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...... | 2,247,670 | 2,092,412 | 2,199,091 | 2,228,318 | 2,307,696 | 11,075,187 |
| 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. | 2,247,670 | 2,092,412 | 2,199,091 | 2,228,318 | 2,307,696 | 11,075,187 |
| 7a | Amounts included on lines 1, 2, and 3 received from disqualified persons... | 0 | |||||
| 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. | 0 | |||||
| c | Add lines 7a and 7b.. | 0 | |||||
| 8 | Public support (Subtract line 7c from line 6.) | 11,075,187 | |||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | 2,247,670 | 2,092,412 | 2,199,091 | 2,228,318 | 2,307,696 | 11,075,187 |
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | 4,140 | 5,968 | 2,357 | 2,241 | 1,860 | 16,566 |
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | ||||||
| c | Add lines 10a and 10b. | 4,140 | 5,968 | 2,357 | 2,241 | 1,860 | 16,566 |
| 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.).. | 2,251,810 | 2,098,380 | 2,201,448 | 2,230,559 | 2,309,556 | 11,091,753 |
| 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 |
|---|
| Return Reference | Explanation |
|---|
| 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 VI, SECTION A, LINE 1 | THE BOARD OF DIRECTORS, BY RESOLUTION ADOPTED BY A MAJORITY OF THE DIRECTORS IN OFFICE, MAY DESIGNATE AND APPOINT ONE OR MORE COMMITTEES, EACH OF WHICH SHALL CONSIST OF TWO OR MORE DIRECTORS, WHICH COMMITTEES, TO THE EXTENT PROVIDED IN SAID RESOLUTION, SHALL HAVE AND EXERCISE THE AUTHORITY OF THE BOARD OF DIRECTORS IN THE MANAGEMENT OF THE CORPORATION, EXCEPT THAT NO SUCH COMMITTEE SHALL HAVE THE AUTHORITY OF THE BOARD OF DIRECTORS IN REFERENCE TO AMENDING, ALTERING, OR REPEALING THE BYLAWS; ELECTING, APPOINTING OR REMOVING ANY SUCH COMMITTEE OR ANY DIRECTOR OR OFFICER OF THE CORPORATION; AMENDING THE ARTICLES OF INCORPORATION; RESTATING ARTICLES OF INCORPORATION; ADOPTING A PLAN OF MERGER OR ADOPTING A PLAN OF CONSOLIDATION WITH ANOTHER CORPORATION; AUTHORIZING THE SALE, LEASE, EXCHANGE OR MORTGAGE OF ALL OR SUBSTANTIALLY ALL OF THE PROPERTY AND ASSETS OF THE CORPORATION; AUTHORIZING THE VOLUNTARY DISSOLUTION OF THE CORPORATION OR REVOKING PROCEEDINGS THEREFOR; ADOPTING A PLAN FOR THE DISTRIBUTION OF THE ASSETS OF THE CORPORATION; OR AMENDING, ALTERING OR REPEALING ANY RESOLUTION OF THE BOARD OF DIRECTORS WHICH BY ITS TERMS PROVIDES THAT IT SHALL NOT BE AMENDED, ALTERED OR REPEALED BY SUCH COMMITTEE. THE DESIGNATION AND APPOINTMENT OF ANY SUCH COMMITTEE AND THE DELEGATION THERETO OF AUTHORITY SHALL NOT OPERATE TO RELIEVE THE BOARD OF DIRECTORS, OR ANY INDIVIDUAL DIRECTOR, OF ANY RESPONSIBILITY IMPOSED UPON HIM BY LAW. |
| FORM 990, PART VI, SECTION A, LINE 6 | PER THE ORGANIZATION'S BY-LAWS, THERE SHALL BE TWO MEMBERS: CGH MEDICAL CENTER AND KATHERINE SHAW BETHEA HOSPITAL. |
