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
St Clair Health Corporation Group Return
Employer identification number
61-1663540
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)
St Clair Memorial Hospital
251010303
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.") ....
1,551,422
1,104,721
1,900,639
1,815,833
2,093,727
8,466,342
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
1,551,422
1,104,721
1,900,639
1,815,833
2,093,727
8,466,342
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)..
2,762,180
6
Public support. Subtract line 5 from line 4.
5,704,162
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..
1,551,422
1,104,721
1,900,639
1,815,833
2,093,727
8,466,342
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
212,890
253,610
263,329
302,071
318,522
1,350,421
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).
9,816,763
12
Gross receipts from related activities, etc. (see instructions)
..................
12
1,132,778
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
58.110 %
15
Public support percentage for 2012 Schedule A, Part II, line 14
...............
15
54.390 %
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:
Software Version:
-
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
St Clair Health Corporation Group Return
Employer identification number
61-1663540
Return Reference
Explanation
Form 990, Part VI, Section A, line 2
Board members Don Jenkins, Gary Zentner and Bryan Hondru each hold greater than 10% of interest in the same non-St Clair related real estate investment partnership.
Form 990, Part VI, Section A, line 6
- St. Clair Memorial Hospital, St. Clair Memorial Hospital Foundation, and St. Clair Medical Services do not have members or stockholders. St. Clair Medical Services is the sole member of St. Clair Anesthesiology Associates and St. Clair Professional Services.
Form 990, Part VI, Section A, line 7a
- According to the governing documents of St. Clair Memorial Hospital and St. Clair Memorial Hospital Foundation, St. Clair Health Corporation, as the parent company, has the power to approve the election or nomination of the board of directors of such organizations. St. Clair Anesthesiology Associates and St. Clair Professional Services are governed by the board of directors of St. Clair Medical Services.
Form 990, Part VI, Section A, line 7b
According to the governing documents of St. Clair Memorial Hospital and St. Clair Memorial Hospital Foundation, St. Clair Health Corporation, as the parent company of such organizations, has the power to make or approve certain decisions of such organizations including approval of the sale or encumberance of a substantial amount of assets, the approval of annual operating and capital budgets, and the approval of strategic plans.
Form 990, Part VI, Section B, line 11
(b) - This Form 990 is prepared internally, reviewed by management, and reviewed by a third-party accounting firm, Ernst & Young LLP. The draft Form 990 is provided to each board member for review via a secure website prior to filing.
Form 990, Part VI, Section B, line 12c
Conflicts are monitored through an annual survey completed by Board Members and Officers. Enforcements of the corporations policies are managed by the CEO and Board Members, to whom all conflicts are reported. The Director of Compliance also manages enforcement of St. Clair Hospital policies. To the extent any conflicts are identified, such Board members or Officers are excluded from participating in the relative decision making process.
Form 990, Part VI, Section B, line 15
(a & b) - A subcommittee of the Board of Directors of St. Clair Health Corporation, the parent of St. Clair Memorial Hospital, St. Clair Memorial Foundation and St. Clair Medical Services, serves as the executive compensation committee and is charged with annually evaluating, determining and approving the annual compensation of executives. Salary survey information and 990 comparative evaluations are considered along with the written performance evaluations for each executive. In addition, data provided by an independent compensation consultant is used to validate and support executive compensation.
Form 990, Part VI, Section C, line 19
Governing documents, conflict of interest policy and financial statements are made available to the public upon request.
Form 990, Part XI, line 9:
Change in pension liability 3,342,434. Transfer (to)/from affiliates 941,526. Investment income 7. Contributions 106,584. Grants received -174,184. Assets released from restriction for operations -27,124. Other increases / (decreases) -710,125.
Form 990, Part IV, Line 2
St. Clair Memorial Hospital receives and reports amounts exceeding $5,000 from any one contributor, and St. Clair Memorial Hospital Foundation receives and reports amounts exceeding the 2% special rule threshold from any one contributor.
Form 990, Part IV, Line 4
St. Clair Hospital is engaged in lobbying activities and has properly reported the allowable costs on Schedule C.
Form 990, Part IV, Line 10
St. Clair Memorial Hospital and St. Clair Memorial Hospital Foundation hold assets in term, permanent, or endowments and have properly reported on Schedule D, Part V.
Form 990, Part IV, Line 18
St. Clair Foundation's gross receipts from fundraising events exceeded $15,000 and have been properly included in Schedule G, Part II.
Form 990, Part IV, Line 20
St. Clair Memorial Hospital operates one hospital and has properly completed Schedule H.
Form 990, Part IV, Line 24a
St. Clair Hospital has tax-exempt bond issues exceeding $100,000 issued after December 31, 2002 and have properly reported on Schedule K.
Form 990, Part V, Line 3a.
St. Clair Memorial Hospital recorded more than $1,000 in unrelated gross business income.
Form 990, Part V, Line 3b.
St. Clair Memorial Hospital has filed a 990-T to report unrelated gross business income.
Form 990, Part V, Line 7a.
St. Clair Memorial Hospital Foundation provided goods or services in exchange for a contribution more than $75. The Foundation notified the donor of the value.
Schedule B, Contributions covered by General or Special Rule
The organizations comprising St. Clair Health Corp Group return are covered by both the General Rule and Special Rule. - St. Clair Memorial Hospital - General Rule - St. Clair Professional Services, Inc. - General Rule - St. Clair Anesthesiology Associates, Inc. - General Rule - St. Clair Medical Services, Inc. - General Rule - St. Clair Memorial Hospital Foundation - Special Rule
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.