Form990
Click to see attachment
Department of the Treasury
Internal Revenue Service
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung benefit trust or private foundation)

MediumBullet The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0047
2011
Open to Public Inspection
A For the calendar year, or tax year beginning 07-01-2011 and ending 06-30-2012
BCheck if applicable:
CName of organization
MERCY MEDICAL CENTER - SIOUX CITY FOUNDATION
 
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
801 5TH STREET
 
Room/suite
City or town, state or country, and ZIP + 4
SIOUX CITY, IA51102
D Employer identification number

14-1880022
E Telephone number

G Gross receipts $ 2,129,259
F Name and address of principal officer:
LEA GREATHOUSE
801 5TH STREET
SIOUX CITY,IA51102
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
WWW.MERCYSIOUXCITY.COM/SERVICES/FOUNDATION
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: 2002
M State of legal domicile: IA
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: FUNDRAISING FOR MERCY MEDICAL CENTER - SIOUX CITY
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a)..... 3 15
4 Number of independent voting members of the governing body (Part VI, line 1b) .... 4 12
5 Total number of individuals employed in calendar year 2011 (Part V, line 2a) ... 5 0
6 Total number of volunteers (estimate if necessary) .... 6 165
7a Total unrelated business revenue from Part VIII, column (C), line 12 .. 7a 0
b Net unrelated business taxable income from Form 990-T, line 34 .. 7b 0
Revenues; Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 887,135 1,468,627
9 Program service revenue (Part VIII, line 2g) ......... 0 0
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 288,072 163,877
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 216,993 173,289
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 1,392,200 1,805,793
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 728,848 1,604,845
14 Benefits paid to or for members (Part IX, column (A), line 4)..... 0 0
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10) 273,937 258,933
16a Professional fundraising fees (Part IX, column (A), line 11e)..... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet32,465    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f).... 309,354 280,382
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 1,312,139 2,144,160
19 Revenue less expenses. Subtract line 18 from line 12....... 80,061 -338,367
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 6,217,356 5,643,763
21 Total liabilities (Part X, line 26)............. 296,985 293,584
22 Net assets or fund balances. Subtract line 21 from line 20..... 5,920,371 5,350,179
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title.
Paid preparer use only
Print/type preparer's name
 
Preparer's signature
Date
PTIN
Firm's name Right pointing arrowhead image

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



Phone no.
May the IRS discuss this return with the preparer shown above? See instructions .........bullet
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2011)
Form 990 (2011)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III .........
1
Briefly describe the organization’s mission: FUNDRAISING FOR MERCY MEDICAL CENTER-SIOUX CITY
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ....................
If “Yes,” describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services? ..........................
If “Yes,” describe these changes on Schedule O.
4
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 1,914,491 including grants of $ 1,604,845 ) (Revenue $ 48,842 )
GRANTS FUNDED TO MERCY HEALTH SERVICES - IOWA, CORP, DOING BUSINESS AS MERCY MEDICAL CENTER - SIOUX CITY AND ITS AFFILIATES TO PROMOTE HEALTH AND WELL BEING FOR THE RESIDENTS OF THE SIOUXLAND COMMUNITIES SERVICED BY THE ORGANIZATION. GRANTS SPECIALIZE IN THE HEALTHCARE NEEDS OF WOMEN AND CHILDREN AND POPULATIONS AT RISK.
4b (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4c (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4d Other program services (Describe in Schedule O.)
(Expenses $   including grants of $   ) (Revenue $   )
4e Total program service expensesMediumBullet$ 1,914,491
Form 990 (2011)
Form 990 (2011)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If “Yes,” complete Schedule AClick to see attachment.....................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors? Click to see attachment........
2
Yes
 
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part I..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities? If “Yes,” complete Schedule C,
Part II.........................
4
 
No
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If “Yes,” complete Schedule C, Part III........................
5
 
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; 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
Yes
 
11
If the organization’s answer to any of the following questions is ‘Yes,’ then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable:
a
Did the organization report an amount for land, buildings, and equipment in Part X, line10? If “Yes,” complete Schedule D, Part VI.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 VII.Click to see attachment
11b
Yes
 
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIII.Click 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 IX.Click 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 X.Click to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If “Yes,” complete Schedule D, Part X.Click to see attachment
11f
 
No
12a
Did the organization obtain separate, independent audited financial statements for the tax year?
If “Yes,” complete Schedule D, Parts XI, XII, and XIII 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, XII, and XIII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States or aggregate foreign investments valued at $100,000 or more? If “Yes,” complete Schedule F, Part I.........
14b
 
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the U.S.? If “Yes,” complete Schedule F, Part II..
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the U.S.? If “Yes,” complete Schedule F, Part III..
16
 
No
17
Did the organization report a total of more than $15,000, of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If “Yes,” complete Schedule G, Part I
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If “Yes,” complete Schedule G, Part II..........
18
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...................
19
Yes
 
20a
Did the organization operate one or more hospitals? If “Yes,” complete Schedule H.....
20a
 
No
b
If “Yes” to line 20a, did the organization attach a copy of its audited financial statement to this return? Note. All Form 990 filers that operated one or more hospitals must attach audited financial statements.
20b
 
 
Form 990 (2011)
Form 990 (2011)
Page 4
Part IV
Checklist of Required Schedules (continued)
21
Did the organization report more than $5,000 of grants and other assistance to any government or organization in the United States on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II.. Click to see attachment
21
Yes
 
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..... Click to see attachment
22
 
No
23
Did the organization answer “Yes” to Part VII, Section A, questions 3, 4, or 5, about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If “Yes,” complete Schedule J................ Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer questions 24b–24d and complete Schedule K. If “No,” go to line 25................
24a
 
No
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
 
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
 
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
 
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If “Yes,” complete Schedule L, Part I......
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I................
25b
 
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highly compensated employee, or disqualified person outstanding as of the end of the organization’s tax year? If “Yes,” complete Schedule L,
Part II.........................
26
 
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member of any of these persons? If “Yes,” complete Schedule L, Part III.........
27
 
No
28
Was the organization a party to a business transaction with one of the following parties? (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If “Yes,” complete Schedule L, Part IV .........................
28a
 
No
b
A family member of a current or former officer, director, trustee, or key employee? If “Yes,”
complete Schedule L, Part IV...................
28b
 
No
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or owner? If “Yes,” complete Schedule L, Part IV..
28c
 
No
29
Did the organization receive more than $25,000 in non-cash contributions? If “Yes,” complete Schedule MClick to see attachment
29
Yes
 
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M............ Click to see attachment
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, Parts II, III, IV, and V, line 1..................... Click to see attachment
34
Yes
 
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
Yes
 
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... Click to see attachment
35b
Yes
 
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 11 and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2011)
Form 990 (2011)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V .........
Yes
No
1a
Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable. .......
1a
0
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable.
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
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
0
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?

Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file. (see instructions)
2b
 
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?.............................
3a
 
No
b
If “Yes,” has it filed a Form 990-T for this year? If “No,” provide an explanation in Schedule O.....
3b
 
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account or securities account)?.......................
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If “Yes” to line 5a or 5b, did the organization file Form 8886-T? ........
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible?..........
6a
 
No
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
Yes
 
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
Yes
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?..........................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?...................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?...............
7h
 
 
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?................
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?.........
9a
 
 
b
Did the organization make a distribution to a donor, donor advisor, or related person?......
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them) ........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year.
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. All 501(c)(29) organizations must list in Schedule O each state in which they are licensed to issue qualified health plans, the amount of reserves required by each state, and the amount of reserves the organization allocated to each state.
13a
 
 
b
Enter the aggregate amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans.
13b
 
c
Enter the aggregate amount of reserves on hand.
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
 
b
If "Yes," has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O..
14b
 
 
Form 990 (2011)
Form 990 (2011)
Page 6
Part VI
Governance, Management, and Disclosure For each “Yes” response to lines 2 through 7b below, and for a “No” response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI .........
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year
If the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
1a
15
b
Enter the number of voting members included in line 1a, above, who are independent .................
1b
12
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
 
No
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? .
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed?
4
 
No
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Did the organization have members or stockholders? ................
6
Yes
 
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? .................
7a
Yes
 
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ............
7b
Yes
 
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .........................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ..........
8b
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 the Form 990. .....
12a
Did the organization have a written conflict of interest policy? If “No,” go to line 13.......
12a
Yes
 
b
Were officers, directors or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ........................
12b
Yes
 
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If “Yes,” describe in Schedule O how this was done ....................
12c
Yes
 
13
Did the organization have a written whistleblower policy? ...............
13
Yes
 
14
Did the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
 
No
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes," to line 15a or 15b, describe the process in Schedule O (see instructions).
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
 
No
b
If “Yes,” did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
 
 
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how), the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization: MediumBullet
LEA GREATHOUSE
801 5TH STREET
SIOUX CITY,IA51102
(712) 279-2475
Form 990 (2011)
Form 990 (2011)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response to any question in this Part VII .........
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation, and current key employees. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

RoundBullet List all of the organization’s current key employees, if any. See instructions for definition of "key employee."
RoundBullet List the organization’s five current highest compensated employees (other than an officer, director, trustee or key employee)
who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the
organization and any related organizations.

RoundBullet List all of the organization’s former officers, key employees, or highest compensated employees who received more than $100,000
of reportable compensation from the organization and any related organizations.

RoundBullet List all of the organization’s former directors or trustees that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organizations compensated any current or former officer, director, or trustee.
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(1) DAVE SMETTER
CHAIR
 1.00 X   X       0 0 0
(2) CINDY MOSER
VICE CHAIR THROUGH 12/11, DIRECTOR
 1.00 X   X       0 0 0
(3) GINA SITZMANN
VICE CHAIR AS OF 1/12
 1.00 X   X       0 0 0
(4) JAN TWAIT
DIRECTOR, TREASURER AS OF 1/12
 1.00 X   X       0 0 0
(5) KEES EDER
TREASURER THROUGH 12/11
 1.00 X   X       0 0 0
(6) KIM KLETSCHKE
SECRETARY THROUGH 12/11
 1.00 X   X       0 0 0
(7) DALE MEYER
SECRETARY AS OF 1/12
 1.00 X   X       0 0 0
(8) GEORGE BOYKIN
DIRECTOR
 1.00 X           0 0 0
(9) MARTHA BURCHARD
DIRECTOR THROUGH 12/11
 1.00 X           0 0 0
(10) GREGG GALLOWAY MD
DIRECTOR
 1.00 X           0 0 0
(11) LINDA KREI
DIRECT.,EX-OFFICIO,VP-MMC-SIOUX CITY
 1.00 X           0 226,825 32,947
(12) CAROLYN LEMAN
DIRECTOR THROUGH 12/11
 1.00 X           0 0 0
(13) ROBERT PEEBLES
DIRECTOR,CEO-MMC-SIOUX CITY
 1.00 X           0 566,715 77,662
(14) GERALD MCGOWAN MD
DIRECTOR THROUGH 12/11
 1.00 X           0 0 0
(15) JEROME PIERSON MD
DIRECTOR
 1.00 X           0 0 0
(16) KENNETH ROACH DVM
DIRECTOR
 1.00 X           0 0 0
(17) THOMAS SMITH
DIRECTOR
 1.00 X           0 0 0
Form 990 (2011)
Form 990 (2011)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(18) AMY CALLAGHAN
DIRECTOR
 1.00 X           0 134,160 20,635
(19) DENNIS GANN
DIRECTOR
 1.00 X           0 0 0
(20) CATHERINE TENHULZEN
DIRECTOR AS OF 1/12
 1.00 X           0 0 0
(21) VERNA WELTE
DIRECTOR
 1.00 X           0 0 0
(22) LEA GREATHOUSE
EXECUTIVE DIRECTOR
 40.00     X       0 104,184 21,109
















1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 0 1,031,884 152,353
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organizationMediumBullet0
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If “Yes,” complete Schedule J for such individual .............
3
 
