Department of the Treasury Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. See separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
Overlake Hospital Association
Employer identification number
91-1274134
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization?
................
11g(i)
No
(ii)
a family member of a person described in (i) above?
......................
11g(ii)
No
(iii)
a 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
No
h
Provide the following information about the supported organization(s).
(i) Name of supported organization
(ii) EIN
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions))
(iv) Is the organization in col. (i) listed in your governing document?
(v) Did you notify the organization in col. (i) of your support?
(vi) Is the organization in col. (i) organized in the U.S.?
(vii) Amount of support?
Yes
No
Yes
No
Yes
No
(1)
Overlake Hospital Auxiliaries
237297831
9
Yes
No
No
0
(2)
Overlake Hospital Foundation
911050325
7
Yes
No
No
0
(3)
Overlake Hospital Medical Center
910652651
3
Yes
Yes
No
876,533
Total
876,533
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the
organization failed to qualify under Part III. If the organization fails to
qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3
The value of services or facilities furnished by a governmental unit to the organization without charge..
4
Total. Add lines 1 through 3..
5
The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included
on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6
Public Support. Subtract line 5 from line 4.
Section B. Total Support
Calendar year(or fiscal year beginning in)
(a) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(f) Total
7
Amounts from line 4..
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
9
Net income from unrelated business activities, whether or not the business is regularly carried on..
10
Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..
11
Total support (Add lines 7 through 10).
12
Gross receipts from related activities, etc. (See instructions.)
..................
12
13
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here..........................................
Section C. Computation of Public Support Percentage
14
Public Support Percentage for 2010 (line 6 column (f) divided by line 11 column (f))
.........
14
15
Public Support Percentage for 2009 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2011.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
......................
b
33 1/3% support test—2010.
If the organization did not check the box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2011.
If the organization did not check a box on line 13, 16a, or 16b and line 14
is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported
organization
..................................................
b
10%-facts-and-circumstances test—2010.
If the organization did not check a box on line 13, 16a, 16b, or 17a and line
15 is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported organization
..............................................
18
Private Foundation
If the organization did not check a box on line 13, 16a, 16b, 17a or 17b, check this box and see
instructions
...................................................
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization
failed to qualify under Part II. If the organization fails to qualify under
the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2
Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
6
Total. Add lines 1 through 5.
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
b
Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c
Add lines 7a and 7b..
8
Public Support (Subtract line 7c from line 6.)
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(f) Total
9
Amounts from line 6...
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
13
Total support (Add lines 9, 10c, 11 and 12.).
14
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public Support Percentage for 2011 (line 8 column (f) divided by line 13 column (f))
.........
15
16
Public support percentage from 2010 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2011 (line 10c column (f) divided by line 13 column (f))
......
17
18
Investment income percentage from 2010 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2011.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3% and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
..........
b
33 1/3% support tests—2010.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
....
20
Private Foundation
If the organization did not check a box on line 14, 19a or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 4
Part IV
Supplemental Information.
Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
Explanation
Schedule A (Form 990 or 990-EZ) 2011
Additional Data
Software ID:
11000144
Software Version:
2011v1.5
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
Overlake Hospital Association
Employer identification number
91-1274134
Identifier
Return Reference
Explanation
Form 990, Part V, Line 7g & 7h
Overlake Hospital Association did not receive any contributions of intellectual property, cars, boats, airplanes, or other vehicles.
Form 990, Part V, Line 2a and 2b
Employees are paid through the use of a common paymaster and reported on the Form W-3 and other required filing of Overlake Hospital Medical Center.
Form 990, Part IV, Line 12
The financial statements of Overlake Hospital Association are audited on a consolidated basis and includes the activities of Overlake Hospital Medical Center, Overlake Hospital Foundation and Overlake Hospital Auxiliaries. This IRS Form 990 for Overlake Hospital Association only contains the activities of the Association while the activities of the related organizations are reported on separate IRS Form 990s.
Form 990, Part I, Line 6 - Volunteers
Overlake Hospital Association had 21 board members that volunteered their time as board members during the year.
