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

MediumBullet The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0047
2012
Open to Public Inspection
A For the 2012 calendar year, or tax year beginning 01-01-2012 , 2012, and ending 12-31-2012
BCheck if applicable:
CName of organization
Adventist Health Mid-America Inc
 
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
9100 W 74th Street
 
Room/suite
City or town, state or country, and ZIP + 4
Shawnee Mission, KS66204
D Employer identification number

52-1347407
E Telephone number

G Gross receipts $ 3,254
F Name and address of principal officer:
Ken Bacon
9100 W 74th Street
Shawnee Mission,KS66204
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
N/A
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 MediumBullet1071
K Form of organization:
 
L Year of formation: 1983
M State of legal domicile: KS
Part I
Summary
Activities  & Governance 1 Briefly describe the organization’s mission or most significant activities: Support of affiliated tax-exempt hospital
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) ........ 3 24
4 Number of independent voting members of the governing body (Part VI, line 1b) ..... 4 19
5 Total number of individuals employed in calendar year 2011 (Part V, line 2a) ...... 5 0
6 Total number of volunteers (estimate if necessary) ............. 6 0
7a Total unrelated business revenue from Part VIII, column (C), line 12 ........ 7a 0
b Net unrelated business taxable income from Form 990-T, line 34 ......... 7b 0
Revenues Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 0 0
9 Program service revenue (Part VIII, line 2g) ......... 0 0
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 3,250 3,254
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 0 0
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 3,250 3,254
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 0 0
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) 0 0
16a Professional fundraising fees (Part IX, column (A), line 11e)..... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet0    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e).... 0 0
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 0 0
19 Revenue less expenses. Subtract line 18 from line 12....... 3,250 3,254
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 160,242 163,496
21 Total liabilities (Part X, line 26)............. 160,242 163,496
22 Net assets or fund balances. Subtract line 21 from line 20..... 0 0
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title
Paid Preparer Use Only
Print/Type preparer's name
 
Preparer's signature
Date
PTIN
Firm's name MediumBullet

Firm's EIN MediumBullet
Firm's address MediumBullet



Phone no.
May the IRS discuss this return with the preparer shown above? (see instructions) ............
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2012)
Form 990 (2012)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III ...............
1
Briefly describe the organization’s mission: Adventist Health System Sunbelt Healthcare Corporation, and all of its subsidiary organizations, were established by the Seventh-Day Adventist Church to bring a ministry of healing and health to the communities served. Our mission is to extend the healing ministry of Christ.
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ......................
If “Yes,” describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services? ............................
If “Yes,” describe these changes on Schedule O.
4
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
Provides support and management services to Shawnee Mission Medical Center and other Seventh-day Adventist Programs. All such supported organizations are exempt under Section 501(c)(3).
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  
Form 990 (2012)
Form 990 (2012)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If “Yes,” complete Schedule AClick to see attachment........................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors (see instructions)? ...
2
 
No
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part I..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities, or have a section 501(h) election in effect during the tax year? If “Yes,” complete Schedule C, Part II........
4
 
No
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If “Yes,” complete Schedule C,
Part III
............................
5
 
No
6
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If “Yes,” complete Schedule D, Part IClick to see attachment........................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas, or historic structures? If “Yes,” complete Schedule D, Part IIClick to see attachment
...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If “Yes,” complete Schedule D, Part III Click to see attachment....................
8
 
No
9
Did the organization report an amount in Part X, line 21 for escrow or custodial account liability; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If “Yes,” complete Schedule D, Part IVClick to see attachment..............
9
 
No
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi-endowments? If “Yes,” complete Schedule D, Part VClick to see attachment......
10
 
No
11
If the organization’s answer to any of the following questions is "Yes," then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable.
a
Did the organization report an amount for land, buildings, and equipment in Part X, line 10?
If “Yes,” complete Schedule D, Part VI.Click to see attachment
...................
11a
 
No
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIIClick to see attachment.......
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIIIClick to see attachment.......
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part IXClick to see attachment............
11d
 
No
e
Did the organization report an amount for other liabilities in Part X, line 25? If “Yes,” complete Schedule D, Part XClick to see attachment
11e
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 XClick to see attachment.........................
11f
Yes
 
12a
Did the organization obtain separate, independent audited financial statements for the tax year?
If “Yes,” complete Schedule D, Parts XI and XII Click to see attachment.................
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If “Yes,” and if the organization answered "No" to line 12a, then completing Schedule D, Parts XI and XII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E....
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?.....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States, or aggregate foreign investments valued at $100,000 or more? If “Yes,” complete Schedule F, Parts I and IV.........
14b
 
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the United States? If “Yes,” complete Schedule F, Parts II and IV
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the United States? If “Yes,” complete Schedule F, Parts III and IV...
16
 
No
17
Did the organization report a total of more than $15,000 of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If “Yes,” complete Schedule G, Part I (see instructions)....
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 hospital facilities? If “Yes,” complete Schedule H....
20a
 
No
b
If “Yes” to line 20a, did the organization attach a copy of its audited financial statements to this return?
20b
 
 
Form 990 (2012)
Form 990 (2012)
Page 4
Part IV
Checklist of Required Schedules (continued)
21
Did the organization report more than $5,000 of grants and other assistance to any government or organization in the United States on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II...
21
 
No
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III........
22
 
No
23
Did the organization answer “Yes” to Part VII, Section A, line 3, 4, or 5 about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If “Yes,” complete Schedule J....................... 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 lines 24b through 24d and complete Schedule K. If “No,” go to line 25................
24a
 
No
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
 
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?
......................
24c
 
 
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
 
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If “Yes,” complete Schedule L, Part I........
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I...................
25b
 
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highest compensated employee, or disqualified person outstanding as of the end of the organization’s tax year? If “Yes,” complete Schedule L,
Part II
..........................
26
 
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member of any of these persons? If “Yes,” complete Schedule L, Part III.........
27
 
No
28
Was the organization a party to a business transaction with one of the following parties (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If “Yes,” complete Schedule L, Part IV ..........................
28a
 
No
b
A family member of a current or former officer, director, trustee, or key employee? If “Yes,”
complete Schedule L, Part IV
.....................
28b
 
No
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or direct or indirect owner? If “Yes,” complete Schedule L, Part IV...
28c
 
No
29
Did the organization receive more than $25,000 in non-cash contributions? If “Yes,” complete Schedule M..
29
 
No
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M.............
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If “Yes,” complete Schedule N,
Part I
...........................
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If “Yes,” complete Schedule N, Part II......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If “Yes,” complete Schedule R, Part I........ Click to see attachment
33
 
No
34
Was the organization related to any tax-exempt or taxable entity? If “Yes,” complete Schedule R, Part II, III, or IV, and Part V, line 1........................ Click to see attachment
34
Yes
 
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
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
 
No
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If “Yes,” complete Schedule R, Part V, line 2............. Click to see attachment
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If “Yes,” complete Schedule R, Part VIClick to see attachment
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11b and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2012)
Form 990 (2012)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V ...............
Yes
No
1a
Enter the number reported in Box 3 of Form 1096 Enter -0- if not applicable ..
1a
0
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable .
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
 
 
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and
Tax Statements, filed for the calendar year ending with or within the year covered by this return ..................
2a
0
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?
Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file (see instructions)
2b
 
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?...
3a
 
No
b
If “Yes,” has it filed a Form 990-T for this year? If “No,” provide an explanation in Schedule O.....
3b
 
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account, securities account, or other financial account)?..........................
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If “Yes,” to line 5a or 5b, did the organization file Form 8886-T? ............
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible as charitable contributions?...
6a
 
No
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
 
No
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
 
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?............................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?............................
7g
 
 
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.
See the instructions for additional information the organization must report on Schedule O.
13a
 
 
b
Enter the amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans ....
13b
 
c
Enter the amount of reserves on hand ............
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
No
b
If "Yes," has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O..
14b
 
 
Form 990 (2012)
Form 990 (2012)
Page 6
Part VI
Governance, Management, and Disclosure For each “Yes” response to lines 2 through 7b below, and for a “No” response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI ...............
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year .....................
1a
24
If there are material differences in voting rights among members of the governing body, or if the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
b
Enter the number of voting members included in line 1a, above, who are independent ...................
1b
19
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
 
No
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? .
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed? ...........................
4
 
No
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Did the organization have members or stockholders? ................
6
Yes
 
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? ....................
7a
Yes
 
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ...................
7b
Yes
 
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .........................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ............
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If “Yes,” provide the names and addresses in Schedule O.......
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal Revenue Code.)
Yes
No
10a
Did the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If “Yes,” did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes?
10b
 
 
11a
Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form? ............................
11a
Yes
 
b
Describe in Schedule O the process, if any, used by the organization to review this Form 990. .....
12a
Did the organization have a written conflict of interest policy? If “No,” go to line 13.......
12a
Yes
 
b
Were officers, directors, or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ..........................
12b
Yes
 
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If “Yes,” describe in Schedule O how this was done.......................
12c
Yes
 
13
Did the organization have a written whistleblower policy? ...............
13
Yes
 
14
Did the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
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
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:
MediumBulletJack Wagner9100 W 74th StreetShawnee MissionKS662044019 (913) 676-2151
Form 990 (2012)
Form 990 (2012)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response to any question in this Part VII ...............
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