No
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person .....
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization’s tax year.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet0
Form 990 (2011)
Form 990 (2011)
Page 9
Part VIII
Statement of Revenue
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, Gifts, Grants and Other Similar Amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c 73,649
d Related organizations...1d 253,668
e Government grants (contributions)1e 412,809
f All other contributions, gifts, grants, and
similar amounts not included above1f 		728,501
g Noncash contributions included in lines 1a-1f:$ 29,190
h Total. Add lines 1a-1f.......MediumBullet 1,468,627
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 83,991     83,991
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 79,886  
b Less: cost or other basis and sales expenses 0  
c Gain or (loss) 79,886  
d Net gain or (loss)..........MediumBullet 79,886     79,886
8a Gross income from fundraising events (not including
$ 73,649
of contributions reported on line 1c). See Part IV, line 18 ...
a 233,416
b Less: direct expenses ...b 176,225
c Net income or (loss) from fundraising events..MediumBullet 57,191   57,191
9a Gross income from gaming activities.
See Part IV, line 19 ...
a 93,304
b Less: direct expenses ...b 44,462
c Net income or (loss) from gaming activities...MediumBullet 48,842 48,842    
10a Gross sales of inventory, less
returns and allowances .
a 170,035
b Less: cost of goods sold ..b 102,779
c Net income or (loss) from sales of inventory..MediumBullet 67,256     67,256
Miscellaneous Revenue Business Code
11a            
b            
c            
d All other revenue ....        
e Total. Add lines 11a–11d ......MediumBullet  
12 Total revenue. See Instructions....MediumBullet 1,805,793 48,842 0 288,324
Form 990 (2011)
Form 990 (2011)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A) but are not required to complete columns (B), (C), and (D).
Check if Schedule O contains a response to any question in this Part IX. .........
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII. 		(A)
Total expenses 		(B)
Program service expenses 		(C)
Management and general expenses 		(D)
Fundraising expenses
1 Grants and other assistance to governments and organizations in the United States. See Part IV, line 21 1,604,845 1,604,845
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 .... 125,320   125,320  
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 96,207 48,913 47,294  
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 2,609 2,478 131  
9 Other employee benefits ....... 20,274 8,258 12,016  
10 Payroll taxes ........... 14,523 3,544 10,979  
11 Fees for services (non-employees):        
a Management ......        
b Legal .........        
c Accounting ...........        
d Lobbying ...........        
e Professional fundraising. See Part IV, line 17..    
f Investment management fees ......        
g Other .......... 10,700 9,827 873  
12 Advertising and promotion .... 870 870    
13 Office expenses ....... 21,703 21,112 591  
14 Information technology ...... 7,686 103   7,583
15 Royalties ..        
16 Occupancy ........... 14,333     14,333
17 Travel ............ 8,416 8,416    
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ......        
19 Conferences, conventions, and meetings .... 7,759 7,114   645
20 Interest ...........        
21 Payments to affiliates .......        
22 Depreciation, depletion, and amortization .....        
23 Insurance ..............        
24 Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24f. If line 24f amount exceeds 10% of line 25, column (A) amount, list line 24f expenses on Schedule O.)
a INTERCO PURCHASED SVCS 193,345 193,345    
b TREASURY FEES 8,372 161   8,211
c SUBSCRIPTIONS & DUES 5,831 4,138   1,693
d MEDICAL SUPPLIES 526 526    
e
f All other expenses 841 841    
25 Total functional expenses. Add lines 1 through 24f 2,144,160 1,914,491 197,204 32,465
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 (2011)
Form 990 (2011)
Page 11
Part X Balance Sheet
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash—non-interest-bearing ..........   1  
2 Savings and temporary cash investments ....... 47,052 2 48,513
3 Pledges and grants receivable, net ......... 284,682 3 236,672
4 Accounts receivable, net .........   4  
5 Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L ..........   5  
6 Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
Schedule L ..........   6  
7 Notes and loans receivable, net .............   7  
8 Inventories for sale or use .............. 28,443 8 26,644
9 Prepaid expenses and deferred charges ............   9  
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 4,051
b Less: accumulated depreciation. ..... 10b 4,051 0 10c 0
11 Investments—publicly traded securities .......... 2,607,604 11 2,011,847
12 Investments—other securities. See Part IV, line 11 ...... 3,061,100 12 3,282,487
13 Investments—program-related. See Part IV, line 11 ..   13  
14 Intangible assets .........   14  
15 Other assets. See Part IV, line 11 ........... 188,475 15 37,600
16 Total assets. Add lines 1 through 15 (must equal line 34)... 6,217,356 16 5,643,763
Liabilities 17 Accounts payable and accrued expenses . 16,298 17 25,057
18 Grants payable ..........   18  
19 Deferred revenue ..........   19  
20 Tax-exempt bond liabilities ..........   20  
21 Escrow or custodial account liability. Complete Part IV of Schedule D..   21  
22 Payables to current and former officers, directors, trustees, key
employees, highest compensated employees, and disqualified
persons. Complete Part II of Schedule L..........   22  
23 Secured mortgages and notes payable to unrelated third parties ..   23  
24 Unsecured notes and loans payable to unrelated third parties ....   24  
25 Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D..... 280,687 25 268,527
26 Total liabilities. Add lines 17 through 25..... 296,985 26 293,584
Net Assets or Fund Balance Organizations that follow SFAS 117, check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets ..... 2,695,550 27 2,612,755
28 Temporarily restricted net assets ..... 3,142,698 28 2,655,301
29 Permanently restricted net assets ..... 82,123 29 82,123
Organizations that do not follow SFAS 117, check here MediumBullet and complete lines 30 through 34.
30 Capital stock or trust principal, or current funds .....   30  
31 Paid-in or capital surplus, or land, building or equipment fund .....   31  
32 Retained earnings, endowment, accumulated income, or other funds   32  
33 Total net assets or fund balances ..... 5,920,371 33 5,350,179
34 Total liabilities and net assets/fund balances ..... 6,217,356 34 5,643,763
Form 990 (2011)
Form 990 (2011)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI .........
1
Total revenue (must equal Part VIII, column (A), line 12) ...
1
1,805,793
2
Total expenses (must equal Part IX, column (A), line 25) ....
2
2,144,160
3
Revenue less expenses. Subtract line 2 from line 1 ...
3
-338,367
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..
4
5,920,371
5
Other changes in net assets or fund balances (explain in Schedule O) ...
5
-231,825
6
Net assets or fund balances at end of year. Combine lines 3, 4, and 5 (must equal Part X, line 33, column (B)) ....
6
5,350,179
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII .........
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?....
2a
 
No
b
Were the organization’s financial statements audited by an independent accountant?........
2b
Yes
 
c
If “Yes,” to 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant? If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O. ...........................
2c
Yes
 
d
If “Yes” to line 2a or 2b, check a box below to indicate whether the financial statements for the year were issued on a separate basis, consolidated basis, or both:
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133? ................
3a
 
No
b
If “Yes,” did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits. ..
3b
 
 
Form 990 (2011)
Additional Data


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

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

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

14-1880022
Part I
Reason for Public Charity Status (All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
f
g
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization? ................
11g(i)
 
 
(ii) a family member of a person described in (i) above? ......................
11g(ii)
 
 
(iii) a 35% controlled entity of a person described in (i) or (ii) above? ................
11g(iii)
 
 
h
(i)
Name of supported organization 		(ii)
EIN 		(iii)
Type of organization (described on lines 1- 9 above or IRC section (see instructions)) 		(iv)
Is the organization in col. (i) listed in your governing document? 		(v)
Did you notify the organization in col. (i) of your support? 		(vi)
Is the organization in col. (i) organized in the U.S.? 		(vii)
Amount of support?
Yes No Yes No Yes No
Total                  

For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year(or fiscal year beginning in) (a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .... 5,696,355 1,672,587 758,547 887,135 1,468,627 10,483,251
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.. 5,696,355 1,672,587 758,547 887,135 1,468,627 10,483,251
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.           10,483,251
Section B. Total Support
Calendar year(or fiscal year beginning in) (a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (f) Total
7 Amounts from line 4.. 5,696,355 1,672,587 758,547 887,135 1,468,627 10,483,251
8 Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. 110,613 77,657 139,447 92,397 83,991 504,105
9 Net income from unrelated business activities, whether or not the business is regularly carried on..            
10 Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..            
11 Total support (Add lines 7 through 10).           10,987,356
12
12
2,242,740
13
Section C. Computation of Public Support Percentage
14
14
95.410 %
15
15
95.470 %
16a
b
17a
b
18
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2)
(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year(or fiscal year beginning in) (a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .            
2 Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......            
3 Gross receipts from activities that are not an unrelated trade or business under section 513..            
4 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...            
5 The value of services or facilities furnished by a governmental unit to the organization without charge..            
6 Total. Add lines 1 through 5.            
7a Amounts included on lines 1, 2, and 3 received from disqualified persons...            
b Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.            
c Add lines 7a and 7b..            
8 Public Support (Subtract line 7c from line 6.)            
Section B. Total Support
Calendar year (or fiscal year beginning in) (a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (f) Total
9 Amounts from line 6...            
10a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..            
b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.            
c Add lines 10a and 10b.            
11 Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.            
12 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)            
13 Total support (Add lines 9, 10c, 11 and 12.).            
14
Section C. Computation of Public Support Percentage
15
15
 
16
16
 
Section D. Computation of Investment Income Percentage
17
17
 
18
18
 
19a
b
20
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 4
Part IV
Supplemental Information. Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
 
Explanation
 
 
 
 
Schedule A (Form 990 or 990-EZ) 2011

Additional Data


Software ID:  
Software Version:  
Schedule B
(Form 990, 990-EZ,
or 990-PF)
Department of the Treasury
Internal Revenue Service
Schedule of Contributors
Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
OMB No. 1545-0047
2011
Name of organization
MERCY MEDICAL CENTER - SIOUX CITY FOUNDATION
 
Employer identification number

14-1880022
Organization type (check one):
Filers of:
Section:
Form 990 or 990-EZ





Form 990-PF




Check if your organization is covered by the General Rule or a Special Rule.  
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.
General Rule
Special Rules
......................... Arrow Bullet   $    
Caution. An Organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2, of its Form 990; or check the box on line H of its
Form 990-EZ or on Part I, line 2, of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).
For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.
Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2011)

Page 2
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Name of organization
MERCY MEDICAL CENTER - SIOUX CITY FOUNDATION
  		Employer identification number

14-1880022
Part I
Contributors (see Instructions). Use duplicate copies of Part I if additional space is needed.
     
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
RESTRICTED
RESTRICTED
 

     
RESTRICTED
RESTRICTED  
RESTRICTED, RESTRICTED   RESTRICTED

$RESTRICTED




(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Page 3
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Name of organization
MERCY MEDICAL CENTER - SIOUX CITY FOUNDATION
  		Employer identification number

14-1880022
Part II
Noncash Property (see Instructions). Use duplicate copies of Part II if additional space is needed.
     
