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
COXHEALTH AUXILIARY
Employer identification number
43-1090590
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) 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.") .
2,558
2,698
3,660
31,906
35,025
75,847
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......
718,879
670,683
694,859
611,625
560,064
3,256,110
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.
721,437
673,381
698,519
643,531
595,089
3,331,957
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.)
3,331,957
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...
721,437
673,381
698,519
643,531
595,089
3,331,957
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
30,860
27,538
26,588
24,798
30,633
140,417
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
30,860
27,538
26,588
24,798
30,633
140,417
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.).
752,297
700,919
725,107
668,329
625,722
3,472,374
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
95.956 %
16
Public support percentage from 2010 Schedule A, Part III, line 15
...............
16
96.660 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2011 (line 10c column (f) divided by line 13 column (f))
......
17
4.044 %
18
Investment income percentage from 2010 Schedule A, Part III, line 17
.............
18
3.340 %
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
COXHEALTH AUXILIARY
Employer identification number
43-1090590
Identifier
Return Reference
Explanation
PROGRAM SERVICES ACCOMPLISHMENTS
FORM 990, PART III, LINE 4A
BELOW IS A PARTIAL LISTING OF THE GRANTS AWARDED THROUGHOUT COXHEALTH AND AFFILIATES: - CHILDREN'S MIRACLE NETWORK, CHILD LIFE PROGRAM - CHILDREN'S MIRACLE NETWORK, C.A.R.E. MOBILE - CHILDREN'S MIRACLE NETWORK, SHAKEN BABY SYNDROME - PREHOSPITAL, SMALL AMBULANCE - WOMEN & NEWBORN CARE, BILIRUBIN ANALYZER - COXHEALTH FOUNDATION, KNOT FORGOTTEN PROGRAM - ACUTE CARE THERAPY, EYE PILLOW MATERIALS - VOLUNTEER SERVICES, HEART PILLOW MATERIALS - CASE MANAGEMENT, MEDICATION FOR THOSE WITH NO INSURANCE OR LIMITED BENEFITS - EMERGENCY DEPT SOUTH, SCALE AND INFANT WARMER - PASTORAL CARE, MEAL TICKETS FOR NEEDY FAMILY MEMBER OF PATIENTS IN THE HOSPITAL - VOLUNTEER SERVICES, UNIFORMS FOR VOLUNTEERS/MEDICAL EXPLORERS THAT CAN'T AFFORD THEM - VOLUNTEER SERVICES, GIFT SHOP - TRAUMA SERVICES, INJURY PREVENTION EDUCATION - VOLUNTEER SERVICES, SECURITY BLANKETS FOR PEDIATRICS - CASE MANAGEMENT, CLOTHING FOR EMERGENCY DEPT - NEW ROOM IN EMERGENCY, 4TH OF 5 PAYMENTS FOR $25,000 GRANT - COXHEALTH FITNESS CENTER, MEDICAL MILE AND 5K - LABOR AND DELIVERY, CLOTHING FOR STILL BORN INFANTS - OUTPATIENT REHAB NORTH, SPEECH THERAPY PHOTO CARDS - COXHEALTH FOUNDATION, BREAST CANCER TOURNEY - LABOR AND DELIVERY, CLOTHING FOR STILL BORN INFANTS - OUTPATIENT REHAB NORTH, SPEECH THERAPY PHOTO CARDS - COXHEALTH FOUNDATION, BREAST CANCER TOURNEY
DECISIONS SUBJECT TO APPROVAL
FORM 990, PART VI, SECTION A, LINE 7B
PER THE BYLAWS, ARTICLE X, ALL FUND RAISING ACTIVITIES OTHER THAN DONATIONS, SHALL BE SUBJECT TO THE APPROVAL OF THE EXECUTIVE ADMINISTRATOR OF THE HOSPITAL (COXHEALTH) OR HIS DESIGNEE. ALSO, PER ARTICLE XIV, THE HOSPITAL (COXHEALTH) BOARD OF DIRECTORS AND THE HOSPITAL ADMINISTRATOR, SHALL APPROVE PROPOSED AMENDMENTS TO THE AUXILIARY BYLAWS.
FORM 990 REVIEW POLICY
FORM 990, PART VI, SECTION B, LINE 11B
THE FORM 990 IS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM BASED ON THE AUDITED FINANCIAL STATEMENTS AND INFORMATION PROVIDED BY THE ACCOUNTING DEPARTMENT OF THE ORGANIZATION. PRIOR TO FILING, A TENTATIVE DRAFT OF THE FORM 990 IS REVIEWED BY MEMBERS OF TOP MANAGEMENT. ONCE NECESSARY UPDATES ARE MADE, AND A FINAL DRAFT IS PROVIDED TO ALL MEMBERS OF THE BOARD OF DIRECTORS.