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

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

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

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organization compensated any current officer, director, or trustee.
(A)
Name and Title
(B)
Average hours per week (list any hours for related organizations below dotted line)
(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee)
(D)
Reportable compensation from the organization (W- 2/1099-MISC)
(E)
Reportable compensation from related organizations (W- 2/1099-MISC)
(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(1) Carlson Ronald........................................................................
Director
.10
.......................3.00
X           0 1,071 0
(2) Cauley DMin Michael F........................................................................
Director
.10
.......................3.00
X           0 1,071 0
(3) Cazeau Esq RoseMarie........................................................................
Director (end 12/12)
.10
.......................3.00
X           0 1,071 0
(4) Craig Carlos........................................................................
Director
.10
.......................3.00
X           0 1,071 0
(5) Davidson James R........................................................................
Director
.10
.......................3.00
X           0 2,071 0
(6) Griffith Jr Buford........................................................................
Director
.10
.......................3.00
X           0 1,821 0
(7) Grove Rodney A........................................................................
Director
.10
.......................3.00
X           0 2,071 0
(8) Hagele Elaine M........................................................................
Director
.10
.......................3.00
X           0 1,821 0
(9) Hayes Alta Sue........................................................................
Director
.10
.......................3.00
X           0 1,071 0
(10) Houmann Lars D........................................................................
Director
.10
.......................50.00
X           0 1,371,852 242,069
(11) Jernigan PhD Donald L........................................................................
Director/CEO
.10
.......................50.00
X           0 1,976,362 106,120
(12) Johnson MD Mark........................................................................
Director
.10
.......................3.00
X           0 1,071 0
(13) Knutson J Deryl........................................................................
Director
.10
.......................3.00
X           0 2,071 0
(14) Lemon Thomas L........................................................................
Vice Chairman/Director
.10
.......................3.00
X           0 2,850 0
(15) Livesay MDiv Donald E........................................................................
Chairman/Director
.10
.......................3.00
X           0 2,850 0
(16) Moore MDiv Larry R........................................................................
Vice Chairman/Director
.10
.......................3.00
X           0 2,850 0
(17) Morel Hubert J........................................................................
Director
.10
.......................3.00
X           0 1,071 0
Form 990 (2012)
Form 990 (2012)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and Title
(B)
Average hours per week (list any hours for related organizations below dotted line)
(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee)
(D)
Reportable compensation from the organization (W- 2/1099-MISC)
(E)
Reportable compensation from related organizations (W- 2/1099-MISC)
(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(18) Pichette Ray........................................................................
Director
.10
.......................3.00
X           0 1,071 0
(19) Reiner Richard K........................................................................
Director
.10
.......................50.00
X           0 1,681,892 62,430
(20) Robinson Randy........................................................................
Director
.10
.......................3.00
X           0 2,071 0
(21) Scott Glynn CW........................................................................
Director
.10
.......................3.00
X           0 2,071 0
(22) Shaw Terry D........................................................................
Director
.10
.......................50.00
X           0 1,343,770 234,647
(23) Smith DMin PhD Ron C........................................................................
Vice Chair/Sec/Director
.10
.......................3.00
X           0 2,671 0
(24) Valentine MDiv II Maurice........................................................................
Director (end 9/12)
.10
.......................3.00
X           0 1,321 0
(25) Werner Thomas L........................................................................
Director
.10
.......................3.00
X           0 1,071 0
(26) Wagner Jack........................................................................
CFO
1.00
.......................50.00
    X       0 545,078 25,959
(27) Bacon Ken........................................................................
CEO
1.00
.......................50.00
    X       0 323,702 93,500
(28) Turner Sr Samuel H........................................................................
Former Officer/CEO
0.00
.......................0.00
          X 0 794,956 26,314




1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 0 8,073,790 791,039
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organizationMediumBullet0
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If “Yes,” complete Schedule J for such individual ..............
3
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
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet0
Form 990 (2012)
Form 990 (2012)
Page 9
Part VIII
Statement of Revenue
Check if Schedule O contains a response to any question in this Part VIII ..............
(A)
Total revenue
(B)
Related or
exempt
function
revenue
(C)
Unrelated
business
revenue
(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, Gifts, Grants and Other Similar Amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c  
d Related organizations...1d  
e Government grants (contributions)1e  
f All other contributions, gifts, grants, and
similar amounts not included above
1f
 
g Noncash contributions included in lines
1a-1f:$
 
h Total. Add lines 1a-1f.......MediumBullet  
 Program Service Revenue Business Code
2a
b
c
d
e
f All other program service revenue .        
g Total. Add lines 2a–2f........MediumBullet  
 Other Revenue 3 Investment income (including dividends, interest, and other similar amounts).......MediumBullet 3,254     3,254
4 Income from investment of tax-exempt bond proceeds..MediumBullet        
5 Royalties...........MediumBullet        
(i) Real (ii) Personal
6a Gross rents    
b Less: rental expenses    
c Rental income or (loss)    
d Net rental income or (loss).......MediumBullet        
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory    
b Less: cost or other basis and sales expenses    
c Gain or (loss)    
d Net gain or (loss)..........MediumBullet        
8a Gross income from fundraising events (not including
$  
of contributions reported on line 1c). See Part IV, line 18 ..
a  
b Less: direct expenses ...b  
c Net income or (loss) from fundraising events..MediumBullet      
9a Gross income from gaming activities.
See Part IV, line 19 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from gaming activities...MediumBullet        
10a Gross sales of inventory, less
returns and allowances .
a  
b Less: cost of goods sold ..b  
c Net income or (loss) from sales of inventory..MediumBullet        
Miscellaneous Revenue Business Code
11a            
b            
c            
d All other revenue ....        
e Total. Add lines 11a–11d ...... MediumBullet  
12 Total revenue. See Instructions......MediumBullet 3,254 0 0 3,254
Form 990 (2012)
Form 990 (2012)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A).Check if Schedule O contains a response to any question in this Part IX ...............
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII.
(A)
Total expenses
(B)
Program service expenses
(C)
Management and general expenses
(D)
Fundraising expenses
1 Grants and other assistance to governments and organizations in the United States. See Part IV, line 21    
2 Grants and other assistance to individuals in the United States. See Part IV, line 22    
3 Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16    
4 Benefits paid to or for members    
5 Compensation of current officers, directors, trustees, and key employees ....        
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....        
7 Other salaries and wages        
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....        
9 Other employee benefits .......        
10 Payroll taxes ...........        
11 Fees for services (non-employees):        
a Management ......        
b Legal .........        
c Accounting ...........        
d Lobbying ...........        
e Professional fundraising services. See Part IV, line 17    
f Investment management fees ......        
g Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........        
12 Advertising and promotion ....        
13 Office expenses .......        
14 Information technology ......        
15 Royalties ..        
16 Occupancy ...........        
17 Travel ............        
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ......        
19 Conferences, conventions, and meetings ....        
20 Interest ...........        
21 Payments to affiliates .......        
22 Depreciation, depletion, and amortization .....        
23 Insurance ..............        
24 Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a
b
c
d
e All other expenses        
25 Total functional expenses. Add lines 1 through 24e 0 0 0 0
26 Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here MediumBullet if following SOP 98-2 (ASC 958-720).        
Form 990 (2012)
Form 990 (2012)
Page 11
Part X Balance Sheet Check if Schedule O contains a response to any question in this Part X ...............
(A)
Beginning of year
(B)
End of year
Assets 1 Cash—non-interest-bearing .............   1  
2 Savings and temporary cash investments ......... 160,242 2 163,496
3 Pledges and grants receivable, net ...........   3  
4 Accounts receivable, net .............   4  
5 Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L ..................
  5  
6 Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
  6  
7 Notes and loans receivable, net .............   7  
8 Inventories for sale or use ..............   8  
9 Prepaid expenses and deferred charges ..........   9  
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a  
b Less: accumulated depreciation ..... 10b     10c  
11 Investments—publicly traded securities ..........   11  
12 Investments—other securities. See Part IV, line 11 .....   12  
13 Investments—program-related. See Part IV, line 11 .....   13  
14 Intangible assets ...............   14  
15 Other assets. See Part IV, line 11 ...........   15  
16 Total assets. Add lines 1 through 15 (must equal line 34)...... 160,242 16 163,496
Liabilities 17 Accounts payable and accrued expenses .........   17  
18 Grants payable .................   18  
19 Deferred revenue ................   19  
20 Tax-exempt bond liabilities .............   20  
21 Escrow or custodial account liability. Complete Part IV of Schedule D..   21  
22 Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
persons. Complete Part II of Schedule L..........   22  
23 Secured mortgages and notes payable to unrelated third parties ..   23  
24 Unsecured notes and loans payable to unrelated third parties ....   24  
25 Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D.................... 160,242 25 163,496
26 Total liabilities. Add lines 17 through 25......... 160,242 26 163,496
Net Assets or Fund Balance Organizations that follow SFAS 117 (ASC 958), check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets ..............   27  
28 Temporarily restricted net assets ...........   28  
29 Permanently restricted net assets ...........   29  
Organizations that do not follow SFAS 117 (ASC 958), check here MediumBullet and complete lines 30 through 34.
30 Capital stock or trust principal, or current funds ........ 0 30 0
31 Paid-in or capital surplus, or land, building or equipment fund ..... 0 31 0
32 Retained earnings, endowment, accumulated income, or other funds 0 32 0
33 Total net assets or fund balances ........... 0 33 0
34 Total liabilities and net assets/fund balances ........ 160,242 34 163,496
Form 990 (2012)
Form 990 (2012)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI ...............
1
Total revenue (must equal Part VIII, column (A), line 12) ............
1
3,254
2
Total expenses (must equal Part IX, column (A), line 25) ............
2
0
3
Revenue less expenses. Subtract line 2 from line 1 ..............
3
3,254
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..
4
0
5
Net unrealized gains (losses) on investments ...............
5
 
6
Donated services and use of facilities .................
6
 
7
Investment expenses .....................
7
 
8
Prior period adjustments .....................
8
 
9
Other changes in net assets or fund balances (explain in Schedule O) ........
9
-3,254
10
Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 33, column (B))
10
0
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII ..............
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?
2a
 
No
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were compiled or reviewed on a separate basis, consolidated basis, or both:
b
Were the organization’s financial statements audited by an independent accountant?
2b
Yes
 
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were audited on a separate basis, consolidated basis, or both:
c
If “Yes,” to line 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant?
2c
Yes
 
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O.
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133?
3a
 
No
b
If “Yes,” did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits
3b
 
 
Form 990 (2012)
Form 990, Special Condition Description:
Special Condition Description
Additional Data


Software ID:  
Software Version:  
SCHEDULE A
(Form 990 or 990EZ)

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

Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
right arrow Attach to Form 990 or Form 990-EZ. right arrow See separate instructions.
OMB No. 1545-0047
2012
Open to Public
Inspection
Name of the organization
Adventist Health Mid-America Inc
 
Employer identification number

52-1347407
Part I
Reason for Public Charity Status (All organizations must complete this part.) See instructions.
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
f
g
(i) A person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the supported organization? ................
11g(i)
 
No
(ii) A family member of a person described in (i) above? ......................
11g(ii)
 
