Form990
Click to see attachment
Department of the Treasury
Internal Revenue Service
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private foundations)
MediumBullet Do not enter Social Security numbers on this form as it may be made public. By law, the IRS
generally cannot redact the information on the form.
MediumBullet Information about Form 990 and its instructions is at www.IRS.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
A For the 2013 calendar year, or tax year beginning 01-01-2013 , 2013, and ending 12-31-2013
BCheck if applicable:
CName of organization
TRINITY HEALTH FOUNDATION
 
Doing Business As
TRINITY FOUNDATION
 
Number and street (or P.O. box if mail is not delivered to street address)
802 KENYON RD
 
Room/suite
City or town, state or province, country, and ZIP or foreign postal code
FORT DODGE, IA50501
D Employer identification number

42-1222381
E Telephone number

G Gross receipts $ 13,883,112
F Name and address of principal officer:
SUSAN K THOMPSON
802 KENYON RD
FORT DODGE,IA50501
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
WWW.UNITYPOINT.ORG/FORTDODGE/FOUNDATION
H(a)
Is this a group return for
subordinates?
H(b)
Are all subordinates
included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet  
K Form of organization:
 
L Year of formation: 1983
M State of legal domicile: IA
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: SUPPORTS TRINITY HEALTH SYSTEMS' MISSION OF "IMPROVING OUR COMMUNITY'S HEALTH."
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) ........ 3 14
4 Number of independent voting members of the governing body (Part VI, line 1b) ..... 4 13
5 Total number of individuals employed in calendar year 2013 (Part V, line 2a) ...... 5 0
6 Total number of volunteers (estimate if necessary) ............. 6 13
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) ......... 3,057,000 1,729,371
9 Program service revenue (Part VIII, line 2g) ......... 0 0
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 2,149,216 1,552,207
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) -4,347 26,374
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 5,201,869 3,307,952
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 3,646,619 996,804
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) 186,210 196,971
16a Professional fundraising fees (Part IX, column (A), line 11e)..... 116,648 66,888
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet345,706    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e).... 183,917 169,629
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 4,133,394 1,430,292
19 Revenue less expenses. Subtract line 18 from line 12....... 1,068,475 1,877,660
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 18,692,133 19,248,160
21 Total liabilities (Part X, line 26)............. 1,568,757 482,985
22 Net assets or fund balances. Subtract line 21 from line 20..... 17,123,376 18,765,175
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 (2013)
Form 990 (2013)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response or note to any line in this Part III ..............
1
Briefly describe the organization’s mission: TRINITY HEALTH FOUNDATION IS A NONPROFIT ORGANIZATION THAT SUPPORTS TRINITY HEALTH SYSTEMS' MISSION OF "IMPROVING OUR COMMUNITY'S HEALTH." THE FOUNDATION'S GOAL IS TO PROVIDE FUNDING TO TRINITY HEALTH SYSTEMS TO ENHANCE PATIENT CARE AND SERVICES.
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 $ 996,804 including grants of $ 996,804 ) (Revenue $ 47 )
GRANTS, ALLOCATIONS AND PROGRAM SUPPORTTRINITY HEALTH FOUNDATION'S PURPOSE IS TO RAISE FUNDS TO MAINTAIN, DEVELOP, INCREASE AND EXTEND THE FACILITIES AND SERVICES OF TRINITY REGIONAL MEDICAL CENTER IN FORT DODGE, IOWA, AND TO PROVIDE BROADER HOSPITAL, MEDICAL AND EDUCATIONAL SERVICE OPPORTUNITIES TO ITS PATIENTS, STUDENTS, STAFF, FACULTY AND RESIDENTS OF THE GEOGRAPHICAL AREA IT SERVES. IT SUPPORTS THE MISSIONS OF TRINITY HEALTH SYSTEMS, INC. AND ITS SUBSIDIARIES BY RAISING FINANCIAL CONTRIBUTIONS AND INVESTING THE PROCEEDS.THE GRANT, ALLOCATIONS AND PROGRAM SUPPORT SERVICES MAY INCLUDE:- CONTRIBUTIONS TO TRINITY REGIONAL MEDICAL CENTER FOR EQUIPMENT PURCHASES, TO OFFSET OPERATING EXPENSES AND MISCELLANEOUS.- SCHOLARSHIPS AND/OR LECTURESHIPS AWARDED TO INDIVIDUALS ASSOCIATED WITH TRINITY REGIONAL MEDICAL CENTER.- GRANTS TO LOCAL RURAL HEALTH COMMUNITIES ASSOCIATED WITH TRINITY REGIONAL MEDICAL CENTER.- MISCELLANEOUS GRANTS AND CONTRIBUTIONS TO ORGANIZATIONS AND/OR INDIVIDUALS ASSOCIATED WITH TRINITY REGIONAL MEDICAL CENTER.
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 expensesMediumBullet996,804
Form 990 (2013)
Form 990 (2013)
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
 
No
6
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If "Yes," complete Schedule D, Part IClick to see attachment........................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas, or historic structures? If "Yes," complete Schedule D, Part IIClick to see attachment...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If "Yes," complete Schedule D, Part III Click to see attachment....................
8
 
No
9
Did the organization report an amount in Part X, line 21 for escrow or custodial account liability; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If "Yes," complete Schedule D, Part IVClick to see attachment..............
9
 
No
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi-endowments? If "Yes," complete Schedule D, Part VClick to see attachment......
10
Yes
 
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 VIIClick to see attachment.......
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part VIIIClick to see attachment.......
11c
Yes
 
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part IXClick to see attachment............
11d
 
No
e
Did the organization report an amount for other liabilities in Part X, line 25? If "Yes," complete Schedule D, Part XClick to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If "Yes," complete Schedule D, Part XClick to see attachment.........................
11f
Yes
 
12a
Did the organization obtain separate, independent audited financial statements for the tax year?
If "Yes," complete Schedule D, Parts XI and XII Click to see attachment.................
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If "Yes," and if the organization answered "No" to line 12a, then completing Schedule D, Parts XI and XII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If "Yes," complete Schedule E....
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?.....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States, or aggregate foreign investments valued at $100,000 or more? If "Yes," complete Schedule F, Parts I and IV.........
14b
 
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or other assistance to or for any foreign organization? 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 other assistance to or for foreign individuals? 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................... Click to see attachment
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 (2013)
Form 990 (2013)
Page 4
Part IV
Checklist of Required Schedules (continued)
21
Did the organization report more than $5,000 of grants or other assistance to any domestic organization or government 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 or 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 25a................
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
Did the organization report any amount on Part X, line 5, 6, or 22 for receivables from or payables to any current or former officers, directors, trustees, key employees, highest compensated employees, or disqualified persons? If so, complete Schedule L, Part II....................
26
 
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member of any of these persons? If "Yes," complete Schedule L, Part III.........
27
 
No
28
Was the organization a party to a business transaction with one of the following parties (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If "Yes," complete Schedule L, Part IV ..........................
28a
 
No
b
A family member of a current or former officer, director, trustee, or key employee? If "Yes,"
complete Schedule L, Part IV.....................
28b
 
No
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or direct or indirect owner? If "Yes," complete Schedule L, Part IV...
28c
 
No
29
Did the organization receive more than $25,000 in non-cash contributions? If "Yes," complete Schedule M..Click to see attachment
29
Yes
 
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If "Yes," complete Schedule M............. Click to see attachment
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If "Yes," complete Schedule N,
Part I...........................
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If "Yes," complete Schedule N, Part II......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If "Yes," complete Schedule R, Part I........ Click to see attachment
33
 
No
34
Was the organization related to any tax-exempt or taxable entity? If "Yes," complete Schedule R, Part II, III, or IV, and Part V, line 1........................ Click to see attachment
34
Yes
 
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
 
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
 
 
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If "Yes," complete Schedule R, Part V, line 2............. Click to see attachment
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If "Yes," complete Schedule R, Part VIClick to see attachment
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11b and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2013)
Form 990 (2013)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response or note to any line in this Part V ..............
Yes
No
1a
Enter the number reported in Box 3 of Form 1096 Enter -0- if not applicable ..
1a
4
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
0
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?
Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file (see instructions)
2b
 
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?...
3a
 
No
b
If “Yes,” has it filed a Form 990-T for this year? If “No” to line 3b, 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 (2013)
Form 990 (2013)
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 or note to any line 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
14
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
13
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
 
No
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? .
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed? ...........................
4
 
No
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Did the organization have members or stockholders? ................
6
Yes
 
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? ....................
7a
 
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
Yes
 
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .........................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ............
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If "Yes," provide the names and addresses in Schedule O.......
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal Revenue Code.)
Yes
No
10a
Did the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If "Yes," did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes?
10b
 
 
11a
Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form? ............................
11a
Yes
 
b
Describe in Schedule O the process, if any, used by the organization to review this Form 990. .....
12a
Did the organization have a written conflict of interest policy? If "No," go to line 13.......
12a
Yes
 
b
Were officers, directors, or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ..........................
12b
Yes
 
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If "Yes," describe in Schedule O how this was done.......................
12c
Yes
 
13
Did the organization have a written whistleblower policy? ...............
13
Yes
 
14
Did the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
Yes
 
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes" to line 15a or 15b, describe the process in Schedule O (see instructions).
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
 
