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
ST CLOUD HOSPITAL
 
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
1406 SIXTH AVENUE NORTH
 
Room/suite
City or town, state or country, and ZIP + 4
ST CLOUD, MN563031901
D Employer identification number

41-0695596
E Telephone number

G Gross receipts $ 687,464,484
F Name and address of principal officer:
Craig Broman
1406 Sixth Ave North
St Cloud,MN563031901
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
WWW.CENTRACARE.COM
H(a)
Is this a group return for
affiliates?
H(b)
Are all affiliates included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet0928
K Form of organization:
 
L Year of formation: 1962
M State of legal domicile: MN
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: AS A CATHOLIC REGIONAL HOSPITAL, WE IMPROVE THE HEALTH AND QUALITY OF LIFE FOR THE PEOPLE WE SERVE IN A MANNER THAT REFLECTS THE HEALING MISSION OF JESUS.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a)..... 3 18
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 5,637
6 Total number of volunteers (estimate if necessary) .... 6 1,171
7a Total unrelated business revenue from Part VIII, column (C), line 12 .. 7a 345,242
b Net unrelated business taxable income from Form 990-T, line 34 .. 7b  
Revenues; Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 3,250,024 2,730,011
9 Program service revenue (Part VIII, line 2g) ......... 628,670,715 652,918,119
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 17,564,262 20,707,719
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 7,878,225 10,039,883
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 657,363,226 686,395,732
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 3,150,317 3,076,305
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) 310,961,098 327,824,130
16a Professional fundraising fees (Part IX, column (A), line 11e)..... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet19,936    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f).... 261,023,346 270,378,997
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 575,134,761 601,279,432
19 Revenue less expenses. Subtract line 18 from line 12....... 82,228,465 85,116,300
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 906,748,676 931,948,155
21 Total liabilities (Part X, line 26)............. 484,422,084 524,782,230
22 Net assets or fund balances. Subtract line 21 from line 20..... 422,326,592 407,165,925
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: AS A CATHOLIC REGIONAL HOSPITAL, WE IMPROVE THE HEALTH AND QUALITY OF LIFE FOR THE PEOPLE WE SERVE IN A MANNER THAT REFLECTS THE HEALING MISSION OF JESUS.
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 $ 519,989,574 including grants of $ 3,076,305 ) (Revenue $ 658,490,646 )
THE ORGANIZATION PROVIDES SERVICES COMMON TO HOSPITAL AND LONG TERM CARE FACILITIES FOR THEIR PATIENTS AND RESIDENTS. SEE SCHEDULE O FOR THE COMMUNITY BENEFIT REPORT.
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$ 519,989,574
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 IClick to see attachment..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities? If “Yes,” complete Schedule C,
Part IIClick to see attachment.........................
4
Yes
 
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 IIIClick to see attachment........................
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
 
No
11
If the organization’s answer to any of the following questions is ‘Yes,’ then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable:
a
Did the organization report an amount for land, buildings, and equipment in Part X, 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
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part 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
 
No
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
 
No
20a
Did the organization operate one or more hospitals? If “Yes,” complete Schedule H..... Click to see attachment
20a
Yes
 
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. Click to see list of attachments
20b
Yes
 
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
Yes
 
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 M
29
 
No
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M............
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If “Yes,” complete Schedule N,
Part I...........................
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If “Yes,” complete Schedule N, Part II.......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If “Yes,” complete Schedule R, Part I........ Click to see attachment
33
 
No
34
Was the organization related to any tax-exempt or taxable entity? If “Yes,” complete Schedule R, 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
388
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
5,637
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?

Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file. (see instructions)
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?.............................
3a
Yes
 
b
If “Yes,” has it filed a Form 990-T for this year? If “No,” provide an explanation in Schedule O.....
3b
Yes
 
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
 
No
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
 
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?..........................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?...................
7g
 
 
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
18
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
 
No
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? .................
7a
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
Yes
 
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
Yes
 
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
MN
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
GREG KLUGHERZ
1406 SIXTH AVE NORTH
St Cloud,MN563031901
(320) 251-2700
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) CRAIG BROMAN
PRESIDENT
 40.0 X   X       689,674 0 143,009
(2) STEVE LARAWAY
DIRECTOR, CHAIR
 2.0 X           0 0 0
(3) PAUL DORSHER MD
DIRECTOR, VICE CHAIR
 2.0 X           0 370,752 58,097
(4) KEVIN SMITH MD
DIRECTOR, CHIEF OF STAFF
 2.0 X           8,219 0 0
(5) ANTHONY AKUBE ED D
DIRECTOR
 2.0 X           0 0 0
(6) JOAN B VOLKMUTH
DIRECTOR
 2.0 X           0 0 0
(7) TERESA BOHNEN
DIRECTOR
 2.0 X           0 0 0
(8) CHRISTOPHER COBORN
DIRECTOR
 2.0 X           0 0 0
(9) RONALD HANSON MD
DIRECTOR
 2.0 X           0 0 0
(10) CLAREEN HENNES OSB
DIRECTOR
 2.0 X           0 0 0
(11) MARY JACKLE OSB
DIRECTOR
 2.0 X           0 0 0
(12) FATHER THOMAS KNOBLACH
DIRECTOR
 2.0 X           0 0 0
(13) CINDA MELLOY MD
DIRECTOR
 2.0 X           6,645 206,864 36,709
(14) SANDY NEUTZLING
DIRECTOR
 2.0 X           0 0 0
(15) JAMES SCHLENNER
DIRECTOR
 2.0 X           0 0 0
(16) CHRIS TACL MD
DIRECTOR
 2.0 X           0 0 0
(17) TIM WENSMAN
DIRECTOR
 2.0 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) PASTOR THOMAS WRIGHT
DIRECTOR
 2.0 X           0 0 0
(19) GREG KLUGHERZ
TREASURER-CFO
 40.0     X       524,194 0 106,835
(20) PAUL HARRIS
SECRETARY
 40.0     X       0 307,893 76,532
(21) JIM DAVIS
VICE-PRESIDENT
 40.0       X     0 380,588 30,235
(22) DANIEL WHITLOCK MD
VICE-PRESIDENT
 40.0       X     614,043 0 33,248
(23) MARK MATTHIAS MD
VICE-PRESIDENT
 40.0       X     138,730 0 18,897
(24) CHARLES DOOLEY
VICE-PRESIDENT
 40.0       X     309,560 0 38,120
(25) LINDA CHMIELEWSKI
VICE-PRESIDENT
 40.0       X     402,867 0 79,315
(26) DUANE RASMUSSON
VICE-PRESIDENT
 40.0       X     328,625 0 75,124
(27) LINDA DOERR
VICE-PRESIDENT
 40.0       X     250,123 0 53,873
(28) ROBERT JOHNSON
DIRECTOR - CCVHC
 40.0       X     193,352 0 18,673
(29) AMY PORWOLL
VICE-PRESIDENT
 40.0       X     222,858 0 48,786
(30) JON BOWAR
PHYSICIAN
 40.0         X   479,549 0 47,221
(31) MARY LUNDE
PHYSICIAN
 40.0         X   429,689 0 42,734
(32) JOEL SPALDING
PHYSICIAN
 40.0         X   366,087 0 45,256
(33) JEFFREY CARLSON
PHYSICIAN
 40.0         X   311,055 0 0
(34) THOMAS MCNANLEY
PHYSICIAN
 40.0         X   475,130 0 23,762
(35) JOHN SECKINGER
FORMER CFO
 0.0           X 283,393 0 0
(36) JOHN FROBENIUS
FORMER CEO
 0.0           X 202,096 0 0
1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 6,235,889 1,266,097 976,426
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organizationMediumBullet239
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
Yes
 
