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
2012
Open to Public Inspection
A For the 2012 calendar year, or tax year beginning 07-01-2012 , 2012, and ending 06-30-2013
BCheck if applicable:
CName of organization
MOUNTAIN STATES HEALTH ALLIANCE
AUXILIARY
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
400 NORTH STATE OF FRANKLIN ROAD
 
Room/suite
City or town, state or country, and ZIP + 4
JOHNSON CITY, TN37604
D Employer identification number

58-1418345
E Telephone number

G Gross receipts $ 1,179,841
F Name and address of principal officer:
LYNNIS HORNSBY
400 NORTH STATE OF FRANKLIN ROAD
JOHNSON CITY,TN37604
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
WWW.MSHA.COM
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: 1980
M State of legal domicile: TN
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: PART III, LINE 1 - THE PURPOSE OF THE ORGANIZATION IS TO RENDER SERVICES TO MOUNTAIN STATES HEALTH ALLIANCE (MSHA) AND ITS RELATED HOSPITALS; ITS PATIENTS, GUESTS, AND TEAM MEMBERS, WHILE ASSISTING MSHA IN PROMOTING THE HEALTH AND WELFARE OF THE COMMUNITY SERVED, AND TO FUNCTION AS AN ADVISORY BOARD TO THE MSHA VOLUNTEER AND AUXILIARY RESOURCES LEADERSHIP TEAM.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) ........ 3 11
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 8
6 Total number of volunteers (estimate if necessary) ............. 6 2,304
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  
Revenues Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 5,000 0
9 Program service revenue (Part VIII, line 2g) .........   0
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 3,074 1,212
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 570,857 481,855
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 578,931 483,067
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 33,180 3,715
14 Benefits paid to or for members (Part IX, column (A), line 4).....   0
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10) 323,751 253,346
16a Professional fundraising fees (Part IX, column (A), line 11e).....   0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet0    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e).... 232,938 202,687
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 589,869 459,748
19 Revenue less expenses. Subtract line 18 from line 12....... -10,938 23,319
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 1,272,613 1,252,630
21 Total liabilities (Part X, line 26)............. 113,200 69,898
22 Net assets or fund balances. Subtract line 21 from line 20..... 1,159,413 1,182,732
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 MediumBullet

