORD ROAD SUITE D
CHATTANOOGA,TN37422
62-1570736 		HEALTHCARE TN MHCS
  		C CORPORATION 0 1,008 100 %
(5) CAPTIVE MANAGEMENT INITIATIVES
PO BOX 10073 APO
GEORGETOWN,GEORGETOWN, GRAND CAYMANKY1-1001
CJ
98-0663022 		CAPTIVE MANAGEMENT CJ CHI
  		C CORPORATION 0 0 100 %
(6) CENTER FOR TRANSLATIONAL RESEARCH
198 INVERNESS DRIVE WEST
ENGLEWOOD,CO80112
27-2269511 		HEALTHCARE CO CHI
  		C CORPORATION -2,247,962 1,668,589 100 %
(7) CENTRAL KANSAS HEALTH SERVICES ASSOCIATION
3515 BROADWAY
GREAT BEND,KS67530
48-1042853 		MEDICAL EQUIPMENT KS CKMC
  		C CORPORATION 0 0 100 %
(8) CGH REALTY COMPANY INC
215 N 12TH ST
READING,PA19603
23-2326801 		REAL ESTATE PA SJHM
  		C CORPORATION 1,007 42,415 100 %
(9) COMCARE SERVICES
4231 W 16TH AVENUE
DENVER,CO80204
84-0904813 		INACTIVE CO CHIC
  		C CORPORATION 0 0 100 %
(10) CONSOLIDATED HEALTH SERVICES
1700 EDISON DRIVE
MILFORD,OH45150
31-1378212 		HOME HEALTH OH CHI
  		C CORPORATION 0 11,595,125 100 %
(11) DAVID DEYLE CHARITABLE REMAINDER UNITRUST
PO BOX 1810
KEARNEY,NE68848
47-6192395 		INVESTMENTS NE GSHF
  		TRUST 4,880 166,425 100 %
(12) DES MOINES MEDICAL CENTER INC
1111 6TH AVENUE
DES MOINES,IA50314
42-0837382 		REAL ESTATE IA CHI-IA CORP
  		C CORPORATION 0 1,253,452 92.98 %
(13) FIRST INITIATIVES INSURANCE LTD
PO BOX 10073 APO
GEORGETOWN,GEORGETOWN, GRAND CAYMANKY1-1001
CJ
98-0203038 		INSURANCE CJ CHI
  		C CORPORATION 0 0 100 %
(14) FRANCISCAN SERVICES INC
198 INVERNESS DRIVE WEST
ENGLEWOOD,CO80112
23-2487967 		HEALTHCARE CO CHI
  		C CORPORATION -507,578 11,914,284 100 %
(15) GOOD SAMARITAN OUTREACH SERVICES
PO BOX 1990
KEARNEY,NE68848
47-0659440 		MEDICAL CLINIC NE CHI NEBRASKA
  		C CORPORATION -2,921,063 355,110 100 %
(16) HAROLD W RASE 1995 CHARITABLE UNITRUST
30 WEST 7TH STREET
DICKINSON,ND58601
45-6090420 		INVESTMENTS ND SJHHC
  		TRUST 1,240 21,553 100 %
(17) HAROLD W RASE 1996 CHARITABLE UNITRUST
30 WEST 7TH STREET
DICKINSON,ND58601
20-6037112 		INVESTMENTS ND SJHHC
  		TRUST 900 15,495 100 %
(18) HAROLD W RASE 1997 CHARITABLE UNITRUST
30 WEST 7TH STREET
DICKINSON,ND58601
20-6037104 		INVESTMENTS ND SJHHC
  		TRUST 1,025 20,261 100 %
(19) HAROLD W RASE 1999 CHARITABLE UNITRUST
30 WEST 7TH STREET
DICKINSON,ND58601
20-6037099 		INVESTMENTS ND SJHHC
  		TRUST 1,313 25,027 100 %
(20) HEALTH SYSTEMS ENTERPRISES INC
PO BOX 1990
KEARNEY,NE68848
47-0664558 		MANAGEMENT NE GSH
  		C CORPORATION 25,289 1,443,049 100 %
(21) HEALTHCARE MGMT SERVICES ORG INC
1149 MARKET ST
TACOMA,WA98402
91-1865474 		HEALTH ORG. WA FHS
  		C CORPORATION 0 0 100 %
(22) JAMES & HENRIETTA NISTLER UNITRUST
30 WEST 7TH STREET
DICKINSON,ND58601
20-6021899 		INVESTMENTS ND SJHHC
  		TRUST -16,708 41,455 100 %
(23) JEANNE DEYLE CHARITABLE REMAINDER UNITRUST
PO BOX 1810
KEARNEY,NE68848
47-6192398 		INVESTMENTS NE GSHF
  		TRUST 4,880 166,320 100 %
(24) JOSEPH A SCHUSTER ANNUITY TRUST #1
400 UNIVERSITY AVENUE
DES MOINES,IA50314
42-1195122 		INVESTMENTS IA MFDM
  		TRUST 18,924 441,488 100 %
(25) LODESCA MILLER CHARITABLE REMAINDER UNITRUST
PO BOX 1810
KEARNEY,NE68848
47-6186933 		INVESTMENTS NE GSHF
  		TRUST 3,387 86,367 100 %
(26) MEDQUEST
1301 15TH AVENUE WEST
WILLISTON,ND58801
45-0392137 		SALE OF DME ND MH OF WILLISTON
