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
THE SUMMIT MEDICAL FITNESS CENTER
Employer identification number
20-3752312
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization?
................
11g(i)
(ii)
a family member of a person described in (i) above?
......................
11g(ii)
(iii)
a 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
h
Provide the following information about the supported organization(s).
(i) Name of supported organization
(ii) EIN
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions))
(iv) Is the organization in col. (i) listed in your governing document?
(v) Did you notify the organization in col. (i) of your support?
(vi) Is the organization in col. (i) organized in the U.S.?
(vii) Amount of support?
Yes
No
Yes
No
Yes
No
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the
organization failed to qualify under Part III. If the organization fails to
qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3
The value of services or facilities furnished by a governmental unit to the organization without charge..
4
Total. Add lines 1 through 3..
5
The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included
on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6
Public Support. Subtract line 5 from line 4.
Section B. Total Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
7
Amounts from line 4..
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
9
Net income from unrelated business activities, whether or not the business is regularly carried on..
10
Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..
11
Total support (Add lines 7 through 10).
12
Gross receipts from related activities, etc. (See instructions.)
..................
12
13
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here..........................................
Section C. Computation of Public Support Percentage
14
Public Support Percentage for 2010 (line 6 column (f) divided by line 11 column (f))
.........
14
15
Public Support Percentage for 2009 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2010.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
......................
b
33 1/3% support test—2009.
If the organization did not check the box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2010.
If the organization did not check a box on line 13, 16a, or 16b and line 14
is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported
organization
..................................................
b
10%-facts-and-circumstances test—2009.
If the organization did not check a box on line 13, 16a, 16b, or 17a and line
15 is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported organization
..............................................
18
Private Foundation
If the organization did not check a box on line 13, 16a, 16b, 17a or 17b, check this box and see
instructions
...................................................
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization
failed to qualify under Part II. If the organization fails to qualify under
the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2,711,235
2,791,143
2,631,453
2,633,086
10,766,917
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......
789,625
830,160
917,268
1,127,465
3,664,518
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.
3,500,860
3,621,303
3,548,721
3,760,551
14,431,435
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
0
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.
0
c
Add lines 7a and 7b..
0
8
Public Support (Subtract line 7c from line 6.)
14,431,435
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...
3,500,860
3,621,303
3,548,721
3,760,551
14,431,435
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
99,081
98,069
119,675
101,169
417,994
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
99,081
98,069
119,675
101,169
417,994
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.).
3,599,941
3,719,372
3,668,396
3,861,720
14,849,429
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
97.190 %
16
Public support percentage from 2009 Schedule A, Part III, line 15
...............
16
97.120 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2010 (line 10c column (f) divided by line 13 column (f))
......
17
2.810 %
18
Investment income percentage from 2009 Schedule A, Part III, line 17
.............
18
2.880 %
19a
33 1/3% support tests—2010.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3% and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
..........
b
33 1/3% support tests—2009.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
....
20
Private Foundation
If the organization did not check a box on line 14, 19a or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 4
Part IV
Supplemental Information.
Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
Explanation
Schedule A (Form 990 or 990-EZ) 2010
Additional Data
Software ID:
Software Version:
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
THE SUMMIT MEDICAL FITNESS CENTER
Employer identification number
20-3752312
Identifier
Return Reference
Explanation
FORM 990, PART VI, SECTION A, LINE 6
THE SUMMIT MEDICAL FITNESS CENTER HAS ONE MEMBER, NORTHWEST HEALTHCARE CORPORATION.
FORM 990, PART VI, SECTION A, LINE 7B
TO BE EFFECTIVE, SIGNIFICANT DECISIONS OF THE GOVERNING BOARD MUST BE APPROVED BY ITS MEMBER, NORTHWEST HEALTHCARE CORPORATION. SIGNIFICANT DECISIONS INCLUDE CHANGES TO THE BOARD OF DIRECTORS, CONFIRMATION OF THE ANNUAL BUDGETS, ENTERING INTO LARGE CONTRACTS, AND REORGANIZATION OF THE ORGANIZATION.
FORM 990, PART VI, SECTION B, LINE 11
THE FORM 990 IS MAILED TO ALL BOARD MEMBERS WITH THE FEBRUARY BOARD PACKET. THE BOARD MEMBERS HAVE A CHANCE TO REVIEW THE FORM BEFORE THE BOARD MEETING WHERE A PRESENTATION ON THE FORM 990 IS DONE AND A QUESTION AND ANSWER SESSION HELD.
