Department of the Treasury Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
LAWRENCE GENERAL HOSPITAL
Employer identification number
04-2103586
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization?
................
11g(i)
(ii)
a family member of a person described in (i) above?
......................
11g(ii)
(iii)
a 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
h
Provide the following information about the supported organization(s).
(i) Name of supported organization
(ii) EIN
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions))
(iv) Is the organization in col. (i) listed in your governing document?
(v) Did you notify the organization in col. (i) of your support?
(vi) Is the organization in col. (i) organized in the U.S.?
(vii) Amount of support?
Yes
No
Yes
No
Yes
No
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the
organization failed to qualify under Part III. If the organization fails to
qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3
The value of services or facilities furnished by a governmental unit to the organization without charge..
4
Total. Add lines 1 through 3..
5
The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included
on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6
Public Support. Subtract line 5 from line 4.
Section B. Total Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
7
Amounts from line 4..
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
9
Net income from unrelated business activities, whether or not the business is regularly carried on..
10
Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..
11
Total support (Add lines 7 through 10).
12
Gross receipts from related activities, etc. (See instructions.)
..................
12
13
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here..........................................
Section C. Computation of Public Support Percentage
14
Public Support Percentage for 2010 (line 6 column (f) divided by line 11 column (f))
.........
14
15
Public Support Percentage for 2009 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2010.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
......................
b
33 1/3% support test—2009.
If the organization did not check the box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2010.
If the organization did not check a box on line 13, 16a, or 16b and line 14
is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported
organization
..................................................
b
10%-facts-and-circumstances test—2009.
If the organization did not check a box on line 13, 16a, 16b, or 17a and line
15 is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported organization
..............................................
18
Private Foundation
If the organization did not check a box on line 13, 16a, 16b, 17a or 17b, check this box and see
instructions
...................................................
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization
failed to qualify under Part II. If the organization fails to qualify under
the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2
Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
6
Total. Add lines 1 through 5.
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
b
Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c
Add lines 7a and 7b..
8
Public Support (Subtract line 7c from line 6.)
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
9
Amounts from line 6...
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
13
Total support (Add lines 9, 10c, 11 and 12.).
14
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public Support Percentage for 2010 (line 8 column (f) divided by line 13 column (f))
.........
15
16
Public support percentage from 2009 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2010 (line 10c column (f) divided by line 13 column (f))
......
17
18
Investment income percentage from 2009 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2010.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3% and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
..........
b
33 1/3% support tests—2009.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
....
20
Private Foundation
If the organization did not check a box on line 14, 19a or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 4
Part IV
Supplemental Information.
Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
Explanation
Schedule A (Form 990 or 990-EZ) 2010
Additional Data
Software ID:
Software Version:
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
LAWRENCE GENERAL HOSPITAL
Employer identification number
04-2103586
Identifier
Return Reference
Explanation
FORM 990, PART VI, SECTION B, LINE 11
FORM 990 IS PREPARED BY THE ASSISTANT CONTROLLER OF THE HOSPITAL AND REVIEWED BY THE CONTROLLER AND CFO. THE HOSPITAL'S EXTERNAL ACCOUNTANT ALSO REVIEWS THE FORM 990. ONCE FORM 990 IS COMPLETED, THE FORM AND ALL ITS ACCOMPANYING SCHEDULES ARE MADE AVAILABLE TO THE HOSPITAL'S BOARD OF TRUSTEES VIA A SECURE INTERNET PORTAL FOR REVIEW. THE CONTROLLER AND CFO ARE MADE AVAILABLE TO FACILITATE THE REVIEW AND ANSWER ANY QUESTIONS REGARDING THE FORM THE TRUSTEES MAY HAVE,
FORM 990, PART VI, SECTION B, LINE 12C
ON AN ANNUAL BASIS, THE HOSPITAL DISTRIBUTES A CONFLICT OF INTEREST POLICY TO THE BOARD OF TRUSTEES. THE TRUSTEES ARE REQUIRED TO DISCLOSE IN WRITING, ANY POTENTIAL CONFLICT THAT THEY ARE AWARE OF.
FORM 990, PART VI, SECTION B, LINE 15
THE CEO'S ANNUAL COMPENSATION IS REVIEWED AND APPROVED BY THE BOARD OF TRUSTEES. THE COMPENSATION FOR THE CFO, COO, AND SENIOR MANAGEMENT ARE DETERMINED BY THE CEO AND REVIEWED BY THE BOARD OF TRUSTEES. INDEPENDENT SURVEYS ARE ALSO PEFORMED TO DETERMINE SALARY REASONABLENESS.