No
b
If "Yes," did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
 
 
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how) the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization:
MediumBulletMIKE J DEWERFF CFO802 KENYON ROADFORT DODGEIA50501 (515) 574-6608
Form 990 (2013)
Form 990 (2013)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response or note to any line 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; OfficerInd; Key Employee; Highest compensated employee; FormerOfcrDirectorTrusteeInd;
(1) GREG BOCKEN........................................................................
BOARD MEMBER
 1.00
.......................0.00 		X           0 0 0
(2) CINDY BURKE........................................................................
BOARD MEMBER
 1.00
.......................0.00 		X           0 0 0
(3) TIM BURNS........................................................................
BOARD MEMBER
 1.00
.......................1.00 		X           0 0 0
(4) CHRIS FRIDERES........................................................................
BOARD MEMBER
 1.00
.......................0.00 		X           0 0 0
(5) ROB GUNDERSON........................................................................
BOARD MEMBER
 1.00
.......................0.00 		X           0 0 0
(6) SEAN HANLEY........................................................................
BOARD MEMBER
 1.00
.......................0.00 		X           0 0 0
(7) SCOTT JOHNSON........................................................................
BOARD SECRETARY/TREASURER
 1.00
.......................0.00 		X   X       0 0 0
(8) MARY LITTLE........................................................................
BOARD MEMBER
 1.00
.......................0.00 		X           0 0 0
(9) BENNETT O'CONNOR........................................................................
BOARD CHAIR
 1.00
.......................0.00 		X   X       0 0 0
(10) TIM O'TOOL........................................................................
BOARD MEMBER
 1.00
.......................0.00 		X           0 0 0
(11) JIM RODENBORN........................................................................
BOARD VICE CHAIR
 1.00
.......................0.00 		X   X       0 0 0
(12) ED SHIMKAT JR........................................................................
BOARD MEMBER
 1.00
.......................0.00 		X           0 0 0
(13) MURRAY STANLEY........................................................................
BOARD MEMBER
 1.00
.......................0.00 		X           0 0 0
(14) KELLI WALLACE MD........................................................................
BOARD MEMBER
 1.00
.......................40.00 		X           0 28,131 2,813
(15) MIKE DEWERFF........................................................................
CFO
 1.00
.......................40.00 		    X       0 276,908 52,872
(16) SUSAN THOMPSON........................................................................
PRESIDENT/CEO
 1.00
.......................40.00 		    X       0 482,565 190,438
(17) RALPH HEASLEY TO 1110........................................................................
FORMER INTERIM CFO
 0.00
.......................40.00 		          X 0 195,629 25,009
Form 990 (2013)
Form 990 (2013)
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; OfficerInd; Key Employee; Highest compensated employee; FormerOfcrDirectorTrusteeInd;
(18) THOMAS TIBBITTS TO 1209........................................................................
FORMER PRESIDENT/CEO
 0.00
.......................40.00 		          X 0 658,337 5,529
























1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 0 1,641,570 276,661
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organizationMediumBullet0
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If "Yes," complete Schedule J for such individual ..............
3
Yes
 
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If "Yes," complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If "Yes," complete Schedule J for such person ........
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization’s tax year.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet0
Form 990 (2013)
Form 990 (2013)
Page 9
Part VIII
Statement of Revenue
Check if Schedule O contains a response or note to any line in this Part VIII .............
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512-514
Contributions, Gifts, GrantAmt and OtherAmt Similar Amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c 27,150
d Related organizations...1d 150,000
e Government grants (contributions)1e  
f All other contributions, gifts, grants, and
similar amounts not included above1f 		1,552,221
g Noncash contributions included in lines
1a-1f:$ 		331,229
h Total. Add lines 1a-1f.......MediumBullet 1,729,371
Program Service RevenueAmt Business Code
2a
b
c
d
e
f All other program service revenue .        
g Total. Add lines 2a–2f........MediumBullet  
OtherAmt RevenueAmt 3 Investment income (including dividends, interest, and other similar amounts).......MediumBullet 673,378     673,378
4 Income from investment of tax-exempt bond proceeds..MediumBullet        
5 Royalties...........MediumBullet        
(i) Real (ii) Personal
6a Gross rents    
b Less: rental expenses    
c Rental income or (loss)    
d Net rental income or (loss).......MediumBullet        
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory 11,432,091  
b Less: cost or other basis and sales expenses 10,553,262  
c Gain or (loss) 878,829  
d Net gain or (loss)..........MediumBullet 878,829     878,829
8a Gross income from fundraising events (not including
$ 27,150
of contributions reported on line 1c). See Part IV, line 18 ..
a 48,225
b Less: direct expenses ...b 21,898
c Net income or (loss) from fundraising events..MediumBullet 26,327   26,327
9a Gross income from gaming activities.
See Part IV, line 19 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from gaming activities...MediumBullet        
10a Gross sales of inventory, less
returns and allowances .
a  
b Less: cost of goods sold ..b  
c Net income or (loss) from sales of inventory..MediumBullet        
Miscellaneous Revenue Business Code
11a MISCELLANEOUS REVENUE 900099 47 47    
b            
c            
d All other revenue ....        
e Total. Add lines 11a–11d ...... MediumBullet 47
12 Total revenue. See Instructions......MediumBullet 3,307,952 47 0 1,578,534
Form 990 (2013)
Form 990 (2013)
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 or note to any line 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 21 975,655 975,655
2 Grants and other assistance to individuals in the United States. See Part IV, line 22 21,149 21,149
3 Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16    
4 Benefits paid to or for members    
5 Compensation of current officers, directors, trustees, and key employees ....        
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....        
7 Other salaries and wages 149,972     149,972
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 5,496     5,496
9 Other employee benefits ....... 33,720     33,720
10 Payroll taxes ........... 7,783     7,783
11 Fees for services (non-employees):        
a Management ...... 44,557   44,557  
b Legal .........        
c Accounting ...........        
d Lobbying ...........        
e Professional fundraising services. See Part IV, line 17 66,888 66,888
f Investment management fees ...... 38,994   38,994  
g Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........ 38,203     38,203
12 Advertising and promotion ....        
13 Office expenses ....... 5,215     5,215
14 Information technology ...... 26,861     26,861
15 Royalties ..        
16 Occupancy ...........        
17 Travel ............ 2,711     2,711
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ......        
19 Conferences, conventions, and meetings .... 310   310  
20 Interest ...........        
21 Payments to affiliates .......        
22 Depreciation, depletion, and amortization ..... 1,436     1,436
23 Insurance .............. 3,921   3,921  
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 MISCELLANEOUS EXPENSE 7,421     7,421
b
c
d
e All other expenses        
25 Total functional expenses. Add lines 1 through 24e 1,430,292 996,804 87,782 345,706
26 Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here MediumBullet if following SOP 98-2 (ASC 958-720).        
Form 990 (2013)
Form 990 (2013)
Page 11
Part X Balance Sheet Check if Schedule O contains a response or note to any line in this Part X ..............
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash–non-interest-bearing ............. 1,227,865 1 440,205
2 Savings and temporary cash investments .........   2  
3 Pledges and grants receivable, net ........... 1,323,543 3 716,734
4 Accounts receivable, net .............   4  
5 Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L ..................
  5  
6 Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
  6  
7 Notes and loans receivable, net .............   7  
8 Inventories for sale or use ..............   8  
9 Prepaid expenses and deferred charges .......... 332 9 349
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 47,718
b Less: accumulated depreciation ..... 10b 47,718 1,436 10c 0
11 Investments—publicly traded securities .......... 13,206,133 11 15,399,827
12 Investments—other securities. See Part IV, line 11 .....   12  
13 Investments—program-related. See Part IV, line 11 ..... 2,932,824 13 2,691,045
14 Intangible assets ...............   14  
15 Other assets. See Part IV, line 11 ...........   15  
16 Total assets. Add lines 1 through 15 (must equal line 34)...... 18,692,133 16 19,248,160
Liabilities 17 Accounts payable and accrued expenses ......... 20,706 17 48,908
18 Grants payable .................   18  
19 Deferred revenue ................ 4,484 19 0
20 Tax-exempt bond liabilities .............   20  
21 Escrow or custodial account liability. Complete Part IV of Schedule D..   21  
22 Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
persons. Complete Part II of Schedule L..........   22  
23 Secured mortgages and notes payable to unrelated third parties ..   23  
24 Unsecured notes and loans payable to unrelated third parties ....   24  
25 Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D.................... 1,543,567 25 434,077
26 Total liabilities. Add lines 17 through 25......... 1,568,757 26 482,985
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 .............. 12,114,779 27 13,822,166
28 Temporarily restricted net assets ........... 3,145,529 28 3,034,530
29 Permanently restricted net assets ........... 1,863,068 29 1,908,479
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 ........... 17,123,376 33 18,765,175
34 Total liabilities and net assets/fund balances ........ 18,692,133 34 19,248,160
Form 990 (2013)
Form 990 (2013)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response or note to any line in this Part XI ..............
1
Total revenue (must equal Part VIII, column (A), line 12) ............
1
3,307,952
2
Total expenses (must equal Part IX, column (A), line 25) ............
2
1,430,292
3
Revenue less expenses. Subtract line 2 from line 1 ..............
3
1,877,660
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..
4
17,123,376
5
Net unrealized gains (losses) on investments ...............
5
430,603
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
-666,464
10
Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 33, column (B))
10
18,765,175
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response or note to any line 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 (2013)
Form 990, Special Condition Description:
Special Condition Description
Additional Data


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

Department of the Treasury
Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section 4947(a)(1) nonexempt charitable trust.
right arrow Attach to Form 990 or Form 990-EZ. right arrow See separate instructions.
right arrow 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
TRINITY HEALTH FOUNDATION
 
Employer identification number

42-1222381
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) 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) right arrow (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.") .... 921,476 904,580 1,844,049 3,057,000 1,729,371 8,456,476
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 3 921,476 904,580 1,844,049 3,057,000 1,729,371 8,456,476
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).. 1,464,574
6 Public support. Subtract line 5 from line 4. 6,991,902
Section B. Total Support
Calendar year (or fiscal year beginning in) right arrow (a) 2009 (b) 2010 (c) 2011 (d) 2012 (e) 2013 (f) Total
7 Amounts from line 4.. 921,476 904,580 1,844,049 3,057,000 1,729,371 8,456,476
8 Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources... 312,768 274,904 230,244 269,350 673,378 1,760,644
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.).. 21,871 34,755 35,388 18,368 48,225 158,607
11 Total support (Add lines 7 through 10). 10,375,727
12
12
236
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
67.390 %
15
15
69.340 %
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) 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) right arrow (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......            
3 Gross receipts from activities that are not an unrelated trade or business under section 513..            
4 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...            
5 The value of services or facilities furnished by a governmental unit to the organization without charge..            
6 Total. Add lines 1 through 5.            
7a Amounts included on lines 1, 2, and 3 received from disqualified persons...            
b Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.            
c Add lines 7a and 7b..            
8 Public support (Subtract line 7c from line 6.)  
Section B. Total Support
Calendar year (or fiscal year beginning in) right arrow (a) 2009 (b) 2010 (c) 2011 (d) 2012 (e) 2013 (f) Total
9 Amounts from line 6...            
10a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..            
b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.            
c Add lines 10a and 10b.            
11 Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.            
12 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.) ..            
13 Total support. (Add lines 9, 10c, 11, and 12.)..            
14
Section C. Computation of Public Support Percentage
15
15
 
