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 black lung benefit trust or private foundation)

MediumBullet The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0047
2012
Open to Public Inspection
A For the 2012 calendar year, or tax year beginning 07-01-2012 , 2012, and ending 06-30-2013
BCheck if applicable:
CName of organization
Mercy Health Foundation Northwest Arkansas
 
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
2710 Rife Medical Lane
Suite
Room/suite
City or town, state or country, and ZIP + 4
Rogers, AR72758
D Employer identification number

71-0601687
E Telephone number

G Gross receipts $ 2,866,112
F Name and address of principal officer:
ERIC PIANALTO
2710 RIFE MEDICAL LANE
ROGERS,AR72758
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
www.mercy.net
H(a)
Is this a group return for
affiliates?
H(b)
Are all affiliates included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet0928
K Form of organization:
 
L Year of formation: 1984
M State of legal domicile: AR
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: AS THE SISTERS OF MERCY BEFORE US, WE BRING TO LIFE THE HEALING MINISTRY OF JESUS THROUGH OUR COMPASSIONATE CARE AND EXCEPTIONAL SERVICE.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) ........ 3 18
4 Number of independent voting members of the governing body (Part VI, line 1b) ..... 4 17
5 Total number of individuals employed in calendar year 2011 (Part V, line 2a) ...... 5 0
6 Total number of volunteers (estimate if necessary) ............. 6 100
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  
Revenues Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 1,784,734 2,028,404
9 Program service revenue (Part VIII, line 2g) ......... 0 0
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 334,440 700,609
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) -141,282 -131,048
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 1,977,892 2,597,965
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 255,087 388,635
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) 275 27
16a Professional fundraising fees (Part IX, column (A), line 11e)..... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet0    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e).... 168,720 553,342
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 424,082 942,004
19 Revenue less expenses. Subtract line 18 from line 12....... 1,553,810 1,655,961
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 9,394,720 11,110,160
21 Total liabilities (Part X, line 26)............. 3,487 5,719
22 Net assets or fund balances. Subtract line 21 from line 20..... 9,391,233 11,104,441
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title
Paid Preparer Use Only
Print/Type preparer's name
 
Preparer's signature
Date
PTIN
Firm's name MediumBullet

Firm's EIN MediumBullet
Firm's address MediumBullet



Phone no.
May the IRS discuss this return with the preparer shown above? (see instructions) ............
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2012)
Form 990 (2012)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III ...............
1
Briefly describe the organization’s mission: AS THE SISTERS OF MERCY BEFORE US, WE BRING TO LIFE THE HEALING MINISTRY OF JESUS THROUGH OUR COMPASSIONATE CARE AND EXCEPTIONAL SERVICE.
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 $ 169,062 including grants of $ 169,062 ) (Revenue $   )
FUNDING OF THE COMMUNITY YMCA FACILITY AND HEALTH PROGRAMS: THE MERCY FOUNDATION HAS HELPED TO FUND A LOCAL YMCA TO BENEFIT THE COMMUNITY THROUGH HEALTH AND WELLNESS PROGRAMS, CHILD CARE, AND A GYM FACILITY. THE YMCA IS OPEN TO THE PUBLIC AND HAS DISCOUNTED FOR FREE MEMBERSHIPS TO FAMILIES IN NEED.
4b (Code:   ) (Expenses $ 53,235 including grants of $ 44,765 ) (Revenue $   )
FUNDING EDUCATION: THE MERCY FOUNDATION RAISES FUNDS TO HELP EDUCATE OUR CO-WORKERS AND COMMUNITY. THE CO-WORKER EDUCATION FUND OFFSETS THE COSTS ASSOCIATED WITH CLASS FEES, LAB FEES, AND BOOKS. CO-WORKER EDUCATION FUNDS INCLUDE THE NURSING SCHOLARSHIPS, CARDIAC EDUCATION SCHOLARSHIPS, AND OTHER SCHOLARSHIPS FOR CO-WORKERS MEETING PROGRAM CRITERIA.
4c (Code:   ) (Expenses $ 136,859 including grants of $ 136,859 ) (Revenue $   )
ENHANCEMENT OF MEDICAL SERVICES: THROUGH VARIOUS INITIATIVES, THE MERCY FOUNDATION RAISES FUNDS TO ENHANCE MEDICAL SERVICES OF MERCY MEDICAL CENTER. DURING THE PERIOD, THE FOUNDATION FUNDED PROJECTS TO ENHANCE SERVICES IN THE FOLLOWING AREAS. PATIENT ASSISTANCE, PALLIATIVE CARE/HOSPICE, PASTORAL CARE, AND A VOLUNTEER NURSING PROGRAM.
4d Other program services (Describe in Schedule O.)
(Expenses $ 562,887 including grants of $ 37,949 ) (Revenue $ 15,419 )
4e Total program service expensesMediumBullet922,043
Form 990 (2012)
Form 990 (2012)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If “Yes,” complete Schedule AClick to see attachment........................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors (see instructions)? Click to see attachment...
2
Yes
 
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part I..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities, or have a section 501(h) election in effect during the tax year? If “Yes,” complete Schedule C, Part II........
4
 
No
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If “Yes,” complete Schedule C,
Part III............................
5
 
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
 
No
11
If the organization’s answer to any of the following questions is "Yes," then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable.
a
Did the organization report an amount for land, buildings, and equipment in Part X, line 10?
If “Yes,” complete Schedule D, Part VI.Click to see attachment...................
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part 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
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part 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
 
No
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 assistance to any organization or entity located outside the United States? If “Yes,” complete Schedule F, Parts II and IV
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the United States? If “Yes,” complete Schedule F, Parts III and IV...
16
 
No
17
Did the organization report a total of more than $15,000 of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If “Yes,” complete Schedule G, Part I (see instructions).... Click to see attachment
17
 
No
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 (2012)
Form 990 (2012)
Page 4
Part IV
Checklist of Required Schedules (continued)
21
Did the organization report more than $5,000 of grants and other assistance to any government or organization in the United States on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II... Click to see attachment
21
Yes
 
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III........ Click to see attachment
22
Yes
 
23
Did the organization answer “Yes” to Part VII, Section A, line 3, 4, or 5 about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If “Yes,” complete Schedule J....................... Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer lines 24b through 24d and complete Schedule K. If “No,” go to line 25................
24a
 
No
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
 
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
 
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
 
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If “Yes,” complete Schedule L, Part I........
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I...................
25b
 
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highest compensated employee, or disqualified person outstanding as of the end of the organization’s tax year? If “Yes,” complete Schedule L,
Part II..........................
26
 
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member of any of these persons? If “Yes,” complete Schedule L, Part III.........
27
 
No
28
Was the organization a party to a business transaction with one of the following parties (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If “Yes,” complete Schedule L, Part IV ..........................
28a
 
No
b
A family member of a current or former officer, director, trustee, or key employee? If “Yes,”
complete Schedule L, Part IV.....................
28b
 
No
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or direct or indirect owner? If “Yes,” complete Schedule L, Part IV...
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
Yes
 
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... Click to see attachment
35b
 
No
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If “Yes,” complete Schedule R, Part V, line 2............. 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 (2012)
Form 990 (2012)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V ...............
Yes
No
1a
Enter the number reported in Box 3 of Form 1096 Enter -0- if not applicable ..
1a
0
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,” provide an explanation in Schedule O.....
3b
 
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account, securities account, or other financial account)?..........................
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If “Yes,” to line 5a or 5b, did the organization file Form 8886-T? ............
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible as charitable contributions?...
6a
 
No
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
Yes
 
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
Yes
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?............................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?............................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?..........................
7h
 
 
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?............
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?..........
9a
 
 
b
Did the organization make a distribution to a donor, donor advisor, or related person?.......
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them.) ..........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year. ....................
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. See the instructions for additional information the organization must report on Schedule O.
13a
 
 
b
Enter the amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans ....
13b
 
c
Enter the amount of reserves on hand ............
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
No
b
If "Yes," has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O..
14b
 
 
Form 990 (2012)
Form 990 (2012)
Page 6
Part VI
Governance, Management, and Disclosure For each “Yes” response to lines 2 through 7b below, and for a “No” response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI ...............
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year .....................
1a
18
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
17
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
Yes
 
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
 
No
b
Other officers or key employees of the organization ................
15b
 
No
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:
MediumBulletBENNY J STOVER CPA VP OF F2710 RIFE MEDICAL LANEROGERSAR72758 (479) 338-2903
Form 990 (2012)
Form 990 (2012)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response to any question in this Part VII ...............
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

RoundBullet List all of the organization’s current key employees, if any. See instructions for definition of "key employee."
RoundBullet List the organization’s five current highest compensated employees (other than an officer, director, trustee or key employee)
who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the
organization and any related organizations.

