Attach to Form 990 or Form 990-EZ.
Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
| (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 listed in your governing document? | (v) Amount of monetary support (see instructions) | (vi) Amount of other support (see instructions) | |
|---|---|---|---|---|---|---|
| Yes | No | |||||
| (A)
MAJOR HOSPITAL |
351118234 | 3 | Yes | 35,000 | 0 | |
Total 1
|
35,000 | |||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .... | ||||||
| 2 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf....... | ||||||
| 3 | The value of services or facilities furnished by a governmental unit to the organization without charge.. | ||||||
| 4 | Total. Add lines 1 through 3 | ||||||
| 5 | The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f).. | ||||||
| 6 | Public support. Subtract line 5 from line 4. | ||||||
Calendar year
(or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 7 | Amounts from line 4.. | ||||||
| 8 | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources... | ||||||
| 9 | Net income from unrelated business activities, whether or not the business is regularly carried on.. | ||||||
| 10 | Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.).. | ||||||
| 11 | Total support Add lines 7 through 10. | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (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.) | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (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 VI.) .. | ||||||
| 13 | Total support. (Add lines 9, 10c, 11, and 12.).. | ||||||
| Section A - Adjusted Net Income | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Net short-term capital gain | 1 | ||||
| 2 | Recoveries of prior-year distributions | 2 | ||||
| 3 | Other gross income (see instructions) | 3 | ||||
| 4 | Add lines 1 through 3 | 4 | ||||
| 5 | Depreciation and depletion | 5 | ||||
| 6 | Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions) | 6 | ||||
| 7 | Other expenses (see instructions) | 7 | ||||
| 8 | Adjusted Net Income (subtract lines 5, 6 and 7 from line 4) | 8 | ||||
| Section B - Minimum Asset Amount | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year): | 1 | ||||
| a | Average monthly value of securities | 1a | ||||
| b | Average monthly cash balances | 1b | ||||
| c | Fair market value of other non-exempt-use assets | 1c | ||||
| d | Total (add lines 1a, 1b, and 1c) | 1d | ||||
| e | Discount claimed for blockage or other factors (explain in detail in Part VI): | |||||
| 2 | Acquisition indebtedness applicable to non-exempt use assets | 2 | ||||
| 3 | Subtract line 2 from line 1d | 3 | ||||
| 4 | Cash deemed held for exempt use. Enter 1-1/2% of line 3 (for greater amount, see instructions). | 4 | ||||
| 5 | Net value of non-exempt-use assets (subtract line 4 from line 3) | 5 | ||||
| 6 | Multiply line 5 by .035 | 6 | ||||
| 7 | Recoveries of prior-year distributions | 7 | ||||
| 8 | Minimum Asset Amount (add line 7 to line 6) | 8 | ||||
| Section C - Distributable Amount | Current Year | |||||
| 1 | Adjusted net income for prior year (from Section A, line 8, Column A) | 1 | ||||
| 2 | Enter 85% of line 1 | 2 | ||||
| 3 | Minimum asset amount for prior year (from Section B, line 8, Column A) | 3 | ||||
| 4 | Enter greater of line 2 or line 3 | 4 | ||||
| 5 | Income tax imposed in prior year | 5 | ||||
| 6 | Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions) | 6 | ||||
| 7 | Check here if the current year is the organization's first as a non-functionally-integrated Type III supporting organization (see instructions) | |||||