  		C CORPORATION 9,852 962,554 100 %
(27) MERCY HEALTH SERVICES CORPORATION
2727 MCCLELLAND BLVD
JOPLIN,MO64804
43-1457881 		DME MO ST JOHN'S RMC
  		C CORPORATION -1,533,371 1,369,083 100 %
(28) MERCY PARK APARTMENTS LTD
1111 6TH AVENUE
DES MOINES,IA50314
42-1202422 		HOUSING IA CHI-IA CORP
  		C CORPORATION 264,489 1,796,053 100 %
(29) MERCY SERVICES CORP
2700 STEWART PARKWAY
ROSEBURG,OR97470
93-0824308 		RETAIL SALES OR MMC
  		C CORPORATION -690,267 954,798 100 %
(30) MOUNTAIN MANAGEMENT SERVICES INC
6028D SHALLOWFORD ROAD
CHATTANOOGA,TN37422
62-1570739 		MGMT SVC ORG TN MHCS
  		C CORPORATION -386,020 4,667,998 100 %
(31) NAZARETH ASSURANCE COMPANY
76 ST PAUL STREET SUITE 500
BURLINGTON,VT05401
03-0304831 		INSURANCE VT CHI
  		C CORPORATION -379 123,535 100 %
(32) PATIENT TRANSPORT SERVICES INC
1700 EDISON DRIVE
MILFORD,OH45150
31-1100798 		HOME HEALTH OH ANC
  		C CORPORATION 662,425 5,325,941 100 %
(33) PHYSICIAN HEALTH SYSTEM NETWORK
1149 MARKET ST
TACOMA,WA98402
91-1746721 		HEALTH ORG. WA FHS
  		C CORPORATION 0 0 100 %
(34) RAY & SHIRLEY DAVID 1999 UNITRUST
30 WEST 7TH STREET
DICKINSON,ND58601
20-6037077 		INVESTMENTS ND SJHHC
  		TRUST 1,250 24,194 100 %
(35) ROBERT & WANDA CHARITABLE REMAINDER UNITRUST
PO BOX 1810
KEARNEY,NE68848
26-6191916 		INVESTMENTS NE GSHF
  		TRUST 13,030 537,775 100 %
(36) SAINT CLARE''S PRIMARY CARE INC
66 FORD ROAD
DENVILLE,NJ07834
22-2441202 		BILLING SERVICES NJ SCCC
  		C CORPORATION -342,970 2,177,166 100 %
(37) SAMARITAN FAMILY CARE INC
40 W FOURTH ST 1700
DAYTON,OH45402
31-1299450 		HEALTHCARE OH SHP
  		C CORPORATION     100 %
(38) SJH SERVICES CORPORATION
198 INVERNESS DRIVE WEST
ENGLEWOOD,CO80112
23-2307408 		HEALTHCARE CO FSI
  		C CORPORATION -518,360 3,180,100 100 %
(39) SJL PHYSICIAN MANAGEMENT SERVICES INC
424 LEWIS HARGETT CR 160
LEXINGTON,KY40503
27-0164198 		MANAGEMENT KY SJHS
  		C CORPORATION 0 0 100 %
(40) ST ANTHONY DEVELOPMENT COMPANY
1415 SOUTHGATE
PENDLETON,OR97801
93-1216943 		ATHLETIC CLUB OR ST ANTHONY H
  		C CORPORATION 53,891 3,007,554 100 %
(41) ST VINCENT COMMUNITY HEALTH SERVICES INC
TWO ST VINCENT CIRCLE
LITTLE ROCK,AR72205
71-0710785 		HEALTHCARE AR SVIMC
  		C CORPORATION 2,309,129 14,049,375 100 %
(42) ST JOSEPH DEVELOPMENT COMPANY
1717 SOUTH J STREET
TACOMA,WA98405
91-1480569 		RENTAL WA FSI
  		C CORPORATION -36,395 12,168,022 100 %
(43) ST JOSEPH OFFICE PARK ASSOCIATION
1401 HARRODSBURG ROAD BLDG B70
LEXINGTON,KY40504
61-1079899 		MANAGEMENT KY SJHS
  		C CORPORATION 16,644 882,139 85 %
(44) TOM DEYLE CHARITABLE REMAINDER UNITRUST
PO BOX 1810
KEARNEY,NE68848
47-6192393 		INVESTMENTS NE GSHF
  		TRUST 4,884 166,321 100 %
(45) TOWSON MANAGEMENT INC
7601 OSLER DRIVE
TOWSON,MD21204
52-1710750 		MANAGEMENT SERVICES MD FSI
  		C CORPORATION -469,016 498,393 100 %
Schedule R (Form 990) 2010
Schedule R (Form 990) 2010
Page 3
Part V
Transactions With Related Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35, 35A, or 36.)
Note. Complete line 1 if any entity is listed in Parts II, III or IV.
Yes
No
1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a Receipt of (i) interest (ii) annuities (iii) royalties (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .
1a
 