RoundBullet List all of the organization’s former officers, key employees, or highest compensated employees who received more than $100,000
of reportable compensation from the organization and any related organizations.

RoundBullet List all of the organization’s former directors or trustees that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organization compensated any current officer, director, or trustee.
(A)
Name and Title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(1) Akers Brent........................................................................
Board member
 1.0
.......................0.0 		X           0 0 0
(2) Atkins RSM Sr Lisa........................................................................
Board member
 1.0
.......................22.0 		X           0 0 0
(3) Galen Steve........................................................................
Board member
 1.0
.......................0.0 		X           0 0 0
(4) Goss Gordon........................................................................
Board member
 1.0
.......................0.0 		X           0 0 0
(5) Harrell John........................................................................
Board member
 1.0
.......................0.0 		X           0 0 0
(6) Hess Jim........................................................................
Board member
 1.0
.......................0.0 		X           0 0 0
(7) Johnson Ron........................................................................
Board member
 1.0
.......................0.0 		X           0 0 0
(8) Jurgens Deanna........................................................................
Board member
 1.0
.......................0.0 		X           0 0 0
(9) O'Brien Chris........................................................................
Board member
 1.0
.......................0.0 		X           0 0 0
(10) Pollard Martine........................................................................
Board member
 1.0
.......................0.0 		X           0 0 0
(11) Rook Barbara........................................................................
Board member
 1.0
.......................0.0 		X           0 0 0
(12) Thrasher David........................................................................
Board member
 1.0
.......................0.0 		X           0 0 0
(13) Trammel Dick........................................................................
Board member
 1.0
.......................1.0 		X           0 0 0
(14) Tuohy Darlene........................................................................
Board member
 1.0
.......................0.0 		X           0 0 0
(15) Umbarger Dr Brad........................................................................
Board member
 1.0
.......................0.0 		X           0 0 0
(16) Vasser Vicki........................................................................
Board member
 1.0
.......................0.0 		X           0 0 0
(17) Roberts Karen........................................................................
Board member & officer
 1.0
.......................0.0 		X   X       0 0 0
Form 990 (2012)
Form 990 (2012)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and Title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(18) Street Scott........................................................................
Chief executive officer
 10.0
.......................50.0 		X   X       0 529,683 115,769
(19) Vitiello Jonathan........................................................................
Chief financial officer
 1.0
.......................59.0 		    X       0 493,118 64,006
(20) Stover Benny........................................................................
VP-Finance
 10.0
.......................50.0 		      X     0 175,634 20,594
(21) Flynn George........................................................................
Former CEO
 0.0
.......................0.0 		          X 0 3,297,507 140,483


















1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 0 4,495,942 340,852
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 $100,000 of compensation from the organization MediumBullet0
Form 990 (2012)
Form 990 (2012)
Page 9
Part VIII
Statement of Revenue
Check if Schedule O contains a response to any question in this Part VIII ..............
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, Gifts, Grants and Other Similar Amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c 529,890
d Related organizations...1d  
e Government grants (contributions)1e  
f All other contributions, gifts, grants, and
similar amounts not included above1f 		1,498,514
g Noncash contributions included in lines
1a-1f:$ 		211,531
h Total. Add lines 1a-1f.......MediumBullet 2,028,404
Program Service Revenue Business Code
2a
b
c
d
e
f All other program service revenue .        
g Total. Add lines 2a–2f........MediumBullet 0
Other Revenue 3 Investment income (including dividends, interest, and other similar amounts).......MediumBullet 96,770     96,770
4 Income from investment of tax-exempt bond proceeds..MediumBullet 0      
5 Royalties...........MediumBullet 0      
(i) Real (ii) Personal
6a Gross rents    
b Less: rental expenses    
c Rental income or (loss) 0 0
d Net rental income or (loss).......MediumBullet 0      
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory 603,839  
b Less: cost or other basis and sales expenses    
c Gain or (loss) 603,839  
d Net gain or (loss)..........MediumBullet 603,839     603,839
8a Gross income from fundraising events (not including
$ 529,890
of contributions reported on line 1c). See Part IV, line 18 ..
a 121,680
b Less: direct expenses ...b 268,147
c Net income or (loss) from fundraising events..MediumBullet -146,467   -146,467
9a Gross income from gaming activities.
See Part IV, line 19 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from gaming activities...MediumBullet 0      
10a Gross sales of inventory, less
returns and allowances .
a  
b Less: cost of goods sold ..b  
c Net income or (loss) from sales of inventory..MediumBullet 0      
Miscellaneous Revenue Business Code
11a All other revenue 900099 15,419 15,419 0 0
b            
c            
d All other revenue ....        
e Total. Add lines 11a–11d ...... MediumBullet 15,419
12 Total revenue. See Instructions......MediumBullet 2,597,965 15,419 0 554,142
Form 990 (2012)
Form 990 (2012)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A).Check if Schedule O contains a response to any question in this Part IX ...............
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII. 		(A)
Total expenses 		(B)
Program service expenses 		(C)
Management and general expenses 		(D)
Fundraising expenses
1 Grants and other assistance to governments and organizations in the United States. See Part IV, line 21 343,870 343,870
2 Grants and other assistance to individuals in the United States. See Part IV, line 22 44,765 44,765
3 Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16 0 0
4 Benefits paid to or for members 0 0
5 Compensation of current officers, directors, trustees, and key employees .... 0 0 0 0
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .... 0 0 0 0
7 Other salaries and wages 0 0 0 0
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 0 0 0 0
9 Other employee benefits ....... 27   27 0
10 Payroll taxes ........... 0 0 0 0
11 Fees for services (non-employees):        
a Management ...... 0 0 0 0
b Legal ......... 1,545   1,545 0
c Accounting ........... 0 0 0 0
d Lobbying ........... 0 0 0 0
e Professional fundraising services. See Part IV, line 17 0 0
f Investment management fees ...... 0 0 0 0
g Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........ 4,532 4,078 454 0
12 Advertising and promotion .... 77,300 69,570 7,730 0
13 Office expenses ....... 15,464 13,918 1,546 0
14 Information technology ...... 0 0 0 0
15 Royalties .. 0 0 0 0
16 Occupancy ........... 0 0 0 0
17 Travel ............ 3,886 3,498 388 0
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ...... 0 0 0 0
19 Conferences, conventions, and meetings .... 6,122 5,510 612 0
20 Interest ........... 0 0 0 0
21 Payments to affiliates ....... 0 0 0 0
22 Depreciation, depletion, and amortization ..... 15,100 13,590 1,510 0
23 Insurance .............. 0 0 0 0
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 Bad Debt 136,291 136,291 0 0
b Repairs & Maintenance 5,280 4,752 528 0
c OFFSET OF INKIND DONATION 211,531 211,531 0 0
d ALL OTHER EXPENSES 76,291 70,670 5,621 0
e All other expenses        
25 Total functional expenses. Add lines 1 through 24e 942,004 922,043 19,961 0
26 Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here MediumBullet if following SOP 98-2 (ASC 958-720). 0      
Form 990 (2012)
Form 990 (2012)
Page 11
Part X Balance Sheet Check if Schedule O contains a response to any question in this Part X ...............
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash—non-interest-bearing ............. 811,484 1 2,167,747
2 Savings and temporary cash investments ......... 0 2 0
3 Pledges and grants receivable, net ........... 2,090,375 3 1,043,878
4 Accounts receivable, net ............. 0 4 0
5 Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L ..................
0 5 0
6 Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
0 6 0
7 Notes and loans receivable, net ............. 0 7 0
8 Inventories for sale or use .............. 0 8 0
9 Prepaid expenses and deferred charges .......... 1,795 9 0
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 6,700
b Less: accumulated depreciation ..... 10b 5,583 16,216 10c 1,117
11 Investments—publicly traded securities .......... 6,473,650 11 7,896,218
12 Investments—other securities. See Part IV, line 11 ..... 0 12 0
13 Investments—program-related. See Part IV, line 11 ..... 0 13 0
14 Intangible assets ............... 0 14 0
15 Other assets. See Part IV, line 11 ........... 1,200 15 1,200
16 Total assets. Add lines 1 through 15 (must equal line 34)...... 9,394,720 16 11,110,160
Liabilities 17 Accounts payable and accrued expenses ......... 0 17 0
18 Grants payable ................. 0 18 0
19 Deferred revenue ................ 0 19 0
20 Tax-exempt bond liabilities ............. 0 20 0
21 Escrow or custodial account liability. Complete Part IV of Schedule D.. 0 21 0
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.......... 0 22 0
23 Secured mortgages and notes payable to unrelated third parties .. 0 23 0
24 Unsecured notes and loans payable to unrelated third parties .... 0 24 0
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.................... 3,487 25 5,719
26 Total liabilities. Add lines 17 through 25......... 3,487 26 5,719
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 .............. 3,482,316 27 4,328,275
28 Temporarily restricted net assets ........... 5,908,917 28 6,776,166
29 Permanently restricted net assets ........... 0 29 0
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 ........... 9,391,233 33 11,104,441
34 Total liabilities and net assets/fund balances ........ 9,394,720 34 11,110,160
Form 990 (2012)
Form 990 (2012)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI ...............
1
Total revenue (must equal Part VIII, column (A), line 12) ............
1
2,597,965
2
Total expenses (must equal Part IX, column (A), line 25) ............
2
942,004
3
Revenue less expenses. Subtract line 2 from line 1 ..............
3
1,655,961
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..
4
9,391,233
5
Net unrealized gains (losses) on investments ...............
5
 