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
CROTHALL HEALTHCARE
13028 COLLECTIONS CENTER DRIVE
CHICAGO,IL60693 		HOUSEKEEPING/LAUNDRY 3,369,159
ANESTHESIOLOGY ASSOCIATES
PO BOX 725
ST CLOUD,MN56302 		ANESTHESIOLOGY SVCS 2,123,643
MAXIT HEALTHCARE
PO BOX 2589
FT WAYNE,IN468012589 		INFORMATION SERVICES 1,880,894
CENTRACARE CLINIC
1200 SIXTH AVENUE NORTH
ST CLOUD,MN56303 		PHYSICIAN SERVICES 1,853,024
AEGIS THERAPIES
7160 DALLAS PARKWAY STE 400
PLANO,TX75024 		THERAPY SERVICES 1,263,481
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet42
Form 990 (2011)
Form 990 (2011)
Page 9
Part VIII
Statement of Revenue
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, Gifts, Grants and Other Similar Amounts 1a Federated campaigns..1a 41,233
b Membership dues....1b  
c Fundraising events....1c  
d Related organizations...1d 32,500
e Government grants (contributions)1e 2,566,426
f All other contributions, gifts, grants, and
similar amounts not included above1f 		89,852
g Noncash contributions included in lines 1a-1f:$  
h Total. Add lines 1a-1f.......MediumBullet 2,730,011
Program Service Revenue Business Code
2a PATIENT/RES SVCS 900,099 650,009,109 650,009,109    
b RENTAL INCOME 531,120 2,909,010 2,909,010    
c
d
e
f All other program service revenue .        
g Total. Add lines 2a–2f........MediumBullet 652,918,119
Other Revenue 3 Investment income (including dividends, interest
and other similar amounts).....MediumBullet 0      
4 Income from investment of tax-exempt bond proceeds..MediumBullet 0      
5 Royalties............MediumBullet 0      
(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 20,610,244 385,020
b Less: cost or other basis and sales expenses   287,545
c Gain or (loss) 20,610,244 97,475
d Net gain or (loss)..........MediumBullet 20,707,719     20,707,719
8a Gross income from fundraising events (not including
$  
of contributions reported on line 1c). See Part IV, line 18 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from fundraising events..MediumBullet 0    
9a Gross income from gaming activities.
See Part IV, line 19 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from gaming activities...MediumBullet 0      
10a Gross sales of inventory, less
returns and allowances .
a 860,524
b Less: cost of goods sold ..b 781,207
c Net income or (loss) from sales of inventory..MediumBullet 79,317     79,317
Miscellaneous Revenue Business Code
11a FOOD SALES 722,100 4,042,797     4,042,797
b INFORMATION SERVICES 541,512 5,161,980 5,004,839 157,141  
c BILLING AND ACCOUNTING 541,200 445,787 329,035 116,752  
d All other revenue .... 310,002 238,653 71,349  
e Total. Add lines 11a–11d ......MediumBullet 9,960,566
12 Total revenue. See Instructions....MediumBullet 686,395,732 658,490,646 345,242 24,829,833
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 2,926,871 2,926,871
2 Grants and other assistance to individuals in the United States. See Part IV, line 22 149,434 149,434
3 Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16 0  
4 Benefits paid to or for members 0  
5 Compensation of current officers, directors, trustees, and key employees .... 4,102,583   4,102,583  
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .... 0      
7 Other salaries and wages 247,360,738 219,396,124 27,964,614  
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 11,395,312 10,002,446 1,392,866  
9 Other employee benefits ....... 46,823,823 41,570,561 5,253,262  
10 Payroll taxes ........... 18,141,674 15,962,063 2,179,611  
11 Fees for services (non-employees):        
a Management ...... 3,342,370 2,614,287 728,083  
b Legal ......... 860,905 6,287 854,618  
c Accounting ........... 407,582 16,171 391,411  
d Lobbying ........... 129,485   129,485  
e Professional fundraising. See Part IV, line 17.. 0  
f Investment management fees ...... 96,159   96,159  
g Other .......... 24,316,966 17,583,297 6,733,669  
12 Advertising and promotion .... 938,329 661,166 277,163  
13 Office expenses ....... 16,249,054 12,675,545 3,573,509  
14 Information technology ...... 8,936,864   8,936,864  
15 Royalties .. 0      
16 Occupancy ........... 6,180,214 5,538,169 640,175 1,870
17 Travel ............ 793,414 611,854 181,560  
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ...... 0      
19 Conferences, conventions, and meetings .... 1,552,021 764,161 787,860  
20 Interest ........... 10,917,507 9,277,544 1,635,204 4,759
21 Payments to affiliates ....... 0      
22 Depreciation, depletion, and amortization ..... 30,574,129 25,822,340 4,738,482 13,307
23 Insurance .............. 1,949,869 345,181 1,604,688  
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 MEDICAL SUPPLIES 63,620,894 63,609,255 11,639  
b DRUGS 39,399,485 39,331,489 67,996  
c CONTRACTED SERVICES 19,137,662 17,019,376 2,118,286  
d BAD DEBTS 11,111,551 11,111,551    
e
f All other expenses 29,864,537 22,994,402 6,870,135  
25 Total functional expenses. Add lines 1 through 24f 601,279,432 519,989,574 81,269,922 19,936
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 .......... 33,013,300 1 43,156,066
2 Savings and temporary cash investments ....... 0 2 0
3 Pledges and grants receivable, net ......... 0 3 0
4 Accounts receivable, net ......... 77,908,855 4 83,005,279
5 Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L .......... 0 5 0
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 .......... 0 6 0
7 Notes and loans receivable, net ............. 0 7 0
8 Inventories for sale or use .............. 5,365,379 8 5,589,738
9 Prepaid expenses and deferred charges ............ 5,508,587 9 5,299,067
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 765,641,233
b Less: accumulated depreciation. ..... 10b 319,417,150 376,793,956 10c 446,224,083
11 Investments—publicly traded securities .......... 389,996,589 11 298,017,436
12 Investments—other securities. See Part IV, line 11 ...... 10,185,122 12 41,246,076
13 Investments—program-related. See Part IV, line 11 .. 0 13 0
14 Intangible assets ......... 0 14 0
15 Other assets. See Part IV, line 11 ........... 7,976,888 15 9,410,410
16 Total assets. Add lines 1 through 15 (must equal line 34)... 906,748,676 16 931,948,155
Liabilities 17 Accounts payable and accrued expenses . 460,757,527 17 468,565,895
18 Grants payable .......... 0 18 0
19 Deferred revenue .......... 0 19 0
20 Tax-exempt bond liabilities .......... 0 20 0
21 Escrow or custodial account liability. Complete Part IV of Schedule D.. 0 21 0
22 Payables to current and former officers, directors, trustees, key
employees, highest compensated employees, and disqualified
persons. Complete Part II of Schedule L.......... 0 22 0
23 Secured mortgages and notes payable to unrelated third parties .. 0 23 0
24 Unsecured notes and loans payable to unrelated third parties .... 0 24 0
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..... 23,664,557 25 56,216,335
26 Total liabilities. Add lines 17 through 25..... 484,422,084 26 524,782,230
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 ..... 422,317,762 27 407,157,082
28 Temporarily restricted net assets ..... 8,830 28 8,843
29 Permanently restricted net assets ..... 0 29 0
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 ..... 422,326,592 33 407,165,925
34 Total liabilities and net assets/fund balances ..... 906,748,676 34 931,948,155
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
686,395,732
2
Total expenses (must equal Part IX, column (A), line 25) ....
2
601,279,432
3
Revenue less expenses. Subtract line 2 from line 1 ...
3
85,116,300
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..
4
422,326,592
5
Other changes in net assets or fund balances (explain in Schedule O) ...
5
-100,276,967
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
407,165,925
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
Yes
 
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
Yes
 
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
ST CLOUD HOSPITAL
 
Employer identification number

41-0695596
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.") ....            
2 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......            
3 The value of services or facilities furnished by a governmental unit to the organization without charge..            
4 Total. Add lines 1 through 3..            
5 The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..            
6 Public Support. Subtract line 5 from line 4.            
Section B. Total Support
Calendar year(or fiscal year beginning in) (a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (f) Total
7 Amounts from line 4..            
8 Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..            
9 Net income from unrelated business activities, whether or not the business is regularly carried on..            
10 Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..            
11 Total support (Add lines 7 through 10).            
12
12
 
13
Section C. Computation of Public Support Percentage
14
14
 
15
15
 
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
ST CLOUD HOSPITAL
 
Employer identification number

41-0695596
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
ST CLOUD HOSPITAL
  		Employer identification number

41-0695596
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
ST CLOUD HOSPITAL
  		Employer identification number

41-0695596
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
ST CLOUD HOSPITAL
  		Employer identification number

41-0695596
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 C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service
Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527
SchCMd Bullet Complete if the organization is described below.
SchCMd Bullet Attach to Form 990 or Form 990-EZ. SchCMd Bullet See separate instructions.
OMB No. 1545-0047
2011
Open to Public
Inspection
If the organization answered “Yes” to Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet Section 527 organizations: Complete Part I-A only.
If the organization answered “Yes” to Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)) Complete Part II-A. Do not complete Part II-B.
Round Bullet Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered “Yes” to Form 990, Part IV, Line 5 (Proxy Tax) or Form 990-EZ, line 35c (Proxy Tax), then
Round Bullet Section 501(c)(4), (5), or (6) organizations: Complete Part III.
Name of the organization
ST CLOUD HOSPITAL
 
Employer identification number

41-0695596
Part I-A
Complete if the organization is exempt under section 501(c) or is a section 527 organization.

1
Provide a description of the organization’s direct and indirect political campaign activities in Part IV.
2
Political expenditures ....................................SchCMd Bullet
$  
3
Volunteer hours ........................................
 

Part I-B
Complete if the organization is exempt under section 501(c)(3).
1
Enter the amount of any excise tax incurred by the organization under section 4955 .........SchCMd Bullet
$  
2
Enter the amount of any excise tax incurred by organization managers under section 4955 ......SchCMd Bullet
$  
3
If the organization incurred a section 4955 tax, did it file Form 4720 for this year? ..............
4a
Was a correction made? .........................................
b
If "Yes," describe in Part IV.
Part I-C
Complete if the organization is exempt under section 501(c) except section 501(c)(3).
1
Enter the amount directly expended by the filing organization for section 527 exempt function activities SchCMd Bullet
$  
2
Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ...................................SchCMd Bullet

$  
3
Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b..SchCMd Bullet

$  
4
Did the filing organization file Form 1120-POL for this year? ..........................
5
Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.
(a) Name (b) Address (c) EIN (d) Amount paid from filing organization's funds. If none, enter -0-. (e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.










For Privacy Act and Paperwork Reduction Act Notice, see the instructions for Form 990.
Cat. No. 50084S
Schedule C (Form 990 or 990-EZ) 2011

Schedule C (Form 990 or 990-EZ) 2011
Page 2
Part II-A
Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).
A Check expenses, and share of excess lobbying expenditures).
B Check
Limits on Lobbying Expenditures
(The term "expenditures" means amounts paid or incurred.) 		(a) Filing
organization's
totals 		(b) Affiliated group
totals
1a Total lobbying expenditures to influence public opinion (grass roots lobbying) ......    
b Total lobbying expenditures to influence a legislative body (direct lobbying) .......    
c Total lobbying expenditures (add lines 1a and 1b) ...................    
d Other exempt purpose expenditures ........................    
e Total exempt purpose expenditures (add lines 1c and 1d) ...............    
f Lobbying nontaxable amount. Enter the amount from the following table in both
columns.		    
  If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:    
  Not over $500,00020% of the amount on line 1e.    
  Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.    
  Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.    
  Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.    
  Over $17,000,000$1,000,000.    
       
g Grassroots nontaxable amount (enter 25% of line 1f) .................    
h Subtract line 1g from line 1a. If zero or less, enter -0-. ................    
i Subtract line 1f from line 1c. If zero or less, enter -0-. ................    
j If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting
section 4911 tax for this year? ......................................

