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 Hospital of Valley City
 
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
570 Chautauqua Blvd
 
Room/suite
City or town, state or country, and ZIP + 4
Valley City, ND58072
D Employer identification number

45-0226553
E Telephone number

G Gross receipts $ 13,246,049
F Name and address of principal officer:
Keith Heuser
570 CHAUTAUQUA BLVD
Valley City,ND58072
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
www.mercyhospitalvalleycity.org
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: 1928
M State of legal domicile: ND
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: The mission of Mercy Hospital and Catholic Health Initiatives is to nurture the healing ministry of the church by bringing it new life, energy and viability in the 21st century.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) .... 3 8
4 Number of independent voting members of the governing body (Part VI, line 1b) .... 4 7
5 Total number of individuals employed in calendar year 2010 (Part V, line 2a) ... 5 185
6 Total number of volunteers (estimate if necessary) .... 6 30
7a Total unrelated business revenue from Part VIII, column (C), line 12 .. 7a 979
b Net unrelated business taxable income from Form 990-T, line 34 .. 7b  
Revenues; Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 190,175 424,271
9 Program service revenue (Part VIII, line 2g) ......... 11,018,043 11,457,847
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 669,246 1,041,283
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 150,164 317,633
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 12,027,628 13,241,034
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 21,657 6,957
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) 6,638,666 6,477,290
16a Professional fundraising fees (Part IX, column (A), line 11e).... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet32,163    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f).... 4,853,651 5,414,108
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 11,513,974 11,898,355
19 Revenue less expenses. Subtract line 18 from line 12...... 513,654 1,342,679
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............ 18,918,694 21,468,156
21 Total liabilities (Part X, line 26)............ 1,116,865 889,355
22 Net assets or fund balances. Subtract line 21 from line 20 ..... 17,801,829 20,578,801
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 $ 10,148,739 including grants of $ 6,957 ) (Revenue $ 11,457,847 )
SEE SCHEDULE H
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$ 10,148,739
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 IClick to see attachment..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities? If “Yes,” complete Schedule C,
Part IIClick to see attachment.........................
4
Yes
 
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 IClick to see attachment.......................
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 IIClick to see attachment...
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
 
No
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 IVClick to see attachment...................
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 VClick to see attachment
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.Click to see attachment
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.Click to see attachment
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 Click to see attachment
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 I
17
 
No
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..........
18
 
No
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..... Click to see attachment
20a
Yes
 
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. ..... Click to see list of attachments
20b
Yes
 
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..... Click to see attachment
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 MClick to see attachment
29
Yes
 
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M............ Click to see attachment
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If “Yes,” complete Schedule N,
Part I........................... Click to see attachment
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........ Click to see attachment
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........... Click to see attachment
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 VIClick to see attachment
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
20
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
185
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
Yes
 
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
 
 
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
8
b
Enter the number of voting members included in line 1a, above, who are independent .................
1b
7
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
Yes
 
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
Yes
 
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
Beth Smith
570 Chautauqua Blvd
Valley City,ND58072
(701) 845-6583
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) PHILLIP MUELLER
BOARD MEMBER
 1.0 X                
(2) SR STELLA OLSON
CHAIR
 1.0 X   X            
(3) CURTIS VANDYKE
VICE CHAIR
 1.0 X   X            
(4) SR PAULA RINGUETTE
BOARD MEMBER
 1.0 X                
(5) JEFFREY DROP
SVP DIVISION OFFICER
 1.0 X             684,808 74,336
(6) SHARON SCHMALZ
BOARD MEMBER
 1.0 X                
(7) MARK OBERLANDER
BOARD MEMBER
 1.0 X                
(8) Margaret Dahlberg
Board Member
 1.0 X                
(9) BETHANY SMITH
TREASURER/CONTROLLER
 40.0     X       50,190   9,567
(10) CAMILLE SETTELMEYER
VP OF PATIENT CARE
 40.0     X       96,649   6,450
(11) KEITH HEUSER
ADMINISTRATOR
 40.0     X         211,307 41,633
(12) RUTH LARSON
BOARD SECRETARY
 40.0     X       38,560   2,474
(13) Russell Kauffman
Physician's Assistant
 45.0         X   128,816   17,118
(14) Joan Stoltz
Physician's Assistant
 40.0         X   116,573   13,570
(15) CLARK KRUTA
CRNA
 40.0         X   184,059   22,469




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 614,847 896,115 187,617
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 in reportable compensation from the organizationMediumBullet3
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
 
No
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 $100,000 in compensation from the organization MediumBullet0
Form 990 (2010)
Form 990 (2010)
Page 9
Part VIII
Statement of Revenue
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, gifts, grants and other similar amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c  
d Related organizations...1d 79,539
e Government grants (contributions)1e 78,842
f All other contributions, gifts, grants, and
similar amounts not included above1f 		265,890
g Noncash contributions included in lines 1a-1f:$ 64,268
h Total. Add lines 1a-1f.......MediumBullet 424,271
Program Service Revenue Business Code
2a Patient Services 900,099 11,573,840 11,573,840    
b Equity changes of unconsolidated orgs 900,099 -136,000 -136,000    
c Rental Income 900,099 20,007 20,007    
d
e
f All other program service revenue .        
g Total. Add lines 2a–2f........MediumBullet 11,457,847
Other Revenue 3 Investment income (including dividends, interest
and other similar amounts).....MediumBullet 325,778   979 324,799
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)    
d Net rental income or (loss).......MediumBullet        
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory 720,520 0
b Less: cost or other basis and sales expenses 0 5,015
c Gain or (loss) 720,520 -5,015
d Net gain or (loss)..........MediumBullet 715,505     715,505
8a Gross income from fundraising events (not including
$  
of contributions reported on line 1c). See Part IV, line 18 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from fundraising events..MediumBullet 0    
9a Gross income from gaming activities.
See Part IV, line 19 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from gaming activities...MediumBullet 0      
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 Insurance 524,298 180,593     180,593
b Services Sold 900,099 53,038     53,038
c Cafeteria 722,100 47,013     47,013
d All other revenue .... 36,989     36,989
e Total. Add lines 11a–11d ......MediumBullet 317,633
12 Total revenue. See Instructions....MediumBullet 13,241,034 11,457,847 979 1,357,937
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 6,957 6,957
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 .... 207,212 63,308 143,904  
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 4,999,342 4,409,122 564,187 26,033
8 Pension plan contributions (include section 401(k) and section 403(b) employer contributions) .... 301,189 258,761 40,975 1,453
9 Other employee benefits ....... 594,094 510,405 80,823 2,866
10 Payroll taxes ........... 375,453 322,564 51,078 1,811
11 Fees for services (non-employees):        
a Management ...... 0      
b Legal ......... 167   167  
c Accounting ........... 0      
d Lobbying ........... 0      
e Professional fundraising. See Part IV, line 17.. 0  
f Investment management fees ...... 0      
g Other .......... 2,008,165 1,456,739 551,426  
12 Advertising and promotion .... 0      
13 Office expenses ....... 1,287,730 1,196,366 91,364  
14 Information technology ...... 0      
15 Royalties .. 0      
16 Occupancy ........... 186,746 162,800 23,946  
17 Travel ............ 59,388 41,139 18,249  
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 ....... 495,336 495,336    
22 Depreciation, depletion, and amortization ..... 531,508 470,067 61,441  
23 Insurance .............. 24,691 24,691    
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 Bad debts 556,458 556,458    
b Repairs and maintenance 125,666 120,656 5,010  
c Education 33,013 24,778 8,235  
d Dues & subscriptions 34,487 20,655 13,832  
e Miscellaneous Expenses 70,753 7,937 62,816  
f All other expenses        
25 Total functional expenses. Add lines 1 through 24f 11,898,355 10,148,739 1,717,453 32,163
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 		       
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 .......... 6,861 1 917
2 Savings and temporary cash investments ....... 789,896 2 548,978
3 Pledges and grants receivable, net .........   3  
4 Accounts receivable, net ......... 1,362,135 4 1,776,028
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 .............. 224,803 8 261,692
9 Prepaid expenses and deferred charges ............ 21,755 9 21,369
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 10,402,297
b Less: accumulated depreciation. ..... 10b 7,493,735 3,147,311 10c 2,908,562
11 Investments—publicly traded securities ..........   11  
12 Investments—other securities. See Part IV, line 11 ...... 13,094,029 12 15,849,259
13 Investments—program-related. See Part IV, line 11 ..   13  
14 Intangible assets .........   14  
15 Other assets. See Part IV, line 11 ........... 271,904 15 101,351
16 Total assets. Add lines 1 through 15 (must equal line 34)... 18,918,694 16 21,468,156
Liabilities 17 Accounts payable and accrued expenses . 1,116,865 17 871,847
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..... 0 25 17,508
26 Total liabilities. Add lines 17 through 25..... 1,116,865 26 889,355
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 ..... 17,756,059 27 20,363,318
28 Temporarily restricted net assets ..... 45,770 28 215,483
29 Permanently restricted net assets .....   29  
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 ..... 17,801,829 33 20,578,801
34 Total liabilities and net assets/fund balances ..... 18,918,694 34 21,468,156
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
13,241,034
2
Total expenses (must equal Part IX, column (A), line 25) . . . . .
2
11,898,355
3
Revenue less expenses. Subtract line 2 from line 1 . . . .
3
1,342,679
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) . .
4
17,801,829
5
Other changes in net assets or fund balances (explain in Schedule O) . . . .
5
1,434,293
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
20,578,801
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:  
Software Version:  
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 Hospital of Valley City
 
Employer identification number

45-0226553
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)
 
 
(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
(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
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:  
Software Version:  
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 Hospital of Valley City
 
Employer identification number

45-0226553
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 Hospital of Valley City
  		Employer identification number

45-0226553
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 Hospital of Valley City
  		Employer identification number

45-0226553
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 Hospital of Valley City
  		Employer identification number

45-0226553
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:  
Software Version:  
SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service
Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527
SchCMd Bullet Complete if the organization is described below.
SchCMd Bullet Attach to Form 990 or Form 990-EZ. SchCMd Bullet See separate instructions.
OMB No. 1545-0047
2010
Open to Public
Inspection
If the organization answered “Yes,” to Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet Section 527 organizations: Complete Part I-A only.
If the organization answered “Yes,” to Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)) Complete Part II-A. Do not complete Part II-B.
Round Bullet Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered “Yes,” to Form 990, Part IV, Line 5 (Proxy Tax) or Form 990-EZ, Part V, line 35a (Proxy Tax), then
Round Bullet Section 501(c)(4), (5), or (6) organizations: Complete Part III.
Name of the organization
Mercy Hospital of Valley City
 
Employer identification number

45-0226553
Part I-A
Complete if the organization is exempt under section 501(c) or is a section 527 organization.

1
Provide a description of the organization's direct and indirect political campaign activities on behalf of or in opposition to candidates for public office in Part IV.
2
Political expenditures ....................................SchCMd Bullet
$  
3
Volunteer hours ........................................
 

Part I-B
Complete if the organization is exempt under section 501(c)(3).
1
Enter the amount of any excise tax incurred by the organization under section 4955 .........SchCMd Bullet
$  
2
Enter the amount of any excise tax incurred by organization managers under section 4955 ......SchCMd Bullet
$  
3
If the organization incurred a section 4955 tax, did it file Form 4720 for this year? ..............
4a
Was a correction made? .........................................
b
If "Yes," describe in Part IV.
Part I-C
Complete if the organization is exempt under section 501(c) except section 501(c)(3).
1
Enter the amount directly expended by the filing organization for section 527 exempt function activities SchCMd Bullet
$  
2
Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt funtion activities ....................................SchCMd Bullet

$  
3
Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b..SchCMd Bullet

$  
4
Did the filing organization file Form 1120-POL for this year? ..........................
5
Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.
(a) Name (b) Address (c) EIN (d) Amount paid from filing organization's funds. If none, enter -0-. (e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.










