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)
ALLINA HEALTH SYS |
363261413 | 3 | Yes | 0 | 0 | |
Total 1
|
0 | |||||
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 III, LINE 3 | SEE SCHEDULE N, PART I, LINE 3 FOR EXPLANATION OF MERGER PLAN INCLUDING PLAN FOR DISTRIBUTION OF ASSETS. |
| FORM 990, PART VI, SECTION A, LINE 4 | AS MORE FULLY DESCRIBED IN THE ATTACHED ARTICLES OF MERGER, CENTER FOR HEALTHCARE INNOVATION FOUNDATION(CHIF) MERGED WITH AND INTO ALLINA HEALTH SYSTEM [EIN: 36-3261413], A MINNESOTA 317A NONPROFIT CORPORATION AND 501(C)(3) TAX EXEMPT ORGANIZATION, ON DECEMBER 31, 2014. ARTICLES OF MERGER OF CHIF INTO ALLINA HEALTH SYSTEM WERE FILED WITH THE MINNESOTA SECRETARY OF STATE. ALLINA HEALTH SYSTEM IS THE SURVIVING AND SUCCESSOR ORGANIZATION. AS A RESULT AND FOR TAX REPORTING PURPOSES, ALL ASSETS AND LIABILTITIES OF CHIF HAVE BEEN TRANSFERRED TO ALLINA HEALTH SYSTEM AS OF DECEMBER 31, 2014. |
| FORM 990, PART VI, SECTION A, LINE 6 | ALLINA HEALTH SYSTEM IS THE SOLE CORPORATE MEMBER ORGANIZATION OF CENTER FOR HEALTHCARE INNOVATION FOUNDATION. CENTER FOR HEALTHCARE INNOVATION FOUNDATION IS THE SUPPORTING ORGANIZATION AND ALLINA HEALTH SYSTEM IS THE SUPPORTED ORGANIZATION. SEE SCHEDULE A AND SCHEDULE R FOR FURTHER DETAILS. CENTER FOR HEALTHCARE INNOVATION FOUNDATION HAS NO EMPLOYEES AND DOES NOT PAY COMPENSATION. COMPENSATION DISCLOSED AS PAID BY A RELATED ORGANIZATION IS DETERMINED SOLELY BY THE RELATED ORGANIZATION. |
| FORM 990, PART VI, SECTION A, LINE 7A | AS THE SOLE CORPORATE MEMBER ORGANIZATION, ALLINA HEALTH SYSTEM HOLDS CERTAIN RESERVED POWERS OVER CENTER FOR HEALTHCARE INNOVATION FOUNDATION. THE RESERVED POWERS ARE FULLY DESCRIBED IN CENTER FOR HEALTHCARE INNOVATION FOUNDATION'S GOVERNING DOCUMENTS AND INCLUDE SUCH POWERS AS ELECTION AND APPROVAL OF DIRECTORS, FINAL APPROVAL OF AMENDMENTS TO ARTICLES OF INCORPORATION OR BYLAWS, APPROVAL OF STRATEGIC PLANS AND CAPITAL AND OPERATING BUDGETS, APPROVAL OF PLANS OF MERGER OR CONSOLIDATION, APPROVAL OF INCURRENCE OF DEBT OR EXPENDITURES IN EXCESS OF CERTAIN AMOUNTS, AND VARIOUS OTHER RESERVED POWERS AS DESCRIBED THEREIN. |
| FORM 990, PART VI, SECTION A, LINE 7B | SEE PART VI, SECTION A, LINE 7A DESCRIPTION ABOVE. |
