Form990
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
SOUTH BEND MEDICAL FOUNDATION INC
 
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
530 North Lafayette Blvd
 
Room/suite
City or town, state or country, and ZIP + 4
South Bend, IN46601
D Employer identification number

35-0868178
E Telephone number

G Gross receipts $ 100,278,370
F Name and address of principal officer:
ROBERT TOMEC MD
530 North Lafayette Blvd
South Bend,IN46601
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
WWW.SBMF.ORG
H(a)
Is this a group return for
affiliates?
H(b)
Are all affiliates included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet  
K Form of organization:
 
L Year of formation: 1946
M State of legal domicile: IN
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: SOUTH BEND MEDICAL FOUNDATION EXISTS FOR THE PURPOSE OF PROVIDING QUALITY AND COST EFFECTIVE LABORATORY AND BLOOD BANKING SERVICES TO HOSPITALS, PHYSICIANS, AND PATIENTS.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) ........ 3 11
4 Number of independent voting members of the governing body (Part VI, line 1b) ..... 4 10
5 Total number of individuals employed in calendar year 2011 (Part V, line 2a) ...... 5 872
6 Total number of volunteers (estimate if necessary) ............. 6 14
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) ......... 0 429,028
9 Program service revenue (Part VIII, line 2g) ......... 97,034,819 99,026,282
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 80,602 140,634
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 585,608 391,040
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 97,701,029 99,986,984
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 2,374,760 2,710,438
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) 46,509,524 46,930,111
16a Professional fundraising fees (Part IX, column (A), line 11e)..... 0 57,197
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet57,197    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e).... 46,468,237 48,795,997
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 95,352,521 98,493,743
19 Revenue less expenses. Subtract line 18 from line 12....... 2,348,508 1,493,241
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 53,629,071 52,639,511
21 Total liabilities (Part X, line 26)............. 46,010,216 47,569,581
22 Net assets or fund balances. Subtract line 21 from line 20..... 7,618,855 5,069,930
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: SOUTH BEND MEDICAL FOUNDATION EXISTS FOR THE PURPOSE OF PROVIDING QUALITY AND COST EFFECTIVE LABORATORY AND BLOOD BANKING SERVICES TO HOSPITALS, PHYSICIANS, AND PATIENTS. (CONTINUED IN SCHEDULE O).
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 $ 82,010,136 including grants of $ 2,710,438 ) (Revenue $ 99,477,727 )
SOUTH BEND MEDICAL FOUNDATION'S (SBMF) MORE THAN 750 EMPLOYEES PROVIDE A WIDE RANGE OF TOP-QUALITY, COST-EFFECTIVE HEALTH CARE SERVICES FOR COMMUNITIES IN INDIANA, MICHIGAN, KENTUCKY, OHIO, AND ILLINOIS. BY WORKING TOGETHER WITH LOCAL HEALTH CARE PROVIDERS, SBMF PRESERVES THE CRITICAL RELATIONSHIP BETWEEN LABORATORY, PHYSICIAN AND PATIENT. UNLIKE MANY LARGE COMMERCIAL LABORATORIES, SBMF OFFERS ITS SERVICES 24 HOURS A DAY, 365 DAYS A YEAR. SBMF PERSONNEL ARE DEDICATED TO BEING A TRUSTED PHYSICIAN RESOURCE, HANDLING EVERYTHING FROM ROUTINE OUTPATIENT ORDERS TO PROVIDING INPATIENT SERVICES AT HOSPITAL AND OTHER HEALTH CARE FACILITIES THROUGHOUT THE REGION. SBMF'S COMMITMENT TO DELIVERING CONSISTENT, RELIABLE, QUALITY MEDICAL CARE HAS PLAYED AN INSTRUMENTAL ROLE IN HELPING THE FOUNDATION ACHIEVE ITS POSITION OF LEADERSHIP AMONG THE NATION'S DIAGNOSTIC LABORATORIES. (CONTINUED IN SCHEDULE O)
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 expensesMediumBullet82,010,136
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)? Click to see attachment...
2
Yes
 
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part I..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities, 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
 
 
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 I........................
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 II...
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 ....................
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 IV..............
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 V......
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
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VII.......
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIII.......
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part IX............
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
Yes
 
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
12b
 
No
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).... Click to see attachment
17
Yes
 
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............ Click to see attachment
18
Yes
 
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If “Yes,” complete Schedule G, Part III...................
19
 
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... Click to see attachment
21
Yes
 
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III........ Click to see attachment
22
Yes
 
23
Did the organization answer “Yes” to Part VII, Section A, 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... Click to see attachment
28c
Yes
 
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........
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........................
34
 
No
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
 
No
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...
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.............
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 VI
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
77
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable .
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
Yes
 
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and
Tax Statements, filed for the calendar year ending with or within the year covered by this return ..................
2a
872
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?
Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file (see instructions)
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?...
3a
 
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
Yes
 
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
Yes
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?............................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?............................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?..........................
7h
 
 
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?............
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?..........
9a
 
 
b
Did the organization make a distribution to a donor, donor advisor, or related person?.......
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them.) ..........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year. ....................
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. 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
11
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
10
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
Yes
 
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? .
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed? ...........................
4
 
No
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Did the organization have members or stockholders? ................
6
 
No
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? ....................
7a
 