Firm's EIN MediumBullet
Firm's address MediumBullet



Phone no.
May the IRS discuss this return with the preparer shown above? (see instructions) ............
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2012)
Form 990 (2012)
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: PART III, LINE 1 - THE PURPOSE OF THE ORGANIZATION IS TO RENDER SERVICES TO MOUNTAIN STATES HEALTH ALLIANCE (MSHA) AND ITS RELATED HOSPITALS; ITS PATIENTS, GUESTS, AND TEAM MEMBERS, WHILE ASSISTING MSHA IN PROMOTING THE HEALTH AND WELFARE OF THE COMMUNITY SERVED, AND TO FUNCTION AS AN ADVISORY BOARD TO THE MSHA VOLUNTEER AND AUXILIARY RESOURCES LEADERSHIP TEAM.
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 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 $ 442,405 including grants of $ 3,715 ) (Revenue $ 433,011 )
MOUNTAIN STATES HEALTH ALLIANCE AUXILIARY (AUXILIARY) SUPPORTS THE HOSPITALS WITHIN THE MOUNTAIN STATES HEALTH ALLIANCE (MSHA) SYSTEM. COMMUNITY MEMBERS NOT EMPLOYED BY MSHA THAT SERVE ON THE AUXILIARY BOARD ARE ALSO VOLUNTEERS WHO FREELY GIVE OF THEIR TIME AND EXPERTISE TO COMMUNITY, FOUNDATION AND AUXILIARY BOARDS OF DIRECTORS AND RELATED COMMITTEES. (CONTINUED ON SCHEDULE O) (CONT'D) THE VOLUNTEERS WITHIN MOUNTAIN STATES HEALTH ALLIANCE AUXILIARY (AUXILIARY) ARE A TEAM OF PEOPLE DEDICATED TO HIGH-QUALITY, PATIENT-CENTERED CARE. IT IS OUR BELIEF THAT WORKING TOGETHER AS A TEAM, SHARING A COMMON OBJECTIVE OF EXCELLENT SERVICE, IS WHAT HAS EARNED MSHA FACILITIES THE RECOGINITION OF BEING PART OF THE FINEST HEALTH CARE PROVIDER IN OUR REGION. WE ARE COMMITTED TO PROVIDING SERVICES TO PATIENTS IN A CARING, LOVING, AND RESPECTFUL WAY. VOLUNTEERS ARE HELPING MSHA TO MEET THE NEEDS OF ALL OUR PATIENTS AND THEIR FAMILIES IN AN ENVIRONMENT OF CARE, UNDERSTANDING AND COMPASSION. THERE ARE MANY DIFFERENT SERVICE AND SPECIAL PROJECT OPPORTUNITIES FOR VOLUNTEERS TO GET INVOLVED WITH THROUGHOUT MSHA'S SERVICE AREAS. THE VOLUNTEER AND AUXILIARY RESOURCES DEPARTMENT WORKS VERY CLOSELY WITH VOLUNTEERS TO ENSURE APPROPRIATE VOLUNTEER PLACEMENT SO THAT EACH VOLUNTEER MAY PROVIDE SERVICE IN AN AREA THAT IS A GOOD MATCH FOR THEM. IN ADDITION TO THE MANY VOLUNTEER HOURS PROVIDED TO THE HOSPITALS, THE AUXILIARY RAISES MONEY FOR THE HOSPITALS TO HELP FUND NEEDED PROJECTS. INDIVIDUAL MSHA HOSPITALS MAKE A REQUEST FOR DONATION TO THE AUXILIARY. FUNDING IS MADE TO A HOSPITAL ONLY AFTER THE AUXILIARY BOARD HAS REVIEWED AND APPROVED A REQUEST. MOST OFTEN, DONATIONS FUND SMALL CAPITAL ITEMS SUCH AS A PIECE OF MEDICAL EQUIPMENT OR ITEMS DIRECTED TOWARD IMPROVED PATIENT CARE OR COMFORT. AUXILIARY VOLUNTEERS GO THROUGH THE SAME ONBOARDING PROCESS AS PAID TEAM MEMBERS; INCLUDING, BUT NOT LIMITED TO, ORIENTATION, BACKGROUND CHECKS AND UNIT/DEPARTMENT TRAINING WHERE THEY WILL BE ASSIGNED. ANNUAL EVALUATIONS ARE CONDUCTED TO ENSURE A CONSISTENT PROVISION OF QUALITY SERVICE TO PATIENTS, VISITORS, AND TEAM MEMBERS. VOLUNTEERS WORK THROUGHOUT THE YEAR TO ASSIST HOSPITAL STAFF, PATIENTS AND PATIENT FAMILIES. SOME OF THE SERVICES PROVIDED BY AUXILIARY VOLUNTEERS DURING FY13 INCLUDE: PATIENT AMBASSADOR PROGRAMS AT JOHNSON CITY MEDICAL CENTER (JCMC), INDIAN PATH MEDICAL CENTER (IPMC), FRANKLIN WOODS COMMUNITY HOSPITAL (FWCH), SYCAMORE SHOALS HOSPITAL (SSH), AND SMYTH COUNTY COMMUNITY HOSPITAL (SCCH) CONSIST OF TRAINED VOLUNTEERS VISITING WITH PATIENTS AND OR FAMILIES, HANDLING OR PROCESSING THEIR CONCERNS AS WELL AS RECOGNIZING TEAM MEMBERS RECEIVING COMPLIMENTS BY PATIENTS AND VISITORS. MENDED HEARTS PROGRAM (JCMC; AND, NEW IN FY13, IPMC). FREE MONTHLY PROGRAM FOR PERSONS WITH A HISTORY OF HEART PROBLEMS. THE PROGRAM INSPIRES HOPE IN HEART DISEASE PATIENTS AND THEIR FAMILIES BY PROVIDING SUPPORT PROGRAMS THAT HELP HEART PATIENTS THROUGH HOSPITALIZATION, REHABILITATION AND BEYOND. THE AUXILIARY HAS 21 TRAINED AND ACCREDITED HOSPITAL VISITORS. THE HEART VISITORS ARE THERE EVERY DAY TO ANSWER QUESTIONS FOR HEART PATIENTS AND THEIR FAMILIES, RELIEVING SOME OF THE PATIENT'S AND FAMILY'S ANXIETY. COURTESY CARTS (JCMC, NISWONGER CHILDREN'S HOSPITAL (NICH)) DELIVER PATIENTS, STAFF AND VISITORS TO/FROM THEIR CARS AND ANY DOOR OF EITHER HOSPITAL. A RED DIRECT LINE PHONE IS IN THE JCMC LOBBY FOR PERSONS TO CALL FOR PICK UP. SURGERY WAITING AREAS (IPMC, JCMC, FWCH, AND SCCH) ARE STAFFED BY VOLUNTEERS. THE VOLUNTEERS KEEP FAMILIES INFORMED ABOUT THE STATUS OF PATIENTS, ARRANGE PRIVATE MEETINGS WITH THE PHYSICIAN AND FAMILY MEMBERS, AND STRIVE TO MEET ANY IMMEDIATE NEED THAT A VOLUNTEER CAN PROVIDE SUCH AS DIRECTIONS, PHONE NUMBERS, SNACKS, ETC. SCHEDULED MUSIC PROGRAMS ARE PROVIDED BY VOLUNTEERS AT ALL MSHA HOSPITALS. FRESH BAKED COOKIES ARE BAKED AND DELIVERED AT NO CHARGE TO WAITING AREAS BY VOLUNTEERS (JCMC, NICH, FWCH, IPMC, SSH). VISUAL ARTS PROGRAM (JCMC, IPMC) DIRECTS ROTATING ART EXHIBITS BY LOCAL ARTISTS, WHICH ARE DISPLAYED IN MAIN HALLWAYS OF THE HOSPITALS. AUXILIARY OPERATED GIFT SHOPS (ALL HOSPITALS) PROVIDE MERCHANDISE FOR PATIENTS, VISITORS AND TEAM MEMBERS. THE GIFT SHOP VOLUNTEERS NOT ONLY SELL MERCHANDISE; BUT, MORE OFTEN THAN NOT, PROVIDE A LISTENING EAR TO FAMILY MEMBERS NEEDING TO VERBALIZE CONCERNS ABOUT THEIR HOSPITALIZED FAMILY MEMBERS. THE CADET PROGRAM (JCMC) IS A VOLUNTEER PROGRAM FOR STUDENTS AGED 10-13 TO NOT ONLY ACQUAINT THEM WITH CAREERS IN HEALTHCARE BUT TO HOPEFULLY INSTILL IN THEM A LIFELONG LOVE OF PROVIDING VOLUNTEER SERVICE IN HEALTHCARE. JUNIOR VOLUNTEER PROGRAM (JCMC, FWCH, IPMC, SSH) IS A SUMMER EDUCATIONAL/VOLUNTEER PROGRAM FOR HIGH SCHOOL STUDENTS WHICH ALLOWS THEM TO TOUR AND PARTICIPATE IN LEARNING ACTIVITIES AT THE MEDICAL SCHOOL, THE PHARMACY SCHOOL, MSHA INFORMATICS, LABS, AND MANY OTHER DEPARTMENTS. THE STUDENTS ALSO VOLUNTEER IN VARIOUS DEPARTMENTS OF INTEREST TO THEM. VOLUNTEER CHAPLAINS WORK IN THE HOSPITALS THROUGHOUT MSHA. THEY PROVIDE PASTORAL CARE VISITATION AND SUPPORT TO PATIENTS, FAMILIES OF PATIENTS AND TEAM MEMBERS. VOLUNTEERS ARE ON CALL AT SOME HOSPITALS 7 DAYS A WEEK, 24 HOURS A DAY, WHILE AT THE LARGER HOSPITALS, VOLUNTEER CHAPLAINS PROVIDE SCHEDULED COVERAGE ON NURSING UNITS 5 DAYS A WEEK, COVERING 8 TO 16 HOUR DAYS. THE AUXILIARY CONTINUES TO BE RESPONSIBLE FOR THE STUDENT OBSERVATION/SHADOWING PROGRAM. THIS IS A LARGE SYSTEM-WIDE PROGRAM AND HAS INCREASED VOLUNTEER HOURS DRAMATICALLY FOR THE AUXILIARY. THE MAJORITY OF THESE STUDENTS ARE WITHIN WASHINGTON COUNTY, TENNESSEE AS MOST OF THE HIGHER EDUCATION INSTITUTIONS ARE HIGH SCHOOL HEALTH OCCUPATIONS SCIENCE ASSOCIATION (HOSA) STUDENTS IN OR CLOSELY AROUND JOHNSON CITY. WE ANTICIPATE THAT OUR NUMBERS OF STUDENT VOLUNTEERS WILL CONTINUE TO INCREASE AS THE PROGRAMS IMPROVE AND WORD SPREADS ABOUT THESE IN-HOSPITAL OPPORTUNITIES. THE AUXILIARY BEGAN SERVING IN THE EMERGENCY DEPARTMENT AT JCMC, MEETING WITH CONGESTIVE HEART FAILURE PATIENTS PRIOR TO DISCHARGE. IN ADDITION, A PATIENT DISCHARGE LIAISON PROGRAM UTILIZES AUXILIARY VOLUNTEERS TO VISIT WITH PATIENTS PRIOR TO DISCHARGE TO CONFIRM THAT EDUCATIONAL NEEDS WERE MET. A NEW PROGRAM BEGAN IN THE CANCER TREATMENT CENTER AT IPMC TO PROVIDE DIVERSIONARY ACTIVITIES FOR CHEMO PATIENTS SUCH AS ART THERAPY, GAMES, ETC. THE AUXILIARY BEGAN PROVIDING WEEKLY ASSISTANCE FOR THE HEALTHCARE RESOURCE CENTER(HRC) IN THE KINGSPORT TOWN CENTER DURING FY13. THE HRC IS AN OUTREACH SERVICE OF MSHA THAT OFFERS HEALTH PROGRAMS AND SCREENINGS DESIGNED TO HELP INDIVIDUALS LIVE HEALTHIER LIVES. THE HRC STAFFS EXPERIENCED REGISTERED NURSES AND OTHER HEALTH PROFESSIONS WHO WILL HELP ANSWER MEDICAL QUESTIONS, AND DISTRIBUTE LITERATURE TO PROVIDE UP-TO-DATE HEALTH INFORMATION FOR THE COMMUNITY.
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 expensesMediumBullet442,405
Form 990 (2012)
Form 990 (2012)
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 (see instructions)? ...
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, or have a section 501(h) election in effect during the tax year? 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
 