4-Year Averaging Period Under Section 501(h)
(Some organizations that made a section 501(h) election do not have to complete all of the five
columns below. See the instructions for lines 2a through 2f on page 4.)
Lobbying Expenditures During 4-Year Averaging Period
  Calendar year (or fiscal year
beginning in) 		(a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) Total
             
2a Lobbying non-taxable amount          
             
b Lobbying ceiling amount
(150% of line 2a, column(e)) 		         
             
c Total lobbying expenditures          
             
d Grassroots nontaxable amount          
             
e Grassroots ceiling amount
(150% of line 2d, column (e))		          
             
f Grassroots lobbying expenditures          
Schedule C (Form 990 or 990-EZ) 2011


Schedule C (Form 990 or 990-EZ) 2011
Page 3
Part II-B
Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).
For each “Yes” response to lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.
(a)
Yes
No
(b)
Amount
1
During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:
a
Volunteers? .........................................
Yes
 
b
Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....
Yes
 
c
Media advertisements? ....................................
 
No
 
d
Mailings to members, legislators, or the public? .........................
 
No
 
e
Publications, or published or broadcast statements? .......................
 
No
 
f
Grants to other organizations for lobbying purposes? .......................
Yes
 
11,202
g
Direct contact with legislators, their staffs, government officials, or a legislative body? ........
Yes
 
118,283
h
Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......
 
No
 
i
Other activities? ..........................
 
No
 
j
Total. Add lines 1c through 1i ...............................
129,485
2a
Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....
 
No
b
If "Yes," enter the amount of any tax incurred under section 4912 .................
 
c
If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....
 
d
If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? .......
 
 
Part III-A
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).
Yes
No
1
Were substantially all (90% or more) dues received nondeductible by members? ................
1
 
 
2
Did the organization make only in-house lobbying expenditures of $2,000 or less? ................
2
 
 
3
Did the organization agree to carry over lobbying and political expenditures from the prior year? ..........
3
 
 
Part III-B
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2 are answered “No” OR (b) Part III-A, line 3 is answered “Yes”.
1
Dues, assessments and similar amounts from members .....................
1
 
2
Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).
a
Current year .........................................
2a
 
b
Carryover from last year ....................................
2b
 
c
Total ...........................................
2c
 
3
Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .
3
 
4
If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ................................
4
 
5
Taxable amount of lobbying and political expenditures (see instructions) ..............
5
 
Part IV
Supplemental Information
Complete this part to provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, Part II-A; line 5; and Part ll-B, line 1.
Also, complete this part for any additional information.
Identifier Return Reference Explanation
Schedule C (Form 990 or 990EZ) 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
ST CLOUD HOSPITAL
 
Employer identification number

41-0695596
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 ....        
b Contributions ........        
c Net investment earnings, gains, and losses ...        
d Grants or scholarships .....        
e Other expenditures for facilities
and programs ........ 		       
f Administrative expenses ....        
g End of year balance ......        
2
Provide the estimated percentage of the year end balance (line 1g) held as:
a
Board designated or quasi-endowment SchDMd Bullet  
b
Permanent endowment SchDMd Bullet  
c
Temporarily restricted endowment SchDMd Bullet  
The percentages in lines 2a, 2b, and 2c should equal 100%.
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) unrelated organizations ........................
3a(i)
 
 
(ii) related organizations ........................
3a(ii)
 
 
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
 
 
4
Describe in Part 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 ................. 0 15,092,350 15,092,349
b Buildings ................ 0 479,044,457 139,526,330 339,518,127
c Leasehold improvements ............ 0 5,169,836 2,258,956 2,910,880
d Equipment ................ 0 252,820,862 177,631,863 75,188,999
e Other ................. 0 13,513,728 0 13,513,728
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......SchDMdBullet 446,224,083
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    
Other








Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)Small Bullet  
Part VIII
Investments—Program Related. See Form 990, Part X, line 13.
(a) Description of investment type (b) Book value (c) Method of valuation:
Cost or end-of-year market value








Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)Small Bullet  
Part IX
Other Assets. See Form 990, Part X, line 15.
(a) Description (b) Book value








Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........Small Bullet  
Part X
Other Liabilities. See Form 990, Part X, line 25.
1.(a) Description of Liability (b) Book value
Federal Income Taxes 0
ACCRUED PENSION LIABILITY 34,457,882
INTEREST RATE AND TOTAL RETURN SWAP 16,330,437
LONG TERM DEFERRED REVENUE 1,897,432
ACCRUED EXECUTIVE BENEFITS 1,583,504
LONG TERM SETTLEMENT RESERVE 1,000,000
KESOP BENEFIT PLAN 538,359
ASSET RETIREMENT OBLIGATION 391,881
OTHER LONG TERM LIABILITIES 16,840

Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 56,216,335
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
Schedule D (Form 990) 2011

Additional Data


Software ID:  
Software Version:  




SCHEDULE H (Form 990)
Department of the Treasury
Internal Revenue Service
Hospitals
MediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, question 20.
MediumBullet Attach to Form 990. MediumBullet See separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
ST CLOUD HOSPITAL
 
Employer identification number

41-0695596
Part I
Charity Care and Certain Other Community Benefits at Cost
Yes
No
1a
Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a....
1a
Yes
 
b
If "Yes," was it a written policy? .......................
1b
Yes
 
2
If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.
3
Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.
a
Did the organization use Federal Poverty Guidelines (FPG) to determine eligibility for providing free care?
If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:
3a
Yes
 
b
Did the organization use FPG to determine eligibility for providing discounted care? If "Yes," indicate which of the
following was the family income limit for eligibility for discounted care: ............
3b
Yes
 
c
If the organization did not use FPG to determine eligibility, describe in Part VI the income based criteria for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, to determine eligibility for free or discounted care.
4
Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? ..............

4

Yes

 
5a
Did the organization budget amounts for free or discounted care provided under its financial assistance policy during the tax year? ............................

5a

Yes

 
b
If "Yes," did the organization's financial assistance expenses exceed the budgeted amount?......
5b
Yes
 
c
If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care?...............
5c
 
No
6a
Did the organization prepare a community benefit report during the tax year?...........
6a
Yes
 
b
If "Yes," did the organization make it available to the public? ...............
6b
Yes
 
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
Financial Assistance and Certain Other Community Benefits at Cost
Financial Assistance
and Means-Tested Government Programs		 (a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community benefit expense (d) Direct offsetting revenue (e) Net community benefit expense (f) Percent of total expense
a Financial Assistance at cost
(from Worksheet 1) .. 		    4,812,453 0 4,812,453 0.820 %
b Medicaid (from Worksheet 3, column a) .....     101,256,717 81,476,164 19,780,553 3.350 %
c Costs of other means-tested government programs (from Worksheet 3, column b) .     0 0 0 0 %
dTotal Financial Assistance and
Means-Tested Government Programs ..... 		    106,069,170 81,476,164 24,593,006 4.170 %
Other Benefits
e Community health improvement
services and community
benefit operations (from
(Worksheet 4) .... 		    947,725 6,788 940,937 0.160 %
f Health professions education
(from Worksheet 5) .. 		    3,948,752 1,088,226 2,860,526 0.480 %
g Subsidized health services
(from Worksheet 6) .. 		    486,193 0 486,193 0.080 %
h Research (from Worksheet 7)     292,170 182,655 109,515 0.020 %
i Cash and in-kind contributions for community benefit (from Worksheet 8) ....     2,349,107 0 2,349,107 0.390 %
jTotal Other Benefits ...     8,023,947 1,277,669 6,746,278 1.130 %
kTotal. Add lines 7d and 7j. ..     114,093,117 82,753,833 31,339,284 5.300 %
For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part II
Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.
(a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community building expense (d) Direct offsetting
revenue 		(e) Net community building expense (f) Percent of total expense
1 Physical improvements and housing            
2 Economic development            
3 Community support   200 14,986   14,986  
4 Environmental improvements            
5 Leadership development and training for community members            
6 Coalition building            
7 Community health improvement advocacy   2,150 6,917   6,917  
8 Workforce development   40 801   801  
9 Other            
10 Total   2,390 22,704   22,704  
Part III
Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt Expense
Yes
No
1
Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................
1
Yes
 
2
Enter the amount of the organization's bad debt expense........
2
4,190,694
3
Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy .....
3
83,591
4
Provide in Part VI the text of the footnote to the organization's financial statements that describes bad debt expense. In addition, describe the costing methodology used in determining the amounts reported on lines 2 and 3, and rationale for including a portion of bad debt amounts as community benefit.
Section B. Medicare
5
Enter total revenue received from Medicare (including DSH and IME).....
5
193,908,086
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
205,035,753
7
Subtract line 6 from line 5. This is the surplus or (shortfall)........
7
-11,127,667
8
Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.Check the box that describes the method used:
Section C. Collection Practices
9a
Did the organization have a written debt collection policy during the tax year? ..........
9a
Yes
 
b
If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI.......................