16
16
 
Section D. Computation of Investment Income Percentage
17
17
 
18
18
 
19a
b
20
Schedule A (Form 990 or 990-EZ) 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:  
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.
Arrow Bullet Information about Schedule B (Form 990, 990-EZ, or 990-PF) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2013
Name of the organization
TRINITY HEALTH FOUNDATION
 
Employer identification number

42-1222381
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 its Form 990PF, Part I, line 2, 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) (2013)

Schedule B (Form 990, 990-EZ, or 990-PF) (2013)
Page 2
Name of organization
TRINITY HEALTH FOUNDATION
  		Employer identification number

42-1222381
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, RESTRICTEDRESTRICTED

$RESTRICTED


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

   
 
 

$  


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

   
 
 

$  


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

   
 
 

$  


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

   
 
 

$  


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

   
 
 

$  


(Complete Part II for noncash contributions.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2013)

Schedule B (Form 990, 990-EZ, or 990-PF) (2013)
Page 3
Name of organization
TRINITY HEALTH FOUNDATION
  		Employer identification number

42-1222381
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) (2013)

Schedule B (Form 990, 990-EZ, or 990-PF) (2013)
Page 4
Name of organization
TRINITY HEALTH FOUNDATION
  		Employer identification number

42-1222381
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) (2013)

Additional Data


Software ID:  
Software Version:  
SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b
SchDMd Bullet Attach to Form 990. SchDMd Bullet See separate instructions. SchDMd Bullet Information about Schedule D (Form 990) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
TRINITY HEALTH FOUNDATION
 
Employer identification number

42-1222381
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) 2013

Schedule D (Form 990) 2013
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 .... 18,510,741 18,310,629 15,888,028 15,213,687 12,487,307
b Contributions ........ 1,310,799 2,124,404 2,761,882 684,060 343,816
c Net investment earnings, gains, and losses 1,355,359 1,762,876 261,656 1,737,772 2,755,129
d Grants or scholarships ..... 853,842 3,633,008 534,479 1,671,715 277,947
e Other expenditures for facilities
and programs ........ 		114 26,345 24,630 22,996 94,618
f Administrative expenses .... 37,580 27,815 41,828 52,780  
g End of year balance ...... 20,285,363 18,510,741 18,310,629 15,888,028 15,213,687
2
Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:
a
Board designated or quasi-endowment SchDMd Bullet75.630 %
b
Permanent endowment SchDMd Bullet9.410 %
c
Temporarily restricted endowment SchDMd Bullet14.960 %
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)
 
No
(ii) related organizations ........................
3a(ii)
 
No
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. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11a. See Form 990, Part X, line 10.
Description of property (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .................      
b Buildings ................        
c Leasehold improvements ............        
d Equipment ................   47,718 47,718 0
e Other .................        
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......SchDMdBullet 0
Schedule D (Form 990) 2013

Schedule D (Form 990) 2013
Page 3
Part VII
Investments—Other Securities. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11b. 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. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11c. See Form 990, Part X, line 13.
(a) Description of investment (b) Book value (c) Method of valuation:
Cost or end-of-year market value
(1) GEORGE MURPHY BENEFICIAL TRUST - WELLS FARGO BANK 2,691,045 F








Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)Small Bullet 2,691,045
Part IX
Other Assets. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11d. 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. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11e or 11f. See Form 990, Part X, line 25.
1.(a) Description of liability (b) Book value
Federal income taxes  
DUE TO AFFILIATES 434,077








Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 434,077
2. Liability for uncertain tax positions 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) 2013

Schedule D (Form 990) 2013
Page 4
Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return Complete if the organization answered 'Yes' to Form 990, Part IV, line 12a.
1 Total revenue, gains, and other support per audited financial statements ....... 1 2,270,000
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains on investments .......... 2a 283,064
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIII.) ............ 2d 22,688
e Add lines 2a through 2d ..................... 2e 305,752
3 Subtract line 2e from line 1..................... 3 1,964,248
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 36,525
b Other (Describe in Part XIII.) ........... 4b 1,307,179
c Add lines 4a and 4b....................... 4c 1,343,704
5 Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ...... 5 3,307,952
Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return. Complete if the organization answered 'Yes' to Form 990, Part IV, line 12a.
1 Total expenses and losses per audited financial statements ........... 1 484,000
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 22,298
e Add lines 2a through 2d...................... 2e 22,298
3 Subtract line 2e from line 1..................... 3 461,702
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 36,525
b Other (Describe in Part XIII.) ............ 4b 932,065
c Add lines 4a and 4b....................... 4c 968,590
5 Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ...... 5 1,430,292
Part XIII
Supplemental Information
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.
Return Reference Explanation
PART V, LINE 4: THE ORGANIZATION RETAINS FUNDS FOR INTENDED FUTURE USES, INCLUDING PURCHASE OF EQUIPMENT, INDIGENT CARE, FUNDING OF MISSION RELATED OPERATIONS, AND HEALTH EDUCATION. IN ADDITION, SOME FUNDS ARE HELD FOR INVESTMENT IN PERPETUITY.
PART X, LINE 2: UNITYPOINT HEALTH AND MOST OF ITS SUBSIDIARIES ARE CLASSIFIED AS TAX-EXEMPT ORGANIZATIONS AS DESCRIBED IN SECTIONS 501(C)(3) AND 501(C)(2) OF THE INTERNAL REVENUE CODE (THE CODE). TAX-EXEMPT ORGANIZATIONS ARE NOT SUBJECT TO FEDERAL AND STATE INCOME TAXES ON RELATED INCOME, PURSUANT TO SECTION 501(A) OF THE CODE. THESE ORGANIZATIONS ARE SUBJECT TO FEDERAL AND STATE INCOME TAXES TO THE EXTENT THEY HAVE UNRELATED BUSINESS INCOME AS DESCRIBED UNDER PROVISIONS OF SECTION 511 OF THE CODE. THE SYSTEM FILES FORM 990 FOR SUBSTANTIALLY ALL OF ITS OPERATING ENTITIES IN THE U.S. FEDERAL JURISDICTION AND IS NO LONGER SUBJECT TO EXAMINATION BY TAX AUTHORITIES FOR THE YEARS BEFORE 2010. THE SYSTEM HAS NO MATERIAL UNCERTAIN TAX POSITIONS. CERTAIN SUBSIDIARIES ARE SUBJECT TO FEDERAL AND STATE INCOME TAXES. SOME OF THESE CORPORATIONS HAVE ACCUMULATED NET OPERATING LOSS CARRYFORWARDS THAT ARE AVAILABLE TO OFFSET FUTURE TAXABLE INCOME DURING THE CARRYFORWARD PERIOD. NO INCOME TAX BENEFIT HAS BEEN RECOGNIZED FOR THE NET OPERATING LOSS CARRYFORWARDS OR OTHER POTENTIAL DEFERRED TAX ASSETS IN THE CONSOLIDATED FINANCIAL STATEMENTS BECAUSE THE SYSTEM BELIEVES REALIZATION OF THESE BENEFITS IS UNLIKELY.
PART XI, LINE 2D - OTHER ADJUSTMENTS: SPECIAL EVENT EXPENSES 21,898. REVENUES NETTED IN EXPENSES 400. ROUNDING 390.
PART XI, LINE 4B - OTHER ADJUSTMENTS: REVENUES IN TEMPORARILY RESTRICTED FUND BALANCE 1,261,768. REVENUES IN PERMANENTLY RESTRICTED FUND BALANCE 45,411.
PART XII, LINE 2D - OTHER ADJUSTMENTS: SPECIAL EVENT EXPENSES 21,898. REVENUES NETTED IN EXPENSES 400.
PART XII, LINE 4B - OTHER ADJUSTMENTS: EXPENSES IN UNRESTRICTED FUND BALANCE 77,416. EXPENSES IN TEMPORARILY RESTRICTED FUND BALANCE 853,841. ROUNDING 808.
Schedule D (Form 990) 2013

Additional Data


Software ID:  
Software Version:  




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. right arrowAttach to Form 990 or Form 990-EZ. right arrowSee separate instructions.
right arrowInformation about Schedule G (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
TRINITY HEALTH FOUNDATION
 
Employer identification number

42-1222381
Part I
Fundraising Activities. Complete if the organization answered "Yes" to Form 990, Part IV, line 17.
Form 990-EZ filers are not required to complete this part.
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
 
THOMPSON & ASSOCIATES OF IOWA INC
229 WARD CIRCLE SUITE A-23
 
BRENTWOOD, TN37027 		ESTATE PLANNING   No 0 66,888 0
             
             
             
             
             
             
             
             
             
Total .................right arrow   66,888  
3
List all states in which the organization is registered or licensed to solicit contributions or has been notified it is exempt from registration or licensing.
IA
For Paperwork Reduction Act Notice, see the Instructions for Form 990or 990-EZ.
Cat. No. 50083H
Schedule G (Form 990 or 990-EZ) 2013
Schedule G (Form 990 or 990-EZ) 2013
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

