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
2011
Open to Public Inspection
A For the calendar year, or tax year beginning 01-01-2011 and ending 12-31-2011
BCheck if applicable:
CName of organization
ALLEN MEDICAL CENTER FOUNDATION
 
Doing Business As
MERCY ALLEN HOSPITAL FOUNDATION
 
Number and street (or P.O. box if mail is not delivered to street address)
200 West Lorain Street
 
Room/suite
City or town, state or country, and ZIP + 4
Oberlin, OH44074
D Employer identification number

34-1675592
E Telephone number

G Gross receipts $ 71,604
F Name and address of principal officer:
DALE PRESTON
200 WEST LORAIN STREET
OBERLIN,OH44074
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
N/A
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 MediumBullet  
K Form of organization:
 
L Year of formation: 1998
M State of legal domicile: OH
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: ALLEN MEDICAL CENTER FOUNDATION WAS ESTABLISHED TO SOLICIT, HOLD, INVEST AND ADMINISTER FUNDS, PROPERTY, AND INTERESTS, AND TO MAKE EXPENDITURES, TRANSFERS OR DISTRIBUTIONS TO OR FOR THE BENEFIT OF ALLEN MEDICAL CENTER. ON JUNE 1, 2011 ALLEN MEDICAL CENTER FOUNDATION MERGED WITH THE COMMUNITY HEALTH PARTNERS REGIONAL FOUNDATION TO FORM MERCY FOUNDATION OF LORAIN COUNTY.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a)..... 3 12
4 Number of independent voting members of the governing body (Part VI, line 1b) .... 4 10
5 Total number of individuals employed in calendar year 2011 (Part V, line 2a) ... 5 0
6 Total number of volunteers (estimate if necessary) .... 6 12
7a Total unrelated business revenue from Part VIII, column (C), line 12 .. 7a 0
b Net unrelated business taxable income from Form 990-T, line 34 .. 7b 0
Revenues; Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 129,182 57,593
9 Program service revenue (Part VIII, line 2g) ......... 0 0
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 58,676 14,011
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 23,924 0
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 211,782 71,604
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 23,774 0
14 Benefits paid to or for members (Part IX, column (A), line 4)..... 0 0
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10) 0 0
16a Professional fundraising fees (Part IX, column (A), line 11e)..... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet0    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f).... 13,700 3,140
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 37,474 3,140
19 Revenue less expenses. Subtract line 18 from line 12....... 174,308 68,464
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 3,537,325 0
21 Total liabilities (Part X, line 26)............. 14,820 0
22 Net assets or fund balances. Subtract line 21 from line 20..... 3,522,505 0
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 use only
Print/type preparer's name
 
Preparer's signature
Date
PTIN
Firm's name Right pointing arrowhead image

Firm's EIN Right pointing arrowhead image
Firm's address Right pointing arrowhead image



Phone no.
May the IRS discuss this return with the preparer shown above? See instructions .........bullet
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2011)
Form 990 (2011)
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 FOUNDATION WAS ESTABLISHED TO SOLICIT, HOLD, INVEST AND ADMINISTER FUNDS, PROPERTY, AND INTERESTS, AND TO MAKE EXPENDITURES, TRANSFERS OR DISTRIBUTIONS FOR THE BENEFIT OF ALLEN MEDICAL CENTER.
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 organization’s program service accomplishments for each of its three largest program services, as measured 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 $ 2,529 including grants of $ 0 ) (Revenue $ 0 )
PROVIDE SUPPORT TO ALLEN MEDICAL CENTER.
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$ 2,529
Form 990 (2011)
Form 990 (2011)
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? ........
2
 
No
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part I..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities? If “Yes,” complete Schedule C,
Part II.........................
4
 
No
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If “Yes,” complete Schedule C, Part III........................
5
 
 
6
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If “Yes,” complete Schedule D, Part I....................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas or historic structures? If “Yes,” complete Schedule D, Part II...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If “Yes,” complete Schedule D, Part III ....................
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 IV...................
9
 
No
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi-endowments? If “Yes,” complete Schedule D, Part V
10
 
No
11
If the organization’s answer to any of the following questions is ‘Yes,’ then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable:
a
Did the organization report an amount for land, buildings, and equipment in Part X, line10? If “Yes,” complete Schedule D, Part VI.
11a
 
No
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.
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIII.
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part IX.
11d
 
No
e
Did the organization report an amount for other liabilities in Part X, line 25? If “Yes,” complete Schedule D, Part X.
11e
 
No
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If “Yes,” complete Schedule D, Part X.Click to see attachment
11f
Yes
 
12a
Did the organization obtain separate, independent audited financial statements for the tax year?
If “Yes,” complete Schedule D, Parts XI, XII, and XIII
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If “Yes,” and if the organization answered ‘No’ to line 12a, then completing Schedule D, Parts XI, XII, and XIII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States or aggregate foreign investments valued at $100,000 or more? 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
20a
Did the organization operate one or more hospitals? If “Yes,” complete Schedule H.....
20a
 
No
b
If “Yes” to line 20a, did the organization attach a copy of its audited financial statement to this return? Note. All Form 990 filers that operated one or more hospitals must attach audited financial statements.
20b
 
 
Form 990 (2011)
Form 990 (2011)
Page 4
Part IV
Checklist of Required Schedules (continued)
21
Did the organization report more than $5,000 of grants and other assistance to any government or organization in the United States on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II..
21
 
No
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III.....
22
 
No
23
Did the organization answer “Yes” to Part VII, Section A, questions 3, 4, or 5, about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If “Yes,” complete Schedule J................ Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer questions 24b–24d and complete Schedule K. If “No,” go to line 25................
24a
 
No
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
 
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
 
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
 
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If “Yes,” complete Schedule L, Part I......
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I................
25b
 
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highly compensated employee, or disqualified person outstanding as of the end of the organization’s tax year? If “Yes,” complete Schedule L,
Part II.........................
26
 
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member of any of these persons? If “Yes,” complete Schedule L, Part III.........
27
 
No
28
Was the organization a party to a business transaction with one of the following parties? (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If “Yes,” complete Schedule L, Part IV .........................
28a
 
No
b
A family member of a current or former officer, director, trustee, or key employee? If “Yes,”
complete Schedule L, Part IV...................
28b
 
No
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or owner? If “Yes,” complete Schedule L, Part IV..
28c
 
No
29
Did the organization receive more than $25,000 in non-cash contributions? If “Yes,” complete Schedule M
29
 
No
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M............
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If “Yes,” complete Schedule N,
Part I........................... Click to see attachment
31
Yes
 
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If “Yes,” complete Schedule N, Part II.......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If “Yes,” complete Schedule R, Part I........
33
 
No
34
Was the organization related to any tax-exempt or taxable entity? If “Yes,” complete Schedule R, Parts II, III, IV, and V, line 1..................... Click to see attachment
34
Yes
 
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
 
No
b
If ‘Yes’ to line 35a, 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...
35b
 
No
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If “Yes,” complete Schedule R, Part V, line 2...........
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If “Yes,” complete Schedule R, Part VI
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11 and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2011)
Form 990 (2011)
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
0
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
 
 
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax Statements filed for the calendar year ending with or within the year covered by this return .....................
2a
0
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?

Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file. (see instructions)
2b
 
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?.............................
3a
 
No
b
If “Yes,” has it filed a Form 990-T for this year? If “No,” provide an explanation in Schedule O.....
3b
 
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account or securities account)?.......................
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If “Yes” to line 5a or 5b, did the organization file Form 8886-T? ........
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible?..........
6a
 
No
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
 
No
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
 
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?..........................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?...................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?...............
7h
 
 
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?................
8
 
No
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?.........
9a
 
 
b
Did the organization make a distribution to a donor, donor advisor, or related person?......
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them) ........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year.
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. All 501(c)(29) organizations must list in Schedule O each state in which they are licensed to issue qualified health plans, the amount of reserves required by each state, and the amount of reserves the organization allocated to each state.
13a
 
 
b
Enter the aggregate amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans.
13b
 
c
Enter the aggregate amount of reserves on hand.
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
 
b
If "Yes," has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O..
14b
 
 
Form 990 (2011)
Form 990 (2011)
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
If the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
1a
12
b
Enter the number of voting members included in line 1a, above, who are independent .................
1b
10
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
Did the organization have members or stockholders? ................
6
Yes
 
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? .................
7a
Yes
 
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ............
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
 
 
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
Did the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If “Yes,” did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes? ....
10b
 
 
11a
Has the organization provided a complete 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
Did the organization have a written conflict of interest policy? If “No,” go to line 13.......
12a
Yes
 
b
Were officers, directors or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ........................
12b
Yes
 
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If “Yes,” describe in Schedule O how this was done ....................
12c
Yes
 