No
(iii) A 35% controlled entity of a person described in (i) or (ii) above? ................
11g(iii)
 
No
h
Provide the following information about the supported organization(s).
(i) Name of supported organization (ii) EIN (iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions)) (iv) Is the organization in col. (i) listed in your governing document? (v) Did you notify the organization in col. (i) of your support? (vi) Is the organization in col. (i) organized in the U.S.? (vii) Amount of monetary support
Yes No Yes No Yes No
(A) Shawnee Mission Medical Center
 
480637331 3 Yes   Yes   Yes   0
Total                 0

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 2
Part II
Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year (or fiscal year beginning in) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....            
2 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......            
3 The value of services or facilities furnished by a governmental unit to the organization without charge..            
4 Total. Add lines 1 through 3            
5 The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..            
6 Public support. Subtract line 5 from line 4.            
Section B. Total Support
Calendar year (or fiscal year beginning in) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (f) Total
7 Amounts from line 4..            
8 Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...            
9 Net income from unrelated business activities, whether or not the business is regularly carried on..            
10 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..            
11 Total support (Add lines 7 through 10).            
12
12
 
13
First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization, check this box and stop here........................................right arrow
Section C. Computation of Public Support Percentage
14
14
 
15
15
 
16a
b
17a
b
18
Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions ..................................................... right arrow
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 3
Part III
Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year (or fiscal year beginning in) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .            
2 Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......            
3 Gross receipts from activities that are not an unrelated trade or business under section 513..            
4 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...            
5 The value of services or facilities furnished by a governmental unit to the organization without charge..            
6 Total. Add lines 1 through 5.            
7a Amounts included on lines 1, 2, and 3 received from disqualified persons...            
b Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.            
c Add lines 7a and 7b..            
8 Public support (Subtract line 7c from line 6.)            
Section B. Total Support
Calendar year (or fiscal year beginning in) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (f) Total
9 Amounts from line 6...            
10a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..            
b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.            
c Add lines 10a and 10b.            
11 Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.            
12 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.) ..            
13 Total support. (Add lines 9, 10c, 11, and 12.)..            
14
Section C. Computation of Public Support Percentage
15
15
 
16
16
 
Section D. Computation of Investment Income Percentage
17
17
 
18
18
 
19a
b
20
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 4
Part IV
Supplemental Information. Complete this part to provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
 
Explanation
 
 
 
 
Schedule A (Form 990 or 990-EZ) 2012

Additional Data


Software ID:  
Software Version:  
SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b
SchDMd Bullet Attach to Form 990. SchDMd Bullet See separate instructions.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
Adventist Health Mid-America Inc
 
Employer identification number

52-1347407
Part I
Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.
(a) Donor advised funds (b) Funds and other accounts
1 Total number at end of year .........    
2 Aggregate contributions to (during year) ...    
3 Aggregate grants from (during year) .....    
4 Aggregate value at end of year ........    
5
Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............
6
Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................
Part II
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.
Held at the End of the Year
a Total number of conservation easements ....................... 2a  
b Total acreage restricted by conservation easements .................. 2b  
c Number of conservation easements on a certified historic structure included in (a) ..... 2c  
d Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register .................... 2d  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................
6
Staff and volunteer hours devoted to monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet $  
8
Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .......................................
9
In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.
1a
If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items.
b
If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts relating to these items:
(i)
Revenues included in Form 990, Part VIII, line 1 ........................SchDMd Bullet $  
(ii)
Assets included in Form 990, Part X ..............................SchDMd Bullet $  
2
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958) relating to these items:
a
Revenues included in Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 52283D
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.
5
During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........
Part IV
Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b
If "Yes," explain the arrangement in Part XIII and complete the following table:
Amount
c Beginning balance ................................. 1c  
d Additions during the year .............................. 1d  
e Distributions during the year ............................. 1e  
f Ending balance ................................... 1f  
2a
Did the organization include an amount on Form 990, Part X, line 21? .....................
b
If “Yes,” explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII ........
Part V
Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
(a)Current year (b)Prior year b (c)Two years back (d)Three years back (e)Four years back
1a Beginning of year balance ....          
b Contributions ........          
c Net investment earnings, gains, and losses          
d Grants or scholarships .....          
e Other expenditures for facilities
and programs ........
         
f Administrative expenses ....          
g End of year balance ......          
2
Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:
a
Board designated or quasi-endowment SchDMd Bullet  
b
Permanent endowment SchDMd Bullet  
c
Temporarily restricted endowment SchDMd Bullet  
The percentages in lines 2a, 2b, and 2c should equal 100%.
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) unrelated organizations ........................
3a(i)
 
 
(ii) related organizations ........................
3a(ii)
 
 
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
 
 
4
Describe in Part XIII the intended uses of the organization's endowment funds.
Part VI
Land, Buildings, and Equipment. See Form 990, Part X, line 10.
Description of property (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .................      
b Buildings ................        
c Leasehold improvements ............        
d Equipment ................        
e Other .................        
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......SchDMdBullet 0
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 3
Part VII
Investments—Other Securities. See Form 990, Part X, line 12.
(a) Description of security or category
(including name of security)
(b)Book value (c) Method of valuation:
Cost or end-of-year market value
(1)Financial derivatives    
(2)Closely-held equity interests    
Other








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








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








Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........Small Bullet  
Part X
Other Liabilities. See Form 990, Part X, line 25.
1.(a) Description of liability (b) Book value
Federal income taxes  
Due to Affiliated 163,496








Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 163,496
2. Fin 48 (ASC 740) Footnote. In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII .....................................................
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 4
Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1 Total revenue, gains, and other support per audited financial statements ....... 1  
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains on investments .......... 2a  
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIII.) ............ 2d  
e Add lines 2a through 2d ..................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b . 4a  
b Other (Describe in Part XIII.) ........... 4b  
c Add lines 4a and 4b....................... 4c  
5 Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ...... 5  
Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1 Total expenses and losses per audited financial statements ........... 1  
2 Amounts included on line 1 but not on Form 990, Part IX, line 25:
a Donated services and use of facilities .......... 2a  
b Prior year adjustments .............. 2b  
c Other losses ................ 2c  
d Other (Describe in Part XIII.) ............ 2d  
e Add lines 2a through 2d...................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part IX, line 25, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b .. 4a  
b Other (Describe in Part XIII.) ............ 4b  
c Add lines 4a and 4b....................... 4c  
5 Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ...... 5  
Part XIII
Supplemental Information
Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.
Identifier Return Reference Explanation
Description of Uncertain Tax Positions Under FIN 48: Part X, Line 2: The filing organization is a subsidiary organization within Adventist Health System (AHS). The consolidated financial statements of AHS contain the following FIN 48 footnote: Please note that dollar amounts are in thousands. Healthcare Corporation and its affiliated organizations, other than North American Health Services, Inc. and its subsidiaries (NAHS), are exempt from state and federal income taxes. Accordingly, Healthcare Corporation and its tax-exempt affiliates are not subject to federal, state, or local income taxes except for any net unrelated business taxable income. For the years ended December 31, 2012 and 2011, unrelated business income activities conducted by Healthcare Corporation and its tax-exempt affiliates did not generate a material amount of combined federal, state and local income tax. NAHS is a wholly owned, for-profit subsidiary of Healthcare Corporation. NAHS and its subsidiaries are subject to federal and state income taxes. NAHS files a consolidated federal income tax return and, where appropriate, consolidated state income tax returns. For the years ended December 31, 2012 and 2011, NAHS generated taxable income of approximately $2,400 and $1,000, respectively. This taxable income was fully offset by net operating loss carryforwards for federal income tax purposes. Although one state in which NAHS conducts business has suspended the utilization of net operating loss carryforwards for the year ended December 31, 2012, no material state income tax liability resulted. Accordingly, there is no provision for current federal or state income tax for the years ended December 31, 2012 and 2011. NAHS also has temporary deductible differences of approximately $64,800 and $67,500 at December 31, 2012 and 2011, respectively, primarily as a result of net operating loss carryforwards. At December 31, 2012, NAHS had net operating loss carryforwards of approximately $64,300 of which $21,000 will expire in 2023, with the remaining $43,300 expiring beginning in 2018 through 2026. Some of these net operating losses are subject to the separate return limitation year rules. Deferred taxes have been provided for these amounts, resulting in a net deferred tax asset of approximately $24,600 and $25,600 at December 31, 2012 and 2011, respectively. A full valuation allowance has been provided at December 31, 2012 and 2011, respectively, to offset the deferred tax asset since Healthcare Corporation has determined that it is more likely than not that the benefit of the net operating loss carryforwards will not be realized in future years. The Income Taxes Topic of the ASC (ASC 740) prescribes the accounting for uncertainty in income tax positions recognized in financial statements. ASC 740 prescribes a recognition threshold and measurement attribute for the financial statement recognition and measurement of a tax position taken or expected to be taken in a tax return.
Schedule D (Form 990) 2012

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
2012
Open to Public Inspection
Name of the organization
Adventist Health Mid-America Inc
 
Employer identification number

52-1347407
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 of 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 filing organization used 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
Yes
 
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 Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50053T
Schedule J (Form 990) 2012

Schedule J (Form 990) 2012
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 (E) amounts for that individual.
(A) Name and Title (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)Houmann Lars DDirector (i)
(ii)
0
869,760
0
266,769
0
235,323
0
189,569
0
52,500
0
1,613,921
0
158,447
(2)Jernigan PhD Donald LDirector/CEO (i)
(ii)
0
947,487
0
288,129
0
740,746
0
13,599
0
92,521
0
2,082,482
0
0
(3)Reiner Richard KDirector (i)
(ii)
0
871,778
0
266,769
0
543,345
0
13,599
0
48,831
0
1,744,322
0
0
(4)Shaw Terry DDirector (i)
(ii)
0
869,760
0
266,769
0
207,241
0
189,569
0
45,078
0
1,578,417
0
158,447
(5)Wagner JackCFO (i)
(ii)
0
327,634
0
90,456
0
126,988
0
8,599
0
17,360
0
571,037
0
0
(6)Bacon KenCEO (i)
(ii)
0
258,366
0
0
0
65,336
0
43,137
0
50,363
0
417,202
0
0
(7)Turner Sr Samuel HFormer Officer/CEO (i)
(ii)
0
0
0
96,308
0
698,648
0
13,599
0
12,715
0
821,270
0
290,716
Schedule J (Form 990) 2012

