Department of the Treasury Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. See separate instructions. Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
INGALLS HEALTH SYSTEM
Employer identification number
36-3181170
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions.
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II, or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) A person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the supported organization?
................
11g(i)
No
(ii)
A family member of a person described in (i) above?
......................
11g(ii)
No
(iii)
A 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
No
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
(A)
THE INGALLS MEMORIAL HOSPITAL
362170866
3
Yes
Yes
Yes
0
Total
0
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 2
Part II
Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the
organization failed to qualify under Part III. If the organization fails to
qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year (or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3
The value of services or facilities furnished by a governmental unit to the organization without charge..
4
Total. Add lines 1 through 3
5
The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included
on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6
Public support. Subtract line 5 from line 4.
Section B. Total Support
Calendar year
(or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
7
Amounts from line 4..
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
9
Net income from unrelated business activities, whether or not the business is regularly carried on..
10
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
11
Total support (Add lines 7 through 10).
12
Gross receipts from related activities, etc. (see instructions)
..................
12
13
First five years.
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.................................................
Section C. Computation of Public Support Percentage
14
Public support percentage for 2013 (line 6, column (f) divided by line 11, column (f))
.........
14
15
Public support percentage for 2012 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2013.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
.......................
b
33 1/3% support test—2012.
If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2013.
If the organization did not check a box on line 13, 16a, or 16b, and line 14
is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization
.....................................................
b
10%-facts-and-circumstances test—2012.
If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported organization
................................................
18
Private foundation.
If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions
.....................................................
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 3
Part III
Support Schedule for Organizations Described in Section 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization
failed to qualify under Part II. If the organization fails to qualify under
the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year (or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2
Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
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)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
9
Amounts from line 6...
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
..
13
Total support. (Add lines 9, 10c, 11, and 12.)..
14
First five years.
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public support percentage for 2013 (line 8, column (f) divided by line 13, column (f))
.........
15
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2013.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
........
b
33 1/3% support tests—2012.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
.....
20
Private foundation.
If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 4
Part IV
Supplemental Information.
Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
Explanation
Schedule A (Form 990 or 990-EZ) 2013
Additional Data
Software ID:
13000248
Software Version:
2013v3.1
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
INGALLS HEALTH SYSTEM
Employer identification number
36-3181170
Return Reference
Explanation
Form 990, Part VI, Sec A, Line 1a, Delegate broad authority to a committee
EXECUTIVE COMMITTEE: THE BOARD OF DIRECTORS SHALL DESIGNATE AN EXECUTIVE COMMITTEE, WHICH SHALL CONSIST OF THE CHAIRMAN, THE PRESIDENT, THE SECRETARY/TREASURER AND SUCH OTHER DIRECTORS AS SHALL BE DESIGNATED FROM TIME TO TIME, WHICH EXECUTIVE COMMITTEE, TO THE EXTENT PROVIDED BY RESOLUTION OF THE BOARD OF DIRECTORS, SHALL HAVE AND MAY EXERCISE, EXCEPT AS TO MATTERS UPON WHICH THE BOARD OF DIRECTORS HAS ACTED, ALL OF THE POWERS OF THE BOARD OF DIRECTORS.
Form 990, Part VI, Sec B, Line 11b, Review of form 990 by governing body
THE FULL FORM 990, INCLUDING SUPPLEMENTAL SCHEDULES, WAS PRESENTED BY THE CHIEF FINANCIAL OFFICER TO THE EXECUTIVE COMMITTEE AT A COMMITTEE MEETING. THE FULL BOARD HAS GRANTED TO THE EXECUTIVE COMMITTEE AUTHORITY TO APPROVE THE FORM 990. THE FULL BOARD WILL RECEIVE A REPORT FROM THE EXECUTIVE COMMITTEE, DESCRIBING THE EXECUTIVE COMMITTEE'S REVIEW PERFORMED. THE FORM 990 WILL BE AVAILABLE AT THE ORGANIZATION'S BOARD MEETING FOR EACH MEMBER'S REVIEW.