For Privacy Act and Paperwork Reduction Act Notice, see the instructions for Form 990.
Cat. No. 50084S
Schedule C (Form 990 or 990-EZ) 2010

Schedule C (Form 990 or 990-EZ) 2010
Page 2
Part II-A
Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).
A Check
B Check
Limits on Lobbying Expenditures
(The term "expenditures" means amounts paid or incurred.) 		(a) Filing
Organization's
Totals 		(b) Affiliated Group
Totals
1a Total lobbying expenditures to influence public opinion (grass roots lobbying) ......    
b Total lobbying expenditures to influence a legislative body (direct lobbying) .......    
c Total lobbying expenditures (add lines 1a and 1b) ...................    
d Other exempt purpose expenditures ........................    
e Total exempt purpose expenditures (add lines 1c and 1d) ...............    
f Lobbying nontaxable amount. Enter the amount from the following table in both
columns.		    
  If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:    
  Not over $500,00020% of the amount on line 1e.    
  Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.    
  Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.    
  Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.    
  Over $17,000,000$1,000,000.    
       
g Grassroots nontaxable amount (enter 25% of line 1f) .................    
h Subtract line 1g from line 1a. If zero or less, enter -0-. ................    
i Subtract line 1f from line 1c. If zero or less, enter -0-. ................    
j If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting
section 4911 tax for this year? ......................................

4-Year Averaging Period Under Section 501(h)
(Some organizations that made a section 501(h) election do not have to complete all of the five
columns below. See the instructions for lines 2a through 2f on page 4.)
Lobbying Expenditures During 4-Year Averaging Period
  Calendar year (or fiscal year
beginning in) 		(a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) Total
             
2a Lobbying non-taxable amount          
             
b Lobbying ceiling amount
(150% of line 2a, column(e)) 		         
             
c Total lobbying expenditures          
             
d Grassroots non-taxable amount          
             
e Grassroots ceiling amount
(150% of line 2d, column (e))		          
             
f Grassroots lobbying expenditures          
Schedule C (Form 990 or 990-EZ) 2010


Schedule C (Form 990 or 990-EZ) 2010
Page 3
Part II-B
Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).
(a)
Yes
No
(b)
Amount
1
During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:
a
Volunteers? .........................................
 
No
b
Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....
 
No
c
Media advertisements? ....................................
 
No
 
d
Mailings to members, legislators, or the public? .........................
 
No
 
e
Publications, or published or broadcast statements? .......................
 
No
 
f
Grants to other organizations for lobbying purposes? .......................
Yes
 
711
g
Direct contact with legislators, their staffs, government officials, or a legislative body? ........
 
No
 
h
Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......
 
No
 
i
Other activities? If "Yes," describe in Part IV ..........................
 
No
 
j
Total. lines 1c through 1i ...................................
711
2a
Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....
 
No
b
If "Yes," enter the amount of any tax incurred under section 4912 .................
 
c
If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....
 
d
If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? .......
 
No
Part III-A
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).
Yes
No
1
Were substantially all (90% or more) dues received nondeductible by members? ................
1
 
 
2
Did the organization make only in-house lobbying expenditures of $2,000 or less? ................
2
 
 
3
Did the organization agree to carryover lobbying and political expenditures from the prior year? ..........
3
 
 
Part III-B
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) if BOTH Part III-A, lines 1 and 2 are answered “No” OR if Part III-A, line 3 is answered “Yes”.
1
Dues, assessments and similar amounts from members .....................
1
 
2
Section 162(e) non-deductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).
a
Current year .........................................
2a
 
b
Carryover from last year ....................................
2b
 
c
Total ...........................................
2c
 
3
Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .
3
 
4
If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ................................
4
 
5
Taxable amount of lobbying and political expenditures (see instructions) ..............
5
 
Part IV
Supplemental Information
Complete this part to provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, line 5; and Part ll-B, line 1i.
Also, complete this part for any additional information.
Identifier Return Reference Explanation
LOBBYING ACTIVITIES EXPLANATION SCH C, PART II-B 1F THE HOSPITAL'S CONTROLLING ORGANIZATION, CATHOLIC HEALTH INITIATIVES, PAYS ANNUAL DUES TO THE AMERICAN HOSPITAL ASSOCIATION ("aha") AND CATHOLIC HEALTH ASSOCIATION ("CHA"), A PORTION OF WHICH IS ALLOCATED TO LOBBYING. IN ADDITION, THE HOSPITAL PAYS LOBBYING EXPENSES THROUGH THEIR NORTH DAKOTA HEALTH ASSOCIATION ("NDHA") DUES. THE AMOUNTS ALLOCATED FROM EACH ASSOCIATION ARE AS FOLLOWS: AHA: $71; CHA: $212 AND NDHA: $428.
Schedule C (Form 990 or 990EZ) 2010

Additional Data


Software ID:  
Software Version:  

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 Hospital of Valley City
 
Employer identification number

45-0226553
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 $  
(ii)
Assets included in Form 990, Part X ..............................SchDMd Bullet $  
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 .................   19,382 19,382
b Buildings ................   6,480,310 4,642,904 1,837,406
c Leasehold improvements ............        
d Equipment ................   3,827,901 2,776,855 1,051,046
e Other .................   74,704 73,976 728
Total. Add lines 1a-1e. (Column (d) should equal Form 990, Part X, column (B), line 10(c).)........SchDMdBullet 2,908,562
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    
(2)Closely-held equity interests    
(3)Other
(A) CHI OIP - Fixed Income 		7,518,010 F

(B) CHI OIP - Equity Securities 		8,331,249 F







Total. (Column (b) should equal Form 990, Part X, col.(B) line 12.)Small Bullet 15,849,259
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
INTERCOMPANY LIABILITIES 17,508








Total. (Column (b) should equal Form 990, Part X, col.(B) line 25.)Small Bullet 17,508
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  
2 Total expenses (Form 990, Part IX, column (A), line 25) ..................... 2  
3 Excess or (deficit) for the year. Subtract line 2 from line 1 ............. 3  
4 Net unrealized gains (losses) on investments .......................... 4  
5 Donated services and use of facilities ............................. 5  
6 Investment expenses ................................... 6  
7 Prior period adjustments .................................. 7  
8 Other (Describe in Part XIV) ................................. 8  
9 Total adjustments (net). Add lines 4 - 8 ............................. 9  
10 Excess or (deficit) for the year per financial statements. Combine lines 3 and 9 ......... 10  
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  
e Add lines 2a through 2d ..................... 2e  
3 Subtract line 2e from line 1..................... 3  
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  
c Add lines 4a and 4b....................... 4c  
5 Total Revenue. Add lines 3 and 4c. (This should equal Form 990, Part I, line 12.) ...... 5  
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  
e Add lines 2a through 2d...................... 2e  
3 Subtract line 2e from line 1..................... 3  
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  
c Add lines 4a and 4b....................... 4c  
5 Total expenses. Add lines 3 and 4c. (This should equal Form 990, Part I, line 18.) ...... 5  
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
FIN 48 (ASC 740) FOOTNOTE SCH D, PART X, Q. 2 Mercy Hospital of Valley City'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:  
Software Version:  




SCHEDULE H
(Form 990)
Department of the Treasury
Internal Revenue Service
Hospitals
MediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, question 20.
MediumBullet Attach to Form 990. MediumBullet See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
Mercy Hospital of Valley City
 
Employer identification number

45-0226553
Part I
Charity Care and Certain Other Community Benefits at Cost
Yes
No
1a
Does the organization have a charity care policy? If "No," skip to question 6a...........
1a
Yes
 
b
If "Yes," is it a written policy? .......................
1b
Yes
 
2
If the organization has multiple hospitals, indicate which of the following best describes application of the charity care policy to the various hospitals.
3
Answer the following based on the charity care eligibility criteria that applies to the largest number of the organization's patients.
a
Does the organization use Federal Poverty Guidelines (FPG) to determine eligibility for providing free care to low
income individuals? If "Yes," indicate which of the following is the FPG family income limit for eligibility for free care:
3a
 
No
b
Does the organization use FPG to determine eligibility for providing discounted care to low income individuals? If
"Yes," indicate which of the following is the family income limit for eligibility for discounted care: .....
3b
 
No
c
If the organization does not use FPG to determine eligibility, describe in Part VI the income based criteria for determining eligibility for free or discounted care. Include in the description whether the organization uses an asset test or other threshold, regardless of income, to determine eligibility for free or discounted care.
4
Does the organization's policy provide free or discounted care to the "medically indigent"? ......
4
Yes
 
5a
Does the organization budget amounts for free or discounted care provided under its charity care policy? ...
5a
Yes
 
b
If "Yes," did the organization's charity care expenses exceed the budgeted amount?.........
5b
 
No
c
If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discounted
care to a patient who was eligibile for free or discounted care?...............
5c
 
 
6a
Does the organization prepare an annual community benefit report?.............
6a
Yes
 
6b
If "Yes," does the organization make it available to the public? ..............
6b
Yes
 
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
Charity Care and Certain Other Community Benefits at Cost
Charity Care and
Means-Tested Government Programs		 (a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community benefit expense (d) Direct offsetting revenue (e) Net community benefit expense (f) Percent of total expense
a Charity care at cost (from
Worksheets 1 and 2) .. 		  141 124,465   124,465 1.100 %
b Unreimbursed Medicaid (from
Worksheet 3, column a) . 		           
c Unreimbursed costs—other means-tested government programs (from Worksheet 3, column b) ....            
dTotal Charity Care and
Means-Tested Government Programs ..... 		  141 124,465   124,465 1.100 %
Other Benefits
e Community health improvement
services and community
benefit operations (from
(Worksheet 4) .... 		37 16,377 149,745 3,909 145,836 1.290 %
f Health professions education
(from Worksheet 5) .. 		9 120 19,449   19,449 0.170 %
g Subsidized health services
(from Worksheet 6) .. 		           
h Research (from Worksheet 7)            
i Cash and in-kind contributions
to community groups
(from Worksheet 8) .. 		18 710 28,338   28,338 0.250 %
jTotal Other Benefits ... 64 17,207 197,532 3,909 193,623 1.710 %
kTotal. Add lines 7d and 7j. .. 64 17,348 321,997 3,909 318,088 2.810 %
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 2
Part II
Community Building Activities Complete this table if the organization conducted any community building activities.
(a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community building expense (d) Direct offsetting
revenue 		(e) Net community building expense (f) Percent of total expense
1 Physical improvements and housing            
2 Economic development 1 121 1,425   1,425 0.010 %
3 Community support 3 161 465   465  
4 Environmental improvements            
5 Leadership development and training for community members            
6 Coalition building 5 531 1,759   1,759 0.020 %
7 Community health improvement advocacy 2 395 1,000   1,000 0.010 %
8 Workforce development            
9 Other 1 559 6,400   6,400 0.060 %
10 Total 12 1,767 11,049   11,049 0.100 %
Part III
Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt Expense
Yes
No
1
Does the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................
1
 
No
2
Enter the amount of the organization's bad debt expense (at cost).....
2
397,867
3
Enter the estimated amount of the organization's bad debt expense (at cost) attributable to patients eligible under the organization's charity care policy ..
3
 
4
Provide in Part VI the text of the footnote to the organization's financial statements that describes bad debt expense. In addition, describe the costing methodology used in determining the amounts reported on lines 2 and 3, and rationale for including a portion of bad debt amounts as community benefit.
Section B. Medicare
5
Enter total revenue received from Medicare (including DSH and IME).....
5
6,507,791
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
6,235,112
7
Subtract line 6 from line 5. This is the surplus or (shortfall)........
7
272,679
8
Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.
Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.
Check the box that describes the method used:
Section C. Collection Practices
9a
Does the organization have a written debt collection policy? ...............
9a
Yes
 
b
If "Yes," does the organization's collection policy contain provisions on the collection practices to be followed for patients who are known to qualify for charity care or financial assistance? Describe in Part VI......
9b
Yes
 
Part IV
Management Companies and Joint Ventures
(a) Name of entity (b) Description of primary
activity of entity 		(c) Organization's
profit % or stock
ownership % 		(d) Officers, directors,
trustees, or key
employees' profit %
or stock ownership% 		(e) Physicians'
profit % or stock
ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 3
Part VFacility Information
Section A. Hospital Facilities
(list in order of size, measured by total revenue per facility, from largest to smallest)
How many hospital facilities did the organization operate during the tax year?1
Name and address 		Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital Research Facility ER-24Hours ER-Other Other (Describe)
1 Mercy Hospital
570 Chautauqua Blvd
Valley City,ND58072 		X X     X   X    
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 4
Part VFacility Information (continued)

Section B. Facility Policies and Practices.

