TY 2014 Form 990

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(1) DR ERIC REINERTSON........................................................................ TRUSTEE	1.0 .......................43.0	X				0	387,774	9,536
(2) GORDON CROSS MD........................................................................ TRUSTEE	1.0 .......................4.0	X				0	0	0
(3) DELORES EAGLESON........................................................................ TRUSTEE	1.0 .......................4.0	X				0	0	0
(4) CURTIS EETON........................................................................ TRUSTEE	1.0 .......................4.0	X				0	0	0
(5) RONALD MILLER........................................................................ TRUSTEE	1.0 .......................4.0	X				0	0	0
(6) JASON PROEHL........................................................................ TRUSTEE	1.0 .......................4.0	X				0	0	0
(7) EDWARD SIROTAK........................................................................ TRUSTEE	1.0 .......................4.0	X				0	0	0
(8) JAMES SMALLEY MD........................................................................ SECRETARY/TREASURER	1.0 .......................4.0	X	X			0	0	0
(9) ANDREW SPARKS........................................................................ VICE CHAIRMAN	1.0 .......................4.0	X	X			0	0	0
(10) MICHAEL TIBBS........................................................................ CHAIRMAN	1.0 .......................4.0	X	X			0	0	0
(11) DIRK ROECKER........................................................................ TRUSTEE	1.0 .......................4.0	X				0	0	0
(12) STEVEN C HALL........................................................................ CFO	40.0 .......................4.0		X			269,789	0	15,064
(13) BOB HALEY........................................................................ CEO	40.0 .......................4.0		X			140,000	0	39,216
(14) GARY JEPSON........................................................................ CEO (FORMER)	43.0 .......................4.0		X			111,962	0	29,992
(15) JO ELLEN PATTERSON........................................................................ CNO	40.0 .......................0.0			X		170,377	0	9,151
(16) MICHAEL JOHNSON........................................................................ ADMIN DIRECTOR OF ANCILLARY SE	40.0 .......................0.0				X	117,123	0	6,015
(17) ANGELIA DREHER........................................................................ DIRECTOR OF PHARMACY	40.0 .......................0.0				X	144,544	0	13,946

(A) Name and business address	(B) Description of services	(C) Compensation
PROFESSIONAL THERAPY SERVICES INC, 2810 FRANK SCOTT PARKWAY STE 824 BELLEVILLE,IL62223	REHAB SERVICES	1,139,140
MIDWEST ANESTHESIA CONSULTANTS SC, 2006 HOGBACK RD ANN ARBOR,MI48105	ANESTHESIOLOGY	1,095,839
QUORUM, 105 CONTINENTAL PLACE PEORIA,IL61615	CONSULTING	819,594
ARAMARK FACILITY SVCS, 22506 NETWORK CHICAGO,IL60673	EQUIPMENT SERVICES	523,112
ARAMARK FOOD, PO BOX 651009 CHARLOTTE,NC28265	DIETARY	511,658
2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization 11

Do not include amounts reported on lines 6b, 7b, 8b, 9b, and 10b of Part VIII.	(A) Total expenses	(B) Program service expenses	(C) Management and general expenses	(D) Fundraising expenses
1	Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21 ....	0
2	Grants and other assistance to domestic individuals. See Part IV, line 22 ....	0
3	Grants and other assistance to foreign organizations, foreign governments, and foreign individuals. See Part IV, lines 15 and 16 ............	0
4	Benefits paid to or for members ....	0
5	Compensation of current officers, directors, trustees, and key employees ....	811,767	196,858	614,909	0
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	0
7	Other salaries and wages ....	25,641,084	23,416,516	2,224,568
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	678,014	607,243	70,771
9	Other employee benefits .......	3,112,409	2,865,849	246,560
10	Payroll taxes ...........	1,907,434	1,708,335	199,099
11	Fees for services (non-employees):
a	Management ......	795,533		795,533
b	Legal .........	184,826		184,826
c	Accounting ...........	60,420		60,420
d	Lobbying ...........	0
e	Professional fundraising services. See Part IV, line 17	0
f	Investment management fees ......	0
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ....	9,254,812	9,254,812
12	Advertising and promotion ....	622,903	203,402	419,501
13	Office expenses .......	8,132,230	8,109,850	22,380
14	Information technology ......	14,468	14,468
15	Royalties ..	0
16	Occupancy ...........	1,083,088	1,077,673	5,415
17	Travel ............	63,861	63,861
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......	0
19	Conferences, conventions, and meetings ....	135,193	126,917	8,276
20	Interest ...........	583,346	583,346
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization .....	3,915,200	3,895,624	19,576
23	Insurance ..............	627,232	471,911	155,321
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a	MEDICAID ASSESSMENT EXPENSE	2,720,380	2,720,380
b	FOOD EXPENSE	595,726	595,726
c	IMPLANT FEES	1,898,219	1,898,219
d	REFERENCE LAB	694,893	694,893
e	All other expenses	438,958	307,046	131,912
25	Total functional expenses. Add lines 1 through 24e	63,971,996	58,812,929	5,159,067	0
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

Part X Balance Sheet Check if Schedule O contains a response or note to any line in this Part X ..............
	1	Cash–non-interest-bearing .............	122,210	1	103,996
2	Savings and temporary cash investments .........	4,991,299	2	5,628,123
3	Pledges and grants receivable, net ...........	0	3	0
4	Accounts receivable, net .............	10,302,326	4	11,523,840
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
		0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
		0	6	0
7	Notes and loans receivable, net .............	0	7	0
8	Inventories for sale or use ..............	1,005,098	8	1,061,171
9	Prepaid expenses and deferred charges ..........	1,162,723	9	1,593,739
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	86,194,566
b	Less: accumulated depreciation .....	10b	63,045,763	24,203,715	10c	23,148,803
11	Investments—publicly traded securities ..........	25,053,928	11	25,108,752
12	Investments—other securities. See Part IV, line 11 .....	0	12	0
13	Investments—program-related. See Part IV, line 11 .....	0	13	0
14	Intangible assets ...............	0	14	0
15	Other assets. See Part IV, line 11 ...........	3,528,276	15	3,390,408
16	Total assets. Add lines 1 through 15 (must equal line 34)......	70,369,575	16	71,558,832
	17	Accounts payable and accrued expenses .........	5,770,289	17	6,618,888
18	Grants payable .................	0	18	0
19	Deferred revenue ................	0	19	0
20	Tax-exempt bond liabilities .............	14,135,000	20	11,405,000
21	Escrow or custodial account liability. Complete Part IV of Schedule D..	0	21	0
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........	0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..	2,774,861	23	2,130,972
24	Unsecured notes and loans payable to unrelated third parties ....	0	24	0
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................	9,257,580	25	13,551,108
26	Total liabilities. Add lines 17 through 25.........	31,937,730	26	33,705,968
		Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............	38,116,431	27	37,500,657
28	Temporarily restricted net assets ...........	315,414	28	352,207
29	Permanently restricted net assets ...........	0	29	0
	Organizations that do not follow SFAS 117 (ASC 958), check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds ........		30
31	Paid-in or capital surplus, or land, building or equipment fund .....		31
32	Retained earnings, endowment, accumulated income, or other funds		32
33	Total net assets or fund balances ...........	38,431,845	33	37,852,864
34	Total liabilities and net assets/fund balances ........	70,369,575	34	71,558,832

- TIN:

SCHEDULE A
(Form 990 or 990EZ)

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.
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Attach to Form 990 or Form 990-EZ.
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Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2014

Open to Public
Inspection

Name of the organization

Pekin Memorial Hospital

Employer identification number

37-0692351

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.)

A church, convention of churches, or association of churches described in section 170(b)(1)(A)(i).

A school described in section 170(b)(1)(A)(ii). (Attach Schedule E.)

A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii).

A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the hospital's name, city, and state:

An organization operated for the benefit of a college or university owned or operated by a governmental unit described in

section 170(b)(1)(A)(iv). (Complete Part II.)

A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v).

An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 170(b)(1)(A)(vi). (Complete Part II.)

A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.)

An organization that normally receives: (1) more than 331/3% of its support from contributions, membership fees, and gross

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.)

An organization organized and operated exclusively to test for public safety. See section 509(a)(4).

An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box in lines 11a through 11d that describes the type of supporting organization and complete lines 11e, 11f, and 11g.

Type I. A supporting organization operated, supervised, or controlled by its supported organization(s), typically by giving the supported organization(s) the power to regularly appoint or elect a majority of the directors or trustees of the supporting organization. You must complete Part IV, Sections A and B.

Type II. A supporting organization supervised or controlled in connection with its supported organization(s), by having control or management of the supporting organization vested in the same persons that control or manage the supported organization(s). You must complete Part IV, Sections A and C.

Type III functionally integrated. A supporting organization operated in connection with, and functionally integrated with, its supported organization(s) (see instructions). You must complete Part IV, Sections A, D, and E.

Type III non-functionally integrated. A supporting organization operated in connection with its supported organization(s) that is not functionally integrated. The organization generally must satisfy a distribution requirement and an attentiveness requirement (see instructions). You must complete Part IV, Sections A and D, and Part V.

Check this box if the organization received a written determination from the IRS that it is a Type I, Type II, Type III functionally integrated, or Type III non-functionally integrated supporting organization.

Enter the number of supported organizations .............................

Provide the following information about the supported organization(s).

(i)Name of supported organization	(ii) EIN	(iv) Is the organization listed in your governing document?		(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)
(i)Name of supported organization	(ii) EIN	Yes	No	(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)


Total

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2014

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) 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.

Section B. Total Support

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.

Gross receipts from related activities, etc. (see instructions) ..................

First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization, check this box and stop here........................................ right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2014 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2013 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2014. 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 ....................... right arrow

33 1/3% support test—2013. 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 ..................... right arrow

17a

10%-facts-and-circumstances test—2014. 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 VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization ..................................................... right arrow

10%-facts-and-circumstances test—2013. 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 VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly
supported organization ................................................ right arrow

Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions ..................................................... right arrow

Schedule A (Form 990 or 990-EZ) 2014

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) 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.)

Section B. Total Support

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.)..

First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization,
check this box and stop here............................................. right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2014 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2013 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2014 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2013 Schedule A, Part III, line 17 .............

19a

33 1/3% support tests—2014. 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 ....... right arrow

33 1/3% support tests—2013. 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 .... right arrow

Private foundation. If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions .... right arrow

Schedule A (Form 990 or 990-EZ) 2014

Page 4

Part IV

Supporting Organizations

(Complete only if you checked a box on line 11 of Part I. If you checked 11a of Part I, complete Sections A and B. If you checked 11b of Part I, complete Sections A and C. If you checked 11c of Part I, complete Sections A, D, and E. If you checked 11d of Part I, complete Sections A and D, and complete Part V.)

Section A. All Supporting Organizations

Yes

Are all of the organization’s supported organizations listed by name in the organization’s governing documents?
If "No," describe in Part VI how the supported organizations are designated. If designated by class or purpose,
describe the designation. If historic and continuing relationship, explain.

Did the organization have any supported organization that does not have an IRS determination of status under section 509(a)(1) or (2)? If "Yes," explain in Part VI how the organization determined that the supported organization was described in section 509(a)(1) or (2).

Did the organization have a supported organization described in section 501(c)(4), (5), or (6)? If "Yes," answer (b) and (c) below.

Did the organization confirm that each supported organization qualified under section 501(c)(4), (5), or (6) and satisfied the public support tests under section 509(a)(2)? If "Yes," describe in Part VI when and how the organization made the determination.

Did the organization ensure that all support to such organizations was used exclusively for section 170(c)(2)(B) purposes? If "Yes," explain in Part VI what controls the organization put in place to ensure such use.

Was any supported organization not organized in the United States ("foreign supported organization")? If “Yes” and if you checked 11a or 11b in Part I, answer (b) and (c) below.

Did the organization have ultimate control and discretion in deciding whether to make grants to the foreign supported organization? If “Yes,” describe in Part VI how the organization had such control and discretion despite being controlled or supervised by or in connection with its supported organizations....

Did the organization support any foreign supported organization that does not have an IRS determination under sections 501(c)(3) and 509(a)(1) or (2)? If “Yes,” explain in Part VI what controls the organization used to ensure that all support to the foreign supported organization was used exclusively for section 170(c)(2)(B) purposes.

Did the organization add, substitute, or remove any supported organizations during the tax year? If “Yes,” answer (b) and (c) below (if applicable). Also, provide detail in Part VI, including (i) the names and EIN numbers of the supported organizations added, substituted, or removed, (ii) the reasons for each such action, (iii) the authority under the organization's organizing document authorizing such action, and (iv) how the action was accomplished (such as by amendment to the organizing document).

Type I or Type II only. Was any added or substituted supported organization part of a class already designated in the organization's organizing document?

Substitutions only. Was the substitution the result of an event beyond the organization's control?

Did the organization provide support (whether in the form of grants or the provision of services or facilities) to anyone other than (a) its supported organizations; (b) individuals that are part of the charitable class benefited by one or more of its supported organizations; or (c) other supporting organizations that also support or benefit one or more of the filing organization’s supported organizations? If “Yes,” provide detail in Part VI.

Did the organization provide a grant, loan, compensation, or other similar payment to a substantial contributor (defined in IRC 4958(c)(3)(C)), a family member of a substantial contributor, or a 35-percent controlled entity with regard to a substantial contributor? If “Yes,” complete Part I of Schedule L (Form 990) .

Did the organization make a loan to a disqualified person (as defined in section 4958) not described in line 7? If “Yes,” complete Part II of Schedule L (Form 990).

Was the organization controlled directly or indirectly at any time during the tax year by one or more disqualified persons as defined in section 4946 (other than foundation managers and organizations described in section 509(a)(1) or (2))? If “Yes,” provide detail in Part VI.

Did one or more disqualified persons (as defined in line 9(a)) hold a controlling interest in any entity in which the supporting organization had an interest? If “Yes,” provide detail in Part VI.

Did a disqualified person (as defined in line 9(a)) have an ownership interest in, or derive any personal benefit from, assets in which the supporting organization also had an interest? If “Yes,” provide detail in Part VI.

10a

Was the organization subject to the excess business holdings rules of IRC 4943 because of IRC 4943(f) (regarding certain Type II supporting organizations, and all Type III non-functionally integrated supporting organizations)? If “Yes,” answer b below.

