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 LUKE'S HEALTH INITIATIVES
Employer identification number
86-0097240
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)
ADELANTE HEALTHCARE
860377821
7
No
Yes
Yes
10,000
(B)
ALHAMBRA SCHOOL DISTRICT
866000534
7
No
Yes
Yes
23,100
(C)
AMERICAN ACADEMY OF PEDIATRICS- ARIZONA FOUNDATION
860917603
7
No
Yes
Yes
7,700
(D)
AREA AGENCY ON AGING
742371957
7
No
Yes
Yes
44,745
(E)
ARIZONA CENTER FOR THE BLIND AND VISUALLY IMPAIRED
860133392
7
No
Yes
Yes
62,870
(F)
ARIZONA COMMUNITY FOUNDATION
860348306
7
No
Yes
Yes
10,000
(G)
ARIZONA GRANTMAKERS FORUM
861040394
7
No
Yes
Yes
6,000
(H)
ARIZONA HOUSING ALLIANCE
263711600
7
No
Yes
Yes
5,000
(I)
ARIZONA PUBLIC HEALTH ASSOCIATION
510198821
7
No
Yes
Yes
5,000
(J)
CENTER FOR THE FUTURE OF ARIZONA-AZ WE WANT
820538372
7
No
Yes
Yes
50,000
(K)
CIRCLE THE CITY
262420730
7
No
Yes
Yes
125,000
(L)
COMMUNITY HEARING AID PROGRAM
261172753
7
No
Yes
Yes
28,750
(M)
CROSSROADS
860182987
7
No
Yes
Yes
17,000
(N)
DESERT MISSION (BOV)
860096941
7
No
Yes
Yes
50,000
(O)
DISCOVERY TRIANGLE - FRESH EXPRESS
272255896
7
No
Yes
Yes
25,000
(P)
EAR FOUNDATION OF ARIZONA
860822784
7
No
Yes
Yes
157,000
(Q)
EAST VALLEY SENIOR SVCS (MESA SENIOR SVCS)
942596075
7
No
Yes
Yes
10,000
(R)
FOUNDATION FOR BLIND CHILDREN
860129981
7
No
Yes
Yes
37,050
(S)
HON KACHINA
860917041
7
No
Yes
Yes
50,000
(T)
HOSPICE OF THE VALLEY
860338886
7
No
Yes
Yes
110,000
(U)
INTERNATIONAL RESCUE COMMITTEE
135660870
7
No
Yes
Yes
125,000
(V)
NATIONAL COUNCIL ON ALCOHOLISM & DRUG DEPENDENCE
860208873
7
No
Yes
Yes
11,850
(W)
NEIGHBORHOOD CHRISTIAN CLINIC (BOV)
860839580
7
No
Yes
Yes
41,000
(X)
SOCIAL ENTERPRISES - GO GREEN PHOENIX
202665380
7
No
Yes
Yes
5,000
(Y)
SOCIETY OF ST VINCENT DE PAUL
860096789
7
No
Yes
Yes
68,735
(Z)
TAPI
454185015
7
No
Yes
Yes
125,000
(AA)
TECHNICAL ASSISTANCE PARTERSHIP - ARIZONA
860872126
7
Yes
Yes
Yes
40,000
Total
1,250,800
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:
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 LUKE'S HEALTH INITIATIVES
Employer identification number
86-0097240
Return Reference
Explanation
FORM 990, PART VI, SECTION A, LINE 7A
AT LEAST HALF OF ALL BOARD MEMBERS MUST BE ELECTED OR APPOINTED BY TAP-AZ, A SUPPORTED ORGANIZATION.
FORM 990, PART VI, SECTION B, LINE 11
THE ORGANIZATION'S AUDIT COMMITTEE AND BOARD OF DIRECTORS REVIEW AND APPROVE THE FORM 990 BEFORE IT IS FILED.
FORM 990, PART VI, SECTION B, LINE 12C
THE ORGANIZATION HAS A WRITTEN CONFLICT OF INTEREST POLICY. THE POLICY REQUIRES A WRITTEN DISCLOSURE AND SIGNATURE FROM ALL MEMBERS OF THE BOARD OF TRUSTEES AND ALL EMPLOYEES ON AN ANNUAL BASIS, AND AS CONFLICTS ARISE. THE FORM REQUIRES THAT THOSE COMPLETING THE FORM DISCLOSE CONFLICTS, IF ANY. THE FORMS ARE COLLECTED AT THE TIME OF THE ANNUAL BOARD OF TRUSTEES MEETING. ANY CONFLICTS DISCLOSED ARE DISCUSSED BY THE BOARD.
FORM 990, PART VI, SECTION B, LINE 15
A COMMITTEE OF THE BOARD OF TRUSTEES, THE EXECUTIVE COMMITTEE, DETERMINES THE ANNUAL COMPENSATION OF THE CEO. THE EXECUTIVE COMMITTEE MAKES THE DETERMINATION BASED ON COMPARABILITY DATA FROM FORMS 990 OF OTHER ORGANIZATIONS AND COMPENSATION STUDIES. THEY ALSO HIRE AN INDEPENDENT CONSULTANT EVERY 3 YEARS TO ASSIST IN DETERMINING THE COMPENSATION. THE EXECUTIVE COMMITTEE REPORTS THE INFORMATION TO THE BOARD OF TRUSTEES ANNUALLY.
FORM 990, PART VI, SECTION C, LINE 19
THE ORGANIZATION'S AUDITED FINANCIAL STATEMENTS, FORM 990, AND ANNUAL REPORT ARE AVAILABLE ON THE ORGANIZATION'S WEBSITE. THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE ALSO MADE AVAILABLE TO THE PUBLIC UPON REQUEST.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.