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Page 4
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Name of organization
MERCY MEDICAL CENTER - SIOUX CITY FOUNDATION
  		Employer identification number

14-1880022
Part III
Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
that total more than $1,000 for the year. Complete columns (a) through (e) and the following line entry.
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet $  
Use duplicate copies of Part III if additional space is needed
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

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
2011
Open to Public Inspection
Name of the organization
MERCY MEDICAL CENTER - SIOUX CITY FOUNDATION
 
Employer identification number

14-1880022
Part I
Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.
(a) Donor advised funds (b) Funds and other accounts
1 Total number at end of year .......    
2 Aggregate contributions to (during year) ...    
3 Aggregate grants from (during year) ...    
4 Aggregate value at end of year .......    
5
Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............
6
Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................
Part II
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.
Held at the End of the Year
a Total number of conservation easements ....................... 2a  
b Total acreage restricted by conservation easements .................. 2b  
c Number of conservation easements on a certified historic structure included in (a) ..... 2c  
d Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register .................... 2d  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................
6
Staff and volunteer hours devoted to monitoring, inspecting and enforcing conservation easements during the year SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet $  
8
Does each conservation easement reported on line 2(d) above satisfy the requirements of section
170(h)(4)(B)(i) and 170(h)(4)(B)(ii)? ....................................
9
In Part XIV, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.
1a
If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of
art, historical treasures, or other similar assets held for public exhibition, education or research in furtherance of public service,
provide, in Part XIV, the text of the footnote to its financial statements that describes these items.
b
If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art,
historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service,
provide the following amounts relating to these items:
(i)
Revenues included in Form 990, Part VIII, line 1 ........................SchDMd Bullet $  
(ii)
Assets included in Form 990, Part X ..............................SchDMd Bullet $  
2
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958), relating to these items:
a
Revenues included in Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 52283D
Schedule D (Form 990) 2011

Schedule D (Form 990) 2011
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
Using the organization’s accession and other records, check any of the following that are a significant use of its collection
items (check all that apply):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIV.
5
During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........
Part IV
Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b
If "Yes," explain the arrangement in Part XIV and complete the following table:
Amount
c Beginning balance ................................. 1c  
d Additions during the year .............................. 1d  
e Distributions during the year ............................. 1e  
f Ending balance ................................... 1f  
2a
Did the organization include an amount on Form 990, Part X, line 21? .....................
b
If “Yes,” explain the arrangement in Part XIV.
Part V
Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
(a)Current Year (b)Prior Year (c)Two Years Back (d)Three Years Back (e)Four Years Back
1a Beginning of year balance .... 99,281 89,920 84,287 97,172
b Contributions ........   1,000    
c Net investment earnings, gains, and losses ... -477 8,361 5,670 -12,885
d Grants or scholarships .....        
e Other expenditures for facilities
and programs ........ 		       
f Administrative expenses ....     37  
g End of year balance ...... 98,804 99,281 89,920 84,287
2
Provide the estimated percentage of the year end balance (line 1g) held as:
a
Board designated or quasi-endowment SchDMd Bullet  
b
Permanent endowment SchDMd Bullet83.120 %
c
Temporarily restricted endowment SchDMd Bullet16.880 %
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)
 
No
(ii) related organizations ........................
3a(ii)
 
No
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
 
 
4
Describe in Part XIV the intended uses of the organization's endowment funds.
Part VI
Land, Buildings, and Equipment. See Form 990, Part X, line 10.
Description of property (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .................      
b Buildings ................        
c Leasehold improvements ............        
d Equipment ................   4,051 4,051 0
e Other .................        
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......SchDMdBullet 0
Schedule D (Form 990) 2011

Schedule D (Form 990) 2011
Page 3
Part VII
Investments—Other Securities. See Form 990, Part X, line 12.
(a) Description of security or category
(including name of security)		 (b)Book value (c) Method of valuation:
Cost or end-of-year market value
(1)Financial derivatives    
(2)Closely-held equity interests    
(3)Other
(A) COMMINGLED FUNDS DIRECTLY HOLDING SECURITIES 		1,853,017 F

(B) EQUITY METHOD INVESTMENTS 		1,429,470 C







Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)Small Bullet 3,282,487
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  
CHARITABLE GIFT ANNUITY-MANALAN/WERTH 145,628
CHARITABLE GIFT ANNUITY-WITTROCK 33,054
CHARITABLE GIFT ANNUITY-WITTROCK- 2 34,246
CHARITABLE GIFT ANNUITY- WITTROCK-3 43,666
CHARITABLE GIFT ANNUITY-D A KELLEN ANNUITY 5,324
CHARITABLE GIFT ANNUITY-LH KELLEN ANNUITY 5,027
INTERCOMPANY PAYABLES 1,582


Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 268,527
2. Fin 48 (ASC 740) Footnote. In Part XIV, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC740).
Schedule D (Form 990) 2011

Schedule D (Form 990) 2011
Page 4
Part XI Reconciliation of Change in Net Assets from Form 990 to Financial Statements
1 Total revenue (Form 990, Part VIII, column (A), line 12) .................... 1  
2 Total expenses (Form 990, Part IX, column (A), line 25) ..................... 2  
3 Excess or (deficit) for the year. Subtract line 2 from line 1 ............. 3  
4 Net unrealized gains (losses) on investments .......................... 4  
5 Donated services and use of facilities ............................. 5  
6 Investment expenses ................................... 6  
7 Prior period adjustments .................................. 7  
8 Other (Describe in Part XIV.) ................................. 8  
9 Total adjustments (net). Add lines 4 through 8 ......................... 9  
10 Excess or (deficit) for the year per financial statements. Combine lines 3 and 9 ......... 10  
Part XII Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1 Total revenue, gains, and other support per audited financial statements ....... 1  
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains on investments .......... 2a  
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIV.) ............ 2d  
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 XIV.) ........... 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 XIII 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 XIV.) ............ 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 XIV.) ............ 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 XIV
Supplemental Information
Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X; Part XI, line 8; Part XII, lines 2d and 4b; and Part XIII, lines 2d and 4b. Also complete this part to provide any additional information.
Identifier Return Reference Explanation
DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: MERCY MEDICAL CENTER - SIOUX CITY FOUNDATION MAINTAINS THREE ENDOWMENT FUNDS: THE BRUEN FUND-TO PROVIDE CHARITY CARE. THE MAKOWSKI FUND-TO PROVIDE FACILITY NEEDS WITHIN THE MERCY MEDICAL CENTER - SIOUX CITY HOSPITAL. THE HEART CENTER FUND-TO PROVIDE FOR FACILITY NEEDS WITHIN THE HEART CENTER OF MERCY MEDICAL CENTER - SIOUX CITY.
Schedule D (Form 990) 2011

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.right arrowAttach to Form 990 or Form 990-EZ. right arrowSee separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
MERCY MEDICAL CENTER - SIOUX CITY FOUNDATION
 
Employer identification number

14-1880022
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. Form 990-EZ filers are not required to complete this table.
(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 Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50083H
Schedule G (Form 990 or 990-EZ) 2011
Schedule G (Form 990 or 990-EZ) 2011
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 on Form 990-EZ, line 6a. List events with gross receipts greater than $5,000.
(a) Event #1

GALA
(event type) 		(b) Event #2

WOMEN'S NIGHT OUT
(event type) 		(c) Other Events

5
(total number) 		(d) Total Events
(Add col. (a) through col. (c))
VerticalRevenue 1 Gross receipts . . . 117,092 95,876 94,097 307,065
2 Less: Charitable
contributions . . . 		73,649 0 0 73,649
3 Gross income (line 1
minus line 2) . . . 		43,443 95,876 94,097 233,416
VerticalDirectExpenses 4 Cash prizes . . .        
5 Non-cash prizes . .        
6 Rent/facility costs . . 1,992 294   2,286
7 Food and beverages . . 45,004 7,042   52,046
8 Entertainment . . . 6,050 93,968 1,100 101,118
9 Other direct expenses . 19,282 0 1,493 20,775
10 Direct expense summary. Add lines 4 through 9 in column (d) ........... right arrow 176,225
11 Net income summary. Combine lines 3 and 10 in column (d)............ right arrow 57,191
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 . . . .     93,304 93,304
VerticalDirectExpenses 2 Cash prizes . . . .     33,368 33,368
3 Non-cash prizes . . .     10,052 10,052
4 Rent/facility costs . . .        
5 Other direct expenses . .     1,042 1,042
6 Volunteer labor . . .
 
 
100.000 %
7 Direct expense summary. Add lines 2 through 5 in column (d) ........... right arrow 44,462
8 Net gaming income summary. Combine lines 1 and 7 in column (d) .......... right arrow 48,842
9
Enter the state(s) in which the organization operates gaming activities: IA
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:
 
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? ..........................
Schedule G (Form 990 or 990-EZ) 2011
Schedule G (Form 990 or 990-EZ) 2011
Page 3
13
Indicate the percentage of gaming activity operated in:
a
The organization's facility ......................
13a
92.900 %
b
An outside facility ........................
13b
7.100 %
14
Provide the name and address of the person who prepares the organization's gaming/special events books and records:
Name right arrow
KAREN PALTZ
Address right arrow
801 5TH STREET
SIOUX CITY,IA51102
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:
Name right arrow
Address right arrow
 
 
16
Gaming manager information:
Name right arrow
LEA GREATHOUSE
Gaming manager compensation right arrow $ 104,184
Description of services provided right arrow
LEA GREATHOUSE IS THE FOUNDATION DIRECTOR. LEA COORDINATED THE GALA AND WOMEN'S NIGHT OUT RAFFLES WITH VOLUNTEERS, AND THE 50/50 CASH RAFFLE, A SEPARATE EVENT.
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
Complete this part to provide additional information for responses to quuestion on Schedule G (see instructions.)
Identifier ReturnReference Explanation
Schedule G (Form 990 or 990-EZ) 2011
Additional Data


Software ID:  
Software Version:  
Schedule I
(Form 990)
Department of the Treasury
Internal Revenue Service
Grants and Other Assistance to Organizations,
Governments and Individuals in the United States
Complete if the organization answered "Yes," to Form 990, Part IV, line 21 or 22.
lBullet Attach to Form 990
OMB No. 1545-0047
2011
Open to Public
Inspection
Name of the organization
MERCY MEDICAL CENTER - SIOUX CITY FOUNDATION
 
Employer identification number
14-1880022
Part I
General Information on Grants and Assistance
1
Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ....................................
2
Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.
Part II
Grants and Other Assistance to Governments and Organizations in the United States. Complete if the organization answered "Yes" to
Form 990, Part IV, line 21 for any recipient that received more than $5,000. Check this box if no one recipient received more than $5,000. Use
Part IV and Schedule I-1 (Form 990) if additional space is needed ......................... lBullet
(a) Name and address of organization
or government		 (b) EIN (c) IRC Code section
if applicable		 (d) Amount of cash grant (e) Amount of non-cash
assistance		 (f) Method of valuation
(book, FMV, appraisal,
other)		 (g) Description of
non-cash assistance		 (h) Purpose of grant
or assistance
(1) MERCY MEDICAL CENTER - SIOUX CITY801 5TH STREET
SIOUX CITY,IA51102 		31-1373080 501(C)(3) 1,476,780       COMMUNITY SUPPORT
(2) IOWA CHAPTER OF CHILDREN'S ADVOCACY CENTERS505 FIFTH AVENUE NO 1001
DES MOINES,IA50309 		27-0473272 501(C)(3) 13,875       COMMUNITY SUPPORT
(3) BAUM HARMON MERCY HOSPITAL255 N WELCH AVENUE
PRIMGHAR,IA51245 		42-1500277 501(C)(3) 35,867       COMMUNITY SUPPORT


















2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................. Bullet Image
3
3
Enter total number of other organizations listed in the line 1 table ......................... . Bullet Image
0
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50055P
Schedule I (Form 990) 2011

Schedule I (Form 990) 2011
Page 2
Part III
Grants and Other Assistance to Individuals in the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 22.
Use Schedule I-1 (Form 990) if additional space is needed.
(a)Type of grant or assistance (b)Number of
recipients		 (c)Amount of
cash grant		 (d)Amount of
non-cash assistance		 (e)Method of valuation (book,
FMV, appraisal, other)		 (f)Description of non-cash assistance













Part IV
Supplemental Information. Complete this part to provide the information required in Part I, line 2, and any other additional information.
Identifier Return Reference Explanation
PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: DONATIONS MADE BY MERCY MEDICAL CENTER - SIOUX CITY FOUNDATION TO CHARITABLE ORGANIZATIONS ARE MADE IN FURTHERANCE OF THE RECIPIENT ORGANIZATION'S EXEMPT PURPOSE AND ARE CONSIDERED UNRESTRICTED WITH REGARD TO THE USE OF THE FUNDS.
Schedule I (Form 990) 2011


Additional Data


Software ID:  
Software Version:  


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

14-1880022
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all the expenses described above? If "No," complete Part III to explain....
1b
 
 
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
officers, directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a? ....
2
 
 
3
Indicate which, if any, of the following the organization uses to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
4
During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment? ...............
4a
 
No
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? ........
4b
Yes
 
c
Participate in, or receive payment from, an equity-based compensation arrangement? ........
4c
 
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.
5
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization? ...........................
5a
 
No
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization? ...........................
6a
 
No
b
Any related organization? .........................
6b
 
No
If "Yes," to line 6a or 6b, describe in Part III.
7
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............
7
 
No
8
Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................
8
 
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 50053T
Schedule J (Form 990) 2011

Schedule J (Form 990) 2011
Page 2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.
For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.

Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and column (E) for that individual.
(A) Name (B) Breakdown of W-2 and/or 1099-MISC compensation (C) Retirement and other deferred compensation (D) Nontaxable
benefits		 (E) Total of columns
(B)(i)-(D) 		(F) Compensation
reported as deferred
in prior Form 990
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
(1) LINDA KREI (i)
(ii)		 0
186,417 		0
39,514 		0
894 		0
28,994 		0
3,953 		0
259,772 		0
0
(2) ROBERT PEEBLES (i)
(ii)		 0
371,901 		0
127,425 		0
67,389 		0
55,365 		0
22,297 		0
644,377 		0
0
(3) AMY CALLAGHAN (i)
(ii)		 0
124,052 		0
0 		0
10,108 		0
6,453 		0
14,182 		0
154,795 		0
0













Schedule J (Form 990) 2011

Schedule J (Form 990) 2011
Page 3
Part III
Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4c, 5a, 5b, 6a, 6b, 7, and 8. Also complete this part for any additional information.
Identifier Return Reference Explanation
  PART I, LINE 4B THE FOLLOWING IS A PARTICIPANT IN THE TRINITY HEALTH PENSION RESTORATION PLAN, A NONQUALIFIED PLAN, WHICH PROVIDES RETIREMENT BENEFITS FOR CERTAIN ASSOCIATES WITH EARNINGS ABOVE THE IRS PAY CAP FOR QUALIFIED PLANS ($245,000 FOR 2011). THE FOLLOWING ACCRUAL FOR 2011 FOR THIS PLAN IS INCLUDED IN COLUMN C OF SCHEDULE J, PART II: ROBERT PEEBLES - $35,765
Schedule J (Form 990) 2011

Additional Data


Software ID:  
Software Version:  
SCHEDULE M
(Form 990)

Department of the Treasury
Internal Revenue Service
NonCash Contributions
Right pointing arrow large imageComplete if the organization answered "Yes" on Form 990, Part IV, lines 29 or 30.
Right pointing arrow large image Attach to Form 990.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
MERCY MEDICAL CENTER - SIOUX CITY FOUNDATION
 
Employer identification number

14-1880022
Part I
Types of Property
(a)
Check if applicable 		(b)
Number of Contributions or items contributed 		(c)
Noncash contribution amounts reported on
Form 990, Part VIII, line 1g 		(d)
Method of determining
noncash contribution amounts
1 Art—Works of art ....        
2 Art—Historical treasures .        
3 Art—Fractional interests ..        
4 Books and publications ..      
5 Clothing and household
goods ....... 		     
6 Cars and other vehicles ..        
7 Boats and planes ....        
8 Intellectual property ...        
9 Securities—Publicly traded .        
10 Securities—Closely held stock .        
11 Securities—Partnership, LLC,
or trust interests .... 		       
12 Securities—Miscellaneous ..        
13 Qualified conservation
contribution—Historic
structures ..... 		       
14 Qualified conservation
contribution—Other ... 		       
15 Real estate—Residential .        
16 Real estate—Commercial ..        
17 Real estate—Other ...        
18 Collectibles .....        
19 Food inventory ...        
20 Drugs and medical supplies .        
21 Taxidermy ......        
22 Historical artifacts ....        
23 Scientific specimens ..        
24 Archeological artifacts ...        
25 Other Right pointing arrow large image ( JEWELRY & TRIP ) X 1 7,680 SELLING PRICE
26 Other Right pointing arrow large image ( BILLBOARDS ) X 1 6,510 SELLING PRICE
27 Other Right pointing arrow large image ( ADVERTISING ) X 1 6,000 SELLING PRICE
28 Other Right pointing arrow large image ( ATLS INSTRUCTOR ) X 2 9,000 SELLING PRICE
29
Number of Forms 8283 received by the organization during the tax year for contributions
for which the organization completed Form 8283, Part IV, Donee Acknowledgement ...
29
 
Yes
No
30a
During the year, did the organization receive by contribution any property reported in Part I, lines 1-28 that it
must hold for at least three years from the date of the initial contribution, and which is not required to be used
for exempt purposes for the entire holding period? ..................
30a
 
No
b
If "Yes," describe the arrangement in Part II.
31
Does the organization have a gift acceptance policy that requires the review of any non-standard contributions?
31
Yes
 
32a
Does the organization hire or use third parties or related organizations to solicit, process, or sell noncash
contributions? ............................
32a
 
No
b
If "Yes," describe in Part II.
33
If the organization did not report revenues in column (c) for a type of property for which column (a) is checked,
describe in Part II.
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 51227J
Schedule M (Form 990) 2011
Schedule M (Form 990) 2011
Page 2
Part II
Supplemental Information. Complete this part to provide the information required by Part I, lines 30b,
32b, and 33 and whether the organization is reporting in Part I, column (b) the number of contributions, the number of items received, or a combination of both. Also complete this part for any additional information.
Identifier Return Reference Explanation
Schedule M (Form 990) 2011
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
2011
Open to Public
Inspection
Name of the organization
MERCY MEDICAL CENTER - SIOUX CITY FOUNDATION
 
Employer identification number

14-1880022
Identifier Return Reference Explanation
  FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF MERCY MEDICAL CENTER - SIOUX CITY FOUNDATION IS MERCY MEDICAL CENTER-SIOUX CITY. SEE LINE 7 FOR ADDITIONAL INFORMATION.
  FORM 990, PART VI, SECTION A, LINE 7A MERCY MEDICAL CENTER-SIOUX CITY IS THE SOLE MEMBER OF MERCY MEDICAL CENTER - SIOUX CITY FOUNDATION. MERCY MEDICAL CENTER-SIOUX CITY HAS THE RIGHT TO APPOINT ALL PERSONS TO THE BOARD OF DIRECTORS OF MERCY MEDICAL CENTER - SIOUX CITY FOUNDATION.
  FORM 990, PART VI, SECTION A, LINE 7B AS SOLE MEMBER, MERCY MEDICAL CENTER-SIOUX CITY MUST APPROVE CERTAIN DECISIONS OF THE GOVERNING BODY, INCLUDING THE STRATEGIC PLAN, ANNUAL CAPITAL PLAN, AND ANNUAL OPERATING BUDGET. MERCY MEDICAL CENTER-SIOUX CITY MUST ALSO APPROVE A MATERIAL CHANGE IN MISSION, AND MODIFICATIONS TO GOVERNING DOCUMENTS.
  FORM 990, PART VI, SECTION B, LINE 11 MERCY MEDICAL CENTER - SIOUX CITY FOUNDATION'S FORM 990 WAS REVIEWED BY MANAGEMENT. MANAGEMENT REVIEW TOOK PLACE BEFORE THE FORM 990 WAS FILED WITH THE INTERNAL REVENUE SERVICE.
  FORM 990, PART VI, SECTION B, LINE 12C MERCY MEDICAL CENTER - SIOUX CITY FOUNDATION HAS ADOPTED A CONFLICT OF INTEREST POLICY WHICH CONTAINS THE ELEMENTS IN THE MODEL CONFLICT OF INTEREST POLICY ISSUED BY THE IRS. IT APPLIES TO ALL "INTERESTED PERSONS" OF MERCY MEDICAL CENTER - SIOUX CITY FOUNDATION, WHICH INCLUDES DIRECTORS, PRINCIPAL OFFICERS AND EXECUTIVES, AND MEMBERS OF COMMITTEES WITH BOARD DESIGNATED POWERS. INTERESTED PERSONS ARE REQUIRED TO ACT AT ALL TIMES IN A MANNER CONSISTENT WITH MERCY MEDICAL CENTER - SIOUX CITY FOUNDATION'S CHARITABLE PURPOSE AND SERVICE TO THE COMMUNITY AND TO AVOID CONFLICTS OF INTEREST. INTERESTED PERSONS ARE REQUIRED TO MAKE FULL DISCLOSURE TO MERCY MEDICAL CENTER - SIOUX CITY FOUNDATION OF ANY FINANCIAL OR BUSINESS INTERESTS THAT MIGHT RESULT IN OR HAVE THE APPEARANCE OF A CONFLICT OF INTEREST. INTERESTED PERSONS ARE REQUIRED TO RECUSE THEMSELVES FROM DISCUSSION AND VOTING ON MATTERS INVOLVING A CONFLICT OF INTEREST. THE BOARD OF DIRECTORS OF MERCY MEDICAL CENTER - SIOUX CITY FOUNDATION IS RESPONSIBLE FOR THE REVIEW AND APPROVAL OF TRANSACTIONS WITH INTERESTED PERSONS, INCLUDING DETERMINING THAT SUCH TRANSACTIONS ARE FAIR AND REASONABLE TO MERCY MEDICAL CENTER - SIOUX CITY FOUNDATION. ON AN ANNUAL BASIS, INTERESTED PERSONS ARE REQUIRED TO COMPLETE A CONFLICT OF INTEREST DISCLOSURE STATEMENT AND TO AFFIRM THEIR RECEIPT OF THE CONFLICT OF INTEREST POLICY, COMPLIANCE WITH ITS REQUIREMENTS, AND AGREE TO NOTIFY THE ORGANIZATION OF CHANGES IMPACTING THEIR ANNUAL DISCLOSURE IN ACCORDANCE WITH THE POLICY. THE DISCLOSURES ARE REVIEWED WITH THE BOARD OF DIRECTORS OF MERCY MEDICAL CENTER - SIOUX CITY FOUNDATION ON AN ANNUAL BASIS.
  FORM 990, PART VI, SECTION B, LINE 15B TRINITY HEALTH FOLLOWS A PROCESS AND POLICY THAT IS INTENDED TO MIRROR THE IRC SECTION 4958 GUIDELINES FOR OBTAINING A "REBUTTABLE PRESUMPTION OF REASONABLENESS" WITH REGARD TO COMPENSATION AND BENEFITS. AS PART OF THAT PROCESS, THE COMPENSATION AND BENEFITS OF CERTAIN OFFICERS, DIRECTORS, AND KEY MANAGEMENT OFFICIALS OF MERCY MEDICAL CENTER - SIOUX CITY FOUNDATION ARE REVIEWED AT LEAST ANNUALLY BY THE TRINITY HEALTH BOARD OR THE TRINITY HEALTH HUMAN RESOURCES AND COMPENSATION COMMITTEE (HRCC) OF THE BOARD, AUTHORIZED TO ACT ON BEHALF OF THE BOARD WITH RESPECT TO CERTAIN COMPENSATION MATTERS. AS PART OF ITS REVIEW PROCESS, THE HRCC RETAINS AN INDEPENDENT FIRM EXPERIENCED IN COMPENSATION AND BENEFIT MATTERS FOR NOT-FOR-PROFIT HEALTHCARE ORGANIZATIONS TO ADVISE IT IN THE DETERMINATIONS IT MAKES ON THE REASONABLENESS OF PROPOSED COMPENSATION AND BENEFITS ARRANGEMENTS.
  FORM 990, PART VI, SECTION C, LINE 19 MERCY MEDICAL CENTER - SIOUX CITY FOUNDATION IS A SUBSIDIARY ORGANIZATION IN THE TRINITY HEALTH SYSTEM. TRINITY HEALTH MAKES CERTAIN OF ITS KEY DOCUMENTS AVAILABLE TO THE PUBLIC ON ITS WEBSITE, WWW.TRINITY-HEALTH.ORG, IN THE "ABOUT US" SECTION. IN THIS SECTION, THE ANNUAL REPORT (WHICH INCLUDES COMMUNITY BENEFIT MINISTRY INFORMATION) AND CONSOLIDATED AUDITED FINANCIAL STATEMENTS ARE PUBLICLY AVAILABLE.
ESTIMATE OF THE AVERAGE HOURS PER WEEK DEVOTED TO RELATED ORGANIZATIONS: FORM 990, PART VII, SECTION A, LINE 1, COLUMN B: THE HOURS LISTED IN COLUMN B OF PART VII, SECTION A, LINE 1 REFLECT ONLY THE INDIVIDUALS' AVERAGE WEEKLY HOURS SPENT DIRECTLY ON THE ACTIVITIES OF THE REPORTING ORGANIZATION. IN ADDITION, THESE ARE THE AVERAGE HOURS PER WEEK DEVOTED TO RELATED ORGANIZATIONS: LINDA KREI - 49 HOURS ROBERT PEEBLES - 49 HOURS AMY CALLAGHAN - 49 HOURS
CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -213,224. OTHER ADJUSTMENTS: CHANGE IN VALUATION OF ANNUITIES: -18,601. TOTAL TO FORM 990, PART XI, LINE 5: -231,825.
  FORM 990, PART XII, LINE 2: MERCY MEDICAL CENTER - SIOUX CITY'S FINANCIAL STATEMENTS WERE INCLUDED IN THE FY12 CONSOLIDATED FINANCIAL STATEMENTS OF TRINITY HEALTH, WHICH WERE AUDITED BY AN INDEPENDENT PUBLIC ACCOUNTING FIRM.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2011