No
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
 
No
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
Yes
 
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
Yes
 
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
IN
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:
MediumBulletJames B Myers118 W Edison RoadMishawakaIN46545 (574) 204-5206
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) BILAL ANSARI MD........................................................................
CHAIRMAN
 1.00
.......................   		X   X       250 0 0
(2) CHARLES E PETERSON MD........................................................................
VICE CHAIRMAN
 1.00
.......................   		X   X       250 0 0
(3) ALAN B ENGEL MD........................................................................
BOARD MEMBER
 1.00
.......................   		X           250 0 0
(4) BARBARA L WILLIAMS MD........................................................................
BOARD MEMBER
 1.00
.......................   		X           250 0 0
(5) BRIAN SUCHARETZA MD........................................................................
BOARD MEMBER
 1.00
.......................   		X           250 0 0
(6) FREDERICK J FERLIC MD........................................................................
PARTIAL YEAR BOARD MEMBER
 1.00
.......................   		X           200 0 0
(7) HENRY KIM MD........................................................................
BOARD MEMBER
 1.00
.......................   		X           250 0 0
(8) JOHN T RICE MD........................................................................
BOARD MEMBER
 1.00
.......................   		X           250 0 0
(9) KURT H STIVER........................................................................
PARTIAL YEAR BOARD MEMBER
 1.00
.......................   		X           200 0 0
(10) MICHELLE A MIGLIORE DO........................................................................
BOARD MEMBER
 1.00
.......................   		X           250 0 0
(11) SAMUEL BORRELLI MD........................................................................
BOARD MEMBER
 1.00
.......................   		X           250 0 0
(12) SLOAN S SHAH MD........................................................................
BOARD MEMBER
 1.00
.......................   		X           250 0 0
(13) STARLA D GRABER MD........................................................................
BOARD MEMBER
 1.00
.......................   		X           250 0 0
(14) STEPHEN F MITROS MD........................................................................
PARTIAL YEAR BOARD MEMBER
 1.00
.......................   		X           200 0 0
(15) ANN SULLIVAN........................................................................
VP OF FINANCE
 40.00
.......................   		    X       232,773 0 42,832
(16) DIANE JANOWIAK........................................................................
VP OF CENTRAL LAB OPERATIONS
 40.00
.......................   		    X       233,474 0 29,004
(17) JAMES FRAIN........................................................................
VP OF HUMAN RESOURCES
 40.00
.......................   		    X       232,993 0 42,092
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) ROBERT KING........................................................................
SENIOR VP
 40.00
.......................   		    X       273,442 0 34,446
(19) ROBERT TOMEC MD........................................................................
PRESIDENT/EXECUTIVE VP
 40.00
.......................   		    X       385,680 0 35,498
(20) WILLIAM KALINEY MD........................................................................
VICE PRESIDENT/EXECUTIVE VP
 40.00
.......................   		    X       384,015 0 36,598
(21) ALFONSO CARDENAS MD........................................................................
PATHOLOGIST
 40.00
.......................   		      X     363,033 0 39,273
(22) AMOBI EZENEKWE MD........................................................................
PATHOLOGIST
 40.00
.......................   		      X     248,662 0 45,410
(23) BLAIR CHRENKA MD........................................................................
PATHOLOGIST
 40.00
.......................   		      X     232,078 0 41,510
(24) BOBBIE SUTTON MD........................................................................
PATHOLOGIST
 40.00
.......................   		      X     285,108 0 31,021
(25) C K KIM MD........................................................................
PATHOLOGIST
 40.00
.......................   		      X     366,137 0 42,073
(26) DAVID JENTZ MD........................................................................
PATHOLOGIST
 40.00
.......................   		      X     364,018 0 34,223
(27) DERRICK FORCHETTI MD........................................................................
PATHOLOGIST
 40.00
.......................   		      X     261,709 0 36,522
(28) FRANCISCO DEOGRACIAS MD........................................................................
PATHOLOGIST
 40.00
.......................   		      X     353,125 0 35,601
(29) FRED BUSSE MD........................................................................
PATHOLOGIST
 40.00
.......................   		      X     259,123 0 35,325
(30) JAMES DYER MD........................................................................
PATHOLOGIST
 40.00
.......................   		      X     248,548 0 19,286
(31) JOHN LANDGRAF MD........................................................................
PATHOLOGIST
 40.00
.......................   		      X     260,223 0 33,425
(32) JOSEPH PRAHLOW MD........................................................................
PATHOLOGIST
 40.00
.......................   		      X     266,461 0 38,655
(33) JOYCE SIMPSON MD........................................................................
PATHOLOGIST
 40.00
.......................   		      X     164,462 0 15,733
(34) KRISTEN JACOBS MD........................................................................
PATHOLOGIST
 24.00
.......................   		      X     571,092 0 37,994
(35) LUIS GALUP MD........................................................................
PATHOLOGIST
 40.00
.......................   		      X     362,643 0 46,064
(36) NICOLE ANEST MD........................................................................
PATHOLOGIST
 40.00
.......................   		      X     226,510 0 32,264
(37) NITA GERIG MD........................................................................
PATHOLOGIST
 32.00
.......................   		      X     285,075 0 41,887
(38) ODETA LAPKUS MD........................................................................
PATHOLOGIST
 40.00
.......................   		      X     254,100 0 34,260
(39) RICKY HOOVER MD........................................................................
PATHOLOGIST
 40.00
.......................   		      X     345,369 0 43,567
(40) CARRIE ROBINSON........................................................................
REGIONAL MARKETING DIRECTOR
 40.00
.......................   		        X   106,412 0 33,879
(41) DEBORAH SUN........................................................................
DIRECTOR - NEW TECHNOLOGY & TEST DEVELOPMENT (PARTIAL YEAR)
 40.00
.......................   		        X   108,217 0 14,633
(42) JANET AGLER........................................................................
REGIONAL MARKETING MANAGER
 40.00
.......................   		        X   102,033 0 28,629
(43) KAY BEAM........................................................................
DIRECTOR, INFORMATION TECHNOLOGY, DATABASE MANAGEMENT
 40.00
.......................   		        X   105,866 0 5,300
(44) PRENTISS JONES........................................................................
DIRECTOR - TOXICOLOGY
 40.00
.......................   		        X   145,530 0 26,223
1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 8,031,261 0 1,013,227
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organizationMediumBullet31
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
ASSOC REG AND UNIV PATHOLOGISTSPO BOX 27964SALT LAKE CITYUT84127 REFERENCE LAB 2,386,480
THERMO ASSET MANAGEMENT SERVICES INCPO BOX 712224CINCINNATIOH452712224 EQUIPMENT MAINTENANCE / REPAIR 906,100
MICHIANA HEALTH INFORMATION NETWORK220 W COLFAX AVENUE SUITE 300SOUH BENDIN46601 COMMUNITY BASED CLINICAL INFO SYSTEM 776,723
CERNER CORPORATIONPO BOX 412702KANSAS CITYMO64141 EQUIPMENT MAINTENANCE / REPAIR 694,128
PARKVIEW PROFESSIONAL PROGRAMSPO BOX 2504FORT WAYNEIN468012504 REFERENCE LAB 585,269
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet16
Form 990 (2012)
Form 990 (2012)
Page 9
Part VIII
Statement of Revenue
Check if Schedule O contains a response to any question in this Part VIII ..............
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, Gifts, Grants and Other Similar Amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c 414,927
d Related organizations...1d  
e Government grants (contributions)1e  
f All other contributions, gifts, grants, and
similar amounts not included above1f 		14,101
g Noncash contributions included in lines
1a-1f:$ 		 
h Total. Add lines 1a-1f.......MediumBullet 429,028
Program Service Revenue Business Code
2a NET OPERATING REVENUES 621500 99,026,282 99,026,282    
b     0      
c     0      
d     0      
e     0      
f All other program service revenue . 0 0 0 0
g Total. Add lines 2a–2f........MediumBullet 99,026,282
Other Revenue 3 Investment income (including dividends, interest, and other similar amounts).......MediumBullet 123,674     123,674
4 Income from investment of tax-exempt bond proceeds..MediumBullet 0      
5 Royalties...........MediumBullet 0      
(i) Real (ii) Personal
6a Gross rents    
b Less: rental expenses    
c Rental income or (loss) 0 0
d Net rental income or (loss).......MediumBullet 0      
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory   31,865
b Less: cost or other basis and sales expenses   14,905
c Gain or (loss) 0 16,960
d Net gain or (loss)..........MediumBullet 16,960     16,960
8a Gross income from fundraising events (not including
$ 414,927
of contributions reported on line 1c). See Part IV, line 18 ..
a 45,980
b Less: direct expenses ...b 276,481
c Net income or (loss) from fundraising events..MediumBullet -230,501   -230,501
9a Gross income from gaming activities.
See Part IV, line 19 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from gaming activities...MediumBullet 0      
10a Gross sales of inventory, less
returns and allowances .
a  
b Less: cost of goods sold ..b  
c Net income or (loss) from sales of inventory..MediumBullet 0      
Miscellaneous Revenue Business Code
11a CLINICAL PATHOLOGY FEES 621500 451,445 451,445    
b TEACHING FEES 611430 76,407     76,407
c     0      
d All other revenue .... 93,689 0 0 93,689
e Total. Add lines 11a–11d ...... MediumBullet 621,541
12 Total revenue. See Instructions......MediumBullet 99,986,984 99,477,727 0 80,229
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 21 204,633 204,633
2 Grants and other assistance to individuals in the United States. See Part IV, line 22 2,505,805 2,505,805
3 Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16 0  
4 Benefits paid to or for members 0  
5 Compensation of current officers, directors, trustees, and key employees .... 8,151,161 6,652,667 1,498,494  
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .... 0      
7 Other salaries and wages 27,679,891 21,979,761 5,700,130  
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 1,073,129 852,172 220,957  
9 Other employee benefits ....... 7,726,682 6,135,758 1,590,924  
10 Payroll taxes ........... 2,299,248 1,833,006 466,242  
11 Fees for services (non-employees):        
a Management ...... 0      
b Legal ......... 56,835   56,835  
c Accounting ........... 81,481   81,481  
d Lobbying ........... 0      
e Professional fundraising services. See Part IV, line 17 57,197 57,197
f Investment management fees ...... 0      
g Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........ 1,950,240 1,045,591 904,649 0
12 Advertising and promotion .... 0      
13 Office expenses ....... 2,930,381 1,470,067 1,460,314  
14 Information technology ...... 0      
15 Royalties .. 0      
16 Occupancy ........... 1,887,456 1,789,097 98,359  
17 Travel ............ 121,545 65,077 56,468  
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ...... 0      
19 Conferences, conventions, and meetings .... 0      
20 Interest ........... 658,845 15,256 643,589  
21 Payments to affiliates ....... 0      
22 Depreciation, depletion, and amortization ..... 3,510,158 3,078,042 432,116  
23 Insurance .............. 729,599 99,151 630,448  
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 MEDICAL LAB 22,653,885 21,870,965 782,920  
b REFERENCE LAB 4,431,550 4,431,550    
c BAD DEBT 3,635,498 3,635,498    
d BUILDING EQUIPMENT/MAINTENANCE 3,635,083 2,431,096 1,203,987  
e All other expenses 2,513,441 1,914,944 598,497 0
25 Total functional expenses. Add lines 1 through 24e 98,493,743 82,010,136 16,426,410 57,197
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). 0      
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 ............. 850 1 841
2 Savings and temporary cash investments ......... 11,644,739 2 9,566,851
3 Pledges and grants receivable, net ...........   3  
4 Accounts receivable, net ............. 11,361,378 4 11,110,618
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 0
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 0
7 Notes and loans receivable, net .............   7  
8 Inventories for sale or use .............. 1,756,111 8 2,117,948
9 Prepaid expenses and deferred charges .......... 1,240,012 9 1,566,976
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 92,583,163
b Less: accumulated depreciation ..... 10b 65,020,370 26,980,187 10c 27,562,793
11 Investments—publicly traded securities ..........   11  
12 Investments—other securities. See Part IV, line 11 ..... 0 12 0
13 Investments—program-related. See Part IV, line 11 ..... 490,286 13 571,791
14 Intangible assets ...............   14  
15 Other assets. See Part IV, line 11 ........... 155,508 15 141,693
16 Total assets. Add lines 1 through 15 (must equal line 34)...... 53,629,071 16 52,639,511
Liabilities 17 Accounts payable and accrued expenses ......... 8,208,104 17 9,693,485
18 Grants payable .................   18  
19 Deferred revenue ................   19  
20 Tax-exempt bond liabilities ............. 11,565,000 20 10,615,000
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 0
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.................... 26,237,112 25 27,261,096
26 Total liabilities. Add lines 17 through 25......... 46,010,216 26 47,569,581
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 .............. 7,618,855 27 5,069,930
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 ........   30  
31 Paid-in or capital surplus, or land, building or equipment fund .....   31  
32 Retained earnings, endowment, accumulated income, or other funds   32  
33 Total net assets or fund balances ........... 7,618,855 33 5,069,930
34 Total liabilities and net assets/fund balances ........ 53,629,071 34 52,639,511
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
99,986,984
2
Total expenses (must equal Part IX, column (A), line 25) ............
2
98,493,743
3
Revenue less expenses. Subtract line 2 from line 1 ..............
3
1,493,241
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..
4
7,618,855
5
Net unrealized gains (losses) on investments ...............
5
374,373
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
-4,416,539
10
Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 33, column (B))
10
5,069,930
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: 12000266
Software Version: v2012.1.0
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
SOUTH BEND MEDICAL FOUNDATION INC
 