9b

Yes

 
Part IV
Management Companies and Joint Ventures
(see instructions)
(a) Name of entity (b) Description of primary
activity of entity 		(c) Organization's
profit % or stock
ownership % 		(d) Officers, directors,
trustees, or key
employees' profit %
or stock ownership% 		(e) Physicians'
profit % or stock
ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information
Section A. Hospital Facilities
(list in order of size from largest to smallest)
How many hospital facilities did the organization operate during the tax year?1
Name and address 		Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital Research Facility ER-24Hours ER-Other Other (Describe)
1 SAINT CLOUD HOSPITAL
1406 SIXTH AVENUE NORTH
SAINT CLOUD,MN563031901 		X X   X     X   REHAB & PSYCH UNITS, HOME HEALTH/HOSPICE, RENAL DIALYSIS
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Section B. Facility Policies and Practices.

(Complete a separate Section B for each of the hospital facilities listed in Part V, Section A)
SAINT CLOUD HOSPITAL
Name of Hospital Facility:  
Line Number of Hospital Facility (from Schedule H, Part V, Section A):1

Yes No
Community Health Needs Assessment (Lines 1 through 7 are optional for 2011)
1 During the tax year or any prior tax year, did the hospital facility conduct a community health needs assessment (“Needs Assessment”)? If “No,” skip to question 8. ..................... 1    
If “Yes,” indicate what the Needs Assessment describes (check all that apply):
a A definition of the community served by the hospital facility
b Demographics of the community
c Existing health care facilities and resources within the community that are available to respond to the health needs of the community
d How data was obtained
e The health needs of the community
f Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups
g The process for identifying and prioritizing community health needs and services to meet the community health needs
h The process for consulting with persons representing the community’s interests
i Information gaps that limit the hospital facility’s ability to assess the community’s health needs
j Other (describe in Part VI)
2 Indicate the tax year the hospital facility last conducted a Needs Assessment: 20  
3 In conducting its most recent Needs Assessment, did the hospital facility take into account input from persons who represent the community served by the hospital facility? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted. 3    
4 Was the hospital facility’s Needs Assessment conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI............................ 4    
5 Did the hospital facility make its Needs Assessment widely available to the public? ........... 5    
If “Yes,” indicate how the Needs Assessment was made widely available (check all that apply):
a Hospital facility’s website
b Available upon request from the hospital facility
c Other (describe in Part VI)
6 If the hospital facility addressed needs identified in its most recently conducted Needs Assessment, indicate how (check all that apply):
a Adoption of an implementation strategy to address the health needs of the hospital facility’s community
b Execution of the implementation strategy
c Participation in the development of a community-wide community benefit plan
d Participation in the execution of a community-wide community benefit plan
e Inclusion of a community benefit section in operational plans
f Adoption of a budget for provision of services that address the needs identified in the Needs Assessment
g Prioritization of health needs in the community
h Prioritization of services that the hospital facility will undertake to meet health needs in its community
i Other (describe in Part VI)
7 Did the hospital facility address all of the needs identified in its most recently conducted Needs Assessment? If “No,” explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs. .... 7    
Financial Assistance Policy
Did the hospital facility have in place during the tax year a written financial assistance policy that:
8 Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care? 8 Yes  
9 Used federal poverty guidelines (FPG) to determine eligibility for providing free care?........... 9 Yes  
If "Yes," indicate the FPG family income limit for eligibility for free care: 175.%
If "No," explain in Part VI the criteria the hospital facility used.
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Yes No
10 Used FPG to determine eligibility for providing discounted care?................. 10 Yes  
If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 250.%
If "No," explain in Part VI the criteria the hospital facility used.
11 Explained the basis for calculating amounts charged to patients?................. 11 Yes  
If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a Income level
b Asset level
c Medical indigency
d Insurance status
e Uninsured discount
f Medicaid/Medicare
g State regulation
h Other (describe in Part VI)
12 Explained the method for applying for financial assistance?................... 12 Yes  
13 Included measures to publicize the policy within the community served by the hospital facility?....... 13 Yes  
If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a The policy was posted on the hospital facility’s web site
b The policy was attached to all billing invoices
c The policy was posted in the hospital facility’s emergency rooms or waiting rooms
d The policy was posted in the hospital facility’s admissions offices
e The policy was provided, in writing, to patients upon admission to the hospital facility
f The policy was available upon request
g Other (describe in Part VI)
Billing and Collections
14 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?....... 14 Yes  
15 Check all of the following collection actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments
e Other similar actions (describe in Part VI)
16 Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?.......... 16 Yes  
If “Yes,” check all actions in which the hospital facility or a third party engaged:
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments
e Other similar actions (describe in Part VI)
17 Indicate which efforts the hospital facility made before initiating any of the actions checked in line 16 (check all that apply):
a Notified patients of the financial assistance policy upon admission
b Notified patients of the financial assistance policy prior to discharge
c Notified patients of the financial assistance policy in communications with the patients regarding the patients’ bills
d Documented its determination of whether patients were eligible for financial assistance under the hospital facility’s financial assistance policy
e Other (describe in Part VI)
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Policy Relating to Emergency Medical Care
Yes No
18 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.......... 18 Yes  
If “No,” indicate why:
a The hospital facility did not provide care for any emergency medical conditions
b The hospital facility’s policy was not in writing
c The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)
d Other (describe in Part VI)
Individuals Eligible for Financial Assistance
19 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged
b The hospital facility used the average of it's three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged
c The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged
d Other (describe in Part VI)
20 Did the hospital facility charge any of its patients who were eligible for assistance under the hospital facility’s financial assistance policy, and to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care?......... 20   No
If “Yes,” explain in Part VI.
21 Did the hospital facility charge any of its FAP-eligible patients an amount equal to the gross charge for any services provided to that patient?............................... 21   No
If “Yes,” explain in Part VI.
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VFacility Information (continued)

Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility
(list in order of size, from largest to smallest)
How many non-hospital health care facilities did the organization operate during the tax year?1
Name and address Type of Facility (describe)
1 SAINT BENEDICT'S SENIOR COMMUNITY
1810 MINNESOTA BLVD
ST CLOUD,MN56304 		SKILLED NURSING FACILITY
2
3
4
5
6
7
8
9
10
Schedule H (Form 990) 2011
Schedule H (Form 990) 2011
Page
Part VI
Supplemental Information
Complete this part to provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; and Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 9, 10, 11h, 13g, 15e, 16e, 17e, 18d, 19d, 20, and 21.
2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any needs assessments reported in Part V, Section B.
3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5 Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
Identifier ReturnReference Explanation
PART I, LINE 3C   N/A
COMMUNITY BENEFIT REPORT PART I, LINE 6A REFER TO SCHEDULE O FOR COMPLETE COMMUNITY BENEFIT REPORT.
FINANCIAL ASSISTANCE AND CERTAIN OTHER COMMUNITY BENEFITS AT COST PART I, LINE 7 COLUMN (F) - THE AMOUNT OF BAD DEBT EXPENSE SUBTRACTED FROM THE DENOMINATOR BEFORE CALCULATING COLUMN (F) IS $11,111,551. 7A - ST. CLOUD PROVIDES CHARITY CARE TO IT'S PATIENT POPULATION BASED ON THE PATIENT'S ABILITY TO PAY, ALONG WITH OTHER FACTORS. IT PROVIDES 100% CHARITY AS WELL AS PARTIAL CHARITY CARE ON THE REMAINING DEDUCTIBLE AND COINSURANCE ON PATIENT'S BILLS. IN 2012, ST CLOUD HOSPITAL PROVIDED $13 MILLION IN CHARITY CARE. THE COST OF THIS CHARITY CARE WAS APPROXIMATELY $4.8 MILLION. FOR LINES 7E, 7G, 7H, & 7I, REFER TO COMMUNITY BENEFIT REPORT FOR DETAILED INFORMATION REGARDING THESE LINES. 7F - THE UNIVERSITY OF MINNESOTA/ST. CLOUD FAMILY MEDICINE RESIDENCY PROGRAM WAS INITIATED IN 1996 TO ADDRESS THE SHORTAGE OF PHYSICIANS IN RURAL MINNESOTA. DESPITE FUNDING FROM THE STATE AND FEDERAL AGENCIES, THE RESIDENCY REQUIRED SUBSIDIES FROM THE ORGANIZATION. DURING THE 2011-12 YEAR, THE ORGANIZATION PROVIDED $667,000 IN SUBSIDIES FOR THE PROGRAM. THE ORGANIZATION ALSO OPERATES A CLINICAL PASTORAL CARE EDUCATION PROGRAM WHICH ALLOWS CHAPLAINS TO GAIN THE KNOWLEDGE AND EXPERIENCE NECESSARY TO PROVIDE SPIRITUAL CARE AND SUPPORT TO PATIENTS AND THEIR FAMILIES IN THEIR TIME OF NEED. THE PROGRAM RECEIVES FEDERAL FUNDING FROM MEDICARE, BUT THE ORGANIZATION SUBSIDIZED THIS PROGRAM IN THE AMOUNT OF $83,500. FINALLY THE ORGANIZATION OPERATES A RADIOLOGIC TECHNOLIGIST PROGRAM. THIS PROGRAM GIVES STUDENTS AN OPPORTUNITY TO TRAIN IN A HIGH DEMAND FIELD. THIS PROGRAM DID NOT REQUIRE A SUBSIDY FROM ST. CLOUD HOSPITAL, AS IT COVERED ITS COSTS BETWEEN TUITION INCOME AND MEDICARE PASS THROUGH REIMBURSEMENT. THIS PROGRAM STILL MEETS A COMMUNITY NEED AND AS SUCH BELONGS WITH COMMUNITY BENEFIT DISCLOSURES.
COMMUNITY BUILDING ACTIVITIES PART II THE ACTIVITIES INCLUDED IN COMMUNITY BUILDING ACTIVITIES INCLUDE COMMUNITY SUPPORT WHICH CONSISTS OF SEVERAL ST. CLOUD HOSPITAL DIRECTORS PARTICIPATING IN A VARIETY OF COMMITTEES SUCH AS THE BOARD OF BIG BROTHERS/BIG SISTERS AND REHAB BOARD ETC. UNDER COMMUNITY HEALTH IMPROVEMENT ADVOCACY, EMPLOYEES PARTICIPATED WITH CREATE COMMUNITY WHICH IS A COLLABORATION TO BUILD INCLUSION AMONGST DIVERSE POPULATION AND SEVERAL COUNTY TASK FORCES TO ADVOCATE FOR MENTAL AND CHEMICAL HEALTH. FINALLY UNDER WORKFORCE DEVELOPMENT, AN EMPLOYEE IS A BOARD MEMBER OF THE STEARNS BENTON WORKFORCE COUNCIL AND STUDENTS WERE GIVEN TOURS OF THE HOSPITAL AND ATTENDED PRESENTATIONS ON CAREERS IN HEALTHCARE.
BAD DEBT PART III, LINE 4 THE PROVISION FOR UNCOLLECTIBLE ACCOUNTS IS BASED UPON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS CONSIDERING HISTORICAL BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN HEALTHCARE COVERAGE, AND OTHER COLLECTION INDICATORS. PERIODICALLY THROUGHOUT THE YEAR, MANAGEMENT ASSESSES THE ADEQUACY OF ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS BASED UPON THE HISTORICAL WRITE-OFF EXPERIENCE BY PAYOR CATEGORY. THE RESULTS OF THIS REVIEW ARE THEN USED TO MAKE ANY MODIFICATIONS TO THE PROVISION FOR UNCOLLECTIBLE ACCOUNTS TO ESTABLISH AN APPROPRIATE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. AFTER SATISFACTION OF AMOUNTS DUE FROM INSURANCE, CENTRACARE FOLLOWS ESTABLISHED GUIDELINES FOR PLACING CERTAIN PAST-DUE PATIENT BALANCES WITH COLLECTION AGENCIES SUBJECT TO THE TERMS OF CERTAIN RESTRICTIONS ON COLLECTION EFFORTS AS DETERMINED BY CENTRACARE. BAD DEBT AT COST WAS DETERMINED BY USING AMOUNTS WRITTEN OFF AS BAD DEBT EXPENSE (WHICH WERE CHARGES) AND MULTIPLYING BY THE INTERNALLY DEVELOPED COST TO CHARGO RATIO.
MEDICARE SHORTFALL PART III, LINE 8 THE SHORTFALL OF $11.1 MILLION OF TREATING MEDICARE PATIENTS SHOULD BE CONSIDERED A COMMUNITY BENEFIT IN ITS ENTIRETY. THE HOSPITAL PROVIDES AN EXCELLENT LEVEL OF CARE TO THE PEOPLE IN THE COMMUNITY. DESPITE THE SHORTFALL IN REIMBURSEMENT FROM MEDICARE, THE HOSPITAL CONTINUES TO PROVIDE ESSENTIAL HEALTHCARE SERVICES TO THE POPULATION. THE AMOUNT ON LINE 7 OF PART III WAS DETERMINED BY UTILIZING THE MEDICARE COST REPORT UTILIZING KEY SECTIONS OF THAT REPORT, PRIMARILY THE D SERIES AND E SERIES ALONG WITH KEY SECTIONS FROM THE HOME HEALTH, HOSPICE AND DIALYSIS SECTIONS.
ORGANIZATION'S COLLECTION POLICY PART III, LINE 9B THE COLLECTION POLICIES AT ST. CLOUD HOSPITAL REQUIRE COLLECTION STAFF TO OFFER CHARITY TO PATIENTS WHO INDICATE THAT PAYMENT MAY BE AN ISSUE. IF A PATIENT DOES QUALIFY FOR FULL CHARITY, ALL OTHER COLLECTION EFFORTS MUST CEASE. IF A PATIENT QUALIFIES FOR PARTIAL CHARITY, COLLECTION EFFORTS WILL CONTINUE ON THE BALANCE OF THE ACCOUNT. THESE PROVISIONS APPLY TO BOTH HOSPITAL EMPLOYED COLLECTION STAFF AND COLLECTION AGENCY STAFF. NO PATIENTS, WHETHER THEY QUALIFY FOR CHARITY OR NOT, ARE REPORTED TO CREDIT RATING AGENCIES. Part V, Sec B, Line 13g Explanation PATIENTS WHO ARE AT A SELF PAY STATUS RECEIVE CHARITY CARE INFORMATION EITHER VIA A TELEPHONE CALL OR A LETTER. PART V, SEC B, LINE 15E EXPLANATION THE ORGANIZATION EMPLOYES THE USE OF COLLECTION AGENCIES TO COLLECT A PATIENT'S BALANCE. AFTER THOSE EFFORTS ARE EXHAUSTED, THE ORGANIZATION DOES UTILIZE LAWSUITS AS WELL. PART V, SEC B, LINE 16E EXPLANATION THE ORGANIZATION CONTRACTS WITH SEVERAL COLLECTION AGENCIES TO ATTEMPT TO COLLECT PATIENT BALANCES. Part V, Sec B, Line 17e Explanation OUR CREDIT COLLECTION AGENCIES ARE REQUIRED TO PROVIDE CHARITY INFORMATION AS PART OF THEIR COLLECTION PROCESS PRIOR TO ANY CONSIDERATION OF LEGAL ACTION AGAINST THE PATIENT. Part V, Sec B, Line 19d Explanation PER AGREEMENT WITH THE MINNESTOA ATTORNEY GENERAL, THE ORGANIZATION PROVIDES A DISCOUNT TO THE UNINSURED EQUAL TO THE AVERAGE DISCOUNT OF OUR LARGEST (BY VOLUME) NON-GOVERNMENTAL PAYOR.
NEEDS ASSESSMENT   ST. CLOUD HOSPITAL FOUNDATION HAS IN PLACE A COMMUNITY COLLABORATION COMMITTEE WHICH HAS A MEMBERSHIP OF OVER 30 MEMBERS. THIS COMMITTEE IS MADE UP OF COMMUNITY LEADERS FROM BOTH THE HEALTHCARE AND BUSINESS WORLD. THESE MEMBERS MEET MONTHLY TO ADDRESS COMMUNITY HEALTH ISSUES (SEE PROMOTION OF COMMUNITY HEALTH FOR MORE DETAIL). THESE IDENTIFIED HEALTH NEEDS ARE THEN COMMUNICATED TO ST. CLOUD HOSPITAL.
PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE   Inpatients who are self pay are identified, and a representative of St. Cloud's billing department explains the charity care policy to patients. They also explain the self pay discount and screens the patient for eligibility for any State or Federal programs. They also assist the patient with any paperwork required to apply for such programs. Outpatients who are self pay receive an automatic self pay discount. If the patient does not remit payment, collection staff attempt to reach the patient by phone. Patients are told about the charity program. For both inpatients and outpatients, all statements contain a letter regarding the availability of charity care. Also, all precollection letters have this same language indicating the availability and process of obtaining charity care.
COMMUNITY INFORMATION   St. Cloud Hospital's immediate service area consists of Stearns, Benton and Sherburne counties. Collectively their population in 2012 is 293,657 and is projected to grow by 7.1% in 2017. The projected population growth by age bracket for 2012 to 2017 is 0-24, 4.3%; 25-44, 2.2%; 45-64, 12.1% and 65+ 18.3%. The other nine counties located in the service area are Crow Wing, Douglas, Kandiyohi, Meeker, Mille Lacs, Morrison, Pope, Todd and Wright. Collectively their population in 2012 was 397,011 and is projected to grow by 6.2% by 2017. That nine county projected population growth to 2017 by age bracket are as follows: 0-24, 8.6%; 25-44, -1.4%; 45-64, 5.3% and 65+ 15.5%. The 2017 ethnicity breakdown for the entire 12-county area is as follows: White - 92.9%; African American - 2.2%; Asian - 1.3%; Two or more races - 1.8%, Other - 1.1%, American Indian or Alaska Native 0.7%. The demographic information is updated every 2 years by the organization, with this reporting year being the first year.
PROMOTION OF COMMUNITY HEALTH   The Organization promotes the health of the community in several important ways. One of these ways is through the Community Collaboration Committee (CCC), a standing committee of the CentraCare Health Foundation. The CCC has a membership of over 30 persons representing healthcare and community needs across Central Minnesota. The CCC meets monthly to discuss ways to address typical health issues through awareness building, education and/or an intervention project. There are several community health outreach initiatives that the Foundation is involved with. These initiatives include: 1) BLEND Childhood Obesity Coalition of Central Minnesota (goal is to reduce the incidence of childhood obesity by 2016), 2) Smoke Free Communities (Continued efforts to create clean indoor and outdoor air for all), 3) QUITPLAN Clinics (Collaboration with CentraCare Clinic to help those trying to quit smoking), and 4) CentraCare Clinic Medical Home Pilot.
AFFILIATED HEALTH CARE SYSTEM   The Organization is part of CentraCare Health System (CCHS) which provides a broad range of health care services to the patients of Centra Minnesota. CCHS is dedicated to improving the health of people living and working in the communities it serves. To accomplish its goals it works actively with its affiliate health care organizations. CCHS continues to focus on providing the best care possible and in reinvesting into the community. CCHS also promotes wellness by sponsoring programs and events in local communities that focus on healthy eating and exercise, and by conducting screenings for conditions such as high blood pressure.
STATE FILING OF COMMUNITY BENEFIT REPORT 990 SCHEDULE H, PART VI MN,
Schedule H (Form 990) 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
ST CLOUD HOSPITAL
 