No
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 IClick to see attachment........................
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 IIClick to see attachment...
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 Click to see attachment....................
8
 
No
9
Did the organization report an amount in Part X, line 21 for escrow or custodial account liability; 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 IVClick to see attachment..............
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 VClick to see attachment......
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, line 10?
If “Yes,” complete Schedule D, Part VI.Click to see attachment...................
11a
Yes
 
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 VIIClick to see attachment.......
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 VIIIClick to see attachment.......
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 IXClick to see attachment............
11d
 
No
e
Did the organization report an amount for other liabilities in Part X, line 25? If “Yes,” complete Schedule D, Part XClick to see attachment
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 XClick 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 and XII Click to see attachment.................
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 and XII 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, Parts I and IV.........
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 United States? If “Yes,” complete Schedule F, Parts II and IV
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 United States? If “Yes,” complete Schedule F, Parts III and IV...
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 (see instructions).... Click to see attachment
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............ Click to see attachment
18
Yes
 
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................... Click to see attachment
19
 
No
20a
Did the organization operate one or more hospital facilities? If “Yes,” complete Schedule H....
20a
 
No
b
If “Yes” to line 20a, did the organization attach a copy of its audited financial statements to this return?
20b
 
 
Form 990 (2012)
Form 990 (2012)
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, line 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.......................
23
 
No
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 lines 24b through 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, highest 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 direct or indirect 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...........................
31
 
No
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........ Click to see attachment
33
 
No
34
Was the organization related to any tax-exempt or taxable entity? If “Yes,” complete Schedule R, Part II, III, or IV, and Part 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
 
 
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............. Click to see attachment
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 VIClick to see attachment
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11b and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2012)
Form 990 (2012)
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
19
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
Yes
 
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
8
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
Yes
 
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, securities account, or other financial 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 as charitable contributions?...
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
 
No
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?..........................
7h
 
No
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
 
 
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. See the instructions for additional information the organization must report on Schedule O.
13a
 
 
b
Enter the 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 amount of reserves on hand ............
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
No
b
If "Yes," has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O..
14b
 
 
Form 990 (2012)
Form 990 (2012)
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 .....................
1a
11
If there are material differences in voting rights among members of the governing body, or if the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
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
 
No
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
 
No
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
 
No
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
Yes
 
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 this 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:
MediumBulletLYNN KRUTAK1021 W OAKLAND AVE STE 207JOHNSON CITYTN37604 (423) 915-5105
Form 990 (2012)
Form 990 (2012)
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. 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 organization compensated any current officer, director, or trustee.
(A)
Name and Title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(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) SAM GREER........................................................................
TREASURER
 4.00
.......................   		X           506 0 0
(2) LYNN FRIERSON........................................................................
PRESIDENT
 4.00
.......................   		X           0 0 0
(3) LORETTA COX........................................................................
SECRETARY
 2.00
.......................   		X           0 0 0
(4) VIVIAN LYLE........................................................................
DIRECTOR
 1.00
.......................   		X           0 0 0
(5) NANCY JEWELL........................................................................
ASSISTANT TR
 1.00
.......................   		X           0 0 0
(6) CAROLYN SLUDER........................................................................
PAST PRESIDE
 1.00
.......................   		X           0 0 0
(7) PHYLLIS EGGERS........................................................................
ASSISTANT SE
 2.00
.......................   		X           0 0 0
(8) VICKIE FORD........................................................................
DIRECTOR
 2.00
.......................   		X           0 0 0
(9) PATSY SORAH........................................................................
DIRECTOR
 1.00
.......................   		X           0 0 0
(10) MARY BRUMIT........................................................................
DIRECTOR
 1.00
.......................   		X           0 0 0
(11) FRANCES ADAMS........................................................................
DIRECTOR
 1.00
.......................   		X           0 0 0












Form 990 (2012)
Form 990 (2012)
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 (list any hours for related organizations below dotted line) 		(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 506    
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organizationMediumBullet  
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
 