Employer identification number

35-0868178
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)
 
 
(ii) A family member of a person described in (i) above? ......................
11g(ii)
 
 
(iii) A 35% controlled entity of a person described in (i) or (ii) above? ................
11g(iii)
 
 
h
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
Total                  

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.") .         429,028 429,028
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...... 92,391,025 94,545,973 94,079,057 97,034,819 99,026,282 477,077,156
3 Gross receipts from activities that are not an unrelated trade or business under section 513.. 193,765 238,981 195,040 169,918 170,096 967,800
4 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...           0
5 The value of services or facilities furnished by a governmental unit to the organization without charge..           0
6 Total. Add lines 1 through 5. 92,584,790 94,784,954 94,274,097 97,204,737 99,625,406 478,473,984
7a Amounts included on lines 1, 2, and 3 received from disqualified persons... 0 0 0 0 15,082 15,082
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. 0 0 0 0 0 0
c Add lines 7a and 7b.. 0 0 0 0 15,082 15,082
8 Public support (Subtract line 7c from line 6.)           478,458,902
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... 92,584,790 94,784,954 94,274,097 97,204,737 99,625,406 478,473,984
10a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. 60,887 -108,281 -69,086 60,573 123,674 67,767
b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.           0
c Add lines 10a and 10b. 60,887 -108,281 -69,086 60,573 123,674 67,767
11 Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.           0
12 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.) .. 353,784 334,004 338,675 415,690 497,425 1,939,578
13 Total support. (Add lines 9, 10c, 11, and 12.).. 92,999,461 95,010,677 94,543,686 97,681,000 100,246,505 480,481,329
14
Section C. Computation of Public Support Percentage
15
15
99.580 %
16
16
99.430 %
Section D. Computation of Investment Income Percentage
17
17
0.010 %
18
18
0.170 %
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
OTHER INCOME, SCHEDULE A, PART III, LINE 12, DESCRIPTION - CLINICAL PATHOLOGY FEES, COLUMN A - 353784, COLUMN B - 334004, COLUMN C - 338675, COLUMN D - 415690, COLUMN E - 451445, COLUMN F - 1893598; DESCRIPTION - FUNDRAISING GROSS RECEIPTS, COLUMN A - 0, COLUMN B - 0, COLUMN C - 0, COLUMN D - 0, COLUMN E - 45980, COLUMN F - 45980;,
 
 
 
Schedule A (Form 990 or 990-EZ) 2012

Additional Data


Software ID: 12000266
Software Version: v2012.1.0
Schedule B
(Form 990, 990-EZ,
or 990-PF)
Department of the Treasury
Internal Revenue Service
Schedule of Contributors
Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
OMB No. 1545-0047
2012
Name of the organization
SOUTH BEND MEDICAL FOUNDATION INC
 