HOSPICE BALL
(event type) 		(b) Event #2

SWING FOR A CURE
(event type) 		(c) Other events

 
(total number) 		(d) Total events
(add col. (a) through col. (c))
VerticalRevenue 1 Gross receipts . . . 49,510 25,865   75,375
2 Less: Contributions . . 14,981 12,169   27,150
3 Gross income (line 1
minus line 2) . . . 		34,529 13,696   48,225
VerticalDirectExpenses 4 Cash prizes . . .        
5 Noncash prizes . .        
6 Rent/facility costs . .        
7 Food and beverages .        
8 Entertainment . . .        
9 Other direct expenses . 9,259 12,639   21,898
10 Direct expense summary. Add lines 4 through 9 in column (d) ........... right arrow 21,898
11 Net income summary. Subtract line 10 from line 3, column (d)........... right arrow 26,327
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. Subtract line 7 from line 1, 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) 2013
Schedule G (Form 990 or 990-EZ) 2013
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. 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).
Return Reference Explanation
SCHEDULE G, PART I, LINE 2B, COLUMN (V) THOMPSON & ASSOCIATES OF IOWA IS PAID A CONSULTING FEE FOR ESTATE PLANNING THAT TOTALED $60,000 IN 2013. EXPENSE REIMBURSEMENTS WERE PAID RELATED TO THIS ACTIVITY IN THE AMOUNT OF $6,888 IN 2013.
Schedule G (Form 990 or 990-EZ) 2013
Additional Data


Software ID:  
Software Version:  
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
lBullet Information about Schedule I (Form 990) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public
Inspection
Name of the organization
TRINITY HEALTH FOUNDATION
 
Employer identification number
42-1222381
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) NORTH CENTRAL IOWA MENTAL HEALTH CENTER INC
802 KENYON ROAD
FORT DODGE,IA50501 		42-0937390 501(C)(3) 26,193       PROGRAM SUPPORT
(2) TRINITY REGIONAL MEDICAL CENTER
802 KENYON ROAD
FORT DODGE,IA50501 		42-1009175 501(C)(3) 867,916       PROGRAM SUPPORT
(3) UNITYPOINT AT HOME
11333 AURORA AVE
URBANDALE,IA50322 		42-1477471 501(C)(3) 80,547       PROGRAM SUPPORT


















2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................ Bullet Image
3
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) 2013

Schedule I (Form 990) 2013
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) SCHOLARSHIPS 13 15,500      
(2) MEDICAL, DENTAL, AND HOSPITAL EXPENSES 165 4,074      
(3) OTHER 322 1,575      








Part IV
Supplemental Information. Provide the information required in Part I, line 2, Part III, column (b), and any other additional information.
Return Reference Explanation
PART I, LINE 2: TRINITY HEALTH FOUNDATION REQUIRES EACH RECIPIENT OF THE GRANTS MENTIONED IN PART II & III (OTHER THAN ASSISTANCE TO RELATED ORGANIZATIONS IN THE FORM OF WORKING CAPITAL) TO APPLY FOR THE GRANT THROUGH A STRUCTURED PROCESS AND OUTLINES A SERIES OF ELIGIBILITY STANDARDS THAT ARE REQUIRED TO BE MET. THE APPROPRIATE FOUNDATION STAFF THEN REVIEWS THESE APPLICATIONS FOR COMPLETENESS AND COMPLIANCE. AFTER ELIGIBILITY FOR GRANT REVIEW IS ESTABLISHED THE APPLICATION IS FORWARDED TO THE FOUNDATION'S DESIGNATED BOARD COMMITTEE FOR REVIEW. THE COMMITTEE MAKES GRANT RECOMMENDATIONS TO THE FOUNDATION'S BOARD OF DIRECTORS. THE FOUNDATION BOARD OF DIRECTORS MAKES THE FINAL DECISION ON ALL GRANT AWARDS.
Schedule I (Form 990) 2013


Additional Data


Software ID:  
Software Version:  


Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, line 23.
SchJMediumBullet Attach to Form 990. SchJMediumBullet See separate instructions.
SchJMediumBullet Information about Schedule J (Form 990) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
TRINITY HEALTH FOUNDATION
 
Employer identification number

42-1222381
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain....
1b
 
 
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
directors, trustees, officers, including the CEO/Executive Director, regarding the items checked in line 1a? ..
2
 
 
3
Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
4
During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment? ................
4a
 
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) 2013

Schedule J (Form 990) 2013
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)MIKE DEWERFFCFO (i)
(ii)		 0
199,687 		0
50,006 		0
27,215 		0
35,027 		0
17,845 		0
329,780 		0
0
(2)SUSAN THOMPSONPRESIDENT/CEO (i)
(ii)		 0
325,066 		0
89,606 		0
67,893 		0
176,032 		0
14,406 		0
673,003 		0
0
(3)RALPH HEASLEY TO 1110FORMER INTERIM CFO (i)
(ii)		 0
172,047 		0
0 		0
23,582 		0
6,422 		0
18,587 		0
220,638 		0
0
(4)THOMAS TIBBITTS TO 1209FORMER PRESIDENT/CEO (i)
(ii)		 0
27,553 		0
81,724 		0
549,060 		0
5,465 		0
64 		0
663,866 		0
547,071
Schedule J (Form 990) 2013

Schedule J (Form 990) 2013
Page 3
Part III
Supplemental Information
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.
Return Reference Explanation
PART I, LINE 4B THE FOLLOWING INDIVIDUAL(S) RECEIVED A PAYMENT FROM A NON-QUALIFIED RETIREMENT PLAN: THOMAS TIBBITTS $547,071. THE FOLLOWING INDIVIDUAL(S) PARTICIPATED IN A NON-QUALIFIED RETIREMENT PLAN WITH THE FOLLOWING CHANGES TO THEIR ACCOUNTS: MIKE DEWERFF $19,259, SUSAN THOMPSON $163,282.
Schedule J (Form 990) 2013

Additional Data


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

Department of the Treasury
Internal Revenue Service
Noncash Contributions
Right pointing arrow large imageComplete if the organizations answered "Yes" on Form 990, Part IV, lines 29 or 30.
Right pointing arrow large image Attach to Form 990.
Right pointing arrow large imageInformation about Schedule M (Form 990) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
TRINITY HEALTH FOUNDATION
 
Employer identification number

42-1222381
Part I
Types of Property
(a)
Check if applicable 		(b)
Number of contributions or items contributed 		(c)
Noncash contribution amounts reported on
Form 990, Part VIII, line 1g 		(d)
Method of determining
noncash contribution amounts
1 Art—Works of art ....        
2 Art—Historical treasures .        
3 Art—Fractional interests ..        
4 Books and publications ..      
5 Clothing and household
goods ....... 		     
6 Cars and other vehicles ..        
7 Boats and planes ....        
8 Intellectual property ...        
9 Securities—Publicly traded . X 15 326,812 FAIR MARKET VALUE
10 Securities—Closely held stock .        
11 Securities—Partnership, LLC,
or trust interests .... 		       
12 Securities—Miscellaneous ..        
13 Qualified conservation
contribution—Historic
structures ..... 		       
14 Qualified conservation
contribution—Other ... 		       
15 Real estate—Residential .        
16 Real estate—Commercial ..        
17 Real estate—Other ...        
18 Collectibles .....        
19 Food inventory ... X 2 4,417 FAIR MARKET VALUE
20 Drugs and medical supplies .        
21 Taxidermy ......        
22 Historical artifacts ....        
23 Scientific specimens ..        
24 Archeological artifacts ...        
25 Other Right pointing arrow large image ( )
26 Other Right pointing arrow large image( )
27 Other Right pointing arrow large image( )
28 Other Right pointing arrow large image ( )
29
Number of Forms 8283 received by the organization during the tax year for contributions
for which the organization completed Form 8283, Part IV, Donee Acknowledgement ...
29
 
Yes
No
30a
During the year, did the organization receive by contribution any property reported in Part I, lines 1 through 28, that
it must hold for at least three years from the date of the initial contribution, and which is not required to be used
for exempt purposes for the entire holding period? ..................
30a
 
No
b
If "Yes," describe the arrangement in Part II.
31
Does the organization have a gift acceptance policy that requires the review of any non-standard contributions?
31
Yes
 
32a
Does the organization hire or use third parties or related organizations to solicit, process, or sell noncash
contributions? ..........................
32a
 
No
b
If "Yes," describe in Part II.
33
If the organization did not report an amount in column (c) for a type of property for which column (a) is checked,
describe in Part II.
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 51227J
Schedule M (Form 990) (2013)
Schedule M (Form 990) (2013)
Page 2
Part II
Supplemental Information. Provide the information required by Part I, lines 30b,
32b, and 33, and whether the organization is reporting in Part I, column (b), the number of contributions, the number of items received, or a combination of both. Also complete this part for any additional information.
Return Reference Explanation
Schedule M (Form 990) (2013)
Additional Data


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

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

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
MediumBullet Attach to Form 990 or 990-EZ.
MediumBullet 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
TRINITY HEALTH FOUNDATION
 