13
Did the organization have a written whistleblower policy? ...............
13
Yes
 
14
Did 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
 
No
b
Other officers or key employees of the organization ................
15b
 
No
If "Yes," to line 15a or 15b, 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,” did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take 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
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 made these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how), the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization: MediumBullet
JIM HEIKKINEN
3700 KOLBE ROAD
LORAIN,OH44053
(440) 960-4000
Form 990 (2011)
Form 990 (2011)
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 (do not check more than one box, unless person is both an officer and a director/trustee) 		(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) CHRISTOPHER R MALLETT
CHAIRMAN
 1.00 X   X       0 0 0
(2) DALE PRESTON
PRESIDENT
 50.00 X   X       0 72,797 11,879
(3) EMMA MASON
TREASURER
 1.00 X   X       0 0 0
(4) HEIDI FREAS
VICE CHAIR
 1.00 X   X       0 0 0
(5) SUSAN BOWERS
BOARD MEMBER, PRESIDENT - AMC
 1.00 X   X       0 168,742 28,527
(6) VIRGINIA O'DELL
SECRETARY
 1.00 X   X       0 0 0
(7) DAVID J EVANS MD
BOARD MEMBER
 1.00 X           0 0 0
(8) DAVID KALTENBACH
BOARD MEMBER
 1.00 X           0 0 0
(9) KRISTIN PETERSON
BOARD MEMBER
 1.00 X           0 0 0
(10) LAD W HARRISON
BOARD MEMBER
 1.00 X           0 0 0
(11) SR ANNE VICTORY HM
BOARD MEMBER
 1.00 X           0 0 0
(12) TIMOTHY CARRION
BOARD MEMBER
 1.00 X           0 0 0










Form 990 (2011)
Form 990 (2011)
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 (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;


























1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 0 241,539 40,406
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organizationMediumBullet0
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If “Yes,” complete Schedule J for such individual .............
3
 
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. Report compensation for the calendar year ending with or within the organization’s tax year.
(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 $100,000 of compensation from the organization MediumBullet0
Form 990 (2011)
Form 990 (2011)
Page 9
Part VIII
Statement of Revenue
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, Gifts, Grants and Other Similar Amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c  
d Related organizations...1d  
e Government grants (contributions)1e  
f All other contributions, gifts, grants, and
similar amounts not included above1f 		57,593
g Noncash contributions included in lines 1a-1f:$  
h Total. Add lines 1a-1f.......MediumBullet 57,593
Program Service Revenue Business Code
2a
b
c
d
e
f All other program service revenue . 0 0 0 0
g Total. Add lines 2a–2f........MediumBullet 0
Other Revenue 3 Investment income (including dividends, interest
and other similar amounts).....MediumBullet 14,011     14,011
4 Income from investment of tax-exempt bond proceeds..MediumBullet 0      
5 Royalties............MediumBullet 0      
(i) Real (ii) Personal
6a Gross rents    
b Less: rental expenses    
c Rental income or (loss) 0 0
d Net rental income or (loss).......MediumBullet 0      
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory    
b Less: cost or other basis and sales expenses    
c Gain or (loss) 0 0
d Net gain or (loss)..........MediumBullet 0      
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            
b            
c            
d All other revenue .... 0 0 0 0
e Total. Add lines 11a–11d ......MediumBullet 0
12 Total revenue. See Instructions....MediumBullet 71,604 0 0 14,011
Form 990 (2011)
Form 990 (2011)
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).
Check if Schedule O contains a response to any question in this Part IX. .........
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 United States. See Part IV, line 21 0  
2 Grants and other assistance to individuals in the United States. See Part IV, line 22 0  
3 Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16 0  
4 Benefits paid to or for members 0  
5 Compensation of current officers, directors, trustees, and key employees .... 0      
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .... 0      
7 Other salaries and wages 0      
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 0      
9 Other employee benefits ....... 0      
10 Payroll taxes ........... 0      
11 Fees for services (non-employees):        
a Management ...... 0      
b Legal ......... 250   250  
c Accounting ........... 0      
d Lobbying ........... 0      
e Professional fundraising. See Part IV, line 17.. 0  
f Investment management fees ...... 0      
g Other .......... 1,467 1,467    
12 Advertising and promotion .... 1,026 1,026    
13 Office expenses ....... 361   361  
14 Information technology ...... 0      
15 Royalties .. 0      
16 Occupancy ........... 0      
17 Travel ............ 36 36    
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ...... 0      
19 Conferences, conventions, and meetings .... 0      
20 Interest ........... 0      
21 Payments to affiliates ....... 0      
22 Depreciation, depletion, and amortization ..... 0      
23 Insurance .............. 0      
24 Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24f. If line 24f amount exceeds 10% of line 25, column (A) amount, list line 24f expenses on Schedule O.)
a MISC 0      
b
c
d
e
f All other expenses 0 0 0 0
25 Total functional expenses. Add lines 1 through 24f 3,140 2,529 611 0
26 Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here MediumBullet if following SOP 98-2 (ASC 958-720). 0      
Form 990 (2011)
Form 990 (2011)
Page 11
Part X Balance Sheet
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash—non-interest-bearing .......... 302,440 1  
2 Savings and temporary cash investments .......   2  
3 Pledges and grants receivable, net ......... 450,000 3  
4 Accounts receivable, net .........   4  
5 Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L ..........   5  
6 Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
Schedule L ..........   6  
7 Notes and loans receivable, net .............   7  
8 Inventories for sale or use ..............   8  
9 Prepaid expenses and deferred charges ............   9  
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 0
b Less: accumulated depreciation. ..... 10b 0 0 10c 0
11 Investments—publicly traded securities .......... 2,784,885 11  
12 Investments—other securities. See Part IV, line 11 ...... 0 12 0
13 Investments—program-related. See Part IV, line 11 .. 0 13 0
14 Intangible assets .........   14  
15 Other assets. See Part IV, line 11 ........... 0 15 0
16 Total assets. Add lines 1 through 15 (must equal line 34)... 3,537,325 16 0
Liabilities 17 Accounts payable and accrued expenses . 14,820 17  
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 (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D..... 0 25 0
26 Total liabilities. Add lines 17 through 25..... 14,820 26 0
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 ..... 1,272,576 27  
28 Temporarily restricted net assets ..... 218,412 28  
29 Permanently restricted net assets ..... 2,031,517 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 ..... 3,522,505 33 0
34 Total liabilities and net assets/fund balances ..... 3,537,325 34 0
Form 990 (2011)
Form 990 (2011)
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
71,604
2
Total expenses (must equal Part IX, column (A), line 25) ....
2
3,140
3
Revenue less expenses. Subtract line 2 from line 1 ...
3
68,464
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..
4
3,522,505
5
Other changes in net assets or fund balances (explain in Schedule O) ...
5
-3,590,969
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
0
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 (2011)
Additional Data


Software ID: 11000230
Software Version: v2011.1.0
Form 990, Special Condition Description:
Special Condition Description
SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service
Public Charity Status and Public Support

Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
right arrow Attach to Form 990 or Form 990-EZ. right arrow See separate instructions.
OMB No. 1545-0047
2011
Open to Public
Inspection
Name of the organization
ALLEN MEDICAL CENTER FOUNDATION
 
Employer identification number

34-1675592
Part I
Reason for Public Charity Status (All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
f
g
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization? ................
11g(i)
 
No
(ii) a family member of a person described in (i) above? ......................
11g(ii)
 
No
(iii) a 35% controlled entity of a person described in (i) or (ii) above? ................
11g(iii)
 
No
h
(i)
Name of supported organization 		(ii)
EIN 		(iii)
Type of organization (described on lines 1- 9 above or IRC section (see instructions)) 		(iv)
Is the organization in col. (i) listed in your governing document? 		(v)
Did you notify the organization in col. (i) of your support? 		(vi)
Is the organization in col. (i) organized in the U.S.? 		(vii)
Amount of support?
Yes No Yes No Yes No
(1) ALLEN MEDICAL CENTER
  		340864230 3 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) 2011
Schedule A (Form 990 or 990-EZ) 2011
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) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (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) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (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) 2011
Schedule A (Form 990 or 990-EZ) 2011
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) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (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) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (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) 2011
Schedule A (Form 990 or 990-EZ) 2011
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) 2011

Additional Data


Software ID: 11000230
Software Version: v2011.1.0
SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b
SchDMd Bullet Attach to Form 990. SchDMd Bullet See separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
ALLEN MEDICAL CENTER FOUNDATION
 
Employer identification number

34-1675592
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 can 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 through 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, and not on a historic structure listed in the National Register .................... 2d  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax 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 (ASC 958), 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 (ASC 958), 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 (ASC 958), 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) 2011

Schedule D (Form 990) 2011
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 Net investment earnings, gains, and 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 (line 1g) held as:
a
Board designated or quasi-endowment SchDMd Bullet  
b
Permanent endowment SchDMd Bullet  
c
Temporarily restricted endowment SchDMd Bullet  
The percentages in lines 2a, 2b, and 2c should equal 100%.
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
Land, Buildings, and Equipment. See Form 990, Part X, line 10.
Description of property (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .................     0
b Buildings ................       0
c Leasehold improvements ............       0
d Equipment ................       0
e Other .................       0
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......SchDMdBullet 0
Schedule D (Form 990) 2011