Schedule J (Form 990) 2012
Page 3
Part III
Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II.
Also complete this part for any additional information.
Identifier Return Reference Explanation
  Part I, Lines 4a-b During the year ending December 31, 2012, Samuel Turner received severance payments in the amount of $ 411,237. Pursuant to the AHSSHC Corporate Executive Policy governing executive severance, severance agreements for executives operating at the Vice President level and above are entered into upon eligibility to facilitate the transition to subsequent employment following an involuntary separation from employment with AHS. The CEO and CFO of the filing organization are compensated by and on the payroll of Adventist Health System Sunbelt Healthcare Corporation (AHSSHC), the parent organization of a healthcare system known as Adventist Health System (AHS). In recognition of the contribution that each executive makes to the success of AHS, AHS provides to eligible executives participation in the AHS Executive FLEX Benefit Program (the Plan). The purpose of the Plan is to offer eligible executives an opportunity to elect from among a variety of supplemental benefits, including deferred compensation benefits taxable under Internal Revenue Code (IRC) Section 457(f), to individually tailor a benefits program appropriate to each executive's needs. Executives on the filing organization's management team that hold the position of Vice-President or above at the filing organization's supported hospital organization are compensated by and on the payroll of Adventist Health System Sunbelt Healthcare Corporation (AHSSHC), the parent organization of a healthcare system known as Adventist Health System (AHS). In recognition of the contribution that each executive makes to the success of AHS, AHS provides to eligible executives participation in the AHS Executive FLEX Benefit Program (the Plan). The purpose of the Plan is to offer eligible executives an opportunity to elect from among a variety of supplemental benefits, including deferred compensation benefits taxable under Internal Revenue Code (IRC) Section 457(f), to individually tailor a benefits program appropriate to each executive's needs. The Plan provides eligible participants a pre-determined benefits allowance credit that is equal to a percentage of the executive's base pay from which is deducted the cost of mandatory and elective employee benefits. The pre-determined benefits allowance credit percentage is approved by the AHS Board Strategy & Compensation Committee, an independent committee of the Board of Directors of AHSSHC. Any funds that remain after the cost of mandatory and elective benefits are subtracted from the annual pre-determined benefits allowance are contributed, at the employee's option, to either an IRC 457(f) deferred compensation account or to an IRC 457(b) eligible deferred compensation plan. Upon attainment of age 65, all previous 457(f) deferred amounts are paid immediately to the participant and any future employer contributions are made quarterly from the Plan directly to the participant. The Plan documents define an employee who is eligible to participate in the Plan to generally include the Chief Executive Officers of AHS entities and Vice Presidents of all AHS entities whose base salary is at least $210,000. The Plan provides for a class year vesting schedule (2 years for each class year) with respect to amounts accumulated in the executive's 457(f) deferred compensation account. Distributions could also be made from the executive's 457(f) deferred compensation account upon attainment of age 65 or upon an involuntary separation. The account is forfeited by the executive upon a voluntary separation. In addition to the Plan, AHS has instituted a defined benefit, non-tax-qualified deferred compensation plan for certain executives who have provided lengthy service to AHS and/or to other Seventh-Day Adventist Church hospitals or health care institutions. Participation in the plan is offered to AHS executives on a prorata schedule beginning with 20 years of service as an employee of AHS and/or another hospital or health care institution controlled by the Seventh-Day Adventist Church and who satisfy certain other qualifying criteria. This supplemental executive retirement plan (SERP) was designed to provide eligible executives with the economic equivalent of an annual income beginning at normal retirement age equal to 60% of the average of the participant's three, five or seven highest years of base salary from AHS active employment inclusive of income from all other Seventh-Day Adventist Church healthcare employer-financed retirement income sources and investment income earned on those contributions through social security normal retirement age as defined in the plan. The number of years included in highest average compensation is determined by the individual's year of entry to the SERP and by the individual's year of entry to the AHS Executive FLEX Benefit Program. Flex Plan Flex Plan/ SERP 457(b) CY CY Employer CY Contrib./ Distributions Contrib. Distributions* Payment ------------------------------------------------------- Lars Houmann $175,971 $161,469 $ 25,617 $ 0 Donald Jernigan $202,164 $185,164 $ 394,589 $ 0 Richard Reiner $182,872 $167,651 $ 255,540 $ 0 Terry Shaw $175,971 $171,709 $ 0 $ 0 Samuel Turner $ 0 $134,062 $ 0 $165,286 Jack Wagner $ 47,020 $ 13,020 $ 0 $ 0 Ken Bacon $ 29,538 $ 0 $ 0 $ 0 * Including Investment Earnings
Supplemental Information Part III Part I, Question 3: As noted in our response to question 15 of Part VI of Form 990, the individual who serves as the CEO of the filing organization is compensated by Adventist Health System Sunbelt Healthcare Corporation (AHSSHC) for that individual's role in serving as the CEO. Compensation and benefits provided to this individual are determined pursuant to policies, procedures, and processes of AHSSHC that are designed to ensure compliance with the intermediate sanctions laws as set forth in IRC Section 4958. AHSSHC uses all of the following to establish compensation of the CEO: - Compensation committee; - Independent compensation consultant; - Compensation survey or study; and - Approval by the board or compensation committee.
Schedule J (Form 990) 2012

Additional Data


Software ID:  
Software Version:  
SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
MediumBullet Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2012
Open to Public
Inspection
Name of the organization
Adventist Health Mid-America Inc
 
Employer identification number

52-1347407
Identifier Return Reference Explanation
  Form 990, Part VI, Section A, line 6 Adventist Health Mid-America, Inc. (the filing organization) has one member. The sole member of the filing organization is Adventist Health System/Sunbelt, Inc. Adventist Health System/Sunbelt, Inc. (AHSSI) is a Florida, not-for-profit corporation that is exempt from federal income tax under Internal Revenue Code (IRC) Section 501(c)(3). There are no other classes of membership in the filing organization.
  Form 990, Part VI, Section A, line 7a The sole member of the filing organization is AHSSI. The Board of Directors of the filing organization are appointed by the sole member, AHSSI, who has the right to elect, appoint or remove any member of the Board of Directors of the filing organization.
  Form 990, Part VI, Section A, line 7b AHSSI, as the sole member of the filing organization, has certain reserved powers as set forth in the Bylaws of the filing organization. These reserved powers include the following: a) to approve and disapprove the executive and/or administrative leadership of the filing organization, and their salaries; b) to adopt, amend, restate, and repeal the Articles of Incorporation or Bylaws of the filing organization; c) to set limits and terms for the borrowing of funds; d) to approve or disapprove major building programs and/or purchase or sale of personal property or real property equal to or in excess of One Million dollars; e) to approve or disapprove the annual operating and capital budgets of the filing organization; f) to direct the placement of funds and capital of the filing organization; g) to establish general guiding policies, and h) to approve or disapprove opening and closing of facilities owned and operated by the filing organization or major changes in operation of the filing organization.
  Form 990, Part VI, Section B, line 11 The filing organization's current year Form 990 was reviewed by the CEO and by the CFO prior to its filing with the IRS. The review conducted by the CEO and the CFO did not include the review of any supporting workpapers that were used in preparation of the current year Form 990, but did include a review of the entire Form 990 and all supporting schedules.
  Form 990, Part VI, Section B, line 12c The Conflict of Interest Policy of the filing organization applies to members of its Board of Directors and its principal officers (to be known as Interested Persons). In connection with any actual or possible conflict of interests, any member of the Board of Directors of the filing organization or any principal officer of the filing organization (i.e. Interested Persons) must disclose the existence of any financial interest with the filing organization and must be given the opportunity to disclose all material facts concerning the financial interest/arrangement to the Board of Directors of the filing organization or to any members of a committee with board delegated powers that is considering the proposed transaction or arrangement. Subsequent to any disclosure of any financial interest/arrangement and all material facts, and after any discussion with the relevant Board member or principal officer, the remaining members of the Board of Directors or committee with board delegated powers shall discuss, analyze, and vote upon the potential financial interest/arrangement to determine if a conflict of interest exists. According to the filing organization's Conflict of Interest Policy, an Interested Person may make a presentation to the Board of Directors (or committee with board delegated powers), but after such presentation, shall leave the meeting during the discussion of, and the vote on, the transaction or arrangement that results in a conflict of interest. Each Interested Person, as defined under the filing organization's Conflict of Interest Policy, shall annually sign a statement which affirms that such person has received a copy of the Conflict of Interests policy, has read and understands the policy, has agreed to comply with the policy, and understands that the filing organization is a charitable organization that must primarily engage in activities which accomplish one or more of its exempt purposes. The filing organization's Conflict of Interest Policy also requires that periodic reviews shall be conducted to ensure that the filing organization operates in a manner consistent with its charitable purposes.
  Form 990, Part VI, Section B, line 15 The top-tier parent of the filing organization is Adventist Health System Sunbelt Healthcare Corporation (AHSSHC). AHSSHC is the parent organization of a healthcare system, known as Adventist Health System, that operates hospitals, nursing home facilities, and other healthcare provider organizations. AHSSHC is exempt from federal income tax under IRC Section 501(c)(3) pursuant to a group ruling issued to the General Conference of Seventh-day Adventists. The individuals who serve as the CEO and CFO of the filing organization are compensated by AHSSHC. Compensation and benefits provided to these individuals is determined pursuant to policies, procedures, and processes of AHSSHC that are designed to ensure compliance with the intermediate sanctions laws as set forth in IRC Section 4958. AHSSHC has taken steps to ensure that processes are in place to satisfy the rebuttable presumption of reasonableness standard as set forth in Treasury Regulation 53.4958-6 with respect to its active executive-level positions. The AHSSHC Board Strategy and Compensation Committee (the Committee) serves as the governing body for all executive compensation matters. The Committee is composed of certain members of the Board of Directors (the Board) of AHSSHC. Voting members of the Committee include only individuals who serve on the Board as independent representatives of the community, who hold no employment positions with AHSSHC and who do not have relationships with any of the individuals whose compensation is under their review that impacts their best independent judgment as fiduciaries of AHSSHC. The Committee's role is to review and approve all components of the executive compensation plan of AHSSHC. As an independent governing body with respect to executive compensation, it should be noted that the Committee will often confer in executive sessions on matters of compensation policy and policy changes. In such executive sessions, no members of management of AHSSHC are present. The Committee is advised by an independent third party compensation advisor. This advisor prepares all the benchmark studies for the Committee. Compensation levels are benchmarked with a national peer group of other not-for-profit healthcare systems and hospitals of similar size and complexity to AHS and each of its affiliated entities. The following principles guide the establishment of individual executive compensation: - The salary of the President/CEO of AHS will not exceed the 40th percentile of comparable salaries paid by similarly situated organizations; and - Other executive salaries shall be established using market medians. The compensation philosophy, policies, and practices of AHSSHC are consistent with the organization's faith-based mission and conform to applicable laws, regulations, and business practices. As a faith-based organization sponsored by the Seventh-day Adventist Church (the Church), AHSSHC's philosophy and principles with respect to its executive compensation practices reflect the conservative approach of the Church's mission of service and were developed in counsel with the Church's leadership.
  Form 990, Part VI, Section C, line 19 As discussed in our response to Question 15a & b in Section B of this Part VI, the filing organization is a part of the system of healthcare organizations known as Adventist Health System (AHS). Each year, AHS publishes an annual report document that includes a financial report for the relevant year as well as a community benefit report. The financial report and community benefit report are presented on a consolidated basis and represent all of the activities, results of operations, and financial position at year-end of the entire AHS system. In addition, the audited consolidated financial statements of AHS and of the AHS "Obligated Group" are filed annually with the Municipal Securities Rulemaking Board (MSRB). The "Obligated Group" is a group of AHSSHC subsidiaries that are jointly and severally liable under a Master Trust Indenture that secures debt primarily issued on a tax-exempt basis. Unaudited quarterly financial statements prepared in accordance with Generally Accepted Accounting Principles (GAAP) are also filed with MSRB for AHS on a consolidated basis and for the grouping of AHS subsidiaries comprising the "Obligated Group". The filing organization does not generally make its governing documents or conflict of interest policy available to the public.
  Part VII, Section A For those Board of Director members and key employees who devote less than full-time to the filing organization (based upon the average number of hours per week shown in column (B) on page 7 of the return) the compensation amounts shown in columns (E) and (F) on page 7 were provided in conjunction with that person's responsibilities and roles in serving in an executive leadership position within Adventist Health System.
Changes in Net Assets or Fund Balances: Form 990, Part XI, line 9: Transfer to affiliated tax-exempt organization -3,254.
  Part X, Line 2 The amounts shown on line 2 of Part X of this return include the filing organization's interest in a central investment pool maintained by Adventist Health System Sunbelt Healthcare Corporation, the filing organization's top-tier parent. The investments in the central investment pool are recorded at market value.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2012

