Department of the Treasury Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
LEWIS AND CLARK HEALTH EDUCATION AND SERVICE AGENCY
Employer identification number
46-0337013
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization?
................
11g(i)
(ii)
a family member of a person described in (i) above?
......................
11g(ii)
(iii)
a 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
h
Provide the following information about the supported organization(s).
(i) Name of supported organization
(ii) EIN
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions))
(iv) Is the organization in col. (i) listed in your governing document?
(v) Did you notify the organization in col. (i) of your support?
(vi) Is the organization in col. (i) organized in the U.S.?
(vii) Amount of support?
Yes
No
Yes
No
Yes
No
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the
organization failed to qualify under Part III. If the organization fails to
qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3
The value of services or facilities furnished by a governmental unit to the organization without charge..
4
Total. Add lines 1 through 3..
5
The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included
on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6
Public Support. Subtract line 5 from line 4.
Section B. Total Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
7
Amounts from line 4..
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
9
Net income from unrelated business activities, whether or not the business is regularly carried on..
10
Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..
11
Total support (Add lines 7 through 10).
12
Gross receipts from related activities, etc. (See instructions.)
..................
12
13
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here..........................................
Section C. Computation of Public Support Percentage
14
Public Support Percentage for 2010 (line 6 column (f) divided by line 11 column (f))
.........
14
15
Public Support Percentage for 2009 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2010.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
......................
b
33 1/3% support test—2009.
If the organization did not check the box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2010.
If the organization did not check a box on line 13, 16a, or 16b and line 14
is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported
organization
..................................................
b
10%-facts-and-circumstances test—2009.
If the organization did not check a box on line 13, 16a, 16b, or 17a and line
15 is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported organization
..............................................
18
Private Foundation
If the organization did not check a box on line 13, 16a, 16b, 17a or 17b, check this box and see
instructions
...................................................
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization
failed to qualify under Part II. If the organization fails to qualify under
the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
17,500
84,125
101,625
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......
1,655,551
1,367,031
1,800,727
1,639,384
1,784,501
8,247,194
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.
1,655,551
1,367,031
1,818,227
1,723,509
1,784,501
8,348,819
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
0
b
Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
893,833
497,645
845,162
1,103,817
1,216,469
4,556,926
c
Add lines 7a and 7b..
893,833
497,645
845,162
1,103,817
1,216,469
4,556,926
8
Public Support (Subtract line 7c from line 6.)
3,791,893
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
9
Amounts from line 6...
1,655,551
1,367,031
1,818,227
1,723,509
1,784,501
8,348,819
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
10,036
3,063
2,221
3,463
2,406
21,189
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
10,036
3,063
2,221
3,463
2,406
21,189
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.).
1,665,587
1,370,094
1,820,448
1,726,972
1,786,907
8,370,008
14
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public Support Percentage for 2010 (line 8 column (f) divided by line 13 column (f))
.........
15
45.300 %
16
Public support percentage from 2009 Schedule A, Part III, line 15
...............
16
59.490 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2010 (line 10c column (f) divided by line 13 column (f))
......
17
0.250 %
18
Investment income percentage from 2009 Schedule A, Part III, line 17
.............
18
0.400 %
19a
33 1/3% support tests—2010.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3% and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
..........
b
33 1/3% support tests—2009.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
....
20
Private Foundation
If the organization did not check a box on line 14, 19a or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 4
Part IV
Supplemental Information.
Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
Explanation
Schedule A (Form 990 or 990-EZ) 2010
Additional Data
Software ID:
Software Version:
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
LEWIS AND CLARK HEALTH EDUCATION AND SERVICE AGENCY
Employer identification number
46-0337013
Identifier
Return Reference
Explanation
FORM 990, PART VI, SECTION A, LINE 2
BARBARA LARSON AND BRYAN SLABA HAVE A BUSINESS RELATIONSHIP WITH PAMELA REZAC.
FORM 990, PART VI, SECTION A, LINE 6
THE SOLE MEMBER OF THE ORGANIZATION, SACRED HEART HEALTH SERVICES, IS A NONPROFIT CORPORATION ORGANIZED AND EXISTING UNDER THE LAWS OF THE STATE OF SOUTH DAKOTA AND EXEMPT UNDER 501(C)(3) OF THE INTERNAL REVENUE CODE OF 1986, AS AMENDED.
FORM 990, PART VI, SECTION A, LINE 7A
SACRED HEART HEALTH SERVICES, AS THE SOLE MEMBER, HAS THE POWER TO APPOINT DIRECTORS; TO FILL VACANCIES ON THE BOARD OF DIRECTORS, AND TO REMOVE DIRECTORS.