Schedule D (Form 990) 2011
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    
Other








Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)Small Bullet  
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) must 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) must 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) Book value
Federal Income Taxes 0








Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 0
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) 2011

Schedule D (Form 990) 2011
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 71,604
2 Total expenses (Form 990, Part IX, column (A), line 25) ..................... 2 3,140
3 Excess or (deficit) for the year. Subtract line 2 from line 1 ............. 3 68,464
4 Net unrealized gains (losses) on investments .......................... 4 130,179
5 Donated services and use of facilities ............................. 5  
6 Investment expenses ................................... 6  
7 Prior period adjustments .................................. 7  
8 Other (Describe in Part XIV.) ................................. 8 -3,721,148
9 Total adjustments (net). Add lines 4 through 8 ......................... 9 -3,590,969
10 Excess or (deficit) for the year per financial statements. Combine lines 3 and 9 ......... 10 -3,522,505
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 71,604
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains on investments .......... 2a  
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIV.) ............ 2d 0
e Add lines 2a through 2d ..................... 2e 0
3 Subtract line 2e from line 1..................... 3 71,604
4 Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b . 4a  
b Other (Describe in Part XIV.) ........... 4b 0
c Add lines 4a and 4b....................... 4c 0
5 Total Revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ...... 5 71,604
Part XIII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1 Total expenses and losses per audited financial statements ............. 1 3,140
2 Amounts included on line 1 but not on Form 990, Part IX, line 25:
a Donated services and use of facilities .......... 2a  
b Prior year adjustments .............. 2b  
c Other losses ................ 2c  
d Other (Describe in Part XIV.) ............ 2d 0
e Add lines 2a through 2d...................... 2e 0
3 Subtract line 2e from line 1..................... 3 3,140
4 Amounts included on Form 990, Part IX, line 25, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b .. 4a  
b Other (Describe in Part XIV.) ............ 4b 0
c Add lines 4a and 4b....................... 4c 0
5 Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ...... 5 3,140
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 Schedule D, Part X, Line 2 THE COMPANY [CATHOLIC HEALTH PARTNERS AND AFFILIATED ENTITIES] COMPLETED AN ANALYSIS OF ITS TAX POSITIONS IN ACCORDANCE WITH APPLICABLE ACCOUNTING GUIDANCE AT DECEMBER 31, 2011 AND 2010, AND DETERMINED THAT NO AMOUNTS WERE REQUIRED TO BE RECOGNIZED IN THE CONSOLIDATED FINANCIAL STATEMENTS AT DECEMBER 31, 2011 OR 2010.
Schedule D (Form 990) 2011

Additional Data


Software ID: 11000230
Software Version: v2011.1.0




Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
SchJMediumBullet Attach to Form 990. SchJMediumBullet See separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
ALLEN MEDICAL CENTER FOUNDATION
 
Employer identification number

34-1675592
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 or provision 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. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
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
 
No
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 Regulations 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) 2011

Schedule J (Form 990) 2011
Page 2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is 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) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and column (E) for that individual.
(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 as deferred
in prior Form 990
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
(1) SUSAN BOWERS (i)
(ii)		 0
157,491 		0
0 		0
11,251 		0
21,511 		0
7,016 		0
197,269 		0
0















Schedule J (Form 990) 2011

Schedule J (Form 990) 2011
Page 3
Part III
Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4c, 5a, 5b, 6a, 6b, 7, and 8. Also complete this part for any additional information.
Identifier Return Reference Explanation
Arrangement used to establish the top management official's compensation Schedule J, Part I, Line 3 THE COMPENSATION OF DALE PRESTON, PRESIDENT, IS DETERMINED BY ALLEN MEDICAL CENTER (AMC), A RELATED TAX-EXEMPT ORGANIZATION. AMC UTILIZES A COMPENSATION COMMITTEE AND AN INDEPENDENT COMPENSATION CONSULTANT WHEN DETERMINING MR. PRESTON'S COMPENSATION.
Supplemental nonqualified retirement plan Schedule J, Part I, Line 4b THE COMMUNITY HEALTH PARTNERS REGIONAL HEALTH SYSTEM NONQUALIFIED SUPPLEMENTAL EMPLOYEE RETIREMENT PLAN IS AN EXECUTIVE RETENTION PLAN FOR CERTAIN HIGHLY COMPENSATED INDIVIDUALS, AS DETERMINED BY THE BOARD OF TRUSTEES' EXECUTIVE EVALUATION AND COMPENSATION COMMITTEE. THE PLAN PURPOSE IS TO PROVIDE A BENEFIT TO REPLACE THE BENEFIT THESE PARTICIPANTS WOULD HAVE RECEIVED UNDER THE APPLICABLE QUALIFIED PLAN PRIOR TO ITS AMENDMENT TO COMPLY WITH THE OMNIBUS BUDGET RECONCILIATION ACT OF 1993. IT PROVIDES A DEFERRED COMPENSATION BENEFIT OF 3% TO 5% OF ANNUAL BASE SALARY. PARTICIPANTS VEST AND RECEIVE PLAN BENEFITS ONCE TWO CONDITIONS ARE SATISFIED: (1) MEET THE VESTING REQUIREMENTS OF THE APPLICABLE QUALIFIED PLAN, AND (2) COMPLETE A 24-MONTH POST-EMPLOYMENT NON-COMPETE REQUIREMENT. AMOUNTS INCLUDIBLE AS TAXABLE COMPENSATION FOR LISTED PARTICIPATING INDIVIDUALS IN THE REPORTING YEAR ARE AS FOLLOWS: SUSAN BOWERS $0.
Schedule J (Form 990) 2011

Additional Data


Software ID: 11000230
Software Version: v2011.1.0
SCHEDULE N
(Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Liquidation, Termination, Dissolution or Significant Disposition of Assets
bullet Complete if the organization answered "Yes" to Form 990, Part IV, lines 31 or 32 or Form 990-EZ, line 36.
bullet Attach certified copies of any articles of dissolution, resolutions or plans.
bullet Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2011
Open to Public
Inspection
Name of the organization
ALLEN MEDICAL CENTER FOUNDATION
 
Employer identification number
34-1675592
Part I
Liquidation, Termination or Dissolution. Complete if the organization answered "Yes" to Form 990, Part IV, line 31, or Form 990-EZ, line
36. Use Part III if additional space is needed.
1(a)Description of asset(s)
distributed or transaction
expenses paid		 (b)Date of
distribution		 (c)Fair market value of
asset(s) distributed or
amount of transaction
expenses		 (d)Method of
determining FMV for
asset(s) distributed or
transaction expenses		 (e)EIN of recipient (f)Name and address of recipient (g)IRC section
of recipient(s) (if
tax-exempt) or type
of entity
CASH 06-01-2011 149,149   34-1504558 COMMUNITY HEALTH PARTNERS REGIONAL FOUNDATION
 
3700 KOLBE RD
LORAIN,OH44053 		501(C)(3)
STOCKS AND SECURITIES 06-01-2011 3,572,381 CURRENT MARKET VALUE AT 6/1/2011 34-1504558 COMMUNITY HEALTH PARTNERS REGIONAL FOUNDATION
 
3700 KOLBE RD
LORAIN,OH44053 		501(C)(3)






















Yes
No
2
Did or will any officer, director, trustee, or key employee of the organization:
a
Become a director or trustee of a successor or transferee organization? . . . . . . . . . . . . . . . . . . . . .
2a
Yes
 
b
Become an employee of, or independent contractor for, a successor or transferee organization? . . . . . . . . . . . . . . . .
2b
Yes
 
c
Become a direct or indirect owner of a successor or transferee organization? . . . . . . . . . . . . . . . . . . . .
2c
 
No
d
Receive, or become entitled to, compensation or other similar payments as a result of the organization's liquidation, termination, or dissolution? . . . . .
2d
 
No
e
If the organization answered "Yes" to any of the questions in this line, provide the name of the person involved and explain in Part III. bullet
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990 or Form 990-EZ.
Cat. No. 50087Z
Schedule N (Form 990 or 990-EZ) 2011

Schedule N (Form 990 or 990-EZ) 2011
Page 2
Part I
Liquidation, Termination or Dissolution (continued)
Note. If the organization distributed all of its assets during the tax year, then Form 990, Part X, column (B), line 16 (Total assets), and line 26 (Total liabilities), should equal -0-.
Yes
No
3
Did the organization distribute its assets in accordance with its governing instrument(s)? If “No,” describe in Part III . . . . . . . . . . .
3
Yes
 
4a
Is the organization required to notify the attorney general or other appropriate state official of its intent to dissolve, liquidate, or terminate? . . . . . .
4a
Yes
 
b
If “Yes,” did the organization provide such notice? . . . . . . . . . . . . . . . . . . . . . . . . . .
4b
Yes
 
5
Did the organization discharge or pay all of its liabilities in accordance with state laws? . . . . . . . . . . . . . . . . .
5
Yes
 
6a
Did the organization have any tax-exempt bonds outstanding during the year? . . . . . . . . . . . . . . . . . . . .
6a
 
No
b
Did the organization discharge or defease all of its tax-exempt bond liabilities during the tax year in accordance with the Internal Revenue Code and state laws? .
6b
 
 
c
If ‘Yes’ to line 6b, describe in Part III how the organization defeased or otherwise settled these liabilities. If “No,” explain in Part III.