Additional Data


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

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

OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
Adventist Health Mid-America Inc
 
Employer identification number

52-1347407
Part I
Identification of Disregarded Entities (Complete if the organization answered "Yes" to Form 990, Part IV, line 33.)
(a)
Name, address, and EIN (if applicable) of disregarded entity


(b)
Primary activity


(c)
Legal domicile (state
or foreign country)

(d)
Total income


(e)
End-of-year assets


(f)
Direct controlling
entity











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


(b)
Primary activity


(c)
Legal domicile (state
or foreign country)

(d)
Exempt Code section


(e)
Public charity status
(if section 501(c)(3))

(f)
Direct controlling
entity

(g)
Section 512(b)(13) controlled entity?
Yes No
(1) Adventist Bolingbrook Hospital

500 Remington Blvd

Bolingbrook,IL60440
65-1219504
Operation of Hospital & Related Services IL 501(c)(3) 170(b)(1)(A)(iii) Adventist Hlth SystemSunbelt Inc
 
 
No
(2) Adventist Care Centers - Courtland Inc

730 Courtland Street

Orlando,FL32804
20-5774723
Operation of Home for the Aged/Hlthcare Delivery FL 501(c)(3) 509(a)(2) Sunbelt Hlth Care Centers Inc
 
 
No
(3) Adventist GlenOaks Hospital

701 Winthrop Avenue

Glendale Heights,IL60139
36-3208390
Operation of Hospital & Related Services IL 501(c)(3) 170(b)(1)(A)(iii) Adventist Hlth SystemSunbelt Inc
 
 
No
(4) Adventist Hlth Mid-America Inc

9100 W 74th Street

Shawnee Mission,KS66204
52-1347407
Hlthcare Related Services KS 501(c)(3) 509(a)(3) Type I Adventist Hlth SystemSunbelt Inc
 
 
No
(5) Adventist Hlth Partners Inc

1000 Remington Blvd Ste 200

Bolingbrook,IL60440
36-4138353
Operate out-patient physician clinics IL 501(c)(3) 170(b)(1)(A)(iii) AHS Midwest Management Inc
 
 
No
(6) Adventist Hlth System Affiliated Benefit Trust

900 Hope Way

Altamonte Springs,FL32714
26-6422966
Promotion of Hlthcare FL 501(c)(3) 509(a)(3) Type I Adventist Hlth System Sunbelt Hlthcare Corp
 
 
No
(7) Adventist Hlth System Sunbelt Hlthcare Corp

900 Hope Way

Altamonte Springs,FL32714
59-2170012
Management Services FL 501(c)(3) 509(a)(3) Type I N/A
 
No
(8) Adventist Hlth SystemGeorgia Inc

1035 Red Bud Road

Calhoun,GA30701
58-1425000
Operation of Hospital & Related Services GA 501(c)(3) 170(b)(1)(A)(iii) Adventist Hlth System Sunbelt Hlthcare Corp
 
 
No
(9) Adventist Hlth SystemSunbelt Inc

900 Hope Way

Altamonte Springs,FL32714
59-1479658
Operation of Hospital & Related Services FL 501(c)(3) 170(b)(1)(A)(iii) Adventist Hlth System Sunbelt Hlthcare Corp
 
 
No
(10) Adventist Hlth SystemTexas Inc

602 Courtland Street

Orlando,FL32804
74-2578952
Leasing Personnel to Affiliated Hospital TX 501(c)(3) 509(a)(3) Type III Adventist Hlth System Sunbelt Hlthcare Corp
 
 
No
(11) Adventist Hinsdale Hospital

120 North Oak Street

Hinsdale,IL60521
36-2276984
Operation of Hospital & Related Services IL 501(c)(3) 170(b)(1)(A)(iii) Adventist Hlth SystemSunbelt Inc
 
 
No
(12) Adventist University of Health Sciences Inc (630 Year End)

671 Lake Winyah Drive

Orlando,FL32803
59-3069793
Education/Operation of School FL 501(c)(3) 170(b)(1)(A)(ii) Adventist Hlth SystemSunbelt Inc
 
 
No
(13) AHS Midwest Management Inc

1000 Remington Blvd Ste 200

Bolingbrook,IL60440
36-3354567
Operation of Physician Practice Mgmt IL 501(c)(3) 509(a)(3) Type I Adventist Hlth SystemSunbelt Inc
 
 
No
(14) AHSCentral Texas Inc

1301 Wonder World Drive

San Marcos,TX78666
74-2621825
Provide Office Space - Medical Professionals TX 501(c)(3) 509(a)(3) Type III-F Adventist Hlth System Sunbelt Hlthcare Corp
 
 
No
(15) Apopka Hlth Care Properties Inc

305 E Oak Street

Apopka,FL32703
51-0605694
Lease to Related Organization GA 501(c)(3) 509(a)(3) Type III-F Sunbelt Hlth Care Centers Inc
 
 
No
(16) Battle Creek Adventist Hospital

1000 Remington Blvd Ste 200

Bolingbrook,IL60440
38-1359189
Inactive MI 501(c)(3) 170(b)(1)(A)(iii) Adventist Hlth SystemSunbelt Inc
 
 
No
(17) Bolingbrook Hospital Foundation

1000 Remington Blvd N Entrance 2nd

Bolingbrook,IL60440
90-0494445
Fund-raising for Tax-exempt hospital IL 501(c)(3) 170(b)(1)(A)(vi) Midwest Hlth Foundation
 
 
No
(18) Bradford Heights Hlth & Rehab Center Inc

950 Highpoint Drive

Hopkinsville,KY42240
20-5782342
Operation of Home for the Aged/Hlthcare Delivery KY 501(c)(3) 509(a)(2) Sunbelt Hlth Care Centers Inc
 
 
No
(19) Burleson Nursing & Rehab Center Inc

301 Huguley Blvd

Burleson,TX76028
20-5782243
Operation of Home for the Aged/Hlthcare Delivery TX 501(c)(3) 509(a)(2) Sunbelt Hlth Care Centers Inc
 
 
No
(20) Caldwell Hlth Care Properties Inc

1333 West Main

Princeton,KY42445
51-0605680
Lease to Related Organization GA 501(c)(3) 509(a)(3) Type III-F Sunbelt Hlth Care Centers Inc
 
 
No
(21) Central Texas Hlthcare Collaborative

1301 Wonder World Drive

San Marcos,TX78666
45-3739929
Support Operation of Hospital TX 501(c)(3) 509(a)(3) Type I Adventist Hlth SystemSunbelt Inc
 
 
No
(22) Cedar Crag Terrace Inc (630 Year End)

Rt 5 Box 900

Manchester,KY40962
61-1120442
Operation of Home for the elderly-disabled KY 501(c)(3) 170(b)(1)(A)(vi) Memorial Hospital Inc
 
 
No
(23) Central Texas Medical Center Foundation

1301 Wonder World Drive

San Marcos,TX78666
74-2259907
Fund-raising for Tax-exempt hospital TX 501(c)(3) 170(b)(1)(A)(vi) Adventist Hlth SystemSunbelt Inc
 
 
No
(24) Chickasaw Hlth Care Properties Inc

250 S Chickasaw Trail

Orlando,FL32825
51-0605681
Lease to Related Organization GA 501(c)(3) 509(a)(3) Type III-F Sunbelt Hlth Care Centers Inc
 