10a

Did the organization have any excess business holdings in the tax year? (Use Schedule C, Form 4720, to determine whether the organization had excess business holdings).

10b

Has the organization accepted a gift or contribution from any of the following persons?

A person who directly or indirectly controls, either alone or together with persons described in (b) and (c) below, the governing body of a supported organization?

11a

A family member of a person described in (a) above?

11b

A 35% controlled entity of a person described in (a) or (b) above? If “Yes” to a, b, or c, provide detail in Part VI.

11c

Schedule A (Form 990 or 990-EZ) 2014

Page 5

Part IV

Supporting Organizations (continued)

Section B. Type I Supporting Organizations

Yes

Did the directors, trustees, or membership of one or more supported organizations have the power to regularly appoint or elect at least a majority of the organization’s directors or trustees at all times during the tax year? If “No,” describe in Part VI how the supported organization(s) effectively operated, supervised, or controlled the organization’s activities. If the organization had more than one supported organization, describe how the powers to appoint and/or remove directors or trustees were allocated among the supported organizations and what conditions or restrictions, if any, applied to such powers during the tax year.

Did the organization operate for the benefit of any supported organization other than the supported organization(s) that operated, supervised, or controlled the supporting organization? If “Yes,” explain in Part VI how providing such benefit carried out the purposes of the supported organization(s) that operated, supervised or controlled the supporting organization.

Section C. Type II Supporting Organizations

Yes

Were a majority of the organization’s directors or trustees during the tax year also a majority of the directors or trustees of each of the organization’s supported organization(s)? If “No,” describe in Part VI how control or management of the supporting organization was vested in the same persons that controlled or managed the supported organization(s).

Section D. All Type III Supporting Organizations

Yes

Did the organization provide to each of its supported organizations, by the last day of the fifth month of the organization’s tax year, (1) a written notice describing the type and amount of support provided during the prior tax year, (2) a copy of the Form 990 that was most recently filed as of the date of notification, and (3) copies of the organization’s governing documents in effect on the date of notification, to the extent not previously provided?

Were any of the organization’s officers, directors, or trustees either (i) appointed or elected by the supported organization(s) or (ii) serving on the governing body of a supported organization? If "No," explain in Part VI how the organization maintained a close and continuous working relationship with the supported organization(s).

By reason of the relationship described in (2), did the organization’s supported organizations have a significant voice in the organization’s investment policies and in directing the use of the organization’s income or assets at all times during the tax year? If "Yes," describe in Part VI the role the organization’s supported organizations played in this regard.

Section E. Type III Functionally-Integrated Supporting Organizations

Check the box next to the method that the organization used to satisfy the Integral Part Test during the year (see instructions):

The organization satisfied the Activities Test. Complete line 2 below.

The organization is the parent of each of its supported organizations. Complete line 3 below.

The organization supported a governmental entity. Describe in Part VI how you supported a government entity (see instructions)

Activities Test. Answer (a) and (b) below.

Yes

Did substantially all of the organization’s activities during the tax year directly further the exempt purposes of the supported organization(s) to which the organization was responsive? If "Yes," then in Part VI identify those supported organizations and explain how these activities directly furthered their exempt purposes, how the organization was responsive to those supported organizations, and how the organization determined that these activities constituted substantially all of its activities.

Did the activities described in (a) constitute activities that, but for the organization’s involvement, one or more of the organization’s supported organization(s) would have been engaged in? If "Yes," explain in Part VI the reasons for the organization’s position that its supported organization(s) would have engaged in these activities but for the organization’s involvement.

Parent of Supported Organizations. Answer (a) and (b) below.

Did the organization have the power to regularly appoint or elect a majority of the officers, directors, or trustees of each of the supported organizations? Provide details in Part VI.

Did the organization exercise a substantial degree of direction over the policies, programs and activities of each of its supported organizations? If "Yes," describe in Part VI the role played by the organization in this regard.

Schedule A (Form 990 or 990-EZ) 2014

Page 6

Part V – Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations

1. Check here if the organization satisfied the Integral Part Test as a qualifying trust on Nov. 20, 1970. See instructions. All other Type III non-functionally integrated supporting organizations must complete Sections A through E.

	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)

Schedule A (Form 990 or 990-EZ) 2014

Page 7

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.......

Schedule A (Form 990 or 990-EZ) (2014)

Schedule A (Form 990 or 990-EZ) 2014

Page 8

Part VI

Supplemental Information. Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; Part III, line 12; Part IV, Section A, lines 1, 2, 3b, 3c, 4b, 4c, 5a, 6, 9a, 9b, 9c, 11a, 11b, and 11c; Part IV, Section B, lines 1 and 2; Part IV, Section C, line 1; Part IV, Section D, lines 2 and 3; Part IV, Section E, lines 1c, 2a, 2b, 3a and 3b; Part V, line 1; Part V, Section B, line 1e; Part V Section D, lines 5, 6, and 8; and Part V, Section E, lines 2, 5, and 6. Also complete this part for any additional information. (See instructions).

Facts And Circumstances Test

Return Reference	Explanation

Schedule A (Form 990 or 990-EZ) 2014

Additional Data

Software ID:
Software Version:

- TIN:

Schedule B
(Form 990, 990-EZ,
or 990-PF)

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

Attach to Form 990, 990-EZ, or 990-PF.

Information about Schedule B (Form 990, 990-EZ, or 990-PF) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2014

Name of the organization

Pekin Memorial Hospital

Employer identification number

37-0692351

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

4947(a)(1) nonexempt charitable trust not treated as a private foundation

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

4947(a)(1) nonexempt charitable trust treated as a private foundation

501(c)(3) taxable private foundation

Check if your organization is covered by the General Rule or a Special Rule.
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.

General Rule

For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, contributions totaling $5,000 or more (in money or
property) from any one contributor. Complete Parts I and II. See instructions for determining a contributor's total contributions.

Special Rules

For an organization described in section 501(c)(3) filing Form 990 or 990-EZ that met the 33¹/3% support test of the regulations
under sections 509(a)(1) and 170(b)(1)(A)(vi), that checked Schedule A (Form 990 or 990-EZ), Part II, line 13, 16a, or 16b, and that received from any one contributor, during the year, total contributions of the greater of (1) $5,000 or (2) 2% of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1. Complete Parts I and II.

For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, total contributions of more than $1,000 exclusively for religious, charitable, scientific, literary, or educational purposes, or for the prevention of cruelty to children or animals. Complete Parts I, II, and III.

For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, contributions exclusively for religious, charitable, etc., purposes, but no such contributions totaled more than $1,000. If this box is checked, enter here the total contributions that were received during the year for an exclusively religious, charitable, etc., purpose. Do not complete any of the parts unless the General Rule applies to this organization because it received nonexclusively religious, charitable, etc., contributions totaling $5,000 or more during the year ......... Arrow Bullet

Caution. An organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2, of its Form 990; or check the box on line H of its
Form 990-EZ or on its Form 990PF, Part I, line 2, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).

For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.

Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2014)

Schedule B (Form 990, 990-EZ, or 990-PF) (2014)

Page 2

Name of organization Pekin Memorial Hospital

Part I	Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
RESTRICTED	,	$RESTRICTED	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2014)

Schedule B (Form 990, 990-EZ, or 990-PF) (2014)

Page 3

Name of organization Pekin Memorial Hospital

Part II	Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
Schedule B (Form 990, 990-EZ, or 990-PF) (2014)

Schedule B (Form 990, 990-EZ, or 990-PF) (2014)

Page 4

Name of organization
Pekin Memorial Hospital

Employer identification number

37-0692351

Part III

Exclusively religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10)
that total more than $1,000 for the year from any one contributor. Complete columns (a) through (e) and the following line entry. For organizations completing Part III, enter the total of exclusively religious, charitable, etc., contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet

$
Use duplicate copies of Part III if additional space is needed.

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

Schedule B (Form 990, 990-EZ, or 990-PF) (2014)

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527
SchCMd Bullet

Complete if the organization is described below. SchCMd Bullet

Attach to Form 990 or Form 990-EZ.
SchCMd Bullet

Information about Schedule C (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2014

Open to Public
Inspection

If the organization answered "Yes" to Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet

Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet

Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet

Section 527 organizations: Complete Part I-A only.
If the organization answered "Yes" to Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet

Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)): Complete Part II-A. Do not complete Part II-B.
Round Bullet

Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered "Yes" to Form 990, Part IV, Line 5 (Proxy Tax) (see separate instructions) or Form 990-EZ, Part V, line 35c (Proxy Tax) (see separate instructions), then
Round Bullet

Section 501(c)(4), (5), or (6) organizations: Complete Part III.

Name of the organization

Pekin Memorial Hospital

Employer identification number

37-0692351

Part I-A

Complete if the organization is exempt under section 501(c) or is a section 527 organization.

Provide a description of the organization’s direct and indirect political campaign activities in Part IV.

Political expenditures .................................... SchCMd Bullet

Volunteer hours ........................................

Part I-B

Complete if the organization is exempt under section 501(c)(3).

Enter the amount of any excise tax incurred by the organization under section 4955 ......... SchCMd Bullet

Enter the amount of any excise tax incurred by organization managers under section 4955 ...... SchCMd Bullet

If the organization incurred a section 4955 tax, did it file Form 4720 for this year? ..............

Yes No

Was a correction made? .........................................

Yes No

If "Yes," describe in Part IV.

Part I-C

Complete if the organization is exempt under section 501(c), except section 501(c)(3).

Enter the amount directly expended by the filing organization for section 527 exempt function activities SchCMd Bullet

Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ................................... SchCMd Bullet

Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b.. SchCMd Bullet

Did the filing organization file Form 1120-POL for this year? ..........................

Yes No

Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.

(a) Name	(b) Address	(c) EIN	(d) Amount paid from filing organization's funds. If none, enter -0-.	(e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.

For Paperwork Reduction Act Notice, see the instructions for Form 990 or 990-EZ.

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2014

Page 2

Part II-A

Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).

A Check SchCMd Bullet

if the filing organization belongs to an affiliated group (and list in Part IV each affiliated group member's name, address, EIN, expenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet

if the filing organization checked box A and "limited control" provisions apply.

Limits on Lobbying Expenditures (The term "expenditures" means amounts paid or incurred.)		(b) Affiliated group totals
1a	Total lobbying expenditures to influence public opinion (grass roots lobbying) ......
b	Total lobbying expenditures to influence a legislative body (direct lobbying) .......
c	Total lobbying expenditures (add lines 1a and 1b) ...................
d	Other exempt purpose expenditures ........................
e	Total exempt purpose expenditures (add lines 1c and 1d) ...............
f	Lobbying nontaxable amount. Enter the amount from the following table in both columns.
	If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:
	Not over $500,00020% of the amount on line 1e.
	Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.
	Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.
	Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.
	Over $17,000,000$1,000,000.

g	Grassroots nontaxable amount (enter 25% of line 1f) .................
h	Subtract line 1g from line 1a. If zero or less, enter -0-. ................
i	Subtract line 1f from line 1c. If zero or less, enter -0-. ................
j	If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting section 4911 tax for this year? ......................................	Yes No

4-Year Averaging Period Under section 501(h) (Some organizations that made a section 501(h) election do not have to complete all of the five columns below. See the separate instructions for lines 2a through 2f.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2011	(b) 2012	(c) 2013	(d) 2014	(e) Total

2a	Lobbying nontaxable amount

b	Lobbying ceiling amount (150% of line 2a, column(e))

c	Total lobbying expenditures

d	Grassroots nontaxable amount

e	Grassroots ceiling amount (150% of line 2d, column (e))

f	Grassroots lobbying expenditures

Schedule C (Form 990 or 990-EZ) 2014

Page 3

Part II-B

Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).

For each "Yes" response to lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.

(a)

Yes

(b)

Amount

During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:

Volunteers? .........................................

Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....

Media advertisements? ....................................

Mailings to members, legislators, or the public? .........................

Publications, or published or broadcast statements? .......................

Grants to other organizations for lobbying purposes? .......................

Yes

30,154

Direct contact with legislators, their staffs, government officials, or a legislative body? ........

Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......

Other activities? ..........................

Total. Add lines 1c through 1i ...............................

30,154

Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....

If "Yes," enter the amount of any tax incurred under section 4912 .................

If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....

If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? .......

Part III-A

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).

Yes

Were substantially all (90% or more) dues received nondeductible by members? ................

Did the organization make only in-house lobbying expenditures of $2,000 or less? ................

Did the organization agree to carry over lobbying and political expenditures from the prior year? ..........

Part III-B

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2, are answered "No" OR (b) Part III-A, line 3, is answered “Yes."

Dues, assessments and similar amounts from members .....................

Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).

Current year .........................................

Carryover from last year ....................................

Total ............................................

Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .

If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ................................

Taxable amount of lobbying and political expenditures (see instructions) ..............

Part IV

Supplemental Information

Provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, line 5; Part II-A (affiliated group list); Part II-A, lines 1 and 2 (see instructions), and Part ll-B, line 1. Also, complete this part for any additional information.

Return Reference	Explanation
SCHEUDLE C, PART II-B, LINE 1	LOBBYING ACTIVITIES LOBBYING EXPENSES ARE ONLY INCURRED THROUGH ASSOCIATIONS WITH NATIONAL ORGANIZATIONS OF WHICH THE ORGANIZATION IS A MEMBER.

Schedule C (Form 990 or 990EZ) 2014

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b.
SchDMd Bullet

Attach to Form 990.
Information about Schedule D (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2014

Open to Public Inspection

Name of the organization

Pekin Memorial Hospital

Employer identification number

37-0692351

Part I

Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.

		(a) Donor advised funds	(b) Funds and other accounts
1	Total number at end of year .........
2	Aggregate value of contributions to (during year)
3	Aggregate value of grants from (during year)
4	Aggregate value at end of year ........

Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............

Yes No

Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................

Yes No

Part II

Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.

Purpose(s) of conservation easements held by the organization (check all that apply).

Preservation of land for public use (e.g., recreation or education) Preservation of an historically important land area

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.


a	Total number of conservation easements .......................	2a
b	Total acreage restricted by conservation easements ..................	2b
c	Number of conservation easements on a certified historic structure included in (a) .....	2c
d	Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register ....................	2d

Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet

Number of states where property subject to conservation easement is located SchDMd Bullet

Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................