(Complete a separate Section B for each of the hospital facilities listed in Part V, Section A)
Name of Hospital Facility:Mercy Hospital
Line Number of Hospital Facility (from Schedule H, Part V, Section A):1

Yes No
Community Health Needs Assessment (Lines 1 through 7 are optional for 2010)
1 During the tax year or any prior tax year, did the hospital facility conduct a community health needs assessment (“Needs Assessment”)? If “No,” skip to question 8. ..................... 1    
If “Yes,” indicate what the Needs Assessment describes (check all that apply):
a A definition of the community served by the hospital facility
b Demographics of the community
c Existing health care facilities and resources within the community that are available to respond to the health needs of the community
d How data was obtained
e The health needs of the community
f Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups
g The process for identifying and prioritizing community health needs and services to meet those needs
h The process for consulting with persons representing the community’s interests
i Information gaps that limit the hospital facility’s ability to assess all of the community’s health needs
j Other (describe in Part VI)
2 Indicate the tax year the hospital facility last conducted a Needs Assessment: 20  
3 In conducting its most recent Needs Assessment, did the hospital facility take into account input from persons who represent the community served by the hospital facility? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted. 3    
4 Was the hospital facility’s Needs Assessment conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI............................ 4    
5 Did the hospital facility make its Needs Assessment widely available to the public? ........... 5    
If “Yes,” indicate how the Needs Assessment was made widely available (check all that apply):
a Hospital facility’s website
b Available upon request from the hospital facility
c Other (describe in Part VI)
6 If the hospital facility addressed needs identified in its most recently conducted Needs Assessment, indicate how (check all that apply):
a Adoption of an implementation strategy to address the health needs of the hospital facility’s community
b Execution of the implementation strategy
c Development of a community benefit plan for the facility
d Participation in community-wide community benefit plan
e Inclusion of a community benefit section in operational plans
f Adoption of a budget for provision of services that address the needs identified in the CHNA
g Prioritization of health needs in the community
h Prioritization of services that the hospital facility will undertake to meet health needs in its community
i Other (describe in Part VI)
7 Did the hospital facility address all of the needs identified in its most recently conducted Needs Assessment? If “No,” explain in Part VI which needs it has not addressed together with the reasons why it has not addressed such needs. 7    
Financial Assistance Policy
Did the hospital facility have in place during the tax year a written financial assistance policy that:
8 Explains eligibility criteria for financial assistance, and whether such assistance includes free or discounted care? 8    
9 Used federal poverty guidelines (FPG) to determine eligibility for providing free care to low incomeindividuals?.. 9    
If “Yes,” indicate the FPG family income limit for eligibility for free care:   %
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 5
Part VFacility Information (continued)

Yes No
10 Used FPG to determine eligibility for providing discounted care to low income individuals?......... 10    
If “Yes,” indicate the FPG family income limit for eligibility for discounted care:   %
11 Explained the basis for calculating amounts charged to patients?................. 11    
If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a Income level
b Asset level
c Medical indigency
d Insurance status
e Uninsured discount
f Medicaid/Medicare
g State regulation
h Other (describe in Part VI)
12 Explained the method for applying for financial assistance?................... 12    
13 Included measures to publicize the policy within the community served by the hospital facility?....... 13    
If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a The policy was posted at all times on the hospital facility’s web site
b The policy was attached to all billing invoices
c The policy was posted in the hospital facility’s emergency rooms or waiting rooms
d The policy was posted in the hospital facility’s admissions offices
e The policy was provided, in writing, to patients upon admission to the hospital facility
f The policy was available upon request
g Other (describe in Part VI)
Billing and Collections
14 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy that explained actions the hospital facility may take upon non-payment?........ 14    
15 Check all of the following collection actions against a patient that were permitted under the hospital facility's policies at any time during the tax year:
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments or arrests
e Other (describe in Part VI)
16 Did the hospital facility engage in or authorize a third party to engage in any of the following collection actions during the tax year?................................... 16    
If “Yes,” check all collection actions in which the hospital facility or a third party engaged (check all that apply):
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments
e Other (describe in Part VI)
17 Indicate which actions the hospital facility took before initiating any of the collection actions checked in question 16 (check all that apply):
a Notified patients of the financial assistance policy upon admission
b Notified patients of the financial assistance policy prior to discharge
c Notified patients of the financial assistance policy in communications with the patients regarding the patients’ bills
d Documented its determination of whether a patient who applied for financial assistance under the financial assistance policy qualified for financial assistance
e Other (describe in Part VI)
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 6
Part VFacility Information (continued)

Policy Relating to Emergency Medical Care
Yes No
18 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.......... 18    
If “No,” indicate the reasons why (check all that apply):
a The hospital facility did not provide care for any emergency medical conditions
b The hospital facility did not have a policy relating to emergency medical care
c The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)
d Other (describe in Part VI)
Charges for Medical Care
19 Indicate how the hospital facility determined the amounts generally billed to individuals who had insurance covering emergency or other medically necessary care (check all that apply):
a The hospital facility used the lowest negotiated commercial insurance rate for those services at the hospital facility
b The hospital facility used the average of the three lowest negotiated commercial insurance rates for those services at the hospital facility
c The hospital facility used the Medicare rate for those services
d Other (describe in Part VI)
20 Did the hospital facility charge any of its patients who were eligible for assistance under the hospital facility’s financial assistance policy, and to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care?......... 20    
If “Yes,” explain in Part VI.
21 Did the hospital facility charge any of its patients an amount equal to the gross charge for services provided to that patient?................................... 21    
If “Yes,” explain in Part VI.
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 7
Part VFacility Information (continued)