Employer identification number
41-0695596
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) SISTERS OF THE ORDER OF ST BENEDICT104 CHAPEL LANE ST
ST JOSEPH,MN56374 		41-0693973 501(C)(3) 100,000   FMV   TO PAY FOR HEALTHCARE COSTS TO SUPPORT THE CENTRACARE FOUNDATION DONATION OF MEDICAL EQUIPMENT AND SUPPLIES TO SUPPORT IMPROVED CLINICAL OUTCOMES IN CARDIAC A GUATEMALA MISSION SUPPORT
(2) CENTRACARE HEALTH SYSTEM1406 SIXTH AVE NORTH
ST CLOUD,MN56303 		41-1855173 501(C)(3) 2,742,332   FMV   TO SUPPORT THE
(3) THE MESSAGE PROGRAM2311 10TH AVE SOUTH ST
ST CLOUD,MN56301 		20-0293323 501(C)(3)   10,665 FMV med equip & supplies  
(4) HELPS INTERNATIONAL15301 DALLAS PARKWAY STE 200
ADDISON,TX75001 		75-1966419 501(C)(3) 8,500   FMV    
(5) TAKE HEART PROGRAM1905 CO ROAD WEST
ROSEVILLE,MN55113 		20-8307526 501(C)(3) 21,087   FMV    














2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................. Bullet Image
5
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
(1) HOME DELIVERED MEALS 218   149,434 FMV MEALS TO THE NEEDY













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
Form 990, Schedule I Description of Organization's Procedures for Monitoring the Use of Grants ST. CLOUD HOSPITAL HAS A CLOSE RELATIONSHIP WITH THE CENTRACARE HEALTH FOUNDATION. THE FOUNDATION HAS SPECIFIC POLICIES IN PLACE GOVERNING THE DISTRIBUTION OF FUNDS FROM THE FOUNDATION. THERE ARE FOUR DIFFERENT CATEGORIES FUND DISTRIBUTIONS MAY COME FROM. 1) UNRESTRICTED, 2) FIELD OF INTEREST, 3) ADVISED FUND, AND 4) DESIGNATED. REQUESTS FOR FUND DISTRIBUTIONS ARE REVIEWED BY A GRANT COMMITTEE WHICH ARE THEN FORWARDED ON TO THE BOARD OF DIRECTORS. THE BOARD OF DIRECTORS ACTS ON THE RECOMMENDATIONS OF THE GRANT COMMITTEE. CHECKS FOR THE RECIPIENTS OF THE GRANT ARE NOT SIGNED UNTIL THE CORRESPONDING APPLICATION FOR FUND FORM IS REVIEWED. CHECKS OVER $5,000 MUST HAVE A SECOND SIGNATURE BY A FOUNDATION OFFICER ON THE APPLICATION FOR FUNDS FORM.
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
ST CLOUD HOSPITAL
 
Employer identification number

41-0695596
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) CRAIG BROMAN (i)
(ii)		 477,434
0 		111,557
0 		100,683
0 		103,917
0 		39,092
0 		832,683
0 		95,270
0
(2) PAUL DORSHER MD (i)
(ii)		 0
323,968 		0
43,935 		0
2,849 		0
34,479 		0
23,618 		0
428,849 		0
0
(3) CINDA MELLOY MD (i)
(ii)		 6,645
165,294 		0
40,092 		0
1,478 		0
15,042 		0
21,667 		6,645
243,573 		0
0
(4) GREG KLUGHERZ (i)
(ii)		 368,764
0 		76,230
0 		79,200
0 		87,297
0 		19,538
0 		631,029
0 		74,990
0
(5) PAUL HARRIS (i)
(ii)		 0
250,007 		0
55,565 		0
2,321 		0
47,172 		0
36,234 		0
391,299 		0
0
(6) JIM DAVIS (i)
(ii)		 0
278,990 		0
52,884 		0
48,714 		0
15,380 		0
21,302 		0
417,270 		0
42,794
(7) DANIEL WHITLOCK MD (i)
(ii)		 284,672
0 		62,533
0 		266,838
0 		17,143
0 		16,105
0 		647,291
0 		211,394
0
(8) MARK MATTHIAS MD (i)
(ii)		 127,676
0 		10,000
0 		1,054
0 		0
0 		18,897
0 		157,627
0 		0
0
(9) CHARLES DOOLEY (i)
(ii)		 163,993
0 		54,397
0 		91,170
0 		22,867
0 		15,253
0 		347,680
0 		44,357
0
(10) LINDA CHMIELEWSKI (i)
(ii)		 271,669
0 		54,511
0 		76,687
0 		56,915
0 		22,400
0 		482,182
0 		71,952
0
(11) DUANE RASMUSSON (i)
(ii)		 242,685
0 		51,922
0 		34,018
0 		49,821
0 		25,303
0 		403,749
0 		31,051
0
(12) LINDA DOERR (i)
(ii)		 190,337
0 		34,135
0 		25,651
0 		35,568
0 		18,305
0 		303,996
0 		22,087
0
(13) ROBERT JOHNSON (i)
(ii)		 175,009
0 		11,345
0 		6,998
0 		14,687
0 		3,986
0 		212,025
0 		0
0
(14) AMY PORWOLL (i)
(ii)		 199,066
0 		16,256
0 		7,536
0 		16,554
0 		32,232
0 		271,644
0 		0
0
(15) JON BOWAR (i)
(ii)		 437,744
0 		41,465
0 		340
0 		18,375
0 		28,846
0 		526,770
0 		0
0
(16) MARY LUNDE (i)
(ii)		 360,400
0 		51,220
0 		18,069
0 		17,888
0 		24,846
0 		472,423
0 		0
0
(17) JOEL SPALDING (i)
(ii)		 299,338
0 		48,436
0 		18,313
0 		18,410
0 		26,846
0 		411,343
0 		0
0
(18) JEFFREY CARLSON (i)
(ii)		 265,816
0 		44,759
0 		480
0 		0
0 		0
0 		311,055
0 		0
0
(19) THOMAS MCNANLEY (i)
(ii)		 440,094
0 		34,856
0 		180
0 		0
0 		23,762
0 		498,892
0 		0
0
(20) JOHN SECKINGER (i)
(ii)		 0
0 		0
0 		283,393
0 		0
0 		0
0 		283,393
0 		283,393
0
(21) JOHN FROBENIUS (i)
(ii)		 0
0 		0
0 		202,096
0 		0
0 		0
0 		202,096
0 		202,096
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
Supplemental Compensation Information SCHEDULE J, PART I, LINE 4(B) CRAIG BROMAN RECEIVED $95,270 ACCRUED $89,217 GREG KLUGHERZ RECEIVED $74,990 ACCRUED $75,047 CHARLES DOOLEY RECEIVED $44,357 ACCRUED $18,532 LINDA CHMIELEWSKI RECEIVED $71,952 ACCRUED $38,504 DUANE RASMUSSON RECEIVED $31,051 ACCRUED $31,265 LINDA DOERR RECEIVED $22,087 ACCRUED $19,198 JIM DAVIS RECEIVED 42,794 ACCRUED $0 JOHN SECKINGER RECEIVED $283,393 ACCRUED $0 JOHN FOBENIUS RECEIVED $202,096 ACCRUED $0 PAUL HARRIS RECEIVED $0 ACCRUED $37,166 DANIEL WHITLOCK RECEIVED $211,394 ACCRUED $0
OFFICER'S COMPENSATION EXPLANATION SCHEDULE J AND PART VII THE CORPORATION'S EXECUTIVES ARE ELIGIBLE TO PARTICIPATE IN BENEFIT PLANS WHICH INCLUDE TAX DEFERRED NON QUALIFIED INVESTMENT ACCOUNTS. THESE PLANS MAY PROVIDE BUT ARE NOT CERTAIN TO PROVIDE, FOR PAYMENT OF TAX DEFERRED COMPENSATION TO THESE EXECUTIVES AT SOME TIME IN THE FUTURE. THE EXECUTIVE HAS NO LEGAL RIGHT TO THESE DOLLARS UNTIL, AND UNLESS, CERTAIN FUTURE EVENTS OCCUR. IN ACCORDANCE WITH THE INSTRUCTIONS TO THE FORM 990, THE AMOUNTS IN SECTION VII AND IN SCHEDULE J REFLECT THIS TAX DEFERRED COMPENSATION. THIS COMPENSATION IS POTENTIALLY REPORTED TWICE ON THE FORM 990. ONCE WHEN THE COMPENSATION IS DEFERRED OR ACCRUED AND AGAIN IF IT IS PAID TO THE EXECUTIVE.
Schedule J (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
ST CLOUD HOSPITAL
 