| Section D - Distributions | Current Year | |
|---|---|---|
| 1 Amounts paid to supported organizations to accomplish exempt purposes | ||
|
2
Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity |
||
| 3 Administrative expenses paid to accomplish exempt purposes of supported organizations | ||
| 4 Amounts paid to acquire exempt-use assets | ||
| 5 Qualified set-aside amounts (prior IRS approval required) | ||
| 6 Other distributions (describe in Part VI). See instructions | ||
| 7Total annual distributions. Add lines 1 through 6. | ||
|
8
Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions |
||
| 9 Distributable amount for 2014 from Section C, line 6 | ||
| 10 Line 8 amount divided by Line 9 amount | ||
| Section E - Distribution Allocations (see instructions) |
(i) Excess Distributions |
(ii) Underdistributions Pre-2014 |
(iii) Distributable Amount for 2014 |
|
|---|---|---|---|---|
|
1
Distributable amount for 2014 from Section C, line 6 |
||||
|
2
Underdistributions, if any, for years prior to 2014 (reasonable cause required--see instructions) |
||||
| 3 Excess distributions carryover, if any, to 2014: | ||||
| a From 2009.......X | ||||
| b From 2010.......X | ||||
| c From 2011.......X | ||||
| d From 2012.......X | ||||
| e From 2013....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2014 distributable amount | ||||
|
i
Carryover from 2009 not applied (see instructions) |
||||
| j Remainder. Subtract lines 3g, 3h, and 3i from 3f. | ||||
| 4Distributions for 2014 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2014 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from 4. | ||||
|
5
Remaining underdistributions for years prior to 2014, if any. Subtract lines 3g and 4a from line 2 (if amount greater than zero, see instructions) |
||||
|
6
Remaining underdistributions for 2014. Subtract lines 3h and 4b from line 1 (if amount greater than zero, see instructions) |
||||
|
7 Excess distributions carryover to 2015. Add lines 3j and 4c. |
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| 8 Breakdown of line 7: | ||||
| a From 2010.......X | ||||
| b From 2011.......X | ||||
| c From 2012.......X | ||||
| d From 2013....... | ||||
| e From 2014....... | ||||
| Facts And Circumstances Test |
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| Return Reference | Explanation |
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| Software ID: | |
| Software Version: |
Attach to Form 990 or 990-EZ.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at| Return Reference | Explanation |
|---|---|
| FORM 990, PART VI, SECTION A, LINE 1 | THE EXECUTIVE COMMITTEE IS APPOINTED BY THE FOUNDATION BOARD PRESIDENT AND IS TO INCLUDE THE HOSPITAL CEO AND REPRESENTATIVE TO THE FOUNDATION BOARD FROM THE HOSPITAL BOARD. NOTE THAT PRESIDENT IS EX-OFFICIO MEMBER OF ALL COMMITTEES. COMMITTEE HAS UP TO SIX MEMBERS, NOT INCLUDING THE BOARD PRESIDENT. THE POWERS OF THE EXECUTIVE COMMITTEE INCLUDE TRANSACTING ROUTINE BUSINESS OF THE BOARD BETWEEN MEETINGS, EXCLUDING THE ADOPTION OF THE BUDGET OR ANY ACTION THAT IS CONTRARY TO OR A SUBSTANTIAL DEPARTURE FROM THE DIRECTION OF THE BOARD, OR WHICH REPRESENTS A MAJOR CHANGE IN THE AFFAIRS, BUSINESS, OR POLICY OF THE ORGANIZATION. THEY MAY ALSO ACT FOR THE BOARD IN A CRISIS, TAKING ONLY SHORT-TERM MEASURES UNTIL THE NEXT MEETING OF THE BOARD. ALL BUSINESS CONDUCTED BETWEEN BOARD MEETINGS OR DURING A CRISIS IS SUBJECT TO RATIFICATION BY THE ENTIRE BOARD AT REGULAR MEETINGS. BUSINESS CONDUCTED BY THE EXECUTIVE COMMITTEE WILL BE LISTED IN THE CONSENT AGENDA. THE BOARD WILL ALSO BE NOTIFIED WITHIN 24 HOURS OF ANY ACTION TAKEN BY THE EXECUTIVE COMMITTEE. TO TRANSACT ROUTINE BUSINESS BETWEEN MEETINGS OR TO ACT FOR THE BOARD IN A CRISIS, THE HOSPITAL CEO, THE FOUNDATION BOARD PRESIDENT, AND THE REPRESENTATIVE FROM THE HOSPITAL BOARD MUST BE PRESENT. |