FORM 990, PART VI, SECTION C, LINE 18
THE HOSPITAL MAKES ALL DOCUMENTS INCLUDING FORM 990 AVAILABLE TO THE GENERAL PUBLIC UPON REQUEST.
FORM 990, PART VI, SECTION C, LINE 19
THE HOSPITAL MAKES ALL DOCUMENTS INCLUDING COPIES OF ITS BY-LAWS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE GENERAL PUBLIC UPON REQUEST.
FORM 990 PART IX LINE 24(F)
CHEMICAL REAGANTS (PROGRAM EXPENSES) = $2,293,087 SURGICAL SUPPLIES (PROGRAM EXPENSES) = $1,441,327 PROTHESES (PROGRAM EXPENSES) = $948,239 OTHER (PROGRAM EXPENSES) = $11,690,790 TOTAL PROGRAM EXPENSES = $16,373,443 FOOD (MANAGEMENT EXPENSES) = $589,510 LOAN FEES (MANAGEMENT EXPENSES) = $332,158 OTHER (MANAGEMENT EXPENSES) = $4,040,183 TOTAL MANAGEMENT EXPENSES = $4,961,851 OTHER (FUNDRAISING EXPENSES) = $29,296 TOTAL OTHER MANAGEMENT EXPENSES = $29,296
CHANGES IN NET ASSETS OR FUND BALANCES:
FORM 990, PART XI, LINE 5:
NET UNREALIZED LOSSES ON INVESTMENTS: -603,999. NET ASSET TRANSFER TO COMMUNITY MEDICAL ASSOCIATES, INC. -830,000. CONTRIBUTIONS RELATED TO EHR PROJECT -412,000. CHANGE IN VALUE OF NET ASSETS HELD BY LGH CHARITABLE TRUST 668,000. INCREASE IN TEMPORARILY RESTRICTED NET ASSETS 12,711,000. CAPITAL GRANT 228,000. OTHER -5,828. TOTAL TO FORM 990, PART XI, LINE 5: 11,755,173.
LOANS TO INTERESTED PERSONS
SCHEDULE L, PART II
AMOUNTS DUE FROM CURRENT AND FORMER OFFICERS PERTAIN TO SPLIT DOLLAR LIFE INSURANCE POLICIES OF THE RESPECTED INDIVIDUALS. THESE POLICIES WERE ORIGINATED AT VARIOUS TIMES DURING THE INSURED'S EMPLOYMENT WITH LAWRENCE GENERAL HOSPITAL. THE CORRESPONDING POLICY PREMIUMS WERE FUNDED BY THE EMPLOYER AS AN EMPLOYEE BENEFIT. IN ACCORDANCE WITH IRS NOTICE 2002-8, TREASURY REGULATION 1.61-22 AND TREASURY REGULATION 1.7872-15, THESE PAYMENTS REQUIRE CLASSIFICATION AS LOANS DUE FROM THE INSURED. THESE LOAN BALANCES ARE REFLECTED ON THE BALANCE SHEET AND SCHEDULE L AT THE NET PRESENT VALUE OF PREMIUMS PAID. THE ACTUAL BALANCE DUE IS THE LOWER OF THE DISCOUNTED CASH SURRENDER VALUE OR DISCOUNTED CUMULATIVE PREMIUMS PAID, WHICH TOTALED $934,500 AND $18,484 FOR GERALD FOLEY AND DIANNE ANDERSON, RESPECTIVELY AT SEPTEMBER 30, 2010. THE ABOVE AMOUNTS RECEIVABLE FROM CURRENT AND FORMER OFFICERS REPRESENTS SPLIT DOLLAR POLICY AGREEMENT LOANS BETWEEN THE ORGANIZATION AND THE INDIVIDUALS. THESE AGREEMENTS WERE PUT IN PLACE AT VARIOUS TIMES DURING THE EMPLOYEE'S EMPLOYMENT IN THE ORGANIZATION. THE MATURITY AND REPAYMENT OF THE LOANS WILL BE AT THE INDIVIDUALS MORTALITY WITH THE PROCEEDS FROM A LIFE INSURANCE POLICY. THE ORGANIZATION UTILIZED THE AFR INTEREST RATES AND THE LOANS ARE SECURED BY THE ASSIGNMENT OF THE LIFE INSURANCE BENEFIT ON THE INDIVIDUAL POLICY. THE LOANS ARE VALUED AT THE LOWER OF THE DISCOUNTED CASH SURRENDER VALUE OR DISCOUNTED CUMULATIVE PREMIUMS PAID OF THE INDIVIDUAL'S POLICY. THESE AMOUNTS WERE REPORTED AS OTHER ASSETS IN PRIOR 990'S.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.