Part II
Sale, Exchange, Disposition or Other Transfer of More Than 25% of the Organization's Assets. Complete if the organization answered "Yes" to Form 990, Part IV, line 32, or Form 990-EZ, line 36. Use Part III if additional space is needed.
1(a)Description of asset(s)
distributed or transaction
expenses paid		 (b)Date of
distribution		 (c)Fair market value of
asset(s) distributed or
amount of transaction
expenses		 (d)Method of
determining FMV for
asset(s) distributed or
transaction expenses		 (e)EIN of recipient (f)Name and address of recipient (g)IRC section
of recipient(s) (if
tax-exempt) or type
of entity


















Yes
No
2
Did or will any officer, director, trustee, or key employee of the organization:
a
Become a director or trustee of a successor or transferee organization? . . . . . . . . . . . . . . . . . . . . .
2a
Yes
 
b
Become an employee of, or independent contractor for, a successor or transferee organization? . . . . . . . . . . . . . . . .
2b
Yes
 
c
Become a direct or indirect owner of a successor or transferee organization? . . . . . . . . . . . . . . . . . . . . .
2c
 
No
d
Receive, or become entitled to, compensation or other similar payments as a result of the organization’s significant disposition of assets? . . . . . . .
2d
 
No
e
If the organization answered "Yes" to any of the questions in this line, provide the name of the person involved and explain in Part III.
Schedule N(Form 990 or 990-EZ) 2011

Schedule N (Form 990 or 990-EZ) 2011
Page 3
Part III
Supplemental Information. Complete to provide the information required by Parts I and II,
and any additional information.
Identifier Return Reference Explanation
Interested person who became a director or trustee of successor organization Schedule N, Part I, Line 2a THREE BOARD MEMBERS FROM THIS ORGANIZATION BECAME BOARD MEMBERS OF THE TRANSFEREE ORGANIZATION: HEIDI FREAS, CHRIS MALLETT AND SR. ANNE VICTORY.
Interested person who became an employee or independent contractor of successor organization Schedule N, Part I, Line 2b DALE PRESTON, THE PRESIDENT OF THIS ORGANZIATION, NOW WORKS FOR THE TRANSFEREE ORGANIZATION.
Schedule N (Form 990 or 990-EZ) 2011


Additional Data


Software ID: 11000230
Software Version: v2011.1.0


SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
MediumBullet Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2011
Open to Public
Inspection
Name of the organization
ALLEN MEDICAL CENTER FOUNDATION
 
Employer identification number

34-1675592
Identifier Return Reference Explanation
Significant changes in program services Form 990, Part III, Line 3 ON JUNE 1, 2011 THE ALLEN MEDICAL CENTER FOUNDATION MERGED WITH THE COMMUNITY HEALTH PARTNERS REGIONAL FOUNDATION TO BECOME THE MERCY FOUNDATION OF LORAIN COUNTY.
Classes of members or stockholders Form 990, Part VI, Section A, Line 6 ALLEN MEDICAL CENTER IS THE MEMBER OF ALLEN MEDICAL CENTER FOUNDATION.
Members or stockholders electing members of governing body Form 990, Part VI, Section A, Line 7a CATHOLIC HEALTH PARTNERS APPROVES MEMBERS THAT ARE APPOINTED TO THE BOARD OF TRUSTEES. ALL MEMBERS OF THE BOARD OF TRUSTEES HAVE FULL VOTING RIGHTS.
Decisions requiring approval by members or stockholders Form 990, Part VI, Section A, Line 7b CERTAIN MATTERS REQUIRE APPROVAL OF THE CHP CORPORATE MEMBER, CHP GOVERNING BODY, OR CHP CEO. THE REGULATIONS OF THE ORGANIZATION DESCRIBE THE LEVEL OF APPROVAL REQUIRED FOR VARIOUS DECISIONS.
Review of form 990 by governing body Form 990, Part VI, Section B, Line 11b THE FORM 990 IS PREPARED BY THE CATHOLIC HEALTH PARTNERS (CHP) TAX DEPARTMENT AND REVIEWED BY MANAGEMENT. UPON REVIEW, THE FORM 990 IS THEN FORWARDED TO THE AUDIT & CORPORATE RESPONSIBILITY COMMITTEE FOR APPROVAL. ADDITIONALLY, THE COMPENSATION COMMITTEE REVIEWS ALL COMPENSATION RELATED SCHEDULES AND DISCLOSURES. BOTH THE AUDIT & CORPORATE RESPONSIBILITY COMMITTEE AND THE COMPENSATION COMMITTEE ARE INDEPENDENT OF THE FILING ORGANIZATION. ONCE THE FORM 990 IS REVIEWED AND APPROVED BY ALL APPLICABLE PARTIES A COPY OF THE FINAL VERSION IS PROVIDED TO ALL MEMBERS OF THE GOVERNING BODY PRIOR TO FILING.
Conflict of interest policy Form 990, Part VI, Section B, Line 12c ALL BOARD MEMBERS ARE COVERED BY THE CHP CONFLICT OF INTEREST POLICY WHICH REQUIRES DISCLOSURE ON AN ANNUAL BASIS. ALL POTENTIAL CONFLICTS OF INTEREST ARE REVIEWED BY CHP CORPORATE COMPLIANCE OFFICER. AT THE BEGINNING OF EACH BOARD MEETING ALL BOARD MEMBERS ARE REQUIRED TO DISCLOSE ANY CONFLICTS OF INTEREST. BOARD MEMBERS DETERMINED TO HAVE A CONFLICT OF INTEREST ARE PROHIBITED FROM PARTICIPATING IN DELIBERATIONS AND DECISION-MAKING FOR THE TRANSACTION IN WHICH THE CONFLICT EXISTS.
Governing documents, conflict of interest policy and financial statements available to the public Form 990, Part VI, Section C, Line 19 THE SYSTEM-WIDE CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE POSTED ON THE CATHOLIC HEALTH PARTNERS WEBSITE.
Average number of hours devoted per week to related organization Form 990, Part VII, Section A, Column B CHRISTOPHER R. MALLETT - 1 HEIDI FREAS - 1 SUSAN BOWERS - 49 SR. ANNE VICTORY, HM - 2 TIMOTHY CARRION - 1
Other changes in net assets or fund balances Form 990, Part XI, Line 5 NET UNREALIZED GAINS (LOSSES) ON INVESTMENTS - 130179; ASSETS TRANSFERRED TO MERCY FOUNDATION OF LORAIN COUNTY - -3721148;
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2011

Additional Data


Software ID: 11000230
Software Version: v2011.1.0
SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBulletAttach to Form 990. MediumBullet See separate instructions.

OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
ALLEN MEDICAL CENTER FOUNDATION
 