Additional Data


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

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

14-1880022
Part I
Identification of Disregarded Entities (Complete if the organization answered "Yes" on Form 990, Part IV, line 33.)
(a)
Name, address, and EIN of disregarded entity


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Total income
(e)
End-of-year assets


 		(f)
Direct controlling
entity

















Part II
Identification of Related Tax-Exempt Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.)
(a)
Name, address, and EIN of related organization


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Exempt Code section
(e)
Public charity status
(if section 501(c)(3))

 		(f)
Direct controlling
entity

 		(g)
Section 512(b)(13) controlled organization
Yes No
(1) ADVANTAGE HEALTHSAINT MARY'S MEDICAL GROUP

245 STATE ST SE

GRAND RAPIDS,MI49503
27-2491974 		HEALTHCARE SERVICES MI 501(C)(3) 9 TRINITY HEALTH-MICHIGAN
 
 
No
(2) AMICARE HOSPICE SERVICES INC

20555 VICTOR PARKWAY

LIVONIA,MI48152
38-2949053 		PROVIDE HOSPICE SERVICES MI 501(C)(3) 11, TYPE I TRINITY HOME HEALTH SERVICES INC
 
 
No
(3) AUXILIARY OF HOLY ROSARY HOSPITAL

351 SW 9TH STREET

ONTARIO,OR97914
94-3059469 		SUPPORTS SERVICES OF RELATED HOSPITAL OR 501(C)(3) 9 SAINT ALPHONSUS MEDICAL CENTER-ONTARIO
 
 
No
(4) BAUM HARMON MERCY HOSPITAL

255 NORTH WELCH AVENUE

PRIMGHAR,IA51245
42-1500277 		ACUTE/AMBULATORY HEALTHCARE SERVICES IA 501(C)(3) 3 MERCY HEALTH SERVICES-IOWA CORP
 
 
No
(5) BAUM HARMON MERCY HOSPITAL & CLINICS FOUNDATION

255 NORTH WELCH AVENUE

PRIMGHAR,IA51245
26-2973307 		SUPPORT THE SERVICES OF RELATED HOSPITAL IA 501(C)(3) 11, TYPE I BAUM HARMON MERCY HOSPITAL
 
 
No
(6) CATHERINE MCAULEY HEALTH SERVICES CORP

PO BOX 995

ANN ARBOR,MI48106
38-2507173 		FURTHER TRINITY HEALTH ACTIVITIES, ORGANIZE AND DEVELOP MEDICAL SERVICES MI 501(C)(3) 11, TYPE II TRINITY HEALTH-MICHIGAN
 
 
No
(7) COMMUNITY HEALTH PARTNERS OF SOUTH BEND

PO BOX 3998

SOUTH BEND,IN46619
26-3051440 		HEALTHCARE SERVICES IN 501(C)(3) 3 SAINT JOSEPH REGIONAL MEDICAL CENTER INC
 
 
No
(8) CRANBROOK HOSPICE CARE

281 ENTERPRISE COURT

BLOOMFIELD HILLS,MI48302
38-3320699 		PROVIDE HOSPICE HEALTH SERVICES MI 501(C)(3) 11, TYPE I TRINITY HOME HEALTH SERVICES INC
 
 
No
(9) DILEY RIDGE MEDICAL CENTER

6150 EAST BROAD STREET

COLUMBUS,OH43213
34-2032340 		HOSPITAL CAMPUS IN FAIRFIELD COUNTY OHIO OH 501(C)(3) 3 MOUNT CARMEL HEALTH SYSTEM
 
 
No
(10) DUBUQUE MERCY HEALTH FOUNDATION INC

250 MERCY DRIVE

DUBUQUE,IA52001
26-2227941 		SUPPORT THE SERVICES OF RELATED HOSPITAL IA 501(C)(3) 11, TYPE I MERCY HEALTH SERVICES-IOWA CORP
 
 
No
(11) DYERSVILLE HEALTH FOUNDATION INC

1111 3RD STREET SW

DYERSVILLE,IA52040
20-5383271 		SUPPORT THE SERVICES OF RELATED HOSPITAL IA 501(C)(3) 11, TYPE I MERCY HEALTH SERVICES-IOWA CORP
 
 
No
(12) GOTTLIEB COMMUNITY HEALTH SERVICES CORPORATION

701 W NORTH AVE

MELROSE PARK,IL60160
36-3332852 		SUPPORT THE SERVICES OF RELATED HOSPITAL IL 501(C)(3) 9 GOTTLIEB MEMORIAL HOSPITAL
 
 
No
(13) GOTTLIEB MEMORIAL FOUNDATION

701 W NORTH AVE

MELROSE PARK,IL60160
74-3260011 		SUPPORT THE SERVICES OF RELATED HOSPITAL IL 501(C)(3) 11, TYPE III-FI N/A
 
No
(14) GOTTLIEB MEMORIAL HOSPITAL

701 W NORTH AVE

MELROSE PARK,IL60160
36-2379649 		HEALTHCARE SERVICES IL 501(C)(3) 3 LOYOLA UNIVERSITY HEALTH SYSTEM
 
 
No
(15) HACKLEY HOSPITAL

1700 CLINTON ST PO BOX 3302

MUSKEGON,MI494433302
38-1358196 		HEALTHCARE SERVICES MI 501(C)(3) 3 MERCY HEALTH PARTNERS
 
 
No
(16) HACKLEY HOSPITAL SELF INSURANCE PROFESSIONAL LIABILITY TRUST

PO BOX 3302

MUSKEGON,MI494433302
38-2299878 		SELF INSURANCE FOR GENERAL AND MALPRACTICE LIABILITY MI 501(C)(3) 11, TYPE III-FI MERCY HEALTH PARTNERS
 
 
No
(17) HACKLEY LIFE COUNSELING

1352 TERRACE ST

MUSKEGON,MI494423545
38-1386362 		COUNSELING, EDUCATION, AND SUPPORT MI 501(C)(3) 9 MERCY HEALTH PARTNERS
 
 
No
(18) HACKLEY VISITING NURSE SERVICES AND HOSPICE INC

888 TERRACE ST

MUSKEGON,MI49440
38-1359598 		PROVIDE HOME HEALTH CARE SERVICES MI 501(C)(3) 7 MERCY HEALTH PARTNERS
 
 
No
(19) HOLY CROSS CARENET INC

PO BOX 9184

FARMINGTON HILLS,MI48333
52-1945054 		LONG-TERM CARE AND REHABILITATION FOR THE ELDERLY MD 501(C)(3) 9 TRINITY CONTINUING CARE SERVICES
 
 
No
(20) HOLY CROSS HOSPITAL FOUNDATION INC

11801 TECH ROAD

SILVER SPRING,MD20904
20-8428450 		CHARITABLE FUNDRAISING MD 501(C)(3) 11, TYPE I HOLY CROSS HOSPITAL OF SILVER SPRING
 
 
No
(21) HOLY CROSS HOSPITAL OF SILVER SPRING INC

1500 FOREST GLEN RD

SILVER SPRING,MD209101484
52-0738041 		HEALTHCARE SERVICES MD 501(C)(3) 3 TRINITY HEALTH CORPORATION
 
 
No
(22) HOLY CROSS MEDICAL CENTER

20555 VICTOR PARKWAY

LIVONIA,MI48152
95-1985442 		HEALTHCARE SERVICES (FORMERLY) CA 501(C)(3) 3 TRINITY HEALTH CORPORATION
 
 
No
(23) HOSPICE OF NORTH IOWA

232 SECOND STREET SE

MASON CITY,IA504016208
42-1173708 		HOSPICE HEALTH CARE SERVICES IA 501(C)(3) 7 MERCY HEALTH SERVICES-IOWA CORP
 
 
No
(24) HOSPICE OF WASHTENAW II

806 AIRPORT BLVD

ANN ARBOR,MI48108
38-3320707 		HOSPICE HEALTH CARE SERVICES MI 501(C)(3) 11, TYPE I TRINITY HEALTH-MICHIGAN
 
 
No
(25) HPCN

1675 LEAHY STREET

MUSKEGON,MI49442
30-0207909 		HEALTHCARE SERVICES MI 501(C)(3) 11, TYPE II MERCY HEALTH PARTNERS
 
 
No
(26) IHA HEALTH SERVICES CORPORATION

24 FRANK LLOYD WRIGHT DR LOBBY J

ANN ARBOR,MI48106
38-3316559 		PROVIDES OFFICE-BASED MEDICAL CARE MI 501(C)(3) 9 TRINITY HEALTH-MICHIGAN
 
 
No
(27) LAKESHORE COMMUNITY HOSPITAL INC

72 S STATE STREET

SHELBY,MI494551228
38-2549295 		ACUTE HEALTHCARE SERVICES MI 501(C)(3) 3 MERCY HEALTH PARTNERS
 
 
No
(28) LOYOLA UNIVERSITY HEALTH SYSTEM

2160 SOUTH FIRST AVENUE

MAYWOOD,IL60153
36-3342448 		HEALTHCARE SYSTEM MANAGEMENT AND SUPPORT IL 501(C)(3) 11, TYPE II TRINITY HEALTH CORPORATION
 
 
No
(29) LOYOLA UNIVERSITY MEDICAL CENTER

2160 SOUTH FIRST AVENUE

MAYWOOD,IL60153
36-4015560 		HEALTHCARE SERVICES IL 501(C)(3) 3 LOYOLA UNIVERSITY HEALTH SYSTEM
 
 
No
(30) MARIAN HOME HEALTHCARE

801 5TH STREET

SIOUX CITY,IA51101
38-3320705 		PROVIDE HOME HEALTH CARE SERVICES IA 501(C)(3) 11, TYPE I MERCY HEALTH SERVICES-IOWA CORP
 
 
No
(31) MCAULEY CLINIC CORPORATION

PO BOX 992

ANN ARBOR,MI48106
38-2561013 		HEALTHCARE SERVICES (FORMERLY) MI 501(C)(3) 3 CATHERINE MCAULEY HEALTH SERVICES CORP
 
 
No
(32) MERCY AMICARE HOME HEALTHCARE OAKLAND

281 ENTERPRISE COURT

BLOOMFIELD HILLS,MI483020312
38-3320698 		PROVIDE HOME HEALTH CARE SERVICES MI 501(C)(3) 11, TYPE I TRINITY HOME HEALTH SERVICES INC
 
 
No
(33) MERCY AMICARE HOME HEALTHCARE PORT HURON

505 HURON AVENUE

PORT HURON,MI48060
38-3320701 		PROVIDE HOME HEALTH CARE SERVICES MI 501(C)(3) 11, TYPE I TRINITY HOME HEALTH SERVICES INC
 