Form 990, Part VI, Sec B, Line 12c, Conflict of interest policy
ALL OFFICERS, DIRECTORS, BOARD MEMBERS, AND KEY EMPLOYEES MUST AVOID SITUATIONS IN WHICH THEIR PERSONAL INTERESTS MAY CONFLICT, OR APPEAR TO CONFLICT, WITH THE INTEREST OF INGALLS; AND INGALLS REVIEWS ITS OWN RELATIONSHIPS WITH OTHER CARE PROVIDERS, EDUCATIONAL INSTITUTIONS, AND PAYERS TO DETERMINE IF POTENTIAL CONFLICTS EXIST. EMPLOYEES SHALL HAVE THE CONTINUING AFFIRMATIVE DUTY TO REPORT TO THE PRESIDENT AND CHIEF EXECUTIVE OFFICER (CEO) OF INGALLS ANY PERSONAL OWNERSHIP INTEREST OR OTHER RELATIONSHIP THAT MIGHT AFFECT THEIR ABILITY TO EXERCISE IMPARTIAL, ETHICAL BUSINESS JUDGMENTS IN THE AREA OF THEIR RESPONSIBILITIES. PER THE ENTITY'S CONFLICT OF INTEREST POLICY, EMPLOYEES AT MANAGEMENT LEVEL WILL BE REQUIRED TO COMPLETE A "CERTIFICATION AND DISCLOSURE" FORM, ON A SCHEDULE DETERMINED BY THE CORPORATE COMPLIANCE OFFICER. COMPLETION OF THIS FORM IS A JOB REQUIREMENT FOR ALL MANAGERIAL EMPLOYEES, AND MAY BE REQUIRED OF NON-MANAGEMENT EMPLOYEES AS DETERMINED BY THE PRESIDENT AND CHIEF EXECUTIVE OFFICER AND THE CORPORATE COMPLIANCE OFFICER. EMPLOYEES ALSO HAVE A DUTY TO REPORT CONFLICTS OR POTENTIAL CONFLICTS OF INTEREST OF WHICH THEY MAY BE AWARE INVOLVING OTHER EMPLOYEES. EACH SITUATION REPORTED SHALL BE REVIEWED BY THE PRESIDENT AND CEO, AND INGALLS CORPORATE COMPLIANCE OFFICER, AND A DETERMINATION SHALL BE MADE AS TO WHETHER A CONFLICT OF INTEREST EXISTS OR MAY ARISE FROM SUCH A SITUATION. THE DECISION OF THE PRESIDENT AND CEO AND CORPORATE COMPLIANCE OFFICER REGARDING WHETHER A CONFLICT EXISTS SHALL BE FINAL. THE EMPLOYEE HANDBOOK MENTIONS THE ENTITY'S CONFLICT OF INTEREST POLICY. EACH EMPLOYEE IS REQUIRED TO SIGN AN ACKNOWLEDGMENT OF THE HANDBOOK UPON EMPLOYMENT.
FORM 990, PART VI, LINE 15A, PROCESS TO ESTABLISH COMPENSATION OF TOP MANAGEMENT OFFICIAL
THE ORGANIZATION DOES NOT COMPENSATE THE ORGANIZATION'S TOP MANAGEMENT OFFICIAL. THEREFORE, THIS QUESTION HAS BEEN MARKED NO IN ACCORDANCE WITH IRS INSTRUCTIONS. THE INGALLS MEMORIAL HOSPITAL (IMH), A RELATED TAX-EXEMPT ORGANIZATION, IS RESPONSIBLE FOR DETERMINING AND ADMINISTERING COMPENSATION FOR ALL OFFICERS AND KEY EMPLOYEES OF EACH RESPECTIVE ENTITY WITHIN THE INGALLS HEALTH SYSTEM CORPORATE STRUCTURE. BELOW IS THE PROCESS USED TO ESTABLISH COMPENSATION FOR THE TOP MANAGEMENT OFFICIAL. TOP MANAGEMENT OFFICIAL: IN SETTING THE TOP MANAGEMENT OFFICIAL'S COMPENSATION, THE EXECUTIVE COMMITTEE RELIES ON RECENT COMPARABILITY STUDIES THAT PROVIDE COMPENSATION DATA FOR SIMILARLY QUALIFIED PERSONS IN COMPARABLE ORGANIZATIONS TO SUPPORT ITS DECISION-MAKING PROCESS. IN ADDITION, THE ORGANIZATION RECEIVED AN INDEPENDENT COMPENSATION REVIEW BY TOWERS WATSON IN THE FALL OF 2014. THE COMMITTEE ADEQUATELY DOCUMENTS ITS COMPENSATION DETERMINATIONS, DELIBERATIONS, AND APPROVAL OF THE TOP MANAGEMENT OFFICIAL'S COMPENSATION IN THE MEETING MINUTES. THE PROCESS FOR REVIEWING AND DETERMINING COMPENSATION FOR THE TOP MANAGEMENT OFFICIAL WAS LAST UNDERTAKEN IN THE FALL OF 2014.