Yes No

Staff and volunteer hours devoted to monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet

Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .......................................

Yes No

In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.

If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items.

If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts relating to these items:

(i)

Revenue included in Form 990, Part VIII, line 1 ........................ SchDMd Bullet

(ii)

Assets included in Form 990, Part X .............................. SchDMd Bullet

If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958) relating to these items:

Revenue included in Form 990, Part VIII, line 1 .......................... SchDMd Bullet

Assets included in Form 990, Part X ............................... SchDMd Bullet

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 52283D

Schedule D (Form 990) 2014

Page 2

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)

Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply):

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.

During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........

Yes No

Part IV

Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.

Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................

Yes No

If "Yes," explain the arrangement in Part XIII and complete the following table:


c	Beginning balance .................................	1c
d	Additions during the year ..............................	1d
e	Distributions during the year .............................	1e
f	Ending balance ...................................	1f

Did the organization include an amount on Form 990, Part X, line 21, for escrow or custodial account liability?

Yes No

If "Yes," explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII .......

Part V

Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.

		(a)Current year	(b)Prior year	b (c)Two years back	(d)Three years back	(e)Four years back
1a	Beginning of year balance ....
b	Contributions ........
c	Net investment earnings, gains, and losses
d	Grants or scholarships .....
e	Other expenditures for facilities and programs ........
f	Administrative expenses ....
g	End of year balance ......

Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Temporarily restricted endowment SchDMd Bullet

The percentages in lines 2a, 2b, and 2c should equal 100%.

Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes

(i) unrelated organizations ........................

3a(i)

(ii) related organizations ........................

3a(ii)

If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........

Describe in Part XIII the intended uses of the organization's endowment funds.

Part VI

Land, Buildings, and Equipment. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11a. See Form 990, Part X, line 10.

Description of property		(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................	1,449,581		1,449,581
b	Buildings ................	11,585,946	8,982,257	2,603,689
c	Leasehold improvements ............	19,494,196	14,725,759	4,768,437
d	Equipment ................	51,116,977	37,638,358	13,478,619
e	Other .................	2,547,866	1,699,389	848,477
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......				23,148,803

Schedule D (Form 990) 2014

Page 3

Part VII

InvestmentsOther Securities. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11b. See Form 990, Part X, line 12.

(a) Description of security or category (including name of security)		(b)Book value	(c) Method of valuation: Cost or end-of-year market value
(1)Financial derivatives
(2)Closely-held equity interests
Other








Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)

Part VIII

InvestmentsProgram Related. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11c. See Form 990, Part X, line 13.

(a) Description of investment		(b) Book value	(c) Method of valuation: Cost or end-of-year market value









Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)

Part IX

Other Assets. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11d. See Form 990, Part X, line 15.

(a) Description				(b) Book value









Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........

Part X

Other Liabilities. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11e or 11f. See Form 990, Part X, line 25.

1.(a) Description of liability		(b) Book value
Federal income taxes		0
DUE TO THIRD PARTIES		3,678,797
MINIMUM PENSION LIABILITY		9,851,755
DUE TO MEDICARE		20,556






Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		13,551,108
2. Liability for uncertain tax positions. In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII

Schedule D (Form 990) 2014

Page 4

Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return Complete if the organization answered 'Yes' to Form 990, Part IV, line 12a.
1	Total revenue, gains, and other support per audited financial statements .......		1
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains (losses) on investments ....	2a
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c
d	Other (Describe in Part XIII.) ............	2d
e	Add lines 2a through 2d .....................		2e
3	Subtract line 2e from line 1.....................		3
4	Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b .	4a
b	Other (Describe in Part XIII.) ...........	4b
c	Add lines 4a and 4b.......................		4c
5	Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ......		5

Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return. Complete if the organization answered 'Yes' to Form 990, Part IV, line 12a.
1	Total expenses and losses per audited financial statements ...........		1
2	Amounts included on line 1 but not on Form 990, Part IX, line 25:
a	Donated services and use of facilities ..........	2a
b	Prior year adjustments ..............	2b
c	Other losses ................	2c
d	Other (Describe in Part XIII.) ............	2d
e	Add lines 2a through 2d......................		2e
3	Subtract line 2e from line 1.....................		3
4	Amounts included on Form 990, Part IX, line 25, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b ..	4a
b	Other (Describe in Part XIII.) ............	4b
c	Add lines 4a and 4b.......................		4c
5	Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ......		5

Part XIII

Supplemental Information

Provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.

Return Reference	Explanation
SCHEDULE D, PART X, LINE 2	FIN 48 DISCLOSURE MANAGEMENT HAS EVALUATED THEIR INCOME TAX POSITIONS UNDER THE GUIDANCE INCLUDED IN ASC 740. BASED ON THEIR REVIEW, MANAGEMENT HAS NOT IDENTIFIED ANY MATERIAL UNCERTAIN TAX POSITIONS TO BE RECORDED OR DISCLOSED IN THE FINANCIAL STATEMENTS.

Schedule D (Form 990) 2014

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H (Form 990)

Department of the TreasuryInternal Revenue Service

Hospitals

Complete if the organization answered "Yes" to Form 990, Part IV, question 20.
MediumBullet

Attach to Form 990.
MediumBullet

Information about Schedule H (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2014

Open to Public Inspection

Name of the organization

Pekin Memorial Hospital

Employer identification number

37-0692351

Part I

Financial Assistance and Certain Other Community Benefits at Cost

Yes

Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a ...

Yes

If "Yes," was it a written policy? .......................

Yes

If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.

Applied uniformly to all hospital facilities Applied uniformly to most hospital facilities Generally tailored to individual hospital facilities

Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.

Did the organization use Federal Poverty Guidelines (FPG) as a factor in determining eligibility for providing free care?

If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:

Yes

100% 150% 200% Other %

Did the organization use FPG as a factor in determining eligibility for providing discounted care? If "Yes," indicate

which of the following was the family income limit for eligibility for discounted care: .........

Yes

200% 250% 300% 350% 400% Other 600 %

If the organization used factors other than FPG in determining eligibility, describe in Part VI the criteria used for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, as a factor in determining eligibility for free or discounted care.

Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? ..............

Yes

Did the organization budget amounts for free or discounted care provided under its financial assistance policy during the tax year? ............................

Yes

If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? ......

If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care? ..............

Did the organization prepare a community benefit report during the tax year? ..........

Yes

If "Yes," did the organization make it available to the public? ..............

Yes

Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance and Means-Tested Government Programs		(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a	Financial Assistance at cost (from Worksheet 1) ..	152,688		152,688	0.240 %
b	Medicaid (from Worksheet 3, column a) ....	14,362,245	6,646,270	7,715,975	12.030 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) .
d	Total Financial Assistance and Means-Tested Government Programs .	14,514,933	6,646,270	7,868,663	12.270 %
Other Benefits		10,487		10,487	0.020 %
e	Community health improvement services and community benefit operations (from Worksheet 4) ..	10,487		10,487	0.020 %
f	Health professions education (from Worksheet 5) ..
g	Subsidized health services (from Worksheet 6) ..
h	Research (from Worksheet 7)
i	Cash and in-kind contributions for community benefit (from Worksheet 8)
j	Total. Other Benefits ..	10,487		10,487	0.020 %
k	Total. Add lines 7d and 7j .	14,525,420	6,646,270	7,879,150	12.290 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2014

Schedule H (Form 990) 2014

Page

Part II

Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.

		(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community building expense	(d) Direct offsetting revenue	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development
3	Community support
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building
7	Community health improvement advocacy
8	Workforce development
9	Other
10	Total

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................

Yes

Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......

1,064,896

Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. ......

159,408

Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements.

Section B. Medicare

Enter total revenue received from Medicare (including DSH and IME).....

14,322,075

Enter Medicare allowable costs of care relating to payments on line 5.....

27,050,869

Subtract line 6 from line 5. This is the surplus (or shortfall)........

-12,728,794

Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.Check the box that describes the method used:

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

Did the organization have a written debt collection policy during the tax year? ..........

Yes

If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI.......................

Yes

Part IV

Management Companies and Joint Ventures(owned 10% or more by officers, directors, trustees, key employees, and physicians—see instructions)

(a) Name of entity	(b) Description of primary activity of entity	(c) Organization's profit % or stock ownership %	(d) Officers, directors, trustees, or key employees' profit % or stock ownership %	(e) Physicians' profit % or stock ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13

Schedule H (Form 990) 2014

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest—see instructions) How many hospital facilities did the organization operate during the tax year?1 Name, address, primary website address, and state license number (and if a group return, the name and EIN of the subordinate hospital organization that operates the hospital facility)
1	PEKIN MEMORIAL HOSPITAL 600 SOUTH 13TH STREET PEKIN,IL61554 PEKINHOSPITAL.ORG 001834	X	X	X

Schedule H (Form 990) 2014

Page

Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)

	PEKIN MEMORIAL HOSPITAL
Name of hospital facility or letter of facility reporting group

Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A):

Yes

Community Health Needs Assessment

Was the hospital facility first licensed, registered, or similarly recognized by a State as a hospital facility in the current tax year or the immediately preceding tax year?.......................

Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C..........

During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 12....................

Yes

If "Yes," indicate what the CHNA report describes (check all that apply):

A definition of the community served by the hospital facility

Demographics of the community

Existing health care facilities and resources within the community that are available to respond to the health needs of the community

How data was obtained

The significant health needs of the community

Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups

The process for identifying and prioritizing community health needs and services to meet the community health needs

The process for consulting with persons representing the community’s interests

Information gaps that limit the hospital facility’s ability to assess the community’s health needs

Other (describe in Section C)

Indicate the tax year the hospital facility last conducted a CHNA: 20 12

In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted .................

Yes

Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C................................

Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C. ............................

Did the hospital facility make its CHNA report widely available to the public? ..............

Yes

If "Yes," indicate how the CHNA report was made widely available (check all that apply):

Hospital facility’s website (list url): SEE PART V, SECTION C

Other website (list url):

Made a paper copy available for public inspection without charge at the hospital facility

Other (describe in Section C)

Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11. .............

Yes

Indicate the tax year the hospital facility last adopted an implementation strategy: 20 12

Is the hospital facility's most recently adopted implementation strategy posted on a website? ........

Yes

If "Yes" (list url): SEE PART V, SECTION C

If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ......

10b

Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.

12a

Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)? ...........................

12a

If "Yes" to line 12a, did the organization file Form 4720 to report the section 4959 excise tax? ......

12b

If "Yes" to line 12b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $

Schedule H (Form 990) 2014

Page

Part VFacility Information (continued)

	PEKIN MEMORIAL HOSPITAL
Name of hospital facility or letter of facility reporting group

Yes

Financial Assistance Policy (FAP)

Did the hospital facility have in place during the tax year a written financial assistance policy that:

Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care?

Yes

If “Yes,” indicate the eligibility criteria explained in the FAP:

Federal poverty guidelines (FPG), with FPG family income limit for eligibility for free care of 200.%
and FPG family income limit for eligibility for discounted care of 600.%

Income level other than FPG (describe in Section C)

Asset level

Medical indigency

Insurance status

Underinsurance discount

Residency

Other (describe in Section C)

Explained the basis for calculating amounts charged to patients?.................

Yes

Explained the method for applying for financial assistance?...................

Yes

If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):

Described the information the hospital facility may require an individual to provide as part of his or her application.

Described the supporting documentation the hospital facility may require an individual to submit as part of his or
her application.

Provided the contact information of hospital facility staff who can provide an individual with information about the
FAP and FAP application process.

Provided the contact information of nonprofit organizations or government agencies that may be sources of
assistance with FAP applications.

Other (describe in Section C)

Included measures to publicize the policy within the community served by the hospital facility?.......

Yes

If "Yes," indicate how the hospital facility publicized the policy (check all that apply):

The FAP was widely available on a website (list url): SEE PART V, SECTION C

The FAP application form was widely available on a website (list url): SEE PART V, SECTION C

A plain language summary of the FAP was widely available on a website (list url):
SEE PART V, SECTION C

The FAP was available upon request and without charge (in public locations in the hospital facility and by mail)

The FAP application form was available upon request and without charge (in public locations in the hospital facility
and by mail)

A plain language summary of the FAP was available upon request and without charge (in public locations in the
hospital facility and by mail)

Notice of availability of the FAP was conspicuously displayed throughout the hospital facility

Notified members of the community who are most likely to require financial assistance about availability of the FAP

Other (describe in Section C)

Billing and Collections

Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained all of the actions the hospital facility or other authorized party may take upon non-payment?..................................

Yes

Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

None of these actions or other similar actions were permitted

Schedule H (Form 990) 2014

Page

Part VFacility Information (continued)

	PEKIN MEMORIAL HOSPITAL
Name of hospital facility or letter of facility reporting group

Yes

Did the hospital facility or other authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?.........

If "Yes," check all actions in which the hospital facility or a third party engaged:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 18. (check all that apply):

Notified individuals of the financial assistance policy on admission

Notified individuals of the financial assistance policy prior to discharge

Notified individuals of the financial assistance policy in communications with the individuals regarding the individuals’ bills

Documented its determination of whether individuals were eligible for financial assistance under the hospital facility’s financial assistance policy

Other (describe in Section C)

None of these efforts were made

Policy Relating to Emergency Medical Care

Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?................

Yes

If "No," indicate why:

The hospital facility did not provide care for any emergency medical conditions

The hospital facility’s policy was not in writing

The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Section C)

Other (describe in Section C)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)

Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.

The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged

The hospital facility used the average of its three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged

The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged

Other (describe in Section C)

During the tax year, did the hospital facility charge any FAP-eligible individual to whom the hospital facility provided emergency or other medically necessary services more than the amounts generally billed to individuals who had insurance covering such care? ................................

If "Yes," explain in Section C.

During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual? ...........................

If "Yes," explain in Section C.