| FORM 990, PART VI, SECTION B, LINE 11 | CENTER FOR HEALTHCARE INNOVATION FOUNDATION'S FORM 990 WAS PREPARED BY THE TAX SERVICES FUNCTION OF ALLINA HEALTH SYSTEM, CENTER FOR HEALTHCARE INNOVATION FOUNDATION'S SOLE CORPORATE MEMBER AND SUPPORTED ORGANIZATION. THE FORM 990 FILING WAS SUBJECTED TO A RIGOROUS REVIEW PROCESS BY ALLINA'S TAX MANAGER AND TAX DIRECTOR. ALLINA'S CHIEF FINANCIAL OFFICER ALSO PERFORMED AN EXECUTIVE REVIEW OF THE FORM 990. AFTER THE MANAGEMENT REVIEW PROCESS DESCRIBED ABOVE WAS COMPLETED, THE FINAL FORM 990, AS ULTIMATELY FILED WITH THE INTERNAL REVENUE SERVICE ['IRS'], WAS PROVIDED TO EACH VOTING MEMBER OF ALLINA HEALTH SYSTEM'S BOARD OF DIRECTORS, AS THE SUCCESSOR IN MERGER. ALLINA HEALTH SYSTEM'S BOARD OF DIRECTORS VOTED ON AND APPROVED A RESOLUTION APPROVING THE FORM 990, THE MINNESOTA CHARITABLE ORGANIZATION ANNUAL REPORT TO BE FILED WITH THE MINNESOTA ATTORNEY GENERAL, AND THE WISCONSIN CHARITABLE ORGANIZATION ANNUAL REPORT TO BE FILED WITH THE WISCONSIN DEPARTMENT OF FINANCIAL INSTITUTIONS. THE BOARD OF DIRECTORS RESOLUTION ALSO DIRECTED OFFICERS TO FILE THE FORM 990 WITH THE IRS, THE CHARITABLE ANNUAL REPORT WITH THE CHARITIES DIVISION OF THE OFFICE OF THE MINNESOTA ATTORNEY GENERAL, AND THE WISCONSIN CHARITABLE ORGANIZATION ANNUAL REPORT WITH THE WISCONSIN DEPARTMENT OF FINANCIAL INSTITUTIONS. THE ABOVE STATED REVIEW AND APPROVAL PROCESS OCCURRED PRIOR TO FILING THE CENTER FOR HEALTHCARE INNOVATION FOUNDATION'S FORM 990 WITH THE IRS, MINNESOTA CHARITABLE ORGANIZATION ANNUAL REPORT WITH THE MINNESOTA ATTORNEY GENERAL, AND WISCONSIN CHARITABLE ORGANIZATION ANNUAL REPORT WITH THE WISCONSIN DEPARTMENT OF FINANCIAL INSTITUTIONS. |
| FORM 990, PART VI, SECTION B, LINE 12C | THE ORGANIZATION HAS SEVERAL METHODS OF MONITORING AND ENFORCING COMPLIANCE WITH ITS CONFLICT OF INTEREST POLICY. FIRST, THE ORGANIZATION REGULARLY DISTRIBUTES CONFLICT OF INTEREST DISCLOSURE QUESTIONNAIRES TO ITS OFFICERS, DIRECTORS, TRUSTEES, AND KEY EMPLOYEES. THESE INDIVIDUALS ARE REQUIRED TO DISCLOSE ANNUALLY ANY INTEREST THAT COULD GIVE RISE TO CONFLICTS, INCLUDING ANY FAMILY OR BUSINESS RELATIONSHIP. SECOND, THE GENERAL COUNSEL'S OFFICE ANNUALLY DELIVERS A REPORT TO ALLINA'S BOARD OF DIRECTORS WHICH INCLUDES, AMONG OTHER THINGS, THE RESULTS OF THE CONFLICT OF INTEREST QUESTIONNAIRE, AN ANALYSIS OF POTENTIAL CONFLICTS, AND GUIDANCE FOR SATISFACTORILY RESOLVING CONFLICTS. THIRD, THE ORGANIZATION UNDERTAKES MANDATORY COMPLIANCE TRAINING OF ALL ITS EMPLOYEES WHICH INCLUDES TRAINING ON CONFLICTS OF INTEREST. FOURTH, ALL EMPLOYEES RECEIVE, AND ARE EXPECTED TO CONDUCT THEMSELVES IN ACCORDANCE WITH, ALLINA'S CODE OF CONDUCT. THE CODE OF CONDUCT CONTAINS EDUCATIONAL MATERIALS AND GUIDANCE TO RESOLVE POTENTIAL CONFLICTS OF INTEREST. FIFTH, ALLINA MAINTAINS A CORPORATE INTEGRITY HOTLINE, A CONFIDENTIAL 24 HOUR EXTERNAL RESOURCE TO HELP ANSWER QUESTIONS RELATED TO ETHICAL BUSINESS CONDUCT. ALL CALLS TO THE INTEGRITY LINE ARE KEPT CONFIDENTIAL. |