 
No
(34) MERCY FOUNDATION INC

2525 SOUTH MICHIGAN AVENUE

CHICAGO,IL60616
36-3227350 		SUPPORTS THE SERVICES OF RELATED HEALTH CARE SYSTEM IL 501(C)(3) 11, TYPE I MERCY HEALTH SYSTEM OF CHICAGO
 
 
No
(35) MERCY GENERAL HEALTH PARTNERS AMICARE HOMECARE

684 HARVEY STREET

MUSKEGON,MI49442
38-3321856 		PROVIDE HOME HEALTH CARE SERVICES MI 501(C)(3) 11, TYPE I TRINITY HOME HEALTH SERVICES INC
 
 
No
(36) MERCY HEALTH PARTNERS

1415 LEAHY STREET

MUSKEGON,MI49442
38-2589966 		HEALTHCARE SYSTEM SUPPORT MI 501(C)(3) 11, TYPE I TRINITY HEALTH-MICHIGAN
 
 
No
(37) MERCY HEALTH SERVICES - IOWA CORP

1000 4TH STREET SW

MASON CITY,IA50401
31-1373080 		HEALTHCARE SERVICES DE 501(C)(3) 3 TRINITY HEALTH-MICHIGAN
 
 
No
(38) MERCY HEALTH SYSTEM OF CHICAGO

2525 SOUTH MICHIGAN AVENUE

CHICAGO,IL60616
36-3163327 		HEALTHCARE SYSTEM MANAGEMENT AND SUPPORT IL 501(C)(3) 11, TYPE I TRINITY HEALTH CORPORATION
 
 
No
(39) MERCY HEALTH SYSTEM OF CHICAGO LIABILITY SELF INSURANCE TRUST

BK OF AMERICA 231 S LASALLE

CHICAGO,IL60697
91-2092113 		SELF INSURANCE FOR PROFESSIONAL AND COMPREHENSIVE LIABILITY IL 501(C)(3) 11, TYPE III-FI MERCY HEALTH SYSTEM OF CHICAGO
 
 
No
(40) MERCY HEALTHCARE FOUNDATION

1410 N 4TH ST

CLINTON,IA52732
42-1316126 		FUNDRAISING AND FINANCIAL ASSISTANCE FOR HOSPITAL CHARITABLE SERVICES IA 501(C)(3) 11, TYPE I MERCY MEDICAL CENTER-CLINTON
 
 
No
(41) MERCY HOSPITAL AND MEDICAL CENTER

2525 SOUTH MICHIGAN AVENUE

CHICAGO,IL60616
36-2170152 		HEALTHCARE SERVICES IL 501(C)(3) 3 MERCY HEALTH SYSTEM OF CHICAGO
 
 
No
(42) MERCY HOSPITAL CADILLAC FOUNDATION

400 HOBART

CADILLAC,MI496012331
20-3357131 		SUPPORT THE SERVICES OF RELATED HOSPITAL MI 501(C)(3) 11, TYPE I TRINITY HEALTH-MICHIGAN
 
 
No
(43) MERCY HOSPITAL GIFT SHOP

2601 ELECTRIC AVE

PORT HURON,MI48060
38-1630480 		VOLUNTEER SERVICE AUXILIARY MI 501(C)(3) 11, TYPE I TRINITY HEALTH-MICHIGAN
 
 
No
(44) MERCY MEDICAL CENTER - CLINTON INC

1410 NORTH 4TH ST

CLINTON,IA527322940
42-1336618 		TO PROVIDE QUALITY HEALTH CARE DE 501(C)(3) 3 MERCY HEALTH SERVICES-IOWA CORP
 
 
No
(45) MERCY MEDICAL CENTER - SIOUX CITY FOUNDATION

801 5TH STREET

SIOUX CITY,IA51102
14-1880022 		SUPPORT THE SERVICES OF RELATED HOSPITAL IA 501(C)(3) 7 MERCY HEALTH SERVICES-IOWA CORP
 
 
No
(46) MERCY MEDICAL CENTER FOUNDATION - NORTH IOWA

1000 4TH STREET SW

MASON CITY,IA504012800
42-1229151 		SUPPORT THE SERVICES OF RELATED HOSPITAL IA 501(C)(3) 11, TYPE III-FI N/A
 
No
(47) MERCY NORTH HOMECARE AND HOSPICE

7985 MACKINAW TRAIL

CADILLAC,MI49601
38-3313897 		HOME HEALTH AND HOSPICE SERVICES MI 501(C)(3) 11, TYPE I TRINITY HOME HEALTH SERVICES INC
 
 
No
(48) MERCY PHYSICIAN GROUP INC

1512 12TH AVENUE ROAD

NAMPA,ID83686
20-8192593 		TO PROVIDE QUALITY HEALTH CARE ID 501(C)(3) 9 SAINT ALPHONSUS MEDICAL CENTER-NAMPA
 
 
No
(49) MERCY SERVICES FOR AGING NON-PROFIT HOUSING CORPORATION

PO BOX 9184

FARMINGTON HILLS,MI483339184
38-2719605 		PROVIDES LONG-TERM CARE FOR THE ELDERLY MI 501(C)(3) 11, TYPE II TRINITY CONTINUING CARE SERVICES INC
 
 
No
(50) MIDWEST MEDFLIGHT

1300 VICTORS WAY

ANN ARBOR,MI48108
38-2684671 		AEROMEDICAL TRANSPORT MI 501(C)(3) 9 TRINITY HEALTH-MICHIGAN
 
 
No
(51) MOUNT CARMEL CARE CONTINUUM SERVICES CORP

793 WEST STATE STREET

COLUMBUS,OH43222
31-1126211 		COOPERATIVE HOSPITAL SERVICE ORGANIZATION OH 501(C)(3) 3 MOUNT CARMEL HEALTH SYSTEM
 
 
No
(52) MOUNT CARMEL COLLEGE OF NURSING

6150 EAST BROAD STREET

COLUMBUS,OH43213
31-1308555 		COLLEGE OF NURSING OH 501(C)(3) 2 MOUNT CARMEL HEALTH
 
 
No
(53) MOUNT CARMEL HEALTH

6150 EAST BROAD STREET

COLUMBUS,OH43213
31-4379602 		HEALTHCARE SERVICES OH 501(C)(3) 3 MOUNT CARMEL HEALTH SYSTEM
 
 
No
(54) MOUNT CARMEL HEALTH INSURANCE COMPANY

6150 EAST BROAD STREET

COLUMBUS,OH43213
25-1912781 		HEALTH INSURANCE OH 501(C)(4) N/A MOUNT CARMEL HEALTH SYSTEM
 
 
No
(55) MOUNT CARMEL HEALTH PLAN INC

6150 EAST BROAD STREET

COLUMBUS,OH43213
31-1471229 		MEDICARE HMO FOR SENIORS OH 501(C)(4) N/A MOUNT CARMEL HEALTH SYSTEM
 
 
No
(56) MOUNT CARMEL HEALTH SYSTEM

6150 EAST BROAD STREET

COLUMBUS,OH43213
31-1439334 		HEALTHCARE SYSTEM MANAGEMENT AND SUPPORT OH 501(C)(3) 11, TYPE I TRINITY HEALTH CORPORATION
 
 
No
(57) MOUNT CARMEL HEALTH SYSTEM FOUNDATION

6150 EAST BROAD STREET

COLUMBUS,OH43213
31-1113966 		SUPPORT THE SERVICES OF RELATED HOSPITAL OH 501(C)(3) 11, TYPE I MOUNT CARMEL HEALTH SYSTEM
 
 
No
(58) MOUNT CARMEL HOME CARE LLC

1144 DUBLIN ROAD SUITE B

COLUMBUS,OH43215
26-2729300 		PROVIDE HOME HEALTH CARE SERVICES OH 501(C)(3) 9 TRINITY HOME HEALTH SERVICES INC
 
 
No
(59) MOUNT CARMEL NEW ALBANY SURGICAL HOSPITAL

7333 SMITHS MILL RD

NEW ALBANY,OH43054
87-0790288 		HEALTHCARE SERVICES OH 501(C)(3) 3 MOUNT CARMEL HEALTH SYSTEM
 
 
No
(60) MRI MOBILE SERVICES OF WEST MICHIGAN

1820 - 44TH STREET

KENTWOOD,MI49508
38-3073745 		OPERATE MAGNETIC IMAGING RESONANCE (FORMERLY) MI 501(C)(3) 9 TRINITY HEALTH-MICHIGAN
 
 
No
(61) MUSKEGON COMMUNITY HEALTH PROJECT

565 W WESTERN AVENUE

MUSKEGON,MI49440
91-1932918 		FACILITATE AND COORDINATE HEALTHCARE AND RELATED SERVICES MI 501(C)(3) 7 MERCY HEALTH PARTNERS
 
 
No
(62) OAKLAND MERCY HOSPITAL

601 EAST 2ND STREET

OAKLAND,NE68045
20-8072234 		HEALTHCARE SERVICES NE 501(C)(3) 3 MERCY HEALTH SERVICES-IOWA CORP
 
 
No
(63) OAKLAND MERCY HOSPITAL FOUNDATION

601 E 2ND STREET

OAKLAND,NE68045
31-1678345 		SUPPORTS SERVICES OF RELATED HOSPITAL NE 501(C)(3) 11, TYPE III-FI OAKLAND MERCY HOSPITAL
 
 
No
(64) PORT HURON MERCY FAMILY CARE INC

2601 ELECTRIC AVE

PORT HURON,MI48060
20-1855647 		HEALTHCARE SERVICES MI 501(C)(3) 11, TYPE I TRINITY HEALTH-MICHIGAN
 
 
No
(65) PROFESSIONAL MED TEAM

965 FORK STREET

MUSKEGON,MI494423257
38-2638284 		MEDICAL CARE, TRANSPORTATION AND EDUCATION MI 501(C)(3) 9 TRINITY HEALTH-MICHIGAN
 
 
No
(66) PROFESSIONAL OFFICE CORPORATION

1303 EAST HERNDON AVE

FRESNO,CA93720
94-2839324 		HEALTHCARE SERVICES CA 501(C)(3) 11, TYPE I SAINT AGNES MEDICAL CENTER
 
 
No
(67) SAINT AGNES MEDICAL CENTER

1303 EAST HERNDON AVE

FRESNO,CA93720
94-1437713 		HEALTHCARE SERVICES CA 501(C)(3) 3 TRINITY HEALTH CORPORATION
 
 
No
(68) SAINT ALPHONSUS BUILDING COMPANY INC

1055 NORTH CURTIS RD

BOISE,ID83706
82-0401011 		SUPPORTS SERVICES OF RELATED HOSPITAL ID 501(C)(3) 11, TYPE I SAINT ALPHONSUS REGIONAL MEDICAL CENTER INC
 
 
No
(69) SAINT ALPHONSUS DIVERSIFIED CARE INC

1055 NORTH CURTIS RD

BOISE,ID83706
94-3028978 		SUPPORTS SERVICES OF RELATED HOSPITAL ID 501(C)(3) 11, TYPE I SAINT ALPHONSUS REGIONAL MEDICAL CENTER INC
 
 
No
(70) SAINT ALPHONSUS FOUNDATION-BAKER CITY INC

3325 POCAHONTAS ROAD

BAKER CITY,OR97814
94-3164869 		SUPPORT THE SERVICES OF RELATED HOSPITAL OR 501(C)(3) 7 SAINT ALPHONSUS MEDICAL CENTER - BAKER CITY
 
 
No
(71) SAINT ALPHONSUS FOUNDATION-ONTARIO INC

351 SW 9TH STREET

ONTARIO,OR97914
20-2683560 		SUPPORT THE SERVICES OF RELATED HOSPITAL OR 501(C)(3) 11, TYPE I SAINT ALPHONSUS MEDICAL CENTER-ONTARIO
 