Schedule H (Form 990) 2014

Page

Part V

Facility Information (continued)

Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16i, 18d, 19d, 20e, 21c, 21d, 22d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A (“A, 1,” “A, 4,” “B, 2,” “B, 3,” etc.) and name of hospital facility.
Form and Line Reference	Explanation
SCHEDULE H, PART V, SECTION B, LINE 5	CHNA - INPUT FROM PERSONS REPRESENTING THE COMMUNITY WE RECEIVED COMMUNITY INPUT FROM 341 AREA RESIDENTS; OCTOBER 23, 2012 THROUGH NOVEMBER 13, 2012. INFORMATION ANALYSIS AUGMENTED BY LOCAL OPINIONS SHOWED HOW TAZEWELL COUNTY RELATES TO ITS PEERS IN TERMS OF PRIMARY AND CHRONIC NEEDS, AS WELL AS OTHER ISSUES OF UNINSURED PERSONS, LOW-INCOME PERSONS AND MINORITY GROUPS; RESPONDENTS COMMENTED ON IF THEY BELIEVE CERTAIN POPULATION GROUPS (OR PEOPLE WITH CERTAIN SITUATIONS) NEED HELP TO IMPROVE THEIR CONDITION.
SCHEDULE H, PART V, SECTION B, LINE 7A	HTTP://PEKINHOSPITAL.ORG/_DATA/FILES/COMMUNITYHEALTHNEEDSASSESSMENT2.PDF
SCHEDULE H, PART V, SECTION B, LINE 16I	PUBLISHING OF FINANCIAL ASSISTANCE POLICY THE POLICY IS ALSO AVAILABLE IN COMMON AREAS OF THE HOSPITAL, IN PATIENT FINANCIAL SERVICES AND ON OUR WEBSITE.
SCHEDULE H, PART V, SECTION B, LINE 22D	DETERMINING MAXIMUM AMOUNTS CHARGED TO FAP-ELIGIBLE INDIVIDUALS APPLICATIONS FOR FINANCIAL ASSISTANCE WILL BE REVIEWED ACCORDING TO THE GUIDELINES. UN-INSURED PATIENTS WHO QUALIFY FOR FINANCIAL ASSISTANCE WILL NOT BE CHARGED MORE THAN THAT GENERALLY BILLED TO INSURED PATIENTS. THE HOSPITAL WILL NOT USE GROSS CHARGES WHEN BILLING PATIENTS WHO QUALIFY FOR FINANCIAL ASSISTANCE. PEKIN HOSPITAL HAS ELECTED TO USE THE LOOK BACK METHOD FOR CALCULATING AGB. THE AGB IS CALCULATED BY REVIEWING ACTUAL CLAIMS THAT HAVE BEEN PAID IN FULL FOR MEDICALLY NECESSARY CARE BY MEDICARE AND COMMERCIAL PAYORS. THE CLAIMS REVIEWED COVER CLAIMS PAID IN FULL FOR THE LAST 12 MONTHS. THE AMOUNTS PAID INCLUDE CO-INSURANCE, COPAYMENTS AND DEDUCTIBLES. THE AGB FOR EMERGENCY AND MEDICALLY NECESSARY CARE PROVIDED TO A FINANCIAL ASSISTANCE-ELIGIBLE INDIVIDUAL IS CALCULATED BY MULTIPLYING GROSS CHARGES FOR THAT CARE BY THE AVERAGE COLLECTION PERCENTAGE FOR MEDICARE AND PRIVATE HEALTH INSURERS. THE PERCENTAGE IS CALCULATED AT LEAST ANNUALLY BY DIVIDING THE SUM OF PAID CLAIMS BY THE SUM OF THE ASSOCIATED GROSS CHARGES FOR THOSE CLAIMS. THE PERCENTAGE IS THEN APPLIED TO INDIVIDUAL'S GROSS CHARGES TO REDUCE THE BILL. A REVISED PERCENTAGE WILL BE CALCULATED AND APPLIED BY THE 45TH DAY AFTER THE FIRST DAY OF THE START OF THE FISCAL YEAR USED TO DETERMINE THE CALCULATIONS.
SCHEDULE H, PART V, SECTION B, LINE 11	HEALTH NEEDS ASSESSMENT REPORT CARD A. HEALTH RESOURCE AVAILABILITY/AFFORDABILITY CONSIDERABLE RESIDENT CONCERN, 71% REPORTED NO ACCESS PROBLEM; NOT HAVING HEALTH INSURANCE 68% LISTED AS A MAJOR CONCERN, WITH SUPPORT OF "INSURANCE LACK" BEING A SECONDARY ISSUE IN THE WRITTEN COMMENTS; HEALTHCARE AVAILABILITY - LEADING PROBLEMS TO SOLVE; TAZEWELL NOT DESIGNATED AS MEDICALLY UNDERSERVED; PRIMARY CARE PHYSICIANS TO POPULATION RATIO - MORE THAN DOUBLE THE STATE AVERAGE AND 350% WORSE THAN THE DESIRED NATIONAL GOAL; UNEMPLOYMENT LOWER THAN IL AND U.S. PROBLEM STATEMENT: SHORTAGE OF PRIMARY CARE PHYSICIANS AND SIZABLE UNINSURED POPULATION. 1. AGGRESSIVELY RECRUIT PRIMARY CARE PROVIDERS TO PROGRESSIVE HEALTH SYSTEMS SERVICE AREA - PROGRESSIVE HEALTH SYSTEMS HAS MADE SIGNIFICANT STRIDES IN THE RECRUITMENT OF PRIMARY CARE PHYSICIANS AND MIDLEVEL PROVIDERS. OVER THE LAST 3 YEARS PROGRESSIVE HEALTH SYSTEMS HAS SUCCESSFULLY RECRUITED 14 PROVIDERS. WE CONTINUE TO RECRUIT PROVIDERS IN THE FOLLOWING SPECIALTIES; INTERNAL MEDICINE, OBGYN, HOSPITALIST, PEDIATRIC NP, (2) GENERAL SURGEONS, PULMONOLOGIST, GASTROENTEROLOGIST NP AND (2) FAMILY MEDICINE PROVIDERS. RECRUITMENT DOLLARS SPENT IN FY 2013 $132,000, FY 2014 $70,000, FY 2015 $66,000 AND FY 2016 $12,000 2. PROVIDE FREE HEALTH SCREENINGS AND EDUCATION TO THE PUBLIC - PROGRESSIVE HEALTH SYSTEMS PROVIDED A VARIETY OF COMMUNITY SCREENINGS TO INCLUDE BONES DENSITY, BLOOD PRESSURE CHECKS, BODY COMPOSITION, CHOLESTEROL CHECKS, HEMOGLOBIN, PULMONARY FUNCTION TESTING, PHYSICAL THERAPY, DISTANT ACUITY, COGNITION ASSESSMENTS, SKIN SCREENING, FOOT SCREENING, HEEL SCANS, SPIROMETRY TESTING AND PERIPHERAL VASCULAR SCREENING. IN ADDITION, AS PART OF MAMMOGRAPHY DAY WE PARTNER WITH TAZEWELL COUNTY HEALTH DEPARTMENT TO OFFER FREE MAMMOGRAMS TO UNINSURED WOMEN AGE OF 40 AND ABOVE. THERE WERE 3,828 SCREENINGS GIVEN IN THE LAST THREE YEARS. PROGRESSIVE HEALTH SYSTEMS ALSO PARTICIPATED IN A NUMBER OF HEALTH FAIRS THROUGHOUT TAZEWELL AND PEORIA COUNTIES. FROM 2013 TO 2015, THE NUMBER OF PEOPLE THAT PARTICIPATED IN HEALTH FAIR SCREENINGS WAS 1,276. PROGRESSIVE HEALTH SYSTEMS CONTINUES TO OFFER EDUCATION ON DIABETES, CPR, WEIGHT LOSS, SKIN CANCER, BONE AND JOINT HEALTH, COLON HEALTH, HEALTHY EATING AND EXERCISE AND CARDIO EDUCATION. IT TOOK ONE THOUSAND FOUR HUNDRED AND FIFTY TWO MAN HOURS TO CONDUCT THE HEALTH FAIRS AND SCREENINGS. 3. PROVIDE PRIMARY CARE SERVICES TO MEDICAID RECIPIENTS THROUGH PROHEALTH PRIMARY CARE PRACTICES - THE PHYSICIANS AT PROHEALTH HAVE PROVIDED 41,000 VISITS TO MEDICAID PATIENTS IN THE LAST THREE YEARS. WE HAVE OPENED UP A PEDIATRIC URGENT CARE WITH EXTENDED HOURS FROM 8:00A TO 8:00P MONDAY THROUGH SATURDAY TO INCREASE PATIENT ACCESS. MEDICAL CARE IS ALSO AVAILABLE TO PATIENTS, BASED ON MEDICAL NECESSITY, REGARDLESS OF THEIR ABILITY TO PAY. PATIENTS MAY REQUEST CHARITY ASSISTANCE APPLICATIONS BY TELEPHONE OR IN PERSON. PEKIN HOSPITAL WAIVES CHARGES BASED ON REVIEW OF THE PATIENT'S FINANCIAL STATUS COMPARED TO FEDERAL POVERTY GUIDELINES. INFORMATION REGARDING CHARITY CARE MAY BE FOUND THROUGHOUT THE HOSPITAL INCLUDING IN PATIENT REGISTRATION, OUTPATIENT DEPARTMENTS, EMERGENCY DEPARTMENT, AND THE PATIENT SERVICE DEPARTMENTS. INFORMATION REGARDING FINANCIAL PROGRAMS, INCLUDING CHARITY CARE, CAN ALSO BE FOUND ON THE HOSPITAL'S WEBSITE AT WWW.PEKINHOSPITAL.ORG. COST: UNCOMPENSATED CARE IS PROVIDED TO PATIENTS UNDER MEDICAID PROGRAMS, ELIGIBILITY IS BASED ON FINANCIAL NEED. THE COST OF UNCOMPENSATED CARE TO THE ORGANIZATION WAS $13,327,000 FY 2013, $11,284,000 FY 2014 AND $13,932,623 FY 2015. THE COST OF PROVIDING CHARITY CARE AMOUNTED TO $3,000,000 OVER THE LAST THREE YEARS. COST: ANNUAL COSTS ASSOCIATED WITH THE PEDIATRIC URGENT CARE ARE $870,000. 4. EXPLORE THE OPPORTUNITY TO PARTNER WITH THE HEARTLAND COMMUNITY CLINIC TO BUILD A FEDERALLY QUALIFIED HEALTH CENTER IN PEKIN - DISCUSSIONS WITH HEARTLAND COMMUNITY CLINIC HAVE BEEN INITIATED BUT NO SOLID COMMITMENTS HAVE BEEN MADE AT THIS TIME. 5. SUPPORT MEDICAID EXPANSION EFFORTS AND THE AFFORDABLE CARE ACT DEVELOPMENT OF INSURANCE EXCHANGES TO PROVIDE SUBSIDIZED HEALTH INSURANCE TO LOW INCOME, UNDERSERVED AND AT-RISK POPULATIONS - IN NOVEMBER 2013, PROGRESSIVE HEALTH SYSTEMS BECAME A CERTIFIED APPLICATION ORGANIZATION SUCCESSFULLY REACHING, EDUCATING, AND ENROLLING UNINSURED AND HARD-TO-REACH POPULATIONS INTO QUALIFIED HEALTH PLANS (QHPS) AND INSURANCE AFFORDABILITY PROGRAMS. SINCE BECOMING CERTIFIED PROGRESSIVE HEALTH SYSTEMS HAS HELPED ENROLL 521 CONSUMERS WHICH INCLUDE BOTH PROGRESSIVE HEALTH SYSTEMS PATIENTS AND INDIVIDUALS FROM THE GENERAL PUBLIC INTO THE EXCHANGE. OUR SERVICE AREA CURRENTLY HAS A POPULATION OF 14,000 THAT ARE UNINSURED. OVER THE NEXT 3 YEARS PROGRESSIVE HEALTH SYSTEMS WILL HIRE 5 NEW NAVIGATORS TO HELP OUR PATIENTS BECOME ENROLLED IN AN INSURANCE PLAN. WE ANTICIPATE 48 EVENTS PER YEAR AND EXPECT TO HAVE ASSISTED 10,500 INDIVIDUALS TO APPLY FOR COVERAGE OVER THE NEXT THREE YEARS. COST OF NAVIGATORS: IN THE FIRST TWO YEARS THE NAVIGATORS HELPED 521 CONSUMERS GET SIGNED UP FOR INSURANCE ON THE EXCHANGE. WE ARE DEDICATING $250,000 PER YEAR FOR THE NEXT THREE YEARS TO EXPAND THE NAVIGATOR PROGRAM TO. THE GOAL IS TO REACH OUT TO THE 14,000 UNINSURED CONSUMERS IN OUR SERVICE AREA. LEADING INDICATOR NUMBER OF VISITS OVER FY 2013 - THE BASE YEAR = 5535 LAGGING INDICATOR FOR IMPROVEMENT TOTAL ENROLLEES IN ILLINOIS MEDICAID PROGRAM 2011 = 24,557 ACTUAL RESULTS 2015 = 27,235 B. CORONARY HEART DISEASE LEADING CAUSE OF DEATH, RATE SIGNIFICANTLY LOWER THAN EXPECTED, ADVERSE FINDING IMPACTING 10% OF POPULATION; LOWEST NATIONAL RATE CLASS FOR DEATHS, RATE FOR NON-HISPANIC BLACKS IS HIGHER: BETTER THAN NATIONAL AND PEER AVERAGES PROBLEM STATEMENT: HEART DISEASE REMAINS THE PROMINENT CAUSE OF DEATH 1. EDUCATE THE PUBLIC AND OUR PATIENTS ABOUT THE DANGERS OF HEART DISEASE, THE ADVANTAGES OF HEART HEALTHY LIFESTYLE AND THE NEED FOR EARLY DIAGNOSIS AND TREATMENT IN FY 2015, PROGRESSIVE HEALTH SYSTEMS CREATED A POSITION TO COORDINATE HEALTH AND WELLNESS OF OUR COMMUNITY. THE POSITION IS AIMED AT IMPROVING THE HEALTH OUTCOMES OF THE COMMUNITY WE SERVE. THE POSITION WORKED WITH LOCAL BUSINESSES AND KEY COMMUNITY PARTNERS AND ORGANIZED AND IMPLEMENTED COMMUNITY PROGRAMS THAT WILL MEASURABLY IMPROVE HEALTH FOR THE PROGRESSIVE HEALTH SYSTEMS POPULATION. THE POSITION GOES AROUND TO SCHOOLS, BUSINESSES AND EDUCATES COMMUNITY MEMBERS ON THE BENEFITS OF LIVING A HEALTHY LIFESTYLE THROUGH EXERCISE AND DIET. $80,000 PER YEAR IS DEDICATED TO PROVIDING INCREASED AWARENESS OF HEALTH AND WELLNESS IN OUR COMMUNIT 2. ALLOCATE RESOURCES TO PROVIDE EDUCATIONAL MATERIAL FOR DISTRIBUTION TO THE PUBLIC AND PATIENTS PROGRESSIVE HEALTH SYSTEMS HAS SEVERAL DEPARTMENTS THAT PROVIDE HANDOUTS TO THEIR PATIENTS AND CONSUMERS AT HEALTH FAIRS AND SCREENINGS. THERAPY, WELLNESS CENTER, HOME HEALTH AND PROHEALTH ARE JUST A FEW OF THE DEPARTMENTS THAT PROVIDE EDUCATIONAL BROCHURES. CLINICAL DEPARTMENTS HAVE EXPENSES ALLOCATED FOR THE COST OF PRINTING AND EDUCATIONAL EXPENSES. 3. PROVIDE A SCHEDULE OF EDUCATIONAL SEMINARS TO PATIENTS AND INTERESTED RESIDENTS - LOCATED ON THE PROGRESSIVE HEALTH SYSTEM'S WEBSITE, IS A CALENDAR OF EVENTS THAT SHOWS UPCOMING EDUCATIONAL CLASSES OFFERED TO THE COMMUNITY. IN ADDITION, OUR WELLNESS CENTER OFFERS THE FOLLOWING TOPICS OF EDUCATION FOR OUR PHASE TWO CARDIAC PATIENTS. THE COURSES ARE HEART ANATOMY AND PHYSIOLOGY, CARDIAC ANGIOGRAM PROCEDURE, HEART SURGERY, CORONARY STENTING, READING FOOD LABELS, STRESS AND HEART DISEASE, CARDIAC RISK FACTORS AND MEDICATIONS 4. PROVIDE SCREENING PROGRAMS THAT SUPPORT EDUCATION AND EARLY HEART DISEASE DETECTION - PROGRESSIVE HEALTH SYSTEMS PROVIDED A VARIETY OF COMMUNITY SCREENS TO INCLUDE BONES DENSITY, BLOOD PRESSURE CHECKS, BODY COMPOSITION, CHOLESTEROL CHECKS, HEMOGLOBIN, PULMONARY FUNCTION TESTING, PHYSICAL THERAPY, DISTANT ACUITY, COGNITION ASSESSMENTS, SKIN SCREENING, FOOT SCREENING, HEEL SCANS, SPIROMETRY TESTING AND PERIPHERAL VASCULAR SCREENING. IN ADDITION, AS PART OF MAMMOGRAPHY DAY WE PARTNER WITH TAZEWELL COUNTY HEALTH DEPARTMENT TO OFFER FREE MAMMOGRAMS TO UNINSURED WOMEN OF THE AGE OF 40. THERE WERE 1,037 SCREENINGS GIVEN IN 2013, 1,980 GIVEN IN 2014 AND 811 IN 2015. PROGRESSIVE HEALTH SYSTEMS ALSO PARTICIPATED IN A NUMBER OF HEALTH FAIRS THROUGHOUT TAZEWELL AND PEORIA COUNTIES. FROM 2013 TO 2015, THE NUMBER OF PEOPLE THAT PARTICIPATED IN HEALTH FAIR SCREENINGS WAS 1276. PROGRESSIVE HEALTH SYSTEMS CONTINUES TO OFFER EDUCATION ON DIABETES, CPR, WEIGHT LOSS, SKIN CANCER, BONE AND JOINT HEALTH, COLON HEALTH, HEALTH EATING AND EXERCISE AND CARDIO EDUCATION. 5. BECOME A CERTIFIED CHEST PAIN CENTER - N/A 6. OPEN A CLINICAL DECISION UNIT ADJACENT TO THE EMERGENCY DEPARTMENT TO ENHANCE OPTIMUM CARE FOR CARDIAC PATIENTS - IN JULY 2013, PROGRESSIVE HEALTH SYSTEMS OPENED A CLINICAL DECISION UNIT (CDU) THAT PROVIDES AN AREA TO CARE FOR PATIENTS WHO HAS HAVE BEEN ADMITTED, BUT WHOSE CONDITION NECESSITATES
SCHEDULE H, PART V, SECTION B, LINE 10A	HTTP://PEKINHOSPITAL.ORG/_DATA/FILES/COMMUNITYHEALTHNEEDSASSESSMENT2.PDF
SCHEDULE H, PART V, SECTION B, LINE 16A	HTTP://PEKINHOSPITAL.ORG/_DATA/FILES/FULL%20FINANCIAL%20ASSISTANCE%20POLIC Y.PDF
SCHEDULE H, PART V, SECTION B, LINE 16B	HTTP://WWW.PEKINHOSPITAL.ORG/_DATA/FILES/1_2_HOSPITAL%20ASSISTANCE%20APPLI CATION_0116.DOCX
SCHEDULE H, PART V, SECTION B, LINE 16C	HTTP://WWW.PEKINHOSPITAL.ORG/_DATA/FILES/1_2_HOSPITAL%20ASSISTANCE%20APPLI CATION_0116.DOCX