Section C. Other Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility
(list in order of size, measured by total revenue per facility, from largest to smallest)
How many non-hospital facilities did the organization operate during the tax year?  
Name and address Type of Facility (Describe)
1
2
3
4
5
6
7
8
9
10
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 8
Part VI
Supplemental Information
Complete this part to provide the following information.
1 Required descriptions. Provide the description required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; and Part V, Section B, lines 1j, 2, 4c, 6i, 7, 11i, 13i, 17l, 18l, 19e, 21d, 25, and 26.
2 Community health needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any community health needs assessments reported in Part V, Section B.
3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5 Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
Identifier ReturnReference Explanation
ELIGIBILITY CRITERIA FOR FREE OR DISCOUNTED CARE SCH H, PART I, Q. 3C Describe the income-based criteria for determining eligibility for free or discounted care under the organization's financial assistance policy. When Catholic Health Initiatives (the ultimate parent organization to Mercy Hospital of Valley City) established its financial assistance policy it was determined that establishing a household income scale based on the U.S. Department of Housing and Urban Development (HUD) very low income guidelines more accurately reflects the socioeconomic dispersions among the 69 urban and rural communities in 19 states served by CHI hospitals and health care facilities. In comparing HUD guidelines to the Federal Poverty Guidelines ("FPG"), we find that on average HUD guidelines compute to approximately 200% to 250% (and sometimes 300%) of FPG. Mercy Hospital of Valley City bases its financial assistance eligibility on HUD's 130% of Very Low Income Guidelines based on geography, and affords the uninsured and underinsured the ability to obtain financial assistance write-offs based on a sliding scale ranging from 25%-100% of charges. Also describe whether the organization uses an asset test or other threshold, regardless of income, to determine eligibility for free or discounted care. An individual's income under the HUD guidelines is a significant factor in determining eligibility for financial assistance. However, in determining whether to extend discounted or free care to a patient, the patient's assets may also be taken into consideration. For example, a patient suffering a catastrophic illness may have a reasonable level of income, but a low level of liquid assets such that the payment of medical bills would be seriously detrimental to the patient's basic financial (and ultimately physical) well-being and survival. Such a patient may be extended discounted or free care based upon the facts and circumstances.
BAD DEBT EXPENSE EXCLUDED FROM FINANCIAL ASSISTANCE CALCULATION SCH H, PART I, Q. 7, COLUMN (F) If applicable, state the bad debt expense included on Form 990 Part IX, line 25, column (A) but subtracted for purposes of calculating the percentage in this column. Total bad debt expense reported on Form 990 Part IX, line 25, Column A was $556,458.
COSTING METHODOLOGY USED TO CALCULATE FINANCIAL ASSISTANCE SCH H, PART I, Q. 7 Provide an explanation of the costing methodology used to calculate the amounts reported in the table. If a cost accounting system was used, indicate whether the cost accounting system addresses all patient segments (for example, inpatient, outpatient, emergency room, private insurance, Medicaid, Medicare, uninsured or self pay). Also indicate whether a cost-to-charge ratio was used for any of the figures reported in the table. Describe whether this cost-to-charge ratio was derived from Worksheet 2, and, if not, what kind of cost-to-charge ratio was used and how it was derived. If some other costing methodology was used besides a cost accounting system, cost-to-charge ratio, or a combination of the two, describe the method used. The cost-to-charge ratio for the year ended 6/30/11 was computed using the following formula: Operating expense (before restructuring, impairment and other losses) divided by gross patient revenue. Based on that formula, this results in a 71.5% cost-to-charge ratio. Worksheet 2 was not used to derive the cost-to-charge ratio.
BAD DEBT EXPENSE - FINANCIAL STATEMENT FOOTNOTE SCH H, PART III, Q. 4 Provide the rationale and the costing methodology used to determine the amount reported in Part III, lines 2 and 3. Describe how the organization accounts for discounts and payments on patient accounts in determining bad debt expense. The Costing methodology for amounts reported on line 2 is determined using the organization's cost-to-charge ratio of 71.5%. When discounts are extended to self-pay patients, these patient account discounts are recorded as a reduction in revenue, not as bad debt expense. Also describe the method the organization uses to determine the amount that reasonably could be attributable to patients who likely would qualify for financial assistance under the hospital's financial assistance policy, if sufficient information has been available to make a determination of their eligibility. Describe the rationale, if any, for including any portion of bad debt as community benefit. Also provide, if applicable, the text of the footnote to the organization's financial statements that describes bad debt expense. If the organization's financial statements include a footnote on these issues that also includes other information, report only the relevant portions of the footnote. If the organization's financial statements do not contain such a footnote, state that the organization's financial statements do not include such a footnote and explain how the financial statements account for bad debt, if at all. Mercy Hospital of Valley City does not believe that any portion of bad debt expense could reasonably be attributed to patients who qualify for financial assistance since amounts due from those individuals' accounts will be reclassified from bad debt expense to charity care within 30 days following the date that the patient is determined to qualify for charity care. Mercy Hospital does not issue separate company audited financial statements. However, the organization is included in the consolidated financial statements of Catholic Health Initiatives. The consolidated footnote reads as follows: "The provision for bad debts is based upon management's assessment of historical and expected net collections considering historical business and economic conditions, trends in health care coverage, and other collection indicators. Management routinely assesses the adequacy of the allowances for uncollectible accounts based upon historical write-off experience by payor category. The results of these reviews are used to modify, as necessary, the provision for bad debts and to establish appropriate allowances for uncollectible net patient accounts receivable."
COMMUNITY BENEFIT & METHODOLGY FOR DETERMINING MEDICARE COSTS SCH H, PART III, Q. 8 Describe the costing methodology used to determine the Medicare allowable costs reported in the organization's Medicare Cost Report, as reflected in the amount reported in Part III, line 6. Mercy Hospital of Valley City is designated as a Critical Access Hospital ("CAH"). CAH's are rural community hospitals that are certified to receive cost-based reimbursement from Medicare. The reimbursement that CAH's receive is intended to improve their financial performance and thereby reduce hospital closures. CAH's are certified under a different set of Medicare Conditions of Participation (CoP). Shortfalls are created when a facility receives payments that are less than the costs of caring for program beneficiaries. Because shortfalls are based on costs, not charges, Mercy Hospital of Valley City, due to its designation as a CAH, received cost-based reimbursement for Medicare purposes; thus, the Hospital will not experience Medicare related shortfalls. Describe, if applicable, the extent to which any shortfall reported in Part III, line 7 should be treated as a community benefit, and the rationale for the organization's position. Mercy Hospital of Valley City believes that excluding Medicare losses from community benefit makes the overall community benefit report more credible for these reasons: Unlike subsidized areas such as burn units or behavioral-health services, Medicare is not a differentiating feature of tax-exempt health care organizations. In fact, for-profit hospitals focus on attracting patients with Medicare coverage, especially in the case of well-paid services that include cardiac and orthopedics. Significant effort and resources are devoted to ensuring that hospitals are reimbursed appropriately by the Medicare program. The Medicare Payment Advisory Commission (MedPAC), an independent Congressional agency, carefully studies Medicare payment and the access to care that Medicare beneficiaries receive. The commission recommends payment adjustments to Congress accordingly. Though Medicare losses are not included by Catholic hospitals as community benefit, the Catholic Health Association guidelines allow hospitals to count as community benefit some programs that specifically serve the Medicare population. For instance, if hospitals operate programs for patients with Medicare benefits that respond to identified community needs, generate losses for the hospital, and meet other criteria, these programs can be included in the CHA framework in Category C as "subsidized health services." Medicare losses are different from Medicaid losses, which are counted in the CHA community benefit framework, because Medicaid reimbursements generally do not receive the level of attention paid to Medicare reimbursement. Medicaid payment is largely driven by what states can afford to pay, and is typically substantially less than what Medicare pays.
COLLECTION PRACTICES FOR PATIENTS ELIGIBLE FOR FINANCIAL ASSISTANCE SCH H, PART III, Q. 9B If the organization has a written debt collection policy and answered "Yes," to Part III, line 9b, describe the collection practices set forth in the policy that apply to patients who it knows qualify for financial assistance, whether or not such practices apply specifically to such patients or more broadly to also cover other types of patients. Mercy Hospital of Valley City's debt collection policy provides that the Hospital will perform a reasonable review of each inpatient account prior to turning an account over to a third-party collection agent and prior to instituting any legal action for non-payment, to assure that the patient and patient guarantor are not eligible for any assistance program (e.g. Medicaid) and do not qualify for coverage through the Hospital's community assistance policy. After having been turned over to a third-party collection agent, any patient account that is subsequently determined to meet the Hospital's community assistance policy is required to be returned immediately by the third-party collection agent to Mercy Hospital of Valley City for appropriate follow-up. Mercy Hospital requires its third-party collection agents to include a message on all statements indicating that if a patient or patient guarantor meets certain stipulated income requirements, the patient or patient guarantor may be eligible for financial assistance. All of Catholic Health Initiatives' hospitals' contracts with third party collection agencies include the following standards: - Neither CHI hospitals nor their collection agencies will request bench or arrest warrants as a result of non-payment; - Neither CHI hospitals nor their collection agencies will seek liens that would require the sale or foreclosure of a primary residence; and - No CHI collection agency may seek court action without hospital approval. Finally, collection agencies are trained on the Catholic Health Initiatives Mission, Core Values and Standards of Conduct to ensure all patients are treated with dignity and respect.
NEEDS ASSESSMENT, COMMUNITY INFORMATION & BUILDING ACTIVITIES, ETC. SCH H, PART II AND PART VI, Q. 2, 4, & 5 INTRODUCTION: I. ORGANIZATION'S MISSION, VISION, AND TAX-EXEMPT PURPOSE The mission of Mercy Hospital of Valley City and Catholic Health Initiatives 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." CHI's Vision is to live up to our name as one CHI. Catholic: Living our Mission and Core Values. Health: Improving the health of the people and communities we serve. Initiatives: Pioneering models and systems of care to enhance care delivery. The primary exempt purpose of Mercy Hospital of Valley City is to provide healthcare services to residents in the community and surrounding area regardless of their ability to pay. Mercy Hospital of Valley City was founded to alleviate a shortage of hospital beds in the community and opened on May 14, 1928. As the first Catholic hospital to serve the community, Mercy Hospital of Valley City embraced the mission of the founding congregation, The Sisters of Mercy, which has since joined with other congregations to form Catholic Health Initiatives. At Mercy Hospital of Valley City, one will find dedicated, committed, highly qualified individuals who can meet your routine and not-so-routine health care needs 365 days of the year without the inconvenience of a 60-mile drive. Services available at Mercy Hospital of Valley City include: Acute Care and Swingbed; Ambulatory Care Department; Cardiac Rehab; Cataract Surgery; Education; Trauma 4 Emergency Room; Faith in Action Program; General Surgery; Intensive and Critical Care Units (ICU-CCU); Lab Services; Nutrition Services; Childbirth Preparation Classes; Occupational Therapy; Physical Therapy; Radiology; Respiratory Therapy; Respite Care; Same Day Surgery; Sleep Studies; Social and Behavioral Services; Counseling Services; Spiritual Services; Sports Medicine; Stress Testing; Mammography; Orthopedic Clinic; Podiatry Clinic; and Healthy Heart Program. The Mercy Hospital of Valley City Board of Directors consists of members representing a cross section of local residents, including women, individuals from various religious backgrounds, and Catholic Health Initiatives representatives. The board has fiduciary responsibility for the quality, legal compliance and financial/business performance of the hospital as well as for hiring the hospital administrator. The board meets six times per year, or more as needed, to assess strategic direction, mission compliance, and monthly performance as compared to established benchmarks. They also routinely evaluate legal compliance, human resources management, medical staff relations, community needs, and new business lines. II. COMMUNITY BENEFIT APPROACH Mercy Hospital of Valley City assists in addressing the spiritual and emotional needs of the Valley City community and portions of the six surrounding counties. The mission department, spiritual care department and social services department provide assistance for those needing additional guidance and help. The Hospital is located in Valley City, Barnes County, North Dakota. Barnes County is the primary service area, with close to 90% of the total patient visits, and almost 72% of patients come from Valley City alone. The hospital's service area also includes portions of Cass, LaMoure, Ransom, Stutsman, Griggs, and Steele counties. The hospital's Service area population is approximately 12,000 individuals and has a total area of 1,491 square miles. According to the U.S. Census Bureau data, the following statistical changes occurred during 2010: - The number of households increased, from 4,884 to 4,992 households; - The number of children under the age of 18 decreased from of 27.4% to 20.4%; - The number of individuals over the age of 65 increased from 15.9% to 20.0%; - The median household income increased from $42,149 to $44,154; - The percentage of the population living below the poverty line increased from 10.80% to 11.10%; - The percentage of the population constituting minority races increased from 2.09% to 3.60%; According to the health resources and service administration (HRSA) Department of Health & Human Services, Mercy Hospital of Valley City is in a Mental Health Professional Shortage Area. The Hospital is providing services and reaching community members through Wellness in the Valley Program. This program acts as an advocate for mental health and suicide prevention through education, understanding and support to the community. COMMUNITY ASSESSMENT: In 2008, a "Faith in Action" services appraisal was carried out through a Community Needs Assessment in Carrington, Lisbon, and Oakes, North Dakota. The results indicated many gaps in services in each of these communities, including transportation, companionship, and other social wellness services. The evaluation indicated that persons in these communities would benefit significantly from a Faith in Action or similar volunteer program model. A need for additional support services in the Barnes County area was identified by Mercy Hospital of Valley City's Healthy Community Initiatives through the hospital's advocacy efforts to improve health care access and quality of life for area residents. The community assessment programs that the Hospital supports are included in the Community Building Activities. In 2009, Gov. John Hoeven's office released statistics on suicide. These statistics provided that suicide is the second leading cause of death in teens and young adults and is the 10th leading cause of death overall in the nation - North Dakota ranks 15th among the states with the highest suicide rates. Mercy Hospital of Valley City has a Licensed Associate Professional Counselor with a National Counselor Certification who counsels and educates community members, runs group counseling sessions, makes referrals, and leads the hospital's Wellness in the Valley suicide prevention group. DESCRIPTIONS: The hospital's primary Community Benefit program is the financial assistance provided to patients who cannot afford to pay for their care. Financial Assistance applications may be obtained at Mercy Hospital of Valley City or on the website: http://www.mercyhospitalvalleycity.org The financial assistance application process is extremely confidential and our goal is to award financial assistance rather than turn patients over to a collection agency for healthcare bills. Charity Care is free or discounted health and health-related services provided to people who cannot afford to pay for medically necessary health care. Eligibility is based on household income as well as an individual's other assets. Consideration is given to a patient who has significant or catastrophic medical bills and does not meet the income guidelines for financial assistance. Charity Care is given to uninsured, low-income patients who are not expected to pay all or part of a bill, or who are able to pay only a portion using an income-related fee schedule. The hospital's Community benefit programs for the poor are geared toward reducing morbidity and mortality in beneficiaries of Medicaid or state or local indigent programs. Eligibility for uninsured/underinsured discounts shall be determined based on 130% of the annually updated U.S. Department of Housing and Urban Development (HUD) Geographic Very-Low Income Guidelines, available assets and any extenuating circumstances. Thus, the standards of eligibility for the application of uninsured/underinsured discounts must consider assets, as well as income. The Hospital shall utilize 130% of the HUD Geographic Very-Low Income guidelines as a minimum. Benefits for the Broader Community are provided to persons other than a "target population" who benefit from a health care organization's community services and programs. III. QUANTITATIVE DESCRIPTION OF COMMUNITY BENEFIT: Human Investments and Statistics Number of activities: 78 Staff hours: 4,974.8 Volunteer hours: 3,372.5 The Total Quantifiable Community Benefits costs equal $318,088 serving 17,348 people. This community benefit is 2.7% of the hospital's expenses and 1.9% of the hospital's revenues. QUALITATIVE DESCRIPTION OF COMMUNITY BENEFIT: Community Benefit is the name given to the programs we create in response to health needs in our service areas. An important part of our mission is building healthier communities through programs designed to serve the needs of people who are poor and disadvantaged in our community. This type of Community Benefit has the added, positive side-effect of delivering an improved quality of life for everyone. Community Benefit most often takes place outside the walls of our facilities and involves partner organizations in the community. Our Community Benefit activities are designed to: - Identify and increase awareness of health needs in Valley City. - Provide resources to meet those needs. - Create collaboration between comm
PATIENT EDUCATION ELIGIBILITY FOR ASSISTANCE SCH H, PART VI, Q. 3 Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization's financial assistance policy. Mercy Hospital of Valley City includes information concerning its financial assistance policy on its website. In addition, the Hospital prominently displays its financial assistance policy in both English and Spanish in obvious locations throughout the hospital, including the emergency rooms and other patient intake areas, as well as in outpatient facilities. In addition, the Hospital's registration clerks are trained to provide consultation to those who have no insurance or potentially inadequate insurance concerning their financial options including application for Medicaid and for financial assistance under the Hospital's financial assistance policy. Upon registration (and once all EMTALA requirements are met), patients who are identified as uninsured (and not covered by Medicare or Medicaid) are provided with a packet of information that addresses the financial assistance policy and procedures including an application for assistance. The Hospital registration clerks read the organization's medical assistance policy to those who appear to be incapable of reading, and provide translators for non English-speaking individuals. The Hospital's staff will also assist the patient/guarantor with applying for other available coverage (such as Medicaid), if necessary. Counselors assist Medicare eligible patients in enrollment by providing referrals to the appropriate government agencies.
AFFILIATED HEALTHCARE SYSTEM SCH H, PART VI, Q. 6 If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served. Mercy Hospital along with its affiliated outpatient facilities are part of Catholic Health Initiatives. Catholic Health Initiatives (CHI) is a national faith-based nonprofit health care organization with headquarters in Englewood, Colorado. CHI's exempt purpose is to serve as an integral part of its national system of hospitals and other charitable entities, which are described as market-based organizations, or MBOs. An MBO is a direct provider of care or services within a defined market area that may be an integrated health system and/or a stand-alone hospital or other facility or service provider. CHI serves as the parent corporation of its MBOs which are comprised of 73 hospitals; 40 long-term care, assisted- and residential-living facilities; two community health-services organizations; two accredited nursing colleges; and home health agencies. Together, these facilities provided $612 million in charity care and community benefit in the 2011 fiscal year, including services for the poor, free clinics, education and research. CHI provides strategic planning and management services as well as centralized "shared services" for the MBOs. The provision of centralized management and shared services - including areas such as accounting, human resources, payroll and supply chain -- provides economies of scale and purchasing power to the MBOs. The cost savings achieved through CHI's centralization enable MBOs to dedicate additional resources to high-quality health care and community outreach services to the most vulnerable members of our society. Mercy Hospital operates with its wholly owned affiliates and community partners, along with its fundraising arm, the Mercy Health Foundation, to serve the health care needs of the Valley City, ND communities.
Schedule H (Form 990) 2010
Additional Data


Software ID:  
Software Version:  
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 Hospital of Valley City
 
Employer identification number
45-0226553
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






















2
Enter total number of section 501(c)(3) and government organizations ......................... Bullet Image
 
3
Enter total number of other organizations ................................ . Bullet Image
 
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
GRANT MONITORING PROCEDURES SCH I, PART I, Q. 2 AMOUNTS LISTED ON PART IX, LINE 1 ARE ASSISTANCE AND DONATIONS PROVIDED TO MULTIPLE ORGANIZATIONS. THERE ARE NOT SPECIFIC PROCEDURES IN PLACE FOR MONITORING THESE AMOUNTS.
Schedule I (Form 990) 2010


Additional Data


Software ID:  
Software Version:  


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 Hospital of Valley City
 
Employer identification number

45-0226553
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
 
No
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
Yes
 
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
 
No
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) JEFFREY DROP (i)
(ii)		  
349,509 		 
146,330 		 
188,969 		 
53,996 		 
20,340 		 
759,144 		 
 
(2) KEITH HEUSER (i)
(ii)		  
155,613 		 
33,607 		 
22,087 		 
30,044 		 
11,589 		 
252,940 		 
 
(3) CLARK KRUTA (i)
(ii)		 183,148
  		 
  		911
  		16,958
  		5,511
  		206,528
  		 
 













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
METHODS USED TO ESTABLISH CEO COMPENSATION Sch J, Part I, Q. 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.
POST-TERMINATION PAYMENTS Sch J, Part I, Q. 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. No reportable individuals received severance payments from CHI during the 2010 calendar year.
SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN Sch J, Part I, Q. 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: Jeffrey Drop and Keith Heuser. During 2010 the following contributions were made by CHI to the deferred compensation plan: Jeffrey Drop $28,868 Keith Heuser $14,014
NON-FIXED PAYMENTS Sch J, Part I, Q. 7 THE ORGANIZATION ACCRUED INCENTIVE BONUSES FOR THE LEADERSHIP TEAM BASED ON BOTH FINANCIAL AND NON-FINANCIAL METRICS. THE LEADERSHIP TEAM CONSISTS OF THE ADMINISTRATOR, CONTROLLER, HR GENERALIST, AND THE VICE ADMINISTRATOR OF CLINICAL SERVICES.
Schedule J (Form 990) 2010

Additional Data


Software ID:  
Software Version:  
SCHEDULE M
(Form 990)

Department of the Treasury
Internal Revenue Service
NonCash Contributions
Right pointing arrow large imageComplete if the organization answered "Yes" on Form 990, Part IV, lines 29 or 30.
Right pointing arrow large image Attach to Form 990.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
Mercy Hospital of Valley City
 
Employer identification number

45-0226553
Part I
Types of Property
(a)
Check if applicable 		(b)
Number of Contributions or items contributed 		(c)
Contribution amounts reported on
Form 990, Part VIII, line 1g 		(d)
Method of determining
contribution amounts
1 Art—Works of art ....        
2 Art—Historical treasures .        
3 Art—Fractional interests ..        
4 Books and publications ..      
5 Clothing and household
goods ....... 		     
6 Cars and other vehicles ..        
7 Boats and planes ....        
8 Intellectual property ...        
9 Securities—Publicly traded .        
10 Securities—Closely held stock .        
11 Securities—Partnership, LLC,
or trust interests .... 		       
12 Securities—Miscellaneous ..        
13 Qualified conservation
contribution—Historic
structures ..... 		       
14 Qualified conservation
contribution—Other ... 		       
15 Real estate—Residential .        
16 Real estate—Commercial ..        
17 Real estate—Other ...        
18 Collectibles .....        
19 Food inventory ...        
20 Drugs and medical supplies . X 4 64,268 FMV
21 Taxidermy ......        
22 Historical artifacts ....        
23 Scientific specimens ..        
24 Archeological artifacts ...        
25 Other Right pointing arrow large image ( )
26 Other Right pointing arrow large image( )
27 Other Right pointing arrow large image( )
28 Other Right pointing arrow large image ( )
29
Number of Forms 8283 received by the organization during the tax year for contributions
for which the organization completed Form 8283, Part IV, Donee Acknowledgement ...
29
 
Yes
No
30a
During the year, did the organization receive by contribution any property reported in Part I, lines 1-28 that it
must hold for at least three years from the date of the initial contribution, and which is not required to be used
for exempt purposes for the entire holding period? ..................
30a
 
No
b
If "Yes," describe the arrangement in Part II.
31
Does the organization have a gift acceptance policy that requires the review of any non-standard contributions?
31
 
No
32a
Does the organization hire or use third parties or related organizations to solicit, process, or sell non-cash
contributions? ............................
32a
 
No
b
If "Yes," describe in Part II.
33
If the organization did not report revenues in column (c) for a type of property for which column (a) is checked,
describe in Part II.
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 51227J
Schedule M (Form 990) 2010
Schedule M (Form 990) 2010
Page 2
Part II
Supplemental Information. Complete this part to provide the information required by Part I, lines 30b,
32b, and 33. Also complete this part for any additional information.
Identifier Return Reference Explanation
Schedule M (Form 990) 2010
Additional Data


Software ID:  
Software Version:  
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 Hospital of Valley City
 
Employer identification number

45-0226553
Identifier Return Reference Explanation
Change in Program Service Accomplishment FORM 990, PART III, Q. 3 DURING THE FISCAL YEAR ENDING JUNE 30, 2011, CATHOLIC HEALTH INITIATIVES ("CHI"), A RELATED ORGANIZATION, CREATED CHI NATIONAL HOME CARE ("CNHC"), A COLORADO NONPROFIT CORPORATION THAT WILL BE OPERATED TO HOUSE CHI'S TAX-EXEMPT HOME HEALTH ACTIVITIES. CHI NATIONAL SERVICES ("CNS"), A COLORADO NONPROFIT AND THE SOLE CORPORATE MEMBER OF CNHC, WAS FORMED TO SERVE AS A SUPPORT STRUCTURE FOR CHI'S NATIONAL SERVICE LINES ACROSS THE COUNTRY. CHI NATIONAL SERVICES WILL SERVE AS A HOLDING COMPANY, PERMITTING MAXIMUM OPERATIONAL AND GOVERNANCE FLEXIBILITY WITH RESPECT TO THE FUTURE FOR-PROFIT AND CURRENT TAX-EXEMPT NATIONAL BUSINESS LINES SERVED BY CHI. THE CONSOLIDATION OF THE HOME CARE OPERATIONS WILL REDUCE VARIATION IN CLINICAL OUTCOMES, LOWER THE COST OF ADMINISTRATIVE AND BACK OFFICE SERVICES, ENHANCE GROWTH THROUGH THE STANDARDIZED MARKETING PROGRAM, AND ENHANCE OVERALL CORPORATE COMPLIANCE THROUGH STANDARDIZATION AND REVIEW. DURING THE FISCAL YEAR ENDING JUNE, 30 2011, MERCY HOSPITAL OF VALLEY CITY TRANSFERRED THEIR HOME CARE SERVICE DIVISION TO CNHC.
Executive Committee FORM 990, PART VI, Q. 1A PURSUANT TO SECTION 8.6 OF THE BYLAWS OF MERCY HOSPITAL OF VALLEY CITY, 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 PRESIDENT AND CHIEF EXECUTIVE OFFICER, 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.
Organization's Corporate Members/ Stockholders FORM 990, PART VI, Q. 6 ACCORDING TO THE BYLAWS OF MERCY HOSPITAL OF VALLEY CITY, THE ENTITY'S SOLE MEMBER IS CATHOLIC HEALTH INITIATIVES, A COLORADO NON-PROFIT CORPORATION.
Members/Stockholders Electing Governing Body Form 990, Part VI, Q. 7A THE SOLE MEMBER HAS THE POWER TO APPOINT ORGANIZATION DIRECTORS, AND AFTER RECOMMENDATION BY THE BOARD OF DIRECTORS, MAY ACCEPT OR REJECT ANY INDIVIDUAL NOMINATED TO SERVE AS A DIRECTOR. THE SOLE MEMBER MAY ALSO UNILATERALLY APPOINT ONE OR MORE INDIVIDUALS TO THE BOARD OF DIRECTORS IF THE BOARD FAILS TO FURNISH A LIST OF QUALIFIED INDIVIDUALS TO SERVE.
Approval of Governing Body Decisions by Members/Stockholders Form 990, Part VI, Q. 7b THE ORGANIZATION'S CORPORATE MEMBER IS CATHOLIC HEALTH INITIATIVES ("CHI"). PURSUANT TO SECTION 5.4 OF THE ORGANIZATION'S BYLAWS, THE CORPORATE MEMBER SHALL HAVE THE SPECIFIC RIGHTS SET FORTH IN THE GOVERNANCE MATRIX. PURSUANT TO THE GOVERNANCE MATRIX THE FOLLOWING RIGHTS ARE RESERVED TO THE CHI BOARD DIRECTLY OR THROUGH POWERS DELEGATED TO THE CHI CHIEF EXECUTIVE OFFICER: - Approve members of the Mercy Hospital of Valley City board - Amendment of the corporate documents of Mercy Hospital of Valley City - Approve removal of a member of the governing body of Mercy Hospital of Valley City - Adoption of long range and strategic plans for Mercy Hospital of Valley City 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 Mercy Hospital of Valley City - Removal of a member of the governing body of Mercy Hospital of Valley City - Approval of issuance of debt by Mercy Hospital of Valley City - Approval of participation of Mercy Hospital of Valley City in a joint venture - Approval of formation of a new corporation by Mercy Hospital of Valley City - Approval of a merger involving Mercy Hospital of Valley City - Approval of the sale of all or substantially all of the assets of Mercy Hospital of Valley City - To require the transfer of assets by Mercy Hospital of Valley City to CHI to accomplish CHI's goals and objectives, and to satisfy CHI debts. Pursuant to Section 5.5 of the organization's bylaws, 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.
Process the Organization uses to review form 990 FORM 990, PART VI, Q. 11b Once the return is prepared, the return is reviewed by the controller. The controlloer provides a copy of the return to the board either at a board meeting or electronically prior to the filing deadline. Subsequent to the return being provided to the board, the tax department files the return with the appropriate federal and state agencies, making any non-substantive changes necessary to effect e-filing. Any such changes are not re-submitted to the board.
Procedures for Monitoring and Enforcing the COI Policy Form 990, Part VI, Q. 12c MERCY HOSPITAL OF VALLEY CITY HAD IN EFFECT FOR FY 2011 A CONFLICT OF INTEREST POLICY COVERING ALL DIRECTORS AND OFFICERS HOLDING THE TITLE OF VICE PRESIDENT OR ABOVE. THE POLICY PLACES ON EACH DIRECTOR A GENERAL OBLIGATION TO DISCLOSE TO THE CHAIR OF THE BOARD OF DIRECTORS ANY SITUATION THAT MAY CREATE A CONFLICT AS SOON AS THEY BECOME AWARE OF SUCH SITUATION. COVERED OFFICERS MUST MAKE SUCH DISCLOSURES TO THE PRESIDENT AND CEO OF MERCY HOSPITAL OF VALLEY CITY, WHO HAS A DUTY TO REPORT SUCH SITUATIONS TO THE BOARD CHAIR. IF ANY DOUBT EXISTS, DIRECTORS AND COVERED OFFICERS ARE REQUIRED TO MAKE A FULL DISCLOSURE TO PERMIT AN IMPARTIAL AND OBJECTIVE DETERMINATION. THE POLICY REQUIRES WRITTEN RECORD OF ALL DISCLOSURES. ADDITIONALLY, ALL DIRECTORS AND COVERED OFFICERS ARE REQUIRED TO, AT LEAST ANNUALLY, COMPLETE, SIGN AND SUBMIT A CONFLICT OF INTEREST DISCLOSURE STATEMENT. THE PRESIDENT AND CEO REVIEW THESE STATEMENTS WITH THE BOARD CHAIR. THE BOARD CHAIR OR A DESIGNEE CONDUCTS FURTHER INVESTIGATION OF CONFLICTS OF INTEREST DISCLOSURES AT THEIR DISCRETION. BASED UPON THE REVIEW AND EVALUATION OF THE RELEVANT FACTS AND CIRCUMSTANCES, THE BOARD CHAIR MAKES AN INITIAL DETERMINATION AS TO WHETHER A CONFLICT EXISTS AND WHETHER REVIEW AND APPROVAL OR OTHER ACTION BY THE BOARD IS REQUIRED. A WRITTEN RECORD OF THE BOARD CHAIR'S DETERMINATION IS KEPT. THE BOARD CHAIR THEN MAKES A REPORT TO THE EXECUTIVE COMMITTEE OF THE BOARD. DIFFERENCES OF OPINION BETWEEN THE BOARD CHAIR AND ANOTHER OFFICER OR DIRECTOR AS TO WHETHER THE FACTS AND CIRCUMSTANCES OF A GIVEN SITUATION CONSTITUTE A CONFLICT OF INTEREST OR WHETHER BOARD OF DIRECTORS REVIEW AND APPROVAL OR OTHER ACTION IS REQUIRED ARE SUBMITTED TO THE EXECUTIVE COMMITTEE TO MAKE A FINAL DETERMINATION AS TO THE MATTER. THE COMMITTEE MINUTES ARE TO REFLECT THE DETERMINATION INCLUDING ALL RELEVANT FACTS AND CIRCUMSTANCES AND THEN REPORTED TO THE BOARD OF DIRECTORS. A DIRECTOR OR OFFICER IS PROHIBITED FROM VOTING OR USING HIS OR HER PERSONAL INFLUENCE ON THE MATTER UNDER CONSIDERATION. FURTHER, THEY ARE TO BE EXCUSED FROM THE MEETING DURING THE DISCUSSION AND VOTE ON THE CONFLICT OF INTEREST.
Process for Determining CEO's Compensation FORM 990, PART VI, Q. 15A The organization's 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.
Process for Determining Compensation - Officers/Key Employees FORM 990, PART VI, Q. 15B DURING THE TAX YEAR ENDED 6/30/11, ANY EXECUTIVE COMPENSATION PAID TO OFFICERS, DIRECTORS OR TRUSTEES WAS REVIWED AND APPROVED BY THE BOARD UTILIZING COMPARABILITY STUDIES TO DETERMINE COMPENSATION.
Public Inspection of Documents Form 990, Part VI, Q. 19 THE ORGANIZATION'S FINANCIAL STATEMENTS ARE INCLUDED IN CATHOLIC HEALTH INITIATIVES' CONSOLIDATED AUDITED FINANCIAL STATEMENTS AND ARE AVAILABLE AT WWW.CATHOLICHEALTHINIT.ORG OR AT WWW.DACBOND.COM. THE ORGANIZATION'S CONFLICT OF INTEREST POLICY AND GOVERNING DOCUMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST.
Estimate of Hours Form 990, Part VII COMPENSATION REPORTED ON FORM 990, PART VII WAS PAID TO THESE INDIVIDUALS BY RELATED ORGANIZATIONS IN EXCHANGE FOR THE FULFILLMENT OF THEIR DUTIES AS FULL-TIME, 60 HOUR-PER-WEEK EMPLOYEES.
Other Changes in Net Assets Form 990, Part XI, Q. 5 Unrealized Gain/Loss $1,423,012 CHI Connect Depreciation 50,425 Capital Resource Pool Contribution (39,144) ----------- Total 1,434,293
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:  
Software Version:  
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 Hospital of Valley City
 