No
b Gift, grant, or capital contribution to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
Yes
 
c Gift, grant, or capital contribution from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c
Yes
 
d Loans or loan guarantees to or for other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1d
 
No
e Loans or loan guarantees by other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1e
 
No
f Sale of assets to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
No
g Purchase of assets from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Exchange of assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Lease of facilities, equipment, or other assets to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
Yes
 
j Lease of facilities, equipment, or other assets from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
 
No
k Performance of services or membership or fundraising solicitations for other organization(s) . . . . . . . . . . . . . . . . . . . . . .
1k
 
No
l Performance of services or membership or fundraising solicitations by other organization(s) . . . . . . . . . . . . . . . . . . . . . .
1l
Yes
 
m Sharing of facilities, equipment, mailing lists, or other assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1m
 
No
n Sharing of paid employees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1n
 
No
o Reimbursement paid to other organization for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
Yes
 
p Reimbursement paid by other organization for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
 
No
q Other transfer of cash or property to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
 
No
r Other transfer of cash or property from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
 
No
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of other organization 		(b)
Transaction
type(a-r) 		(c)
Amount involved 		(d)
Method of determining amount involved
(1) MERCY MEDICAL CENTER

 B 380,577 FMV
(1)
(2)
(3)
(4)
(5)
(6)
Schedule R (Form 990) 2010
Schedule R (Form 990) 2010
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 37.)
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity 		(b)
Primary activity 		(c)
Legal domicile
(state or foreign
country) 		(d)
Are all
partners
section
501(c)(3)
organizations? 		(e)
Share of
end-of-year
assets 		(f)
Disproprtionate allocations? 		(g)
Code V—UBI
amount in box
20 of Schedule K-1
(Form 1065) 		(h)
General or
managing
partner?
Yes No Yes No Yes No






























Schedule R (Form 990) 2010
Schedule R (Form 990) 2010
Page 5
Part VII
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule R (see instructions).
Identifier Return Reference Explanation
Additional Data


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