Schedule H (Form 990) 2014

Page

Part VFacility Information (continued)

Section D. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, from largest to smallest) How many non-hospital health care facilities did the organization operate during the tax year?2
Name and address		Type of Facility (describe)
1	PEKIN HOSPITAL MRI BUILDING 1300 PARK AVENUE PEKIN,IL61554	DIAGNOSTIC CENTER
2	PEKIN HOSPITAL PAIN MANAGEMENT LLC 600 SOUTH 13TH STREET PEKIN,IL61554	PAIN CLINIC
3
4
5
6
7
8
9
10

Schedule H (Form 990) 2014

Page

Part VI

Supplemental Information

Provide the following information.

1	Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b.
2	Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B.
3	Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4	Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5	Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6	Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7	State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.

Form and Line Reference	Explanation
SCHEDULE H, PART III, SECTION A, LINE 2	BAD DEBT METHODOLOGY THE COST OF BAD DEBT EXPENSE TO THE ORGANIZATION IS DETERMINED BY COMPUTING A RATIO OF COST (TOTAL OPERATING EXPENSE) TO GROSS CHARGES AND THEN MULTIPLYING THAT RATIO BY THE BAD DEBT EXPENSE REPORTED FOR THE HOSPITAL.
SCHEDULE H, PART III, SECTION A, LINE 3	BAD DEBT INCLUDED IN COMMUNITY BENEFIT THE ORGANIZATION ESTIMATED THE COST OF BAD DEBT AT 15%. PERCENTAGE WAS OBTAINED UTILIZING LOXOGON TESTING. THE HOSPITAL COMMITS SIGNIFICANT TIME AND RESOURCES TO ENDEAVORS AND CRITICAL SERVICES WHICH MEET OTHERWISE UNFILLED COMMUNITY NEEDS. MANY OF THESES ACTIVITIES ARE SPONSORED WITH THE KNOWLEDGE THAT THEY WILL NOT BE SELF-SUPPORTING OR FINANCIALLY VIABLE. ADDITIONALLY, AMOUNTS IN LINE 3 EXIST DUE TO THE NUMBER OF PATIENTS WHO DID NOT TAKE THE TIME TO APPLY FOR CHARITY CARE, BUT OTHERWISE QUALIFIED.
SCHEDULE H, PART III, SECTION A, LINE 4	BAD DEBT EXPENSE ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTABILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR UNCOLLECTIBLE ACCOUNTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR UNCOLLECTIBLE ACCOUNTS, IF NECESSARY (FOR EXAMPLE, FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYER HAS NOT YET PAID, OR FOR PAYERS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY). FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL RECORDS A SIGNIFICANT PROVISION FOR UNCOLLECTIBLE ACCOUNTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED OR PROVIDED BY POLICY) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS.
SCHEDULE H, PART III, SECTION B, LINE 8	SHORTFALL LINE 6 IS TAKEN FROM MCR COST REPORT - COST TO CHARGE RATIO. THE MEDICARE COST REPORT IS FILED FOLLOWING THE COST REPORT GUIDELINES. MEDICARE PAYMENT SHORTFALLS SHOULD BE REFLECTED AS COMMUNITY BENEFIT AS THE FEDERAL GOVERNMENT PROSPECTIVELY SETS THE HOSPITAL PAYMENT RATES; THE RATES ARE NOT NEGOTIABLE AND CONSEQUENTLY, NO LONGER COVER THE HOSPITAL'S COST TO PROVIDE SERVICES TO MEDICARE BENEFICIARIES.
SCHEDULE H, PART III, SECTION C, LINE 9B	DEBT COLLECTION POLICY PEKIN FOLLOWS THE CHARITY POLICY, REGARDLESS OF THEIR INSURANCE SITUATION. FOR EXAMPLE, IF THE PERSON HAS A FORM OF INSURANCE, THE INSURANCE COMPANY PAYS, AND PEKIN APPLIES CHARITY CARE BENEFITS TO THE SELF-PAY PORTION REMAINING AFTER THE INSURANCE PAYMENT.
SCHEDULE H, PART VI, LINE 2	NEEDS ASSESSMENT PEKIN HOSPITAL CONTRACTED WITH QHR, ITS MANAGEMENT CONSULTANT, TO ASSIST WITH THE CREATION OF ITS STRATEGIC PLAN. THE COMMUNITY ASSESSMENT WAS PERFORMED THROUGH A SERIES OF FOCUS GROUPS, COMMUNITY SURVEYS, PHYSICIAN PANEL DISCUSSIONS, INTERNAL STATISTICAL DATA, AND COUNTY AND SERVICE AREA DEMOGRAPHICS.
SCHEDULE H, PART VI, LINE 3	PATIENT EDUCATION OF ELIGIBILITY TO MAKE OUR PATIENTS, FAMILIES AND THE BROADER COMMUNITY AWARE OF THE HOSPITAL'S FINANCIAL ASSISTANCE PROGRAM, THE HOSPITAL HAS TAKEN A NUMBER STEPS TO NOTIFY VISITORS TO ITS FACILITY OF THIS POLICY AND TO WIDELY PUBLICIZE THIS POLICY TO MEMBERS OF THE BROADER COMMUNITY SERVED BY THE HOSPITAL INCLUDING: POSTING OF LEGIBLE SIGNAGE IN HEAVILY TRAFFICKED PATIENT AREAS SUCH AS ADMITTING, EMERGENCY DEPARTMENT AND AMBULATORY REGISTRATION AREAS; PROVIDING PAMPHLETS AND BROCHURES DURING THE ADMISSION AND/OR DISCHARGE PROCESS; PROVIDING NOTICE OF AVAILABILITY OF FINANCIAL ASSISTANCE OR DISCOUNTED CARE AND OTHER FORMS OF COMMUNICATIONS; OFFERING PATIENT AND FAMILY COUNSELING SESSIONS WITH REGISTRARS, PATIENT ACCOUNTING STAFF, OR FINANCIAL COUNSELORS EITHER BEFORE, DURING OR AFTER THE TIME OF SERVICE, AS APPROPRIATE; AND PROVIDING INFORMATION ABOUT THIS POLICY ON THE HOSPITAL'S WEBSITE, INCLUDING THE APPLICATION AND A PLAIN LANGUAGE SUMMARY OF THE POLICY IN A WIDELY AVAILABLE FORMAT, FOR EXAMPLE AS A PDF DOCUMENT. PROVIDING A PLAIN LANGUAGE SUMMARY OF THE POLICY WITH ALL BILLING STATEMENTS (AT LEAST 3 BILLING STATEMENTS) AND ALL OTHER WRITTEN COMMUNICATIONS REGARDING THE BILL DURING THE NOTIFICATION PERIOD; OFFERING AN APPLICATION BEFORE DISCHARGE FROM THE HOSPITAL; INFORMING PATIENTS ABOUT THE HOSPITAL'S POLICY IN ALL ORAL COMMUNICATION REGARDING THE AMOUNT DUE; AND PROVIDING AT LEAST ONE WRITTEN NOTICE STATING WHAT ECAS THE HOSPITAL MAY TAKE IF NO APPLICATION IS RECEIVED OR NO PAYMENTS ARE MADE BY A SPECIFIED DATE (AT LEAST AS LONG AS NOTIFICATION PERIOD) AND THIS NOTICE IS PROVIDED AT LEAST 30 DAYS BEFORE THE DEADLINE. SIGNAGE MUST COMMUNICATE IN CAPITAL LETTERS IF YOU ARE UNINSURED, A SOCIAL SECURITY NUMBER IS NOT REQUIRED TO QUALIFY FOR FREE OR DISCOUNTED CARE. ALL PRINTED INFORMATION AND/OR FORMS REGARDING THE FINANCIAL ASSISTANCE PROGRAM WILL BE AVAILABLE IN PRIMARY LANGUAGES SPOKEN BY POPULATIONS WE SERVE IN ACCORDANCE WITH STATE AND FEDERAL LAW. PRINTED COPIES OF THIS POLICY (INCLUDING THE APPLICATION), ITS PLAIN LANGUAGE SUMMARY, AND THE HOSPITAL'S COLLECTIONS POLICY MAY BE OBTAINED AT NO EXTRA COST BY VISITING OR CALLING THE HOSPITAL'S BUSINESS OFFICE.
SCHEDULE H, PART VI, LINE 4	COMMUNITY INFORMATION PEKIN HOSPITAL PRIMARILY SERVES TAZEWELL, MASON AND PEORIA COUNTIES IN THE STATE OF ILLINOIS. IT IS ONE OF THE LARGEST EMPLOYERS IN THE CITY OF PEKIN AND IN TAZEWELL COUNTY. THE SERVICE AREA SITS TO THE SOUTH AND EAST OF THE GREATER PEORIA AREA, WHERE CATERPILLAR IS A MAJOR INDUSTRIAL EMPLOYER. ITS PRIMARY SERVICE AREA HAS A POPULATION OF 58,997 WITH A SECONDARY SERVICE AREA OF APPROXIMATELY 14,213. THE MEDIAN AGE OF ITS SERVICE AREA IS 43 YEARS, WHILE THE MEDIAN HOUSEHOLD INCOME IS $54,500.
SCHEDULE H, PART VI, LINE 5	PROMOTION OF COMMUNITY HEALTH PEKIN HOSPITAL PROVIDES MANY FREE HEALTH SCREENINGS THROUGHOUT THE YEAR TO PROMOTE EARLY DETECTION AND PREVENTION. THIS INCLUDES BUT IS NOT LIMITED TO MAMMOGRAPHY, BONE DENSITY, BLOOD PRESSURE, COLON, OBESITY AND SPIROMETRY. PEKIN HOSPITAL HAS ENGAGED ITS PHYSICIANS TO SPEAK AT DIFFERENT COMMUNITY ORGANIZATIONS, TO SHARE INFORMATION ON HEALTH AND WELL-BEING. IT HAS ALSO SENT REPRESENTATIVES OUT TO DISCUSS HEALTHCARE REFORM. IN FY 2014, PEKIN HOSPITAL HAD CONSOLIDATED COST OF BAD DEBT, CHARITY CARE, AND UNREIMBURSED MEDICAID COSTS TOTALING $7,751,000. IN FY 2015 THAT NUMBER WAS $9,128,000.
SCHEDULE H, PART VI, LINE 6	AFFILIATED HEALTH CARE SYSTEM PROGRESSIVE HEALTH SYSTEM IS THE SOLE MEMBER OF PEKIN HOSPITAL, PEKIN HOSPITAL FOUNDATION, PARK COURT LIMITED, PRO HEALTH INC AND PEKIN PAIN MANAGEMENT, LLC. PEKIN HOSPITAL IS A NOT-FOR-PROFIT ENTITY AND IS THE ONLY HOSPITAL UNDER THE PROGRESSIVE HEALTH SYSTEM UMBRELLA. THE FOUNDATION IS A NOT-FOR-PROFIT ENTITY THAT RAISES FUNDS ON BEHALF OF PEKIN HOSPITAL TO ASSIST WITH PURCHASES OF CAPITAL EQUIPMENT AND OTHER LARGE EXPENSES FOR MEDICAL CARE. PARK COURT LIMITED IS A NOT-FOR-PROFIT ENTITY THAT FUNCTIONS AS A PROPERTY HOLDING COMPANY WHICH LEASES MEDICAL OFFICE SPACE TO MEDICAL CARE PROVIDERS. PRO HEALTH INC. IS A FOR-PROFIT PHYSICIAN CLINIC THAT EMPLOYS PHYSICIANS TO CARE FOR ITS PATIENTS AND WHO ALSO HAVE ADMITTING RIGHTS TO PEKIN HOSPITAL. PEKIN HOSPTAL PARTNERED WITH TAZEWELL PAIN MANAGEMENT, LLC TO BRING A PAIN MANAGEMENT SERVICES TO THE COMMUNITY. THE PAIN SERVICES ARE OFFERED UNDER PEKIN PAIN MANAGEMENT, LLC.
SCHEDULE H, PART VI, LINE 7	STATEMENT FILING OF COMMUNITY BENEFIT REPORT ILLINOIS ONLY
SCHEDULE H, PART I, LINE 7	COST METHODOLOGY THE COSTS REPORTED IN THE TABLE IN PART I, LINE 7 USED A RATIO OF PATIENT CARE COSTS TO CHARGES AS COMPUTED IN WORKSHEET 2 OF THE FORM INSTRUCTIONS. THIS METHODOLOGY WAS USED FOR ALL PATIENT SEGMENTS.
SCHEDULE H, PART I, LINE 7, COLUMN F	BAD DEBT NO BAD DEBT EXPENSE WAS INCLUDED IN PART IX, LINE 25.