 
No
(72) SAINT ALPHONSUS HEALTH SYSTEM INC

1055 N CURTIS ROAD

BOISE,ID83706
27-1929502 		HEALTHCARE SYSTEM MANAGEMENT AND SUPPORT ID 501(C)(3) 11, TYPE I TRINITY HEALTH CORPORATION
 
 
No
(73) SAINT ALPHONSUS MEDICAL CENTER-BAKER CITY

3325 POCAHONTAS ROAD

BAKER CITY,OR97814
27-1790052 		TO PROVIDE QUALITY HEALTH CARE OR 501(C)(3) 3 SAINT ALPHONSUS HEALTH SYSTEM INC
 
 
No
(74) SAINT ALPHONSUS MEDICAL CENTER-NAMPA

1512 12TH AVENUE ROAD

NAMPA,ID83686
82-0200896 		TO PROVIDE QUALITY HEALTH CARE ID 501(C)(3) 3 SAINT ALPHONSUS HEALTH SYSTEM INC
 
 
No
(75) SAINT ALPHONSUS MEDICAL CENTER-NAMPA HEALTH FOUNDATION INC

1512 12TH AVENUE ROAD

NAMPA,ID83686
26-1737256 		SUPPORT THE SERVICES OF RELATED HOSPITAL ID 501(C)(3) 7 SAINT ALPHONSUS MEDICAL CENTER-NAMPA
 
 
No
(76) SAINT ALPHONSUS MEDICAL CENTER-ONTARIO

351 SW 9TH STREET

ONTARIO,OR97914
27-1789847 		TO PROVIDE QUALITY HEALTH CARE OR 501(C)(3) 3 SAINT ALPHONSUS HEALTH SYSTEM INC
 
 
No
(77) SAINT ALPHONSUS REGIONAL MEDICAL CENTER

1055 NORTH CURTIS RD

BOISE,ID83706
82-0200895 		HEALTHCARE SERVICES ID 501(C)(3) 3 SAINT ALPHONSUS HEALTH SYSTEM INC
 
 
No
(78) SAINT JOSEPH REGIONAL MEDICAL CENTER - PLYMOUTH CAMPUS INC

1915 LAKE AVENUE PO BOX 670

PLYMOUTH,IN46563
35-1142669 		HEALTHCARE SERVICES IN 501(C)(3) 3 SAINT JOSEPH REGIONAL MEDICAL CENTER INC
 
 
No
(79) SAINT JOSEPH REGIONAL MEDICAL CENTER - SOUTH BEND CAMPUS INC

PO BOX 1935

SOUTH BEND,IN466341935
35-0868157 		HEALTHCARE SERVICES IN 501(C)(3) 3 SAINT JOSEPH REGIONAL MEDICAL CENTER INC
 
 
No
(80) SAINT JOSEPH REGIONAL MEDICAL CENTER MISHAWAKA AUXILIARY INC

5215 HOLY CROSS PARKWAY

MISHAWAKA,IN46545
35-6033285 		HOSPITAL SERVICE AUXILIARY IN 501(C)(4) N/A SAINT JOSEPH REGIONAL MEDICAL CENTER-S BEND
 
 
No
(81) SAINT JOSEPH REGIONAL MEDICAL CENTER PLYMOUTH AUXILIARY INC

1915 LAKE AVENUE

PLYMOUTH,IN46563
35-6043563 		HOSPITAL SERVICE AUXILIARY IN 501(C)(3) 11, TYPE II SAINT JOSEPH REGIONAL MEDICAL CENTER-PLYMOUTH
 
 
No
(82) SAINT JOSEPH REGIONAL MEDICAL CENTER INC

801 EAST LASALLE AVE

SOUTH BEND,IN46617
35-1568821 		HEALTHCARE SYSTEM MANAGEMENT AND SUPPORT IN 501(C)(3) 11, TYPE I TRINITY HEALTH CORPORATION
 
 
No
(83) SAINT JOSEPH'S TOWER INC

PO BOX 9184

FARMINGTON HILLS,MI483339184
31-1040468 		PROVIDES HOUSING FOR LOW INCOME ELDERLY INDIVIDUALS IN 501(C)(3) 9 TRINITY CONTINUING CARE SERVICES-INDIANA
 
 
No
(84) SAINT MARY'S AMICARE HOME HEALTHCARE

1430 MONROE NW

GRAND RAPIDS,MI49505
38-3320700 		PROVIDE HOME HEALTH CARE SERVICES MI 501(C)(3) 11, TYPE I TRINITY HOME HEALTH SERVICES INC
 
 
No
(85) SAINT MARY'S FOUNDATION (FKA SAINT MARY'S DORAN FOUNDATION)

200 JEFFERSON ST SE

GRAND RAPIDS,MI49503
38-1779602 		SUPPORTS SERVICES OF RELATED HOSPITAL MI 501(C)(3) 7 TRINITY HEALTH-MICHIGAN
 
 
No
(86) ST JOSEPH MERCY OAKLAND FOUNDATION

44405 WOODWARD AVE

PONTIAC,MI48341
35-2356789 		SUPPORTS SERVICES OF RELATED HOSPITAL MI 501(C)(3) 11, TYPE I TRINITY HEALTH-MICHIGAN
 
 
No
(87) ST ANN'S HOSPITAL

500 SOUTH CLEVELAND AVE

WESTERVILLE,OH43081
31-4412701 		HEALTHCARE SERVICES OH 501(C)(3) 3 MOUNT CARMEL HEALTH SYSTEM
 
 
No
(88) THE FOUNDATION OF SAINT JOSEPH REGIONAL MEDICAL CENTER

4215 EDISON LAKES PARKWAY

MISHAWAKA,IN46545
35-1654543 		SUPPORTS SERVICES OF RELATED HOSPITAL IN 501(C)(3) 11, TYPE I SAINT JOSEPH REGIONAL MEDICAL CENTER INC
 
 
No
(89) TRI-HOSPITAL MRI CENTER

4190 24TH AVENUE

FORT GRATIOT,MI48054
38-2884297 		MRI SERVICES MI 501(C)(3) 3 TRINITY HEALTH-MICHIGAN
 
 
No
(90) TRINITY CONTINUING CARE SERVICES

PO BOX 9184

FARMINGTON HILLS,MI483339184
38-2559656 		MANAGEMENT SERVICES FOR LONG TERM CARE AND SENIOR LIVING FACILITIES MI 501(C)(3) 11, TYPE I TRINITY HEALTH CORPORATION
 
 
No
(91) TRINITY CONTINUING CARE SERVICES - INDIANA INC

PO BOX 9184

FARMINGTON HILLS,MI483339184
93-0907047 		PROVIDES LONG-TERM CARE AND RESIDENTIAL HOUSING IN 501(C)(3) 9 TRINITY CONTINUING CARE SERVICES
 
 
No
(92) TRINITY HEALTH - MICHIGAN

20555 VICTOR PARKWAY

LIVONIA,MI48152
38-2113393 		HEALTHCARE SERVICES MI 501(C)(3) 3 TRINITY HEALTH CORPORATION
 
 
No
(93) TRINITY HEALTH CORPORATION

20555 VICTOR PARKWAY

LIVONIA,MI48152
35-1443425 		HEALTHCARE SYSTEM MANAGEMENT AND SUPPORT IN 501(C)(3) 11, TYPE I N/A
 
No
(94) TRINITY HEALTH INTERNATIONAL

20555 VICTOR PARKWAY

LIVONIA,MI48152
42-1253527 		HEALTHCARE TRAINING AND SUPPORT SERVICES MI 501(C)(3) 11, TYPE I TRINITY HEALTH CORPORATION
 
 
No
(95) TRINITY HEALTH WELFARE BENEFIT TRUST

20555 VICTOR PARKWAY

LIVONIA,MI48152
20-8151733 		RETIREE MEDICAL AND RETIREE LIFE INSURANCE COVERAGE MI 501(C)(9) N/A TRINITY HEALTH CORPORATION
 
 
No
(96) TRINITY HOME HEALTH SERVICES INC

17410 COLLEGE PARKWAY

LIVONIA,MI48152
38-2621935 		HOME HEALTH CARE SYSTEM MANAGEMENT SERVICES MI 501(C)(3) 11, TYPE I TRINITY HEALTH CORPORATION
 
 
No
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 2
Part III
Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.)
(a)
Name, address, and EIN of
related organization



 		(b)
Primary activity




 		(c)
Legal
domicile
(state or foreign
country)


 		(d)
Direct controlling
entity



 		(e)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(f)
Share of total income




 		(g)
Share of end-of-year
assets



 		(h)
Disproprtionate allocations?




 		(i)
Code V—UBI
amount in box 20 of
Schedule K-1
(Form 1065)
 		(j)
General or
managing
partner?



 		(k)
Percentage
ownership
Yes No Yes No
(1) ADVENT REHABILITATION LLC

607 DEWEY AVENUE SUITE 300
GRAND RAPIDS,MI49504
38-3306673 		REHABILITATION THERAPY SERVICES MI N/A
 N/A       No     No  
(2) BIG RUN MEDICAL OFFICE BUILDING LIMITED PARTNERSHIP

793 W STATE STREET
COLUMBUS,OH43222
31-1608125 		MEDICAL OFFICE BUILDING RENTAL OH N/A
 N/A       No     No  
(3) CENTER FOR DIGESTIVE CARE LLC

5300 ELLIOTT DRIVE
YPSILANTI,MI48197
03-0447062 		PROVIDE GASTROINTESTINAL SERVICES MI N/A
 N/A       No     No  
(4) CENTRAL OHIO SLEEP MEDICINE LTD

6150 EAST BROAD STREET
COLUMBUS,OH43213
31-1701029 		SLEEP MEDICINE SERVICES OH N/A
 N/A       No     No  
(5) CLINTON IMAGING SERVICES LLC

615 VALLEY VIEW DR STE 202
MOLINE,IL61265
41-2044739 		MRI DIAGNOSTIC SERVICES IA N/A
 N/A       No     No  
(6) FOREST PARK IMAGING LLC

1000 4TH STREET SW
MASON CITY,IA50401
13-4365966 		X-RAY AND MAMMOGRAPHY SERVICES IA N/A
 N/A       No     No  
(7) FRANCES WARDE MEDICAL LABORATORY

300 WEST TEXTILE ROAD
ANN ARBOR,MI48104
38-2648446 		LABORATORY MI N/A
 N/A       No     No  
(8) FRESNO IMAGING CENTER

1303 E HERNDON AVE
FRESNO,CA93720
77-0363563 		DIAGNOSTIC IMAGING CA N/A
 N/A       No     No  
(9) HAWARDEN REGIONAL HEALTH CLINICS LLC

1122 AVENUE L
HAWARDEN,IA51023
20-1444339 		MEDICAL CLINIC IA N/A
 N/A       No     No  
(10) IDAHO GYNONCOLOGY SERVICES LLC

1055 N CURTIS RD
BOISE,ID83706
20-2975807 		PROVIDE GYN ONCOLOGY SERVICES ID N/A
 N/A       No     No  
(11) INTERMOUNTAIN MEDICAL IMAGING LLC

877 WEST MAIN ST STE 603
BOISE,ID83702
82-0514422 		PROVIDE IMAGING SERVICES ID N/A
 N/A       No     No  
(12) LOYOLA AMBULATORY SURGERY CENTER

1S224 SUMMIT AVE STE 201
OAKBROOK TERRACE,IL60181
36-4119522 		SURGICAL SERVICES IL N/A
 N/A       No     No  
(13) MAGNETIC RESONANCE SERVICES PARTNERSHIP

1416 SIXTH STREET SW
MASON CITY,IA50401
42-1328388 		MRI SERVICES IA N/A
 N/A       No     No  
(14) MASON CITY AMBULATORY SURGERY CENTER LLC

990 4TH STREET SW
MASON CITY,IA50401
20-1960348 		SURGERY-SAME DAY IA N/A
 N/A       No     No  
(15) MCE MOB IV LIMITED PARTNERSHIP

793 W STATE STREET
COLUMBUS,OH43222
42-1544707 		MEDICAL OFFICE BUILDING RENTAL OH N/A
 N/A       No     No  
(16) MCMC POB III LIMITED PARTNERSHIP

