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
CRITICAL CARE SERVICES INC
Employer identification number
41-1518013
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.") .
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......
28,572,458
31,813,358
25,657,655
28,180,673
29,880,307
144,104,451
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.
28,572,458
31,813,358
25,657,655
28,180,673
29,880,307
144,104,451
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.)
144,104,451
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...
28,572,458
31,813,358
25,657,655
28,180,673
29,880,307
144,104,451
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
61,183
53,317
100,881
121,786
111,631
448,798
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
61,183
53,317
100,881
121,786
111,631
448,798
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.)
..
32,143
32,143
13
Total support. (Add lines 9, 10c, 11, and 12.)..
28,633,641
31,866,675
25,758,536
28,302,459
30,024,081
144,585,392
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
99.670 %
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
99.580 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
0.310 %
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
0.320 %
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
CRITICAL CARE SERVICES INC
Employer identification number
41-1518013
Return Reference
Explanation
FORM 990, PART VI, SECTION A, LINE 1
THE EXECUTIVE COMMITTEE CONSISTS OF THE CHAIR, VICE-CHAIR, SECRETARY, PRESIDENT, CHIEF MEDICAL OFFICER AND THE IMMEDIATE PAST CHAIR. THE EXECUTIVE COMMITTEE HAS THE AUTHORITY OF THE BOARD OF DIRECTORS IN THE MANAGEMENT OF THE BUSINESS OF THE CORPORATION IN BETWEEN MEETINGS OF THE BOARD OF DIRECTORS, PROVIDED THAT THE EXECUTIVE COMMITTEE DOES NOT HAVE THE AUTHORITY TO ACT ON ANY MATTER REQUIRING SUPERMAJORITY VOTE OR ANY PROHIBITED ACTIONS AS DEFINED IN THE BYLAWS.
FORM 990, PART VI, SECTION A, LINE 6
THERE IS ONLY ONE CLASS OF MEMBER - NON-PROFIT HEALTHCARE ORGANIZATIONS. LIFE LINK III OPERATES AS A CONSORTIUM WITH NINE MEMBERS INCLUDING: ALLINA HEALTH SYSTEM; CHILDREN'S HEALTH CARE; HENNEPIN HEALTHCARE SYSTEM, INC.; REGIONS HOSPITAL; FAIRVIEW HEALTH SERVICES; CENTRACARE HEALTH SYSTEM; SACRED HEART HOSPITAL OF THE HOSPITAL SISTERS OF THE THIRD ORDER OF ST. FRANCIS; ST. LUKE'S HOSPITAL OF DULUTH, INC.; AND ESSENTIA - ST. MARY'S MEDICAL CENTER.
FORM 990, PART VI, SECTION A, LINE 7A
ALL MEMBERS ARE ENTITLED TO APPOINT ONE PERSON TO THE BOARD OF DIRECTORS AND UPON DISSOLUTION OF THE ORGANIZATION, SHARE EQUALLY IN ANY SURPLUS OF PROPERTY.
FORM 990, PART VI, SECTION B, LINE 11
THE RETURN WAS REVIEWED IN DETAIL BY THE CHIEF FINANCIAL OFFICER (CFO). THE CFO PROVIDED A DRAFT OF THE FORM TO THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS FOR THEIR REVIEW AND APPROVAL. THE BOARD OF DIRECTORS THEN RECEIVED A FINAL DRAFT AND APPROVED PRIOR TO FILING WITH THE IRS.
FORM 990, PART VI, SECTION B, LINE 12C
DIRECTORS, OFFICERS AND KEY EMPLOYEES ARE REQUIRED TO ANNUALLY COMPLETE AND SIGN THE CONFLICT OF INTEREST STATEMENT. THE SIGNED STATEMENTS REMAIN ON FILE WITH THE ORGANIZATION'S CEO FOR THE CALENDAR FISCAL YEAR. CONFLICTS ARE REVIEWED AND DETERMINED BY THE CEO IN CONJUNCTION WITH THE EXECUTIVE COMMITTEE. PERSONS WITH A CONFLICT ARE REQUIRED TO DISCLOSE AND REFRAIN FROM VOTING ON MATTERS WHERE THAY HAVE A CONFLICT. ACTUAL CONFLICTS ARE NOTED IN MEETING MINUTES.
FORM 990, PART VI, SECTION B, LINE 15A
THE COMPENSATION FOR THE CEO WAS ESTABLISHED AS PART OF A NATIONAL SEARCH FOR A CEO IN 2010. THE SEARCH COMMITTEE OF THE BOARD OF DIRECTORS RELIED ON AN OUTSIDE NATIONAL RECRUITMENT FIRM TO GATHER RELEVANT MARKET DATA TO ESTABLISH COMPENSATION COMPARABLES, DATA PROVIDED BY AN INDEPENDENT COMPENSATION CONSULTANT, THE 2010 HHRAM EXECUTIVE COMPENSATION SURVEY (MOST RECENT AVAILABLE AT THE TIME OF THE SEARCH), AND IN CONSIDERATION OF THE NEEDS OF THE ORGANIZATION CONSISTENT WITH THE DIRECTION OF THE BOARD WERE ALL USED TO ARRIVE AT THE COMPENSATION FOR THE CEO. IN 2013, THE PROCESS OF REVIEWING THE CEO'S COMPENSATION INCLUDED REVIEW AND APPROVAL BY INDEPENDENT PERSONS, COMPARABILITY DATA AND CONTEMPORANEOUS SUBSTANTIATION. FOR ALL OTHER OFFICERS AND KEY EMPLOYEES, THE DIRECTOR OF HUMAN RESOURCES IDENTIFIES AND OBTAINS COMPENSATION SURVEYS, INDUSTRY AND MARKET DATA, AND OTHER EXTERNAL COMPETITIVE INFORMATION SOURCES FOR EVALUATION. THIS INFORMATION IS EVALUATED AND CONSIDERED IN THE CONTEXT OF THE JOB DESCRIPTION, POSITION SKILLS AND EXPERIENCE REQUIREMENTS BY THE DIRECTOR OF HUMAN RESOURCES AND THE CEO TO ESTABLISH A RANGE TO BE USED FOR COMPENSATION AND DEVELOPING COMPENSATION RANGES TO BE USED DURING A HIRING PROCESS. THIS PROCESS WAS LAST PERFORMED IN 2013.
FORM 990, PART VI, SECTION C, LINE 19
THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE IN THE CARE OF THE ORGANIZATION'S CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER AND ARE AVAILABLE FOR INSPECTION UPON REQUEST AT THE ORGANIZATION'S OFFICE DURING NORMAL BUSINESS HOURS.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.