 
No
(25) Chippewa Valley Hospital & Oakview Care Center Inc

1220 Third Avenue West

Durand,WI54736
39-1365168
Operation of Hospital & Related Services WI 501(c)(3) 170(b)(1)(A)(iii) Adventist Hlth SystemSunbelt Inc
 
 
No
(26) Cobb Medical Associates LLC

3949 South Cobb Drive SE

Smyrna,GA300806342
58-2617089
Operation of Physician Practices & Medical Services GA 501(c)(3) 170(b)(1)(A)(iii) Emory-Adventist Inc
 
 
No
(27) Courtland Hlth Care Properties Inc

730 Courtland Street

Orlando,FL32804
51-0605682
Lease to Related Organization GA 501(c)(3) 509(a)(3) Type III-F Sunbelt Hlth Care Centers Inc
 
 
No
(28) Creekwood Place Nursing & Rehab Center Inc

683 E Third Street

Russellville,KY42276
20-5782260
Operation of Home for the Aged/Hlthcare Delivery KY 501(c)(3) 509(a)(2) Sunbelt Hlth Care Centers Inc
 
 
No
(29) Dairy Road Hlth Care Properties Inc

7350 Dairy Road

Zephyrhills,FL33540
51-0605684
Lease to Related Organization GA 501(c)(3) 509(a)(3) Type III-F Sunbelt Hlth Care Centers Inc
 
 
No
(30) East Orlando Hlth & Rehab Center Inc

250 S Chickasaw Trail

Orlando,FL32825
20-5774748
Operation of Home for the Aged/Hlthcare Delivery FL 501(c)(3) 509(a)(2) Sunbelt Hlth Care Centers Inc
 
 
No
(31) Emory-Adventist Inc

3949 South Cobb Drive

Smyrna,GA30080
58-2171011
Operation of Hospital & Related Svcs GA 501(c)(3) 170(b)(1)(A)(iii) Adventist Hlth SystemSunbelt Inc
 
 
No
(32) Fletcher Hospital Inc

100 Hospital Drive

Hendersonville,NC28792
56-0543246
Operation of Hospital & Related Svcs NC 501(c)(3) 170(b)(1)(A)(iii) Adventist Hlth System Sunbelt Hlthcare Corp
 
 
No
(33) FLNC Inc

3355 E Semoran Blvd

Apopka,FL32703
20-5774761
Operation of Home for the Aged/Hlthcare Delivery FL 501(c)(3) 509(a)(2) Sunbelt Hlth Care Centers Inc
 
 
No
(34) Florida Hospital Waterman Inc

1000 Waterman Way

Tavares,FL32778
59-3140669
Operation of Hospital & Related Services FL 501(c)(3) 170(b)(1)(A)(iii) Adventist Hlth System Sunbelt Hlthcare Corp
 
 
No
(35) Florida Hospital Zephyrhills Inc

7050 Gall Blvd

Zephyrhills,FL33541
59-2108057
Operation of Hospital & Related Services FL 501(c)(3) 170(b)(1)(A)(iii) Adventist Hlth SystemSunbelt Inc
 
 
No
(36) Florida Hospital Medical Group Inc

900 Winderley Place

Maitland,FL32751
59-3214635
Operation of Physician Practices & Medical Services FL 501(c)(3) 170(b)(1)(A)(iii) Adventist Hlth SystemSunbelt Inc
 
 
No
(37) Foundation for Shawnee Mission Medical Center Inc

9100 W 74th Street

Shawnee Mission,KS66204
48-0868859
Fund-raising for Tax-exempt hospital KS 501(c)(3) 509(a)(3) Type I Shawnee Mission Medical Center Inc
 
 
No
(38) GlenOaks Hospital Foundation

701 Winthrop Avenue

Glendale Heights,IL60139
36-3926044
Fund-raising for Tax-exempt hospital IL 501(c)(3) 170(b)(1)(A)(vi) Midwest Hlth Foundation
 
 
No
(39) Hays Memorial Hospital Association of Seventh-Day Adventists

1301 Wonder World Drive

San Marcos,TX78667
74-1362785
Lease of Hospital Personnel TX 501(c)(3) 509(a)(3) Type II Adventist Hlth System Sunbelt Hlthcare Corp
 
 
No
(40) Helen Ellis Memorial Hospital Auxiliary Inc

1395 S Pinellas Ave

Tarpon Springs,FL34689
59-2106043
Fund-raising for Tax-exempt hospital/foundation FL 501(c)(3) 509(a)(3) Type I Tarpon Springs Hospital Foundation Inc
 
 
No
(41) Helen Ellis Memorial Hospital Foundation Inc

1395 S Pinellas Ave

Tarpon Springs,FL34689
59-3690149
Fund-raising for Tax-exempt hospital FL 501(c)(3) 509(a)(3) Type I Tarpon Springs Hospital Foundation Inc
 
 
No
(42) Hinsdale Hospital Foundation

7 Salt Creek Lane Suite 203

Hinsdale,IL60521
52-1466387
Fund-raising for Tax-exempt hospital IL 501(c)(3) 170(b)(1)(A)(vi) Midwest Hlth Foundation
 
 
No
(43) Huguley Community Care Corp

11801 South Freeway

Burleson,TX76028
45-2793120
Support Operation of Hospital TX 501(c)(3) 509(a)(3) Type I Adventist Hlth SystemSunbelt Inc
 
 
No
(44) In-Motion Rehab Inc

602 Courtland Street Ste 200

Orlando,FL32804
20-8023411
Therapy services to tax exempt nursing homes KS 501(c)(3) 509(a)(3) Type II Sunbelt Hlth Care Centers Inc
 
 
No
(45) Jellico Community Hospital Inc

188 Hospital Lane

Jellico,TN37762
62-0924706
Operation of Hospital & Related Services TN 501(c)(3) 170(b)(1)(A)(iii) Adventist Hlth System Sunbelt Hlthcare Corp
 
 
No
(46) La Grange Memorial Hospital Foundation

5101 S Willow Springs Rd

La Grange,IL60525
30-0247776
Fund-raising for Tax-exempt hospital IL 501(c)(3) 170(b)(1)(A)(vi) Midwest Hlth Foundation
 
 
No
(47) Memorial Hlth Systems Foundation Inc

770 West Granada Blvd

Ormond Beach,FL32174
31-1771522
Fund-raising for Tax-exempt hospital FL 501(c)(3) 170(b)(1)(A)(vi) Memorial Hlth Systems Inc
 
 
No
(48) Memorial Hlth Systems Inc

301 Memorial Medical Parkway

Daytona Beach,FL32117
59-0973502
Operation of Hospital & Related Services FL 501(c)(3) 170(b)(1)(A)(iii) Adventist Hlth SystemSunbelt Inc
 
 
No
(49) Memorial Hospital Flagler Inc

60 Memorial Medical Parkway

Palm Coast,FL32164
59-2951990
Operation of Hospital & Related Services FL 501(c)(3) 170(b)(1)(A)(iii) Memorial Hlth Systems Inc
 
 
No
(50) Memorial Hospital - West Volusia Inc

701 West Plymouth Avenue

Deland,FL32720
59-3256803
Operation of Hospital & Related Services FL 501(c)(3) 170(b)(1)(A)(iii) Memorial Hlth Systems Inc
 
 
No
(51) Memorial Hospital Inc

210 Marie Langdon Drive

Manchester,KY40962
61-0594620
Operation of Hospital & Related Services KY 501(c)(3) 170(b)(1)(A)(iii) Adventist Hlth System Sunbelt Hlthcare Corp
 
 
No
(52) Merriam Hlth Care Properties Inc

9700 West 62nd Street

Merriam,KS66203
36-4595806
Lease to Related Organization KS 501(c)(3) 509(a)(3) Type III-F Sunbelt Hlth Care Centers Inc
 
 
No
(53) Metroplex Adventist Hospital Inc

2201 S Clear Creek Road

Killeen,TX76549
74-2225672
Operation of Hospital & Related Services TX 501(c)(3) 170(b)(1)(A)(iii) Adventist Hlth System Sunbelt Hlthcare Corp
 
 
No
(54) Metroplex Clinic Physicians Inc

2201 S Clear Creek Road

Killeen,TX76549
11-3762050
Physician Hlthcare services to the community TX 501(c)(3) 170(b)(1)(A)(iii) Metroplex Adventist Hospital Inc
 
 
No
(55) Metroplex Hospital Inc (1023-123112)

900 Hope Way

Altamonte Springs,FL32714
46-1256516
Future Operation of Hospital & Related Svcs FL 501(c)(3) 170(b)(1)(A)(iii) Adventist Hlth System Sunbelt Hlthcare Corp
 
 
No
(56) Midwest Hlth Foundation

120 North Oak Street

Hinsdale,IL60521
35-2230515
Support of subsidiary Foundations IL 501(c)(3) 509(a)(3) Type II N/A
 
No
(57) Mills Hlth & Rehab Center Inc

500 Beck Lane

Mayfield,KY42066
20-5782320
Operation of Home for the Aged/Hlthcare Delivery KY 501(c)(3) 509(a)(2) Sunbelt Hlth Care Centers Inc
 
 
No
(58) Mission Strategies Inc

602 Courtland Street Ste 200

Orlando,FL32804
20-5982365
Provision of support to the nursing home division KS 501(c)(3) 509(a)(3) Type II Sunbelt Hlth Care Centers Inc
 
 
No
(59) Mission Strategies of Georgia Inc

3949 S Cobb Drive

Smyrna,GA30080
90-0866024
Provision of support to the nursing home division GA 501(c)(3) 509(a)(3) Type II Sunbelt Hlth Care Centers Inc
 
 
No
(60) Missouri Adventist Hlth Inc

9100 W 74th Street

Shawnee Mission,KS66204
43-1224729
Support Hlth Care Services MO 501(c)(3) 509(a)(3) Type III-O Adventist Hlth Mid-America Inc
 
Yes
 
(61) North Regional EMS Inc

188 Hospital Lane

Jellico,TN37762
26-2653616
EMS Services TN 501(c)(3) 509(a)(2) Jellico Community Hospital Inc
 
 
No
(62) Ormond Beach Memorial Hospital Auxiliary Inc

301 Memorial Medical Parkway

Daytona Beach,FL32117
59-1721962
Volunteer support services FL 501(c)(3) 509(a)(3) Type III-F Memorial Hlth Systems Inc
 
