Department of the Treasury Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
CHI KENTUCKY INC
Employer identification number
20-2741651
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization?
................
11g(i)
No
(ii)
a family member of a person described in (i) above?
......................
11g(ii)
No
(iii)
a 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
No
h
Provide the following information about the supported organization(s).
(i) Name of supported organization
(ii) EIN
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions))
(iv) Is the organization in col. (i) listed in your governing document?
(v) Did you notify the organization in col. (i) of your support?
(vi) Is the organization in col. (i) organized in the U.S.?
(vii) Amount of support?
Yes
No
Yes
No
Yes
No
(1)
CATHOLIC HEALTH INITIATIVES
470617373
9
Yes
Yes
Yes
0
Total
0
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the
organization failed to qualify under Part III. If the organization fails to
qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3
The value of services or facilities furnished by a governmental unit to the organization without charge..
4
Total. Add lines 1 through 3..
5
The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included
on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6
Public Support. Subtract line 5 from line 4.
Section B. Total Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
7
Amounts from line 4..
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
9
Net income from unrelated business activities, whether or not the business is regularly carried on..
10
Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..
11
Total support (Add lines 7 through 10).
12
Gross receipts from related activities, etc. (See instructions.)
..................
12
13
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here..........................................
Section C. Computation of Public Support Percentage
14
Public Support Percentage for 2010 (line 6 column (f) divided by line 11 column (f))
.........
14
15
Public Support Percentage for 2009 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2010.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
......................
b
33 1/3% support test—2009.
If the organization did not check the box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2010.
If the organization did not check a box on line 13, 16a, or 16b and line 14
is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported
organization
..................................................
b
10%-facts-and-circumstances test—2009.
If the organization did not check a box on line 13, 16a, 16b, or 17a and line
15 is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported organization
..............................................
18
Private Foundation
If the organization did not check a box on line 13, 16a, 16b, 17a or 17b, check this box and see
instructions
...................................................
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization
failed to qualify under Part II. If the organization fails to qualify under
the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2
Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
6
Total. Add lines 1 through 5.
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
b
Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c
Add lines 7a and 7b..
8
Public Support (Subtract line 7c from line 6.)
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
9
Amounts from line 6...
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
13
Total support (Add lines 9, 10c, 11 and 12.).
14
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public Support Percentage for 2010 (line 8 column (f) divided by line 13 column (f))
.........
15
16
Public support percentage from 2009 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2010 (line 10c column (f) divided by line 13 column (f))
......
17
18
Investment income percentage from 2009 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2010.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3% and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
..........
b
33 1/3% support tests—2009.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
....
20
Private Foundation
If the organization did not check a box on line 14, 19a or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 4
Part IV
Supplemental Information.
Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
Explanation
Schedule A (Form 990 or 990-EZ) 2010
Additional Data
Software ID:
10000128
Software Version:
v2010.1.0
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
CHI KENTUCKY INC
Employer identification number
20-2741651
Identifier
Return Reference
Explanation
PROGRAM SERVICE ACCOMPLISHMENTS
FORM 990, PART III, LINE 4A
CHI KENTUCKY WAS FORMED IN CONNECTION WITH THE CONSOLIDATION OF TWO LOUISVILLE, KENTUCKY, BASED HOSPITAL SYSTEMS: CARITAS HEALTH SERVICES, INC. AND JEWISH HOSPITAL HEALTHCARE SERVICES, INC. THESE TWO ORGANIZATIONS FORMED A JOINT OPERATING ORGANIZATION - JEWISH HOSPITAL AND ST. MARY'S HEALTHCARE, INC. (JHSMH) - TO OPERATE THE COMBINED CHARITABLE ACTIVITIES PREVIOUSLY OPERATED SEPARATELY BY THE TWO SYSTEMS. CHI KENTUCKY, ONE OF THE TWO MEMBERS OF JHSMH, WAS FORMED AS A SUBORDINATE OF CATHOLIC HEALTH INITIATIVES (CHI) TO CARRY OUT CERTAIN GOVERNANCE AND OTHER FUNCTIONS OF CHI VIS-A-VIS JHSMH. CHI KENTUCKY PROVIDES FOCUSED OVERSIGHT OVER THE CHARITABLE ACTIVITIES OF JHSMH AND HOLDS TITLE TO REAL ESTATE FORMERLY OWNED BY CARITAS HEALTH SERVICES, INC.
Classes of members or stockholders
Form 990, Part VI, Section A, Line 6
THE ORGANIZATION'S SOLE CORPORATE MEMBER IS CATHOLIC HEALTH INITIATIVES (CHI), A COLORADO NONPROFIT CORPORATION.
Members or stockholders electing members of governing body
Form 990, Part VI, Section A, Line 7a
THE ORGANIZATION'S SOLE CORPORATE MEMBER HAS THE POWER TO APPOINT, REPLACE OR REMOVE THE MEMBERS OF THE BOARD OF DIRECTORS.