Employer identification number

42-1222381
Return Reference Explanation
FORM 990, PART VI, SECTION A, LINE 6 TRINITY HEALTH SYSTEMS, INC., A TAX-EXEMPT IOWA NONPROFIT CORPORATION, IS SOLE MEMBER.
FORM 990, PART VI, SECTION A, LINE 7B TRINITY HEALTH SYSTEMS, INC., AS SOLE MEMBER, APPROVES BOARD OF DIRECTORS, BUDGETS, APPOINTS PRESIDENT/CEO, APPROVES ESTABLISHING SUBSIDIARIES, AFFILIATES AND JOINT VENTURES, APPROVES MERGERS, CONSOLIDATIONS OR DISSOLUTIONS, AND APPROVES CHANGES IN PURPOSE.
FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS PREPARED INTERNALLY BY THE IOWA HEALTH SYSTEM TAX DEPARTMENT USING INFORMATION GATHERED FROM VARIOUS FUNCTIONAL AREAS OF THE ORGANIZATION. EACH SECTION OF THE RETURN IS REVIEWED BY THE RESPONSIBLE FUNCTIONAL AREA ALONG WITH THE TAX DEPARTMENT. A DRAFT COPY OF THE RETURN IS PROVIDED TO THE CFO FOR REVIEW. A FULL COPY OF THE FORM 990 IS PROVIDED TO THE BOARD OF DIRECTORS PRIOR TO FILING WITH THE IRS.
FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION HAS A CONFLICT OF INTEREST POLICY. ANNUALLY ALL OFFICERS, DIRECTORS, KEY EMPLOYEES AND REPORTING PHYSICIANS ARE REQUESTED TO COMPLETE A QUESTIONNAIRE TO REPORT POTENTIAL CONFLICTS OF INTEREST. PERSONS WHO HAVE NOT RETURNED QUESTIONNAIRES ARE CONTACTED ADDITIONAL TIMES IN AN EFFORT TO RECEIVE COMPLETE AND ACCURATE RESPONSES FROM ALL PERSONS. THE ANNUAL QUESTIONNAIRES INCLUDE AN ACKNOWLEDGEMENT THAT THE OFFICER, DIRECTOR, KEY EMPLOYEE OR REPORTING PHYSICIAN: 1) HAS ACCESS TO A COPY OF THE CONFLICT OF INTEREST POLICY; 2) HAS READ AND UNDERSTANDS THE POLICY; 3) AGREES TO COMPLY WITH THE POLICY; 4) UNDERSTANDS THAT THE POLICY APPLIES TO ALL COMMITTEES AND SUBCOMMITTEES HAVING BOARD-DELEGATED POWERS; AND 5) UNDERSTANDS THAT THE ORGANIZATION IS A CHARITABLE ORGANIZATION AND THAT IN ORDER TO MAINTAIN ITS TAX-EXEMPT STATUS, IT MUST CONTINUOUSLY ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. SENIOR ADMINISTRATIVE STAFF AT ALL RELATED ORGANIZATIONS PROVIDE INFORMATION TO A CENTRAL COORDINATOR RELATED TO THE IDENTIFICATION OF WHICH INDIVIDUALS SHOULD RECEIVE THE QUESTIONNAIRE FOR COMPLETION. THE RESULTS ARE COMPILED CENTRALLY AND REVIEWED BY THE IOWA HEALTH SYSTEM COMPLIANCE OFFICER AND DIRECTOR OF INTERNAL AUDIT. THE DETAIL RESULTS ARE REPORTED TO A COMMITTEE OF THE SYSTEM BOARD. THE RESULTS RELATED TO SPECIFIC REGIONAL PARENT COMPANIES, THEIR HOSPITALS AND RELATED ORGANIZATIONS, ARE DISTRIBUTED IN DETAIL TO THE CHAIRPERSON OF THE REGIONAL PARENT ORGANIZATION, THE CHIEF EXECUTIVE OFFICER, CHIEF FINANCIAL OFFICER AND COMPLIANCE MANAGER. THESE INDIVIDUALS ARE ALSO REMINDED OF THE APPROPRIATE PROCESS TO BE FOLLOWED DURING THE YEAR TO ADDRESS POTENTIAL CONFLICTS OF INTEREST THAT RELATE TO MATTERS THAT ARE BROUGHT TO THE BOARD OF DIRECTORS FOR ACTION. THE INFORMATION DISCLOSED IS USED TO IDENTIFY POTENTIAL CONFLICTS OF INTEREST AND TO ASSIST IN COMPLETING IRS AND MEDICAID QUESTIONNAIRES. ANY DUALITY OF INTEREST OR POSSIBLE CONFLICT OF INTEREST ON THE PART OF ANY ORGANIZATIONAL OFFICER, DIRECTOR, KEY EMPLOYEE OR REPORTING PHYSICIAN TOGETHER WITH ALL MATERIAL FACTS, SHOULD BE DISCLOSED TO THE BOARD OF DIRECTORS AND MADE A MATTER OF RECORD, EITHER THROUGH AN ANNUAL PROCEDURE OR WHEN THE INTEREST OCCURS OR BECOMES A MATTER OF BOARD ACTION. ANY ORGANIZATIONAL OFFICER, DIRECTOR, KEY EMPLOYEE OR REPORTING PHYSICIAN HAVING A CONFLICT OF INTEREST IN ANY MATTER SHOULD NOT BE PRESENT DURING GENERAL DISCUSSION NOR VOTE OR USE HIS OR HER PERSONAL INFLUENCE ON THE MATTER, AND HE OR SHE SHOULD NOT BE COUNTED IN DETERMINING THE EXISTENCE OF A QUORUM FOR PURPOSES OF THE MATTER OR ITEM AS TO WHICH A CONFLICT EXISTS. THE BOARD SHOULD EXCLUDE THE INDIVIDUAL FROM ANY DISCUSSION OR VOTE IN WHICH THE BOARD DECIDES WHETHER OR NOT A CONFLICT OF INTEREST EXISTS. IN CASES IN WHICH AN OFFICER, DIRECTOR, KEY EMPLOYEE, REPORTING PHYSICIAN OR THE INDIVIDUAL'S HOUSEHOLD MEMBER HAS A CONFLICT OF INTEREST IN AN ARRANGEMENT OR TRANSACTION, THE FOLLOWING ADDITIONAL STEPS MAY BE TAKEN AT THE DIRECTION OF THE BOARD OF DIRECTORS: 1) AFTER DISCLOSURE OF THE FINANCIAL INTEREST AND ALL MATERIAL FACTS, AND AFTER ANY DISCUSSION WITH THE INTERESTED PERSON, HE OR SHE SHALL LEAVE THE BOARD OR COMMITTEE MEETING WHILE THE DETERMINATION OF A CONFLICT OF INTEREST IS DISCUSSED AND VOTED UPON. THE REMAINING BOARD OR COMMITTEE MEMBERS SHALL 1) DECIDE IF A CONFLICT OF INTEREST EXISTS, 2) A DISINTERESTED PERSON OR COMMITTEE MAY BE APPOINTED TO INVESTIGATE ALTERNATIVES TO THE PROPOSED ARRANGEMENT OR TRANSACTION; 3) IN ORDER TO APPROVE THE ARRANGEMENT OR TRANSACTION, THE BOARD MUST FIRST FIND, BY MAJORITY VOTE OF DISINTERESTED MEMBERS, THAT THE ARRANGEMENT OR TRANSACTION IS IN THE ORGANIZATION'S BEST INTEREST, IS FAIR AND REASONABLE TO THE ORGANIZATION, AND, AFTER REASONABLE INVESTIGATION, THE DISINTERESTED MEMBERS HAVE DETERMINED THAT A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT CANNOT BE OBTAINED WITH REASONABLE EFFORTS UNDER THE CIRCUMSTANCES; THE MINUTES OF THE BOARD AND ALL COMMITTEES WITH BOARD-DELEGATED POWERS SHALL CONTAIN: 1) THE NAMES OF THE PERSONS WHO DISCLOSED OR OTHERWISE WERE FOUND TO HAVE A FINANCIAL INTEREST IN CONNECTION WITH AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, THE NATURE OF THE FINANCIAL INTEREST, ANY ACTION TAKEN TO DETERMINE WHETHER A CONFLICT OF INTEREST WAS PRESENT, AND THE BOARD'S OR COMMITTEE'S DECISION AS TO WHETHER A CONFLICT OF INTEREST IN FACT EXISTED; 2) THE NAMES OF THE PERSONS WHO WERE PRESENT FOR DISCUSSIONS AND VOTES RELATING TO THE TRANSACTION OR ARRANGEMENT, THE CONTENT OF THE DISCUSSION, INCLUDING ANY ALTERNATIVES TO THE PROPOSED TRANSACTION OR ARRANGEMENT, AND A RECORD OF ANY VOTES TAKEN IN CONNECTION THEREWITH; IN ORDER TO PROTECT THE ORGANIZATION'S BEST INTERESTS, APPROPRIATE DISCIPLINARY ACTION MAY BE TAKEN WITH RESPECT TO AN OFFICER, DIRECTOR, KEY EMPLOYEE OR REPORTING PHYSICIAN WHO VIOLATES THE CONFLICT OF INTEREST POLICY.
FORM 990, PART VI, SECTION B, LINE 15 THE EXECUTIVE COMMITTEE OF THE IOWA HEALTH SYSTEM BOARD OF DIRECTORS ("COMMITTEE") CONDUCTS A COMPREHENSIVE ANNUAL REVIEW OF ALL COMPENSATION AND BENEFITS PROVIDED TO THE ORGANIZATION'S OFFICERS AND KEY EMPLOYEES, INCLUDING THE IHS CHIEF EXECUTIVE OFFICER (THE "CEO"). THIS ANNUAL REVIEW COMPARES THE TOTAL COMPENSATION AND VALUE OF BENEFITS PROVIDED TO EACH EXECUTIVE, ON A POSITION BY POSITION BASIS, TO THAT PROVIDED TO FUNCTIONALLY SIMILAR POSITIONS IN SIMILARLY SITUATED ORGANIZATIONS. THIS REVIEW IS CONDUCTED BY THE COMMITTEE WITH THE ASSISTANCE OF A NATIONAL, INDEPENDENT COMPENSATION CONSULTANT REPORTING DIRECTLY TO THE COMMITTEE. THE COMMITTEE HAS BEEN DELEGATED THE RESPONSIBILITY FOR OVERSIGHT OF EXECUTIVE COMPENSATION AND IS MADE UP ENTIRELY OF INDEPENDENT DIRECTORS WITHIN THE MEANING OF THE "REBUTTABLE PRESUMPTION OF REASONABLENESS" UNDER THE FEDERAL INCOME TAX INTERMEDIATE SANCTIONS RULES. THE COMPENSATION CONSULTANT HOLDS ITSELF OUT TO THE PUBLIC AS A COMPENSATION CONSULTANT, PERFORMS THESE VALUATIONS ON A REGULAR BASIS, IS QUALIFIED TO MAKE THE VALUATIONS OF THE SERVICES INVOLVED, AND HAS SO INDICATED IN A WRITTEN CERTIFICATION TO THE COMMITTEE. BASED UPON THE ADVICE OF THE COMPENSATION CONSULTANT, AND APPLYING THE BOARD'S COMPENSATION PHILOSOPHY, THE COMMITTEE ESTABLISHES THE OVERALL ADJUSTMENT IN COMPENSATION AND BENEFITS FOR APPROXIMATELY THE TOP FIFTY EXECUTIVES IN THE ENTIRE HEALTH SYSTEM (SEVERAL OF WHICH ARE EMPLOYEES OF THE FILING ORGANIZATION) AND DELEGATES TO THE CEO THE AUTHORITY TO MAKE ADJUSTMENTS, CONSISTENT WITH THE COMMITTEE'S DIRECTION, FOR THE OTHER EXECUTIVES. THE COMMITTEE DETERMINES ALL ASPECTS OF THE COMPENSATION AND BENEFITS OF THE CEO. THE COMMITTEE INTENTIONALLY TAKES ALL THE STEPS NECESSARY TO QUALIFY FOR THE REBUTTABLE PRESUMPTION OF REASONABLENESS UNDER THE FEDERAL INCOME TAX LAW INTERMEDIATE SANCTIONS RULES, INCLUDING CONTEMPORANEOUS SUBSTANTIATION OF ALL COMMITTEE MEETINGS AND ACTIONS. THE ORGANIZATION BELIEVES IT IS IN FULL COMPLIANCE WITH SECTION 4958 OF THE IRC, PROVIDES NO MORE THAN REASONABLE AND FAIR MARKET VALUE COMPENSATION AND BENEFITS FOR ITS EMPLOYEES AND DOES NOT PROVIDE ANY EXCESS COMPENSATION OR BENEFITS AS PROHIBITED BY SECTION 4958. THE ANNUAL REVIEW OF COMPENSATION AND BENEFITS WAS LAST PERFORMED IN DECEMBER 2013 FOR THE FOLLOWING INDIVIDUALS: MIKE DEWERFF AND SUSAN THOMPSON. THE COMPENSATION AND BENEFITS OF THE OTHER PERSONS LISTED ON FORM 990, PART VII WAS ESTABLISHED BY AN INDEPENDENT PERSON/COMMITTEE USING AN INDEPENDENT COMPENSATION CONSULTANT AND/OR COMPENSATION SURVEY OR STUDY FOR SIMILARLY QUALIFED PERSONS IN FUNCTIONALLY COMPARABLE POSITIONS AT SIMILARLY SITUATED ORGANIZATIONS. COMPENSATION AND BENEFITS ARE BASED ON THE FAIR MARKET VALUE OF THE SERVICES PROVIDED TO THE ORGANIZATION.
FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS ARE AVAILABLE UPON REQUEST THROUGH THE IOWA HEALTH SYSTEM, OUR PARENT ORGANIZATION, LEGAL DEPARTMENT. THE ORGANIZATION'S CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE PUBLICLY AVAILABLE ON THE IOWA HEALTH SYSTEM WEBSITE, WWW.UNITYPOINT.ORG.
FORM 990, PART XI, LINE 9: CHANGE IN PLEDGE VALUE -666,464.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2013