Employer identification number

35-0868178
Organization type (check one):
Filers of:
Section:
Form 990 or 990-EZ





Form 990-PF




Check if your organization is covered by the General Rule or a Special Rule.  
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.
General Rule
Special Rules
......................... Arrow Bullet   $    
Caution. An organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2 of its Form 990; or check the box on line H of its
Form 990-EZ or on Part I, line 2 of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).
For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.
Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)
Page 2
Name of organization
SOUTH BEND MEDICAL FOUNDATION INC
  		Employer identification number

35-0868178
Part I
Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
     
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
RESTRICTED
RESTRICTED
 

     
RESTRICTED
RESTRICTED  
RESTRICTED, RESTRICTED   RESTRICTED

$RESTRICTED


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

     
 
   

$  


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

     
 
   

$  


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

     
 
   

$  


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

     
 
   

$  


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

     
 
   

$  


(Complete Part II if there is a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)
Page 3
Name of organization
SOUTH BEND MEDICAL FOUNDATION INC
  		Employer identification number

35-0868178
Part II
Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
     
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)
Page 4
Name of organization
SOUTH BEND MEDICAL FOUNDATION INC
  		Employer identification number

35-0868178
Part III
Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
that total more than $1,000 for the year. Complete columns (a) through (e) and the following line entry.
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet$  
Use duplicate copies of Part III if additional space is needed.
(a) No.
from
Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Additional Data


Software ID: 12000266
Software Version: v2012.1.0
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
SOUTH BEND MEDICAL FOUNDATION INC
 
Employer identification number

35-0868178
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 .................   1,115,907 1,115,907
b Buildings ................   43,197,792 25,593,551 17,604,241
c Leasehold improvements ............   807,978 791,390 16,588
d Equipment ................   46,245,230 38,635,429 7,609,801
e Other .................   1,216,256   1,216,256
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......SchDMdBullet 27,562,793
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 0
ACCRUED PENSION AND POSTRETIREMENT BENEFITS 25,183,732
FAIR VALUE OF INTEREST RATE SWAP 1,964,673
CAPITAL LEASE OBLIGATION 112,691






Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 27,261,096
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
FIN 48 (ASC 740) footnote Schedule D, Part X, Line 2 THE FOUNDATION IS A NOT-FOR-PROFIT ORGANIZATION PURSUANT TO SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS EXEMPT FROM FEDERAL AND STATE INCOME TAXES PURSUANT TO SECTION 501(A). ACCORDINGLY, NO PROVISION FOR INCOME TAXES IS REFLECTED IN THE FOUNDATION'S FINANCIAL STATEMENTS. THE FOUNDATION IS SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAXING AUTHORITIES FOR THE YEARS ENDED DECEMBER 31, 2009 THROUGH 2012. THE FOUNDATION FOLLOWS GUIDANCE ISSUED BY THE FINANCIAL ACCOUNTING STANDARDS BOARD WITH RESPECT TO ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES. A TAX POSITION IS A BENEFIT ONLY IF IT IS "MORE LIKELY THAN NOT" THAT THE TAX POSITION WOULD BE SUSTAINED IN A TAX EXAMINATION, WITH A TAX EXAMINATION BEING PRESUMED TO OCCUR. THE AMOUNT RECOGNIZED IS THE LARGEST AMOUNT OF TAX BENEFIT THAT IS GREATER THAN 50% LIKELY OF BEING REALIZED ON EXAMINATION. FOR TAX POSITIONS NOT MEETING THE "MORE LIKELY THAN NOT" TEST, NO TAX BENEFIT IS RECORDED. MANAGEMENT HAS DETERMINED THAT THERE IS NO LIABILITY FOR UNCERTAIN TAX POSITIONS AND DOES NOT EXPECT THIS TO CHANGE OVER THE NEXT 12 MONTHS.
Schedule D (Form 990) 2012

Additional Data


Software ID: 12000266
Software Version: v2012.1.0




SCHEDULE G (Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Supplemental Information Regarding
Fundraising or Gaming Activities
Complete if the organization answered "Yes" to Form 990, Part IV, lines 17, 18, or 19, or if the organization entered more than $15,000 on Form 990-EZ, line 6a. Form 990-EZ filers are not required to complete this part. right arrowAttach to Form 990 or Form 990-EZ. right arrowSee separate instructions.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
SOUTH BEND MEDICAL FOUNDATION INC
 
Employer identification number

35-0868178
Part I
Fundraising Activities. Complete if the organization answered "Yes" to Form 990, Part IV, line 17.
1
Indicate whether the organization raised funds through any of the following activities. Check all that apply.
a e
b f
c g
d
2a
Did the organization have a written or oral agreement with any individual (including officers, directors, trustees
or key employees listed in Form 990, Part VII) or entity in connection with professional fundraising services?
b
If “Yes,” list the ten highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is
to be compensated at least $5,000 by the organization.
(i) Name and address of individual
or entity (fundraiser) 		(ii) Activity (iii) Did fundraiser have custody or control of contributions? (iv) Gross receipts
from activity 		(v) Amount paid to
(or retained by)
fundraiser listed in
col. (i) 		(vi) Amount paid to
(or retained by)
organization
Yes No
 
DONNA KYLE
21556 LAKE STREET
 
CASSOPOLIS, MI49031 		FUNDRAISING EVENT CONSULTING & SOLICIATION   No 460,907 52,197 408,710
 
LOU BEHRE
1660 SIGNAL POINT DRIVE
 
NILES, MI49120 		FUNDRAISING EVENT COORDINATOR   No   5,000 -5,000
             
             
             
             
             
             
             
             
Total .................right arrow 460,907 57,197 403,710
3
List all states in which the organization is registered or licensed to solicit funds or has been notified it is exempt from registration or licensing.
IN
For Paperwork Reduction Act Notice, see the Instructions for Form 990or 990-EZ.
Cat. No. 50083H
Schedule G (Form 990 or 990-EZ) 2012
Schedule G (Form 990 or 990-EZ) 2012
Page 2
Part II
Fundraising Events. Complete if the organization answered "Yes" to Form 990, Part IV, line 18, or reported more than $15,000 of fundraising event contributions and gross income on Form 990-EZ, lines 1 and 6b. List events with gross receipts greater than $5,000.
(a) Event #1

100TH ANNIVERSARY GALA
(event type) 		(b) Event #2

 
(event type) 		(c) Other events

 
(total number) 		(d) Total events
(add col. (a) through col. (c))
VerticalRevenue 1 Gross receipts . . . 460,907     460,907
2 Less: Contributions . . 414,927     414,927
3 Gross income (line 1
minus line 2) . . . 		45,980 0 0 45,980
VerticalDirectExpenses 4 Cash prizes . . .       0
5 Noncash prizes . .       0
6 Rent/facility costs . .       0
7 Food and beverages .       0
8 Entertainment . . .       0
9 Other direct expenses . 276,481     276,481
10 Direct expense summary. Add lines 4 through 9 in column (d) ........... right arrow 276,481
11 Net income summary. Combine line 3, column (d), and line 10. .......... right arrow -230,501
Part III
Gaming. Complete if the organization answered "Yes" to Form 990, Part IV, line 19, or reported more than $15,000 on Form 990-EZ, line 6a.
VerticalRevenue (a) Bingo (b) Pull tabs/Instant
bingo/progressive bingo 		(c) Other gaming (d) Total gaming (add col.(a) through col.(c))
1 Gross revenue . . . .        
VerticalDirectExpenses 2 Cash prizes . . . .        
3 Non-cash prizes . . .        
4 Rent/facility costs . . .        
5 Other direct expenses . .        
6 Volunteer labor . . .
 