 
No
(63) Overland Park Nursing & Rehab Center Inc

6501 West 75th Street

Overland Park,KS66204
20-5774821
Operation of Home for the Aged/Hlthcare Delivery KS 501(c)(3) 509(a)(2) Sunbelt Hlth Care Centers Inc
 
 
No
(64) Paragon Hlth Care Properties Inc

950 Highpoint Drive

Hopkinsville,KY42240
51-0605686
Lease to Related Organization GA 501(c)(3) 509(a)(3) Type III-F Sunbelt Hlth Care Centers Inc
 
 
No
(65) Pasco-Pinellas Hillsborough Community Hlth System Inc

2400 Bedford Road

Orlando,FL32803
20-8488713
Operation of Hospital & Related Services FL 501(c)(3) 170(b)(1)(A)(iii) N/A
 
No
(66) Portercare Adventist Hlth System (630 Year End)

2525 S Downing Street

Denver,CO80210
84-0438224
Operation of Hospital & Related Services CO 501(c)(3) 170(b)(1)(A)(iii) Adventist Hlth System Sunbelt Hlthcare Corp
 
 
No
(67) Portland Nursing & Rehab Center Inc

215 Highland Circle Drive

Portland,TN37148
20-5774842
Operation of Home for the Aged/Hlthcare Delivery TN 501(c)(3) 509(a)(2) Sunbelt Hlth Care Centers Inc
 
 
No
(68) Princeton Hlth & Rehab Center Inc

1333 West Main

Princeton,KY42445
20-5782272
Operation of Home for the Aged/Hlthcare Delivery KY 501(c)(3) 509(a)(2) Sunbelt Hlth Care Centers Inc
 
 
No
(69) Princeton Professional Services Inc

601 E Rollins Street

Orlando,FL32803
59-1191045
Provision of Hlthcare Services FL 501(c)(3) 509(a)(2) Adventist Hlth System Sunbelt Hlthcare Corp
 
 
No
(70) Quality Circle for Hlthcare Inc

900 Hope Way

Altamonte Springs,FL32714
26-3789368
Hlthcare Quality Services FL 501(c)(3) 509(a)(3) Type III-F Adventist Hlth System Sunbelt Hlthcare Corp
 
 
No
(71) Resource Personnel Inc

602 Courtland Street Ste 200

Orlando,FL32804
20-8040875
Provide administrative support to tax exempt nursing homes FL 501(c)(3) 509(a)(3) Type II Sunbelt Hlth Care Centers Inc
 
 
No
(72) Rocky Mountain Adventist Hlthcare Foundation (630 Year End)

2525 South Downing Street

Denver,CO80210
84-0745018
Fund-raising for Tax-exempt hospital CO 501(c)(3) 170(b)(1)(A)(vi) PorterCare Adventist Hlth System
 
 
No
(73) Rollins Bedford Corp

602 Courtland Street Ste 200

Orlando,FL32804
37-0908840
Inactive FL 501(c)(3) 509(a)(3) Type II Sunbelt Hlth Care Centers Inc
 
 
No
(74) Rollins Brook Community Care Corp (1120-123112)

2201 S Clear Creek Road

Killeen,TX76549
46-1656773
Inactive TX 501(c)(3)   Metroplex Adventist Hospital Inc
 
 
No
(75) Russellville Hlth Care Properties Inc

683 East Third Street

Russellville,KY42276
51-0605691
Lease to Related Organization GA 501(c)(3) 509(a)(3) Type III-F Sunbelt Hlth Care Centers Inc
 
 
No
(76) San Marcos Hlth Care Properties Inc

1900 Medical Parkway

San Marcos,TX78666
51-0605693
Lease to Related Organization GA 501(c)(3) 509(a)(3) Type III-F Sunbelt Hlth Care Centers Inc
 
 
No
(77) San Marcos Nursing & Rehab Center Inc

1900 Medical Parkway

San Marcos,TX78666
20-5782224
Operation of Home for the Aged/Hlthcare Delivery TX 501(c)(3) 509(a)(2) Sunbelt Hlth Care Centers Inc
 
 
No
(78) Shawnee Mission Hlth Care Inc

6501 West 75th Street

Overland Park,KS66204
48-0952508
Lease to Related Organization KS 501(c)(3) 509(a)(3) Type III-F Sunbelt Hlth Care Centers Inc
 
 
No
(79) Shawnee Mission Medical Center Inc

9100 W 74th Street

Shawnee Mission,KS66204
48-0637331
Operation of Hospital & Related Services KS 501(c)(3) 170(b)(1)(A)(iii) Adventist Hlth Mid-America Inc
 
Yes
 
(80) South Central Nursing Homes Properties Inc

900 Hope Way

Altamonte Springs,FL32714
59-3686109
Management Support GA 501(c)(3) 509(a)(3) Type III-O South Central Inc
 
 
No
(81) South Central Nursing Homes Inc

602 Courtland Street

Orlando,FL32804
61-1242373
Management Support KY 501(c)(3) 509(a)(3) Type III-O South Central Inc
 
 
No
(82) South Central Properties III Inc

900 Hope Way

Altamonte Springs,FL32714
59-3692860
Real Estate GA 501(c)(2)   South Central Nursing Homes Properties Inc
 
 
No
(83) South Central Properties IV Inc

900 Hope Way

Altamonte Springs,FL32714
59-3692862
Real Estate GA 501(c)(2)   South Central Nursing Homes Properties Inc
 
 
No
(84) South Central Properties VI Inc

900 Hope Way

Altamonte Springs,FL32714
59-3692857
Real Estate GA 501(c)(2)   South Central Nursing Homes Properties Inc
 
 
No
(85) South Central Properties Inc

900 Hope Way

Altamonte Springs,FL32714
59-3651692
Real Estate GA 501(c)(2)   South Central Nursing Homes Properties Inc
 
 
No
(86) South Central Inc

602 Courtland Street

Orlando,FL32804
59-3689740
Management Support GA 501(c)(3) 509(a)(3) Type III-F N/A
 
No
(87) South Pasco Hlth Care Properties Inc

38250 A Avenue

Zephyrhills,FL33542
51-0605679
Lease to Related Organization GA 501(c)(3) 509(a)(3) Type III-F Sunbelt Hlth Care Centers Inc
 
 
No
(88) Southwest Volusia Hlth Services Inc

1055 Saxon Blvd

Orange City,FL327638468
59-3281591
Medical Office Building for Hospital FL 501(c)(3) 509(a)(3) Type I Southwest Volusia Hlthcare Corp
 
 
No
(89) Southwest Volusia Hlthcare Corp

1055 Saxon Blvd

Orange City,FL327638468
59-3149293
Operation of Hospital & Related Services FL 501(c)(3) 170(b)(1)(A)(iii) Adventist Hlth SystemSunbelt Inc
 
 
No
(90) Specialty Physicians of Central Texas Inc

1301 Wonder World Drive

San Marcos,TX78666
20-8814408
Physician Hlthcare services to the community TX 501(c)(3) 170(b)(1)(A)(iii) Adventist Hlth SystemSunbelt Inc
 
 
No
(91) Spring View Hlth & Rehab Center Inc

718 Goodwin Lane

Leitchfield,KY42754
20-5782288
Operation of Home for the Aged/Hlthcare Delivery KY 501(c)(3) 509(a)(2) Sunbelt Hlth Care Centers Inc
 
 
No
(92) Sunbelt Hlth & Rehab Center - Apopka Inc

305 East Oak Street

Apopka,FL32703
20-5774856
Operation of Home for the Aged/Hlthcare Delivery FL 501(c)(3) 509(a)(2) Sunbelt Hlth Care Centers Inc
 
 
No
(93) Sunbelt Hlth Care Centers Inc

602 Courtland Street Ste 200

Orlando,FL32804
58-1473135
Management Services TN 501(c)(3) 509(a)(3) Type II Adventist Hlth System Sunbelt Hlthcare Corp
 
 
No
(94) SunSystem Development Corp

900 Hope Way

Altamonte Springs,FL32714
59-2219301
Fund Raising for Affiliated Tax-Exempt Hospitals FL 501(c)(3) 170(b)(1)(A)(vi) Adventist Hlth System Sunbelt Hlthcare Corp
 
 
No
(95) Tarpon Springs Hospital Foundation Inc

1395 S Pinellas Ave

Tarpon Springs,FL34689
59-0898901
Operation of Hospital & Related Services FL 501(c)(3) 170(b)(1)(A)(iii) University Community Hospital Inc
 
 
No
(96) Tarrant County Hlth Care Properties Inc

301 Huguley Blvd

Burleson,TX76028
51-0605677
Lease to Related Organization GA 501(c)(3) 509(a)(3) Type III-F Sunbelt Hlth Care Centers Inc
 
 
No
(97) Taylor Creek Hlth Care Properties Inc

718 Goodwin Lane

Leitchfield,KY42754
51-0605678
Lease to Related Organization GA 501(c)(3) 509(a)(3) Type III-F Sunbelt Hlth Care Centers Inc
 
 
No
(98) Texas Hlth Huguley Inc (11-43012)

900 Hope Way

Altamonte Springs,FL32714
45-2694620
Operation of Hospital & Related Services FL 501(c)(3) 170(b)(1)(A)(iii) Adventist Hlth SystemSunbelt Inc
 
 
No
(99) The Volunteer Auxiliary of Florida Hospital - Flagler Inc

60 Memorial Medical Parkway

Palm Coast,FL32164
59-2486582
Volunteer support services FL 501(c)(3) 509(a)(3) Type III-F Memorial Hospital Flagler Inc
 
 
No
(100) Trinity Nursing & Rehab Center Inc

9700 West 62nd Street

Merriam,KS66203
20-5774890
Operation of Home for the Aged/Hlthcare Delivery KS 501(c)(3) 509(a)(2) Sunbelt Hlth Care Centers Inc
 
 
No
(101) University Community Hospital Auxiliary Inc

3100 E Fletcher Ave

Tampa,FL33613
23-7011345
Volunteer support services FL 501(c)(3) 509(a)(3) Type III-F University Community Hospital Inc
 