Additional Data


Software ID:  
Software Version:  
SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
MediumBulletAttach to Form 990. MediumBullet See separate instructions.
MediumBullet Information about Schedule R (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
TRINITY HEALTH FOUNDATION
 
Employer identification number

42-1222381
Part I
Identification of Disregarded Entities Complete if the organization answered "Yes" on Form 990, Part IV, line 33.
(a)
Name, address, and EIN (if applicable) of disregarded entity


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Total income


 		(e)
End-of-year assets


 		(f)
Direct controlling
entity










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


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Exempt Code section


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

 		(f)
Direct controlling
entity

 		(g)
Section 512(b)(13) controlled entity?
Yes No
(1) ALLEN COLLEGE

1825 LOGAN AVENUE

WATERLOO,IA50703
42-1351526 		EDUCATE AND DEVELOP HEALTHCARE PROFESSIONALS IA 501(C)(3) 170(B)(1) (A)(II) ALLEN HEALTH SYSTEMS INC
 
 
No
(2) ALLEN HEALTH SYSTEMS INC

1825 LOGAN AVENUE

WATERLOO,IA50703
42-1201924 		SUPPORT AFFILIATES' MISSION TO IMPROVE HEALTH CARE IA 501(C)(3) 509(A)(3), TYPE II IOWA HEALTH SYSTEM
 
 
No
(3) ALLEN MEMORIAL HOSPITAL CORPORATION

1825 LOGAN AVENUE

WATERLOO,IA50703
42-0698265 		HOSPITAL IA 501(C)(3) 170(B)(1) (A)(III) ALLEN HEALTH SYSTEMS INC
 
 
No
(4) ANAMOSA AREA AMBULANCE SERVICE

101 GRANT WOOD DRIVE

ANAMOSA,IA52205
42-1466284 		PROVIDE AMBULANCE SERVICES IA 501(C)(3) 509(A)(2) ST LUKE'SJONES REGIONAL MEDICAL CENTER
 
 
No
(5) CENTRAL IOWA HEALTH PROPERTIES CORPORATION

1200 PLEASANT STREET

DES MOINES,IA50309
42-1233759 		PROPERTY HOLDING COMPANY IA 501(C)(2)   CENTRAL IOWA HEALTH SYSTEM
 
 
No
(6) CENTRAL IOWA HEALTH SYSTEM

1200 PLEASANT STREET

DES MOINES,IA50309
42-1189791 		SUPPORT AFFILIATES' MISSION TO IMPROVE HEALTH CARE IA 501(C)(3) 509(A)(3), TYPE II IOWA HEALTH SYSTEM
 
 
No
(7) CENTRAL IOWA HOSPITAL CORPORATION

1200 PLEASANT STREET

DES MOINES,IA50309
42-0680452 		HOSPITAL IA 501(C)(3) 170(B)(1) (A)(III) CENTRAL IOWA HEALTH SYSTEM
 
 
No
(8) FINLEY TRI-STATES HEALTH GROUP INC

350 NORTH GRANDVIEW AVENUE

DUBUQUE,IA52001
42-1307495 		SUPPORT AFFILIATES' MISSION TO IMPROVE HEALTH CARE IA 501(C)(3) 509(A)(3), TYPE II IOWA HEALTH SYSTEM
 
 
No
(9) HULT CENTER FOR HEALTHY LIVING INC

5409 N KNOXVILLE AVE

PEORIA,IL61614
36-3510390 		HEALTH EDUCATION TO THE COMMUNITY IL 501(C)(3) 170(B)(1) (A)(VI) PROCTOR HOSPITAL
 
 
No
(10) IOWA HEALTH FOUNDATION

1415 WOODLAND AVE SUITE E-200

DES MOINES,IA50309
42-1467682 		CHARITABLE FUNDRAISING IA 501(C)(3) 170(B)(1) (A)(VI) CENTRAL IOWA HEALTH SYSTEM
 
 
No
(11) IOWA HEALTH SYSTEM

1776 WEST LAKES PKWY 400

WEST DES MOINES,IA50266
42-1435199 		SUPPORT AFFILIATES' MISSION TO IMPROVE HEALTH CARE IA 501(C)(3) 509(A)(3), TYPE III  
 
No
(12) IOWA PHYSICIANS CLINIC MEDICAL FOUNDATION

8101 BIRCHWOOD COURT

JOHNSTON,IA50131
42-1411630 		PRIMARY HEALTH CARE SERVICES IA 501(C)(3) 170(B)(1) (A)(III) IOWA HEALTH SYSTEM
 
 
No
(13) MEMORIAL FOUNDATION OF ALLEN HOSPITAL

1825 LOGAN AVENUE

WATERLOO,IA50703
42-1201138 		CHARITABLE FUNDRAISING IA 501(C)(3) 170(B)(1) (A)(VI) ALLEN HEALTH SYSTEMS INC
 
 
No
(14) METHODIST HEALTH SERVICES CORPORATION

221 NORTHEAST GLEN OAK AVENUE

PEORIA,IL61636
37-1111135 		SUPPORT AFFILIATES' MISSION TO IMPROVE HEALTH CARE IL 501(C)(3) 509(A)(3), TYPE III IOWA HEALTH SYSTEM
 
 
No
(15) METHODIST MEDICAL CENTER FOUNDATION

221 NORTHEAST GLEN OAK AVENUE

PEORIA,IL61636
51-0186460 		CHARITABLE FUNDRAISING IL 501(C)(3) 170(B)(1) (A)(VI) METHODIST HEALTH SERVICES CORPORATION
 
 
No
(16) METHODIST MEDICAL CENTER OF ILLINOIS

221 NORTHEAST GLEN OAK AVENUE

PEORIA,IL61636
37-0661223 		HOSPITAL IL 501(C)(3) 170(B)(1) (A)(III) METHODIST HEALTH SERVICES CORPORATION
 
 
No
(17) METHODIST SERVICES INC

221 NORTHEAST GLEN OAK AVENUE

PEORIA,IL61636
37-1111134 		OFFICE RENTAL IL 501(C)(3) 509(A)(2) METHODIST HEALTH SERVICES CORPORATION
 
 
No
(18) NELLIE R SHERWOOD TRUST

1026 A AVENUE NE

CEDAR RAPIDS,IA52402
42-6061621 		PAY MEDICAL BILLS OF RETIRED TEACHERS UNABLE TO PAY IA 501(C)(3) 509(A)(3), TYPE I ST LUKE'S METHODIST HOSPITAL
 
 
No
(19) NORTH CENTRAL IOWA MENTAL HEALTH CENTER INCORPORATED

720 KENYON DRIVE

FORT DODGE,IA50501
42-0937390 		MENTAL HEALTH CARE IA 501(C)(3) 170(B)(1) (A)(III) TRINITY HEALTH SYSTEMS INC
 
 
No
(20) NORTHWEST IOWA HOSPITAL CORPORATION

2720 STONE PARK BLVD

SIOUX CITY,IA51104
42-1019872 		HOSPITAL IA 501(C)(3) 170(B)(1) (A)(III) IOWA HEALTH SYSTEM
 
 
No
(21) PROCTOR HEALTH CARE INCORPORATED

5409 N KNOXVILLE AVE

PEORIA,IL61614
37-1133412 		SUPPORT AFFILIATES' MISSION TO IMPROVE HEALTH CARE IL 501(C)(3) 170(B)(1) (A)(III) METHODIST HEALTH SERVICES CORPORATION
 