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
57,247
10
Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 33, column (B))
10
11,104,441
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII ..............
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?
2a
 
No
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were compiled or reviewed on a separate basis, consolidated basis, or both:
b
Were the organization’s financial statements audited by an independent accountant?
2b
Yes
 
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were audited on a separate basis, consolidated basis, or both:
c
If “Yes,” to line 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant?
2c
Yes
 
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O.
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133?
3a
 
No
b
If “Yes,” did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits
3b
 
 
Form 990 (2012)
Form 990, Special Condition Description:
Special Condition Description
Additional Data


Software ID:  
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.
OMB No. 1545-0047
2012
Open to Public
Inspection
Name of the organization
Mercy Health Foundation Northwest Arkansas
 
Employer identification number

71-0601687
Part I
Reason for Public Charity Status (All organizations must complete this part.) See instructions.
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
f
g
(i) A person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the supported organization? ................
11g(i)
 
 
(ii) A family member of a person described in (i) above? ......................
11g(ii)
 
 
(iii) A 35% controlled entity of a person described in (i) or (ii) above? ................
11g(iii)
 
 
h
Provide the following information about the supported organization(s).
(i) Name of supported organization (ii) EIN (iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions)) (iv) Is the organization in col. (i) listed in your governing document? (v) Did you notify the organization in col. (i) of your support? (vi) Is the organization in col. (i) organized in the U.S.? (vii) Amount of monetary support
Yes No Yes No Yes No
Total                  

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 2
Part II
Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year (or fiscal year beginning in) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .... 440,690 491,430 1,297,038 1,784,734 2,028,404 6,042,296
2 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......           0
3 The value of services or facilities furnished by a governmental unit to the organization without charge..           0
4 Total. Add lines 1 through 3 440,690 491,430 1,297,038 1,784,734 2,028,404 6,042,296
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)..           4,905,668
6 Public support. Subtract line 5 from line 4.           1,136,628
Section B. Total Support
Calendar year (or fiscal year beginning in) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (f) Total
7 Amounts from line 4.. 440,690 491,430 1,297,038 1,784,734 2,028,404 6,042,296
8 Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources... -210,802 29,331 42,600 67,031 96,770 24,930
9 Net income from unrelated business activities, whether or not the business is regularly carried on..           0
10 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.).. 0 0 53,131 94,518 15,419 163,068
11 Total support (Add lines 7 through 10).           6,230,294
12
12
295,500
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
18.244 %
15
15
6.738 %
16a
b
17a
b
18
Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions ..................................................... right arrow
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 3
Part III
Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year (or fiscal year beginning in) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .            
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) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (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) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 4
Part IV
Supplemental Information. Complete this part to provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
 
Explanation
Mercy Health Foundation Northwest Arkansas is a nonprofit charitable organization that is organized to raise funds in support of Mercy Health and its subsidiaries, and to fund community health and education programs. The foundation qualifies as publicly-supported because it meets the "10% plus facts and circumstances" under Treas. Reg. 1.170A-9(E)(3) in the following respects: 1. 10% of Support Limitation - Mercy Health Foundation Northwest Arkansas Foundation's public support percentage is 18.24%, which is well above the 10% threshold. 2. Sources of Support - Mercy Health Foundation Northwest Arkansas Foundation is organized and operated to attract new and additional support on a continuous basis. The foundation attracts both corporate and individual donors; there have been hundreds of donors over the preceding 5-year period. 3. Representative governing body - The foundation had an 18-member governing body as of June 30, 2013. 17 of the 18 members are independent voting members representing a broad cross-section of the foundation's community, and represent the broad interests of the public.
 
 
 
Schedule A (Form 990 or 990-EZ) 2012

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.
OMB No. 1545-0047
2012
Name of the organization
Mercy Health Foundation Northwest Arkansas
 
Employer identification number

71-0601687
Organization type (check one):
Filers of:
Section:
Form 990 or 990-EZ





Form 990-PF




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

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)
Page 2
Name of organization
Mercy Health Foundation Northwest Arkansas
  		Employer identification number

71-0601687
Part I
Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
     
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
RESTRICTED
RESTRICTED
 

     
RESTRICTED
RESTRICTED  
RESTRICTED, RESTRICTED   RESTRICTED

$RESTRICTED


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

     
 
   

$  


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

     
 
   

$  


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

     
 
   

$  


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

     
 
   

$  


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

     
 
   

$  


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

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)
Page 3
Name of organization
Mercy Health Foundation Northwest Arkansas
  		Employer identification number

71-0601687
Part II
Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
     
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)
Page 4
Name of organization
Mercy Health Foundation Northwest Arkansas
  		Employer identification number

71-0601687
Part III
Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
that total more than $1,000 for the year. Complete columns (a) through (e) and the following line entry.
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet$  
Use duplicate copies of Part III if additional space is needed.
(a) No.
from
Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Additional Data


Software ID:  
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.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
Mercy Health Foundation Northwest Arkansas
 
Employer identification number

71-0601687
Part I
Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.
(a) Donor advised funds (b) Funds and other accounts
1 Total number at end of year .........    
2 Aggregate contributions to (during year) ...    
3 Aggregate grants from (during year) .....    
4 Aggregate value at end of year ........    
5
Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............
6
Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................
Part II
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.
Held at the End of the Year
a Total number of conservation easements ....................... 2a  
b Total acreage restricted by conservation easements .................. 2b  
c Number of conservation easements on a certified historic structure included in (a) ..... 2c  
d Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register .................... 2d  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................
6
Staff and volunteer hours devoted to monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet $  
8
Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .......................................
9
In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.
1a
If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items.
b
If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts relating to these items:
(i)
Revenues included in Form 990, Part VIII, line 1 ........................SchDMd Bullet $  
(ii)
Assets included in Form 990, Part X ..............................SchDMd Bullet $  
2
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958) relating to these items:
a
Revenues included in Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 52283D
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.
5
During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........
Part IV
Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b
If "Yes," explain the arrangement in Part XIII and complete the following table:
Amount
c Beginning balance ................................. 1c  
d Additions during the year .............................. 1d  
e Distributions during the year ............................. 1e  
f Ending balance ................................... 1f  
2a
Did the organization include an amount on Form 990, Part X, line 21? .....................
b
If “Yes,” explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII ........
Part V
Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
(a)Current year (b)Prior year b (c)Two years back (d)Three years back (e)Four years back
1a Beginning of year balance ....          
b Contributions ........          
c Net investment earnings, gains, and losses          
d Grants or scholarships .....          
e Other expenditures for facilities
and programs ........ 		         
f Administrative expenses ....          
g End of year balance ......          
2
Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:
a
Board designated or quasi-endowment SchDMd Bullet  
b
Permanent endowment SchDMd Bullet  
c
Temporarily restricted endowment SchDMd Bullet  
The percentages in lines 2a, 2b, and 2c should equal 100%.
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) unrelated organizations ........................
3a(i)
 
 
(ii) related organizations ........................
3a(ii)
 
 
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
 
 
4
Describe in Part XIII the intended uses of the organization's endowment funds.
Part VI
Land, Buildings, and Equipment. See Form 990, Part X, line 10.
Description of property (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .................      
b Buildings ................        
c Leasehold improvements ............        
d Equipment ................   6,700 5,583 1,117
e Other .................        
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......SchDMdBullet 1,117
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 3
Part VII
Investments—Other Securities. See Form 990, Part X, line 12.
(a) Description of security or category
(including name of security)		 (b)Book value (c) Method of valuation:
Cost or end-of-year market value
(1)Financial derivatives    
(2)Closely-held equity interests    
Other








Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)Small Bullet  
Part VIII
Investments—Program Related. See Form 990, Part X, line 13.
(a) Description of investment type (b) Book value (c) Method of valuation:
Cost or end-of-year market value








Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)Small Bullet  
Part IX
Other Assets. See Form 990, Part X, line 15.
(a) Description (b) Book value








Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........Small Bullet  
Part X
Other Liabilities. See Form 990, Part X, line 25.
1.(a) Description of liability (b) Book value
Federal income taxes 0
DUE TO AFFILIATES 5,719








Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 5,719
2. Fin 48 (ASC 740) Footnote. In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII .....................................................
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 4
Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1 Total revenue, gains, and other support per audited financial statements ....... 1  
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains on investments .......... 2a  
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIII.) ............ 2d  
e Add lines 2a through 2d ..................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b . 4a  
b Other (Describe in Part XIII.) ........... 4b  
c Add lines 4a and 4b....................... 4c  
5 Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ...... 5  
Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1 Total expenses and losses per audited financial statements ........... 1  
2 Amounts included on line 1 but not on Form 990, Part IX, line 25:
a Donated services and use of facilities .......... 2a  
b Prior year adjustments .............. 2b  
c Other losses ................ 2c  
d Other (Describe in Part XIII.) ............ 2d  
e Add lines 2a through 2d...................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part IX, line 25, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b .. 4a  
b Other (Describe in Part XIII.) ............ 4b  
c Add lines 4a and 4b....................... 4c  
5 Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ...... 5  
Part XIII
Supplemental Information
Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.
Identifier Return Reference Explanation
FORM 990, SCHEDULE D, PART X, LINE 2 ASC 740 FOOTNOTE THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS OF MERCY HEALTH AND AFFILIATES DO NOT INCLUDE A FOOTNOTE TO REPORT THE ORGANIZATION'S LIABILITY FOR UNCERTAIN TAX PROVISIONS UNDER ASC 740, AS THEY ARE DEEMED IMMATERIAL FOR DISCLOSURE.
Schedule D (Form 990) 2012

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. Form 990-EZ filers are not required to complete this part. right arrowAttach to Form 990 or Form 990-EZ. right arrowSee separate instructions.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
Mercy Health Foundation Northwest Arkansas
 
Employer identification number

71-0601687
Part I
Fundraising Activities. Complete if the organization answered "Yes" to Form 990, Part IV, line 17.
1
Indicate whether the organization raised funds through any of the following activities. Check all that apply.
a e
b f
c g
d
2a
Did the organization have a written or oral agreement with any individual (including officers, directors, trustees
or key employees listed in Form 990, Part VII) or entity in connection with professional fundraising services?
b
If “Yes,” list the ten highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is
to be compensated at least $5,000 by the organization.
(i) Name and address of individual
or entity (fundraiser) 		(ii) Activity (iii) Did fundraiser have custody or control of contributions? (iv) Gross receipts
from activity 		(v) Amount paid to
(or retained by)
fundraiser listed in
col. (i) 		(vi) Amount paid to
(or retained by)
organization
Yes No
             
             
             
             
             
             
             
             
             
             
Total .................right arrow      
3
List all states in which the organization is registered or licensed to solicit funds or has been notified it is exempt from registration or licensing.
For Paperwork Reduction Act Notice, see the Instructions for Form 990or 990-EZ.
Cat. No. 50083H
Schedule G (Form 990 or 990-EZ) 2012
Schedule G (Form 990 or 990-EZ) 2012
Page 2
Part II
Fundraising Events. Complete if the organization answered "Yes" to Form 990, Part IV, line 18, or reported more than $15,000 of fundraising event contributions and gross income on Form 990-EZ, lines 1 and 6b. List events with gross receipts greater than $5,000.
(a) Event #1

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

GOLF Tourney
(event type) 		(c) Other events

0
(total number) 		(d) Total events
(add col. (a) through col. (c))
VerticalRevenue 1 Gross receipts . . . 576,204 75,366   651,570
2 Less: Contributions . . 488,184 41,706   529,890
3 Gross income (line 1
minus line 2) . . . 		88,020 33,660   121,680
VerticalDirectExpenses 4 Cash prizes . . .        
5 Noncash prizes . . 15,720     15,720
6 Rent/facility costs . . 113,836 18,367   132,203
7 Food and beverages . 52,981 2,126   55,107
8 Entertainment . . . 36,750     36,750
9 Other direct expenses . 6,705 21,662   28,367
10 Direct expense summary. Add lines 4 through 9 in column (d) ........... right arrow 268,147
11 Net income summary. Combine line 3, column (d), and line 10. .......... right arrow -146,467
Part III
Gaming. Complete if the organization answered "Yes" to Form 990, Part IV, line 19, or reported more than $15,000 on Form 990-EZ, line 6a.
VerticalRevenue (a) Bingo (b) Pull tabs/Instant
bingo/progressive bingo 		(c) Other gaming (d) Total gaming (add col.(a) through col.(c))
1 Gross revenue . . . .        
VerticalDirectExpenses 2 Cash prizes . . . .        
3 Non-cash prizes . . .        
4 Rent/facility costs . . .        
5 Other direct expenses . .        
6 Volunteer labor . . .
 
 
 
7 Direct expense summary. Add lines 2 through 5 in column (d) ........... right arrow  
8 Net gaming income summary. Combine lines 1 and 7 in column (d) .......... right arrow  
9
Enter the state(s) in which the organization operates gaming activities:
a
Is the organization licensed to operate gaming activities in each of these states? ............
b
If "No," explain:
 
10a
Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year? .....
b
If "Yes," explain:
 
Schedule G (Form 990 or 990-EZ) 2012
Schedule G (Form 990 or 990-EZ) 2012
Page 3
11
Does the organization operate gaming activities with nonmembers? .................
12
Is the organization a grantor, beneficiary or trustee of a trust or a member of a partnership or other entity
formed to administer charitable gaming? ..........................
13
Indicate the percentage of gaming activity operated in:
a
The organization's facility ......................
13a
 
b
An outside facility ........................
13b
 
14
Enter the name and address of the person who prepares the organization's gaming/special events books and records:
Name right arrow
Address right arrow
15a
Does the organization have a contract with a third party from whom the organization receives gaming
revenue? ......................................
b
If "Yes," enter the amount of gaming revenue received by the organization right arrow $   and the
amount of gaming revenue retained by the third party right arrow $   .
c
If "Yes," enter name and address of the third party:
Name right arrow
Address right arrow
 
 
16
Gaming manager information:
Name right arrow
Gaming manager compensation right arrow $  
Description of services provided right arrow
 
17
Mandatory distributions:
a
Is the organization required under state law to make charitable distributions from the gaming proceeds to
retain the state gaming license? ............................
b
Enter the amount of distributions required under state law distributed to other exempt organizations or spent
in the organization's own exempt activities during the tax year right arrow$  
Part IV
Supplemental Information. Complete this part to provide the explanations required by Part I, line 2b, columns (iii) and (v), and Part III, lines 9, 9b, 10b, 15b, 15c, 16, and 17b, as applicable. Also complete this part to provide any additional information (see instructions).
Identifier Return Reference Explanation
Schedule G (Form 990 or 990-EZ) 2012
Additional Data


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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
OMB No. 1545-0047
2012
Open to Public
Inspection
Name of the organization
Mercy Health Foundation Northwest Arkansas
 
Employer identification number
71-0601687
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) YMCA
4701 Chouteau Avenue
Neosho,MO64850 		43-1729473 501(C)(3) 169,062       FUNDING YMCA AND HEALTH PROGRAMS
(2) MERCY HOSPITAL ROGERS
2710 Rife Medical Lane
ROGERS,AR72758 		71-0294390 501(C)(3) 136,859       to support operations and mission of the hospital
(3) UNITED WAY OF NW ARKANSAS
100 PARKWOOD ST
LOWELL,AR72745 		71-0305700 501(C)(3) 33,849       TO SUPPORT MISSION


















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
 
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50055P
Schedule I (Form 990) 2012

Schedule I (Form 990) 2012
Page 2
Part III
Grants and Other Assistance to Individuals in the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 22.
Part III can be duplicated if additional space is needed.
(a)Type of grant or assistance (b)Number of
recipients		 (c)Amount of
cash grant		 (d)Amount of
non-cash assistance		 (e)Method of valuation (book,
FMV, appraisal, other)		 (f)Description of non-cash assistance
(1) Scholarships 27 44,765      












