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
2011
Open to Public Inspection
Name of the organization
LIVING WELL FOUNDATION
Employer identification number
20-5705242
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization?
................
11g(i)
No
(ii)
a family member of a person described in (i) above?
......................
11g(ii)
No
(iii)
a 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
No
h
Provide the following information about the supported organization(s).
(i) Name of supported organization
(ii) EIN
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions))
(iv) Is the organization in col. (i) listed in your governing document?
(v) Did you notify the organization in col. (i) of your support?
(vi) Is the organization in col. (i) organized in the U.S.?
(vii) Amount of support?
Yes
No
Yes
No
Yes
No
(1)
HOSPITAL SERVICE DISTRICT 1 PARISH OF OUACHITA STATE OF LOUISIANA
721194469
6
Yes
Yes
Yes
0
Total
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
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—2011.
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—2010.
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—2011.
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—2010.
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) 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
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 2011 (line 8 column (f) divided by line 13 column (f))
.........
15
16
Public support percentage from 2010 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2011 (line 10c column (f) divided by line 13 column (f))
......
17
18
Investment income percentage from 2010 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2011.
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—2010.
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) 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:
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
2011
Open to Public Inspection
Name of the organization
LIVING WELL FOUNDATION
Employer identification number
20-5705242
Identifier
Return Reference
Explanation
ORGANIZATION'S MISSION
FORM 990 - ORGANIZATION'S MISSION
THE FOUNDATION ADMINISTERED ACTIVITIES RELATED TO RENDERING CARE TO THE SICK AND INJURED OR IN THE PROMOTION OF HEALTH, COOPERATED WITH OTHER PUBLIC AND PRIVATE INSTITUTIONS AND AGENCIES ENGAGED IN PROVIDING HOSPITAL AND OTHER HEALTH CARE SERVICES TO RESIDENTS OF THE DISTRICT, AND PARTICIPATED IN ACTIVITIES DESIGNED AND CONDUCTED TO PROMOTE THE GENERAL HEALTH OF THE COMMUNITY. THE FOUNDATION'S AREA OF SERVICE INCLUDED THE FOLLOWING EIGHT NORTHEASTERN LOUISIANA PARISHES: CALDWELL, FRANKLIN, JACKSON, LINCOLN, MOREHOUSE, OUACHITA, RICHLAND AND UNION.
FIRST ACCOMPLISHMENT DESCRIPTION
FORM 990, PAGE 2, PART III, LINE 4A
STUDENTS WHO ARE LIMITED IN THEIR ABILITY TO ACCESS THE EXISTING HEALTHCARE SYSTEMS IN THE COMMUNITY. DURING 2011 THE FOUNDATION PROVIDED FUNDING OF 121,711 TO RISER MIDDLE SCHOOL AND 130,476 TO WEST MONROE HIGH SCHOOL. ON DECEMBER 31, 2009 THE FOUNDATION ENTERED INTO A TEN-YEAR AGREEMENT ENDING DECEMBER 31, 2018 WITH THE POLICE JURY TO PROVIDE TWO SCHOOL BASED HEALTH CENTERS IN EAST OUACHITA PARISH AT MARTIN LUTHER KING, JR. MIDDLE SCHOOL AND RICHWOOD HIGH SCHOOL. ST FRANCIS MEDICAL CENTER AGREED TO PARTNER WITH THE FOUNDATION AND POLICE JURY TO PROVIDE THE MEDICAL NEEDS AT THESE CLINICS. STUDENTS FROM MINNIE RUFFIN ELEMENTARY, BURG JONES LANE ELEMENTARY, JEFFERSON UPPER ELEMENTARY AND MARTIN LUTHER KING, JR MIDDLE SCHOOL WILL BE SERVED AT THE MARTIN LUTHER KING, JR. MIDDLE SCHOOL LOCATION. STUDENTS FROM SHADY GROVE ELEMENTARY, SWAYZE ELEMENTARY, ROBINSON ELEMENTARY AND RICHWOOD JUNIOR AND HIGH SCHOOLS WILL BE SERVED AT THE RICHWOOD HIGH LOCATION. UNDER THIS AGREEMENT THE FOUNDATION PROVIDED 15,000 TO EACH OF THE TWO LOCATIONS WHICH WILL BE MATCHED BY THE POLICE JURY. THE PROGRAMS HAVE NOT BEEN CURRENTLY ESTABLISHED BECAUSE THE STATE PORTION OF THE FUNDS HAS NOT BEEN AWARDED. AS OF DECEMBER 31, 2011, 90,000 WAS PAYABLE TO OUACHITA PARISH SCHOOL BOARD FOR THE HEALTH BASED SCHOOL CENTERS IN EAST OUACHITA PARISH.
