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.") . | 82,000 | 142,376 | 184,546 | 118,019 | 526,941 | |
| 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...... | 19,368,139 | 20,110,647 | 21,061,880 | 19,900,300 | 24,755,655 | 105,196,621 |
| 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. | 19,450,139 | 20,110,647 | 21,204,256 | 20,084,846 | 24,873,674 | 105,723,562 |
| 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.) | 105,723,562 | |||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | 19,450,139 | 20,110,647 | 21,204,256 | 20,084,846 | 24,873,674 | 105,723,562 |
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | 845,485 | 806,239 | 719,642 | 848,837 | 849,420 | 4,069,623 |
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | ||||||
| c | Add lines 10a and 10b. | 845,485 | 806,239 | 719,642 | 848,837 | 849,420 | 4,069,623 |
| 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.) .. | 335,636 | 376,034 | 373,177 | 419,549 | 298,271 | 1,802,667 |
| 13 | Total support. (Add lines 9, 10c, 11, and 12.).. | 20,631,260 | 21,292,920 | 22,297,075 | 21,353,232 | 26,021,365 | 111,595,852 |
| Section A - Adjusted Net Income | (A) Prior Year |
(B) Current Year (optional) |
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| 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 |
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|
2
Underdistributions, if any, for years prior to 2014 (reasonable cause required--see instructions) |
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| 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) |
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|
6
Remaining underdistributions for 2014. Subtract lines 3h and 4b from line 1 (if amount greater than zero, see instructions) |
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|
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 |
|---|---|
| SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: | A/P DISCOUNTS - 2010 AMOUNT: $ 2,494. 2014 AMOUNT: $ 72. TELEPHONE REVENUE - 2010 AMOUNT: $ 66,042. 2011 AMOUNT: $ 42,293. 2012 AMOUNT: $ 58,043. 2013 AMOUNT: $ 66,344. 2014 AMOUNT: $ 67,289. CAFE/DINING REVENUE - 2010 AMOUNT: $ 128,766. 2011 AMOUNT: $ 139,157. 2012 AMOUNT: $ 155,323. 2013 AMOUNT: $ 159,971. 2014 AMOUNT: $ 178,628. RESIDENT SERVICES - 2010 AMOUNT: $ 11,400. 2011 AMOUNT: $ 11,400. 2013 AMOUNT: $ 11,400. 2014 AMOUNT: $ 11,400. INSURANCE PROCEEDS - 2010 AMOUNT: $ 126,384. 2012 AMOUNT: $ 23,517. MISCELLANEOUS REVENUE - 2010 AMOUNT: $ 550. 2011 AMOUNT: $ 561. 2013 AMOUNT: $ 181,834. 2014 AMOUNT: $ 40,882. CATERING - RELATED PARTY - 2011 AMOUNT: $ 145,461. 2012 AMOUNT: $ 136,294. BAD DEBT RECOVERY - 2011 AMOUNT: $ 37,162. |
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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 6 | MATHER HEALTH SYSTEM INC. IS THE MEMBER OF THE CORPORATION. THE MEMBER APPROVES THE ELECTION AND REMOVAL OF MEMBERS OF THE BOARD OF DIRECTORS, THE AMENDMENT OF THE PURPOSES, CERTIFICATE OF INCORPORATION OR BYLAWS OF THE CORPORATION, THE SALE, ASSIGNMENT OR DISPOSAL OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF THE CORPORATION, THE FORMATION OR PURCHASE OF A RELATED ENTITY OR CORPORATION. |