Part IV
Supplemental Information.
Complete this part to provide the information required in Part I, line 2, Part III, column (b), and any other additional information.
Identifier Return Reference Explanation
FORM 990, SCHEDULE I, PART I, LINE 2 DESCRIPTION OF ORGANIZATION'S PROCEDURES FOR MONITORING THE USE OF GRANTS CASH DISTRIBUTION IS APPROVED BY THE FOUNDATION BOARD OF TRUSTEES. IF THE AMOUNT OF A SCHOLARSHIP OR ANY PAYMENT IS OVER $500 - A SECOND SIGNATURE OR APPROVAL IS OBTAINED - PRIOR TO A CHECK REQUEST AND CHECK BEING PROCESSED. PART II: -YMCA FUNDING IS FUNDED THROUGH UNRESTRICTED DOLLARS. A TOTAL GIFT WAS APPROVED BY THE FOUNDATION'S BOARD OF DIRECTORS. -A FINANCIAL REPORT - ADMINISTERED BY MERCY ACCOUNTING - ASSURES THAT THE DOLLARS USED DOES NOT EXCEED THE BOARD'S APPROVAL CAP. -AN INVOICE IS RECEIVED BY THE YMCA AND THEN GIVEN TO THE FOUNDATION FOR PAYMENT. PART III: -EACH SCHOLARSHIP HAS A COMMITTEE THAT OVERSEES THE SELECTION OF CANDIDATES AND ASSURES THE RECIPIENTS FALL WITHIN THE SCHOLARSHIP GUIDELINES. -A CERTAIN GPA IS REQUIRED, ALONG WITH TENURE AND A TIME COMMITMENT OF EMPLOYMENT, AND REVIEW OF SUCH ITEMS IS PART OF THE COMMITTEE'S REVIEW PROCESS.
Schedule I (Form 990) 2012


Additional Data


Software ID:  
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Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
SchJMediumBullet Attach to Form 990. SchJMediumBullet See separate instructions.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
Mercy Health Foundation Northwest Arkansas
 
Employer identification number

71-0601687
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 officers,
directors, trustees, and 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
Yes
 
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
Yes
 
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization? ...........................
6a
 
No
b
Any related organization? .........................
6b
 
No
If "Yes," to line 6a or 6b, describe in Part III.
7
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............
7
 
No
8
Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................
8
 
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50053T
Schedule J (Form 990) 2012

Schedule J (Form 990) 2012
Page 2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.
For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.
(A) Name and Title (B) Breakdown of W-2 and/or 1099-MISC compensation (C) Retirement and other deferred compensation (D) Nontaxable
benefits		 (E) Total of columns
(B)(i)-(D) 		(F) Compensation
reported as deferred
in prior Form 990
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
(1)Street ScottChief executive officer (i)
(ii)		 0
388,618 		0
120,181 		0
20,884 		0
98,296 		0
17,473 		0
645,452 		0
0
(2)Vitiello JonathanChief financial officer (i)
(ii)		 0
294,647 		0
102,118 		0
96,353 		0
47,736 		0
16,270 		0
557,124 		0
0
(3)Stover BennyVP-Finance (i)
(ii)		 0
130,156 		0
25,143 		0
20,335 		0
5,691 		0
14,903 		0
196,228 		0
0
(4)Flynn GeorgeFormer CEO (i)
(ii)		 0
24,154 		0
136,500 		0
3,136,853 		0
139,018 		0
1,465 		0
3,437,990 		0
2,299,930
Schedule J (Form 990) 2012

Schedule J (Form 990) 2012
Page 3
Part III
Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II.
Also complete this part for any additional information.
Identifier Return Reference Explanation
FORM 990, SCHEDULE J, PART I, QUESTION 3   FOR THOSE CLASSIFIED AS OFFICERS (AND THUS DISQUALIFIED PERSONS), THE ORGANIZATION RELIES UPON MERCY HEALTH, WHICH USES THE FOLLOWING TO ESTABLISH THE COMPENSATION: EXTERNAL MARKET SALARY SURVEYS, EXTERNAL MARKET SALARY STUDIES, ENGAGEMENT OF AN INDEPENDENT COMPENSATION CONSULTANT, AND REVIEW/APPROVAL OF COMPENSATION BY THE EXECUTIVE COMPENSATION COMMITTEE OF THE BOARD OF MERCY HEALTH. FOR THOSE CLASSIFIED AS KEY EMPLOYEES, MERCY HEALTH USES THE FOLLOWING TO ESTABLISH THE COMPENSATION: EXTERNAL MARKET SALARY SURVEYS, EXTERNAL MARKET SALARY STUDIES, AND REVIEW/APPROVAL OF EXECUTIVE MANAGEMENT. COMPENSATION REVIEWS ARE COMPLETED ON AN ANNUAL BASIS, AND A REVIEW WAS COMPLETED DURING THE REPORTING YEAR. FORM 990, SCHEDULE J, PART I, QUESTION 4A THE FOLLOWING INDIVIDUAL RECEIVED A SEVERANCE PAYMENT DURING CALENDAR YEAR 2012: GEORGE FLYNN, $720,175 FORM 990, SCHEDULE J, PART I, QUESTION 4B MERCY HEALTH OFFERS SUPPLEMENTAL RETIREMENT PLANS TO CERTAIN EXECUTIVES WHICH PROVIDE BENEFITS UPON RETIREMENT BASED ON COMPENSATION, AGE AT THE TIME OF BENEFIT COMMENCEMENT, LENGTH OF SERVICE WITH THE COMPANY AND/OR ITS AFFILIATES, AND LENGTH OF TENURE IN THE PLAN. THE INDIVIDUALS REPORTABLE ON THIS RETURN WHO PARTICIPATE IN THE SUPPLEMENTAL RETIREMENT PLANS INCLUDE: SCOTT STREET, JONATHAN VITIELLO, AND GEORGE FLYNN. THE AMOUNT OF ALL ACCRUED BENEFITS IS INCLUDED IN COMPENSATION AMOUNTS PROVIDED IN SCHEDULE J, PART II, COLUMN (C). FORM 990, SCHEDULE J, PART II THE AMOUNT FOR GEORGE FLYNN IN COLUMN (F) IS INCLUDED IN COLUMN BIII AS OTHER REPORTABLE COMPENSATION. THIS IS A PAYOUT OF THE SUPPLEMENTAL RETIREMENT PLAN AND WAS INCLUDED IN COLUMN (C) OF PREVIOUSLY FILED FORMS 990.
Schedule J (Form 990) 2012

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.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
Mercy Health Foundation Northwest Arkansas
 
Employer identification number

71-0601687
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 .... X 1 160 FMV
2 Art—Historical treasures .        
3 Art—Fractional interests ..        
4 Books and publications ..      
5 Clothing and household
goods ....... 		X 7,860 FMV
6 Cars and other vehicles ..        
7 Boats and planes ....        
8 Intellectual property ...        
9 Securities—Publicly traded .        
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 ... X 1 20,000 FMV
18 Collectibles .....        
19 Food inventory ... X 5 21,150 FMV
20 Drugs and medical supplies . X 2 3,110 FMV
21 Taxidermy ......        
22 Historical artifacts ....        
23 Scientific specimens ..        
24 Archeological artifacts ...        
25 Other Right pointing arrow large image ( MEDIA ) X 20 130,695 FMV
26 Other Right pointing arrow large image ( PRIZES ) X 13 11,720 FMV
27 Other Right pointing arrow large image ( SPONSORSHIPS ) X 3 11,000 FMV
28 Other Right pointing arrow large image ( MISCALLENOUS ) X 3 5,836 FMV
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
0
Yes
No
30a
During the year, did the organization receive by contribution any property reported in Part I, lines 1-28 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
 
No
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) (2012)
Schedule M (Form 990) (2012)
Page 2
Part II
Supplemental Information. Complete this part to 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.
Identifier Return Reference Explanation
FORM 990, SCHEDULE M, PART 1, COLUMN B   THE FILING ORGANIZATION IS REPORTING THE NUMBER OF CONTRIBUTIONS RECEIVED.
Schedule M (Form 990) (2012)
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.
OMB No. 1545-0047
2012
Open to Public
Inspection
Name of the organization
Mercy Health Foundation Northwest Arkansas
 