793 W STATE STREET
COLUMBUS,OH43222
31-1392994 		MEDICAL OFFICE BUILDING RENTAL OH N/A
 N/A       No     No  
(17) MEDILUCENT MOB I

793 W STATE STREET
COLUMBUS,OH43222
20-4911370 		MEDICAL OFFICE BUILDING RENTAL OH N/A
 N/A       No     No  
(18) MERCY ADVANCED MRI LLC

2525 SOUTH MICHIGAN AVE
CHICAGO,IL60616
26-2116721 		SUBLEASE MRI EQUIPMENT IL N/A
 N/A       No     No  
(19) MERCY HEART & VASCULAR LLC

2525 SOUTH MICHIGAN AVE
CHICAGO,IL60616
20-5272726 		SUBLEASE CT EQUIPMENT IL N/A
 N/A       No     No  
(20) MERCY HEART CTR OP SERVICES LLC

1000 4TH STREET SW
MASON CITY,IA50401
13-4237594 		CARDIOVASCULAR SERVICES IA N/A
 N/A       No     No  
(21) MERCY OUTPATIENT SURGERY CENTER LLC

1512 12TH AVENUE ROAD
NAMPA,ID83686
84-1380439 		OUTPATIENT SURGERY ID N/A
 N/A       No     No  
(22) MICHIANA HEALTH INFORMATION NETWORK LLC

215 WEST MADISON STREET
SOUTH BEND,IN46601
35-2050128 		COMMUNITY BASED CLINICAL INFO SYS & DATA DEPOSITORY IN N/A
 N/A       No     No  
(23) MOUNT CARMEL EAST POB III LIMITED PARTNERSHIP

793 W STATE STREET
COLUMBUS,OH43222
31-1369473 		MEDICAL OFFICE BUILDING RENTAL OH N/A
 N/A       No     No  
(24) NEWCO AMBULATORY SURGERY CTR LLP

4190 24TH AVENUE
FORT GRATIOT,MI48059
30-0136708 		OUTPATIENT SURGERY CENTER MI N/A
 N/A       No     No  
(25) RIVERVIEW MEDICAL OFFICE BUILDING LIMITED PARTNERSHIP

793 W STATE STREET
COLUMBUS,OH43222
31-1531135 		MEDICAL OFFICE BUILDING RENTAL OH N/A
 N/A       No     No  
(26) SARMED OUTPATIENT PHARMACY LLC

999 N CURTIS RD STE 102
BOISE,ID83706
51-0483218 		PHARMACY ID N/A
 N/A       No     No  
(27) SIXTY FOURTH STREET LLC

2373 64TH ST STE 2200
BYRON CENTER,MI49315
20-2443646 		PROVIDE OUTPATIENT SURGICAL CARE MI N/A
 N/A       No     No  
(28) ST ALPHONSUS CALDWELL CANCER CTR LLC

3123 MEDICAL DR
CALDWELL,ID83605
82-0526861 		RADIATION ONCOLOGY ID N/A
 N/A       No     No  
(29) ST ANN'S MEDICAL OFFICE BLDG II LIMITED PARTNERSHIP

793 W STATE STREET
COLUMBUS,OH43222
31-1603660 		MEDICAL OFFICE BUILDING RENTAL OH N/A
 N/A       No     No  
(30) TAMARACK MEDICAL CLINIC LLC

610 VILLAGE DRIVE
DONNELLY,ID83615
20-1637921 		OUTPATIENT MEDICAL SERVICES ID N/A
 N/A       No     No  
(31) WESTAR MEDICAL OFFICE BUILDING LIMITED PARTNERSHIP

793 W STATE STREET
COLUMBUS,OH43222
31-1784409 		MEDICAL OFFICE BUILDING RENTAL OH N/A
 N/A       No     No  
(32) WOODLAND IMAGING CENTER LLC

5301 E HURON RIVER DR
ANN ARBOR,MI48106
76-0820959 		RADIOLOGY/IMAGING MI N/A
 N/A       No     No  
Part IV
Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.)
(a)
Name, address, and EIN of related organization



 		(b)
Primary activity



 		(c)
Legal domicile
(state or
foreign
country)
 		(d)
Direct controlling
entity


 		(e)
Type of entity
(C corp, S corp,
or trust)

 		(f)
Share of total income



 		(g)
Share of
end-of-year
assets

 		(h)
Percentage
ownership
(1) COMMUNITY HEALTH VENTURES INC
565 W WESTERN AVE
MUSKEGON,MI49440
38-3522260 		SOFTWARE MARKETING MI N/A
 C      
(2) GOTTLIEB MANAGEMENT SERVICES INC
701 W NORTH AVE
MELROSE PARK,IL60160
36-3330529 		MANAGEMENT SERVICES IL N/A
 C      
(3) HACKLEY HEALTH MANAGEMENT CENTER
1415 LEAHY ST
MUSKEGON,MI49442
38-2961814 		WEIGHT MANAGEMENT MI N/A
 C      
(4) HACKLEY HEALTH VENTURES INC
1415 LEAHY ST
MUSKEGON,MI49442
38-2589959 		OTHER MEDICAL SERVICES MI N/A
 C      
(5) HACKLEY HEALTHCARE EQUIPMENT
1415 LEAHY ST
MUSKEGON,MI49442
38-2578569 		HOME MEDICAL EQUIPMENT MI N/A
 C      
(6) HACKLEY PROFESSIONAL CENTER
1415 LEAHY ST
MUSKEGON,MI49442
38-3024797 		REAL ESTATE RENTAL MI N/A
 C      
(7) HACKLEY PROFESSIONAL PHARMACY
1415 LEAHY ST
MUSKEGON,MI49442
38-2447870 		PHARMACY MI N/A
 C      
(8) HEF INC
1415 LEAHY ST
MUSKEGON,MI49442
38-3086401 		OFFICE STAFFING MI N/A
 C      
(9) HOLY CROSS PRIVATE HOME SERVICES CORP
11801 TECH ROAD
SILVER SPRING,MD20904
52-1986562 		HOME CARE SERVICES MD N/A
 C      
(10) HPC CO-OWNERS ASSOCIATION
1700 CLINTON
MUSKEGON,MI49442
27-0734448 		CONDOMINIUM ASSOCIATION MI N/A
 C      
(11) HURON ARBOR CORPORATION
5301 EAST HURON RIVER DR PO BOX 992
ANN ARBOR,MI48106
38-2475644 		PROVIDES OFFICE RENTAL SPACE MI N/A
 C      
(12) IHA AFFILIATION CORPORATION
24 FRANK LLOYD WRIGHT DR LOBBY J
ANN ARBOR,MI48106
38-3188895 		MEDICAL MANAGEMENT MI N/A
 C      
(13) LOYOLA UNIVERSITY OF CHICAGO INSURANCE CO LTD
23 LIME TREE BAY AVENUE
GRAND CAYMAN    
CJ
PROVISION OF INSURANCE COVERAGE CJ N/A
 C      
(14) MARYLAND CARE GROUP INC
11801 TECH ROAD
SILVER SPRING,MD20904
52-1815313 		HEALTHCARE HOLDING MD N/A
 C      
(15) MEDNOW INC
1512 12TH AVENUE ROAD
NAMPA,ID83686
82-0389927 		OUTPATIENT PHARMACY ID N/A
 C      
(16) MERCY MEDICAL SERVICES
801 5TH STREET
SIOUX CITY,IA51101
42-1283849 		PRIMARY CARE PHYSICIANS IA N/A
 C      
(17) MERCY SERVICES CORPORATION
2525 SOUTH MICHIGAN AVENUE
CHICAGO,IL60616
36-3227348 		DORMANT IL N/A
 C      
(18) MICHIGAN ATHLETIC CLUB
2500 BURTON
GRAND RAPIDS,MI49546
38-2647304 		ATHLETIC CLUB MI N/A
 C      
(19) MOUNT CARMEL BEHAVIORAL HEALTHCARE SERVICES INC
6150 EAST BROAD STREET
COLUMBUS,OH43213
31-0971510 		BEHAVIORAL HEALTHCARE SERVICES OH N/A
 C      
(20) MOUNT CARMEL HEALTH PROVIDERS INC
6150 EAST BROAD STREET
COLUMBUS,OH43213
31-1382442 		MEDICAL SERVICES OH N/A
 C      
(21) NORTH IOWA MERCY MEDICAL SERVICES INC
1000 4TH ST SW
MASON CITY,IA50401
42-1382308 		MEDICAL SERVICES IA N/A
 C      
(22) PRIORITY PLUS OF CALIFORNIA
PO BOX 27230
FRESNO,CA93729
77-0395267 		FORMERLY HLTH MGMT NOW DISCONTINUED OPERATIONS CA N/A
 C      
(23) SAINT ALPHONSUS PHYSICIANS PA
1055 NORTH CURTIS ROAD
BOISE,ID837061370
33-1078261 		PHYSICIANS ID N/A
 C      
(24) SAINT MARY'S HEALTH MANAGEMENT COMPANY
1640 EAST PARIS SE
GRAND RAPIDS,MI49546
38-3450733 		ATHLETIC CLUB MI N/A
 C      
(25) SURGERY CENTER FINANCING CORPORATION
6150 EAST BROAD STREET
COLUMBUS,OH43213
31-1531102 		FINANCE, INSURANCE AND REAL ESTATE OH N/A
 C      
(26) THRE SERVICES LLC
20555 VICTOR PARKWAY
LIVONIA,MI48152
45-2603654 		REAL ESTATE BROKERAGE SERVICES MI N/A
 C      
(27) TRINITY HEALTH EMPLOYEE BENEFIT TRUST
20555 VICTOR PARKWAY
LIVONIA,MI48152
38-3410377 		GRANTOR TRUST MI N/A
 T      
(28) VENZKE INSURANCE COMPANY LTD
PO BOX 1051 GRAND CAYMAN
GRAND CAYMAN    
CJ
98-0453602 		PROVISION OF INSURANCE COVERAGE CJ N/A
 C      
(29) WESTSHORE HEALTH NETWORK
1820 44TH STREET
KENTWOOD,MI49508
38-3280200 		PHYSICIAN HOSPITAL ORGANIZATION MI N/A
 C      
(30) WORKPLACE HEALTH OF GRAND HAVEN
1415 LEAHY ST
MUSKEGON,MI49442
38-3112035 		OCCUPATIONAL HEALTH MI N/A
 C      
Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 3
Part V
Transactions With Related Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35, 35A, or 36.)
Note. Complete line 1 if any entity is listed in Parts II, III or IV.
Yes
No
1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a Receipt of (i) interest (ii) annuities (iii) royalties (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .
1a
 
No
b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
Yes
 
c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c
Yes
 
d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1d
 
No
e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1e
 
No
f Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
No
g Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
 
No
j Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
Yes
 
k Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .
1k
Yes
 
l Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .
1l
Yes
 
m Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .
1m
 
No
n Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1n
 
No
o Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
Yes
 
p Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
 
No
q Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
 
No
r Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
 
No
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of other organization 		(b)
Transaction
type(a-r) 		(c)
Amount involved 		(d)
Method of determining amount involved
(1) MERCY HEALTH SERVICES-IOWA CORP

 B 1,336,260 PER BOOKS
(2) MERCY HEALTH SERVICES-IOWA CORP

 C 243,668 PER BOOKS
(3) MERCY HEALTH SERVICES-IOWA CORP

 L 213,908 PER BOOKS
(4) BAUM HARMON MERCY HOSPITAL

 B 56,659 PER BOOKS
(5)
(6)
Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 37.)
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity 		(b)
Primary activity 		(c)
Legal domicile
(state or foreign
country) 		(d)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(e)
Are all
partners
section
501(c)(3)
organizations? 		(f)
Share of total income




 		(g)
Share of
end-of-year
assets 		(h)
Disproprtionate allocations? 		(i)
Code V—UBI
amount in box
20 of Schedule K-1
(Form 1065) 		(j)
General or
managing
partner? 		(k)
Percentage
ownership
Yes No Yes No Yes No






























Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 5
Part VII
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule R (see instructions).
Identifier Return Reference Explanation
Additional Data


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