 
No
(22) PROCTOR HEALTH SYSTEMS

5409 N KNOXVILLE AVE

PEORIA,IL61614
36-4147437 		PRIMARY HEALTH CARE SERVICES IL 501(C)(3) 170(B)(1) (A)(III) PROCTOR HEALTH CARE INCORPORATED
 
 
No
(23) PROCTOR HOSPITAL

5409 N KNOXVILLE AVE

PEORIA,IL61614
37-0681540 		HOSPITAL IL 501(C)(3) 170(B)(1) (A)(III) PROCTOR HEALTH CARE INCORPORATED
 
 
No
(24) SELF INSURANCE TRUST AGREEMENT EST BY METHODIST MEDICAL CENTER OF ILLINOIS

221 NORTHEAST GLEN OAK AVENUE

PEORIA,IL61636
37-6181831 		FUND SELF-INSURANCE PLAN IL 501(C)(3) 509(A)(3), TYPE I METHODIST MEDICAL CENER OF ILLINOIS
 
 
No
(25) SIOUXLAND PACE INC

313 COOK STREET

SIOUX CITY,IA51103
26-1120134 		ALL-INCLUSIVE CARE FOR THE ELDERLY IA 501(C)(3) 170(B)(1) (A)(III) ST LUKE'S HEALTH SYSTEM INC
 
 
No
(26) ST LUKE'S HEALTH RESOURCES

2720 STONE PARK BLVD

SIOUX CITY,IA51104
42-1059182 		OUTPATIENT CLINICS AND HEALTHCARE SERVICES IA 501(C)(3) 509(A)(2) ST LUKE'S HEALTH SYSTEM INC
 
 
No
(27) ST LUKE'S HEALTH SYSTEM INC

2720 STONE PARK BLVD

SIOUX CITY,IA51104
42-1294091 		SUPPORT AFFILIATES' MISSION TO IMPROVE HEALTH CARE IA 501(C)(3) 509(A)(3), TYPE III IOWA HEALTH SYSTEM
 
 
No
(28) ST LUKE'S HEALTHCARE

1026 A AVENUE NE

CEDAR RAPIDS,IA52402
42-1487968 		SUPPORT AFFILIATES' MISSION TO IMPROVE HEALTH CARE IA 501(C)(3) 509(A)(3), TYPE II IOWA HEALTH SYSTEM
 
 
No
(29) ST LUKE'S METHODIST HOSPITAL

1026 A AVENUE NE

CEDAR RAPIDS,IA52402
42-0504780 		HOSPITAL IA 501(C)(3) 170(B)(1) (A)(III) ST LUKE'S HEALTHCARE
 
 
No
(30) ST LUKE'SJONES REGIONAL MEDICAL CENTER

1795 HIGHWAY 64 EAST

ANAMOSA,IA52205
42-1487967 		HOSPITAL IA 501(C)(3) 170(B)(1) (A)(III) ST LUKE'S HEALTHCARE
 
 
No
(31) STL CARE COMPANY

1026 A AVENUE NE

CEDAR RAPIDS,IA52402
42-1276632 		IMPROVE PUBLIC HEALTH SERVICES IA 501(C)(3) 509(A)(2) ST LUKE'S HEALTHCARE
 
 
No
(32) THE DUBUQUE VISITING NURSE ASSOCIATION

350 NORTH GRANDVIEW AVENUE

DUBUQUE,IA52001
42-0680410 		PUBLIC HEALTH SERVICES/HOME CARE IA 501(C)(3) 509(A)(2) FINLEY TRI-STATES HEALTH GROUP INC
 
 
No
(33) THE FINLEY HOSPITAL

350 NORTH GRANDVIEW AVENUE

DUBUQUE,IA52001
42-0680354 		HOSPITAL IA 501(C)(3) 170(B)(1) (A)(III) FINLEY TRI-STATES HEALTH GROUP INC
 
 
No
(34) THE ROBERT YOUNG CENTER FOR COMMUNITY MENTAL HEALTH

2701 17TH STREET

ROCK ISLAND,IL61201
36-3678909 		MENTAL HEALTH CARE IL 501(C)(3) 170(B)(1) (A)(VI) TRINITY REGIONAL HEALTH SYSTEM
 
 
No
(35) TRIMARK PHYSICIANS GROUP

802 KENYON ROAD

FORT DODGE,IA50501
45-3791448 		SUPPORT SERVICES FOR MEDICAL CARE AND HEALTH SERVICES IA 501(C)(3) 170(B)(1) (A)(III) TRINITY HEALTH SYSTEMS INC
 
 
No
(36) TRINITY BUILDING CORPORATION

802 KENYON ROAD

FORT DODGE,IA50501
42-1376187 		PROPERTY HOLDING COMPANY IA 501(C)(2)   TRINITY HEALTH SYSTEMS INC
 
 
No
(37) TRINITY HEALTH FOUNDATION

802 KENYON ROAD

FORT DODGE,IA50501
42-1222381 		CHARITABLE FUNDRAISING IA 501(C)(3) 170(B)(1) (A)(VI) TRINITY HEALTH SYSTEMS INC
 
 
No
(38) TRINITY HEALTH FOUNDATION

2701 17TH STREET

ROCK ISLAND,IL61201
36-3321751 		CHARITABLE FUNDRAISING IL 501(C)(3) 170(B)(1) (A)(VI) TRINITY REGIONAL HEALTH SYSTEM
 
 
No
(39) TRINITY HEALTH SYSTEMS INC

802 KENYON ROAD

FORT DODGE,IA50501
42-1222877 		SUPPORT AFFILIATES' MISSION TO IMPROVE HEALTH CARE IA 501(C)(3) 509(A)(3), TYPE II IOWA HEALTH SYSTEM
 
 
No
(40) TRINITY MEDICAL CENTER

2701 17TH STREET

ROCK ISLAND,IL61201
36-2739299 		HOSPITAL IL 501(C)(3) 170(B)(1) (A)(III) TRINITY REGIONAL HEALTH SYSTEM
 
 
No
(41) TRINITY REGIONAL HEALTH SYSTEM

2701 17TH STREET

ROCK ISLAND,IL61201
36-3351952 		SUPPORT AFFILIATES' MISSION TO IMPROVE HEALTH CARE IL 501(C)(3) 509(A)(3), TYPE II IOWA HEALTH SYSTEM
 
 
No
(42) TRINITY REGIONAL HOSPITAL AUXILIARY

802 KENYON ROAD

FORT DODGE,IA50501
42-6081474 		CHARITABLE FUNDRAISING AND VOLUNTEER SERVICES IA 501(C)(3) 509(A)(2) TRINITY REGIONAL MEDICAL CENTER
 
 
No
(43) TRINITY REGIONAL MEDICAL CENTER

802 KENYON ROAD

FORT DODGE,IA50501
42-1009175 		HOSPITAL IA 501(C)(3) 170(B)(1) (A)(III) TRINITY HEALTH SYSTEMS INC
 
 
No
(44) UNITY HEALTHCARE

1518 MULBERRY AVENUE

MUSCATINE,IA52761
42-0680337 		HOSPITAL IA 501(C)(3) 170(B)(1) (A)(III) TRINITY REGIONAL HEALTH SYSTEM
 
 
No
(45) UNITY HEALTHCARE FOUNDATION

1518 MULBERRY AVENUE

MUSCATINE,IA52761
42-1525031 		SUPPORT AFFILIATES' MISSION TO IMPROVE HEALTH CARE IA 501(C)(3) 509(A)(3), TYPE I TRINITY REGIONAL HEALTH SYSTEM
 
 
No
(46) UNITYPOINT AT HOME

11333 AURORA AVENUE

URBANDALE,IA50322
42-1477471 		HOME HEALTH CARE IA 501(C)(3) 509(A)(2) IOWA HEALTH SYSTEM
 
 
No
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2013
Schedule R (Form 990) 2013
Page 2
Part III
Identification of Related Organizations Taxable as a Partnership Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.
(a)
Name, address, and EIN of
related organization



 		(b)
Primary activity




 		(c)
Legal
domicile
(state or foreign
country)


 		(d)
Direct controlling
entity



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

(f)
Share of total income




 		(g)
Share of end-of-year
assets



 		(h)
Disproprtionate allocations?