Schedule H (Form 990) 2014

Additional Data

Software ID:
Software Version:

- TIN:

Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet

Complete if the organization answered "Yes" to Form 990, Part IV, line 23.
SchJMediumBullet

Attach to Form 990.
SchJMediumBullet

Information about Schedule J (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2014

Open to Public Inspection

Name of the organization

Pekin Memorial Hospital

Employer identification number

37-0692351

Part I

Questions Regarding Compensation

Yes

Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.

First-class or charter travel Housing allowance or residence for personal use

Travel for companions Payments for business use of personal residence

Tax idemnification and gross-up payments Health or social club dues or initiation fees

Discretionary spending account Personal services (e.g., maid, chauffeur, chef)

If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain....

Yes

Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
directors, trustees, officers, including the CEO/Executive Director, regarding the items checked in line 1a? ..

Yes

Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

Form 990 of other organizations Approval by the board or compensation committee

During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:

Receive a severance payment or change-of-control payment? ................

Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........

Participate in, or receive payment from, an equity-based compensation arrangement? .........

If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.

Only 501(c)(3), 501(c)(4), and 501(c)(29) organizations must complete lines 5-9.

For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 5a or 5b, describe in Part III.

For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 6a or 6b, describe in Part III.

For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............

Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................

If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50053T

Schedule J (Form 990) 2014

Page 2

Part II

Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.

For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.

(A) Name and Title		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation in column(B) reported as deferred in prior Form 990
(A) Name and Title		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)
1STEVEN C HALLCFO	(i) (ii)	269,789 ............................... 0	0 ............................... 0	0 ............................... 0	9,384 ............................... 0	5,680 ............................... 0	284,853 ............................... 0	0 ............................... 0
2BOB HALEYCEO	(i) (ii)	140,000 ............................... 0	0 ............................... 0	0 ............................... 0	0 ............................... 0	39,216 ............................... 0	179,216 ............................... 0	0 ............................... 0
3DR ERIC REINERTSONTRUSTEE	(i) (ii)	0 ............................... 385,473	0 ............................... 0	0 ............................... 2,301	0 ............................... 0	0 ............................... 9,536	0 ............................... 397,310	0 ............................... 0
4GARY JEPSONCEO (FORMER)	(i) (ii)	111,962 ............................... 0	0 ............................... 0	0 ............................... 0	0 ............................... 0	29,992 ............................... 0	141,954 ............................... 0	0 ............................... 0
5ANGELIA DREHERDIRECTOR OF PHARMACY	(i) (ii)	144,361 ............................... 0	0 ............................... 0	183 ............................... 0	4,410 ............................... 0	9,536 ............................... 0	158,490 ............................... 0	0 ............................... 0
6JO ELLEN PATTERSONCNO	(i) (ii)	169,177 ............................... 0	0 ............................... 0	1,200 ............................... 0	7,951 ............................... 0	1,200 ............................... 0	179,528 ............................... 0	0 ............................... 0

Schedule J (Form 990) 2014

Page 3

Part III

Supplemental Information

Provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II.
Also complete this part for any additional information.

Return Reference	Explanation
SCHEDULE J, PART I, LINE 1A	HEALTH OR SOCIAL CLUB DUES OR INITIATION FEES BOB HALEY, CEO, IS THE ONLY INDIVIDUAL THAT RECEIVED PAYMENT FOR HEALTH/SOCIAL CLUB MEMBERSHIP DUES. THE ORGANIZATION ONLY PAYS FOR EXPENSES RELATED TO THE BUSINESS USE OF THE MEMBERSHIP.
SCHEDULE J, PART I, LINE 1B	WRITTEN POLICY REGARDING PAYMENT OR REIMBURSEMENT THE COUNTRY CLUB DOES NOT ALLOW MEMBERSHIPS TO BE IN THE NAME OF ANY BUSINESS, THEREFORE, THE ORGANIZATION IS USING THE NAME OF ITS CEO. THE ORGANIZATION ONLY PAYS FOR EXPENSES RELATED TO THE BUSINESS USE OF THE MEMBERSHIP.
COMPENSATION PAID BY AN UNRELATED MANAGEMENT COMPANY	THE FORMER CEO, GARY JEPSON, AND THE PRESENT CEO, BOB HALEY, ARE PAID BY AN UNRELATED MANAGEMENT COMPANY, QUORUM HEALTH RESOURCES. QUORUM PROVIDED GARY JEPSON AND BOB HALEY WITH COMPENSATION IN THE AMOUNT OF $141,954 AND $179,216 RESPECTIVELY. ALL FEES ARE PAID TO QUORUM BY PEKIN MEMORIAL HOSPITAL.

Schedule J (Form 990) 2014

Additional Data

Software ID:
Software Version:

- TIN:

Schedule K
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Information on Tax Exempt Bonds

Complete if the organization answered "Yes" to Form 990, Part IV, line 24a. Provide descriptions,
explanations, and any additional information in Part VI.
SchKMediumBullet

Attach to Form 990.
SchKMediumBullet

Information about Schedule K (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2014

Open to Public
Inspection

Name of the organization
Pekin Memorial Hospital

Employer identification number
37-0692351

Part I

Bond Issues

(a) Issuer name		(b) Issuer EIN	(c) CUSIP #	(d) Date issued	(e) Issue price	(f) Description of purpose	(g) Defeased		(h) On behalf of issuer		(i) Pool financing
(a) Issuer name		(b) Issuer EIN	(c) CUSIP #	(d) Date issued	(e) Issue price	(f) Description of purpose	Yes	No	Yes	No	Yes	No
A	CITY OF PEKIN TAZEWELL COUNTY ILLINOIS	37-6002169		03-30-2010	23,530,000	SEE PART VI		X		X		X

Part II

Proceeds

	A		B		C		D
	1 Amount of bonds retired . . . . . . . . . . . . . .	12,125,000
2 Amount of bonds legally defeased . . . . . . . . . . .	0
3 Total proceeds of issue . . . . . . . . . . . . . .	23,530,000
4 Gross proceeds in reserve funds . . . . . . . . . . . .	2,835,000
5 Capitalized interest from proceeds . . . . . . . . . . .	0
6 Proceeds in refunding escrows . . . . . . . . . . . .	11,405,000
7 Issuance costs from proceeds . . . . . . . . . . . .	283,000
8 Credit enhancement from proceeds . . . . . . . . . . .	0
9 Working capital expenditures from proceeds . . . . . . . . .	0
10 Capital expenditures from proceeds . . . . . . . . . . .	0
11 Other spent proceeds . . . . . . . . . . . . . .	0
12 Other unspent proceeds . . . . . . . . . . . . . .	0
13 Year of substantial completion . . . . . . . . . . . .	2010
	Yes	No	Yes	No	Yes	No	Yes	No
14 Were the bonds issued as part of a current refunding issue? . . . . .	X
15 Were the bonds issued as part of an advance refunding issue? . . . . .		X
16 Has the final allocation of proceeds been made? . . . . . . . .		X
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? . . . . . . . . . . . . . .	X

Part III

Private Business Use

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds? . . . . . . .		X
2 Are there any lease arrangements that may result in private business use of bond-financed property? . . . . . . . . .	X

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50193E

Schedule K (Form 990) 2014

Page 2

Part III

Private Business Use (Continued)

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
3a Are there any management or service contracts that may result in private business use of bond-financed property? . . . . . . . . . . . .		X
b If "Yes" to line 3a, does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts relating to the financed property?
c Are there any research agreements that may result in private business use of bond-financed property? . . . . . . . . . . . . . . .		X
d If "Yes" to line 3c, does the organization routinely engage bond counsel or other outside counsel to review any research agreements relating to the financed property?
4 Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government . .	2.400 %
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government . . . . . . .	0 %
6 Total of lines 4 and 5 . . . . . . . . . . . . .	2.400 %
7 Does the bond issue meet the private security or payment test? . . . . .		X
8a Has there been a sale or disposition of any of the bond-financed property to a nongovernmental person other than a 501(c)(3) organization since the bonds were issued?. . . . . . . . . . . . . . . . .		X
b If "Yes" to line 8a, enter the percentage of bond-financed property sold or disposed of.
c If "Yes" to line 8a, was any remedial action taken pursuant to Regulations sections 1.141-12 and 1.145-2? . . . . . . . . . . . . .		X
9 Has the organization established written procedures to ensure that all nonqualified bonds of the issue are remediated in accordance with the requirements under Regulations sections 1.141-12 and 1.145-2? . . . . . . .	X

Part IV

Arbitrage

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Has the issuer filed Form 8038-T, Arbitrage Rebate, Yield Reduction and Penalty in Lieu of Arbitrage Rebate? . .	X
2 If "No" to line 1, did the following apply? . . . .
a Rebate not due yet? . . . . . . . .
b Exception to rebate? . . . . . . . .
c No rebate due? . . . . . . . .
If "Yes" to line 2c, provide in Part VI the date the rebate computation was performed . . . . . .
3 Is the bond issue a variable rate issue? . . . .		X
4a Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue?		X
b Name of provider . . . . . . . . .	0
c Term of hedge . . . . . . . . . .
d Was the hedge superintegrated? . . . .
e Was the hedge terminated? . . . . . .

Schedule K (Form 990) 2014

Page 3

Part IV

Arbitrage (Continued)

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
5a Were gross proceeds invested in a guaranteed investment contract (GIC)? . . . . . . . . .		X
b Name of provider . . . . . . . . .	0
c Term of GIC . . . . . . . . . .
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? . . . . .
6 Were any gross proceeds invested beyond an available temporary period? . . . . . . . .		X
7 Has the organization established written procedures to monitor the requirements of section 148? . . .		X

Part V

Procedures To Undertake Corrective Action

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
Has the organization established written procedures to ensure that violations of federal tax requirements are timely identified and corrected through the voluntary closing agreement program if self-remediation is not available under applicable regulations?		X

Part VI

Supplemental Information. Provide additional information for responses to questions on Schedule K (see instructions).

Return Reference	Explanation
PART I, LINE A, COLUMN F	REV REFUNDING BONDS SER 1993B AND C AND 1997

Schedule K (Form 990) 2014

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 990-EZ or to provide any additional information.
MediumBullet

Attach to Form 990 or 990-EZ.
MediumBullet

Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.

