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 | |||||
| Total | ||||||
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. |
||||
| 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 | THE ORGANIZATION DECLARED BANKRUPCY ON JANUARY 31, 2014 AND IS IN THE PROCESS OF LIQUDATING. AS OF THE DATE OF THE BANKRUPCY THE ORGANIZATION CEASED OPERATIONS AND TURNED OVER ALL ASSETS TO THE BANKRUPCY TRUSTEE COHNREZNICK LLP FOR LIQUIDATION. |
| FORM 990, PART VI, SECTION A, LINE 6 | ST. FRANCIS HOSPITAL HAS A SINGLE MEMBER, HASTINGS HEALTH SYSTEMS, INC. THE ORGANIZATION DECLARED BANKRUPCY ON JANUARY 31, 2014 AND IS IN THE PROCESS OF LIQUDATING. AS OF THE DATE OF THE BANKRUPCY THE ORGANIZATION CEASED OPERATIONS AND TURNED OVER ALL ASSETS TO THE BANKRUPCY TRUSTEE COHNREZNICK LLP FOR LIQUIDATION. |
| FORM 990, PART VI, SECTION A, LINE 7A | HASTINGS HEALTH SYSTEM, INC. AS THE SOLE MEMBER OF THE CORPORATION SHALL ELECT QUALIFIED PERSONS TO THE BOARD OF TRUSTEES AT ITS ANNUAL MEETING IN ACCORDANCE WITH THE PROVISIONS OF THE ORGANIZATION'S BY-LAWS. THE ORGANIZATION DECLARED BANKRUPCY ON JANUARY 31, 2014 AND IS IN THE PROCESS OF LIQUDATING. AS OF THE DATE OF THE BANKRUPCY THE ORGANIZATION CEASED OPERATIONS AND TURNED OVER ALL ASSETS TO THE BANKRUPCY TRUSTEE COHNREZNICK LLP FOR LIQUIDATION. |
| FORM 990, PART VI, SECTION A, LINE 7B | HASTINGS HEALTH SYSTEM, INC. AS THE SOLE MEMBER OF THE CORPORATION, SHALL CONSIDER THE ANNUAL REPORT OF THE CORPORATION AT ITS ANNUAL MEETING, TO BE SUBMITTED AND VERIFIED BY THE PRESIDENT AND THE TREASURER OR A MAJORITY OF THE TRUSTEES. THE FOLLOWING POWERS ARE RESERVED EXCLUSIVELY TO THE MEMBER, AND NO ATTEMPTED EXERCISE OF ANY SUCH POWERS BY ANYONE OTHER THAN THE MEMBER SHALL BE VALID OR OF ANY FORCE OR EFFECT WHATSOEVER: 1. TO CHANGE THE PHILOSOPHY, MISSION, AND PURPOSE OF THE CORPORATION; 2. TO ADOPT AND/OR AMEND THE CERTIFICATE OF INCORPORATION; 3. TO ADOPT AND/OR AMEND BYLAWS, 4. TO ELECT THE BOARD OF TRUSTEES AND TO REMOVE BOARD MEMBERS WITH OR WITHOUT CAUSE; 5. TO APPOINT THE PRESIDENT AND CHIEF EXECUTIVE OFFICER OF THE ORGANIZATION; 6. TO APPROVE THE PURCHASE, SALE, LEASE, MORTGAGE OR REAL PROPERTY; TO APPROVE THE PURCHASE, SALE, OR GIFT OF CAPITAL ASSETS; 7. TO APPROVE THE MERGER, CONSOLIDATION, OR AFFILIATION OF THE CORPORATION WITH ANOTHER CORPORATION, ORGANIZATION, OR PROGRAM; 8. TO APPROVE THE DISSOLUTION OF THE CORPORATION AND DISPOSITION OF ASSETS. THE ORGANIZATION DECLARED BANKRUPCY ON JANUARY 31, 2014 AND IS IN THE PROCESS OF LIQUDATING. AS OF THE DATE OF THE BANKRUPCY THE ORGANIZATION CEASED OPERATIONS AND TURNED OVER ALL ASSETS TO THE BANKRUPCY TRUSTEE COHNREZNICK LLP FOR LIQUIDATION. |
| FORM 990, PART VI, SECTION B, LINE 11 | THE RETURN IS PREPARED BY THE ACCOUNTING FIRM AND REVIEWED BY THE PLAN ADMINISTRATOR. DUE TO TIME CONSTRAINTS THE RETURN WILL NOT BE PROVIDED TO THE BOARD. |