CONFLICT OF INTEREST POLICY
FORM 990, PART VI, SECTION B, LINE 12C
COXHEALTH OFFICERS, DIRECTORS AND KEY EMPLOYEES, AS WELL AS OFFICERS, DIRECTORS, AND KEY EMPLOYEES OF THE COXHEALTH AFFILIATES, ARE ANNUALLY REQUIRED TO DISCLOSE POTENTIAL CONFLICTS OF INTEREST FOLLOWING THE CORPORATE COMPLIANCE POLICY, SET FORTH BELOW. IN ADDITION, THE COXHEALTH BYLAWS CONTAIN A CONFLICT OF INTEREST PROVISION TO ENSURE BOARD MEMBERS MAKE DECISIONS THAT ARE CONFLICT FREE, OR IF A CONFLICT IS PRESENT, THAT IT IS FULLY DISCLOSED FOR THE BOARD'S CONSIDERATION. COXHEALTH'S EMPLOYEES AND BOARD MEMBERS MUST AVOID ALL ACTIVITIES, ASSOCIATIONS OR INTERESTS THAT CREATE A CONFLICT OF INTEREST. CONFLICTS OF INTEREST FOR EMPLOYEES MUST BE REPORTED TO THE CORPORATE INTEGRITY DEPARTMENT. A FILE WILL BE MAINTAINED OF ALL REPORTED CONFLICTS OF INTEREST. FOR MEDICAL STAFF MEMBERS, THE CONFLICT OF INTEREST PROCESS MAY BE ACCESSED THROUGH THE MEDICAL STAFF OFFICE. FOR BOARD MEMBERS, THE CONFLICT OF INTEREST PROCESS IS HANDLED THROUGH THE EXECUTIVE OFFICE AND IS DEFINED IN THE BOARD BYLAWS. IF ANY OFFICER OR DIRECTOR IS FOUND TO HAVE A CONFLICT OF INTEREST, SUCH PERSON SHALL NEITHER VOTE NOR USE HIS OR HER INFLUENCE TO AFFECT ANY DECISION RELATING TO THE CONFLICT, AND SUCH PERSON SHOULD NOT BE INCLUDED IN DETERMINING WHETHER A QUORUM PARTICIPATED IN THE DECISION. SUCH PERSON IS PERMITTED TO BRIEFLY STATE HIS OR HER POSITION ON THE MATTER, AND ANSWER PERTINENT QUESTIONS ABOUT IT, IF HIS OR HER KNOWLEDGE OR EXPERTISE COULD ASSIST THOSE PARTICIPATING IN THE DECISION. FOR VENDORS, THE POLICY IS DISTRIBUTED AT THEIR FIRST CONTRACT WITH COXHEALTH.
DOCUMENT DISCLOSURE
FORM 990, PART VI, SECTION C, LINE 19
COXHEALTH AND ITS AFFILIATES MAKES AVAILABLE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE FOR ALL LEGITIMATE BUSINESS PURPOSES AS DETERMINED BY MANAGEMENT.
HOURS FOR RELATED ORGANIZATIONS
FORM 990, PART VII, SECTION A, COLUMN B
THE FOLLOWING DIRECTORS SERVE ON THE BOARDS OF COX ALTERNATIVE CARE OF THE OZARKS, INC., COXHEALTH HOME CARE SERVICES OF THE MIDWEST, INC., HEALTHCARE SERVICES OF THE OZARKS, INC., COX HPS OF THE OZARKS, INC., COX-MONETT HOSPITAL, INC., EACH A RELATED ORGANIZATION. EACH INDIVIDUAL AVERAGED ONE HOUR OF SERVICE PER WEEK FOR EACH ORGANIZATION: JAN HARRIS STEVE EDWARDS ROBERT BEZANSON LAURIE DUFF (OFFICER ONLY) THE FOLLOWING DIRECTORS SERVE ON THE BOARD OF PRIMROSE PLACE, INC., A RELATED ORGANIZATION, AND AVERAGED ONE HOUR OF SERVICE PER WEEK: STEVE EDWARDS ROBERT BEZANSON LAURIE DUFF (OFFICER ONLY) THE FOLLOWING DIRECTORS SERVE AS OFFICERS AT LESTER E. COX MEDICAL CENTERS, A RELATED ORGANIZATION, AND AVERAGED 40 HOURS OF SERVICE PER WEEK. STEVE EDWARDS ROBERT BEZANSON LAURIE DUFF THE FOLLOWING DIRECTOR SERVES ON THE BOARD OF LESTER E. COX MEDICAL CENTERS, A RELATED ORGANIZATION, AND AVERAGED ONE HOUR OF SERVICE PER WEEK. JAN HARRIS
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.