Employer identification number

71-0601687
Identifier Return Reference Explanation
FORM 990 PART III LINE 4D OTHER PROGRAM SERVICES THE MERCY FOUNDTAION OF NWA SUPPORTS MERCY HOSPITAL OF NWA. IT HAS TWO MAIN FUNDRASING EVENTS TO HELP RAISE FUNDS INCLUDING A CHARITY BALL AND A GOLF TOURNAMENT. THESE EVENTS ARE USED TO RAISE MONEY FOR MEDICAL EQUIPMENT NEEDS AND GROWTH OF THE HOSPITAL. THE FOUNDATION ALSO RAISES MONEY TO SUPPORT THE CO-WORKERS OF THE HOSPITAL THROUGH AN EMPLOYEE CRISIS FUND AND A MERCY WAY DRIVE, WHICH SUPPORTS THE HEALTH CARE OF THE HOSPITAL EMPLOYEES. THE FOUNDATION ALSO RAISES FUNDS TO SUPPORT THE UNITED WAY. FORM 990, PART V, QUESTION 1A FORM 1099/1096 FILING VENDORS FOR THE FILING ORGANIZATION ARE PAID BY MERCY HEALTH (EIN 43-1423050). AS SUCH, ALL REQUIRED FORM 1099 AND FORM 1096 REPORTING IS MADE FOR THE ENTIRE MERCY HEALTH SYSTEM (WITH LIMITED EXCEPTIONS) UNDER THE MERCY HEALTH EIN. FORM 990, PART V, QUESTION 2A FORM W-3 FILING EMPLOYEES ARE PAID BY A RELATED ORGANIZATION UNDER A COMMON PAYMASTER ARRANGEMENT. AS SUCH ALL REQUIRED PAYROLL FILING (INCLUDING W-2 AND W-3'S) WAS REPORTED UNDER THE RELATED ORGANIZATION'S EIN. FORM 990, PART VI, LINE 6A, LINE 7A, 7B CLASSES OF MEMBERS OR STOCKHOLDERS THE FILING ORGANIZATION HAS A SOLE CORPORATE MEMBER, MERCY HOSPITAL ROGERS. ALL OF THE BUSINESS AND AFFAIRS OF THE FOUNDATION ARE MANAGED AND CONTROLLED BY THE FOUNDATION BOARD OF TRUSTEES, EXCEPT THAT CERTAIN MATTERS WHICH MUST BE SUBMITTED TO AND RECEIVE THE APPROVAL OF THE FOUNDATION BOARD OF TRUSTEES MUST ALSO BE SUBMITTED TO AND RECEIVE THE APPROVAL OF THE CORPORATE MEMBER'S BOARD OF DIRECTORS. THE FOLLOWING ARE THE MATTERS WHICH MUST BE SUBMITTED TO AND RECEIVE THE APPROVAL OF BOTH THE FOUNDATION BOARD OF TRUSTEES AND THE CORPORATE MEMBER'S BOARD OF DIRECTORS: -THE MERGER, CONSOLIDATION OR DISSOLUTION OF THE FOUNDATION; -THE SALE, LEASE, EXCHANGE, PLEDGE OR MORTGAGE OF ANY SUBSTANTIAL PART OF THE ASSETS OF THE FOUNDATION, OR ANY CONTRACT, OPTION OR OTHER AGREEMENT WITH RESPECT THERETO; -THE SELECTION OR REMOVAL OF THE INDEPENDENT AUDITOR; -SUCH OTHER MATTERS AS MAY BE REQUIRED BY LAW TO BE SUBMITTED TO BOTH BOARDS, OR WHICH THE FOUNDATION BOARD OF TRUSTEES DETERMINES BY RESOLUTION TO SO SUBMIT. FORM 990, PART VI, QUESTION 11B DSCR THE PROCESS USED BY MANAGEMENT &/OR GOVERNING BODY TO REVIEW 990 THE FORM 990 IS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM, USING INFORMATION PROVIDED BY THE FILING ORGANIZATION. A DRAFT FORM 990 IS REVIEWED BY THE FILING ORGANIZATION'S FINANCE TEAM, INCLUDING THE MANAGER OF ACCOUNTING AND THE VICE-PRESIDENT OF FINANCE. THE DRAFT FORM 990 IS ALSO REVIEWED BY MERCY HEALTH'S TAX DEPARTMENT, TO ENSURE ACCURACY AND CONSISTENCY WITH OTHER RELATED ORGANIZATIONS' FORM 990S. AFTER QUESTIONS ARISING FROM THE VARIOUS REVIEWS ARE ADDRESSED AND INCORPORATED INTO THE FORM 990, A REVISED DRAFT IS PROVIDED TO THE FILING ORGANIZATION'S LEADERSHIP TEAM, INCLUDING THE CFO AND CEO, FOR REVIEW. ONCE REVIEWED AND APPROVED BY THE FILING ORGANIZATION'S LEADERSHIP TEAM, THE FORM 990 IS PROVIDED TO THE BOARD OF DIRECTORS FOR REVIEW; IT IS THEN SIGNED AND FILED WITH THE IRS. FORM 990, PART VI, QUESTION 12C DESCRIPTION OF PROCESS TO MONITOR TRANSACTIONS FOR CONFLICTS OF INTEREST OFFICERS, DIRECTORS, KEY EMPLOYEES AND OTHER DISQUALIFIED PERSONS ARE REQUIRED TO COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE ANNUALLY AND DID SO IN THE NORMAL COURSE FOR THE YEAR ENDED JUNE 30, 2013. THIS PROCESS IS ADMINISTERED AT THE MERCY HEALTH LEVEL BY MERCY'S BUSINESS RISK (INTERNAL AUDIT) DEPARTMENT. THE QUESTIONNAIRES ARE REVIEWED WITH LEADERSHIP AT THE LOCAL LEVEL AND POTENTIAL CONFLICTS DISCUSSED AND RESOLVED. THE CONFLICTS AND THEIR RESPECTIVE RESOLUTIONS ARE SHARED AT THE MERCY LEVEL WITH A TEAM INCLUDING MERCY'S CHIEF FINANCIAL OFFICER, CHIEF COMPLIANCE OFFICER AND OTHER MEMBERS OF FINANCE, LEGAL AND HR. SUMMARY RESULTS ARE REVIEWED WITH MERCY'S STEWARDSHIP COMMITTEE (FORMERLY FINANCE, AUDIT AND COMPLIANCE COMMITTEE) OF THE BOARD OF DIRECTORS. FORM 990, PART VI, QUESTION 19 AVAIL OF GOV DOCS, CONFLICT OF INTEREST POLICY, & FIN STMT TO GEN PUBLIC GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST BUT ARE NOT PUBLISHED PUBLICLY. FORM 990, PART VII, SECTION A, COLUMN B AVERAGE HOURS PER WEEK THE HOURS PER WEEK DISCLOSED IN PART VII IS THE AVERAGE HOURS THE LISTED PERSON WORKED OR DEVOTED PER WEEK WHILE EMPLOYED OR ASSOCIATED WITH THE FILING ORGANIZATION AND RELATED ORGANIZATIONS (IF APPLICABLE). FORM 990, PART XI, LINE OTHER CHANGES IN NET ASSETS TRANSFER OF LAND TO HOSPITAL $(810,000) RESTRICTED GIFTS & PLEDGE ADJUSTMENTS $1,104,120 RELEASE OF FUNDS $(236,873) TOTAL 57,247 FORM 990, PART XII, QUESTION 2C AUDIT OF FINANCIAL STATEMENTS THE FILING ORGANIZATION'S FINANCIAL STATEMENTS WERE INCLUDED IN MERCY HEALTH AND SUBSIDIARIES ANNUAL FINANCIAL STATEMENT AUDIT. MERCY HEALTH AND SUBSIDIARIES RECEIVED AN UNQUALIFIED OPINION FROM THE EXTERNAL AUDITORS FOR FISCAL 2013 (THE TAX YEAR CURRENTLY BEING REPORTED). HOWEVER, NO SEPARATE AUDIT OPINION WAS ISSUED ON THE FINANCIAL STATEMENTS OF THE FILING ORGANIZATION. THE ULTIMATE RESPONSIBILITY FOR OVERSIGHT OF THE FINANCIAL STATEMENT AUDIT AND SELECTION OF THE EXTERNAL AUDITOR LIES WITH THE STEWARDSHIP COMMITTEE (FORMERLY FINANCE, AUDIT, AND COMPLIANCE COMMITTEE) OF THE MERCY HEALTH BOARD OF DIRECTORS. AUDIT RESULTS ARE COMMUNICATED TO THIS COMMITTEE.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2012

Additional Data


Software ID:  
Software Version:  
SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBulletAttach to Form 990. MediumBullet See separate instructions.

OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
Mercy Health Foundation Northwest Arkansas
 
Employer identification number

71-0601687
Part I
Identification of Disregarded Entities (Complete if the organization answered "Yes" to 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" to 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) Casa de Misericordia

1602 McClelland Street

Laredo,TX78044
74-2912461 		SHELTER TX 501(C)(3) 7 MM LAREDO
 
Yes
 
(2) Laredo Medical Group

14528 S Outer Forty Ste 100

Chesterfield,MO63017
74-2764726 		INACTIVE TX 501(C)(3) 9 MHS TEXAS
 
Yes
 
(3) McAuley Portfolio Management Company

14528 S Outer Forty Ste 100

Chesterfield,MO63017
26-1708048 		PORT MGMT MO 501(C)(3) 11b MERCY HEALTH
 
Yes
 
(4) Mercy Clinic East Communities

14528 S Outer Forty Ste 100

Chesterfield,MO63017
43-1771217 		PHYS GROUP MO 501(C)(3) 9 MH EAST COMM
 
Yes
 
(5) Mercy Clinic Fort Smith Communities

7301 Rogers Avenue

Fort Smith,AR72903
26-1318597 		PHYS CLINIC AR 501(C)(3) 9 MH FS COMM
 
Yes
 
(6) Mercy Clinic Hot Springs Communities

1 Mercy Lane

Hot Springs,AR71913
26-1125131 		PHYS CLINIC AR 501(C)(3) 9 MH HS COMM
 
Yes
 
(7) Mercy Clinic Oklahoma Communities Inc

4300 W Memorial Road

Oklahoma City,OK73120
27-0473057 		PHYS GROUP OK 501(C)(3) 9 MH OK COMM
 
Yes
 
(8) Mercy Clinic Springfield Communities

1965 Fremont Street Ste 2950

Springfield,MO65804
43-1560263 		PHYS GROUP MO 501(C)(3) 9 MH SF COMM
 
Yes
 
(9) Mercy Family Center

14528 S Outer Forty Ste 100

Chesterfield,MO63017
72-1069468 		COUNSELING MO 501(C)(3) 7 MERCY HEALTH
 
Yes
 
(10) Mercy Foundation for Health Innovation

14528 S Outer Forty Ste 100

Chesterfield,MO63017
20-0901499 		FOUNDATION MO 501(C)(3) 11b MERCY HEALTH
 
Yes
 
(11) Mercy Health

14528 S Outer Forty Ste 100

Chesterfield,MO63017
43-1423050 		CORP OFFICE MO 501(C)(3) 1 NA
 
 
No
(12) Mercy Health East Communities

14528 S Outer Forty Ste 100

Chesterfield,MO63017
43-1718408 		HLTH SYSTEM MO 501(C)(3) 11b MERCY HEALTH
 
Yes
 
(13) Mercy Health East Communities South Reg

14528 S Outer Forty Ste 100

Chesterfield,MO63017
46-1412322 		HLTH SYSTEM MO 501(C)(3) 11b MH EAST COMM
 
Yes
 
(14) Mercy Health Fort Smith Communities

7301 Rogers Avenue

Fort Smith,AR72917
26-1318515 		HOLDING CO AR 501(C)(3) 11b MERCY HEALTH
 
Yes
 
(15) Mercy Health Foundation Ardmore

1011 14th Avenue NW

Ardmore,OK73401
71-0962525 		FOUNDATION OK 501(C)(3) 11a MH ARDMORE
 
Yes
 
(16) Mercy Health Foundation Berryville

214 Carter Street

Berryville,AR72616
71-0759301 		FOUNDATION AR 501(C)(3) 11a MH BRYVILLE
 
Yes
 
(17) Mercy Health Foundation Fort Scott

401 Woodland Hills Blvd

Fort Scott,KS66701
48-1077073 		FOUNDATION KS 501(C)(3) 11c M KS COMM
 
Yes
 
(18) St Edward Mercy Foundation

7301 Rogers Avenue

Fort Smith,AR72917
23-7330425 		FOUNDATION AR 501(C)(3) 7 MH FT SMITH
 
Yes
 
(19) Mercy Health Foundation Hot Springs

300 Werner Street

Hot Springs,AR71913
71-0804718 		FOUNDATION AR 501(C)(3) 11b MH H SPRINGS
 
Yes
 
(20) Mercy Health Foundation Independence

800 W Myrtle

Independence,KS67301
48-1079981 		FOUNDATION KS 501(C)(3) 11a M KS COMM
 
Yes
 
(21) Mercy Health Foundation Jefferson

1400 US Highway 61 South

Festus,MO63028
46-2797051 		FOUNDATION MO 501(C)(3) 11b MH E COMM SR
 
Yes
 
(22) Mercy Health Foundation Joplin

2817 St Johns Blvd

Joplin,MO64804
27-0906136 		FOUNDATION MO 501(C)(3) 11a MH SWMK COMM
 
Yes
 
(23) Mercy Health Foundation Oklahoma City

4300 W Memorial Road

Oklahoma City,OK73120
73-1593024 		FOUNDATION OK 501(C)(3) 11a MH OK CITY
 
Yes
 
(24) Mercy Health Foundation of Oklahoma

4300 W Memorial Road

Oklahoma City,OK73120
45-4732301 		FOUNDATION OK 501(C)(3) 11a MH OK COMM
 
Yes
 
(25) Mercy Health Foundation Springfield

1235 E Cherokee Street

Springfield,MO65804
32-0195818 		FOUNDATION MO 501(C)(3) 11b MH SF COMM
 
Yes
 
(26) Mercy Health Foundation St Louis

14528 S Outer Forty Ste 100

Chesterfield,MO63017
56-2410020 		FOUNDATION MO 501(C)(3) 11b MH EAST COMM
 
Yes
 
(27) Mercy Health Foundation Washington

901 E Fifth Street

Washington,MO63090
56-2410022 		FOUNDATION MO 501(C)(3) 11b MH EAST COMM
 
Yes
 
(28) Mercy Health Hot Springs Communities

300 Werner Street

Hot Springs,AR71913
26-1125064 		HOLDING CO AR 501(C)(3) 11b MERCY HEALTH
 
Yes
 
(29) Mercy Health NW Arkansas Communities

2710 Rife Medical Lane

Rogers,AR72758
62-1684203 		PHYS GROUP AR 501(C)(3) 11b MERCY HEALTH
 
 
No
(30) Mercy Health Oklahoma Communities Inc

4300 W Memorial Road

Oklahoma City,OK73120
73-1453048 		HOLDING CO OK 501(C)(3) 11b MERCY HEALTH
 
Yes
 
(31) Mercy Health Southwest MOKS Communities

2817 St Johns Blvd

Joplin,MO64804
30-0584463 		HLTH SYSTEM MO 501(C)(3) 11b MERCY HEALTH
 
Yes
 
(32) Mercy Health Springfield Communities

1235 E Cherokee Street

Springfield,MO65804
43-1856028 		HLTH SYSTEM MO 501(C)(3) 11b MERCY HEALTH
 
Yes
 
(33) Mercy Health System of Texas Inc

14528 S Outer Forty Ste 100

Chesterfield,MO63017
74-2764727 		INACTIVE TX 501(C)(3) 11b MERCY HEALTH
 
Yes
 
(34) Mercy Home Health Berryville

804 W Freeman Suite 4

Berryville,AR72616
87-0781247 		HOME HEALTH AR 501(C)(3) 11c MH SF
 
Yes
 
(35) Mercy Hospital Ada Inc

430 N Monte Vista Street

Ada,OK74820
46-2288155 		HOSPITAL OK 501(C)(3) 3 MH OK COMM
 
Yes
 
(36) Mercy Hospital Ardmore Inc

1011 14th Avenue NW

Ardmore,OK73401
73-1500629 		HOSPITAL OK 501(C)(3) 3 MH OK COMM
 
Yes
 
(37) Mercy Hospital Aurora

500 Porter Avenue

Aurora,MO65605
43-1936696 		HOSPITAL MO 501(C)(3) 3 MH SF COMM
 
Yes
 
(38) Mercy Hospital Berryville

214 Carter Street

Berryville,AR72616
71-0759299 		HOSPITAL AR 501(C)(3) 3 MH SF COMM
 
Yes
 
(39) Mercy Hospital Carthage

3125 Dr Russell Smith Way

Carthage,MO64836
45-3808607 		HOSPITAL MO 501(C)(3) 3 MH SWMK COMM
 
Yes
 
(40) Mercy Hospital Cassville

94 Main Street

Cassville,MO65625
43-1936699 		HOSPITAL MO 501(C)(3) 3 MH SF COMM
 
Yes
 
(41) Mercy Hospital Columbus

220 Pennsylvania Avenue

Columbus,KS66725
27-0842031 		HOSPITAL MO 501(C)(3) 3 MH SWMK COMM
 
Yes
 
(42) Mercy Hospital El Reno Inc

2115 Parkview Drive

El Reno,OK73036
27-2716065 		HOSPITAL OK 501(C)(3) 3 MH OK COMM
 
Yes
 
(43) Mercy Hospital Fort Smith

7301 Rogers Avenue

Fort Smith,AR72917
71-0240352 		HOSPITAL AR 501(C)(3) 3 MH FS COMM
 
Yes
 
(44) Mercy Hospital Healdton Inc

918 South 8th Street

Healdton,OK73438
26-3173902 		HOSPITAL OK 501(C)(3) 3 MH ARDMORE
 
Yes
 
(45) Mercy Hospital Hot Springs

300 Werner Street

Hot Springs,AR71913