| FORM 990, PART VI, SECTION A, LINE 7A | THE GOVERNING BODY CONSISTS OF FIVE DIRECTORS, TWO OF WHICH ARE CHOSEN BY THE BOARD OF DIRECTORS OF CGH MEDICAL CENTER AND TWO OF WHICH ARE CHOSEN BY THE KATHERINE SHAW BETHEA HOSPITAL. THE FIFTH DIRECTOR IS DETERMINED BASED UPON DISCUSSION OF THE OTHER FOUR DIRECTORS WITH A MAJORITY VOTE OF THOSE FOUR REQUIRED TO APPROVE THE FIFTH DIRECTOR. |
| FORM 990, PART VI, SECTION A, LINE 7B | ALL OF ARTICLE I, SECTIONS 3, 9 AND 11 OF ARTICLE IV, ALL OF ARTICLE V, ALL OF ARTICLE X AND ARTICLE XVI, MAY ONLY BE ALTERED, AMENDED OR REPEALED BY NEW BY-LAWS APPROVED BY THE BOARD OF DIRECTORS OF KATHERINE SHAW BETHEA HOSPITAL AND THE BOARD OF DIRECTORS OF CGH MEDICAL CENTER. NO OFFICES OR SERVICE CENTERS MAY BE ESTABLISHED OR ELIMINATED WITHOUT THE PRIOR WRITTEN APPROVAL OF THE BOARD OF DIRECTORS OF BOTH KATHERINE SHAW BETHEA HOSPITAL AND CGH MEDICAL CENTER. |
| FORM 990, PART VI, SECTION B, LINE 11 | A DRAFT COPY OF FORM 990 IS REVIEWED BY THE EXECUTIVE DIRECTOR AND THE TREASURER OF THE BOARD PRIOR TO FILING. ALL OTHER BOARD MEMBERS ARE NOTIFIED THAT FORM 990 IS AVAILABLE FOR THEIR REVIEW IF THEY WOULD LIKE TO REVIEW IT. IF CHANGES ARE NECESSARY, THEY ARE REPORTED TO THE RETURN PREPARER AND INCORPORATED INTO THE FINAL RETURN. |
| FORM 990, PART VI, SECTION B, LINE 12C | ANY POSSIBLE CONFLICT OF INTEREST ON THE PART OF A DIRECTOR SHALL BE DISCLOSED TO THE BOARD. WHEN ANY SUCH INTEREST BECOMES A MATTER OF BOARD ACTION, SUCH DIRECTOR SHALL NOT VOTE OR USE PERSONAL INFLUENCE ON THE MATTER, AND SHALL NOT BE COUNTED IN THE QUORUM FOR A MEETING AT WHICH THE BOARD ACTION IS TO BE TAKEN ON THE MATTER. THE DIRECTOR MAY, HOWEVER, BRIEFLY STATE A POSITION ON THE MATTER, AND ANSWER PERTINENT QUESTIONS OF THE BOARD MEMBERS. THE MINUTES OF ALL ACTIONS TAKEN ON SUCH MATTER CLEARLY DOCUMENT THAT THESE REQUIREMENTS HAVE BEEN MET. |
| FORM 990, PART VI, SECTION B, LINE 15 | ALL WAGE/SALARY RANGES ARE RESEARCHED AND COMPARED TO SELECTED COMPENSATION SURVEY DATA TO DETERMINE REQUIRED MARKET ADJUSTMENTS. POSITION DESCRIPTIONS MUST BE MAINTAINED ON A CURRENT BASIS AND WILL BE USED AS A BASIS OF COMPARISON TO MARKET DATA. THIS PROCESS WILL TAKE PLACE AT LEAST ONCE PER YEAR. ADDITIONAL COMPARISONS WILL BE CONDUCTED ANY TIME THE MARKETPLACE INDICATES PRESSURE ON KEY POSITIONS. OVERALL MARKET ADJUSTMENTS ARE EFFECTIVE THE FIRST FULL PAY OF JULY OF EACH YEAR, WITH ADDITIONAL ADJUSTMENTS MADE AS CONDITIONS SO WARRANT. COMPENSATION FOR THE CORPORATION'S DIRECTOR IS APPROVED BY THE BOARD. THE BOARD REVIEWS THE EXECUTIVE DIRECTOR'S SALARY ANNUALLY AND SETS IT. |
| 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. |
| FORM 990, PART IX, LINE 24E | COLLECTION FEES: PROGRAM SERVICE EXPENSES 13,219. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 13,219. EQUIPMENT RENTAL: PROGRAM SERVICE EXPENSES 12,775. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 12,775. |
| FORM 990, PART XII, LINE 2C: | PROCESS HAS NOT CHANGED FROM PRIOR YEAR. |
| Software ID: | |
| Software Version: |