 
 
7 Direct expense summary. Add lines 2 through 5 in column (d) ........... right arrow  
8 Net gaming income summary. Combine lines 1 and 7 in column (d) .......... right arrow  
9
Enter the state(s) in which the organization operates gaming activities:
a
Is the organization licensed to operate gaming activities in each of these states? ............
b
If "No," explain:
 
10a
Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year? .....
b
If "Yes," explain:
 
Schedule G (Form 990 or 990-EZ) 2012
Schedule G (Form 990 or 990-EZ) 2012
Page 3
11
Does the organization operate gaming activities with nonmembers? .................
12
Is the organization a grantor, beneficiary or trustee of a trust or a member of a partnership or other entity
formed to administer charitable gaming? ..........................
13
Indicate the percentage of gaming activity operated in:
a
The organization's facility ......................
13a
 
b
An outside facility ........................
13b
 
14
Enter the name and address of the person who prepares the organization's gaming/special events books and records:
Name right arrow
Address right arrow
15a
Does the organization have a contract with a third party from whom the organization receives gaming
revenue? ......................................
b
If "Yes," enter the amount of gaming revenue received by the organization right arrow $   and the
amount of gaming revenue retained by the third party right arrow $   .
c
If "Yes," enter name and address of the third party:
Name right arrow
Address right arrow
 
 
16
Gaming manager information:
Name right arrow
Gaming manager compensation right arrow $  
Description of services provided right arrow
 
17
Mandatory distributions:
a
Is the organization required under state law to make charitable distributions from the gaming proceeds to
retain the state gaming license? ............................
b
Enter the amount of distributions required under state law distributed to other exempt organizations or spent
in the organization's own exempt activities during the tax year right arrow$  
Part IV
Supplemental Information. Complete this part to provide the explanations required by Part I, line 2b, columns (iii) and (v), and Part III, lines 9, 9b, 10b, 15b, 15c, 16, and 17b, as applicable. Also complete this part to provide any additional information (see instructions).
Identifier Return Reference Explanation
Schedule G (Form 990 or 990-EZ) 2012
Additional Data


Software ID: 12000266
Software Version: v2012.1.0
Schedule I
(Form 990)
Department of the Treasury
Internal Revenue Service
Grants and Other Assistance to Organizations,
Governments and Individuals in the United States
Complete if the organization answered "Yes," to Form 990, Part IV, line 21 or 22.
lBullet Attach to Form 990
OMB No. 1545-0047
2012
Open to Public
Inspection
Name of the organization
SOUTH BEND MEDICAL FOUNDATION INC
 
Employer identification number
35-0868178
Part I
General Information on Grants and Assistance
1
Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ....................................
2
Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.
Part II
Grants and Other Assistance to Governments and Organizations in the United States. Complete if the organization answered "Yes" to
Form 990, Part IV, line 21, for any recipient that received more than $5,000. Part II can be duplicated if additional space is needed.
(a) Name and address of organization
or government		 (b) EIN (c) IRC Code section
if applicable		 (d) Amount of cash grant (e) Amount of non-cash
assistance		 (f) Method of valuation
(book, FMV, appraisal,
other)		 (g) Description of
non-cash assistance		 (h) Purpose of grant
or assistance
(1) THE FOUNDATION OF ST JOSEPH REGIONAL MEDICAL CENTER
837 EAST CEDAR STREET SUITE 350
SOUTH BEND,IN466172069 		35-1654543 501(C)(3) 10,000 0 N/A N/A GENERAL SUPPORT
(2) BOYS AND GIRLS CLUB OF ST JOSEPH COUNTY
1411 LINCOLNWAY W
MISHAWAKA,IN46544 		35-1329625 501(C)(3) 11,000 0 N/A N/A GENERAL SUPPORT
(3) NORTHERN INDIANA HISTORICAL SOCIETY
808 W WASHINGTON ST
SOUTH BEND,IN46601 		35-1124156 501(C)(3) 5,000 0 N/A N/A GENERAL SUPPORT
(4) INDIANA UNIVERSITY FOUNDATION
PO BOX 500
BLOOMINGTON,IN47204 		35-6018940 501(C)(3) 10,000 0 N/A N/A GENERAL SUPPORT - IU SCHOOL OF MEDICINE - SOUTH BEND
(5) LAKELAND HEALTH FOUNDATION NILES
1234 NAPIER AVE
ST JOSEPH,MI49085 		38-3130558 501(C)(3) 5,035 0 N/A N/A GENERAL SUPPORT
(6) MARCH OF DIMES - INDIANA CHAPTER
136 EAST MARKET STREET
SUITE 500
INDIANAPOLIS,IN46204 		13-1846366 501(C)(3) 5,000 0 N/A N/A GENERAL SUPPORT
(7) MEMORIAL HOSPITAL OF SOUTH BEND
615 N MICHIGAN STREET
SOUTH BEND,IN46601 		35-0868132 501(C)(3) 5,000 0 N/A N/A GENERAL SUPPORT
(8) UNITED WAY OF ST JOSEPH COUNTY
3517 E JEFFERSON BLVD
SOUTH BEND,IN46615 		35-1063368 501(C)(3) 5,000 0 N/A N/A GENERAL SUPPORT
(9) O'HANA HERITAGE FOUNDATION DBA A ROSIE PLACE
53131 QUINCE ROAD
SOUTH BEND,IN46628 		37-1523448 501(C)(3) 5,000 0 N/A N/A GENERAL SUPPORT
(10) MEDICAL EDUCATION FOUNDATION
PO BOX 4394
SOUTH BEND,IN46634 		35-1291588 501(C)(3) 5,000 0 N/A N/A GENERAL SUPPORT - IUSB CLINICAL TRAINING
(11) LOGAN COMMUNITY RESOURCES
2505 E JEFFERSON BLVD
SOUTH BEND,IN46615 		35-0965639 501(C)(3) 5,500 0 N/A N/A GENERAL SUPPORT
(12) COMMUNITY FOUNDATION OF ST JOSEPH COUNTY
PO BOX 837
SOUTH BEND,IN46624 		23-7365930 501(C)(3) 75,540 0 N/A N/A GENERAL SUPPORT
(13) CENTER FOR HOSPICE
111 SUNNYBROOK CT
SOUTH BEND,IN46637 		31-0952866 501(C)(3) 5,140 0 N/A N/A GENERAL SUPPORT
2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................ Bullet Image
13
3
Enter total number of other organizations listed in the line 1 table ........................ . Bullet Image
0
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50055P
Schedule I (Form 990) 2012

Schedule I (Form 990) 2012
Page 2
Part III
Grants and Other Assistance to Individuals in the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 22.
Part III can be duplicated if additional space is needed.
(a)Type of grant or assistance (b)Number of
recipients		 (c)Amount of
cash grant		 (d)Amount of
non-cash assistance		 (e)Method of valuation (book,
FMV, appraisal, other)		 (f)Description of non-cash assistance
(1) PATIENT MEDICAL ASSISTANCE   0 1,919,979 BOOK VALUE FREE OR REDUCED MEDICAL CARE
(2) TIME OF SERVICE DISCOUNTS   0 585,826 BOOK VALUE DISCOUNT PROVIDED AT TIME OF PAYMENT