| FORM 990, PART VI, SECTION B, LINE 12C | ALL MEMBERS OF THE HOSPITAL'S BOARD OF TRUSTEES, AS WELL AS ALL OFFICERS AND EMPLOYEES MUST ANNUALLY FILE A CONFLICT OF INTEREST DISCLOSURE STATEMENT WITH THE HOSPITAL'S COMPLIANCE OFFICER, WHO SHALL KEEP A CONFIDENTIAL FILE OF THESE STATEMENTS AND CONSULT WITH OUTSIDE COUNSEL, AS NECESSARY, CONCERNING ANY POTENTIAL PROBLEMS OR POSSIBLE CONFLICTS OF INTEREST. THE COMPLIANCE OFFICER WILL REVIEW ANY DISCLOSURE (INCLUDING BOARD MEMBERS AND OTHER PERSONNEL COVERED BY THIS POLICY), CONSULT WITH COUNSEL AS NECESSARY, AND DETERMINE IF SUCH FINANCIAL INTEREST OR OUTSIDE RELATIONSHIP CREATES A CONFLICT OF INTEREST, IS IMPROPER, OR CREATES THE APPEARANCE OF A CONFLICT OF INTEREST OR OF IMPROPER CONDUCT. THE COMPLIANCE OFFICER WILL ALSO REVIEW THE INFORMATION TO DETERMINE IF ADDITIONAL DISCLOSURES OR OTHER ACTION IS NECESSARY. FULL DISCLOSURE AND RECOMMENDATIONS WILL THEN BE MADE TO THE AUDIT AND COMPLIANCE COMMITTEE OF THE BOARD OF TRUSTEES AS TO THE APPROPRIATE COURSE OF CONDUCT OR CORRECTIVE ACTION FOR THE HOSPITAL AND FOR THE PERSONNEL INVOLVED. ONCE A FINAL DECISION IS MADE ON HOW TO PROCEED, THE PERSONNEL WILL BE INSTRUCTED AS TO THE COURSE OF ACTION DECIDED UPON. |
| FORM 990, PART VI, SECTION B, LINE 15 | THE EXECUTIVE COMMITTEE SERVES AS THE COMPENSATION COMMITTEE FOR DURING AN ANNUAL EVALUATION OF THE PRESIDENT AND CEO. THE COMMITTEE UTILIZES SURVEY DATA TO DETERMINE COMPARABILITY FOR COMPENSATION. COMPENSATION OF OTHER OFFICERS AND KEY EMPLOYEES IS DETERMINED BY THE CEO, WITH CONSULTATION AND RECOMMENDATIONS FROM THE EXECUTIVE COMMITTEE. SURVEY DATA IS UTILIZED IN CONJUNCTION WITH THE STANDARD HOSPITAL ANNUAL EMPLOYEE APPRAISAL PROCESS. COMPENSATION DECISIONS AND REPORTS ARE CONTEMPORANEOUSLY DOCUMENTED IN THE MINUTES OF THE MEETING OF THE COMMITTEE WHEN THE DECISIONS ARE MADE. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST AS DEEMED APPROPRIATE. GENERAL INFORMATION REGARDING GOVERNANCE, COMPLIANCE, AND FINANCIAL REPORTING IS MADE AVAILABLE TO THE PUBLIC ON THE HOSPITAL'S WEBSITE, THROUGH ANNUAL COMMUNITY BENEFIT REPORTS, AND ANNUAL PUBLICATION OF THE ST. FRANCIS MAGAZINE. |
| FORM 990, PART IX, LINE 11G | OTHER PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 152,933. MANAGEMENT AND GENERAL EXPENSES 16,992. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 169,925. BANKRUPTCY PROFESSIONALS: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 7,765,930. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 7,765,930. MEDICAL PROFESSIONALS: PROGRAM SERVICE EXPENSES 1,570,162. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,570,162. |
| FORM 990, PART XI, LINE 9: | NET ASSETS TRANSFERRED -7,992,504. |
| FROM 990 PART IV | THIS RETURN HAS BEEN PREPARED BASED ON ALL AVAILABLE INFORMATION AT THE TIME OF FILING. ON JANUARY 31, 2014, THE ORGANIZATION DECLARED BANKRUPTCY. AT THE TIME OF FILING THIS TAX RETURN THE INFORMATION REQUIRED TO COMPLETE CERTAIN SCHEDULES WAS NOT AVAILABLE AS THE COMPANY WAS IN THE PROCESS OF LIQUIDATING. IF THE INFORMATION DOES BECOME AVAILABLE THE ORGANIZATION WILL AMEND FORM 990 TO INCLUDE THE APPROPRIATE SCHEDULES. |
| FROM 990 PART IV, LINE 20A: | THE ORGANIZATION DID OPERATE A HOSPITAL DURING 2014. HOWEVER, ON JANUARY 31, 2014, THE ORGANIZATION DECLARED BANKRUPTCY. AT THE TIME OF FILING THIS TAX RETURN THE INFORMATION REQUIRED TO COMPLETE SCHEDULE H WAS NOT AVAILABLE AS THE COMPANY WAS IN THE PROCESS OF LIQUIDATING. IF THE INFORMATION DOES BECOME AVAILABLE THE ORGANIZATION WILL AMEND FORM 990 TO INCLUDE THE APPROPRIATE SCHEDULE H. |
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| Software Version: |