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)
REHABILITATION HOSPITAL OF INDIANA |
351786005 | 3 | Yes | 0 | 30,198 | |
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 |
|---|
| Return Reference | Explanation |
|---|
| Software ID: | 14000329 |
| Software Version: | 2014v1.0 |
Attach to Form 990 or 990-EZ.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at| Return Reference | Explanation |
|---|---|
| CoreFormPartIII_PartIIILine4d Description of other program services | (Expenses $ 37,999 including grants of $) COUPLES CARING AND RELATING WITH EMPATHY-BRAIN INJURY PROGRAM. A SKILLS BASED INTERVENTION TO IMPROVE MARITAL SATIFACTION AND ADJUSTMENT AFTER BRAIN INJURY. THIS IS A 2-YEAR STUDY THAT WILL BE LOOKING AT THE EFFICACY OF DOING A 16 WEEK, SMALL GROUP, MARITAL TREATMENT PROGRAM FOR COUPLES AFTER ONE OF THEM HAS SUSTAINED A BRAIN INJURY (BI). THIS PROGRAM WILL CONSIST OF PSYCHOEDUCATION, IN-SESSION ACTIVITIES, HOMEWORK ACTIVITIES, AND SMALL GROUP INTERVENTION AND WILL BE TAUGHT BY 2 FACILITATORS. THE PROGRAM WILL CONSIST OF COGNITIVE-BEHAVIORAL TREATMENT, DIALECTICAL-BEHAVIORAL TREATMENT, AS WELL AS STANDARD MARRIAGE WORKSHOP-LIKE TRAINING. THE INTERVENTION WILL BE MANUALIZED AND SCRIPTED SO THAT ALL FACILITATORS CAN AT LEAST REVIEW THE SAME CONTENT, EVEN IF THEY USE SLIGHTLY DIFFERENT WORDING. YEAR 1: IN THIS YEAR, WE WILL RUN 2 GROUPS THAT WILL RUN SIMULTANEOUSLY FOR THE 16 WEEKS. THE PURPOSE OF THIS IS TO DO BASELINE TESTING, RUN A FOCUS SESSION AT THE END TO ASK WHAT PEOPLE LIKED OR DIDN'T LIKE ABOUT THE GROUP, AND TO DO POST-INTERVENTION TESTING ON THE 16TH SESSION. MODIFICATIONS WILL BE MADE BASED ON FEEDBACK. YEAR 2: IN THIS YEAR, WE WILL RUN A TX GROUP VS WAIT-LIST CONTROL GROUP FOR 16 WEEKS. WE WILL DO THAT TWICE. ALSO, WE WILL FOLLOW-UP WITH 3 MONTH TESTING. |
| Form 990, Part V, Line 2a NUMBER OF EMPLOYEES REPORTED ON FORM W-3 | THE EMPLOYEE REPORTED HERE WAS PAID BY REHABILITATION HOSPITAL OF INDIANA, A RELATED TAX-EXEMPT ORGANIZATION, FOR SERVICES PROVIDED SOLELY TO RHI FOUNDATION. |
| Form 990, Part VI, Line 15b PROCESS USED TO ESTABLISH COMPENSATION OF OTHER OFFICERS/KEY EMPLOYEES | THE FOUNDATION DOES NOT HAVE ANY OTHER COMPENSATED OFFICERS OR KEY EMPLOYEES. THEREFORE, THIS QUESTION HAS BEEN ANSWERED "NO" IN ACCORDANCE WITH THE FORM 990 INSTRUCTIONS. |
| Form 990, Part VI, Line 1a Delegate broad authority to a committee | The Executive Committee shall consist of not less than four (4) not more than ten (10) members, all of whom must be members of the Foundation's board of director. Members of the Executive Committee shall be appointed by the board of directors. When action is taken by the Executive Committee, it will be reported to the board of directors at its next meeting. The Executive Committee shall have power to transact all regular business of the Foundation during the period between meetings of the board of directors subject to any prior limitation imposed by the board of directors and subject to any limitations imposed by law. |
| Form 990, Part VI, Line 6 Classes of members or stockholders | Rehabilitation Hospital of Indiana is the sole corporate member of the RHI Foundation. The sole corporate member will fill any vacancies on the RHI Foundation board of directors. In addition, some decisions of the governing body require the approval of its sole corporate member. |
| Form 990, Part VI, Line 7a Members or stockholders electing members of governing body | Members of the board of directors are elected an an annual or special meeting of the corporate member, Rehabilitation Hospital of Indiana. In addition, the corporate member, after conferring with the board of directors, annually appoints the Executive Director. |
| Form 990, Part VI, Line 7b Decisions requiring approval by members or stockholders | The following matters require the approval of the corporate member, Rehabilitation Hospital of Indiana: 1. Approve, interpret and change any statement of mission, philosophy, role and purpose of the Foundation. 2. Approve and amend the Bylaws or the Articles of Incorporation of the Foundation. 3. Fix the number of directors of the Foundation. 4. Approve the merger, dissolution, consolidation or reorganization of the Foundation. 5. Approve the formation of other entities by the Foundation. 6. Approve the acquisition, sale, lease, transfer or other alienation of property of the Foundation, other than in the usual and regular course of the Foundation's business, when such acquisition, sale, lease, transfer or other alienation is above specified financial levels set in accordance with policies established from time to time by the Corporate Member. 7. Approve capital and operating budgets of the Foundation. 8. Approve debt incurred by the Foundation which is in excess of such limits as are established by the Corporate Member. 9. Approve the disposition of the assets of the Foundation at the time of its dissolution. 10. Establish policy concerning quality of care and services or establish policy and procedures concerning finance and resources for the Foundation, which are inconsistent with policies established by the Corporate Member. 11. Approve the long-range financial and strategic plans for the Foundation. 12. Approve an internal auditing program for the Foundation which is consistent with the internal auditing program established by the Corporate Member. 13. Appoint and remove the Executive director of the Foundation, provided, however, that the corporate member shall confer with the board of directors concerning the appointment of removal of the executive director. 14. Approve the criteria and the process for the evaluation of the Executive Director of the Foundation. 15. Take any action which would be inconsistent with the governing documents or policies of the Corporate Member. |
| Form 990, Part VI, Line 11b Review of form 990 by governing body | A DETAILED REVIEW IS PERFOMED BY MANAGEMENT AND A REPRESENTATIVE FROM MAJORITY OWNER MEMBER ORGANIZATION OF REHABILITATION HOSPITAL OF INDIANA (A RELATED TAX-EXEMPT ORGANIZATION). THEN A FINAL DRAFT IS SENT TO THE BOARD OF DIRECTORS PRIOR TO FILING WITH THE IRS. |
| Form 990, Part VI, Line 12c Conflict of interest policy | All board members are required to complete a conflict of interest form annually. The executive director of the foundation and the chairman of the board review the conflict of interest forms. If a board member has a conflict regarding an issue at hand, then that member would remove themselves from both the discussion and voting on the conflicted item. In the event the board member failing to remove themselves from the conflicting issue, the board member would be asked to recuse themselves from the discussion and vote. |
| Form 990, Part VI, 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. As such, these documents are not available to the public at this time. |
| Form 990, Part IX, Line 11g Other Fees | CONSULTING - Total Expense: 186705, Program Service Expense: 180510, Management and General Expenses: 6195, Fundraising Expenses: ; |
| Software ID: | 14000329 |
| Software Version: | 2014v1.0 |