FORM 990, PART VI, LINE 15B, PROCESS TO ESTABLISH COMPENSATION OF OTHER EMPLOYEES
THE ORGANIZATION DOES NOT COMPENSATE THE ORGANIZATION'S OTHER OFFICERS OR KEY EMPLOYEES. THEREFORE, THIS QUESTION HAS BEEN MARKED NO IN ACCORDANCE WITH IRS INSTRUCTIONS. THE INGALLS MEMORIAL HOSPITAL (IMH), A RELATED TAX-EXEMPT ORGANIZATION, IS RESPONSIBLE FOR DETERMINING AND ADMINISTERING COMPENSATION FOR ALL OFFICERS AND KEY EMPLOYEES OF EACH RESPECTIVE ENTITY WITHIN THE INGALLS HEALTH SYSTEM CORPORATE STRUCTURE. BELOW IS THE PROCESS USED TO ESTABLISH COMPENSATION FOR OTHER OFFICERS AND KEY EMPLOYEES. OTHER OFFICERS AND KEY EMPLOYEES: AN OUTSIDE COMPENSATION CONSULTANT IS USED TO RENDER A REASONABLE OPINION AS TO WHAT PERCENTAGE OF INCREASE A VICE PRESIDENT SHOULD RECEIVE BY PERFORMING A MARKET COMPARISON FOR ALL VICE PRESIDENTS. THE PROCESS TO DETERMINE AN INCREASE IN COMPENSATION FOR VICE PRESIDENTS WAS PERFORMED IN THE PRIOR YEAR FOR THE CURRENT YEAR'S COMPENSATION. SALARY INCREASES ARE APPROVED ANNUALLY BY THE PRESIDENT AND EXECUTIVE COMMITTEE ONCE RECEIVED BY THE OUTSIDE CONSULTANT. DIRECTORS AND MANAGERS RECEIVE AN INCREASE IN COMPENSATION BASED ON WHETHER OR NOT PERFORMANCE GOALS HAVE BEEN REACHED. BEFORE A FISCAL YEAR STARTS PERFORMANCE GOALS ARE PUT TOGETHER BY THE DIRECTOR OR MANAGER AND SUBMITTED TO THE VICE PRESIDENT FOR APPROVAL. APPROVED GOALS ARE THEN REVIEWED BY ALL OTHER EXECUTIVES. ONCE APPROVED BY ALL, THESE ARE THE GOALS FOR THE YEAR. AFTER THE YEAR IS OVER THE PERFORMANCE GOALS ARE REVIEWED BY THE VP AND DIRECTOR OR MANAGER. MARKET ADJUSTMENTS ARE SET BY THE IMMEDIATE VP AND SENT TO ALL EXECUTIVES FOR THEIR APPROVAL.
Form 990, Part VI, Sec C, Line 19, Required documents available to the public
FINANCIAL STATEMENTS, GOVERNING DOCUMENTS, AND CONFLICT OF INTEREST POLICIES ARE NOT REQUIRED DISCLOSURES PURSUANT TO INTERNAL REVENUE CODE (IRC) SECTION 6104. THESE DOCUMENTS ARE NOT AVAILABLE TO THE PUBLIC AT THIS TIME.
FORM 990, PART VII, SECTION B, LINE 1, EXPENSES FOR INGALLS HEALTH SYSTEM
EXPENSES OF INGALLS HEALTH SYSTEM (IHS) AND RELATED ENTITIES (SEE SCHEDULE R) ARE PAID BY IHS. IHS IS RESPONSIBLE FOR ISSUING THE 1099'S TO INDEPENDENT CONTRACTORS, AND SUBSEQUENTLY ALLOCATES A PERCENTAGE OF THE EXPENSE AND RECEIVES REIMBURSEMENT FROM THE RELATED ENTITIES.
FORM 990, PART VIII, LINE 7A, GROSS AMOUNT OF SALES OF SECURITIES
THE ORGANIZATION'S INVESTMENTS ARE HELD IN A POOLED INVESTMENT ACCOUNT MANAGED BY NORTHERN TRUST. REALIZED GAINS AND LOSSES ARE POOLED AND ALLOCATED TO THE PARTICIPANTS. THE INGALLS MEMORIAL HOSPITAL RECEIVES MONTHLY INFORMATION ON THE FUNDS FROM NORTHERN TRUST AND DETERMINES THE TOTAL GAIN OR LOSS AMOUNTS. HOWEVER DETAIL IS NOT PROVIDED.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.