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



 		(k)
Percentage
ownership
Yes No Yes No
(1) ALLEN MEMORIAL HOSPITAL ORTHOPEDIC CO-MANAGEMENT CO LLC

1825 LOGAN AVE
WATERLOO,IA50703
45-3237125 		ORTHOPEDIC MANAGEMENT & ADMINISTRATIVE SERVICES IA N/A
                  
(2) CENTRAL IOWA CARDIOVASCULAR CO-MANAGEMENT CO LLC

1200 PLEASANT ST
DES MOINES,IA50309
27-3625869 		CARDIOVASCULAR MANAGEMENT & ADMINISTRATIVE SERVICES IA N/A
                  
(3) CENTRAL IOWA ONCOLOGY CO-MANAGEMENT COMPANY

1200 PLEASANT STREET
DES MOINES,IA50309
45-3017991 		ONCOLOGY MANAGEMENT & ADMINISTRATIVE SERVICES IA N/A
                  
(4) DUBUQUE ENDOSCOPY CENTER LC

1515 DELHI STREET SUITE 500
DUBUQUE,IA52001
20-1597161 		AMBULATORY SURGERY CENTER IA N/A
                  
(5) ENSEVA - HIAWATHA LLC

755 METZGER DRIVE
HIAWATHA,IA52233
45-3437363 		COLLOCATION FACILITY IA N/A
                  
(6) FINLEY DEPT OF SURGERY CO-MGMT CO LLC

350 N GRANDVIEW AVE
DUBUQUE,IA52001
42-2808785 		SURGERY DEPARTMENT MANAGEMENT SERVICES IA N/A
                  
(7) HEALTH CARE AFFILIATES OF THE TRI-STATES LLC

350 N GRANDVIEW AVE
DUBUQUE,IA52001
42-1428503 		PROVIDE ACCESS TO LICENSED SOFTWARE IA N/A
                  
(8) HEALTH ENTERPRISES VENTURES LC

4250 GLASS ROAD NE
CEDAR RAPIDS,IA52402
39-1894290 		INVESTMENT VEHICLE OWNING CLINICAL JVS IA N/A
                  
(9) HY-VEEIOWA HEALTH LC

5820 WESTOWN PARKWAY
WEST DES MOINES,IA50266
26-3293530 		PRIMARY CARE CLINIC IA N/A
                  
(10) IOWA HEALTH SYSTEM CONTRACTING SERVICES LC

1776 WEST LAKES PKWY 400
WEST DES MOINES,IA50266
42-1511142 		GROUP PURCHASING IA N/A
                  
(11) MEDICAL LABORATORIES OF EASTERN IOWA LC

1026 A AVE NE
CEDAR RAPIDS,IA52402
42-1359640 		MEDICAL LABORATORY SERVICES IA N/A
                  
(12) MMCI ORTHOPEDIC CO-MANAGEMENT COMPANY LLC

221 NE GLEN OAK AVE
PEORIA,IL61636
46-1219459 		ORTHOPEDIC MANAGEMENT & ADMINISTRATIVE SERVICES IL N/A
                  
(13) MR ASSOCIATES LLP

1455 SHERMAN ROAD
HIAWATHA,IA52233
42-1260463 		OWN AND OPERATE MR UNIT IA N/A
                  
(14) REHABILITATION THERAPY SERVICES LLC

416 ST MARKS CT 110
PEORIA,IL61603
81-0584193 		REHABILATION THERAPY IL N/A
                  
(15) SLRMC CARDIOVASCULAR CO-MANAGEMENT COMPANY LLC

2720 STONE PARK BLVD
SIOUX CITY,IA51104
45-5322324 		CARDIOVASCULAR MANAGEMENT & ADMINISTRATIVE SERVICES IA N/A
                  
(16) THE OUTPATIENT SURGERY CENTER OF CEDAR RAPIDS LLC

1075 FIRST AVENUE SE
CEDAR RAPIDS,IA52403
72-1550812 		AMBULATORY SURGERY CENTER. IA N/A
                  
(17) TRINITY BETTENDORF ORTHOPEDIC CO-MANAGEMENT COMPANY LLC

4500 UTICA RIDGE RD
BETTENDORF,IA52722
27-2562753 		ORTHOPEDIC SERVICE LINES ADMINISTRATIVE SERVICES IA N/A
                  
(18) WEST HOSPITAL ORTHOPEDIC CO-MANAGEMENT COMPANY LLC

1660 60TH STREET
WEST DES MOINES,IA50266
27-1414600 		ORTHOPEDIC SERVICE LINES MANAGEMENT IA N/A
                  
Part IV
Identification of Related Organizations Taxable as a Corporation or Trust Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.
(a)
Name, address, and EIN of
related organization
 		(b)
Primary activity
 		(c)
Legal
domicile
(state or foreign
country)
 		(d)
Direct controlling
entity
 		(e)
Type of entity
(C corp, S corp,
or trust) 		(f)
Share of total income
 		(g)
Share of end-of-year
assets
 		(h)
Percentage
ownership
 		(i)
Section 512(b)(13) controlled entity?
Yes No
(1) ASSOCIATED CHIROPRACTIC PROVIDERS INC

5409 N KNOXVILLE AVE
PEORIA,IL61614
37-1304745 		CHIROPRACTIC SERVICES IL N/A
 C         No
(2) BELCREST SERVICES LTD

5409 N KNOXVILLE AVE
PEORIA,IL61614
37-1196307 		MEDICAL SERVICES IL N/A
 C         No
(3) BROADBAND INC

1776 WEST LAKES PKWY 400
WEST DES MOINES,IA50266
27-3819741 		INFORMATION TECHNOLOGY MGMT. IA N/A
 C         No
(4) DELHI POINT CONDO ASSOCIATION

350 N GRANDVIEW
DUBUQUE,IA52001
42-1467002 		REAL ESTATE MANAGEMENT IA N/A
 C         No
(5) HEALTH PLUS INC

5409 N KNOXVILLE AVE
PEORIA,IL61614
37-1295532 		MANAGED CARE ADMINISTRATION IL N/A
 C         No
(6) HNC SERVICES

1776 WEST LAKES PKWY 400
WEST DES MOINES,IA50266
27-0987243 		FIBER OPTIC NETWORK SERVICES IA N/A
 C         No
(7) MEDIMORE INC

1776 WEST LAKES PKWY 400
WEST DES MOINES,IA50266
42-1414390 		MANAGED CARE IA N/A
 C         No
(8) METHODIST HEALTH VENTURES INC

PO BOX 87
PEORIA,IL61650
37-1140939 		PHARMACY/OFFICE STAFFING IL N/A
 C         No
(9) METHODIST PHYSICIAN SERVICES INC

PO BOX 87
PEORIA,IL61650
36-3858550 		MEDICAL SERVICES IL N/A
 C         No
(10) PRECEDENCE INC

4622 PROGRESS DRIVE STE A
DAVENPORT,IA52807
37-1288604 		MANAGED MENTAL CARE IA N/A
 C         No
(11) PROVIDER RESOURCE MANAGEMENT INC

PO BOX 87
PEORIA,IL61650
37-1223550 		RESOURCE MANAGEMENT IL N/A
 C         No
(12) RURAL IOWA SPECIALTY PHYSICIAN CONSORTIUM INC

700 E UNIVERSITY AVE
DES MOINES,IA50316
26-1271143 		SPECIALTY PHYSICIANS MEDICAL CARE IA N/A
 C         No
(13) STL HEALTH RESOURCES CO

1026 A AVE NE
CEDAR RAPIDS,IA52402
42-1193499 		PHYSICIAN OFFICE RENTAL IA N/A
 C         No
(14) TRINITY HEALTH ENTERPRISES INC

2701 17TH ST
ROCK ISLAND,IL61201
36-3320141 		RETAIL DURABLE MEDICAL EQUIPMENT & PHARMACY IL N/A
 C         No
(15) TRINITY PHYSICIAN HOSPITAL ORGANIZATION LTD

4622 PROGRESS DRIVE STE A
DAVENPORT,IA52807
36-3924720 		MANAGED HEALTH CARE IA N/A
 C         No
Schedule R (Form 990) 2013
Schedule R (Form 990) 2013
Page 3
Part V
Transactions With Related Organizations Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35b, or 36.
Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.
Yes
No
1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a Receipt of (i) interest (ii) annuities (iii) royalties or (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .
1a
 
No
b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
Yes
 
c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c
Yes
 
d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1d
 
No
e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1e
 
No
f Dividends from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
No
g Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
 
No
j Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
 
No
k Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1k
 
No
l Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .
1l
 
No
m Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .
1m
Yes
 
n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .
1n
 
No
o Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
 
No
p Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
 
No
q Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
 
No
r Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
 
No
s Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1s
 
No
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of related organization 		(b)
Transaction
type (a-s) 		(c)
Amount involved 		(d)
Method of determining amount involved





Schedule R (Form 990) 2013
Schedule R (Form 990) 2013
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership Complete if the organization answered "Yes" on Form 990, Part IV, line 37.
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity 		(b)
Primary activity 		(c)
Legal domicile
(state or foreign
country) 		(d)
Predominant income (related, unrelated, excluded from tax under sections 512-514)

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




 		(g)
Share of
end-of-year
assets 		(h)
Disproprtionate allocations? 		(i)
Code V?UBI
amount in box 20
of Schedule K-1
(Form 1065) 		(j)
General or
managing
partner? 		(k)
Percentage
ownership
Yes No Yes No Yes No






























Schedule R (Form 990) 2013
Schedule R (Form 990) 2013
Page 5
Part VII
Supplemental Information
Provide additional information for responses to questions on Schedule R (see instructions).
Return Reference Explanation
SCHEDULE R, PARTS I - IV: IOWA HEALTH SYSTEM AND SUBSIDIARIES (D/B/A UNITYPOINT HEALTH) IOWA HEALTH SYSTEM IS AN IOWA NONPROFIT CORPORATION FORMED IN DECEMBER 1994. IOWA HEALTH SYSTEM AND ITS SUBSIDIARIES PROVIDE INPATIENT AND OUTPATIENT CARE AND PHYSICIAN SERVICES FROM SIXTEEN HOSPITAL FACILITIES AND VARIOUS AMBULATORY SERVICE AND CLINIC LOCATIONS IN IOWA AND ILLINOIS. PRIMARY, SECONDARY AND TERTIARY CARE SERVICES ARE PROVIDED TO RESIDENTS OF IOWA, ILLINOIS AND ADJACENT STATES. ON APRIL 16, 2013, IOWA HEALTH SYSTEM BEGAN BEING PUBLICLY KNOWN AS UNITYPOINT HEALTH (THE SYSTEM). THIS NAME CHANGE REFLECTS THE TRANSFORMATION OF CLINICAL PROCESSES UNDERWAY WITHIN THE SYSTEM AND THE ADAPTATION TO BETTER ADDRESS THE HEALTH CARE NEEDS OF COMMUNITIES, INCLUDING BUILDING A MODEL OF DELIVERING HEALTH CARE THAT COORDINATES CARE AROUND THE PATIENT WHILE FOCUSING ON IMPROVING THE QUALITY OF CARE AND REDUCING COSTS. THE LEGAL NAME OF THE PARENT REMAINS IOWA HEALTH SYSTEM, WITH THE UNITYPOINT HEALTH NAME REFLECTING A DOING BUSINESS AS (D/B/A).
Schedule R (Form 990) 2013
Additional Data


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