No
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 $100,000 of compensation from the organization MediumBullet  
Form 990 (2012)
Form 990 (2012)
Page 9
Part VIII
Statement of Revenue
Check if Schedule O contains a response to any question in this Part VIII ..............
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, Gifts, Grants and Other Similar Amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c  
d Related organizations...1d  
e Government grants (contributions)1e  
f All other contributions, gifts, grants, and
similar amounts not included above1f 		 
g Noncash contributions included in lines
1a-1f:$ 		 
h Total. Add lines 1a-1f.......MediumBullet  
Program Service Revenue Business Code
2a
b
c
d
e
f All other program service revenue .        
g Total. Add lines 2a–2f........MediumBullet  
Other Revenue 3 Investment income (including dividends, interest, and other similar amounts).......MediumBullet 1,212     1,212
4 Income from investment of tax-exempt bond proceeds..MediumBullet        
5 Royalties...........MediumBullet        
(i) Real (ii) Personal
6a Gross rents    
b Less: rental expenses    
c Rental income or (loss)    
d Net rental income or (loss).......MediumBullet        
(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)    
d Net gain or (loss)..........MediumBullet        
8a Gross income from fundraising events (not including
$  
of contributions reported on line 1c). See Part IV, line 18 ..
a 263,621
b Less: direct expenses ...b 214,777
c Net income or (loss) from fundraising events..MediumBullet 48,844   48,844
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        
10a Gross sales of inventory, less
returns and allowances .
a 915,008
b Less: cost of goods sold ..b 481,997
c Net income or (loss) from sales of inventory..MediumBullet 433,011 433,011    
Miscellaneous Revenue Business Code
11a            
b            
c            
d All other revenue ....        
e Total. Add lines 11a–11d ...... MediumBullet  
12 Total revenue. See Instructions......MediumBullet 483,067 433,011   50,056
Form 990 (2012)
Form 990 (2012)
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).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 3,715 3,715
2 Grants and other assistance to individuals in the United States. See Part IV, line 22    
3 Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16    
4 Benefits paid to or for members    
5 Compensation of current officers, directors, trustees, and key employees .... 460 460    
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....        
7 Other salaries and wages 214,055 214,055    
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....        
9 Other employee benefits ....... 21,832 21,832    
10 Payroll taxes ........... 16,999 16,999    
11 Fees for services (non-employees):        
a Management ......        
b Legal .........        
c Accounting ........... 2,608   2,608  
d Lobbying ...........        
e Professional fundraising services. See Part IV, line 17    
f Investment management fees ......        
g Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........ 62,536 62,536    
12 Advertising and promotion .... 1,676 1,676    
13 Office expenses ....... 23,524 11,174 12,350  
14 Information technology ......        
15 Royalties .. 14,819 14,819    
16 Occupancy ...........        
17 Travel ............ 3,500 3,500    
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ......        
19 Conferences, conventions, and meetings .... 440 440    
20 Interest ...........        
21 Payments to affiliates .......        
22 Depreciation, depletion, and amortization ..... 71,335 71,335    
23 Insurance ..............        
24 Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a MAINTENANCE & REPAIRS 12,754 12,754    
b TAXES 7,110 7,110    
c DUES & SUBSCRIPTIONS 2,259   2,259  
d OTHER EXPENSES 126   126  
e All other expenses        
25 Total functional expenses. Add lines 1 through 24e 459,748 442,405 17,343 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).        
Form 990 (2012)
Form 990 (2012)
Page 11
Part X Balance Sheet Check if Schedule O contains a response to any question in this Part X ...............
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash—non-interest-bearing ............. 136,210 1 261,713
2 Savings and temporary cash investments ......... 332,186 2 256,316
3 Pledges and grants receivable, net ...........   3  
4 Accounts receivable, net ............. 52,130 4 73,769
5 Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L ..................
  5  
6 Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
  6  
7 Notes and loans receivable, net .............   7  
8 Inventories for sale or use .............. 283,901 8 263,314
9 Prepaid expenses and deferred charges .......... 5,255 9 5,922
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 851,309
b Less: accumulated depreciation ..... 10b 466,900 453,869 10c 384,409
11 Investments—publicly traded securities ..........   11  
12 Investments—other securities. See Part IV, line 11 .....   12  
13 Investments—program-related. See Part IV, line 11 .....   13  
14 Intangible assets ...............   14  
15 Other assets. See Part IV, line 11 ........... 9,062 15 7,187
16 Total assets. Add lines 1 through 15 (must equal line 34)...... 1,272,613 16 1,252,630
Liabilities 17 Accounts payable and accrued expenses ......... 113,200 17 69,898
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 Loans and other 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....................   25  
26 Total liabilities. Add lines 17 through 25......... 113,200 26 69,898
Net Assets or Fund Balance Organizations that follow SFAS 117 (ASC 958), check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets .............. 1,159,413 27 1,182,732
28 Temporarily restricted net assets ...........   28  
29 Permanently restricted net assets ...........   29  
Organizations that do not follow SFAS 117 (ASC 958), 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 ........... 1,159,413 33 1,182,732
34 Total liabilities and net assets/fund balances ........ 1,272,613 34 1,252,630
Form 990 (2012)
Form 990 (2012)
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
483,067
2
Total expenses (must equal Part IX, column (A), line 25) ............
2
459,748
3
Revenue less expenses. Subtract line 2 from line 1 ..............
3
23,319
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..
4
1,159,413
5
Net unrealized gains (losses) on investments ...............
5
 
6
Donated services and use of facilities .................
6
 
7
Investment expenses .....................
7
 
8
Prior period adjustments .....................
8
 
9
Other changes in net assets or fund balances (explain in Schedule O) ........
9
 
10
Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 33, column (B))
10
1,182,732
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
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were compiled or reviewed on a separate basis, consolidated basis, or both:
b
Were the organization’s financial statements audited by an independent accountant?
2b
Yes
 
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were audited on a separate basis, consolidated basis, or both:
c
If “Yes,” to line 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?
2c
 
No
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O.
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 (2012)
Form 990, Special Condition Description:
Special Condition Description
Additional Data


Software ID:  
Software Version:  
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
2012
Open to Public
Inspection
Name of the organization
MOUNTAIN STATES HEALTH ALLIANCE
AUXILIARY
Employer identification number

58-1418345
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 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 monetary support
Yes No Yes No Yes No
(A) MOUNTAIN STATES HEALTH ALLIANCE
  		620476282 3 Yes   Yes   Yes   20,810
Total                 20,810

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 2
Part II
Support Schedule for Organizations Described in Sections 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) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (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) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (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. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..            
11 Total support (Add lines 7 through 10).            
12
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........................................right arrow
Section C. Computation of Public Support Percentage
14
14
 
15
15
 
16a
b
17a
b
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 ..................................................... right arrow
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 3
Part III
Support Schedule for Organizations Described in Section 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) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (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) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (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) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 4
Part IV
Supplemental Information. Complete this part to provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and 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) 2012

Additional Data


Software ID:  
Software Version:  
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
2012
Open to Public Inspection
Name of the organization
MOUNTAIN STATES HEALTH ALLIANCE
AUXILIARY
Employer identification number

58-1418345
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 section 170(h)(4)(B)(ii)? .......................................
9
In Part XIII, 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 XIII, 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 Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 52283D
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
Using the organization’s acquisition, 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 XIII.
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 XIII 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 XIII. Check here if the explanation has been provided in Part XIII ........
Part V
Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
(a)Current year (b)Prior year b (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 current year end balance (line 1g, column (a)) 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 XIII 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 .................      
b Buildings ................   294,352 103,667 190,685
c Leasehold improvements ............   168,520 98,439 70,081
d Equipment ................   388,437 264,794 123,643
e Other .................        
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......SchDMdBullet 384,409
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
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  








Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet  
2. Fin 48 (ASC 740) Footnote. In Part XIII, 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 (ASC 740). Check here if the text of the footnote has been provided in Part XIII .....................................................
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 4
Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1 Total revenue, gains, and other support per audited financial statements ....... 1  
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 XIII.) ............ 2d  
e Add lines 2a through 2d ..................... 2e  
3 Subtract line 2e from line 1..................... 3  
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 XIII.) ........... 4b  
c Add lines 4a and 4b....................... 4c  
5 Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ...... 5  
Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1 Total expenses and losses per audited financial statements ........... 1  
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 XIII.) ............ 2d  
e Add lines 2a through 2d...................... 2e  
3 Subtract line 2e from line 1..................... 3  
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 XIII.) ............ 4b  
c Add lines 4a and 4b....................... 4c  
5 Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ...... 5  
Part XIII
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, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.
Identifier Return Reference Explanation
LIABILITY UNDER FIN 48 FOOTNOTE SCHEDULE D, PAGE 3, PART X LINE 2: MOUNTAIN STATES HEALTH ALLIANCE AUXILIARY IS INCLUDED IN THE AUDITED CONSOLIDATED FINANCIAL STATEMENTS OF MOUNTAIN STATES HEALTH ALLIANCE (MSHA). THE FOOTNOTE EXPLANATION RELATIVE TO INCOME TAXES READS:"THE ALLIANCE IS CLASSIFIED AS AN ORGANIZATION EXEMPT FROM INCOME TAXES UNDER SECTION 501(C)(3)OF THE INTERNAL REVENUE CODE. AS SUCH, NO PROVISION FOR INCOME TAXES HAS BEEN MADE IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS FOR THE ALLIANCE AND ITS TAX-EXEMPT SUBSIDIARIES. TAXABLE ENTITIES ACCOUNT FOR INCOME TAXES IN ACCORDANCE WITH FASB ASC 740, INCOME TAXES. THE ALLIANCE HAS NO SIGNIFICANT UNCERTAIN TAX POSITIONS AT JUNE 30, 2013 AND 2012."
Schedule D (Form 990) 2012