Part IV
Supplemental Information.
Complete this part to provide the information required in Part I, line 2, Part III, column (b), and any other additional information.
Identifier Return Reference Explanation
NUMBER OF RECIPIENTS SCHEDULE I, PART III, COLUMN (B) CURRENTLY, SOUTH BEND MEDICAL FOUNDATION DOES NOT HAVE AN EFFECTIVE WAY TO TRACK THE UNDUPLICATED NUMBER OF PATIENTS THAT RECEIVE FREE OR REDUCED CARE AND TIME OF SERVICE DISCOUNTS.
Procedures for monitoring use of grant funds Schedule I, Part I, Line 2 SOUTH BEND MEDICAL FOUNDATION (SBMF) PROVIDES FUNDING TO OTHER COMMUNITY NOT-FOR-PROFIT ORGANIZATIONS. GENERALLY, THESE ARE UNRESTRICTED CONTRIBUTIONS THAT THE RECEIVING ORGANIZATION CAN USE TO FURTHER THEIR MISSION AND PROGRAMS AT THEIR DISCRETION. THE USE OF THESE CONTRIBUTIONS IS NOT MONITORED. SBMF ALSO PROVIDES ASSISTANCE TO INDIVIDUALS IN THE FORM OF FREE OR REDUCED FEE MEDICAL CARE AT VARIOUS LOCATIONS THROUGHOUT THE COMMUNITIES SERVED. THESE INDIVIDUALS MEET SBMF'S CHARITY CARE ELIGIBILITY REQUIREMENTS, OR THE REQUIREMENTS OF THE REFERRING HEALTH CARE PROVIDER. DETERMINATION AND MONITORING OF CHARITY CARE IS PERFORMED ON A CASE-BY-CASE BASIS. SBMF ALSO PROVIDES DISCOUNTS FOR PAYMENT AT TIME OF SERVICE TO PATIENTS WHO DO NOT HAVE GOVERNMENT PROVIDED INSURANCE COVERAGE OR DO NOT WISH TO HAVE A CLAIM FILED WITH THEIR COMMERCIAL INSURANCE CARRIER. THERE IS NO ACTUAL EXCHANGE OF FUNDS, AS THE DISCOUNTS ARE CREDITED DIRECTLY TO THE PATIENTS' ACCOUNTS. TIME OF SERVICE DISCOUNTS ARE MONITORED AT THE ORGANIZATION LEVEL, IN THE AGGREGATE.
Schedule I (Form 990) 2012


Additional Data


Software ID: 12000266
Software Version: v2012.1.0


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
SOUTH BEND MEDICAL FOUNDATION INC
 
Employer identification number

35-0868178
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
Yes
 
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
Yes
 
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
 
No
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........
4b
Yes
 
c
Participate in, or receive payment from, an equity-based compensation arrangement? .........
4c
 
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.
5
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization? ...........................
5a
 
No
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization? ...........................
6a
 
No
b
Any related organization? .........................
6b
 
No
If "Yes," to line 6a or 6b, describe in Part III.
7
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............
7
 
No
8
Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................
8
 
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For 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)ALFONSO CARDENAS MDPATHOLOGIST (i)
(ii)		 362,982
0 		51
0 		0
0 		7,350
0 		31,923
0 		402,306
0 		0
0
(2)AMOBI EZENEKWE MDPATHOLOGIST (i)
(ii)		 245,633
0 		73
0 		2,956
0 		7,350
0 		38,060
0 		294,072
0 		0
0
(3)BLAIR CHRENKA MDPATHOLOGIST (i)
(ii)		 229,422
0 		203
0 		2,453
0 		4,752
0 		36,758
0 		273,588
0 		0
0
(4)BOBBIE SUTTON MDPATHOLOGIST (i)
(ii)		 285,035
0 		73
0 		0
0 		7,350
0 		23,671
0 		316,129
0 		0
0
(5)C K KIM MDPATHOLOGIST (i)
(ii)		 362,916
0 		73
0 		3,148
0 		7,350
0 		34,723
0 		408,210
0 		0
0
(6)DAVID JENTZ MDPATHOLOGIST (i)
(ii)		 360,819
0 		51
0 		3,148
0 		7,350
0 		26,873
0 		398,241
0 		0
0
(7)DERRICK FORCHETTI MDPATHOLOGIST (i)
(ii)		 261,641
0 		68
0 		0
0 		7,350
0 		29,172
0 		298,231
0 		0
0
(8)FRANCISCO DEOGRACIAS MDPATHOLOGIST (i)
(ii)		 349,926
0 		51
0 		3,148
0 		7,350
0 		28,251
0 		388,726
0 		0
0
(9)FRED BUSSE MDPATHOLOGIST (i)
(ii)		 239,114
0 		53
0 		19,956
0 		7,350
0 		27,975
0 		294,448
0 		0
0
(10)JAMES DYER MDPATHOLOGIST (i)
(ii)		 245,633
0 		73
0 		2,842
0 		4,793
0 		14,493
0 		267,834
0 		0
0
(11)JOHN LANDGRAF MDPATHOLOGIST (i)
(ii)		 250,977
0 		51
0 		9,195
0 		7,350
0 		26,075
0 		293,648
0 		0
0
(12)JOSEPH PRAHLOW MDPATHOLOGIST (i)
(ii)		 263,491
0 		73
0 		2,897
0 		7,350
0 		31,305
0 		305,116
0 		0
0
(13)JOYCE SIMPSON MDPATHOLOGIST (i)
(ii)		 164,462
0 		0
0 		0
0 		6,541
0 		9,192
0 		180,195
0 		0
0
(14)KRISTEN JACOBS MDPATHOLOGIST (i)
(ii)		 214,547
0 		51
0 		356,494
0 		6,594
0 		31,400
0 		609,086
0 		353,882
0
(15)LUIS GALUP MDPATHOLOGIST (i)
(ii)		 359,070
0 		73
0 		3,500
0 		7,350
0 		38,714
0 		408,707
0 		0
0
(16)NICOLE ANEST MDPATHOLOGIST (i)
(ii)		 222,550
0 		68
0 		3,892
0 		5,433
0 		26,831
0 		258,774
0 		0
0
(17)NITA GERIG MDPATHOLOGIST (i)
(ii)		 265,347
0 		70
0 		19,658
0 		7,350
0 		34,537
0 		326,962
0 		0
0
(18)ODETA LAPKUS MDPATHOLOGIST (i)
(ii)		 254,032
0 		68
0 		0
0 		4,900
0 		29,360
0 		288,360
0 		0
0
(19)RICKY HOOVER MDPATHOLOGIST (i)
(ii)		 342,170
0 		51
0 		3,148
0 		7,350
0 		36,217
0 		388,936
0 		0
0
(20)ROBERT TOMEC MDPRESIDENT/EXECUTIVE VP (i)
(ii)		 364,977
0 		51
0 		20,652
0 		7,350
0 		28,148
0 		421,178
0 		0
0
(21)ROBERT KINGSENIOR VP (i)
(ii)		 270,165
0 		68
0 		3,209
0 		7,350
0 		27,096
0 		307,888
0 		0
0
(22)WILLIAM KALINEY MDVICE PRESIDENT/EXECUTIVE VP (i)
(ii)		 363,477
0 		51
0 		20,487
0 		7,350
0 		29,248
0 		420,613
0 		0
0
(23)DIANE JANOWIAKVP OF CENTRAL LAB OPERATIONS (i)
(ii)		 232,699
0 		73
0 		702
0 		6,981
0 		22,023
0 		262,478
0 		0
0
(24)ANN SULLIVANVP OF FINANCE (i)
(ii)		 229,171
0 		68
0 		3,534
0 		6,721
0 		36,111
0 		275,605
0 		0
0
(25)JAMES FRAINVP OF HUMAN RESOURCES (i)
(ii)		 230,171
0 		68
0 		2,754
0 		6,981
0 		35,111
0 		275,085
0 		0
0
(26)PRENTISS JONESDIRECTOR - TOXICOLOGY (i)
(ii)		 145,462
0 		68
0 		0
0 		4,447
0 		21,776
0 		171,753
0 		0
0
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
Health or social club dues or initiation fees Schedule J, Part I, Line 1a THE ORGANIZATION INCLUDES THE PERSONAL USE OF SOCIAL CLUB DUES IN TAXABLE COMPENSATION FOR THE ORGANIZATION'S VICE PRESIDENT OF FINANCE AND VICE PRESIDENT OF CENTRAL LAB OPERATIONS. PERSONAL USE IS DETERMINED BY SIGNED ACKNOWLEDGEMENT OF EACH OFFICER.
Supplemental nonqualified retirement plan Schedule J, Part I, Line 4b THE ORGANIZATION HAS A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN THAT WAS DESIGNED TO REPLACE RETIREMENT BENEFITS LOST BY INDIVIDUALS DUE TO 1998 CHANGES IN PENSION LAWS AND A REDESIGN OF THE PENSION PLAN TO MAXIMIZE BENEFITS FOR LOWER COMPENSATED EMPLOYEES. THE ORGANIZATION'S BOARD OF DIRECTORS ELECTED TO FREEZE THIS PLAN, AND THEREFORE NO BENEFITS WERE PROVIDED DURING 2012.
Schedule J (Form 990) 2012