Decisions requiring approval by members or stockholders
Form 990, Part VI, Section A, Line 7b
THE ORGANIZATION'S CORPORATE MEMBER IS CATHOLIC HEALTH INITIATIVES (CHI). PURSUANT TO SECTION 5.4.1 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: - SUBSTANTIAL CHANGE IN THE MISSION OR PHILOSOPHY OF CHI KENTUCKY; - AMENDMENT OF THE CORPORATE DOCUMENTS OF CHI KENTUCKY; - APPROVE MEMBERS OF THE CHI KENTUCKY BOARD; - REMOVAL OF A MEMBER OF THE GOVERNING BODY OF CHI KENTUCKY; - APPROVAL OF ISSUANCE OF DEBT BY CHI KENTUCKY; - APPROVAL OF PARTICIPATION OF CHI KENTUCKY IN A JOINT VENTURE; - APPROVAL OF FORMATION OF A NEW CORPORATION BY CHI KENTUCKY ; - APPROVAL OF A MERGER INVOLVING CHI KENTUCKY; - APPROVAL OF THE SALE OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF CHI KENTUCKY; - TO REQUIRE THE TRANSFER OF ASSETS BY CHI KENTUCKY TO CHI TO ACCOMPLISH CHI'S GOALS AND OBJECTIVES, AND TO SATISFY CHI DEBTS; AND - ADOPTION OF LONG RANGE AND STRATEGIC PLANS FOR CHI KENTUCKY. PURSUANT TO SECTION 5 OF THE ORGANIZATION'S BYLAWS, CHI MAY, IN EXERCISE OF ITS APPROVAL POWERS, GRANT OR WITHHOLD APPROVAL IN WHOLE OR IN PART, OR MAY, IN ITS COMPLETE DISCRETION, AFTER CONSULTATION WITH THE BOARD AND THE PRESIDENT AND CHIEF EXECUTIVE OFFICER OF THE ORGANIZATION, RECOMMEND SUCH OTHER OR DIFFERENT ACTIONS AS IT DEEMS APPROPRIATE.
Review of form 990 by governing body
Form 990, Part VI, Section B, Line 11a
THE CHI KENTUCKY TREASURER IS PROVIDED A COPY OF THE FORM 990, AS PREPARED BY THE CHI TAX DEPARTMENT, FOR REVIEW AND SIGNATURE. A COPY IS THEN DISTRIBUTED TO EACH MEMBER OF THE BOARD OF DIRECTORS. SUBSEQUENT TO 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.
Conflict of interest policy
Form 990, Part VI, Section B, Line 12c
THE ORGANIZATION HAS ADOPTED CATHOLIC HEALTH INITIATIVES' (CHI) CONFLICT OF INTEREST POLICY. THE FOLLOWING CHI CONFLICT OF INTEREST POLICY APPLIES TO THE CHI KENTUCKY OFFICERS AND BOARD MEMBERS WHO ARE ALSO MEMBERS OF THE BOARD OF STEWARDSHIP TRUSTEES, OFFICERS, AND EMPLOYEES OF CHI. ALL CHI OFFICERS, TRUSTEES AND EMPLOYEES ARE COVERED BY A CONFLICT OF INTEREST POLICY. THE BOARD OF STEWARDSHIP TRUSTEES CONFLICT OF INTEREST POLICY PROVIDES THAT ALL MEMBERS OF THE BOARD OF STEWARDSHIP TRUSTEES AND OFFICERS ARE REQUIRED TO PROMPTLY AND FULLY DISCLOSE TO THE BOARD CHAIR SITUATIONS THAT MAY CREATE A CONFLICT OF INTEREST WHEN HE OR SHE BECOMES AWARE OF THE SITUATION. IN ADDITION, ALL MEMBERS OF THE BOARD OF STEWARDSHIP TRUSTEES, INCLUDING OFFICERS OF THE BOARD, ARE REQUIRED TO ANNUALLY DISCLOSE ANY CONFLICTS OF INTEREST VIA COMPLETION OF A CONFLICT OF INTEREST FORM WHICH IS REVIEWED BY THE ORGANIZATION'S SENIOR VICE PRESIDENT LEGAL SERVICES AND GENERAL COUNSEL. ANY RESULTING POTENTIAL INVESTIGATION OF CONFLICT(S) OF INTEREST AS HE OR SHE DEEMS APPROPRIATE; DOCUMENTATION OF CONCLUSIONS WITH RESPECT TO EXISTENCE OF A CONFLICT (INCLUDING RELEVANT FACTS AND CIRCUMSTANCES); AND REPORTING TO THE EXECUTIVE COMMITTEE CONCERNING THE REVIEW, EVALUATION AND CONFLICT DETERMINATION. TO THE EXTENT THAT THE BOARD CHAIR AND ANY OTHER TRUSTEE DISAGREE AS TO WHETHER A CIRCUMSTANCE GIVES RISE TO A CONFLICT, THE BOARD'S EXECUTIVE COMMITTEE MAKES THE FINAL DETERMINATION AS TO THE EXISTENCE OF A CONFLICT. THE POTENTIALLY CONFLICTED BOARD MEMBER IS EXCLUDED FROM VOTING AS TO THE EXISTENCE OF A CONFLICT, AND IS EXCUSED FROM THE ROOM WHILE VOTING CONCERNING THE MATTER IS CONDUCTED. IN ANY CIRCUMSTANCE WHERE A BOARD MEMBER HAS BEEN IDENTIFIED AS HAVING A CONFLICT OF INTEREST WITH RESPECT TO A PARTICULAR TRANSACTION, THAT BOARD MEMBER IS ALSO EXCLUDED FROM VOTING WITH RESPECT TO THAT TRANSACTION. THE CONFLICT OF INTEREST POLICY WITH RESPECT TO CHI EMPLOYEES REQUIRES THAT EMPLOYEES AT THE LEVEL OF DIRECTOR AND ABOVE MUST CERTIFY UPON HIRING THAT THEY HAVE NO CONFLICT OF INTEREST. FURTHER, THESE INDIVIDUALS ARE REQUIRED TO DISCLOSE TO THEIR SUPERVISORS ANY CONFLICTS THAT ARISE DURING THE YEAR. FINALLY, THESE INDIVIDUALS MUST, IN CONJUNCTION WITH THE PERFORMANCE EVALUATION PROCESS, ANNUALLY CERTIFY THAT NO CONFLICTS EXIST.