Employer identification number

41-0695596
Identifier Return Reference Explanation
COMMUNITY BENEFIT REPORT - EXECUTIVE SUMMARY FORM 990, PART III, LINE 4A ST. CLOUD HOSPITAL CONTRIBUTES SIGNIFICANTLY AND DIVERSELY TO ITS COMMUNITY. THE MISSION STATEMENT CHARGES ST. CLOUD HOSPITAL (AS A COLLECTION OF INDIVIDUALS AND AS A NOT-FOR-PROFIT ORGANIZATION) "TO IMPROVE THE HEALTH AND QUALITY OF LIFE FOR THE PEOPLE OF CENTRAL MINNESOTA..." ST. CLOUD HOSPITAL RESPONDS TO THIS CHALLENGE BY PROVIDING HIGH QUALITY SERVICES TO THE BROAD COMMUNITY, CHARITY CARE AND OUTREACH SERVICES TO THE POOR AND NEEDY, ASSISTING IN THE EDUCATION OF MEDICAL AND HEALTH PROFESSIONALS AND TAKING A LEADERSHIP ROLE IN IDENTIFYING AND RESPONDING TO HEALTH AND HEALTH-RELATED PROBLEMS. THE COMMUNITY BENEFIT INVENTORY FOR SOCIAL ACCOUNTABILITY (CBISA) SOFTWARE DOCUMENTS THE RESOURCES ST. CLOUD HOSPITAL PROVIDES IN FULFILLING THIS MISSION OF COMMUNITY SERVICE. TOO OFTEN THE FOCUS ON PROVIDING COMMUNITY SERVICES RESTS SOLELY ON THE AMOUNT OF CHARITY CARE PROVIDED BY A NOT-FOR-PROFIT HOSPITAL. AS A RESULT, THE TOTAL AMOUNT OF COMMUNITY SERVICE THAT A HOSPITAL PROVIDES GOES UNNOTICED OR, AT BEST, UNDERESTIMATED. THIS CBISA REPORT INCLUDES NOT ONLY CHARITY CARE AND OTHER SERVICES FOR THE POOR, BUT ALSO THE FULL RANGE OF COMMUNITY SERVICES THAT ARE A PART OF ST. CLOUD HOSPITAL'S MISSION OF SERVING THE HEALTH CARE NEEDS OF OUR COMMUNITY. AS A HEALTHCARE LEADER IN CENTRAL MINNESOTA, ST. CLOUD HOSPITAL MUST BE INVOLVED, CARING AND RESPONSIVE TO OUR COMMUNITY. WE HAVE STRONG TIES TO OUR REGION AND FEEL AN OBLIGATION TO MEET THE NEEDS OF THE PEOPLE WE SERVE. WE BELIEVE THAT PROVIDING QUALITY HEALTH CARE MEANS LOOKING BEYOND OUR OWN WALLS TO ENSURE THAT THE REGION'S HEALTH CARE NEEDS ARE BEING MET. THE RESOURCES NECESSARY TO MEET MANY OF THESE NEEDS COST MORE THAN THE HOSPITAL CAN RECLAIM IN FEES. IF ST. CLOUD HOSPITAL DID NOT PARTICIPATE IN IMPLEMENTING SOME OF THESE NEEDS-DRIVEN COMMUNITY SERVICES, OUR REGION WOULD BE LEFT WITH A VOID IN THESE AREAS THAT WOULD HARM THE QUALITY OF LIFE FOR MANY PEOPLE IN OUR COMMUNITY. REPORT HIGHLIGHTS - UNCOMPENSATED CARE IN FISCAL YEAR 2011-12 THE HOSPITAL PROVIDED UNCOMPENSATED CARE TO THE PEOPLE OF CENTRAL MINNESOTA. THESE SERVICES COST THE HOSPITAL NEARLY $4.8 MILLION TO PROVIDE. - UNPAID COST OF MEDICAID AND OTHER PUBLIC PROGRAMS MEDICAID DOES NOT FULLY REIMBURSE THE HOSPITAL FOR THE COST OF THE CARE PROVIDED. IN FISCAL YEAR 2011-12, THE HOSPITAL LOST AN ESTIMATED $19.7 MILLION. - UNPAID COST OF MEDICARE MEDICARE DOES NOT FULLY REIMBURSE THE HOSPITAL FOR THE COST OF CARE PROVIDED. IN FISCAL YEAR 2011-12, THE HOSPITAL LOST AN ESTIMATED $11.1 MILLION IN UNPAID COSTS IN TREATING MEDICARE PATIENTS. - FAMILY MEDICINE CENTER AND FAMILY MEDICINE RESIDENCY THE FAMILY MEDICINE CENTER OPENED IN SEPTEMBER 1990, TO SERVE THE PRIMARY HEALTH CARE NEEDS OF THE ESTIMATED 19,000 UNINSURED AND UNDERINSURED PEOPLE WITHIN A 30 MILE RADIUS OF ST. CLOUD. THE CLINIC HAS 8,900 PATIENTS ENROLLED, THE MAJORITY OF WHICH ARE WOMEN AND CHILDREN. THROUGH Project H.E.A.L. (HEALTH EDUCATION ACCESS LINK), H.E.A.L. is an outreach collaborative effort lead by Mid Minnesota Family Medicine Center. Project H.E.A.L. provides free health screening clinics staffed with volunteer Physicians and Nurses from local congregations. The clinics take place at area social service agencies such as: Salvation Army, Catholic Charities, Place of Hope, St. Mary's Church in Melrose, St. Mary's Church in Long Prairie and Reynolds Baptist Church in Long Prairie. These community service sites host a Project H.E.A.L. screening clinic once or twice per month serving over 266 individuals. The University of Minnesota/St. Cloud Hospital Family Medicine Residency Program was initiated in 1996 to help address the shortage of family practice physicians in rural Minnesota. Despite funding from the state and federal agencies, the residency program required operating subsidies from the St. Cloud Hospital. St. Cloud Hospital in fiscal year 2011-12, provided over $1.29 million in cost subsidies for the Family Medicine Center and the Family Medicine Residency program. - CASH DONATIONS TO THE NEEDY Many times patients and families do not have money for food or a ride home from the hospital. At staff discretion, hospital funds are available for such emergencies. Last year nearly $23,000 in cash contributions were given to patients and families with an immediate need. During the months of September through May, local churches open their facilities for sleeping space for homeless people after shelters are full. Blankets are provided to them and laundered by the St. Cloud Hospital's laundry service once per week. During the coldest times of the year, the loads can total 250-300 blankets. - CASH DONATIONS TO MEDICAL MISSIONS Each year the St. Cloud Hospital donates $500 dollars to each employee who participates in a medical mission such as HELPS International in Guatemala. The money is used for travel expenses or is donated directly to the mission. Last year, over $34,000 was donated to support medical missions through employee sponsorship and supplies to countries such as Guatemala and Honduras. - FOUNDATION FUNDING St. Cloud Hospital is committed to supporting the CentraCare Foundation. In Fiscal Year 2011-12 St. Cloud Hospital subsidized the Foundation for more than $2.2 million. This nongovernmental organization (NGO) is dedicated to enhancing the health status in Central Minnesota as well as contributing to other Community projects. The Community Collaboration Committee (CCC), a standing committee of CentraCare Health Foundation, has a membership of over 30 persons representing healthcare and community needs across Central Minnesota. The CCC meets monthly to discuss ways to address typical health issues through awareness building, education and/or an intervention project. There are several community healthy outreach initiatives that the Foundation is involved with, these initiates include: *BLEND Childhood Obesity Coalition of Central Minnesota (goal is to reduce the incidence of childhood obesity by 2016) *Smoke Free Communities (Continued efforts to create clean indoor and outdoor air for all) *QUITPLAN Clinics (Collaboration with CentraCare Clinics to help those trying to quit smoking) *CentraCare Clinic Medical Home Pilot
COMMUNITY BENEFIT REPORT - EXECUTIVE SUMMARY (CONT) FORM 990, PART III, LINE 4A NARRATIVE REPORT The quantitative nature of the Community Benefit Inventory for Social Accountability (CBISA) necessitates a separate section to highlight the human side of the valuable services that the hospital and its employees provide. There are two important details about the nature of the St. Cloud Hospital employees' and organizational community contributions that should be noted here. First, is that behind every community service activity listed in this report are the people who made that activity happen. These people have reached beyond their job description, set aside their important projects, and taken time away from their busy schedules to seek out worthy uses of hospital resources in order to make their community a healthier, safer place to live. The second detail is not reflected in the numbers above at all, but is nevertheless a paramount validation of the St. Cloud Hospital employees' dedication to the health of their community. This is the sum of all the personal time and financial resources that the St. Cloud Hospital's work force has invested in its community. Quantifying the thousands of volunteer hours given to the hundreds of various service organizations by the hospital employees is beyond the scope of this narrative. Examples of these volunteer activities include, but are not limited to: *Hospice volunteers *Skin cancer screening at Coborns *Board meetings to plan for health care services in Honduras *Volunteering vacation time in Honduras performing numerous medical services ranging from general medicine to kidney dialysis *United Way volunteering (Big Brother/Sister, etc.) *American Heart Association Heart Walk *Inservice to school nurses for children with diabetes *Coaching children in different sporting events *Assisting in classrooms with children activities Probably the most salient