OMB No. 1545-0047

2014

Open to Public
Inspection

Name of the organization

Pekin Memorial Hospital

Employer identification number

37-0692351

Return Reference	Explanation
FORM 990, PART VI, SECTION A, LINE 2	FAMILY AND BUSINESS RELATIONSHIPS DR. SMALLEY AND CURTIS EETON HAVE A BUSINESS RELATIONSHIP. ALL BOARD MEMBERS AND OFFICERS HAVE A BUSINESS RELATIONSHIP WITH EACH OTHER AS A RESULT OF ALL SERVING AS BOARD MEMBERS OR OFFICERS OF PEKIN PROHEALTH, INC., A FOR-PROFIT AFFILIATE OF THE ORGANIZATION.
FORM 990, PART VI, SECTION A, LINE 3	DELEGATING AUTHORITY THE BOARD OF DIRECTORS HAS CONTRACTED WITH QUORUM HEALTH RESOURCES (QHR) TO SERVE AS A MANAGEMENT CORPORATION TO ASSIST IN THE LEADERSHIP OF THE HOSPITAL. QHR PROVIDES PEKIN HOSPITAL WITH LEADERSHIP VIA THE CEO ALONG WITH OTHER CONSULTING SERVICES ON FINANCIAL AND STAFFING NEEDS.
FORM 990, PART VI, SECTION A, LINE 6	MEMBERS AND STOCKHOLDERS PROGRESSIVE HEALTH SYSTEMS IS THE SOLE MEMBER OF THE ORGANIZATION.
FORM 990, PART VI, SECTION A, LINE 7A	ELECTION OF GOVERNING BODY THE SOLE MEMBER, PROGRESSIVE HEALTH SYSTEMS, HAS THE POWER TO ELECT AND REMOVE THE MEMBERS OF THE BOARD OF TRUSTEES OF THE ORGANIZATION.
FORM 990, PART VI, SECTION A, LINE 7B	APPROVAL BY MEMBERS THE SOLE MEMBER, PROGRESSIVE HEALTH SYSTEMS, HAS THE RIGHT TO APPROVE THE FOLLOWING DECISIONS BY THE GOVERNING BODY: A) ESTABLISHMENT OR MODIFICATION OF COMPENSATION AND BENEFIT POLICIES; B) DEVELOPMENT OR MODIFICATION OF CORPORATE COMPLIANCE PROGRAMS, INCLUDING PROGRAMS DESIGNED TO DETECT OR PREVENT HEALTH CARE FRAUD OR IMPROPER THIRD PARTY BILLING, ACTIVITIES REGARDING LEGAL AND REGULATORY COMPLIANCE RELATING TO THE CODE, ENVIRONMENTAL ISSUES, OCCUPATIONAL SAFETY AND HEALTH, ANTITRUST, FEDERAL ELECTION LAWS, AND ALL OTHER LAWS APPLICABLE TO THE CORPORATION. VARIOUS OTHER POWERS ARE RESERVED EXCLUSIVELY TO THE SOLE MEMBER, AS OUTLINED IN THE BYLAWS OF THE ORGANIZATION.
FORM 990, PART VI, SECTION B, LINE 11B	PROCESS TO REVIEW 990 FORM 990 WAS REVIEWED BY THE CEO, CFO, AND CONTROLLER. PRIOR TO FILING, THE 990 WAS PROVIDED TO THE BOARD OF DIRECTORS ELECTRONICALLY, AND REVIEWED INDEPENDENTLY BY EACH MEMBER. QUESTIONS BY BOARD MEMBERS WERE HANDLED ON AN INDIVIDUAL BASIS WITH MANAGEMENT.
FORM 990, PART VI, SECTION B, LINE 12C	ORGANIZATION'S POLICY FOR MONITORING COMPLIANCE PERIODIC SURVEYS ARE PERFORMED REQUESTING DISCLOSURES OF CONFLICTS OF INTEREST. IF IT IS DETERMINED THAT A CONFLICT EXISTS, THE EMPLOYEE WILL BE REQUIRED TO RELINQUISH EITHER THE OUTSIDE BUSINESS INTEREST/ARRANGEMENT OR HIS/HER PHS EMPLOYMENT. THE CONFLICT OF INTEREST POLICIES APPLY TO INDIVIDUALS WHO SERVE AS TRUSTEES, MANAGERS (DEPARTMENT HEADS AND ABOVE), CHIEFS OF CLINICAL DEPARTMENTS, AND ANY OTHER EMPLOYEE, MEDICAL STAFF MEMBER OR NON-EMPLOYED CONTRACTOR ACTING IN A MANAGERIAL OR CLINICAL LEADERSHIP CAPACITY DEEMED BY AN ADMINISTRATIVE OFFICER OR CHIEF OF SERVICE TO BE IN A POSITION TO INFLUENCE DECISION-MAKING FOR THE ORGANIZATION. DISCLOSURE WILL OCCUR THROUGH AN ANNUAL CONFLICT OF INTEREST DISCLOSURE STATEMENT AND THE DISCLOSURE OF OTHER ACTUAL OR POTENTIAL CONFLICTS AS THEY ARISE. POTENTIAL CONFLICTS OF INTEREST SHOULD BE REPORTED TO AN IMMEDIATE UPERVISOR, WHO, IN TURN, IS OBLIGATED TO REPORT THE MATTER TO THE CORPORATE COMPLIANCE OFFICER. THE CORPORATE COMPLIANCE OFFICER IS EXPECTED TO INVESTIGATE REPORTED CONFLICTS AND MAKE A REPORT TO THE COMPLIANCE COMMITTEE ON A QUARTERLY BASIS. ALL BOARD MEMBERS ARE REQUIRED TO REPORT ANY POTENTIAL CONFLICTS OFINTEREST TO THE BOARD OR AN APPLICABLE COMMITTEE OF THE BOARD. AFTER EXCUSING THE MEMBER WITH A POTENTIAL CONFLICT, THE REMAINING MEMBERS OF THE BOARD OR COMMITTEE WILL DISCUSS AND DECIDE IF A CONFLICT EXISTS, BOARD MEMBERS FOUND TO HAVE A CONFLICT ARE REQUIRED TO EXCUSE THEMSELVES FROM ANY DISCUSSIONS REGARDING A TRANSACTION RELATED TO A POTENTIAL CONFLICT AND ARE PROHIBITED FROM VOTING ON ANY SUCH MATTER.
FORM 990, PART VI, SECTION C, LINE 19	DISCLOSURE THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE NOT MADE AVAILABLE TO THE PUBLIC.
FORM 990, PART IX, LINE 9	OTHER CHANGES IN NET ASSETS CHANGE IN MINIMUM PENSION LIABILITY <3,654,386> TRANSFERS TO AFFILIATES <4,090,916> CHANGE IN INVESTMENT IN FOUNDATION 36,793 ------------- TOTAL OTHER CHANGE IN NET ASSETS <7,708,509>
FORM 990, SUPPLEMENT TO PART III, LINE 4A	STATEMENT OF PROGRAM SERVICE ACCOMPLISHMENT PROGRESSIVE HEALTH SYSTEMS PEKIN HOSPITAL COMPREHENSIVE COMMUNITY BENEFIT REPORT FOR THE YEAR-ENDED APRIL 30, 2015 MISSION STATEMENT: TO IMPROVE THE HEALTH AND WELL-BEING OF OUR COMMUNITY AND TO DO SO WITH LOVE, COMPASSION AND EXTRAORDINARY MEDICAL CARE. OUR VISION: PEKIN HOSPITAL WILL CONSISTENTLY PROVIDE A SUPERIOR HEALTH CARE EXPERIENCE THAT EARNS THE TRUST OF OUR COMMUNITY. PEKIN HOSPITAL IS: ACCREDITED BY: JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS LICENSED BY: THE STATE OF ILLINOIS DEPARTMENT OF PUBLIC HEALTH AFFILIATED WITH: OSF HEALTHCARE SYSTEM UNIVERSITY OF ILLINOIS COLLEGE OF MEDICINE AT PEORIA PROFESSIONAL THERAPY SERVICES ILLINOIS CENTRAL COLLEGE BRADLEY UNIVERSITY QUORUM HEALTH RESOURCES MEMBER OF: AMERICAN HOSPITAL ASSOCIATION AMERICAN RED CROSS PEORIA REGIONAL BLOOD PROGRAM CONSORTIUM FOR TOTAL HEALTH CARE ILLINOIS ASSOCIATION OF HOME CARE (IAHC) ILLINOIS HOSPITAL ASSOCIATION ILLINOIS MATERNAL CHILD HEALTH COUNCIL PEKIN CHAMBER OF COMMERCE REGION IB TRAUMA AND PERINATAL NETWORKS CERTIFIED BY ILLINOIS DEPARTMENT OF PUBLIC HEALTH DESIGNATED AFFILIATE TRAUMA HOSPITAL EMERGENCY DEPARTMENT APPROVED FOR PEDIATRICS (EDAP) COMMUNITY BENEFIT PLAN - GOALS AND OBJECTIVES A. MEDICATION RECONCILIATION TO FURTHER PROMOTE PATIENT SAFETY, PEKIN HOSPITAL'S MEDICATION RECONCILIATION TEAM WILL HEIGHTEN COMMUNITY AWARENESS OF THE IMPORTANCE OF HAVING AN ACCURATE LISTING OF THEIR MEDICATIONS, AS WELL AS ANY HERBALS, SUPPLEMENTS, OVER-THE-COUNTERS, ETC. B. COMMUNITY EDUCATION TO IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE, PEKIN HOSPITAL WILL OFFER A VARIETY OF EDUCATIONAL OPPORTUNITIES FOR AREA RESIDENTS INCLUDING LECTURES AND CLASSROOM SESSIONS. C. COMMUNITY SUPPORT UNITED WAY - PEKIN HOSPITAL CONTRIBUTES TO THE ANNUAL CAMPAIGN. D. COMMUNITY EMERGENCY RESPONSE E. PROVIDING CARE BASED ON NEED 1. CHARITY CARE 2. MEDICAID 3. MEDICARE F. COMMUNITY INVOLVEMENT 1. COMMUNITY OUTREACH THE MARKETING AND COMMUNITY RELATIONS DEPARTMENT PLAYS AN ACTIVE ROLE IN THE COMMUNITY. OUTREACH AND ENGAGEMENT EFFORTS INCLUDE REGULAR PARTICIPATION IN EVENTS AND SERVICE ORGANIZATIONS INCLUDING BUT NOT LIMITED TO LOCAL CHAMBERS OF COMMERCE, LOCAL CONVENTION AND VISITORS BUREAUS, LOCAL PARK DISTRICTS, LOCAL NOT-FOR-PROFITS, ROTARY, PEKIN MAIN STREET, AND NETWORKING GROUPS. OUR TEAM IS DEVELOPING STRONGER RELATIONSHIPS WITH OUR VALUED COMMUNITY PARTNERS, INCLUDING MEMBERS OF THE LOCAL MEDIA. 2. PEKIN AREA CHAMBER OF COMMERCE PEKIN HOSPITAL WILL CONTINUE ITS ACTIVE ROLE WITH THE CHAMBER OF COMMERCE, AND WILL ENCOURAGE EMPLOYEE PARTICIPATION IN THEIR MANY EVENTS AND/OR VOLUNTEER ROLES. 3. COMMUNITY LEADERSHIP ACADEMY PEKIN HOSPITAL IS DEDICATED TO IDENTIFYING AND PROMOTING FUTURE COMMUNITY LEADERS AND WILL CONTINUE TO ENROLL EMPLOYEES IN THE PEKIN AREA CHAMBER OF COMMERCE ANNUAL COMMUNITY LEADERSHIP ACADEMY. THE ACADEMY AIMS TO INFORM AND EDUCATE EXISTING AND EMERGING LEADERS OF THE LOCAL COMMUNITY, AND TO MOTIVATE THEM TOWARD LEADERSHIP RESPONSIBILITIES BY EXPOSING THEM TO THE REALITIES, OPPORTUNITIES AND CHALLENGES OF THE LOCAL COMMUNITY. G. COMMUNITY SCREENINGS TO FURTHER PROMOTE THE HEALTH OF THE COMMUNITIES WE SERVE, PEKIN HOSPITAL IS COMMITTED TO OFFERING FREE COMMUNITY SCREENINGS EACH MONTH. POPULATIONS AND COMMUNITIES SERVED BY THE HOSPITAL PEKIN HOSPITAL'S PRIMARY SERVICE AREA IS COMPRISED OF THE THREE PEKIN ZIP CODES (INCLUDES SOUTH PEKIN) AND SEVEN ADDITIONAL ZIP CODES LOCATED WEST, SOUTH AND EAST OF PEKIN WITH A TOTAL POPULATION OF APPROXIMATELY 58,997. PEKIN HOSPITAL'S SECONDARY SERVICE AREA IS COMPRISED OF FIVE ZIP CODES LOCATED NORTHWEST, NORTHEAST AND EAST OF PEKIN WITH A TOTAL POPULATION OF APPROXIMATELY 14,213. MEDIAN AGE PRIMARY SERVICE AREA: 40.7 YEARS MEDIAN AGE SECONDARY SERVICE AREA: 42.5 YEARS MEDIAN AGE ILLINOIS: 38.2 YEARS COMPARED TO THE STATE OF ILLINOIS OVERALL, THE PRIMARY SERVICE AREA RESIDENTS HAVE LESS HOUSEHOLD INCOME AND THE SECONDARY SERVICE AREA RESIDENTS HAVE MORE HOUSEHOLD INCOME. MEAN HOUSEHOLD INCOME PRIMARY SERVICE AREA: $54,500 MEAN HOUSEHOLD INCOME SECONDARY SERVICE AREA: $68,864 MEAN HOUSEHOLD INCOME ILLINOIS: $60,363 CHARITY CARE MEDICAL CARE IS AVAILABLE TO PATIENTS, BASED ON MEDICAL NECESSITY, REGARDLESS OF THEIR ABILITY TO PAY. PATIENTS MAY REQUEST CHARITY ASSISTANCE APPLICATIONS BY TELEPHONE OR IN PERSON. PEKIN HOSPITAL WAIVES CHARGES BASED ON REVIEW OF THE PATIENT'S FINANCIAL STATUS COMPARED TO FEDERAL POVERTY GUIDELINES. INFORMATION REGARDING CHARITY CARE MAY BE FOUND THROUGHOUT THE HOSPITAL INCLUDING IN PATIENT REGISTRATION, OUTPATIENT DEPARTMENTS, EMERGENCY DEPARTMENT, AND THE PATIENT SERVICE DEPARTMENTS. INFORMATION REGARDING FINANCIAL PROGRAMS, INCLUDING CHARITY CARE, CAN ALSO BE FOUND ON THE HOSPITAL'S WEBSITE AT WWW.PEKINHOSPITAL.ORG. CHARITY CARE DOES NOT INCLUDE BAD DEBT OR UNREIMBURSED COSTS OF MEDICARE, MEDICAID OR OTHER GOVERNMENT PROGRAMS. THE COST OF PROVIDING CHARITY CARE FOR THE FISCAL YEAR ENDING APRIL 30, 2015 WAS $159,000 COMMUNITY BENEFITS A. LANGUAGE ASSISTANT SERVICES BASED ON THE NEEDS OF OUR NON-ENGLISH SPEAKING GUESTS, PEKIN HOSPITAL PROVIDES INTERPRETER PHONE SERVICES FOR A VARIETY OF LANGUAGES. PEKIN ALSO HAS INTERNAL INTERPRETERS. B. GOVERNMENT SPONSORED INDIGENT HEALTH CARE UNREIMBURSED CARE PROVIDED TO PATIENTS UNDER MEDICARE AND PUBLIC AID PROGRAMS, ELIGIBILITY WHICH IS BASED ON FINANCIAL NEED. INPATIENT AND OUTPATIENTS COSTS ARE INCLUDED. UNREIMBURSED CARE FROM MEDICARE WAS $6,761,000 AND PUBLIC AID WAS $7,728,000 FOR FISCAL YEAR ENDING APRIL 30, 2015 FOR A TOTAL OF $14,489,000. C. DIRECT SUPPORT OF OTHER COMMUNITY ORGANIZATIONS - 1. CONFERENCE SPACE: OVER 400 HOURS WERE DONATED FOR CONFERENCE ROOMS - MOMS WHOLEHEARTED SUPPORT GROUP, CHILDBIRTH EDUCATION, HELP AT HOME, THE COMPASSIONATE FRIENDS, TAZEWELL COUNTY HEALTH DEPARTMENT, PRENATAL AND BREASTFEEDING EDUCATION AND SUPPORT GROUPS, BREASTFEEDING MOTHERS, PEKIN AREA CHAMBER OF COMMERCE, CENTRAL ILLINOIS BREASTFEEDING TASK FORCE, 4-H, ILLINOIS CANCER CENTER, THE UNITED WAY, RED CROSS, AND THE BUSINESS FORUM. 2. UNITED WAY OF PEKIN: $8,000 WAS DONATED IN SUPPORT OF THE 2015 UNITED WAY CAMPAIGN. D. VOLUNTEERS 1. VOLUNTEER HOURS - 19,133 2. VOLUNTEER HOURS FROM SCREENINGS - 525 E. SCREENINGS/HEALTH FAIRS 1. COMMUNITY SCREENINGS: FROM MAY 1, 2014 THROUGH APRIL 30, 2015, PEKIN HOSPITAL PROVIDED A VARIETY OF FREE COMMUNITY SCREENINGS TO 811 INDIVIDUALS IN THE PEKIN AREA. OF THE 811 INDIVIDUALS SCREENED, 218 HAD ABNORMAL RESULTS. THE FOLLOWING SCREENINGS WERE PROVIDED: SKIN SCREENING, BONE DENSITY, HEEL SCANS, BLOOD PRESSURE CHECKS, BODY COMPOSITION, SPIROMETRY TESTING, PERIPHERAL VASCULAR SCREENING, AND PHYSICAL THERAPY FITNESS. PEKIN HIGH SCHOOL BOYS AND GIRLS PHYSICALS IN AUGUST OF 2014, 130 PHYSICALS COMPLETED. WOMEN'S LIFESTYLE SHOW, PERFORMED BONE DENSITY SCREENING, 93 NORMAL SCREENINGS AND 23 ABNORMAL SCREENINGS. SCHRAMM SCHOOL BONE DENSITY SCREENINGS, 15 NORMAL AND 1 ABNORMAL SCREENING. AS PART OF NATIONAL MAMMOGRAPHY DAY 2014, PEKIN HOSPITAL PARTNERED WITH TAZEWELL COUNTY HEALTH DEPARTMENT TO OFFER FREE MAMMOGRAMS TO TAZEWELL COUNTY WOMEN AGES 40 AND OVER WHO ARE UNINSURED. THERE WERE 26 FREE MAMMOGRAMS PROVIDED, WITH 3 ABNORMAL RESULTS. THIS WAS THE 13TH YEAR FOR THE ANNUAL EVENT. 2. HEALTH FAIRS: PEKIN HOSPITAL PARTICIPATED BY PROVIDING SCREENINGS AT A NUMBER OF LOCAL HEALTH FAIRS. A. HERGET BANK HEALTH FAIR: 12 WERE SCREENED FOR BONE DENSITY, 21 FOR SPIROMETRY SCREENING AND 16 FOR BLOOD PRESSURE SCREENING, AND 27 FLU SHOTS ADMINISTERED. B. AVENTINE HEALTH FAIR: 170 PARTICIPATED IN THE LIFTING APTITUDE TEST, 65 FLU SHOTS ADMINISTERED, 144 PARTICIPANTS RECEIVED BLOOD DRAWS. C. PEKIN INSURANCE HEALTH FAIR: 139 FLU SHOTS ADMINISTERED. D. CITY OF PEKIN/TAZEWELL COUNTY HEALTH FAIR: 67 RECEIVED BONE DENSITY SCREENINGS, 16 HAD FOOT SCREENINGS, 9 HAD SKIN SCREENINGS, AND 35 HAD PHYSICAL THERAPY FITNESS SCREENINGS. E. FAMILY & BUSINESS SHOWCASE: 13 PARTICIPANTS RECEIVED BLOOD PRESSURE SCREENINGS, 15 RECEIVED BONE DENSITY SCREENINGS, AND 9 RECEIVED SPIROMETRY SCREENINGS, 6 PARTICIPATED IN THE PHYSICAL THERAPY CHALLENGE, 5 PARTICIPATED IN THE SKIN CANCER SCREENING. F. WOMEN'S LIFESTYLE SHOW: 116 PARTICIPATED IN THE BONE DENSITY SCREENING. G. TREMONT UNITED METHODIST CHURCH: 22 RECEIVED SPIROMETRY SCREENINGS, AND 28 RECEIVED BONE DENSITY SCREENINGS. H. PERIPHERAL VASCULAR DISEASE SCREENING: 23 NORMAL SCREENINGS, 1 ABNORMAL SCREENING. F. COMMUNITY EDUCATION 1. DIABETES EDUCATION: NINE (THREE-HOUR) COMMUNITY DIABETES CLASSES WERE OFFERED TO INCLUDE A TOTAL OF 20 PARTICIPANTS. 2. MEDICATION RECONCILIATION: TO RAISE COMMUNITY AWARENESS ON THIS TOPIC, WALLET CARDS THAT ASSIST PATIENTS IN KEEPING ACCURATE LISTS OF MEDICATIONS WERE PLACED IN ALL INPATIENT FOLDERS. THE WALLET CARDS WERE ALSO PROVIDED AT OUR RETAIL PHARMACY, SENIOR EXPO EVENTS, AND OTHER COMMUNITY EVENTS. 3. PUBLIC LECTURES: A. STRETCH BREAK WORKSHOP AT PEKIN INSURANCE MAIN OFFICE 02/24/2014: 27 PARTICIPANTS B. WO
FORM 990, PART VI, SECTION B, LINE 15A	COMPENSATION REVIEW THE CEO IS EMPLOYED BY AN OUTSIDE MANAGEMENT COMPANY.
FORM 990, PART VI, SECTION B, LINE 15B	COMPENSATION REVIEW HUMAN RESOURCES AND THE CEO REVIEW THE COMPENSATION OF OTHER OFFICERS AND KEY EMPLOYEES OF THE ORGANIZATION ON AN ANNUAL BASIS.
FORM 990 PART IX LINE 11G	DESCRIPTION:PHYSICIAN FEES TOTAL FEES:1198189
FORM 990 PART IX LINE 11G	DESCRIPTION:BLOOD PROCESSING FEES TOTAL FEES:537744
FORM 990 PART IX LINE 11G	DESCRIPTION:RADIOISOTOPES TOTAL FEES:213655
FORM 990 PART IX LINE 11G	DESCRIPTION:THERAPY FEES TOTAL FEES:1082430
FORM 990 PART IX LINE 11G	DESCRIPTION:SERVICE CONTRACTS TOTAL FEES:2348736
FORM 990 PART IX LINE 11G	DESCRIPTION:COLLECTION AGENCY FEES TOTAL FEES:331921
FORM 990 PART IX LINE 11G	DESCRIPTION:CONTRACT LABOR & OTHER PUR SRV TOTAL FEES:3542137