| FORM 990, PART VI, SECTION B, LINE 15 | CENTER FOR HEALTHCARE INNOVATION FOUNDATION HAS NO EMPLOYEES AND DOES NOT PAY COMPENSATION. ANY COMPENSATION DISCLOSED AS PAID BY A RELATED ORGANIZATION IS DETERMINED SOLELY BY THE RELATED ORGANIZATION. THEREFORE, PART VI, SECTION B, LINE 15A AND LINE 15B ARE NOT APPLICABLE TO CENTER FOR HEALTHCARE INNOVATION FOUNDATION. |
| FORM 990, PART VI, SECTION C, LINE 19 | CENTER FOR HEALTHCARE INNOVATION FOUNDATION MAKES ITS FORM 990, FORM 1023, GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. TO ARRANGE AN INSPECTION OR RECEIVE A COPY, PLEASE CONTACT THE FOLLOWING: CENTER FOR HEALTHCARE INNOVATION FOUNDATION TAX SERVICES MAIL ROUTE 10890 P.O. BOX 43 MINNEAPOLIS, MN 55407-0043 TELEPHONE: 612-262-0660 PHYSICAL ADDRESS: 2925 CHICAGO AVENUE MINNEAPOLIS, MN 55407-1321 THE FORM 990 AND FORM 1023 ARE ALSO AVAILABLE DIRECTLY FROM THE INTERNAL REVENUE SERVICE. THE FORM 990 AND FINANCIAL STATEMENTS ARE ALSO AVAILABLE FROM THE CHARITIES DIVISION OF THE OFFICE OF THE MINNESOTA ATTORNEY GENERAL. |
| FORM 990, PART XI, LINE 9: | TRANSFER FUND BALANCE TO ALLINA HEALTH SYSTEM -736,967. |
| FORM 990, PART IV, LINE 12A AND FORM 990, PART XII, LINE 2B | CENTER FOR HEALTHCARE INNOVATION FOUNDATION'S FINANCIAL STATEMENTS WERE INCLUDED AS A COMPONENT PART OF THE CONSOLIDATED FINANCIAL STATEMENTS OF ITS PARENT ORGANIZATION, ALLINA HEALTH SYSTEM (AHS). THE CONSOLIDATED AHS FINANCIAL STATEMENTS WERE AUDITED BY THE INDEPENDENT PUBLIC ACCOUNTING FIRM KPMG, LLP. THE AUDIT WAS CONDUCTED IN ACCORDANCE WITH AUDITING STANDARDS GENERALLY ACCEPTED IN THE UNITED STATES. KPMG, LLP ISSUED AN UNQUALIFIED OPINION ON THE CONSOLIDATED FINANCIAL STATEMENTS, MEANING THE 2014 CONSOLIDATED FINANCIAL STATEMENTS OF AHS PRESENT FAIRLY, IN ALL MATERIAL RESPECTS, THE FINANCIAL POSITION OF AHS AS OF DECEMBER 31, 2014, AND THE RESULTS OF ITS OPERATIONS AND ITS CASH FLOWS FOR THE YEAR THEN ENDED WERE IN CONFORMITY WITH U.S. GENERALLY ACCEPTED ACCOUNTING PRINCIPLES. |
| FORM 990, PART XII, LINE 2C: | AS A RESULT OF THE MERGER WITH AND INTO ALLINA HEALTH SYSTEM ON DECEMBER 31,2014, THE ALLINA HEALTH SYSTEM AUDIT AND COMPLIANCE COMMITTEE ASSUMED AUTHORITY, RESPONSIBILITY AND OVERSIGHT,INCLUDING THE SELECTION PROCESS OF THE INDEPENDENT ACCOUNTANT. CENTER FOR HEALTHCARE INNOVATION FOUNDATION WAS INCLUDED ON A CONSOLIDATED BASIS IN THE AUDITED FINANCIAL STATEMENTS OF ALLINA HEALTH SYSTEM. |
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| Software Version: |