Additional Data


Software ID: 12000266
Software Version: v2012.1.0
Schedule L
(Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Transactions with Interested Persons
MediumBullet Complete if the organization answered
"Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c,
or Form 990-EZ, Part V, line 38a or 40b.
MediumBullet Attach to Form 990 or Form 990-EZ. MediumBullet See separate instructions.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
SOUTH BEND MEDICAL FOUNDATION INC
 
Employer identification number

35-0868178
Part I
Excess Benefit Transactions (section 501(c)(3) and section 501(c)(4) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.
1(a) Name of disqualified person (b) Relationship between disqualified person and organization (c) Description of transaction (d) Corrected?
Yes No





2
Enter the amount of tax incurred by organization managers or disqualified persons during the year under section 4958. ........................... Bullet Image$
 
3
Enter the amount of tax, if any, on line 2, above, reimbursed by the organization ....... Bullet Image$
 

Part II
Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990-EZ, Part V, line 38a, or Form 990, Part IV, line 26; or if the organization reported an amount on Form 990, Part X, line 5, 6, or 22
(a) Name of interested person (b) Relationship with organization (c) Purpose of loan (d) Loan to or from the organization? (e)Original principal amount (f)Balance due (g) In default? (h) Approved by board or committee? (i)Written agreement?
To From Yes No Yes No Yes No
Total ......Small Bullet $  
Part III
Grants or Assistance Benefitting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.
(a) Name of interested person (b) Relationship between interested person and the organization (c) Amount of assistance (d) Type of assistance (e) Purpose of assistance
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 50056A
Schedule L (Form 990 or 990-EZ) 2012
Schedule L (Form 990 or 990-EZ) 2012
Page 2
Part IV
Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.
(a) Name of interested person (b) Relationship between interested person and the organization (c) Amount of transaction (d) Description of transaction (e) Sharing of organization's revenues?
Yes No
(1) MICHIANA HEALTH INFORMATION NETWORK LLC (MHIN)
  		R. KING & R. TOMEC (SBMF OFFICERS) ARE MHIN BOARD MEMBERS 803,564 SEE PART V   No
(2) MICHIANA HEMATOLOGY ONCOLOGY PC (MHO)
  		B. ANSARI (SBMF BOARD MEMBER) IS AN OFFICER/DIRECTOR OF MHO. 110,053 SEE PART V   No
Part V
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule L (see instructions).
Identifier Return Reference Explanation
DESCRIPTION OF TRANSACTION (MHIN) SCHEDULE L, PART IV, COLUMN (D) SBMF OWNS AN INTEREST IN MHIN, A JOINT VENTURE THAT MAINTAINS A COMMUNITY-BASED MEDICAL INFORMATION SYSTEM AND CLINICAL DATA REPOSITORY. SBMF PURCHASED SERVICES AT FMV FROM MHIN AGGREGATING $756,000 DURING 2012. IN ADDITION, MHIN PURCHASED CERTAIN SERVICES AT FMV FROM SBMF AMOUNTING TO $47,564 DURING 2012.
DESCRIPTION OF TRANSACTION (MHO) SCHEDULE L, PART IV, COLUMN (D) SBMF MADE $110,053 IN PAYMENTS (AT FMV) TO MHO FOR RENTAL OF SPACE.
Schedule L (Form 990 or 990-EZ) 2012

Additional Data


Software ID: 12000266
Software Version: v2012.1.0




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
SOUTH BEND MEDICAL FOUNDATION INC
 
Employer identification number

35-0868178
Identifier Return Reference Explanation
ORGANIZATION'S MISSION (CONTINUED FROM PART III) FORM 990, PART III, LINE 1 TO FULFILL OUR MISSION WE SHALL: (I) PROVIDE THE HOSPITALS WE SERVICE WITH THE HIGHEST QUALITY LABORATORY RESOURCES AND--TAKING INTO ACCOUNT THAT LENGTH OF STAY IS CRUCIAL FOR INPATIENT CARE--WITH THE SHORTEST RESPONSE TIME WHILE ACHIEVING A HIGH DEGREE OF COST EFFECTIVENESS. (II) PROVIDE OUR PHYSICIAN CUSTOMERS WITH THE HIGHEST QUALITY LABORATORY RESULTS UTILIZING THE LATEST TECHNOLOGY AND MAKING AVAILABLE TO THEM READILY ACCESSIBLE CONSULTATIVE OPPORTUNITIES IN THE MEDICAL AND ADMINISTRATIVE ASPECTS OF THEIR PRACTICES. (III) CREATE AND MAINTAIN A WORK ENVIRONMENT WHERE EMPLOYEES CAN GROW PERSONALLY AND PROFESSIONALLY WITH COMPENSATION AND BENEFIT SYSTEMS THAT ARE COMPETITIVE, EQUITABLE AND COST EFFECTIVE AS WELL AS AN ENVIRONMENT WHERE EMPLOYEES ARE PROVIDED STABLE EMPLOYMENT AND EACH INDIVIDUAL IS TREATED WITH RESPECT AND DIGNITY. (IV) PROVIDE TO THE PATIENT POPULATION IN THE COMMUNITIES WE SERVE READILY ACCESSIBLE, REASONABLY PRICED LABORATORY SERVICES, WITH AS WIDE A SCOPE AND VARIETY AS POSSIBLE TO MEET ALL THEIR NEEDS LOCALLY. (V) RECOGNIZING OUR SOCIAL RESPONSIBILITIES TO THE COMMUNITY, PROVIDE SERVICES WITHIN OUR MEANS TO THOSE LESS FORTUNATE, AND SUPPORT PUBLIC AND PRIVATE EFFORTS DIRECTED TO IMPROVE OUR HEALTH CARE ENVIRONMENT.
PROGRAM SERVICE ACCOMPLISHMENTS (CONTINUED FROM PART III) FORM 990, PART III, LINE 4A THE ALTRUISTIC ACTIVITIES OF THE ORGANIZATION ARE INTENDED TO RELIEVE DISEASE, SUFFERING, AND CONSTRAINT. MANY SERVICES ARE PROVIDED AS CHARITY OR PRO BONO. THE AMOUNT OF CHARITY CARE, PROVIDED AT SBMF'S ESTABLISHED RATES, WAS APPROXIMATELY $881,500 FOR THE YEAR ENDED DECEMBER 31, 2012.
Delegate broad authority to a committee Form 990, Part VI, Section A, Line 1a THE ADMINISTRATIVE COMMITTEE SHALL CONSIST OF THE OFFICERS OF THE CORPORATION. SUBJECT TO THE CONTROL OF THE BOARD OF DIRECTORS, THE ADMINISTRATIVE COMMITTEE SHALL HAVE FULL AUTHORITY TO ACT FOR AND ON BEHALF OF THE CORPORATION AND EXERCISE ALL OF THE POWERS OF THE BOARD OF DIRECTORS THAT MAY BE LAWFULLY DELEGATED BY SUCH BOARD TO SUCH COMMITTEE EXCEPT, HOWEVER, THE ADMINISTRATIVE COMMITTEE SHALL HAVE NO POWER TO DONATE ANY PART OF THE ASSETS OF THE CORPORATION. THE ADMINISTRATIVE COMMITTEE SHALL RECEIVE STATUS REPORTS ON OTHER COMMITTEE ACTIVITIES AND DISCUSS ITEMS OF INTEREST TO THE GROUP AS A WHOLE OR TO INDIVIDUAL OFFICERS FOR THE PERFORMANCE OF THEIR DUTIES. THE ADMINISTRATIVE COMMITTEE SHALL KEEP MINUTES OF ITS MEETINGS.
Family/business relationships amongst interested persons Form 990, Part VI, Section A, Line 2 BOB SUTTON (HUSBAND OF BOBBIE SUTTON) AND FRED BUSSE - BUSINESS RELATIONSHIP, ANA CARDENAS (WIFE OF ALFONSO CARDENAS) AND JOHN JACOBS (HUSBAND OF KRISTEN JACOBS) - BUSINESS RELATIONSHIP, FREDERICK J. FERLIC, M.D. AND HENRY KIM, M.D. - BUSINESS RELATIONSHIP
Review of form 990 by governing body Form 990, Part VI, Section B, Line 11b PRIOR TO NOVEMBER 15, 2013, EACH BOARD MEMBER WAS PROVIDED A COPY OF THE RETURN FOR THEIR REVIEW AND INSTRUCTED TO SUBMIT ANY QUESTIONS OR COMMENTS TO THE VP OF FINANCE. AFTER COMMENTS AND QUESTIONS ARE REVIEWED, THE RETURN WAS COMPLETED AND FILED WITH THE IRS ON OR BEFORE NOVEMBER 15, 2013.
Conflict of interest policy Form 990, Part VI, Section B, Line 12c ANNUAL CONFLICT OF INTEREST QUESTIONNAIRES ARE COMPLETED BY ALL BOARD MEMBERS, OFFICERS, KEY EMPLOYEES, AND HIGHEST COMPENSATED EMPLOYEES. THE ORGANIZATION'S VICE PRESIDENT OF FINANCE AND TAX ADVISERS REVIEW ALL RESPONSES TO DETERMINE WHETHER OR NOT A POTENTIAL OR ACTUAL CONFLICT OF INTEREST EXISTS. IF AN ACTUAL CONFLICT OF INTEREST IS DETERMINED TO EXIST, PERSONS WITH A CONFLICT ARE RECUSED FROM VOTING ON THE CONFLICTING ISSUE.
Process used to establish compensation of top management official Form 990, Part VI, Section B, Line 15a ON AN ANNUAL BASIS, THE ORGANIZATION'S COMPENSATION COMMITTEE REVIEWS AND APPROVES COMPENSATION FOR THE PRESIDENT/EXECUTIVE VICE PRESIDENT, AS WELL AS OTHER OFFICERS, ADMINISTRATORS, AND PROFESSIONAL STAFF, INCLUDING KEY EMPLOYEES. THE COMMITTEE REVIEWS CURRENT SALARIES AND PAY STRUCTURES AGAINST VARIOUS SOURCES OF COMPARABILITY DATA, INCLUDING: THE COLLEGE OF AMERICAN PATHOLOGY PATHOLOGISTS COMPENSATION SURVEY; PATHOLOGY COMPENSATION DATA FOR PATHOLOGISTS, WHICH OUTLINES PATHOLOGY AND PHYSICIAN SALARIES BY SPECIALTY, PROVIDED FROM MERRITT HAWKINS AND ASSOCIATES; THE GUIDESTAR NATIONAL COMPENSATION REPORT; AND COMPENSATION REPORTED ON LOCAL AREA HOSPITALS' FORMS 990. AFTER REVIEWING THE COMPARABILITY DATA, THE COMMITTEE DISCUSSES THE CURRENT ECONOMY AND FINANCIAL POSITION OF THE ORGANIZATION TO DETERMINE THE AMOUNT OF ANY COMPENSATION INCREASES AND/OR DECREASES, IF ANY, THAT WILL BE GIVEN. THIS PROCESS IS DOCUMENTED IN THE COMPENSATION COMMITTEE'S MEETING MINUTES. THE COMPENSATION REVIEW COMMITTEE MET APRIL 26, 2012 AND REPORTED AT THE MAY BOARD OF DIRECTOR'S MEETING.
Process used to establish compensation of other officers/key employees Form 990, Part VI, Section B, Line 15b SEE NARRATIVE FOR FORM 990, PART VI, SECTION B, LINE 15A.
Governing documents, conflict of interest policy and financial statements available to the public Form 990, Part VI, Section C, Line 19 WHEN REQUESTS FOR THE ORGANIZATION'S FINANCIAL STATEMENTS ARE MADE, THE DATA IS PROVIDED ON SITE. WHEN REQUESTS FOR THE ORGANIZATION'S GOVERNING DOCUMENTS ARE MADE, THE PERSON IS REFERRED TO WWW.IRS.GOV, WHERE COPIES ARE AVAILABLE. THE ORGANIZATION MAKES ITS CONFLICT OF INTEREST POLICY AVAILABLE TO THE PUBLIC ON SITE.
Other changes in net assets or fund balances Form 990 , Part XI, Line 9 PENSION AND POSTRETIREMENT BENEFIT-RELATED CHANGES OTHER THAN NET PERIODIC BENEFIT COST - -4313414; GALA 2013 RECEIPTS - -103125;
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: 12000266
Software Version: v2012.1.0