Employer identification number

34-1675592
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 PARTNERS

615 ELSINORE PLACE

CINCINNATI,OH45202
31-1161086 		HEALTHCARE SYSTEM PARENT OH 501(C)(3) 11 - Type III - FI NA
 
 
No
(2) CATHOLIC HEALTH PARTNERS FOUNDATION

615 ELSINORE PLACE

CINCINNATI,OH45202
20-1072726 		FUNDRAISING OH 501(C)(3) 7 CATHOLIC HEALTH PARTNERS
 
 
No
(3) CATHOLIC HEALTHCARE PARTNERS HOUSING DEVELOPMENT

615 ELSINORE PLACE

CINCINNATI,OH45202
20-8943658 		HUD PARENT OH 501(C)(3) 9 CATHOLIC HEALTH PARTNERS
 
 
No
(4) CATHOLIC HEALTHCARE PARTNERS RETIREMENT TRUST

615 ELSINORE PLACE

CINCINNATI,OH45202
31-6046304 		RETIREMENT TRUST OH 501(C)(3) 8 CATHOLIC HEALTH PARTNERS
 
 
No
(5) COMMUNITY HEALTH PARTNERS REGIONAL HEALTH SYSTEM

3700 KOLBE ROAD

LORAIN,OH44053
27-0071694 		REGIONAL PARENT OH 501(C)(3) 11 - Type II CATHOLIC HEALTH PARTNERS
 
 
No
(6) COMMUNITY HEALTH PARTNERS REGIONAL MEDICAL CENTER

3700 KOLBE ROAD

LORAIN,OH44053
34-0714704 		HOSPITAL OH 501(C)(3) 3 COMMUNITY HEALTH PARTNERS REGIONAL HEALTH SYSTEM
 
 
No
(7) ALLEN MEDICAL CENTER

200 WEST LORAIN ST

OBERLIN,OH44074
34-0864230 		HOSPITAL OH 501(C)(3) 3 COMMUNITY HEALTH PARTNERS REGIONAL HEALTH SYSTEM
 
 
No
(8) COMMUNITY HEALTH PARTNERS REGIONAL FOUNDATION

3700 KOLBE ROAD

LORAIN,OH44053
34-1504558 		FOUNDATION OH 501(C)(3) 11 - Type III - FI COMMUNITY HEALTH PARTNERS REGIONAL MEDICAL CENTER
 
 
No
(9) COMMUNITY HEALTH PARTNERS PHYSICIANS OFFICE BUILDINGS

3700 KOLBE ROAD

LORAIN,OH44053
34-1268828 		MEDICAL OFFICE RENTAL OH 501(C)(3) 9 COMMUNITY HEALTH PARTNERS REGIONAL MEDICAL CENTER
 
 
No
(10) ALLEN MEDICAL CENTER FOUNDATION

200 WEST LORAIN ST

OBERLIN,OH44074
34-1675592 		FOUNDATION OH 501(C)(3) 11 - Type I ALLEN MEDICAL CENTER
 
 
No
(11) ALLEN MEDICAL CENTER MEDICAL OFFICE BUILDING

200 WEST LORAIN ST

OBERLIN,OH44074
36-4504991 		MEDICAL OFFICE RENTAL OH 501(C)(3) 11 - Type II ALLEN MEDICAL CENTER
 
 
No
(12) MERCY HEALTH PARTNERS OF SOUTHWEST OHIO

4600 MCAULEY PLACE

CINCINNATI,OH45242
31-1063783 		REGIONAL PARENT OH 501(C)(3) 11 - Type III - FI CATHOLIC HEALTH PARTNERS
 
 
No
(13) MERCY HEALTH PARTNERS OF SOUTHWEST OHIO FOUNDATION

4600 MCAULEY PLACE

CINCINNATI,OH45242
31-1217563 		FOUNDATION OH 501(C)(3) 7 MERCY HEALTH PARTNERS OF SOUTHWEST OHIO
 
 
No
(14) MERCY HOSPITALS WEST

2446 KIPLING AVENUE

CINCINNATI,OH45239
31-1091597 		HOSPITAL OH 501(C)(3) 3 MERCY HEALTH PARTNERS OF SOUTHWEST OHIO
 
 
No
(15) MERCY HOSPITAL ANDERSON

7500 STATE ROAD

CINCINNATI,OH45255
31-0537085 		HOSPITAL OH 501(C)(3) 3 MERCY HEALTH PARTNERS OF SOUTHWEST OHIO
 
 
No
(16) THE SISTERS OF MERCY OF HAMILTON OHIO

3000 MACK ROAD

FAIRFIELD,OH45014
31-0538532 		HOSPITAL OH 501(C)(3) 3 MERCY HEALTH PARTNERS OF SOUTHWEST OHIO
 
 
No
(17) THE SISTERS OF MERCY OF CLERMONT COUNTY OHIO

3000 HOSPITAL DRIVE

BATAVIA,OH45103
31-0830955 		HOSPITAL OH 501(C)(3) 3 MERCY HEALTH PARTNERS OF SOUTHWEST OHIO
 
 
No
(18) MERCY FRANCISCAN SENIOR HEALTH AND HOUSING SERVICES INC

7010 ROWAN HILLS DR

CINCINNATI,OH45227
31-1308729 		RETIREMENT HOME OH 501(C)(3) 9 MERCY HEALTH PARTNERS OF SOUTHWEST OHIO
 
 
No
(19) MERCY SACRED HEART INC

2120 PAYNE STREET

LOUISVILLE,KY40206
61-1318326 		RETIREMENT HOME KY 501(C)(3) 9 MERCY HEALTH PARTNERS OF SOUTHWEST OHIO
 
 
No
(20) MERCY LONG TERM CARE INITIATIVE

4915 CHARLESTOWN RD

NEW ALBANY,IN47150
31-1332491 		RETIREMENT HOME IN 501(C)(3) 9 MERCY HEALTH PARTNERS OF SOUTHWEST OHIO
 
 
No
(21) MERCY FRANCISCAN SOCIAL MINISTRIES INC

1800 LOGAN STREET

CINCINNATI,OH45210
31-1222942 		LOW INCOME HOUSING OH 501(C)(3) 7 MERCY HEALTH PARTNERS OF SOUTHWEST OHIO
 
 
No
(22) MERCY FRANCISCAN AT ST RAPHAEL INC

610 HIGH STREET

HAMILTON,OH45011
20-2934871 		SERVICES TO THE POOR OH 501(C)(3) 7 MERCY HEALTH PARTNERS OF SOUTHWEST OHIO
 
 
No
(23) COMMUNITY MERCY HEALTH SYSTEM

ONE S LIMESTONE ST

SPRINGFIELD,OH45502
30-0272454 		REGIONAL PARENT OH 501(C)(3) 11 - Type III - FI CATHOLIC HEALTH PARTNERS
 
 
No
(24) COMMUNITY MERCY HEALTH PARTNERS

ONE S LIMESTONE ST

SPRINGFIELD,OH45502
31-0785684 		HOSPITAL OH 501(C)(3) 3 COMMUNITY MERCY HEALTH SYSTEM
 
 
No
(25) THE COMMUNITY MERCY FOUNDATION

1343 N FOUNTAIN BLVD

SPRINGFIELD,OH45504
31-1443778 		FOUNDATION OH 501(C)(3) 7 COMMUNITY MERCY HEALTH SYSTEM
 
 
No
(26) C H HEALTH SERVICES COMPANY

ONE S LIMESTONE ST

SPRINGFIELD,OH45502
31-1181984 		HOSPITAL OH 501(C)(3) 3 COMMUNITY MERCY HEALTH SYSTEM
 
 
No
(27) CLARKE & CHAMPAIGN COUNTIES HEALTH INFORMATION EXCHANGE

1150 E HOME ROAD

SPRINGFIELD,OH45503
26-0698515 		MEDICAL INFORMATION EXCHANGE OH 501(C)(3) 9 COMMUNITY MERCY HEALTH SYSTEM
 
 
No
(28) THE WALLACE S MURRAY AND FRANCES RABBITTS MURRAY MEMORIAL TRUST

ONE S LIMESTONE ST

SPRINGFIELD,OH45502
34-6827136 		INDIGENT MEDICAL CARE OH 501(C)(3) 11 - Type I NA
 
 
No
(29) MERCY HEALTH SYSTEM - NORTHERN REGION

2200 JEFFERSON AVENUE

TOLEDO,OH43604
34-1344482 		REGIONAL PARENT OH 501(C)(3) 11 - Type III - FI CATHOLIC HEALTH PARTNERS
 
 
No
(30) MERCY PROPERTY HOLDINGS

2200 JEFFERSON AVENUE

TOLEDO,OH43604
30-0699825 		TITLE HOLDING COMPANY OH 501(C)(2) N/A MERCY HEALTH SYSTEM - NORTHERN REGION
 
 
No
(31) ST CHARLES MERCY HOSPITAL OF OREGON OHIO

2600 NAVARRE AVENUE

OREGON,OH43616
34-4445373 		HOSPITAL OH 501(C)(3) 3 MERCY HEALTH SYSTEM - NORTHERN REGION
 
 
No
(32) ST CHARLES MERCY HEALTH FOUNDATION

2600 NAVARRE AVENUE

OREGON,OH43616
34-1414900 		FOUNDATION OH 501(C)(3) 11 - Type III - FI ST CHARLES MERCY HOSPITAL OF OREGON OHIO
 
 