71-0236913 		HOSPITAL AR 501(C)(3) 3 MH HS COMM
 
Yes
 
(46) Mercy Hospital Jefferson

1400 Highway 61 South

Festus,MO63028
43-0687077 		HOSPITAL MO 501(C)(3) 3 MH E COMM SR
 
Yes
 
(47) Mercy Hospital Joplin

2817 St Johns Blvd

Joplin,MO64804
27-0814858 		HOSPITAL MO 501(C)(3) 3 MH SWMK COMM
 
Yes
 
(48) Mercy Hospital Lebanon

100 Hospital Drive

Lebanon,MO65536
43-1767432 		HOSPITAL MO 501(C)(3) 3 MH SF COMM
 
Yes
 
(49) Mercy Hospital Logan County Inc

200 South Academy

Guthrie,OK73044
45-2998842 		HOSPITAL OK 501(C)(3) 3 MH OK COMM
 
Yes
 
(50) Mercy Hospital of Laredo

14528 S Outer Forty Ste 100

Chesterfield,MO63017
74-1189682 		INACTIVE TX 501(C)(3) 3 MHS TEXAS
 
Yes
 
(51) Mercy Hospital Oklahoma City Inc

4300 W Memorial Road

Oklahoma City,OK73120
73-0579285 		HOSPITAL OK 501(C)(3) 3 MH OK COMM
 
Yes
 
(52) Mercy Hospital Ozark

801 W River Street

Ozark,AR72949
71-0689680 		HOSPITAL AR 501(C)(3) 3 MH FT SMITH
 
Yes
 
(53) Mercy Hospital Paris

500 E Academy

Paris,AR72855
71-0655753 		HOSPITAL AR 501(C)(3) 3 MH FT SMITH
 
Yes
 
(54) Mercy Hospital Rogers

2710 Rife Medical Lane

Rogers,AR72758
71-0294390 		HOSPITAL AR 501(C)(3) 3 MH NWAR COMM
 
 
No
(55) Mercy Hospital Springfield

1235 E Cherokee Street

Springfield,MO65804
44-0552485 		HOSPITAL MO 501(C)(3) 3 MH SF COMM
 
Yes
 
(56) Mercy Hospital Tishomingo Inc

1000 South Byrd

Tishomingo,OK73460
27-4433830 		HOSPITAL OK 501(C)(3) 3 MH ARDMORE
 
Yes
 
(57) Mercy Hospital Waldron

1341 W 6th Street

Waldron,AR72958
71-0557895 		HOSPITAL AR 501(C)(3) 3 MH FT SMITH
 
Yes
 
(58) Mercy Hospital Watonga Inc

500 Clarence Nash Blvd

Watonga,OK73772
45-5199762 		HOSPITAL OK 501(C)(3) 3 MH OK COMM
 
Yes
 
(59) Mercy Hospitals East Communities

14528 S Outer Forty Ste 100

Chesterfield,MO63017
43-0653493 		HOSPITAL MO 501(C)(3) 3 MH EAST COMM
 
Yes
 
(60) Mercy Kansas Communities Inc

401 Woodland Hills Blvd

Ft Scott,KS66701
48-0956045 		HOSPITAL KS 501(C)(3) 3 MH SWMK COMM
 
Yes
 
(61) Mercy Medical Research Institute

1235 E Cherokee Street

Springfield,MO65804
87-0796305 		RESEARCH MO 501(C)(3) 4 MH SF COMM
 
Yes
 
(62) Mercy Ministries of Laredo

2500 Zacatecas

Laredo,TX78046
20-0198462 		OUTREACH TX 501(C)(3) 7 MERCY HEALTH
 
Yes
 
(63) Mercy St Francis Hospital

100 W Highway 60

Mountain View,MO65548
44-0607149 		HOSPITAL MO 501(C)(3) 3 MH SF COMM
 
Yes
 
(64) Mercy Support Services

14528 S Outer Forty Ste 100

Chesterfield,MO63017
43-1677952 		INACTIVE MO 501(C)(3) 11c MH EAST COMM
 
Yes
 
(65) MHM Support Services

14528 S Outer Forty Ste 100

Chesterfield,MO63017
20-2553101 		HLTH SYSTEM MO 501(C)(3) 11b MERCY HEALTH
 
Yes
 
(66) Mission Clinical Services

300 Werner Street

Hot Springs,AR71913
13-4239691 		NURSING HOME AR 501(C)(3) 9 MH HS COMM
 
Yes
 
(67) St John's Children's Hospital Inc

1235 E Cherokee Street

Springfield,MO65804
 INACTIVE MO 501(C)(3) 3 MH SF COMM
 
Yes
 
(68) St Mary's Hospital of Enid Oklahoma

14528 S Outer Forty Ste 100

Chesterfield,MO63017
73-0614655 		INACTIVE OK 501(C)(3) 3 MH OK COMM
 
Yes
 
(69) The Sister M Cornelia Blasko Foundation

100 W Highway 60

Mountain View,MO65548
43-1873914 		FOUNDATION MO 501(C)(3) 11a M ST FRANCIS
 
Yes
 
(70) Unity Ambulatory Care

14528 S Outer Forty Ste 100

Chesterfield,MO63017
43-1861745 		INACTIVE MO 501(C)(3) 11c MH EAST COMM
 
Yes
 
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 2
Part III
Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to 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) Merc Ambu Surg CTR

7301 Rogers Av
Fort Smith,AR72903
71-0827721 		AMBUL SURG CTR AR NA
  		                 
(2) RES OPT & INNOV

645 Maryville Centre Dr 200
St Louis,MO63141
46-0468368 		CENTRAL DIST. MO NA
  		                 
(3) SO OK DIAG CTR

1011 14TH Ave NW
Ardmore,OK73401
43-1971232 		MRI Services OK NA
  		                 
(4) Fort Smith EMS

1701 S Greenwood
Fort Smith,AR72901
71-0416615 		Emergency Med AR NA
  		                 
(5) St Ed Mer Med MOB

7301 Rogers Ave
Fort Smith,AR72903
71-0554050 		Office Building AR NA
  		                 




Part IV
Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" to 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) Frontenac Properties Inc

14528 S Outer Forty Suite 100
Chesterfield,MO63017
52-1914421 		HOLDING COMP DE NA
  		C-Corp       Yes  
(2) Inveno Health Inc

1235 E Cherokee Street
Springfield,MO65804
26-4509571 		RESEARCH MO NA
  		C-Corp       Yes  
(3) Mercy Community Services Inc

401 Woodland Hills Blvd
Fort Scott,KS66701
48-1078101 		RETAIL PHARMACY KS NA
  		C-Corp       Yes  
(4) Mercy Health Center Condominium Inc

4300 W Memorial Rd
Oklahoma City,OK73120
68-0640970 		REAL ESTATE OK NA
  		C-Corp       Yes  
(5) Mercy Health Network of the Southern Reg

1011 14th Avenue NW
Ardmore,OK73401
73-1580607 		HEALTH CARE OK NA
  		C-Corp       Yes  
(6) Mercy Health Network Inc

4300 W Memorial Road
Oklahoma City,OK73120
73-1381689 		HEALTH CARE OK NA
  		C-Corp       Yes  
(7) Mercy Managed Care Corporation

4300 W Memorial Road
Oklahoma City,OK73120
73-1441665 		HOLDING COMP OK NA
  		C-Corp       Yes  
(8) UH L Corp Inc

645 Maryville Centre Drive Suite 1
St Louis,MO63141
74-2499535 		HOLDING COMP MO NA
  		C-Corp       Yes  
(9) Unity Support Services Inc

645 Maryville Centre Drive Suite 1
St Louis,MO63141
43-1797042 		PRACTICE MGT MO NA
  		C-Corp       Yes  
(10) Jefferson Land Company Inc

14528 South Outer Forty Suite 100
Chesterfield,MO63017
43-1330360 		HOLDING COMP MO NA
  		C-Corp       Yes  
(11) The Apothecary Services Inc

PO Box 350
Crystal City,MO63019
43-1627267 		RETAIL PHARMACY MO NA
  		C-Corp       Yes  
Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 3
Part V
Transactions With Related Organizations (Complete if the organization answered "Yes" to 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
 
No
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
 
No
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 other organization 		(b)
Transaction
type (a-s) 		(c)
Amount involved 		(d)
Method of determining amount involved





Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to 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 section 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) 2012
Schedule R (Form 990) 2012
Page 5
Part VII
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule R (see instructions).
Identifier Return Reference Explanation

Additional Data


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