Additional Data


Software ID:  
Software Version:  




SCHEDULE G (Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Supplemental Information Regarding
Fundraising or Gaming Activities
Complete if the organization answered "Yes" to Form 990, Part IV, lines 17, 18, or 19, or if the organization entered more than $15,000 on Form 990-EZ, line 6a. Form 990-EZ filers are not required to complete this part. right arrowAttach to Form 990 or Form 990-EZ. right arrowSee separate instructions.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
MOUNTAIN STATES HEALTH ALLIANCE
AUXILIARY
Employer identification number

58-1418345
Part I
Fundraising Activities. Complete if the organization answered "Yes" to Form 990, Part IV, line 17.
1
Indicate whether the organization raised funds through any of the following activities. Check all that apply.
a e
b f
c g
d
2a
Did the organization have a written or oral agreement with any individual (including officers, directors, trustees
or key employees listed in Form 990, Part VII) or entity in connection with professional fundraising services?
b
If “Yes,” list the ten highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is
to be compensated at least $5,000 by the organization.
(i) Name and address of individual
or entity (fundraiser) 		(ii) Activity (iii) Did fundraiser have custody or control of contributions? (iv) Gross receipts
from activity 		(v) Amount paid to
(or retained by)
fundraiser listed in
col. (i) 		(vi) Amount paid to
(or retained by)
organization
Yes No
             
             
             
             
             
             
             
             
             
             
Total .................right arrow      
3
List all states in which the organization is registered or licensed to solicit funds or has been notified it is exempt from registration or licensing.
For Paperwork Reduction Act Notice, see the Instructions for Form 990or 990-EZ.
Cat. No. 50083H
Schedule G (Form 990 or 990-EZ) 2012
Schedule G (Form 990 or 990-EZ) 2012
Page 2
Part II
Fundraising Events. Complete if the organization answered "Yes" to Form 990, Part IV, line 18, or reported more than $15,000 of fundraising event contributions and gross income on Form 990-EZ, lines 1 and 6b. List events with gross receipts greater than $5,000.
(a) Event #1

UNIFORM SALE
(event type) 		(b) Event #2

JEWELRY SALE
(event type) 		(c) Other events

1
(total number) 		(d) Total events
(add col. (a) through col. (c))
VerticalRevenue 1 Gross receipts . . . 134,984 93,565 31,939 260,488
2 Less: Contributions . .        
3 Gross income (line 1
minus line 2) . . . 		134,984 93,565 31,939 260,488
VerticalDirectExpenses 4 Cash prizes . . .        
5 Noncash prizes . .        
6 Rent/facility costs . .        
7 Food and beverages .        
8 Entertainment . . .        
9 Other direct expenses . 115,224 74,852 22,233 212,309
10 Direct expense summary. Add lines 4 through 9 in column (d) ........... right arrow 212,309
11 Net income summary. Combine line 3, column (d), and line 10. .......... right arrow 48,179
Part III
Gaming. Complete if the organization answered "Yes" to Form 990, Part IV, line 19, or reported more than $15,000 on Form 990-EZ, line 6a.
VerticalRevenue (a) Bingo (b) Pull tabs/Instant
bingo/progressive bingo 		(c) Other gaming (d) Total gaming (add col.(a) through col.(c))
1 Gross revenue . . . .        
VerticalDirectExpenses 2 Cash prizes . . . .        
3 Non-cash prizes . . .        
4 Rent/facility costs . . .        
5 Other direct expenses . .        
6 Volunteer labor . . .
 
 
 
7 Direct expense summary. Add lines 2 through 5 in column (d) ........... right arrow  
8 Net gaming income summary. Combine lines 1 and 7 in column (d) .......... right arrow  
9
Enter the state(s) in which the organization operates gaming activities:
a
Is the organization licensed to operate gaming activities in each of these states? ............
b
If "No," explain:
 
10a
Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year? .....
b
If "Yes," explain:
 
Schedule G (Form 990 or 990-EZ) 2012
Schedule G (Form 990 or 990-EZ) 2012
Page 3
11
Does the organization operate gaming activities with nonmembers? .................
12
Is the organization a grantor, beneficiary or trustee of a trust or a member of a partnership or other entity
formed to administer charitable gaming? ..........................
13
Indicate the percentage of gaming activity operated in:
a
The organization's facility ......................
13a
 
b
An outside facility ........................
13b
 
14
Enter the name and address of the person who prepares the organization's gaming/special events books and records:
Name right arrow
Address right arrow
15a
Does the organization have a contract with a third party from whom the organization receives gaming
revenue? ......................................
b
If "Yes," enter the amount of gaming revenue received by the organization right arrow $   and the
amount of gaming revenue retained by the third party right arrow $   .
c
If "Yes," enter name and address of the third party:
Name right arrow
Address right arrow
 
 
16
Gaming manager information:
Name right arrow
Gaming manager compensation right arrow $  
Description of services provided right arrow
 
17
Mandatory distributions:
a
Is the organization required under state law to make charitable distributions from the gaming proceeds to
retain the state gaming license? ............................
b
Enter the amount of distributions required under state law distributed to other exempt organizations or spent
in the organization's own exempt activities during the tax year right arrow$  
Part IV
Supplemental Information. Complete this part to provide the explanations required by Part I, line 2b, columns (iii) and (v), and Part III, lines 9, 9b, 10b, 15b, 15c, 16, and 17b, as applicable. Also complete this part to provide any additional information (see instructions).
Identifier Return Reference Explanation
Schedule G (Form 990 or 990-EZ) 2012
Additional Data


Software ID:  
Software Version:  
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
2012
Open to Public
Inspection
Name of the organization
MOUNTAIN STATES HEALTH ALLIANCE
AUXILIARY
Employer identification number