No
(33) RIVERSIDE MERCY HOSPITAL

3404 W SYLVANIA AVE

TOLEDO,OH43623
31-1556401 		HOSPITAL OH 501(C)(3) 3 MERCY HEALTH SYSTEM - NORTHERN REGION
 
 
No
(34) MERCY HOME CARE INC

2200 JEFFERSON AVENUE

TOLEDO,OH43604
34-1587572 		HOME HEALTHCARE OH 501(C)(3) 9 MERCY HEALTH SYSTEM - NORTHERN REGION
 
 
No
(35) MERCY COLLEGE OF NORTHWEST OHIO

2221 MADISON AVENUE

TOLEDO,OH43604
34-1726619 		MEDICAL COLLEGE OH 501(C)(3) 2 MERCY HEALTH SYSTEM - NORTHERN REGION
 
 
No
(36) MERCY COLLEGE OF NORTHWEST OHIO FOUNDATION INC

2221 MADISON AVENUE

TOLEDO,OH43604
14-1963204 		FOUNDATION OH 501(C)(3) 11 - Type I MERCY COLLEGE OF NORTHWEST OHIO
 
 
No
(37) MERCY HOSPITAL OF TIFFIN OHIO

45 ST LAWRENCE DRIVE

TIFFIN,OH44883
34-4431174 		HOSPITAL OH 501(C)(3) 3 MERCY HEALTH SYSTEM - NORTHERN REGION
 
 
No
(38) MERCY TIFFIN HEALTH FOUNDATION

45 ST LAWRENCE DRIVE

TIFFIN,OH44883
34-1499894 		FOUNDATION OH 501(C)(3) 11 - Type III - FI MERCY HOSPITAL OF TIFFIN OHIO
 
 
No
(39) THE SISTERS OF MERCY OF WILLARD OHIO

110 EAST HOWARD ST

WILLARD,OH44890
34-1577110 		HOSPITAL OH 501(C)(3) 3 MERCY HEALTH SYSTEM - NORTHERN REGION
 
 
No
(40) MERCY HOSPITAL OF WILLARD FOUNDATION

110 EAST HOWARD ST

WILLARD,OH44890
11-3742347 		FOUNDATION OH 501(C)(3) 11 - Type III - FI THE SISTERS OF MERCY OF WILLARD OHIO
 
 
No
(41) ST VINCENT MERCY MEDICAL CENTER

2213 CHERRY STREET

TOLEDO,OH43608
34-4428250 		HOSPITAL OH 501(C)(3) 3 MERCY HEALTH SYSTEM - NORTHERN REGION
 
 
No
(42) ST VINCENT MERCY MEDICAL CENTER FOUNDATION

2213 CHERRY STREET

TOLEDO,OH43608
23-7393213 		FOUNDATION OH 501(C)(3) 11 - Type III - FI ST VINCENT MERCY MEDICAL CENTER
 
 
No
(43) LIFESTAR AMBULANCE INC

2200 JEFFERSON AVENUE

TOLEDO,OH43604
34-1354653 		MEDICAL TRANSPORTATION OH 501(C)(3) 11 - Type II MERCY HEALTH SYSTEM - NORTHERN REGION
 
 
No
(44) RSM MEDICAL FOUNDATION

2200 JEFFERSON AVENUE

TOLEDO,OH43624
34-1693671 		HOSPITAL OH 501(C)(3) 3 MERCY HEALTH SYSTEM - NORTHERN REGION
 
 
No
(45) ST MARGUERITE D'YOUVILLE FOUNDATION II

2213 CHERRY STREET

TOLEDO,OH43608
13-4350655 		FOUNDATION OH 501(C)(3) 11 - Type II CATHOLIC HEALTH PARTNERS
 
 
No
(46) SIMON OUTREACH SERVICES

2600 NAVARRE AVENUE

OREGON,OH43616
34-1383325 		MEDICAL OFFICE RENTAL OH 501(C)(3) 11 - Type II ST CHARLES MERCY HOSPITAL OF OREGON OHIO
 
 
No
(47) FARLEY HEALTHCARE CORPORATION

2200 JEFFERSON AVENUE

TOLEDO,OH43604
34-1363204 		HEALTH SERVICES OH 501(C)(3) 9 MERCY HEALTH SYSTEM - NORTHERN REGION
 
 
No
(48) ST RITA'S MEDICAL CENTER

730 W MARKET STREET

LIMA,OH45801
34-1105619 		HOSPITAL OH 501(C)(3) 3 CATHOLIC HEALTH PARTNERS
 
 
No
(49) SRHC FOUNDATION

730 W MARKET STREET

LIMA,OH45801
34-1368429 		FOUNDATION OH 501(C)(3) 11 - Type III - FI ST RITA'S MEDICAL CENTER
 
 
No
(50) NEW VISION MEDICAL LABORATORIES INC

750 W HIGH ST STE 400

LIMA,OH45801
34-1937267 		MEDICAL LAB SERVICES OH 501(C)(3) 11 - Type III - FI ST RITA'S MEDICAL CENTER
 
 
No
(51) HUMILITY OF MARY HEALTH PARTNERS

1044 BELMONT AVENUE

YOUNGSTOWN,OH44501
34-0505560 		HOSPITAL OH 501(C)(3) 3 CATHOLIC HEALTH PARTNERS
 
 
No
(52) THE ASSUMPTION VILLAGE

9800 N MARKET STREET

NORTH LIMA,OH44452
34-1013695 		NURSING HOME OH 501(C)(3) 9 HUMILITY OF MARY HEALTH PARTNERS
 
 
No
(53) HOSPICE OF THE VALLEY

5190 MARKET STREET

YOUNGSTOWN,OH44512
34-1288745 		HOSPICE SERVICES OH 501(C)(3) 9 HUMILITY OF MARY HEALTH PARTNERS
 
 
No
(54) HUMILITY OF MARY DEVELOPMENT FOUNDATION

1044 BELMONT AVENUE

YOUNGSTOWN,OH44501
34-1826978 		FOUNDATION OH 501(C)(3) 11 - Type III - FI HUMILITY OF MARY HEALTH PARTNERS
 
 
No
(55) HUMILITY HOUSE

755 OHLTOWN ROAD

AUSTINTOWN,OH44515
34-1894783 		NURSING HOME OH 501(C)(3) 9 HUMILITY OF MARY HEALTH PARTNERS
 
 
No
(56) LAUREL LAKE RETIREMENT COMMUNITY INC

200 LAUREL LAKE DRIVE

HUDSON,OH44236
34-1481142 		NURSING HOME OH 501(C)(3) 9 HUMILITY OF MARY HEALTH PARTNERS
 
 
No
(57) LAUREL LAKE RETIREMENT COMMUNITY FOUNDATION INC

200 LAUREL LAKE DRIVE

HUDSON,OH44236
34-1779303 		FOUNDATION OH 501(C)(3) 7 LAUREL LAKE RETIREMENT COMMUNITY INC
 
 
No
(58) ST JOSEPH HEALTH CENTER AUXILIARY

677 EASTLAND SE

WARREN,OH44484
34-6556121 		FUNDRAISING OH 501(C)(3) 9 HUMILITY OF MARY HEALTH PARTNERS
 
 
No
(59) MERCY HEALTH PARTNERS - LOURDES INC

1530 LONE OAK ROAD

PADUCAH,KY42003
61-0600313 		HOSPITAL KY 501(C)(3) 3 CATHOLIC HEALTH PARTNERS
 
 
No
(60) LOURDES FOUNDATION INC

1530 LONE OAK ROAD

PADUCAH,KY42003
61-1258960 		FOUNDATION KY 501(C)(3) 7 MERCY HEALTH PARTNERS - LOURDES INC
 
 
No
(61) LOURDES HOSPITAL AUXILIARY GIFT SHOP

1530 LONE OAK ROAD

PADUCAH,KY42003
61-0927805 		FUNDRAISING KY 501(C)(3) 11 - Type III - FI LOURDES FOUNDATION INC
 
 
No
(62) MARCUM AND WALLACE MEMORIAL HOSPITAL INC

60 MERCY COURT

IRVINE,KY40336
61-0927491 		HOSPITAL KY 501(C)(3) 3 MERCY HEALTH PARTNERS - LOURDES INC
 
 
No
(63) MARCUM AND WALLACE HOSPITAL FOUNDATION INC

60 MERCY COURT

IRVINE,KY40336
32-0026557 		FOUNDATION KY 501(C)(3) 11 - Type III - FI MARCUM AND WALLACE MEMORIAL HOSPITAL INC
 
 
No
(64) MERCY HEALTH PARTNERS INC

900 EAST OAK HILL AVE

KNOXVILLE,TN37917
73-1627534 		REGIONAL PARENT TN 501(C)(3) 11 - Type I CATHOLIC HEALTH PARTNERS
 
 
No
(65) MERCY HEALTH SYSTEM INC

900 EAST OAK HILL AVE

KNOXVILLE,TN37917
62-0480068 		HOSPITAL TN 501(C)(3) 3 MERCY HEALTH PARTNERS INC
 
 
No
(66) ST MARY'S MEDICAL CENTER OF CAMPBELL COUNTY INC

923 EAST CENTRAL AVE

LAFOLLETTE,TN37766
62-1817376 		HOSPITAL TN 501(C)(3) 3 MERCY HEALTH PARTNERS INC
 
 
No
(67) MERCY HEALTH PARTNERS FOUNDATION INC

900 EAST OAK HILL AVE

KNOXVILLE,TN37917
62-1247676 		FOUNDATION TN 501(C)(3) 7 MERCY HEALTH PARTNERS INC
 
 
No
(68) JEFFERSON MEMORIAL HOSPITAL INC

110 HOSPITAL DRIVE

JEFFERSON CITY,TN37760
62-1660663 		HOSPITAL TN 501(C)(3) 3 MERCY HEALTH PARTNERS INC
 
 
No
(69) JEFFERSON MEMORIAL FOUNDATION INC

110 HOSPITAL DRIVE

JEFFERSON CITY,TN37760
62-1660666 		FOUNDATION TN 501(C)(3) 11 - Type III - FI JEFFERSON MEMORIAL HOSPITAL INC
 
 
No
(70) ST MARY'S MEDICAL CENTER OF SCOTT COUNTY INC

18797 ALBERTA STREET

ONEIDA,TN37841
26-1535503 		HOSPITAL TN 501(C)(3) 3 MERCY HEALTH PARTNERS INC
 
 
No
(71) THE BAPTIST HEALTH SYSTEM FOUNDATION INC

101 BLOUNT AVE BOX 1788

KNOXVILLE,TN37920
58-1565290 		FOUNDATION TN 501(C)(3) 7 MERCY HEALTH PARTNERS INC
 
 
No
(72) BAPTIST HOSPITAL OF EAST TENNESSEE INC

137 BLOUNT AVE

KNOXVILLE,TN37920
62-0506166 		HOSPITAL TN 501(C)(3) 3 MERCY HEALTH PARTNERS INC
 
 
No
(73) BAPTIST HOSPITAL OF COCKE COUNTY INC

435 SECOND STREET

NEWPORT,TN37821
62-1133149 		HOSPITAL TN 501(C)(3) 3 MERCY HEALTH PARTNERS INC
 
 
No
(74) MERCY HEALTH AND REHABILITATION CENTER INC

3916 BOYDS BRIDGE PIKE

KNOXVILLE,TN37917
62-1592992 		REHAB CENTER TN 501(C)(3) 9 MERCY HEALTH PARTNERS INC
 
 
No
(75) MERCY HEALTH PARTNERS - NORTHEAST REGION INC

746 JEFFERSON AVENUE

SCRANTON,PA18510
23-2813196 		REGIONAL PARENT PA 501(C)(3) 11 - Type III - FI CATHOLIC HEALTH PARTNERS
 
 
No
(76) MERCY HEALTHCARE FOUNDATION

746 JEFFERSON AVENUE

SCRANTON,PA18510
23-2972928 		FOUNDATION PA 501(C)(3) 11 - Type III - FI MERCY HEALTH PARTNERS - NORTHEAST REGION INC
 
 
No
(77) MERCY HOSPITAL SCRANTON PA

746 JEFFERSON AVENUE

SCRANTON,PA18510
24-0795456 		HOSPITAL PA 501(C)(3) 3 MERCY HEALTH PARTNERS - NORTHEAST REGION INC
 
 
No
(78) MERCY COMMUNITY CARE CORPORATION

746 JEFFERSON AVENUE

SCRANTON,PA18510
23-2310566 		MEDICAL CARE PA 501(C)(3) 9 MERCY HEALTH PARTNERS - NORTHEAST REGION INC
 
 
No
(79) MERCY MED-CARE INC

746 JEFFERSON AVENUE

SCRANTON,PA18510
23-2261991 		HOSPITAL PA 501(C)(3) 3 MERCY HEALTH PARTNERS - NORTHEAST REGION INC
 
 
No
(80) MERCY HOSPITAL NANTICOKE

128 W WASHINGTON ST

NANTICOKE,PA18634
23-2604818 		HOSPITAL PA 501(C)(3) 3 MERCY HEALTH PARTNERS - NORTHEAST REGION INC
 
 
No
(81) MERCY HOSPITAL OF WILKES-BARRE

746 JEFFERSON AVENUE

SCRANTON,PA18510
24-0795625 		HOSPITAL PA 501(C)(3) 3 MERCY HEALTH PARTNERS - NORTHEAST REGION INC
 
 
No
(82) MERCY HEALTH CARE CENTER

746 JEFFERSON AVENUE

SCRANTON,PA18510
23-2322809 		HOSPITAL PA 501(C)(3) 3 MERCY HEALTH PARTNERS - NORTHEAST REGION INC
 
 
No
(83) MERCY TYLER HEALTH SYSTEMS

880 SR 6W

TUNKHANNOCK,PA18657
23-2772476 		SUPPORTING ORG PA 501(C)(3) 11 - Type II MERCY HEALTH PARTNERS - NORTHEAST REGION INC
 
 
No
(84) MERCY TYLER HOSPITAL

880 SR 6W

TUNKHANNOCK,PA18657
24-0779665 		HOSPITAL PA 501(C)(3) 3 MERCY TYLER HEALTH SYSTEMS
 
 
No
(85) MERCY TYLER HOME HEALTH SERVICES

880 SR 6W

TUNKHANNOCK,PA18657
23-2723529 		IN-HOME MEDICAL CARE PA 501(C)(3) 9 MERCY TYLER HEALTH SYSTEMS
 
 
No
(86) SIENA SPRINGS

615 ELSINORE PLACE

CINCINNATI,OH45202
31-1052772 		HUD HOUSING PROJECT OH 501(C)(3) 9 CATHOLIC HEALTH PARTNERS
 
 
No
(87) SIENA SPRINGS II

615 ELSINORE PLACE

CINCINNATI,OH45202
31-1591780 		HUD HOUSING PROJECT OH 501(C)(3) 9 CATHOLIC HEALTH PARTNERS
 
 
No
(88) CHARLES MEADOW CORPORATION

615 ELSINORE PLACE

CINCINNATI,OH45202
34-1552671 		HUD HOUSING PROJECT OH 501(C)(3) 9 CATHOLIC HEALTH PARTNERS
 
 
No
(89) CHARLES CREST CORPORATION

615 ELSINORE PLACE

CINCINNATI,OH45202
34-1399869 		HUD HOUSING PROJECT OH 501(C)(3) 9 CATHOLIC HEALTH PARTNERS
 
 
No
(90) CHARLES CREST II CORPORATION

615 ELSINORE PLACE

CINCINNATI,OH45202
34-1714407 		HUD HOUSING PROJECT OH 501(C)(3) 9 CATHOLIC HEALTH PARTNERS
 
 
No
(91) ST THERESA VILLAGE INC

615 ELSINORE PLACE

CINCINNATI,OH45202
31-1411529 		HUD HOUSING PROJECT OH 501(C)(3) 9 CATHOLIC HEALTH PARTNERS
 
 
No
(92) SACRED HEART VILLAGE INC

615 ELSINORE PLACE

CINCINNATI,OH45202
31-1411531 		HUD HOUSING PROJECT OH 501(C)(3) 9 CATHOLIC HEALTH PARTNERS
 
 
No
(93) SACRED HEART VILLAGE II INC

615 ELSINORE PLACE

CINCINNATI,OH45202
61-1339396 		HUD HOUSING PROJECT OH 501(C)(3) 9 CATHOLIC HEALTH PARTNERS
 
 
No
(94) SACRED HEART VILLAGE III INC

615 ELSINORE PLACE

CINCINNATI,OH45202
61-1367719 		HUD HOUSING PROJECT OH 501(C)(3) 9 CATHOLIC HEALTH PARTNERS
 
 
No
(95) MCAULEY MANOR INC

615 ELSINORE PLACE

CINCINNATI,OH45202
31-1548500 		HUD HOUSING PROJECT OH 501(C)(3) 9 CATHOLIC HEALTH PARTNERS
 
 
No
(96) DUBLIN MANOR INC

615 ELSINORE PLACE

CINCINNATI,OH45202
02-0655254 		HUD HOUSING PROJECT OH 501(C)(3) 9 CATHOLIC HEALTH PARTNERS
 
 
No
(97) MERCY MANOR INC

615 ELSINORE PLACE

CINCINNATI,OH45202
61-1344092 		HUD HOUSING PROJECT OH 501(C)(3) 9 CATHOLIC HEALTH PARTNERS
 
 
No
(98) ST MARY'S VILLA INC

615 ELSINORE PLACE

CINCINNATI,OH45202
31-1548512 		HUD HOUSING PROJECT OH 501(C)(3) 9 CATHOLIC HEALTH PARTNERS
 
 
No
(99) RIVERVIEW ST MARY'S INC

615 ELSINORE PLACE

CINCINNATI,OH45202
62-1782683 		HUD HOUSING PROJECT OH 501(C)(3) 9 CATHOLIC HEALTH PARTNERS
 
 
No
(100) ST MARY'S VILLA AT RIVERVIEW II INC

615 ELSINORE PLACE

CINCINNATI,OH45202
31-1723287 		HUD HOUSING PROJECT OH 501(C)(3) 9 CATHOLIC HEALTH PARTNERS
 
 
No
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
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) NWO INTEGRATED LABORATORIES MERCY LLC