 
No
(102) University Community Hospital Foundation Inc

3100 E Fletcher Ave

Tampa,FL33613
59-2554889
Fund-raising for Tax-exempt hospital FL 501(c)(3) 509(a)(3) Type I University Community Hospital Inc
 
 
No
(103) University Community Hospital Specialty Care Inc

3100 E Fletcher Ave

Tampa,FL33613
59-3231322
Inactive FL 501(c)(3) 509(a)(3) University Community Hospital Inc
 
 
No
(104) University Community Hospital Inc

3100 E Fletcher Ave

Tampa,FL33613
59-1113901
Operation of Hospital & Related Services FL 501(c)(3) 170(b)(1)(A)(iii) Adventist Hlth System Sunbelt Hlthcare Corp
 
 
No
(105) West Kentucky Hlth Care Properties Inc

500 Beck Lane

Mayfield,KY42066
51-0605676
Lease to Related Organization GA 501(c)(3) 509(a)(3) Type III-F Sunbelt Hlth Care Centers Inc
 
 
No
(106) Zephyr Haven Hlth & Rehab Center Inc

38250 A Avenue

Zephyrhills,FL33542
20-5774930
Operation of Home for the Aged/Hlthcare Delivery FL 501(c)(3) 509(a)(2) Sunbelt Hlth Care Centers Inc
 
 
No
(107) Zephyrhills Hlth & Rehab Center Inc

7350 Dairy Road

Zephyrhills,FL33540
20-5774967
Operation of Home for the Aged/Hlthcare Delivery FL 501(c)(3) 509(a)(2) Sunbelt Hlth Care Centers Inc
 
 
No
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 2
Part III
Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.)
(a)
Name, address, and EIN of
related organization



(b)
Primary activity




(c)
Legal
domicile
(state or foreign
country)


(d)
Direct controlling
entity



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

(f)
Share of total income




(g)
Share of end-of-year
assets



(h)
Disproprtionate allocations?




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



(k)
Percentage
ownership


Yes No Yes No
(1) Appalachian Therapy Services LLC

100 Hospital Drive
Hendersonville,NC28792
20-2463851
Therapy Staffing NC N/A
                 
(2) Clear Creek MOB Ltd

2201 S Clear Creek Rd
Killeen,TX76549
74-2609195
Real Estate TX N/A
                 
(3) Florida Hospital DMERT LLC

2450 Maitland Center Pkwy Ste 200
Maitland,FL32751
20-2392253
Medical Equipment FL N/A
                 
(4) Florida Hospital Home Infusion

2450 Maitland Center Pkwy Ste 200
Maitland,FL32751
59-3142824
Home Infusion Services FL N/A
                 
(5) Huguley Surgery Ctr LLP (11-4112)

15305 Dallas Pkwy Ste 1600 LB 28
Addison,TX75001
20-0910694
Outpatient Surgery TX N/A
                 
(6) KCCCSMMC Cancer Center LLC

9100 W 74th Street
Shawnee Mission,KS66204
27-0909763
Equipment Rental KS N/A
                 
(7) PAHSUSP Surgery Centers LLC

15305 Dallas Pkwy Ste 1600 LB 28
Addison,TX75010
26-3057950
Medical Services CO N/A
                 
(8) Shawnee Mission Open MRI LLC

9100 W 74th Street Box 2923
Shawnee Mission,KS66201
27-0011796
Imaging & Testing KS N/A
                 
(9) Skyland MRI LLC (11-12012)

100 Hospital Drive
Hendersonville,NC28792
04-3646559
Imaging & Testing KS N/A
                 
Part IV
Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" to Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.)
(a)
Name, address, and EIN of
related organization
(b)
Primary activity
(c)
Legal
domicile
(state or foreign
country)
(d)
Direct controlling
entity
(e)
Type of entity
(C corp, S corp,
or trust)
(f)
Share of total income
(g)
Share of end-of-year
assets
(h)
Percentage
ownership
(i)
Section 512(b)(13) controlled entity?
Yes No
(1) Altamonte Medical Plaza Condominium Association Inc

601 East Rollins Street
Orlando,FL32803
59-2855792
Condo Association FL N/A
C         No
(2) Apopka Medical Plaza Condominium Association Inc

601 East Rollins Street
Orlando,FL32803
59-3000857
Condo Association FL N/A
C         No
(3) Arapahoe Medical Building I Inc (7111-12512)

2525 S Downing Street
Denver,CO80210
84-1574506
Real Estate Leasing CO N/A
C         No
(4) Arapahoe Medical Building II Inc (7111-12512)

2525 S Downing Street
Denver,CO80210
84-1574507
Real Estate Leasing CO N/A
C         No
(5) CC MOB Inc

2201 S Clear Creek Road
Killeen,TX76549
74-2616875
Real Estate Rental TX N/A
C         No
(6) Central Texas Medical Associates

1301 Wonder World Drive
San Marcos,TX78666
74-2729873
Physician Clinics TX N/A
C         No
(7) Central Texas Provider's Network

1301 Wonder World Drive
San Marcos,TX78666
74-2827652
Physician Hospital Org. TX N/A
C         No
(8) Florida Hospital Flagler Medical Offices Association Inc

60 Memorial Medical Parkway
Palm Coast,FL32164
26-2158309
Condo Association FL N/A
C         No
(9) Florida Hospital Healthcare System Inc

602 Courtland Street
Orlando,FL32804
59-3215680
PHO/TPA FL N/A
C         No
(10) Florida Hospital Wesley Chapel Inc (11-51512)

900 Hope Way
Altamonte Springs,FL32714
20-3965753
Inactive FL N/A
C         No
(11) Florida Medical Plaza Condo Association Inc

601 East Rollins Street
Orlando,FL32803
59-2855791
Condo Association FL N/A
C         No
(12) Florida Memorial Health Network Inc

770 W Granada Blvd Ste 317
Ormond Beach,FL32174
59-3403558
Physician Hospital Org. FL N/A
C         No
(13) Harvard Park East Inc (7111-12512)

2525 S Downing Street
Denver,CO80210
84-1574365
Real Estate Leasing CO N/A
C         No
(14) Helen Ellis Memorial Hospital Real Estate Corp (11-101912)

1395 S Pinellas Ave
Tarpon Springs,FL34689
59-3375731
Real Estate Rental FL N/A
C         No
(15) Huguley Alliance Foundation

11801 South Freeway
Fort Worth,TX76115
75-2642209
Inactive TX N/A
C         No
(16) Huguley Medical Associates Inc (11-43012)

11801 South Freeway
Burleson,TX76028
75-2547668
Physician Clinics TX N/A
C         No
(17) Kissimmee Multispecialty Clinic Condominium Association Inc

201 Hilda Street Suite 30
Kissimmee,FL34741
59-3539564
Condo Association FL N/A
C         No
(18) Midwest Management Services Inc

9100 West 74th Street
Shawnee Mission,KS66204
48-0901551
Real Estate Rental KS Adventist Hlth Mid-America Inc
 
C -391 32,486 100.000 % Yes  
(19) Metroplex Adventist Hospital CRNA

2201 S Clear Creek Road
Killeen,TX76549
26-0760794
Support hospital - provide allied health professionals TX N/A
C         No
(20) North American Health Services Inc & Subs

111 N Orlando Avenue
Winter Park,FL32789
62-1041820
Lessor/Holding Co. TN N/A
C         No
(21) Ormond Professional Condo Association (430 Year End)

770 W Granada Blvd Ste 101
Ormond Beach,FL32174
59-2694434
Condo Association FL N/A
C         No
(22) Park Ridge Property Owner's Association Inc

1 Park Place Naples Road
Fletcher,NC28732
03-0380531
Condo Association NC N/A
C         No
(23) Porter Affiliated Hlth Services Inc dba Diversified Affiliated Hlth Svcs

2525 S Downing Street
Denver,CO80210
84-0956175
Healthcare Services CO N/A
C         No
(24) Porter Medical Plaza Inc (7111-12512)

2525 S Downing Street
Denver,CO80210
84-1574369
Real Estate Leasing CO N/A
C         No
(25) San Marcos Regional MRI Inc

1301 Wonder World Drive
San Marcos,TX78666
77-0597968
Holding Company TX N/A
C         No
(26) The Garden Retirement Community Inc

602 Courtland Street Ste 200
Orlando,FL32804
59-3414055
Real Estate Rental FL N/A
C         No
(27) University Community Health Insurance Company SPC Ltd

C/O AON Insurance Managers PO Box
  Grand Cayman  
CJ
Captive Insurance CJ N/A
C         No
(28) UCH Services Inc

3100 East Fletcher Ave
Tampa,FL33613
59-3508454
Management Company FL N/A
C         No
(29) West Coast Medical Group Inc (11-101912)

1395 S Pinellas Ave
Tarpon Springs,FL34689
59-3537305
Physician Clinics FL N/A
C         No
(30) Winter Park Medical Office Building I Condo Assoc Inc

200 Lakemont Ave
Winter Park,FL32792
45-2228478
Physician Clinics FL N/A
C         No
Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 3
Part V
Transactions With Related Organizations (Complete if the organization answered "Yes" to Form 990, Part IV, line 34, 35b, or 36.)
Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.
Yes
No
1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a Receipt of (i) interest (ii) annuities (iii) royalties or (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .
1a
 
No
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
Yes
 
f Dividends from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
No
g Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
 
No
j Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
 
No
k Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1k
 
No
l Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .
1l
 
No
m Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .
1m
 
No
n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .
1n
 
No
o Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
 
No
p Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
 
No
q Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
 
No
r Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
 
No
s Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1s
 
No
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of other organization
(b)
Transaction
type (a-s)
(c)
Amount involved
(d)
Method of determining amount involved





Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to Form 990, Part IV, line 37.)
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity
(b)
Primary activity
(c)
Legal domicile
(state or foreign
country)
(d)
Predominant income (related, unrelated, excluded from tax under section 512-514)

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




(g)
Share of
end-of-year
assets
(h)
Disproprtionate allocations?
(i)
Code V—UBI
amount in box 20
of Schedule K-1
(Form 1065)
(j)
General or
managing
partner?
(k)
Percentage
ownership


Yes No Yes No Yes No






























Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 5
Part VII
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule R (see instructions).
Identifier Return Reference Explanation

Additional Data


Software ID:  
Software Version: