Department of the Treasury Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. See separate instructions. Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
CRITTENTON CANCER CENTER
Employer identification number
38-3239057
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions.
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II, or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) A person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the 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) 2013
Schedule A (Form 990 or 990-EZ) 2013
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)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3
The value of services or facilities furnished by a governmental unit to the organization without charge..
4
Total. Add lines 1 through 3
5
The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included
on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6
Public support. Subtract line 5 from line 4.
Section B. Total Support
Calendar year
(or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(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
Gross receipts from related activities, etc. (see instructions)
..................
12
13
First five years.
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.................................................
Section C. Computation of Public Support Percentage
14
Public support percentage for 2013 (line 6, column (f) divided by line 11, column (f))
.........
14
15
Public support percentage for 2012 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2013.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
.......................
b
33 1/3% support test—2012.
If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2013.
If the organization did not check a box on line 13, 16a, or 16b, and line 14
is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization
.....................................................
b
10%-facts-and-circumstances test—2012.
If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported organization
................................................
18
Private foundation.
If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions
.....................................................
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
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)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
72
25,000
25,072
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......
4,854,806
3,682,043
5,686,171
3,964,250
1,404,069
19,591,339
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
6
Total. Add lines 1 through 5.
4,854,878
3,707,043
5,686,171
3,964,250
1,404,069
19,616,411
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
0
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
c
Add lines 7a and 7b..
0
8
Public support (Subtract line 7c from line 6.)
19,616,411
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
9
Amounts from line 6...
4,854,878
3,707,043
5,686,171
3,964,250
1,404,069
19,616,411
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
5,015
502
11
5,528
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
5,015
502
11
5,528
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
..
130
75
205
13
Total support. (Add lines 9, 10c, 11, and 12.)..
4,860,023
3,707,620
5,686,182
3,964,250
1,404,069
19,622,144
14
First five years.
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public support percentage for 2013 (line 8, column (f) divided by line 13, column (f))
.........
15
99.970 %
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
99.530 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
0.030 %
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
0.460 %
19a
33 1/3% support tests—2013.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
........
b
33 1/3% support tests—2012.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
.....
20
Private foundation.
If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 4
Part IV
Supplemental Information.
Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
Explanation
Schedule A (Form 990 or 990-EZ) 2013
Additional Data
Software ID:
Software Version:
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
CRITTENTON CANCER CENTER
Employer identification number
38-3239057
Return Reference
Explanation
FORM 990, PART VI, SECTION A, LINE 6
THE SOLE MEMBER OF OF THE ORGANIZATION IS CRITTENTON HOSPITAL MEDICAL CENTER.
FORM 990, PART VI, SECTION A, LINE 7A
APPROVAL BY THE MEMBER OF THE CORPORATION SHALL BE REQUIRED FOR GOVERNANCE DECISIONS AND HAS THE POWER TO ELECT AND APPROVE BOARD MEMBERS UNDER THE ARTICLES OF INCORPORATION.
FORM 990, PART VI, SECTION A, LINE 8B
CRITTENTON CANCER CENTER DOES NOT HAVE ANY COMMITTEES SET UP THEREFORE THIS QUESTION IS NOT APPLICABLE.
FORM 990, PART VI, SECTION B, LINE 11
THE 990 RETURN WAS GIVEN TO EACH OF THE BOARD MEMBERS FOR REVIEW WITH TIME TO BE ABLE TO ASK QUESTIONS AND/OR MAKE COMMENTS REGARDING ANY ITEM ON THE RETURN PRIOR TO IT BEING FILED WITH THE IRS.
FORM 990, PART VI, SECTION B, LINE 12C
THE SECRETARY OF THE BOARD IS THE HOSPITAL'S COMPLIANCE OFFICER. THE HOSPITAL POLICY STATES THAT ALL EMPLOYEES HAVE A CONTINUOUS OBLIGATION TO DISCLOSE CONFLICTS OF INTEREST, AN ACTUAL IMPROPRIETY, AND/OR AN APPEARANCE OF IMPROPRIETY. EMPLOYEES AT THE MANAGER LEVEL AND ABOVE EACH SIGN A STATEMENT ON AN ANNUAL BASIS ACKNOWLEDGING THEIR UNDERSTANDING OF THE POLICY AND VERIFYING THEIR APPROPRIATE DISCLOSURE OF ANY CONFLICTS. ALL REPORTED CONFLICTS SHALL BE REVIEWED BY THE CEO IN CONJUNCTION WITH THE COMPLIANCE OFFICER AND DEPARTMENT OF LEGAL AFFAIRS. IF IT IS DETERMINED THAT A CONFLICT EXISTS THE EMPLOYEE SHALL DISCONTINUE ALL ACTIVITIES SURROUNDING THAT CONFLICT. THE EMPLOYEE MAY ALSO SEEK A WAIVER OF THE CONFLICT FROM THE CEO. CHMC ALSO HAS A QUESTIONNAIRE FOR INDIVIDUALS AND THEIR IMMEDIATE FAMILY MEMBERS REGARDING CONFLICTS OF INTEREST AND THIS MUST BE SIGNED BY THE INDIVIDUALS. THE QUESTIONNAIRE INCLUDES THE FOLLOWING: 1. IDENTIFY YOUR SERVICE ON ANY BOARD OF DIRECTORS OR TRUSTEES OF ANY OF THE COMPANY'S WITH WHICH CHMC OR ANY OF ITS AFFILIATES DOES BUSINESS. 2. IDENTIFY WHETHER YOU ARE ASSOCIATED DIRECTLY OR INDIRECTLY OR HOLD A POSITION OR FINANCIAL INTEREST IN ANY OUTSIDE ORGANIZATION OR CONCERN WITH WHICH CRITTENTON DOES BUSINESS. 3. IDENTIFY WHETHER YOU DIRECT, MANAGE, OR PROVIDE SERVICES OR CONSULTATION TO ANY OUTSIDE ORGANIZATION OR CONCERN THAT DOES BUSINESS WITH OR COMPETES WITH CRITTENTON. 4. IDENTIFY ANY ACTIVITIES IN WHICH YOU ARE ENGAGED THAT MIGHT BE REGARDED AS CONSTITUTING A POTENTIAL CONFLICT OF INTEREST WITH CRITTENTON. 5. DISCLOSE ANY DIRECT OR INDIRECT COMPENSATION THAT YOU RECEIVE, OR ANTICIPATE RECEIVING, FROM ANY PERSON, FIRM, CORPORATION, OR MARKET IN ANY WAY RELATED TO YOUR POSITION WITH CRITTENTON. IF AT ANY TIME THERE IS A MATTER UNDER CONSIDERATION WHICH MAY CREATE A DIRECT OR INDIRECT CONFLICT OF INTEREST, IT IS THE INDIVIDUAL'S OBLIGATION TO DISCLOSE THE FACTS SURROUNDING THE POSSIBLE CONFLICT TO THE CORPORATE COMPLIANCE OFFICER OR DEPARTMENT OF HUMAN RESOURCES AND THAT THE INDIVIDUAL AGREES TO PROMPTLY REPORT ANY NEW SITUATIONS THAT REQUIRE DISCLOSURE UNDER THIS QUESTIONNAIRE. THERE IS A SIGNED WRITTEN AGREEMENT/DOCUMENTATION FOR ANY BOARD MEMBER OR OFFICER IF A CONFLICT OF INTEREST ARISES. CURRENTLY THERE HAVE NOT BEEN ANY RESTRICTIONS PLACED ON ANY BOARD MEMBER OR OFFICER AS AN ISSUE HAS NOT ARISEN TO WARRANT THIS.
FORM 990, PART VI, SECTION B, LINE 15
COMPENSATION OF CRITTENTON CANCER CENTER'S MANAGEMENT IS PAID BY A RELATED ORGANIZATION, CRITTENTON HOSPITAL MEDICAL CENTER(CHMC). THE HUMAN RESOURCES DEPARTMENT OF CHMC CONDUCTS A BI-ANNUAL WAGE SURVEY OF SELECT POSITIONS TO DETERMINE MARKET COMPETITIVENESS. SURVEYS ARE CONDUCTED ON BEHALF OF CHMC BY A THIRD PARTY TO ASSURE COMPARABILITY OF POSITION SCOPE, SPAN OF CONTROL AND ACCOUNTABILITY WHEN OBTAINING SURVEY RESULTS FROM OTHER LOCAL AREA HEALTH CARE INSTITUTIONS. THE THIRD PARTY COMPILES SURVEY RESULTS AND SUBMITS THEM TO HUMAN RESOURCES FOR REVIEW, ANALYSIS AND RECOMMENDATIONS. HUMAN RESOURCES PREPARES SALARY RECOMMENDATIONS AND REVIEWS THEM WITH THE LEADERSHIP TEAM FOR IMPLEMENTATION SUBJECT TO FUNDING.
FORM 990, PART VI, SECTION C, LINE 19
THIS INFORMATION IS SENT OUT UPON REQUEST EITHER IN HARD COPY OR ELECTRONIC FORM AS INDICATED IN EACH REQUEST.
FORM 990, PART IX, LINE 11G
CONTRACT SERVICES - PHYSICIANS: PROGRAM SERVICE EXPENSES 393,048. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 393,048. CONTRACT SERVICES - HEALTH CARE PROF.: PROGRAM SERVICE EXPENSES 120,681. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 120,681. MAINTENANCE CONTRACTS: PROGRAM SERVICE EXPENSES 503,765. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 503,765. GROUNDS MAINTENANCE: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 33,683. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 33,683. HOUSEKEEPING AND LAUNDRY: PROGRAM SERVICE EXPENSES 61,425. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 61,425. COLLECTION FEES: PROGRAM SERVICE EXPENSES 38,942. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 38,942. CONTRACT SERVICES - CLERICAL: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 25,127. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 25,127.
FORM 990, PART XII, LINE 2C:
THE PROCESS HAS NOT CHANGED FROM PRIOR YEARS.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.