| FORM 990, PART VI, SECTION A, LINE 2 | BETSY CRANDALL AND CARRIE PUMPHREY HAVE A BUSINESS RELATIONSHIP. |
| FORM 990, PART VI, SECTION A, LINE 4 | A SIGNIFICANT CHANGE TO THE ORGANIZATION'S BYLAWS WERE MADE DURING THE YEAR. THE NUMBER OF VOTING MEMBERS WERE INCREASED TO ELEVEN AND A QUORUM WILL BE CONSIDERED A MAJORITY. |
| FORM 990, PART VI, SECTION A, LINE 7A | ANY AND ALL VACANCIES ON THE BOARD OF DIRECTORS, WHETHER EXISTING BY REASON OF DEATH, RESIGNATION OR ANY OTHER CAUSE, SHALL BE FILLED BY APPOINTMENT MADE BY THE BOARD OF DIRECTORS OF MAJOR HOSPITAL. |
| FORM 990, PART VI, SECTION A, LINE 7B | SOME OF THE DECISIONS MADE BY THE FOUNDATION'S BOARD MUST BE RATIFIED BY THE BOARD OF MAJOR HOSPITAL. THE BOARD OF MAJOR HOSPITAL APPOINTS THE FOUNDATION'S GOVERNING BOARD MEMBERS. |
| FORM 990, PART VI, SECTION B, LINE 11 | THE 990 IS FIRST REVIEWED BY THE EXECUTIVE COMMITTEE. NEXT, EACH MEMBER OF THE BOARD RECEIVES A COPY IN ADVANCE OF THE NEXT BOARD MEETING. AT THE BOARD MEETING, THE EXECUTIVE COMMITTEE REVIEWS THE 990 WITH THE BOARD AND ENTERTAINS ANY QUESTIONS THEY MAY HAVE. THE EXECUTIVE COMMITTEE WILL RECOMMEND WHETHER OR NOT TO FILE THE 990 AS PRESENTED AND THE BOARD WILL VOTES ON THEIR RECOMMENDATION. AT THIS TIME THE EXECUTIVE COMMITTEE WILL ALSO MAKE ANY RECOMMENDATIONS FOR THE BOARD'S DELIBERATION REGARDING GOVERNANCE, POLICIES, DISCLOSURE, ETC. |
| FORM 990, PART VI, SECTION B, LINE 12C | THE WRITTEN CONFLICT OF INTEREST POLICY IS REGULARLY AND CONSISTENTLY MONITORED AND COMPLIANCE ENFORCED BY THE BOARD OF DIRECTORS. THE SCOPE OF THIS POLICY INCLUDES STAFF AND BOARD MEMBERS. THE POLICY IS IN PLACE TO IDENTIFY, EVALUATE, AND ADDRESS ANY REAL, POTENTIAL, OR APPARENT CONFLICTS OF INTEREST THAT MIGHT, IN FACT OR APPEARANCE, CALL INTO QUESTION THE DUTY OF UNDIVIDED LOYALTY TO THE FOUNDATION. THE COVERED PERSONS ARE TO REFRAIN FROM TRANSACTIONS WITH ANY OTHER PARTY WITH WHOM THEY HAVE A SIGNIFICANT OR BUSINESS RELATIONSHIP WHEREBY THE FOUNDATION'S INTERESTS ARE COMPROMISED. A SELF DISCLOSURE FROM COVERED PERSONS TO THE BOARD IS REQUIRED ON ANY POTENTIAL CONFLICTS OF INTEREST. THE COVERED PERSONS ARE TO RECUSE FROM PARTICIPATING IN ANY DELIBERATION OR DECISIONS ON SUCH TRANSACTIONS. COVERED TRANSACTIONS ARE REVIEWED BY THE BOARD. |
| FORM 990, PART VI, SECTION B, LINE 15A | THE PROCESS FOR DETERMINING THE EXECUTIVE DIRECTOR'S COMPENSATION ENTAILS A REVIEW AND APPROVAL BY MAJOR HOSPITAL'S CEO AND, ALSO, REVIEWED BY THE FOUNDATION'S BOARD. MAJOR HOSPITAL'S HUMAN RESOURCE DEPARTMENT PROVIDES COMPARABLE SALARY INFORMATION TO THE CEO FOR DETERMINATION OF SALARY AND DOCUMENTATION OF THE DECISION MADE IS RECORDED IN THE EMPLOYEE'S PERSONNEL FILE. ADDITIONALLY, THE FOUNDATION REIMBURSES THE HOSPITAL FOR THE SERVICES PROVIDED BY THE EXECUTIVE DIRECTOR TO THE FOUNDATION. |
| FORM 990, PART VI, SECTION C, LINE 19 | GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST BY CONTACTING THE FOUNDATION'S OFFICE AT 150 WEST WASHINGTON STREET, SHELBYVILLE, IN 46716 |
| PART XI, LINE 2C, OVERSIGHT OF AUDIT: | THE FOUNDATION'S BOARD OF DIRECTORS REVIEWS THE ANNUAL FINANCIAL STATEMENTS. HOWEVER, THE INDEPENDENT ACCOUNTANT IS SELECTED BY MAJOR HOSPITAL'S BOARD OF DIRECTORS. NO CHANGES HAVE BEEN MADE THE PROCESS FROM PRIOR YEAR. |
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| Software Version: |