CLASSES OF MEMBERS OR STOCKHOLDERS
FORM 990, PAGE 6, PART VI, LINE 6
THE FOUNDATION HAS ONE MEMBER, THE HOSPITAL SERVICE DISTRICT 1 OF THE PARISH OF OUACHITA STATE OF LOUISIANA
ELECTION OF MEMBERS AND THEIR RIGHTS
FORM 990, PAGE 6, PART VI, LINE 7A
THE HOSPITAL SERVICE DISTRICT 1 PARISH OF OUACHITA STATE OF LOUISIANA SHALL BE ENTITLED TO ELECT TWO-THIRDS OF THE DIRECTORS AND THE POLICE JURY OF OUACHITA PARISH STATE OF LOUISIANA SHALL BE ENTITLED TO ELECT ONE-THIRD OF THE DIRECTORS. THE MEMBERS OF THE BOARD OF DIRECTORS MUST MEET THE REQUIREMENTS SET FORTH IN THE ARTICLES OF INCORPORATION OF LIVING WELL FOUNDATION.
DECISIONS SUBJECT TO APPROVAL OF MEMBERS
FORM 990, PAGE 6, PART VI, LINE 7B
CERTAIN MATTERS AS LISTED IN THE BY-LAWS OF LIVING WELL FOUNDATION REQUIRE APPROVAL OF THE BOARD OF COMMISSIONERS OF HOSPITAL DISTRICT 1 PARISH OF OUACHITA STATE OF LOUISIANA.
ORGANIZATION'S PROCESS USED TO REVIEW FORM 990
FORM 990, PAGE 6, PART VI, LINE 11B
THE 990 GOES TO THE FINANCE COMMITTEE WHICH REVIEWS THE TAX RETURN AND THEN GIVES A REPORT THE THE BOARD OF DIRECTORS.
ENFORCEMENT OF CONFLICTS POLICY
FORM 990, PAGE 6, PART VI, LINE 12C
BEFORE PERSONS BECOME BOARD MEMBERS,THEY ARE PRESENTED WITH THE CONFLICT OF INTEREST POLICY WITH WHICH THEY ARE EXPECTED TO COMPLY. AFTER BECOMING BOARD MEMBERS THEY ARE EXPECTED TO NOTIFY THE BOARD OF ANY CONFLICTS OF INTEREST THAT MAY ARISE.
COMPENSATION PROCESS FOR TOP OFFICIAL
FORM 990, PAGE 6, PART VI, LINE 15A
IN DETERMINING THE COMPENSATION FOR THE CEO, THE PLANNING/OPERATIONS COMMITTEE INCLUDES COMPARABILITY DATA, A REVIEW AND APPROVAL BY INDEPENDENT PERSONS AND SUBSTANTIATION OF THE DELIBERATION AND DECISIONS MADE.
GOVERNING DOCUMENTS DISCLOSURE EXPLANATION
FORM 990, PAGE 6, PART VI, LINE 19
LIVING WELL FOUNDATION FURNISHES THE ARTICLES OF INCORPORATION BYLAWS, GRANT MAKING GUIDELINES, MINUTES OF ALL MEETINGS, BUDGETS FINANCIAL STATEMENTS AND OTHER INFORMATION ON THE ORGANIZATION WEBSITE WWW.LIVINGWELLFOUNDATION.NET
OTHER CHANGES IN NET ASSETS EXPLANATION
FORM 990, PART XI, LINE 5
NET UNREALIZED GAINS ON INVESTMENTS 146,533.
CHANGE IN FINANCIAL REVIEW PROCESS
FORM 990, PAGE 12, PART XII, LINE 2C
THE THREE-MEMBER AUDIT COMMITTEE SELECTS THE INDEPENDENT ACCOUNTANT SUBJECT TO THE APPROVAL OF THE BOARD OF DIRECTORS. THE AUDIT COMMITTEE OVERSEES THE AUDIT OF THE FINANCIAL STATEMENT. THE PROCESS OF SELECTING THE AUDITOR AND OVERSEEING THE AUDIT HAS NOT CHANGED FROM THE PRIOR YEAR.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.