Attach to Form 990 or Form 990-EZ.
See separate instructions.| (i) Name of supported organization |
(ii) EIN |
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions)) |
(iv) Is the organization in col. (i) listed in your governing document? |
(v) Did you notify the organization in col. (i) of your support? |
(vi) Is the organization in col. (i) organized in the U.S.? |
(vii) Amount of support? |
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|---|---|---|---|---|---|---|---|---|---|
| Yes | No | Yes | No | Yes | No | ||||
| (1)
PEKIN MEMORIAL HOSPITAL |
370692351 | 03 | Yes | 0 | |||||
| Total | |||||||||
| Calendar year(or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .... | ||||||
| 2 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf....... | ||||||
| 3 | The value of services or facilities furnished by a governmental unit to the organization without charge.. | ||||||
| 4 | Total. Add lines 1 through 3.. | ||||||
| 5 | The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f).. | ||||||
| 6 | Public Support. Subtract line 5 from line 4. | ||||||
| Calendar year(or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 7 | Amounts from line 4.. | ||||||
| 8 | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | ||||||
| 9 | Net income from unrelated business activities, whether or not the business is regularly carried on.. | ||||||
| 10 | Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets.. | ||||||
| 11 | Total support (Add lines 7 through 10). | ||||||






| Calendar year(or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") . | ||||||
| 2 | Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose...... | ||||||
| 3 | Gross receipts from activities that are not an unrelated trade or business under section 513.. | ||||||
| 4 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf... | ||||||
| 5 | The value of services or facilities furnished by a governmental unit to the organization without charge.. | ||||||
| 6 | Total. Add lines 1 through 5. | ||||||
| 7a | Amounts included on lines 1, 2, and 3 received from disqualified persons... | ||||||
| b | Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year. | ||||||
| c | Add lines 7a and 7b.. | ||||||
| 8 | Public Support (Subtract line 7c from line 6.) | ||||||
| Calendar year (or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | ||||||
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | ||||||
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | ||||||
| c | Add lines 10a and 10b. | ||||||
| 11 | Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on. | ||||||
| 12 | Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.) | ||||||
| 13 | Total support (Add lines 9, 10c, 11 and 12.). | ||||||




| Facts And Circumstances Test |
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| Explanation |
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Attach to Form 990 or 990-EZ.| Identifier | Return Reference | Explanation |
|---|---|---|
| FAMILY RELATIONSHIP | FORM 990, PART VI, SECTION A, LINE 2 | JANET LANGE AND RICHARD KRIEGSMAN HAVE A FAMILY RELATIONSHIP; RON MILLER HAS A BUSINESS RELATIONSHIP WITH RICHARD KRIEGSMAN. ALL BOARD MEMBERS AND OFFICERS HAVE A BUSINESS RELATIONSHIP WITH EACH OTHER AS A RESULT OF ALL SERVING AS BOARD MEMBERS OR OFFICERS OF PEKIN PROHEALTH, INC., A FOR-PROFIT AFFILIATE OF THE ORGANIZATION. |
| DELEGATING AUTHORITY | FORM 990, PART VI, SECTION A, LINE 3 | THE BOARD OF DIRECTORS HAS CONTRACTED WITH QUORUM HEALTH RESOURCES (QHR) TO SERVE AS A MANAGEMENT CORPORATION TO ASSIST IN THE LEADERSHIP OF THE HOSPITAL. QHR PROVIDES PROGRESSIVE HEALTH SYSTEM WITH LEADERSHIP VIA THE CEO ALONG WITH OTHER CONSULTING SERVICES. |
| PROCESS TO REVIEW 990 | FORM 990, PART VI, SECTION A, LINE 11B | FORM 990 WAS REVIEWED BY THE CEO, CFO, AND CONTROLLER. IT WAS PROVIDED TO THE BOARD OF DIRECTORS ELECTRONICALLY, AND REVIEWED INDEPENDENTLY BY EACH MEMBER. QUESTIONS BY BOARD MEMBERS WERE HANDLED ON AN INDIVIDUAL BASIS WITH MANAGEMENT. |
| ORGANIZATION'S POLICY FOR MONITORING COMPLIANCE | FORM 990, PART VI, SECTION B, LINE 12C | PERIODIC SURVEYS ARE PERFORMED REQUESTING DISCLOSURE. IF IT IS DETERMINED THAT A CONFLICT EXISTS, THE EMPLOYEE WILL BE REQUIRED TO RELINQUISH EITHER THE OUTSIDE BUSINESS INTEREST/ARRANGEMENT OR HIS/HER PHS EMPLOYMENT. |
| COMPENSATION REVIEW | FORM 990, PART VI, SECTION B, LINE 15A | THE CEO IS EMPLOYED BY AN OUTSIDE MANAGEMENT COMPANY. |
| COMPENSATION REVIEW | FORM 990, PART VI, SECTION B, LINE 15B | HUMAN RESOURCES AND THE CEO REVIEW THE COMPENSATION OF OTHER OFFICERS AND KEY EMPLOYEES OF THE ORGANIZATION ON AN ANNUAL BASIS. |
| DISCLOSURE | FORM 990, PART VI, LINE 19 | THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE NOT MADE AVAILABLE TO THE PUBLIC. |
| INDEPENDENT VOTING MEMBERS | FORM 990, PART VI, LINE 1B | ALL BOARD MEMBERS ARE NOT CONSIDERED INDEPENDENT DUE TO THE FACT THAT THEY ARE INVOLVED IN A TRANSACTION REPORTED ON SCHEDULE L FILED BY A RELATED ORGANIZATION. IF NOT FOR THE REQUIREMENT TO REPORT THIS TRANSACTION, THERE WOULD BE 8 INDEPENDENT VOTING MEMBERS. |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:JANET LANGE TITLE:TRUSTEE HOURS:4 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:CURTIS EETEN TITLE:TRUSTEE HOURS:4 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:JASON PROHEL TITLE:TRUSTEE HOURS:4 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:DR. KATHRYN KRAMER TITLE:TRUSTEE HOURS:4 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:DR. JOHN LOVELL TITLE:TRUSTEE HOURS:4 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:DR. ERIC V. REINERTSON TITLE:TRUSTEE HOURS:4 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:RONALD MILLER TITLE:CHAIRMAN (FORMER) HOURS:4 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:RICHARD KRIEGSMAN TITLE:CHAIRMAN HOURS:4 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:EDWARD SIROTAK TITLE:TRUSTEE HOURS:4 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:MICHAEL TIBBS TITLE:SECRETARY/TREASURER HOURS:4 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:ANDREW SPARKS TITLE:VICE-CHAIRMAN HOURS:4 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:KEVIN R. ANDREWS TITLE:CEO HOURS:43 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:STEVEN C. HALL TITLE:CFO HOURS:43 |
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