FORM 990, PART VI, SECTION A, LINE 7B
THE FOLLOWING POWERS ARE RESERVED TO SACRED HEART HEALTH SERVICES 1) TO ADOPT, APPROVE OR CHANGE THE PHILOSOPHY AND MISSION OF LEWIS & CLARK; 2) TO APPROVE THE ADOPTION, AMENDMENT OR REPEAL OF THE ARTICLES OF INCORPORATION OF LEWIS & CLARK; 3) TO ADOPT, AMEND OR REPEAL THE BY-LAWS OF LEWIS & CLARK, EXCEPT AS LIMITED BY ARTICLE X OF THESE BY-LAWS; 4) TO APPOINT DIRECTORS OF LEWIS & CLARK; TO FILL VACANCIES ON THE BOARD OF DIRECTORS, AND TO REMOVE DIRECTORS WHENEVER IN THE CORPORATE MEMBER'S SOLE JUDGMENT THE BEST INTERESTS OF LEWIS & CLARK WOULD BE SERVED THEREBY; 5) TO APPROVE THE PURCHASE, SALE, LEASE OR MORTGAGE OF REAL PROPERTY OR BUILDINGS; 6) TO APPROVE THE MERGER, CONSOLIDATION OR AFFILIATION OF LEWIS & CLARK WITH ANOTHER CORPORATION, ORGANIZATION OR PROGRAM, OR THE DISSOLUTION OF LEWIS & CLARK; 7)TO APPROVE THE ANNUAL OPERATING AND CAPITAL BUDGETS OF LEWIS & CLARK, AND VARIANCES THERETO IF GREATER THAN LIMITS ESTABLISHED BY THE CORPORATE MEMBER FROM TIME TO TIME; AND 8) TO APPROVE THE LONG-RANGE STRATEGIC PLAN OF LEWIS & CLARK. 9) TO APPROVE ANY OTHER ACT NOT INCONSISTENT WITH STATE OR FEDERAL LAW.
FORM 990, PART VI, SECTION A, LINE 8B
THE ORGANIZATION DOES NOT HAVE A COMMITTEE WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BOARD.
FORM 990, PART VI, SECTION B, LINE 11
THE FORM 990 IS REVIEWED BY THE CEO AND CFO OF SACRED HEART HEALTH SERVICES, THE SOLE MEMBER. THE RETURN IS PROVIDED TO THE BOARD PRIOR TO FILING.
FORM 990, PART VI, SECTION B, LINE 12C
THE CONFLICT OF INTEREST POLICY COVERS BOARD MEMBERS, OFFICERS AND KEY EMPLOYEES. AT EACH BOARD MEETING, A REQUEST IS MADE FOR ALL BOARD MEMBERS TO DISCLOSE ANY POTENTIAL CONFLICT OF INTEREST PERTAINING TO ANY ITEM LISTED ON THE AGENDA OR PERTAINING TO ANY POTENTIAL ITEM THAT COULD BE DISCUSSED DURING THE COURSE OF THE MEETING. THE DECLARATION OF CONFLICT OF INTEREST IS RECORDED IN THE MEETING MINUTES. THE BOARD MAKES A DETERMINATION OF WHETHER THERE IS A CONFLICT OF INTEREST AND IF SO, IMPLEMENTS THE PROCEDURE FOR EVALUATING THE ISSUE OR TRANSACTION INVOLVED. THE BOARD MEMBER OR OFFICER WITH THE CONFLICT MUST REFRAIN FROM VOTING. A STATEMENT OF CONFLICT OF INTEREST DISCLOSURE IS MADE ON AN ANNUAL BASIS BY OFFICERS AND DIRECTORS. THE INFORMATION IS MAINTAINED IN A DATABASE AND A REPORT IS PROVIDED TO THE BOARD.
FORM 990, PART VI, SECTION B, LINE 15: ANNUALLY THE COMPENSATION COMMITTEE OF AVERA SACRED HEART HOSPITAL, WHICH IS COMPRISED OF BOARD MEMBERS ELECTED BY THE SYSTEM, CONFERS WITH AN INDEPENDENT CONSULTANT REGARDING FAIR MARKET VALUE OF OFFICERS AND KEY EMPLOYEES. THE COMPENSATION COMMITTEE APPROVES ALL SALARIES BASED ON COMPARABLE DATA AND DOCUMENTS THE BASIS FOR THEIR DECISION IN MEETING MINUTES.
FORM 990, PART VI, SECTION C, LINE 19
THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC.
FORM 990, PART VII:
THE COMPENSATION FOR RACHAEL SHERARD IS PAID BY AVERA HEALTH. OF THAT AMOUNT, NONE OF THE GROSS WAGES AND BENEFITS IS RELATED TO HER POSITION ON THE GOVERNING BODY OF LEWIS AND CLARK HEALTH EDUCATION AND SERVICE AGENCY. THE COMPENSATION FOR KAYLEEN LEE IS PAID BY AVERA MCKENNAN. OF THAT AMOUNT, NONE OF THE GROSS WAGES AND BENEFITS IS RELATED TO HER POSITION ON THE GOVERNING BODY OF LEWIS AND CLARK HEALTH EDUCATION AND SERVICE AGENCY. IN ADDITION TO SERVING ON THE BOARD OF LEWIS AND CLARK THE BOARD MEMBERS SERVE THE FOLLOWING HOURS PER WEEK AT RELATED ENTITIES: PAMELA REZAC 60 BARBARA LARSON 40 RACHAEL SHERARD 40 BRYAN SLABA 40 KAYLEEN LEE 40
CHANGES IN NET ASSETS OR FUND BALANCES:
FORM 990, PART XI, LINE 5:
NET UNREALIZED GAINS ON INVESTMENTS: 61,485.
FORM 990, PART XII, LINE 2C:
THE AUDIT COMMITTEE OF AVERA HEALTH, PARENT ORGANIZATION OF SACRED HEART HEALTH SERVICES, SELECTS THE AUDITOR AND REVIEWS THE AUDITED FINANCIAL STATEMENTS FOR SACRED HEART HEALTH SERVICES AND ITS SUBSIDIARIES, WHICH INCLUDES LEWIS AND CLARK HEALTH EDUCATION AND SERVICE AGENCY.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.