Employer identification number

45-0226553
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) Catholic Health Initiatives

198 Inverness Drive West

Englewood,CO80112
47-0617373 		Healthcare CO 501(c)(3) 9 CHI
 
 
 
(2) Bornemann Healthcare Corporation

2500 Bernville Road PO Box 316

Reading,PA19603
23-2187242 		Healthcare PA 501(c)(3) 11a CHI
 
 
 
(3) CHI Institute For Research and Innovatio

198 Inverness Drive West

Englewood,CO80112
27-1050565 		Healthcare CO 501(c)(3) 11a CHI
 
 
 
(4) CHI National Foundation

198 Inverness Drive West

Englewood,CO80112
27-0930004 		Fundraising CO 501(c)(3) 11a CHI
 
 
 
(5) CHI National Services

198 Inverness Drive West

Englewood,CO80112
45-2532084 		Healthcare CO 501(c)(3) 9 CHI
 
 
 
(6) CHI National Home Care

198 Inverness Drive West

Englewood,CO80112
45-1261716 		Healthcare CO 501(c)(3) 11a CHI
 
 
 
(7) Global Health Initiatives

198 Inverness Drive West

Englewood,CO80112
20-1536108 		Ministries CO 501(c)(3) 11a CHI
 
 
 
(8) St Joseph Physician Enterprises

7601 Osler Drive

Towson,MD21204
52-1311775 		Physicians MD 501(c)(3) 11a CHI
 
 
 
(9) St Vincent Infirmary Medical Center

2 St Vincent Circle

Little Rock,AR72205
71-0236917 		Healthcare AR 501(c)(3) 3 CHI
 
 
 
(10) St Anthony's Hospital Association

4 Hospital Drive

Morrilton,AR72110
71-0245507 		Healthcare AR 501(c)(3) 3 SVIMC
 
 
 
(11) St Vincent Foundation

Two St Vincent Circle

Little Rock,AR72205
51-0169537 		Fundraising AR 501(c)(3) 11a SVIMC
 
 
 
(12) St Vincent Medical Group

2 St Vincent Circle

Little Rock,AR72205
71-0830696 		Healthcare AR 501(c)(3) 9 SVIMC
 
 
 
(13) CHI Colorado

188 Inverness Drive West

Englewood,CO80112
84-0405257 		Healthcare CO 501(c)(3) 3 CHI
 
 
 
(14) Mercy Regional Medical Center of Durango

1010 Three Springs Blvd

Durango,CO81301
84-0405515 		Healthcare CO 501(c)(3) 3 CHI
 
 
 
(15) Catholic Health Initiatives Colorado Fou

961 East Colorado Avenue

Colorado Springs,CO80903
84-0902211 		Fundraising CO 501(c)(3) 7 CHI Colorado
 
 
 
(16) Health SET

4200 West Conejos Place 436

Denver,CO80204
84-1102943 		Low Inc.Care CO 501(c)(3) 7 CHI Colorado
 
 
 
(17) Pueblo Stepup

1925 East Orman Avenue Suite G52

Pueblo,CO81004
84-1234295 		Community CO 501(c)(3) 7 CHI
 
 
 
(18) 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
 
 
 
(19) Total Healthcare

PO Box 7021

Colorado Springs,CO80933
84-0927232 		Healthcare CO 501(c)(3) 3 CHI Colorado
 
 
 
(20) CHI-Iowa Corp

1111 6th Avenue

Des Moines,IA50314
42-0680448 		Healthcare IA 501(c)(3) 3 MHN
 
 
 
(21) Bishop Drumm Retirement Center

1111 6th Avenue

Des Moines,IA50314
42-0725196 		LTerm Care IA 501(c)(3) 9 CHI-IA Corp
 
 
 
(22) House of Mercy

1111 6th Avenue

Des Moines,IA50314
42-1323808 		Shelter IA 501(c)(3) 7 CHI-IA Corp
 
 
 
(23) Mercy Clinics Inc

1111 6th Avenue

Des Moines,IA50314
42-1193699 		Physician IA 501(c)(3) 9 CHI-IA Corp
 
 
 
(24) Mercy College of Health Sciences

1111 6th Avenue

Des Moines,IA50314
42-1511682 		Education IA 501(c)(3) 2 CHI-IA Corp
 
 
 
(25) Mercy Foundation of Des Moines IA

1111 6th Avenue

Des Moines,IA50314
23-7358794 		Fundraising IA 501(c)(3) 7 CHI-IA Corp
 
 
 
(26) Mercy Auxiliary of Central Iowa

1111 6th Avenue

Des Moines,IA50314
42-6076069 		Auxiliary IA 501(c)(3) 11a CHI-IA Corp
 
 
 
(27) Mercy Professional Practice Associates

1111 6th Avenue

Des Moines,IA50314
42-1470935 		Physician IA 501(c)(3) 9 CHI-IA Corp
 
 
 
(28) Mercy Medical Center - Centerville FKA

1 St Josephs Drive

Centerville,IA52544
42-0680308 		Healthcare IA 501(c)(3) 3 CHI-IA Corp
 
 
 
(29) St Rose Ambulatory and Surgery Center F

3515 Broadway

Great Bend,KS67530
48-0543724 		Surgery Cntr KS 501(c)(3) 3 CHI
 
 
 
(30) St Catherine Hospital

401 East Spruce Street

Garden City,KS67846
48-0543721 		Healthcare KS 501(c)(3) 3 CHI
 
 
 
(31) St Catherine Hospital Development Found

401 East Spruce Street

Garden City,KS67846
20-0598702 		Fundraising KS 501(c)(3) 11a SCH
 
 
 
(32) CHI Kentucky Inc

3900 Olympic Blvd Suite 400

Erlanger,KY41018
20-2741651 		Healthcare KY 501(c)(3) 11a CHI
 
 
 
(33) Saint Joseph Health System Inc

150 N Eagle Creek Dr

Lexington,KY40509
61-1334601 		Healthcare KY 501(c)(3) 3 CHI
 
 
 
(34) Continuing Care Hospital

150 North Eagle Creek Drive

Lexington,KY40509
61-1400619 		LTACH KY 501(c)(3) 3 SJHS
 
 
 
(35) Flaget Healthcare DBA Flaget Memorial

4305 New Shepherdsville Road

Bardstown,KY40004
61-1345363 		Healthcare KY 501(c)(3) 3 CHI
 
 
 
(36) Flaget Memorial Hospital Foundation Inc

4305 New Shepherdsville Road

Bardstown,KY40004
56-2351341 		Fundraising KY 501(c)(3) 11a FH
 
 
 
(37) Saint Joseph London Foundation Inc

310 East Ninth Street

London,KY40741
26-0438748 		Fundraising KY 501(c)(3) 11a SJHS
 
 
 
(38) Saint Joseph Berea Hospital Foundation

305 Estill Street

Berea,KY40403
26-0152877 		Fundraising KY 501(c)(3) 7 SJHS
 
 
 
(39) St Joseph Hospital Foundation Inc

305 Estill Street

Lexington,KY40504
61-1159649 		Fundraising KY 501(c)(3) 11a SJHS
 
 
 
(40) Saint Joseph Medical Foundation Inc

One St Joseph Drive

Lexington,KY40504
31-1539059 		Phy Practices KY 501(c)(3) 3 SJHS
 
 
 
(41) Saint Joseph Mount Sterling Foundation

50 Sterling Avenue

Mount Sterling,KY40353
27-2884584 		Fundraising KY 501(c)(3) 7 SJHS
 
 
 
(42) St Joseph Medical Center Inc

7601 Osler Drive

Towson,MD21204
52-0591461 		Healthcare MD 501(c)(3) 3 CHI
 
 
 
(43) St Joseph Medical Center Foundation In

7601 Osler Drive

Towson,MD21204
52-1681044 		Fundraising MD 501(c)(3) 7 SJMC
 
 
 
(44) Alverna Apartments

300 SE 8th Avenue

Little Falls,MN56345
41-1351177 		Lterm Care MN 501(c)(3) 9 CHI
 
 
 
(45) Lakewood Health Center

600 Main Avenue South

Baudette,MN56623
41-0758434 		LTerm Care MN 501(c)(3) 3 CHI
 
 
 
(46) St Francis Home

2400 St Francis Drive

Breckenridge,MN56520
41-0729978 		LTerm Care MN 501(c)(3) 9 CHI
 
 
 
(47) Appletree Court

601 Oak Street

Breckenridge,MN56520
41-1850500 		Senior Homes MN 501(c)(3) 9 SFH
 
 
 
(48) St Francis Medical Center

2400 St Francis Drive

Breckenridge,MN56520
41-0695598 		Healthcare MN 501(c)(3) 3 CHI
 
 
 
(49) Healthcare and Wellness Foundation

2400 St Francis Drive

Breckenridge,MN56520
76-0761782 		Fundraising MN 501(c)(3) 11a SFMC
 
 
 
(50) St Joseph's Area Health Services

600 Pleasant Avenue

Park Rapids,MN56470
41-0695603 		Healthcare MN 501(c)(3) 3 CHI
 
 
 
(51) Unity Family Healthcare

815 2nd Street SE

Little Falls,MN56345
41-0721642 		Healthcare MN 501(c)(3) 3 CHI
 
 
 
(52) St John's Regional Medical Center

2727 McClelland Blvd

Joplin,MO64804
44-0545809 		Healthcare MO 501(c)(3) 3 CHI
 
 
 
(53) Mercy Lifecare Systems

2727 McClelland Blvd

Joplin,MO64804
43-1305163 		Property Mgmt MO 501(c)(3) 11a SJRMC
 
 
 
(54) MNMCH Inc

220 North Pennsylvania

Columbus,KS66725
48-1216238 		Healthcare KS 501(c)(3) 3 SJRMC
 
 
 
(55) St John's Medical Group

2727 McClelland Blvd

Joplin,MO64804
43-1882377 		Phys Practice MO 501(c)(3) 9 SJRMC
 
 
 
(56) St John's Mercy Regional Foundation

2727 McClelland Blvd

Joplin,MO64804
43-1308084 		Fundraising MO 501(c)(3) 7 SJRMC
 
 
 