58-1418345
Identifier Return Reference Explanation
ORGANIZATION'S MISSION FORM 990 - ORGANIZATION'S MISSION PART III, LINE 1 - THE PURPOSE OF THE ORGANIZATION IS TO RENDER SERVICES TO MOUNTAIN STATES HEALTH ALLIANCE (MSHA) AND ITS RELATED HOSPITALS; ITS PATIENTS, GUESTS, AND TEAM MEMBERS, WHILE ASSISTING MSHA IN PROMOTING THE HEALTH AND WELFARE OF THE COMMUNITY SERVED, AND TO FUNCTION AS AN ADVISORY BOARD TO THE MSHA VOLUNTEER AND AUXILIARY RESOURCES LEADERSHIP TEAM.
FIRST ACCOMPLISHMENT DESCRIPTION FORM 990, PAGE 2, PART III, LINE 4A (CONT'D) THE VOLUNTEERS WITHIN MOUNTAIN STATES HEALTH ALLIANCE AUXILIARY (AUXILIARY) ARE A TEAM OF PEOPLE DEDICATED TO HIGH-QUALITY, PATIENT-CENTERED CARE. IT IS OUR BELIEF THAT WORKING TOGETHER AS A TEAM, SHARING A COMMON OBJECTIVE OF EXCELLENT SERVICE, IS WHAT HAS EARNED MSHA FACILITIES THE RECOGINITION OF BEING PART OF THE FINEST HEALTH CARE PROVIDER IN OUR REGION. WE ARE COMMITTED TO PROVIDING SERVICES TO PATIENTS IN A CARING, LOVING, AND RESPECTFUL WAY. VOLUNTEERS ARE HELPING MSHA TO MEET THE NEEDS OF ALL OUR PATIENTS AND THEIR FAMILIES IN AN ENVIRONMENT OF CARE, UNDERSTANDING AND COMPASSION. THERE ARE MANY DIFFERENT SERVICE AND SPECIAL PROJECT OPPORTUNITIES FOR VOLUNTEERS TO GET INVOLVED WITH THROUGHOUT MSHA'S SERVICE AREAS. THE VOLUNTEER AND AUXILIARY RESOURCES DEPARTMENT WORKS VERY CLOSELY WITH VOLUNTEERS TO ENSURE APPROPRIATE VOLUNTEER PLACEMENT SO THAT EACH VOLUNTEER MAY PROVIDE SERVICE IN AN AREA THAT IS A GOOD MATCH FOR THEM. IN ADDITION TO THE MANY VOLUNTEER HOURS PROVIDED TO THE HOSPITALS, THE AUXILIARY RAISES MONEY FOR THE HOSPITALS TO HELP FUND NEEDED PROJECTS. INDIVIDUAL MSHA HOSPITALS MAKE A REQUEST FOR DONATION TO THE AUXILIARY. FUNDING IS MADE TO A HOSPITAL ONLY AFTER THE AUXILIARY BOARD HAS REVIEWED AND APPROVED A REQUEST. MOST OFTEN, DONATIONS FUND SMALL CAPITAL ITEMS SUCH AS A PIECE OF MEDICAL EQUIPMENT OR ITEMS DIRECTED TOWARD IMPROVED PATIENT CARE OR COMFORT. AUXILIARY VOLUNTEERS GO THROUGH THE SAME ONBOARDING PROCESS AS PAID TEAM MEMBERS; INCLUDING, BUT NOT LIMITED TO, ORIENTATION, BACKGROUND CHECKS AND UNIT/DEPARTMENT TRAINING WHERE THEY WILL BE ASSIGNED. ANNUAL EVALUATIONS ARE CONDUCTED TO ENSURE A CONSISTENT PROVISION OF QUALITY SERVICE TO PATIENTS, VISITORS, AND TEAM MEMBERS. VOLUNTEERS WORK THROUGHOUT THE YEAR TO ASSIST HOSPITAL STAFF, PATIENTS AND PATIENT FAMILIES. SOME OF THE SERVICES PROVIDED BY AUXILIARY VOLUNTEERS DURING FY13 INCLUDE: PATIENT AMBASSADOR PROGRAMS AT JOHNSON CITY MEDICAL CENTER (JCMC), INDIAN PATH MEDICAL CENTER (IPMC), FRANKLIN WOODS COMMUNITY HOSPITAL (FWCH), SYCAMORE SHOALS HOSPITAL (SSH), AND SMYTH COUNTY COMMUNITY HOSPITAL (SCCH) CONSIST OF TRAINED VOLUNTEERS VISITING WITH PATIENTS AND OR FAMILIES, HANDLING OR PROCESSING THEIR CONCERNS AS WELL AS RECOGNIZING TEAM MEMBERS RECEIVING COMPLIMENTS BY PATIENTS AND VISITORS. MENDED HEARTS PROGRAM (JCMC; AND, NEW IN FY13, IPMC). FREE MONTHLY PROGRAM FOR PERSONS WITH A HISTORY OF HEART PROBLEMS. THE PROGRAM INSPIRES HOPE IN HEART DISEASE PATIENTS AND THEIR FAMILIES BY PROVIDING SUPPORT PROGRAMS THAT HELP HEART PATIENTS THROUGH HOSPITALIZATION, REHABILITATION AND BEYOND. THE AUXILIARY HAS 21 TRAINED AND ACCREDITED HOSPITAL VISITORS. THE HEART VISITORS ARE THERE EVERY DAY TO ANSWER QUESTIONS FOR HEART PATIENTS AND THEIR FAMILIES, RELIEVING SOME OF THE PATIENT'S AND FAMILY'S ANXIETY. COURTESY CARTS (JCMC, NISWONGER CHILDREN'S HOSPITAL (NICH)) DELIVER PATIENTS, STAFF AND VISITORS TO/FROM THEIR CARS AND ANY DOOR OF EITHER HOSPITAL. A RED DIRECT LINE PHONE IS IN THE JCMC LOBBY FOR PERSONS TO CALL FOR PICK UP. SURGERY WAITING AREAS (IPMC, JCMC, FWCH, AND SCCH) ARE STAFFED BY VOLUNTEERS. THE VOLUNTEERS KEEP FAMILIES INFORMED ABOUT THE STATUS OF PATIENTS, ARRANGE PRIVATE MEETINGS WITH THE PHYSICIAN AND FAMILY MEMBERS, AND STRIVE TO MEET ANY IMMEDIATE NEED THAT A VOLUNTEER CAN PROVIDE SUCH AS DIRECTIONS, PHONE NUMBERS, SNACKS, ETC. SCHEDULED MUSIC PROGRAMS ARE PROVIDED BY VOLUNTEERS AT ALL MSHA HOSPITALS. FRESH BAKED COOKIES ARE BAKED AND DELIVERED AT NO CHARGE TO WAITING AREAS BY VOLUNTEERS (JCMC, NICH, FWCH, IPMC, SSH). VISUAL ARTS PROGRAM (JCMC, IPMC) DIRECTS ROTATING ART EXHIBITS BY LOCAL ARTISTS, WHICH ARE DISPLAYED IN MAIN HALLWAYS OF THE HOSPITALS. AUXILIARY OPERATED GIFT SHOPS (ALL HOSPITALS) PROVIDE MERCHANDISE FOR PATIENTS, VISITORS AND TEAM MEMBERS. THE GIFT SHOP VOLUNTEERS NOT ONLY SELL MERCHANDISE; BUT, MORE OFTEN THAN NOT, PROVIDE A LISTENING EAR TO FAMILY MEMBERS NEEDING TO VERBALIZE CONCERNS ABOUT THEIR HOSPITALIZED FAMILY MEMBERS. THE CADET PROGRAM (JCMC) IS A VOLUNTEER PROGRAM FOR STUDENTS AGED 10-13 TO NOT ONLY ACQUAINT THEM WITH CAREERS IN HEALTHCARE BUT TO HOPEFULLY INSTILL