Form 990 Part VII Section A, Line 1a
Cecily Hall devoted 1 hour to a related organization.Jim Doud devoted 3 hours to a related organization.Patricia Bedient devoted 1.5 hours to a related organization.Bertrand Valdman devoted 1 hour to a related organization.Larry Hebner devoted 3 hours to a related organization.John Murphy devoted 2 hours to a related organization.Robert Campbell devoted 2 hours to a related organization.Tom Cleveland devoted 2 hours to a related organization.Gregory Collins devoted 2 hours to related organizations.Patty Edwards devoted 3 hours to related organizations.Janine Florence devoted 1 hour to a related organization.Kemper Freeman Jr. devoted 1 hour to a related organization.Kathleen Gibson, MD devoted 1 hour to a related organization.John Hayhurst devoted 1.5 hours to a related organization.Ken Johnsen devoted 1 hour to a related organization.Linda Mahaffey devoted 3.5 hours to related organizations.Douglas Martin devoted 1 hour to a related organization.Tom Miller, MD devoted 1 hour to a related organization.Nolan Newman devoted 1.5 hours to a related organization.Walter Smith devoted 3 hours to a related organization.Russell Stockdale devoted .5 hour to a related organization.Craig Hendrickson devoted 65 hours to related organizations.Gary McLaughlin devoted 50 hours to related organizations.
Form 990, Part VI, Line 19
Form 990, Part VI, Line 19: Other Organization Documents Publicly Available
Overlake Hospital Association makes its governing documents, conflict of interest policy, and audited financial statements available through the Hospital's administration office. The Overlake Hospital Association consolidated financial statements are also available on the Overlake Medical Center's website.
Form 990, Part VI, Line 15b
Form 990, Part VI, Line 15b: Compensation Review and Approval Process for Officers and Key Employees
Overlake's policy and process for Executive Compensation is fully documented in the "Executive Compensation Administration and Compliance Manual" which was last updated April 2012. This manual details the charter of the Compensation Committee of the Board, the compensation philosophy and how salary increases, incentives, benefits and perquisites are administered. Compensation Committee members are independent board members as required by the Charter and By-laws. The process includes an independent consultant who works directly for the Compensation Committee and a review of comparable data from external sources. All compensation related decisions for the CEO, COO and Vice Presidents are discussed, deliberated and voted on by the Compensation Committee and documented in the minutes of the meeting. Officers Craig Hendrickson and Gary McLaughlin are paid by related affiliate Overlake Hospital Medical Center.
Form 990, Part VI, Line 12c
Form 990, Part VI, Line 12c: Explanation of Monitoring and Enforcement of Conflicts
Board members and management annually signs a statement which affirms that such person: 1) has received a copy of the Conflict of Interest Policy, 2) has read and understands the policy, 3) has agreed to comply with the policy, and 4) understands that the corporation is a charitable organization and that in order to maintain their federal tax exemption they must avoid conflicts of interest and engage primarily in activities which accomplice one or more of their tax-exempt functions. A list of all financial interests or other relationships with any organization that has, or can be reasonably expected to have, a transaction with the corporation, competes against the corporation, or whose interest materially conflicts with the interest of the corporation is submitted annually to the Overlake Hospital Medical Center Compliance Officer for review. The Compliance Officer summarizes any conflicts of interest and discusses these results with the Chair of the Audit & Compliance Committee, CEO, Overlake Hospital Medical Center VP Human Resources and General Counsel. This information is also shared with the Chair-Elect, Committee Chairs, and the CFO. At Board meetings, members are expected to recuse themselves from voting on issues when there is a conflict of interest.
Form 990, Part VI, Line 11
Form 990, Part VI, Line 11: Form 990 Review Process
The 990 is prepared internally and reviewed by an independent accounting firm. The 990 is then reviewed by the President and CEO, CFO and Overlake Hospital Medical Center Finance Committee. The 990 is sent to the Overlake Hospital Association Board members prior to submission to the IRS.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.