| FORM 990, PART VI, SECTION A, LINE 7A | AS SOLE MEMBER OF THE CORPORATION, MATHER HEALTH SYSTEM, INC. APPROVES THE ELECTION AND REMOVAL OF MEMBERS OF THE BOARD OF DIRECTORS. |
| FORM 990, PART VI, SECTION A, LINE 7B | AS SOLE MEMBER OF THE CORPORATION, MATHER HEALTH SYSTEM, INC. APPROVES THE AMENDMENT OF THE PURPOSES, CERTIFICATE OF INCORPORATION OR BYLAWS OF THE CORPORATION; THE SALE, ASSIGNMENT OR DISPOSAL OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF THE CORPORATION; AND THE FORMATION OR PURCHASE OF A RELATED ENTITY OR CORPORATION. |
| FORM 990, PART VI, SECTION B, LINE 11 | A FINAL COPY OF THE FORM 990 AND ALL REQUIRED SCHEDULES ARE PRESENTED TO THE BOARD OF DIRECTORS PRIOR TO ITS FILING. |
| FORM 990, PART VI, SECTION B, LINE 12C | CONFLICT OF INTEREST POLICY STATEMENT- OFFICERS, DIRECTORS AND KEY EMPLOYEES OF THE ORGANIZATION WILL, AT LEAST ANNUALLY, FILE A CONFLICT OF INTEREST DISCLOSURE STATEMENT/QUESTIONNAIRE WITH THE COMPLIANCE OFFICER. PERSONNEL SHALL DISCLOSE ALL SITUATIONS THAT POSE A POTENTIAL OR ACTUAL CONFLICT OF INTEREST. PERSONNEL HAVE AN AFFIRMATIVE OBLIGATION TO UPDATE THEIR ANNUAL DISCLOSURE STATEMENT/QUESTIONNAIRE WHENEVER NEW INFORMATION ARISES WHICH IS OTHERWISE REQUIRED TO BE DISCLOSED IN THE ANNUAL DISCLOSURE STATEMENT/QUESTIONNAIRE BY COMPLETING A NEW DISCLOSURE STATEMENT/QUESTIONNAIRE AND PROVIDING IT TO THE COMPLIANCE OFFICER. THE COMPLIANCE OFFICER WILL REVIEW DISCLOSURE STATEMENTS/QUESTIONNAIRES IN LIGHT OF THE PRINCIPLES SET FORTH IN THE CONFLICT OF INTEREST POLICY, CONSULT WITH OUTSIDE COUNSEL AS NECESSARY, SEEK ADDITIONAL INFORMATION AS NECESSARY, AND DETERMINE IF THE INFORMATION DISCLOSED CREATES A CONFLICT OF INTEREST, IS IMPROPER, OR CREATES THE APPEARANCE OF A CONFLICT OF INTEREST OR OF IMPROPER CONDUCT. THE COMPLIANCE COMMITTEE WILL REVIEW THE COMPLIANCE OFFICER'S REPORTS ANNUALLY AND ON A PERIODIC BASIS, AND CONDUCT ITS OWN REVIEW, AS NECESSARY, TO DETERMINE WHETHER A POTENTIAL OR ACTUAL CONFLICT OF INTEREST EXISTS. IF THE COMMITTEE DETERMINES THAT IT NEEDS TO CONDUCT A FURTHER REVIEW, THE CHAIRMAN OF THE COMPLIANCE COMMITTEE MAY APPOINT AN AD HOC COMMITTEE COMPRISED OF BOARD MEMBERS AND THE COMPLIANCE OFFICER TO REVIEW A PARTICULAR MATTER AND MAKE A RECOMMENDATION TO THE COMPLIANCE COMMITTEE. THE COMPLIANCE OFFICER AND OUTSIDE COUNSEL SHALL ASSIST THE COMPLIANCE COMMITTEE, WHICH SHALL REPORT ITS RECOMMENDATION AND FINDINGS TO THE ENTIRE BOARD OF DIRECTORS. THE BOARD OF DIRECTORS SHALL REVIEW THE RECOMMENDATION AND FINDINGS OF THE COMPLIANCE COMMITTEE AND MAKE ITS FINDINGS WHICH SHALL BE FINAL AND BINDING. |
| FORM 990, PART VI, SECTION B, LINE 15 | THE ORGANIZATION ENGAGES WITH AN OUTSIDE CONSULTANT TO PREPARE A COMPENSATION REVIEW OF MANAGEMENT, INCLUDING THE CEO AND THE HEALTH CENTER ADMINISTRATOR. IN ADDITION, THE ORGANIZATION REGULARLY REVIEWS SALARY AND BENEFIT SURVEYS PREPARED BY INDUSTRY ASSOCIATIONS AND EVALUATES COMPENSATION STRUCTURES FOR LOCAL SIMILAR ORGANIZATION FOR ALL KEY EMPLOYEES. A COMPENSATION COMMITTEE REVIEWS AND APPROVES THE COMPENSATION AND THE DECISIONS ARE DOCUMENTED IN THE COMMITTEE MINUTES. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE ALL FURNISHED TO THE PUBLIC UPON REQUEST. |
| FORM 990, PART XI, LINE 9: | CHANGE IN INTEREST IN NET ASSETS OF FOUNDATION 117,398. |
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