IN THEM A LIFELONG LOVE OF PROVIDING VOLUNTEER SERVICE IN HEALTHCARE. JUNIOR VOLUNTEER PROGRAM (JCMC, FWCH, IPMC, SSH) IS A SUMMER EDUCATIONAL/VOLUNTEER PROGRAM FOR HIGH SCHOOL STUDENTS WHICH ALLOWS THEM TO TOUR AND PARTICIPATE IN LEARNING ACTIVITIES AT THE MEDICAL SCHOOL, THE PHARMACY SCHOOL, MSHA INFORMATICS, LABS, AND MANY OTHER DEPARTMENTS. THE STUDENTS ALSO VOLUNTEER IN VARIOUS DEPARTMENTS OF INTEREST TO THEM. VOLUNTEER CHAPLAINS WORK IN THE HOSPITALS THROUGHOUT MSHA. THEY PROVIDE PASTORAL CARE VISITATION AND SUPPORT TO PATIENTS, FAMILIES OF PATIENTS AND TEAM MEMBERS. VOLUNTEERS ARE ON CALL AT SOME HOSPITALS 7 DAYS A WEEK, 24 HOURS A DAY, WHILE AT THE LARGER HOSPITALS, VOLUNTEER CHAPLAINS PROVIDE SCHEDULED COVERAGE ON NURSING UNITS 5 DAYS A WEEK, COVERING 8 TO 16 HOUR DAYS. THE AUXILIARY CONTINUES TO BE RESPONSIBLE FOR THE STUDENT OBSERVATION/SHADOWING PROGRAM. THIS IS A LARGE SYSTEM-WIDE PROGRAM AND HAS INCREASED VOLUNTEER HOURS DRAMATICALLY FOR THE AUXILIARY. THE MAJORITY OF THESE STUDENTS ARE WITHIN WASHINGTON COUNTY, TENNESSEE AS MOST OF THE HIGHER EDUCATION INSTITUTIONS ARE HIGH SCHOOL HEALTH OCCUPATIONS SCIENCE ASSOCIATION (HOSA) STUDENTS IN OR CLOSELY AROUND JOHNSON CITY. WE ANTICIPATE THAT OUR NUMBERS OF STUDENT VOLUNTEERS WILL CONTINUE TO INCREASE AS THE PROGRAMS IMPROVE AND WORD SPREADS ABOUT THESE IN-HOSPITAL OPPORTUNITIES. THE AUXILIARY BEGAN SERVING IN THE EMERGENCY DEPARTMENT AT JCMC, MEETING WITH CONGESTIVE HEART FAILURE PATIENTS PRIOR TO DISCHARGE. IN ADDITION, A PATIENT DISCHARGE LIAISON PROGRAM UTILIZES AUXILIARY VOLUNTEERS TO VISIT WITH PATIENTS PRIOR TO DISCHARGE TO CONFIRM THAT EDUCATIONAL NEEDS WERE MET. A NEW PROGRAM BEGAN IN THE CANCER TREATMENT CENTER AT IPMC TO PROVIDE DIVERSIONARY ACTIVITIES FOR CHEMO PATIENTS SUCH AS ART THERAPY, GAMES, ETC. THE AUXILIARY BEGAN PROVIDING WEEKLY ASSISTANCE FOR THE HEALTHCARE RESOURCE CENTER(HRC) IN THE KINGSPORT TOWN CENTER DURING FY13. THE HRC IS AN OUTREACH SERVICE OF MSHA THAT OFFERS HEALTH PROGRAMS AND SCREENINGS DESIGNED TO HELP INDIVIDUALS LIVE HEALTHIER LIVES. THE HRC STAFFS EXPERIENCED REGISTERED NURSES AND OTHER HEALTH PROFESSIONS WHO WILL HELP ANSWER MEDICAL QUESTIONS, AND DISTRIBUTE LITERATURE TO PROVIDE UP-TO-DATE HEALTH INFORMATION FOR THE COMMUNITY.
ORGANIZATION'S PROCESS USED TO REVIEW FORM 990 FORM 990, PAGE 6, PART VI, LINE 11B PRIOR TO FILING THE FORM 990 WITH THE IRS, THE COMPLETED RETURN WAS REVIEWED BY THE EXECUTIVE COMMITTEE OF THE AUXILIARY'S BOARD OF DIRECTORS. COPIES OF THE RETURN WERE ALSO PROVIDED FOR ABSENT BOARD MEMBERS. THE REVIEW WAS CONDUCTED BY A MOUNTAIN STATES HEALTH ALLIANCE SENIOR TAX ACCOUNTANT. THE AUXILIARY DIRECTOR, BOARD MEMBERS AND FINANCE DIRECTOR TOOK THE TIME TO REVIEW AND DISCUSS THE ENTIRE RETURN. THE EXECUTIVE COMMITTEE IS COMPRISED OF INDIVIDUALS WITH LONG TENURE WITH THE AUXILIARY SO THEY ARE VERY FAMILIAR WITH THE FORM 990.
ENFORCEMENT OF CONFLICTS POLICY FORM 990, PAGE 6, PART VI, LINE 12C ANNUALLY, THE CORPORATE AUDIT AND COMPLIANCE DEPARTMENT OF MSHA FORWARDS THE CONFLICT OF INTEREST POLICY AND DISCLOSURE FORM TO ALL MSHA MANAGEMENT TEAM MEMBERS AND BOARD MEMBERS. EMPLOYEES AND BOARD MEMBERS MUST NOTE ANY CONFLICTS OR ATTEST THEY HAVE "NONE", AND RETURN THE FORM TO THE AUDIT AND COMPLIANCE DEPARTMENT. ANY NOTED DISCLOSURES ARE FORWARDED TO THE APPROPRIATE MANAGEMENT OR BOARD PERSONNEL TO EVALUATE AND UTILIZE WHEN A TRANSACTION INVOLVING A CONFLICTED PERSON ARISES. ADDITIONALLY, PERSONNEL WHO HAVE A CONFLICT ARISE BETWEEN THE ANNUAL DISTRIBUTION OF THE POLICY AND FORMS ARE REQUIRED TO DISCLOSE THE CONFLICT, AND WOULD BE DISCIPLINED IN ANY INSTANCE WHERE THEY HAVE NOT DISCLOSED AND ENGAGED IN A CONFLICTED TRANSACTION.
COMPENSATION PROCESS FOR TOP OFFICIAL FORM 990, PAGE 6, PART VI, LINE 15A THE AUXILIARY IS LED BY A DIRECTOR OF MOUNTAIN STATES HEALTH ALLIANCE AND UNDERGOES THE SAME EMPLOYMENT REQUIREMENTS OF ANY DIRECTOR LEVEL TEAM MEMBER. SINCE THE DIRECTOR IS NOT A VICE-PRESIDENT OR IN A SENIOR LEADERSHIP POSITION, THE DIRECTOR'S COMPENSATION AND BENEFITS ARE CONSISTENT WITH OTHER MHSA NON-EXECUTIVE POSITIONS.
GOVERNING DOCUMENTS DISCLOSURE EXPLANATION FORM 990, PAGE 6, PART VI, LINE 19 MOUNTAIN STATES HEALTH ALLIANCE AUXILIARY MAKES ITS GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST.
OTHER FEES FOR SERVICES FORM 990, PART IX, LINE 11G CONTRACT LABOR 62,536 0 0
CHANGE IN FINANCIAL REVIEW PROCESS FORM 990, PAGE 12, PART XII, LINE 2C THE AUXILIARY FALLS UNDER THE MOUNTAIN STATES HEALTH ALLIANCE CONSOLIDATED AUDIT. MOUNTAIN STATES HEALTH ALLIANCE'S FINANCE AND AUDIT COMMITTEE ASSUMES RESPONSIBILITY AND OVERSIGHT OF THE AUDIT.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2012