(57) Alegent Health - Bergan Mercy Health Sys

7500 Mercy Road

Omaha,NE68124
47-0484764 		Healthcare NE 501(c)(3) 3 CHI
 
 
 
(58) Alegent Health - Mercy Hospital Corning

PO Box 368

Corning,IA50841
42-0782518 		Healthcare IA 501(c)(3) 3 AHBMHS
 
 
 
(59) Mercy Health Care Foundation

PO Box 368

Corning,IA50841
42-1461064 		Fundraising NE 501(c)(3) 11a AHMH
 
 
 
(60) Mercy Hospital Foundation Council Bluff

800 Mercy Drive

Council Bluffs,IA51503
42-1178204 		Fundraising IA 501(c)(3) 11a AHBMHS
 
 
 
(61) CHI Nebraska

555 South 70th Street

Lincoln,NE68510
36-3233121 		Healthcare NE 501(c)(3) 11a CHI
 
 
 
(62) The Physician Network

8055 O Street Suite 300

Lincoln,NE68510
47-0780857 		Phys Practice NE 501(c)(3) 11a CHI Nebraska
 
 
 
(63) Good Samaritan Hospital

PO Box 1990

Kearney,NE68848
47-0379755 		HealthCare NE 501(c)(3) 3 CHI Nebraska
 
 
 
(64) Good Samaritan Hospital Foundation

PO Box 1810

Kearney,NE68848
47-0659443 		Fundraising NE 501(c)(3) 7 GSH
 
 
 
(65) Catholic Health Care Federation

198 Inverness Drive West

Englewood,CO80112
20-8473567 		Jurdic Person CO 501(c)(3) 11a CHI
 
 
 
(66) Saint Elizabeth Regional Medical Center

555 South 70th Street

Lincoln,NE68510
47-0379836 		Healthcare NE 501(c)(3) 3 CHI Nebraska
 
 
 
(67) Saint Elizabeth Foundation

555 South 70th Street

Lincoln,NE68510
47-0625523 		Fundraising NE 501(c)(3) 7 SERMC
 
 
 
(68) Saint Elizabeth Health Services

555 South 70th Street

Lincoln,NE68510
36-3233120 		Healthcare NE 501(c)(3) 3 SERMC
 
 
 
(69) Saint Francis Medical Center

PO Box 9804

Grand Island,NE68802
47-0376601 		HealthCare NE 501(c)(3) 3 CHI Nebraska
 
 
 
(70) Saint Francis Medical Center Foundation

PO Box 9804

Grand Island,NE68802
47-0630267 		Fundraising NE 501(c)(3) 7 SFMC
 
 
 
(71) St Mary's Hospital

1314 3rd Avenue

Nebraska City,NE68410
47-0443636 		Healthcare NE 501(c)(3) 3 CHI Nebraska
 
 
 
(72) St Mary's Hospital Foundation

1314 3rd Avenue

Nebraska City,NE68410
47-0707604 		Fundraising NE 501(c)(3) 7 SMH
 
 
 
(73) Saint Clare's Health Services Inc

25 Pocono Road

Denville,NJ07834
22-3639733 		Management NJ 501(c)(3) 7 CHI
 
 
 
(74) Saint Clare's Community Care

66 Ford Road

Denville,NJ07834
22-2876836 		Healthcare NJ 501(c)(3) 11b SCHS
 
 
 
(75) Saint Clare's Foundation Inc

66 Ford Road

Denville,NJ07834
22-2502997 		Fundraising NJ 501(c)(3) 7 SCHS
 
 
 
(76) Saint Clare's Hospital

66 Ford Road

Denville,NJ07834
22-3319886 		Healthcare NJ 501(c)(3) 3 CHI
 
 
 
(77) St Francis Life Care Corporation

19 Pocono Road

Denville,NJ07834
22-2536017 		Elderly Care NJ 501(c)(3) 9 SCHS
 
 
 
(78) Visiting Nurse Association of Saint Clar

191 Woodport Road

Sparta,NJ07871
22-1768334 		Home Health NJ 501(c)(3) 9 SCHS
 
 
 
(79) St Joseph Community Health Services

300 Central Ave SW Suite 3000W

Albuquerque,NM87102
71-0897107 		Community NM 501(c)(3) 11a CHI
 
 
 
(80) CHI Health Connect at Home - Fargo

4816 Amber Valley Parkway

Fargo,ND58104
27-1966847 		Healthcare ND 501(c)(3) 3 CHI
 
 
 
(81) Carrington Health Center

800 North 4th Street

Carrington,ND58421
45-0227311 		Healthcare ND 501(c)(3) 3 CHI
 
 
 
(82) Lisbon Area Health Services

905 Main Street

Lisbon,ND58054
82-0558836 		Healthcare ND 501(c)(3) 3 CHI
 
 
 
(83) Mercy Hospital of Devils Lake

1031 East Seventh Street

Devils Lake,ND58301
45-0227012 		Healthcare ND 501(c)(3) 3 CHI
 
 
 
(84) The Mercy Hospital of Devils Lake Fdn

1031 East Seventh Street

Devils Lake,ND58301
35-2367360 		Fundraising ND 501(c)(3) 11a MHDL
 
 
 
(85) Mercy Hospital of Valley City

570 Chautauqua Boulevard

Valley City,ND58072
45-0226553 		Healthcare ND 501(c)(3) 3 CHI
 
 
 
(86) Mercy Medical Center

1301 15th Avenue West

Williston,ND58801
45-0231183 		Healthcare ND 501(c)(3) 3 CHI
 
 
 
(87) Mercy Medical Foundation

1301 15th Avenue West

Williston,ND58801
45-0381803 		Fundraising ND 501(c)(3) 11a MMC
 
 
 
(88) Oakes Community Hospital

314 South 8th Street

Oakes,ND58474
45-0231675 		Healthcare ND 501(c)(3) 3 CHI
 
 
 
(89) Oakes Community Hospital Foundation

314 South 8th Street

Oakes,ND58474
71-0966606 		Fundraising ND 501(c)(3) 11a OCH
 
 
 
(90) St Joseph's Hospital and Health Center

30 West 7th Street

Dickinson,ND58601
45-0226429 		Healthcare ND 501(c)(3) 3 CHI
 
 
 
(91) Saint Joseph's Hospital Foundation

30 West 7th Street

Dickinson,ND58601
36-3418207 		Fundraising ND 501(c)(3) 11a SJHHC
 
 
 
(92) Villa Nazareth Inc

801 Page Drive

Fargo,ND58103
45-0226714 		LT Care ND 501(c)(3) 9 CHI
 
 
 
(93) Samaritan Health Partners

2222 Philadelphia Drive

Dayton,OH45406
31-1107411 		Healthcare OH 501(c)(3) 11a CHI
 
 
 
(94) Samaritan Behavioral Health

601 S Edwin C Moses Blvd

Dayton,OH45408
02-0633634 		Healthcare OH 501(c)(3) 3 SHP
 
 
 
(95) Samaritan Health Foundation

2222 Philadelphia Drive

Dayton,OH45406
23-7296923 		Fundraising OH 501(c)(3) 7 SHP
 
 
 
(96) The Good Samaritan Hospital of Cincinnat

619 Oak Street Accounting-3 West

Cincinnati,OH45206
31-0537486 		Healthcare OH 501(c)(3) 3 TRI-HEALTH
 
 
 
(97) The Community Limited Care Dialysis Cent

619 Oak Street Accounting-3 West

Cincinnati,OH45206
23-7419853 		Dialysis OH 501(c)(2) none GSH
 
 
 
(98) Good Samaritan College of Nursing & Heal

375 Dixmyth Ave

Cincinnati,OH45220
31-1778403 		Education KY 501(c)(3) 2 GHS
 
 
 
(99) Good Samaritan Foundation of Cincinnati

619 Oak Street Accounting-3 West

Cincinnati,OH45206
31-1206047 		Fundraising OH 501(c)(3) 11a GSH
 
 
 
(100) Hospital Association for St Joseph Hosp

7601 Osler Drive

Towson,MD21204
52-6050777 		Healthcare MD 501(c)(3) 9 SJMC
 
 
 
(101) Mercy Medical Center

2700 Stewart Parkway

Roseburg,OR97470
93-0386868 		Healthcare OR 501(c)(3) 3 CHI
 
 
 
(102) Centennial Medical Group Inc

2700 Stewart Parkway

Roseburg,OR97470
90-0433062 		Physicians OR 501(c)(3) 9 MMC
 
 
 
(103) Linus Oakes Inc

2700 Stewart Parkway

Roseburg,OR97470
93-0821381 		Senior Living OR 501(c)(3) 9 MMC
 
 
 
(104) Mercy Foundation Inc

2700 Stewart Parkway

Roseburg,OR97470
93-6088946 		Fundraising OR 501(c)(3) 7 MMC
 
 
 
(105) Mt St Joseph Inc

3060 SE Stark Street

Portland,OR97214
93-0386870 		Nursing Care OR 501(c)(3) 9 CHI
 
 
 
(106) St Anthony Hospital

1601 SE Court Avenue

Pendleton,OR97801
93-0391614 		Healthcare OR 501(c)(3) 3 CHI
 
 
 
(107) St Anthony Hospital Foundation

1601 SE Court Avenue

Pendleton,OR97801
93-0992727 		Fundraising OR 501(c)(3) 11a SA Hospital
 
 
 
(108) St Dominic at Ontario

351 SW 9th Street

Ontario,OR97914
93-0433692 		Healthcare OR 501(c)(3) 3 CHI
 
 
 
(109) St Francis of Baker City

3325 Pocahontas Road

Baker City,OR97814
93-0412495 		Healthcare OR 501(c)(3) 3 CHI
 
 
 
(110) St Joseph Health Ministries

1929 Lincoln Hwy E Ste 150

Lancaster,PA17602
23-2342997 		Health PA 501(c)(3) 11a CHI
 
 
 
(111) St Joseph Health Ministries Foundation

1929 Lincoln Hwy E Ste 150

Lancaster,PA17602
23-2605579 		Fundraising PA 501(c)(3) 11a SJHM
 
 
 
(112) St Joseph Health Services Inc

1929 Lincoln Hwy E Ste 150

Lancaster,PA17602
20-1425375 		Dental care PA 501(c)(3) 11a SJHM
 
 
 
(113) St Joseph Regional Health Network

2500 Bernville Road PO Box 316

Reading,PA19603
23-1352211 		Healthcare PA 501(c)(3) 3 CHI
 
 
 
(114) St Joseph Medical Group

2500 Bernville Road PO Box 316

Reading,PA19603
20-8544021 		Healthcare PA 501(c)(3) 9 BHC
 
 
 
(115) St Joseph Medical Center Foundation

2500 Bernville Road PO Box 316

Reading,PA19603
23-2649362 		Fundraising PA 501(c)(3) 11a SJRHN
 
 
 
(116) St Mary's Healthcare Center

801 East Sioux Avenue

Pierre,SD57501
46-0230199 		Healthcare SD 501(c)(3) 3 CHI
 
 
 
(117) Gettysburg Medical Center

606 East Garfield Avenue

Gettysburg,SD57442
46-0234354 		Healthcare SD 501(c)(3) 3 SMHC
 
 
 
(118) Memorial Health Care System Inc

2525 De Sales Avenue

Chattanooga,TN37404
62-0532345 		Healthcare TN 501(c)(3) 3 CHI
 
 
 
(119) Memorial Health Care System Foundation

2525 De Sales Avenue

Chattanooga,TN37404
62-1839548 		Fundraising TN 501(c)(3) 7 MHCS
 
 
 
(120) Memorial Health Partners Foundation Inc

6028 Shallowford Road

Chattanooga,TN37421
03-0417049 		Healthcare TN 501(c)(3) 9 MHCS
 
 
 
(121) Franciscan Health System FKA Franciscan

1717 South J Street

Tacoma,WA98405
91-0564491 		Healthcare WA 501(c)(3) 3 CHI
 
 
 
(122) Enumclaw Regional Hospital Association

1450 Battersby Avenue

Enumclaw,WA98022
91-0715805 		Healthcare WA 501(c)(3) 3 FHS
 
 
 
(123) Franciscan Foundation

1717 South J Street

Tacoma,WA98405
91-1145592 		Fundraising WA 501(c)(3) 9 FHS
 
 
 
(124) Franciscan Medical Group

1708 South Yakima Avenue

Tacoma,WA98405
91-1939739 		Healthcare WA 501(c)(3) 9 FHS
 
 
 