FORM 990, PART VI, SECTION B, LINE 12C
THE CONFLICT OF INTEREST POLICY COVERS ALL TRUSTEES, DIRECTORS, OFFICERS, AND KEY EMPLOYEES. THE COMPLIANCE OFFICE REVIEWS THEM, IDENTIFIES POTENTIAL CONFLICTS, AND FORWARDS TO THE ADMINISTRATIVE TEAM IF A POTENTIAL CONFLICT EXISTS, AS OUTLINED IN THE ORGANIZATIONAL POLICY.
FORM 990, PART VI, SECTION B, LINE 15
NORTHWEST HEALTHCARE HAS A CONSISTENT COMPENSATION PHILOSOPHY FOR ALL ITS EMPLOYEES, INCLUDING THE SENIOR EXECUTIVES. SALARY AND BENEFITS FOR THE PRESIDENT/CHIEF EXECUTIVE OFFICER ARE DETERMINED BY THE NORTHWEST HEALTHCARE BOARD OF DIRECTORS EXECUTIVE COMPENSATION COMMITTEE AND REPORTED TO THE NORTHWEST HEALTHCARE BOARD. THE EXECUTIVE COMPENSATION COMMITTEE OF THE BOARD REVIEWS BASE SALARY AND TOTAL COMPENSATION DATA FROM AN ARRAY OF COMPENSATION SURVEYS OF HOSPITALS THAT ARE SIMILAR IN SIZE AND COMPLEXITY TO NORTHWEST HEALTHCARE. THESE REPORTS ARE CONSIDERED BY THE COMMITTEE, AND A DETERMINATION IS MADE AS TO THE STATUS OF THE BASE SALARY, BENEFITS, AND TOTAL COMPENSATION FOR THE PRESIDENT/CEO. THE BOARD AND EXECUTIVE COMPENSATION COMMITTEE EMBRACE THE PHILOSOPHY OF MAINTAINING A COMPENSATION LEVEL WHICH WILL FAVOR RETENTION OF KEY LEADERSHIP IN ORDER TO MAINTAIN STABILITY IN KEY INITIATIVES. ADDITIONALLY, THE PRESIDENT/CEO UTILIZES THE PERIODIC RETENTION OF A COMPENSATION CONSULTANT AND MARKET INFORMATION PROVIDED TO DETERMINE RECOMMENDATIONS FOR OTHER SENIOR EXECUTIVES AND ENGAGES IN AN ANALYSIS THROUGH USE OF INDEPENDENT SURVEY RESULTS. THE BOARD COMMITTEE ALSO INCLUDES A REVIEW OF PERFORMANCE TARGETS WHICH ALLOW EXECUTIVES TO EARN ADDITIONAL COMPENSATION. THESE MEASURES INCLUDE ORGANIZATIONAL AND INDIVIDUAL GOALS, EFFORTS TO FURTHER THE MISSION AND VISION OF NORTHWEST HEALTHCARE, QUALITY INDICATORS, CUSTOMER/PATIENT SATISFACTION, AND FINANCIAL PERFORMANCE OBJECTIVES. THE BOARD COMMITTEE REVIEWS BENEFIT LEVELS AND TOTAL COMPENSATION TO ENSURE APPROPRIATENESS IN THE NOT-FOR-PROFIT HEALTH CARE SECTOR. THE BOARD EXECUTIVE COMPENSATION COMMITTEE MAKES ITS REPORT TO THE NORTHWEST HEALTHCARE BOARD OF DIRECTORS.
FORM 990, PART VI, SECTION C, LINE 19
ONLY FORM 990 IS AVAILABLE.
AVERAGE HOURS PER WEEK
FORM 990, PART VII, SECTION A, COLUMN (B)
THE OFFICERS OF THE SUMMIT MEDICAL FITNESS CENTER DIVIDE THEIR TIME AMONG THE OTHER RELATED ENTITIES FOR WHICH THEY ARE ALSO OFFICERS. THEIR TOTAL AVERAGE WEEKLY HOURS DEVOTED TO ALL OF THE ENTITIES IS IN EXCESS OF 50 HOURS.
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:
-
TIN:
TY 2010 ReasonableCauseExplanation
Name:
THE SUMMIT MEDICAL FITNESS CENTER
EIN: 20-3752312
Explanation:
THIS RETURN IS BEING FILED BETWEEN MARCH 1, 2012 AND MARCH 30, 2012, AS DIRECTED BY THE IRS IN NOTICE 2012-4, BECAUSE ELECTRONIC FILING WAS NOT AVAILABLE JANUARY 1, 2012 THROUGH FEBRUARY 29, 2012. WE REQUEST THAT PENALTIES BE WAIVED BECAUSE IT WOULD BE INEQUITABLE TO IMPOSE A PENALTY ON US DUE TO THE UNUSUAL CIRCUMSTANCES REQUIRING US TO DELAY THE FILING OF THE RETURN.