2200 JEFFERSON AVENUE
TOLEDO,OH43624
34-1898285 		LABORATORY SERVICES OH NA
  		EXCLUDED                
(2) TIFFIN AMBULATORY SURGICAL ASSOCIATES

45 ST LAWRENCE DRIVE
TIFFIN,OH44833
37-1567866 		AMBULATORY SURGERY CENTER OH NA
  		EXCLUDED                
(3) MERCY HOSPITAL OF DEFIANCE LLC

1404 E SECOND ST
DEFIANCE,OH43512
02-0701635 		HOSPITAL OH NA
  		EXCLUDED                
(4) WEST CENTRAL OHIO REGIONAL HEALTHCARE ALLIANCE

FORT AMANDA ROAD
LIMA,OH45804
34-1817078 		REG HOSPITALS OH NA
  		EXCLUDED                
(5) WEST CENTRAL OHIO SURGERY & ENDO CENTER

770 W HIGH ST SUITE 100
LIMA,OH45801
34-1868154 		AMBULATORY SURGERY CENTER OH NA
  		EXCLUDED                
(6) NEW VISION MEDICAL LAB LLC

750 W HIGH STREET
LIMA,OH45801
34-1913433 		LAB SERVICES OH NA
  		EXCLUDED                
(7) WEST CENTRAL OHIO GROUP LTD

801 MEDICAL DRIVE
LIMA,OH45804
34-1848147 		ORTHOPEDIC HOSPITAL OH NA
  		EXCLUDED                
(8) KIDNEY SERVICES OF WEST CENTRAL OHIO

750 W HIGH STREET SUITE 100
LIMA,OH45801
06-1644264 		DIALYSIS CENTER OH NA
  		EXCLUDED                
(9) ST ELIZABETH CARDIAC CATH LAB LLC

1044 BELMONT AVE
YOUNGSTOWN,OH44501
30-0023795 		CARDIAC CATH LAB OH NA
  		EXCLUDED                
(10) ST ELIZABETH SOUTHWOODS IMAGING

250 DEBARTOLO PLACE BLDG B
YOUNGSTOWN,OH44512
26-1626482 		DIAGNOSTIC IMAGING OH NA
  		EXCLUDED                
(11) UROLOGIC ONCOLOGY OF MAHONING VALLEY LLC

1044 BELMONT AVE
YOUNGSTOWN,OH44501
26-2989686 		RADIATION THERAPY OH NA
  		EXCLUDED                
(12) HMHPUSP SURGERY CENTERS LLC

15305 DALLAS PKWY STE 1600
ADDISON,TX75001
27-1953122 		SURGERY CENTER TX NA
  		EXCLUDED                
(13) OSC-HMHP LLC

6505 MARKET ST BLDG B STE 101
BOARDMAN,OH44512
01-0724836 		ORTHOPEDIC SURGERY CENTER OH NA
  		EXCLUDED                
(14) LOURDES AMBULATORY SURGERY CENTER

225 MEDICAL CENTER DRIVE
PADUCAH,KY42003
61-1258960 		SURGERY CENTER KY NA
  		EXCLUDED                
(15) EAST TENNESSEE DIAGNOSTIC CENTER LLC

1450 DOWELL SPRINGS BLVD SUITE 250
KNOXVILLE,TN37909
20-4773300 		DIAGNOSTIC SERVICES TN NA
  		EXCLUDED                
(16) ST MARY''S AMBULATORY SURGERY CENTER LLC

1515 ST MARYS ST
KNOXVILLE,TN37917
62-1757542 		SURGERY CENTER TN NA
  		EXCLUDED                
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) CHP INSURANCE LTD
615 ELSINORE PLACE
CINCINNATI,OH45202
98-0621978 		INSURANCE CJ NA
  		C CORPORATION      
(2) SISTERS OF MERCY WORKERS COMPENSATION SELF-INSURANCE TRUST
615 ELSINORE PLACE
CINCINNATI,OH45202
31-0990309 		WORKERS COMPENSATION TRUST MA NA
  		TRUST      
(3) MHSWO HEALTH VENTURES INC
1 S LIMESTONE ST
SPRINGFIELD,OH45502
31-1072139 		PHYSICIAN PRACTICES OH NA
  		C CORPORATION      
(4) NORTHPARKE MEDICAL COMMONS CONDO ASSN
333 N LIMESTONE ST
SPRINGFIELD,OH45503
31-1391230 		REAL PROPERTY MGMNT OH NA
  		C CORPORATION      
(5) MERCY HEALTH AFFILIATES INC
2200 JEFFERSON AVENUE
TOLEDO,OH43604
34-1372633 		PHYSICIAN SERVICES OH NA
  		C CORPORATION      
(6) PHYSICIAN'S HEALTH COLLABORATIVE
2200 JEFFERSON AVENUE
TOLEDO,OH43604
20-3986844 		MEDICAL & HOSPITAL SERVICES OH NA
  		C CORPORATION      
(7) NORTHSIDE CORPORATION
2200 JEFFERSON AVENUE
TOLEDO,OH43604
34-1318438 		RESIDENT RENTALS OH NA
  		C CORPORATION      
(8) MERCY WORK SOLUTIONS
2200 JEFFERSON AVENUE
TOLEDO,OH43604
30-0066340 		WORKERS COMPENSATION OH NA
  		C CORPORATION      
(9) MERCY HEALTH SYSTEM PHO
2200 JEFFERSON AVENUE
TOLEDO,OH43604
34-1778321 		MEDICAL SERVICES OH NA
  		C CORPORATION      
(10) PHYSICIAN MANAGED CARE INC
2200 JEFFERSON AVENUE
TOLEDO,OH43604
34-1565320 		HEALTH SERVICES OH NA
  		C CORPORATION      
(11) MCAULEY MANAGEMENT SERVICES INC
730 W MARKET STREET
LIMA,OH45801
34-1379037 		PROPERTY RENTAL OH NA
  		C CORPORATION      
(12) LIMA MEDICAL SUPPLIES INC
730 W MARKET STREET
LIMA,OH45801
34-0944477 		MEDICAL EQUIPMENT OH NA
  		C CORPORATION      
(13) COMMUNITY HEALTH PARTNERS ENTERPRISES INC
3700 KOLBE ROAD
LORAIN,OH44053
34-1455525 		HOLDING COMPANY OH NA
  		C CORPORATION      
(14) COMMUNITY HEALTH PARTNERS PHYSICIANS INC
3700 KOLBE ROAD
LORAIN,OH44053
34-1803352 		PHYSICIAN PRACTICES OH NA
  		C CORPORATION      
(15) AMC PHYSICIANS INC
200 W LORAIN STREET
OBERLIN,OH44074
37-1439554 		PHYSICIAN SERVICES OH NA
  		C CORPORATION      
(16) MERCY HEALTH VENTURES INC
4600 MCAULEY PLACE
CINCINNATI,OH45242
31-1185477 		DIVERSIFIED ACTIVITIES OH NA
  		C CORPORATION      
(17) MERCY FRANCISCAN AT WINTON WOODS I INC
10290 MILL ROAD
CINCINNATI,OH45231
31-1658668 		LOW-INCOME HOUSING OH NA
  		C CORPORATION      
(18) MERCY HEALTH MANAGEMENT INC
1530 LONE OAK ROAD
PADUCAH,KY42003
61-1086762 		MEDICAL OFFICES KY NA
  		C CORPORATION      
(19) HEALTH DYNAMICS INC
900 E OAK HILL AVENUE
KNOXVILLE,TN37917
62-1247729 		MEDICAL EQUIPMENT SALES TN NA
  		C CORPORATION      
(20) HEALTH VENTURES INC & SUBSIDIARIES
P O BOX 1788
KNOXVILLE,TN37901
62-1175587 		MEDICAL SERVICES TN NA
  		C CORPORATION      
(21) ANNE KILCAWLEY CHRISTMAN FOUNDATION
100 FEDERAL PLAZEA EAST
YOUNGSTOWN,OH44503
35-6735706 		BENEFICIAL TRUST OH NA
  		TRUST      
(22) RALPH EWE TRUST
270 PARK AVENUE
NEW YORK,NY10017
34-6866422 		BENEFICIAL TRUST NY NA
  		TRUST      
(23) ELIZABETH HINES CATES TRUST
1900 E 9TH STREET
CLEVELAND,OH44114
34-6515678 		BENEFICIAL TRUST OH NA
  		TRUST      
Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
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 related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
 
No
c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c
 
No
d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1d
 
No
e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1e
 
No
f Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
No
g Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
 
No
j Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
 
No
k Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .
1k
 
No
l Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .
1l
 
No
m Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .
1m
 
No
n Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1n
Yes
 
o Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
Yes
 
p Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
 
No
q Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
 
No
r Other transfer of cash or property from related 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)
(2)
(3)
(4)
(5)
(6)
Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
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)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(e)
Are all
partners
section
501(c)(3)
organizations? 		(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 Yes No






























Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
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


Software ID: 11000230
Software Version: v2011.1.0