Additional Data


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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
2012
Open to Public Inspection
Name of the organization
MOUNTAIN STATES HEALTH ALLIANCE
AUXILIARY
Employer identification number

58-1418345
Part I
Identification of Disregarded Entities (Complete if the organization answered "Yes" to Form 990, Part IV, line 33.)
(a)
Name, address, and EIN (if applicable) 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" to 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 entity?
Yes No
(1) MOUNTAIN STATES HEALTH ALLIANCE

400 N STATE OF FRANKLIN ROAD

JOHNSON CITY,TN37604
62-0476282 		HOSPITAL TN 501C3 3 NA
 
 
No
(2) MOUNTAIN STATES FOUNDATION

2335 KNOB CREEK ROAD

JOHNSON CITY,TN37604
58-1418862 		RAISEFUNDS TN 501C3 11A NA
 
 
No
(3) SMYTH COUNTY COMMUNITY HOSPITAL

245 MEDICAL PARK DRIVE

MARION,VA24354
54-0794913 		HOSPITAL VA 501C3 3 NA
 
 
No
(4) NORTON COMMUNITY HOSPITAL

100 15TH STREET NORTHWEST

NORTON,VA24273
54-0566029 		HOSPITAL VA 501C3 3 N/A
 
No
(5) DICKENSON COMMUNITY HOSPITAL

PO BOX 1440 HOSPITAL DRIVE

CLINTWOOD,VA24228
77-0599553 		HOSPITAL VA 501C3 3 NA
 
 
No
(6) JOHNSTON MEMORIAL HOSPITAL

16000 JOHNSTON MEMORIAL DRIVE

ABINGDON,VA24211
54-0544705 		HOSPITAL VA 501C3 3 N/A
 
No
(7) ABINGDON PHYSICIAN PARTNERS

351 COURT ST NW

ABINGDON,VA24210
20-5485346 		MED. SERV. VA 501C3 3 N/A
 
No
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 2
Part III
Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to 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) INTEGRATED HEALTH SOLUTIONS NETWORK

400 N STATE OF FRANKLIN ROAD
JOHNSON CITY,TN37604
62-1711997 		INVEST CO. TN NA
  		        No     No  
(2) EMMAUS

6070 HWY 11E
PINEY FLATS,TN37686
20-0577483 		MED. SERV. TN NA
  		        No     No  
(3) INTEGRATED HEALTH SOLUTIONS NETWORK

400 N STATE OF FRANKLIN ROAD
JOHNSON CITY,TN37604
62-1711997 		INVEST CO. TN NA
  		        No     No  
(4) EMMAUS

6070 HWY 11E
PINEY FLATS,TN37686
20-0577483 		MED. SERV. TN NA
  		        No     No  






Part IV
Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" to 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
 		(i)
Section 512(b)(13) controlled entity?
Yes No
(1) BLUE RIDGE MEDICAL MGMT CORP

1021 W OAKLAND AVENUE
JOHNSON CITY,TN37604
62-1490616 		PHY. OFF. TN NA
  		C CORP         No
(2) MEDISERVE MED EQUIP OF KINGSPORT

1021 W OAKLAND AVENUE
JOHNSON CITY,TN37604
62-1212286 		DME TN NA
  		C CORP         No
(3) MOUNTAIN STATES PROPERTIES

1021 W OAKLAND AVENUE
JOHNSON CITY,TN37604
62-1845895 		PROP. MGMT TN NA
  		C CORP         No
(4) MOUNTAIN STATES MED GROUP

1021 W OAKLAND AVENUE
JOHNSON CITY,TN37604
62-1700412 		HEALTHCARE TN NA
  		C CORP         No
(5) COMMUNITY HOME CARE INC

100 15TH ST NW
NORTON,VA24273
54-1453810 		MED. EQUIP VA NA
  		C CORP         No
(6) SOUTHWEST COMMUNITY HEALTH SERV

565 RADIO HILL RD PO BOX 880
MARION,VA24354
54-1460695 		MED. SERV. VA NA
  		          No
(7) BLUE RIDGE MEDICAL MGMT CORP

1021 W OAKLAND AVENUE
JOHNSON CITY,TN37604
62-1490616 		PHY. OFF. TN NA
  		C CORP         No
(8) MEDISERVE MED EQUIP OF KINGSPORT

1021 W OAKLAND AVENUE
JOHNSON CITY,TN37604
62-1212286 		DME TN NA
  		C CORP         No
(9) MOUNTAIN STATES PROPERTIES

1021 W OAKLAND AVENUE
JOHNSON CITY,TN37604
62-1845895 		PROP. MGMT TN NA
  		C CORP         No
(10) MOUNTAIN STATES MED GROUP

1021 W OAKLAND AVENUE
JOHNSON CITY,TN37604
62-1700412 		HEALTHCARE TN NA
  		C CORP         No
(11) COMMUNITY HOME CARE INC

100 15TH ST NW
NORTON,VA24273
54-1453810 		MED. EQUIP VA NA
  		C CORP         No
(12) SOUTHWEST COMMUNITY HEALTH SERV

565 RADIO HILL RD PO BOX 880
MARION,VA24354
54-1460695 		MED. SERV. VA NA
  		          No
Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 3
Part V
Transactions With Related Organizations (Complete if the organization answered "Yes" to Form 990, Part IV, line 34, 35b, or 36.)
Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.
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 or (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .
1a
Yes
 
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 Dividends from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
No
g Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
 
No
j Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
 
No
k Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1k
 
No
l Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .
1l
Yes
 
m Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .
1m
 
No
n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .
1n
 
No
o Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
 
No
p Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
Yes
 
q Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
 
No
r Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
Yes
 
s Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1s
 
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-s) 		(c)
Amount involved 		(d)
Method of determining amount involved





Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to 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 section 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) 2012
Schedule R (Form 990) 2012
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


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