(125) Franciscan Villa of South Milwaukee Inc

3601 South Chicago Avenue

South Milwaukee,WI53172
39-1093829 		Healthcare WI 501(c)(3) 9 CHI
 
 
 
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) CHI Operating Investment Program LP

198 Inverness Drive West
Englewood,CO80112
47-0727942 		Investments CO CHI
  		Investment 139,679,805 2,069,974,790   No 371,292 Yes   100.000 %
(2) North River Surgery Center LLC

2209 Wildwood Avenue
Sherwood,AR72120
71-0799771 		Ambul Surg Ctr AR SVIMC
  		Related 198,313 1,758,688   No     No 57.450 %
(3) 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     No 50.100 %
(4) OrthoColorado LLC

11650 West 2nd Place
Lakewood,CO80255
37-1577105 		Ortho Hospital CO THC
  		Related -3,249,314 10,905,384   No     No 60.000 %
(5) Penrad Imaging

1390 Kelly Johnson Blvd
Colorado Springs,CO80920
84-1072619 		Medical Imaging CO THC
  		Related 1,857,228 5,457,224   No     No 70.000 %
(6) St Anthony Regional Mtn Cancer Center

4231 W 16th Avenue
Denver,CO80112
37-1568013 		Cancer Center CO THC
  		Related -290,552     No     No 51.000 %
(7) 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     No 51.000 %
(8) Bluegrass Regional Imaging Center

1218 South Broadway Suite 310
Lexington,KY40504
61-1386736 		Diagnostic KY SJ HospitalLex
  		Related       No     No 65.000 %
(9) St Joseph-PAML LLC

424 Lewis Hargett Circle Ste 160
Lexington,KY40503
45-2116736 		Mgmt Svcs KY SJHS
  		Related       No   Yes   62.500 %
(10) Saint Joseph SCA Holdings LLC

424 Lewis Hargett Circle Ste 160
Lexington,KY40503
45-3801157 		OP Surgery DE SJHS
  		Related       No   Yes   51.000 %
(11) Surgery Center of Lexington LLC

1451 Harrodsburg Road
Lexington,KY40504
62-1179539 		Surgery Center DE SJHS
  		Related 808,840 4,236,901   No   Yes   51.000 %
(12) Ruxton Surgicenter LLC

8322 Bellona Avenue Suite 201
Baltimore,MD21204
52-2095835 		Surgery Center MD SJMC
  		Related       No   Yes   51.000 %
(13) Avantas LLC

1207 South 13 Street
Omaha,NE68108
39-2045003 		Healthcare NE AHMH
  		Unrelated       No     No 95.000 %
(14) Healthcare Support Services LLC

PO Box 9804
Grand Island,NE68802
72-1546196 		Laundry NE CHI
  		Related 196,124 3,913,481   No -58,436   No 100.000 %
(15) Central Nebraska Home Care Services

PO Box 1146-4510 Second Avenue
Kearney,NE68848
47-0692112 		Healthcare Srvc NE HSEINC
  		Related -99,941 1,021,498   No -48,712 Yes   100.000 %
(16) Superior Medical Imaging LLC

5000 North 26th Street
Lincoln,NE68521
26-2884555 		OP Diagnostics NE SERMC
  		Related       No     No 51.000 %
(17) Central Nebraska Rehab Services

3004 W Faidley Ave
Grand Island,NE68802
81-0653461 		Physical Therapy NE CHI
  		Related 1,857,991 2,262,775   No     No 51.000 %
(18) St Francis Medical Center Associates

1717 South J Street
Tacoma,WA98405
91-1352698 		Med. Office WA FHS
  		Related 116,948 1,652,280   No     No 54.210 %
(19) 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     No 60.000 %
(20) Berywood Office Properties LLC

400 Berywood Trail
Cleveland,TN37312
62-1875199 		Phys Office TN MHCS
  		Related       No   Yes   63.000 %
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 Service
3900 Olympic Boulevard Suite 400
Erlanger,KY41018
84-1112049 		Management Servic CO CHI
  		C Corp   3,267,441 100.000 %
(2) Captive Management Initiatives
6028D Shallowford Road
Chattanooga,TN37422
98-0663022 		Captive Managemen CJ CHI
  		C Corp     100.000 %
(3) Center for Translational Research
198 Inverness Drive West
Englewood,CO80112
27-2269511 		Healthcare CO CHI
  		C Corp -2,247,962 1,668,589 100.000 %
(4) First Initiatives Insurance Ltd
1415 Southgate
Pendleton,OR97801
98-0203038 		Insurance CJ CHI
  		C Corp     100.000 %
(5) Franciscan Services Inc
198 Inverness Drive West
Englewood,CO80112
23-2487967 		Healthcare CO CHI
  		C Corp -507,578 11,914,284 100.000 %
(6) SJH Services Corporation
198 Inverness Drive West
Englewood,CO80112
23-2307408 		Healthcare CO FSI
  		C Corp -518,360 3,180,100 100.000 %
(7) St Joseph Development Company Inc
1717 South J Street
Tacoma,WA98405
91-1480569 		Rental WA FSI
  		C Corp -36,395 12,168,022 100.000 %
(8) Towson Management Inc
7601 Osler Drive
Towson,MD21204
52-1710750 		Management Servic MD FSI
  		C Corp -469,016 498,393 100.000 %
(9) Nazareth Assurance Company
76 St Paul Street Suite 500
Burlington,VT05401
03-0304831 		Insurance VT CHI
  		C Corp -379 123,535 100.000 %
(10) St Vincent Community Health Services In
Two St Vincent Circle
Little Rock,AR72205
71-0710785 		Healthcare AR SVIMC
  		C Corp 2,309,129 14,049,375 100.000 %
(11) Comcare Services
4231 W 16th Avenue
Denver,CO80204
84-0904813 		Inactive CO CHIC
  		C Corp     100.000 %
(12) Des Moines Medical Center Inc
1111 6th Avenue
Des Moines,IA50314
42-0837382 		Real Estate IA CHI-IA Corp
  		C Corp   1,253,452 92.980 %
(13) Mercy Park Apartments Ltd
1111 6th Avenue
Des Moines,IA50314
42-1202422 		Housing IA CHI-IA Corp
  		C Corp 264,489 1,796,053 100.000 %
(14) Central Kansas Health Services Associati
3515 Broadway
Great Bend,KS67530
48-1042853 		MEDICAL EQUIPMENT KS CKMC
  		C Corp     100.000 %
(15) SJL Physician Management Services Inc
424 Lewis Hargett Cr 160
Lexington,KY40503
27-0164198 		Management KY SJHS
  		C Corp     100.000 %
(16) St Joseph Office Park Association
1401 HarrodsBurg Road Bldg B70
Lexington,KY40504
61-1079899 		Management KY SJHS
  		C Corp 16,644 882,139 85.000 %
(17) Mercy Health Services Corporation
2727 McClelland Blvd
Joplin,MO64804
43-1457881 		DME MO St John's RMC
  		C Corp -1,533,371 1,369,083 100.000 %
(18) Good Samaritan Outreach Services
PO BOX 1990
Kearney,NE68848
47-0659440 		MEDICAL CLINIC NE CHI Nebraska
  		C Corp -2,921,063 355,110 100.000 %
(19) Health Systems Enterprises Inc
PO BOX 1990
Kearney,NE68848
47-0664558 		MANAGEMENT NE GSH
  		C Corp 25,289 1,443,049 100.000 %
(20) Saint Clare's Primary Care Inc
66 Ford Road
Denville,NJ07834
22-2441202 		Billing Services NJ SCCC
  		C Corp -342,970 2,177,166 100.000 %
(21) MedQuest
1301 15th Avenue West
Williston,ND58801
45-0392137 		Sale of DME ND MHof Williston
  		C Corp 9,852 962,554 100.000 %
(22) Consolidated Health Services
1700 Edison Drive
Milford,OH45150
31-1378212 		Home Health OH CHI
  		C Corp   11,595,125 100.000 %
(23) American Nursing Care
1700 Edison Drive
Milford,OH45150
31-1085414 		Home Health OH CHS
  		C Corp 1,778,617 44,470,358 100.000 %
(24) Amerimed Inc
1700 Edison Drive
Milford,OH45150
31-1158699 		Home Health OH ANC
  		C Corp 2,395,230 11,869,657 100.000 %
(25) Patient Transport Services Inc
1700 Edison Drive
Milford,OH45150
31-1100798 		Home Health OH ANC
  		C Corp 662,425 5,325,941 100.000 %
(26) Samaritan Family Care Inc
40 W Fourth St 1700
Dayton,OH45402
31-1299450 		Healthcare OH SHP
  		C Corp     100.000 %
(27) Mercy Services Corp
2700 Stewart Parkway
Roseburg,OR97470
93-0824308 		Retail Sales OR MMC
  		C Corp -690,267 954,798 100.000 %
(28) St Anthony Development Company
1415 Southgate
Pendleton,OR97801
93-1216943 		Athletic Club OR St Anthony H
  		C Corp 53,891 3,007,554 100.000 %
(29) CGH Realty Company Inc
215 N 12th St
Reading,PA19603
23-2326801 		Real Estate PA SJHM
  		C Corp 1,007 42,415 100.000 %
(30) Caduceus Medical Associates Inc
6028 Shallowford Road Suite D
Chattanooga,TN37422
62-1570736 		Healthcare TN MHCS
  		C Corp   1,008 100.000 %
(31) Mountain Management Services Inc
6028D Shallowford Road
Chattanooga,TN37422
62-1570739 		mgmt svc org TN MHCS
  		C Corp -386,020 4,667,998 100.000 %
(32) Physician Health System Network
1149 Market St
Tacoma,WA98402
91-1746721 		Health Org. WA FHS
  		C Corp     100.000 %
(33) Healthcare Mgmt Services Org Inc
1149 Market St
Tacoma,WA98402
91-1865474 		Health Org. WA FHS
  		C Corp     100.000 %
(34) Harold W Rase 1995 Charitable Unittrust
30 West 7th Street
Dickinson,ND58601
45-6090420 		Investments ND SJHHC
  		Trust 1,240 21,533 100.000 %
(35) Harold W Rase 1996 Charitable Unittrust
30 West 7th Street
Dickinson,ND58601
20-6037112 		Investments ND SJHHC
  		Trust 900 15,495 100.000 %
(36) Harold W Rase 1997 Charitable Unittrust
30 West 7th Street
Dickinson,ND58601
20-6037104 		Investments ND SJHHC
  		Trust 1,025 20,261 100.000 %
(37) Harold W Rase 1999 Charitable Unittrust
30 West 7th Street
Dickinson,ND58601
20-6037099 		Investments ND SJHHC
  		Trust 1,313 25,027 100.000 %
(38) James & Henrietta Nistler Unitrust
30 West 7th Street
Dickinson,ND58601
20-6021899 		Investments ND SJHHC
  		Trust -16,708 41,455 100.000 %
(39) Joseph A Schuster Annuity Trust #1
400 Univerity Avenue
Des Moines,IA50314
42-1195122 		Investments IA MFDM
  		Trust 18,924 441,488 100.000 %
(40) Ray & Shirley David 1999 Unitrust
30 West 7th Street
Dickinson,ND58601
20-6037077 		Investments ND SJHHC
  		Trust 1,250 24,194 100.000 %
(41) Tom Deyle Charitable Remainder Unitrust
PO Box 1810
Kearney,NE68848
47-6192393 		Investments NE GSHF
  		Trust 4,884 166,321 100.000 %
(42) David Deyle Charitable Remainder Unitrus
PO Box 1810
Kearney,NE68848
47-6192395 		Investments NE GSHF
  		Trust 4,880 166,425 100.000 %
(43) Jeanne Deyle Charitable Remainder Unitru
PO Box 1810
Kearney,NE68848
47-6192398 		Investments NE GSHF
  		Trust 4,880 166,320 100.000 %
(44) Lodesca Miller Charitable Remainder Unit
PO Box 1810
Kearney,NE68848
47-6186933 		Investments NE GSHF
  		Trust 3,387 86,367 100.000 %
(45) Robert & Wanda Charitable Remainder Unit
PO Box 1810
Kearney,NE68848
26-6191916 		Investments NE GSHF
  		Trust 13,030 537,775 100.000 %
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
 
No
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
 
No
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) Catholic Health Initiatives

 c 79,539  
(2) Catholic Health Initiatives

 l 2,256,572  
(3) Catholic Health Initiatives

 o 90,979  
(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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