collective example of the 4,200 St. Cloud Hospital employees pitching-in to support local common assets is the donation of over $260,000 to the United Way and more than $693,959 to the CentraCare Health Foundation in fiscal year 2011-12. These people, who balance their personal and professional lives in order to contribute positively to their community, are truly the foundations of a prosperous community. While the hospital cannot take credit for the time, effort and dollars its employees have given outside of work, it cannot help but reflect their commitment to the community. The Community Benefit Inventory for Social Accountability is a quantitative exercise to determine how the hospital benefits the community. The hospital is little more than a building, some equipment, and a collection of caring individuals. And it is clearly those individuals who are so selflessly dedicated to the betterment of their community as well as their careers, which make St. Cloud Hospital the invaluable community asset it is. AUDITED FINANCIAL STATEMENTS FORM 990, PART IV, LINE 12B ST. CLOUD HOSPITAL AND ST. BENEDICT'S SENIOR COMMUNITY ARE INCLUDED IN THE CONSOLIDATED FINANCIAL STATEMENTS OF THE CENTRACARE HEALTH SYSTEM, WHICH WERE PREPARED IN ACCORDANCE WITH GAAP. THESE FINANCIAL STATEMENTS ARE AUDITED BY A INDEPENDENT CERTIFIED PUBLIC ACCOUNTING FIRM. THE CONSOLIDATED FINANCIAL STATEMENTS RECEIVED AN UNQUALIFIED OPINION FROM THE ACCOUNTING FIRM. TAX EXEMPT BONDS FORM 990, PART IV, LINE 24A ALL TAX EXEMPT BOND FINANCING IS REPORTED ON THE CENTRACARE HEALTH SYSTEM FORM 990 (FEIN 41-1813221). Description of Classes of Persons and the Nature of Their Rights Form 990, Part VI, QuestionS 6, 7A, AND 7B ST. CLOUD HOSPITAL'S MEMBERS CONSIST OF EX-OFFICIO REPRESENTATIVES OF THE DIOCESE OF ST. CLOUD AND THE SISTERS OF THE ORDER OF SAINT BENEDICT AND TWO TO FOUR MEMBERS APPOINTED BY THESE EX-OFFICIO MEMBERS. THE MEMBERS APPOINT THE ST. CLOUD HOSPITAL BOARD. IN ADDITION TO APPOINTING THE ST. CLOUD HOSPITAL BOARD, THE MEMBERS APPROVE AMENDMENTS TO THE ARTICLES OF INCORPORATION, APPROVE THE DISSOULTION OF THE HOSPITAL, AND SUPPORT AND ASSESS THE HOSPITAL'S ROMAN CATHOLIC IDENTIFY AND MISSIONS.
Mailing address of persons to be contacted at a different address Form 990, Part VI, Question 9 CHARLES DOOLEY WAS VICE PRESIDENT/CIO UNTIL 6-11-11 AND OFFICIALLY TERMINATED EMPLOYMENT 7-11-11. AMY PORWOLL BECAME THE NEW VICE PRESIDENT/CIO AS OF 6-12-11. CHARLES' CURRENT ADDRESS IS 3119 CLUB VIEW COURT, ST. CLOUD, MN, 56301.
Describe the Process used by Management &/or Governing Body to Review 990 Form 990, Part VI, Question 11B MANAGEMENT REVIEWS THE 990 TAX RETURN REGULARLY DURING THE PREPARATION PROCESS, THEY FIELD QUESTIONS FROM STAFF AND MANAGE DEADLINES WHICH MUST BE MET. THEY ARE ALSO ACTIVELY INVOLVED WITH THE THIRD PARTY FIRM WHO ASSISTS IN THE FINAL COMPILATION OF THE REPORT. ONCE A COMPLETED 990 REPORT HAS BEEN PRODUCED, ANNUALLY AT THE BOARD'S APRIL MEETING, PRIOR TO FILING, THE FULL BOARD HAS AN OPPORTUNITY TO REVIEW THE IRS FORM 990 WITH THE STAFF, TO ASK QUESTIONS AND SEEK CLARIFICATIONS, AND TO APPROVE THE FINAL DOCUMENT.
Description of Process to Monitor Transactions for Conflicts of Interest Form 990, Part VI, Question 12c THE BOARD MEMBERS ARE REQUIRED TO REVIEW AND SIGN A CONFLICT OF INTEREST QUESTIONNAIRE TWICE A YEAR. ALL STAFF SIGN CONFLICTS OF INTEREST FORMS ON AN ANNUAL BASIS. THE QUESTIONNAIRES ARE REVIEWED BY THE CORPORATE COMPLIANCE OFFICER AS WELL AS THE CORPORATE COMPLIANCE GROUP (A COMPLIANCE COMMITTEE WHICH INCLUDES INTERNAL MEMBERS AND OUTSIDE COUNSEL) THE RESPONSES TO THE QUESTIONNAIRE ARE THEN REVIEWED WITH THE EXECUTIVE COMMITTE OF THE BOARD. THE CORPORATE COMPLIANCE OFFICER IS RESPONSIBLE FOR MONITORING CONFLICTS OF INTERESTS RELATED TO BOARD AND STAFF AND TO ALERT AFFECTED PARTIES WHEN A CONFLICT ARISES. WHEN AN ACTUAL CONFLICT ARISES, THE AFFECTED PARTY IS ASKED TO RECUSE HIM/HER SELF FROM THE DECISION MAKING PROCESS. THE CORPORATE COMPLIANCE OFFICER ATTENDS BOARD MEETINGS AND SPECIFIED BOARD COMMITTEE MEETINGS WHERE CONFLICT ISSUES MAY ARISE.
Offices & Positions for Which Process was Used, & Year Process was Begun Form 990, Part VI, Question 15a THE COMPENSATION AND BENEFITS OF THE PRESIDENT IS SUBJECT TO FULL COMPENSATION AND BENEFITS COMPARABILITY STUDIES CONDUCTED BIENNIALLY BY A THIRD PARTY INDEPENDENT COMPENSATION CONSULTANT. HOWEVER, THE COMPENSATION PORTION OF THE STUDY IS REVIEWED ANNUALLY BY THE CONSULTANT AND UPDATED FOR COMPENSATION COMMITTEE AND BOARD OF DIRECTORS REVIEW AND APPROVAL. THE MOST RECENT FULL REVIEW WAS DONE IN MAY 2012. THE THIRD PARTY INDEPENDENT COMPENSATION CONSULTANT IS RETAINED BY ST. CLOUD HOSPITAL TO PERFORM THESE SERVICES.
Offices & Positions for Which Process was Used, & Year Process was Begun Form 990, Part VI, Question 15b THE COMPENSATION AND BENEFITS OF THE VICE PRESIDENTS (NON-MEDICAL PROVIDERS) ARE SUBJECT TO FULL COMPENSATION AND BENEFITS COMPARABILITY STUDIES CONDUCTED BIENNIALLY BY A THIRD PARTY INDEPENDENT COMPENSATION CONSULTANT. HOWEVER, THE COMPENSATION PORTION OF THE STUDY IS REVIEWED ANNUALLY BY THE CONSULTANT AND UPDATED FOR COMPENSATION COMMITTEE AND BOARD OF DIRECTORS REVIEW AND APPROVAL. THE MOST RECENT FULL REVIEW WAS DONE IN MAY 2012. THE THIRD PARTY INDEPENDENT COMPENSATION CONSULTANT IS RETAINED BY ST. CLOUD HOSPITAL TO PERFORM THESE SERVICES.
Avail of Gov Docs, Conflict of Interest Policy, & Fin Stmts to Gen Public Form 990, Part VI, Question 19 THE HOSPITAL/CENTRACARE HEALTH SYSTEM DOES NOT GENERALLY MAKE ITS GOVERNING DOCUMENTS OR CONFLICT OF INTEREST POLICY AVAILABLE TO THE PUBLIC. THE HOSPITAL/CENTRACARE HEALTH SYSTEM DOES DO AN ANNUAL REPORT TO THE COMMUNITY IN WHICH FINANCIAL RESULTS ARE REPORTED TO AND DISCUSSED WITH THE PUBLIC. THIS REPORT IS AVAILABLE TO THE PUBLIC ON THE ORGANIZATION'S WEBSITE. HOURS DEVOTED TO RELATED ORGANIZATIONS FORM 990, PART VII GREG KLUGHERZ, TREASURER-CFO OF ST. CLOUD HOSPITAL, ALSO DEVOTES 20 HOURS PER WEEK TO CENTRACARE HEALTH SYSTEM.
Balance Sheet Other Change in Net Assets Part X Balance Sheet Part XI Other Change In Net Assets: Unrealized Interest Income ($57,401,757) Contributions of Property and Equipment $5,362,896 Adjustment to Funded Status of Pension Plan ($35,345,861) Net Transfers to (from) Affiliated Organizations ($12,892,431) Other $186 -------------- TOTAL ($100,276,967) ===============
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:PAUL DORSHER, MD TITLE:DIRECTOR, VICE CHAIR HOURS:40
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:CINDA MELLOY, MD TITLE:DIRECTOR HOURS:40
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


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

OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
ST CLOUD HOSPITAL
 
Employer identification number

41-0695596
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) CENTRACARE HEALTH SYSTEM

1406 SIXTH AVENUE NORTH

ST CLOUD,MN56303
41-1813221 		HEALTHCARE MN 501(C)(3) IIC III-FI NA
 
 
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












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












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
Yes
 
b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
 
No
c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c
 
No
d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1d
 
No
e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1e
 
No
f 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
 
No
k Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .
1k
 
No
l Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .
1l
 
No
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
Yes
 
o Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
Yes
 
p Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
Yes
 
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
Yes
 
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) CENTRACARE HEALTH SYSTEM

 A (IV 15,465 FMV
(2) CENTRACARE HEALTH SYSTEM

 N 419,765 FMV
(3) CENTRACARE HEALTH SYSTEM

 O 1,402,617 FMV
(4) CENTRACARE HEALTH SYSTEM

 P 35,846,788 FMV
(5) CENTRACARE HEALTH SYSTEM

 R 12,892,431 FMV
(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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