Process used to establish compensation of top management official
Form 990, Part VI, Section B, Line 15a
THE ORGANIZATION'S PRESIDENT'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 CHIS COMPENSATION PHILOSOPHY, AND FOR COMPARABILITY TO THE NOT-FOR-PROFIT HEALTHCARE MARKET. THIS INDEPENDENT REVIEW IS DELIVERED BY HAY GROUP TO THE HR COMMITTEE OF THE CHI BOARD OF STEWARDSHIP TRUSTEES ANNUALLY AT THEIR SEPTEMBER MEETING AND MINUTES ARE SHARED WITH THE FULL BOARD AT THE DECEMBER MEETING. THE LAST REVIEW WAS SEPTEMBER, 2011. IN ADDITION, IN DECEMBER 2009, HAY GROUP COMPLETED A COMPREHENSIVE REVIEW OF ALL POSITIONS AT THE LEVEL OF VICE PRESIDENT AND ABOVE TO DETERMINE AND VALIDATE APPROPRIATE COMPENSATION LEVELS.
Public Disclosure
Form 990, Part VI, Section C, Line 19
THE ORGANIZATION'S GOVERNING DOCUMENTS ARE AVAILABLE FROM THE KENTUCKY SECRETARY OF STATE. THE ORGANIZATION'S CONFLICT OF INTEREST POLICY IS NOT AVAILABLE TO THE PUBLIC. THE ORGANIZATION'S FINANCIAL STATEMENTS ARE INCLUDED IN CATHOLIC HEALTH INITIATIVES' CONSOLIDATED AUDITED FINANCIAL STATEMENTS THAT ARE AVAILABLE AT WWW.CATHOLICHEALTHINIT.ORG OR AT WWW.DACBOND.ORG.
PROCESS USED TO ESTABLISH COMPENSATION OF OTHER OFFICERS/KEY EMPLOYEES
FORM 990, PART VI, SECTION B, LINE 15B
DURING THE TAX YEAR ENDED 6/30/11, NO OTHER OFFICERS, DIRECTORS, TRUSTEES OR KEY EMPLOYEES RECEIVED COMPENSATION FROM THE ORGANIZATION. ANY EXECUTIVE COMPENSATION PAID TO OTHER OFFICERS, DIRECTORS, TRUSTEES OR KEY EMPLOYEES BY RELATED ORGANIZATIONS WAS SET BY THE RELATED ORGANIZATION'S COMPENSATION COMMITTEE UTILIZING BOTH AN INDEPENDENT CONSULTANT AND COMPARABILITY STUDIES TO DETERMINE COMPENSATION.
DOCUMENT RETENTION AND DESTRUCTION POLICY
FORM 990, PART VI, SECTION B, LINE 14
THE ORGANIZATION HAS A DOCUMENT RETENTION AND DESTRUCTION POLICY; HOWEVER THE POLICY HAD NOT BEEN FORMALLY ADOPTED BY THE GOVERNING BOARD AS OF THE END OF THE TAX YEAR.
ESTIMATE OF HOURS DEVOTED TO RELATED ORGANIZATIONS
FORM 990, PART VII, SECTION A, LINE 1A
THE INDIVIDUALS LISTED IN PART VII THAT REPORT COMPENSATION PAID BY A RELATED ORGANIZATION DEVOTE APPROXIMATELY 60 HOURS PER WEEK TO THE RELATED ORGANIZATIONS AND RECEIVE COMPENSATION IN EXCHANGE FOR THEIR SERVICES PROVIDED.
Other changes in net assets or fund balances
Form 990, Part XI, Line 5
UNREALIZED EQUITY CHANGES - 2240000;
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.