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2014

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

Complete if the organization answered "Yes" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
MediumBullet

Attach to Form 990.
MediumBullet

Information about Schedule R (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2014

Open to Public Inspection

Name of the organization

Pekin Memorial Hospital

Employer identification number

37-0692351

Part I

Identification of Disregarded Entities Complete if the organization answered "Yes" on Form 990, Part IV, line 33.

(a) Name, address, and EIN (if applicable) of disregarded entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Total income	(e) End-of-year assets	(f) Direct controlling entity

Part II

Identification of Related Tax-Exempt Organizations Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1) PROGRESSIVE HEALTH SYSTEMS 600 SOUTH 13TH STREET PEKIN,IL61554 37-1200263	SUPPORT ORG	IL	501(C)3	11 - II	NA		No
(2) PARK COURT LIMITED 600 SOUTH 13TH STREET PEKIN,IL61554 37-1178386	SUPPORT ORG	IL	501(C)3	11 - II	PROG HEALTH		No
(3) PEKIN MEMORIAL HOSPITAL FOUNDATION 600 SOUTH 13TH STREET PEKIN,IL61554 37-1200267	SUPPORT ORG	IL	501(C)3	11 - II	PROG HEALTH		No

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50135Y

Schedule R (Form 990) 2014

Page 2

Part III

Identification of Related Organizations Taxable as a Partnership Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Predominant income(related, unrelated, excluded from tax under sections 512-514)	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?		(k) Percentage ownership
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity		(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No
(1) PEKIN HOSP PAIN MGT 600 SOUTH 13TH STREET PEKIN,IL61554 46-5038592	CLINIC	IL	PEKIN HOSP	RELATED	-24,917	38,138		No		Yes		51.000 %

Part IV

Identification of Related Organizations Taxable as a Corporation or Trust Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(i) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	Yes	No
(1) PRO HEALTH INC (PHI) 600 SOUTH 13TH STREET PEKIN,IL61554 37-1117052	CLINIC	IL	PROG HEALTH	C CORP	0	0		No
(2) MARIGOLD CITY LAND TRUST NO ONE 2956 COURT STREET PEKIN,IL61554 27-2750273	PROPERTY MGMT	IL	PARK COURT	TRUST	0	0		No

Schedule R (Form 990) 2014

Page 3

Part V

Transactions With Related Organizations Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35b, or 36.

Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.

Yes

1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?

a Receipt of (i) interest, (ii) annuities, (iii) royalties, or (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .

Yes

b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

f Dividends from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

g Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

h Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

i Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

j Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

k Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .

l Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .

Yes

m Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .

n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .

Yes

o Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

p Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

q Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

r Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

s Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.

(a) Name of related organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved
(1) PEKIN PAIN MANAGEMENT LLC	A	21,148	FMV
(2) PEKIN PAIN MANAGEMENT LLC	J	78,452	COST +O/H ALLOC
(3) PEKIN PAIN MANAGEMENT LLC	J	161,673	SALARY/BENEFITS
(4) PEKIN PAIN MANAGEMENT LLC	L	29,241	COST +O/H ALLOC
(5) PEKIN PAIN MANAGEMENT LLC	L	13,602	MARKETING COST
(6) PEKIN PAIN MANAGEMENT LLC	L	9,882	COST +O/H ALLOC
(7) PEKIN PAIN MANAGEMENT LLC	R	294,309	PPM PAYMENTS

Schedule R (Form 990) 2014

Page 4

Part VI

Unrelated Organizations Taxable as a Partnership Complete if the organization answered "Yes" on Form 990, Part IV, line 37.

Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.

(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(e) Are all partners section 501(c)(3) organizations?		(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	Yes	No	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Schedule R (Form 990) 2014

Page 5

Part VII

Supplemental Information

Provide additional information for responses to questions on Schedule R (see instructions).

Return Reference	Explanation

Schedule R (Form 990) 2014

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: TO IMPROVE THE HEALTH AND WELL-BEING OF OUR COMMUNITY AND TO DO SO WITH LOVE, COMPASSION AND EXTRAORDINARY MEDICAL CARE.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	11
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	10
5	Total number of individuals employed in calendar year 2014 (Part V, line 2a) ......	5	807
6	Total number of volunteers (estimate if necessary) .............	6	137
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	1,072,923
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	387,071	82,928
9	Program service revenue (Part VIII, line 2g) .........	64,938,205	67,745,618
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	1,703,389	1,522,760
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	2,734,781	1,303,413
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	69,763,446	70,654,719
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	0	0
14	Benefits paid to or for members (Part IX, column (A), line 4).....	0	0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	32,672,990	32,150,708
16a	Professional fundraising fees (Part IX, column (A), line 11e).....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	31,655,182	31,821,288
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	64,328,172	63,971,996
19	Revenue less expenses. Subtract line 18 from line 12.......	5,435,274	6,682,723
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	70,369,575	71,558,832
21	Total liabilities (Part X, line 26).............	31,937,730	33,705,968
22	Net assets or fund balances. Subtract line 21 from line 20.....	38,431,845	37,852,864

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 58,812,929 including grants of $ 0 ) (Revenue $ 68,328,211 )
	PEKIN MEMORIAL HOSPITAL PROVIDES INPATIENT, OUTPATIENT AND EMERGENCY SERVICES TO PATIENTS IN PEKIN, ILLINOIS AND SURROUNDING AREAS. THE HOSPITAL OPERATES A LICENSED 97 ACUTE CARE BED FACILITY. PATIENT DAYS WERE 14,577; ADJUSTED PATIENT DAYS WERE 42,847; CASE MIX INDEX WAS 1.2366. SEE SCHEDULE O.

4b	(Code: ) (Expenses $ including grants of $ ) (Revenue $ )












4c	(Code: ) (Expenses $ including grants of $ ) (Revenue $ )












4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses58,812,929

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	1,293,730	387,774	147,068

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)		(D) Reportable compensation from the organization (W- 2/1099-MISC)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(A) Name and Title
(18) CYNTHIA DORR HARTHAN........................................................................ PHARMACIST	40.0 .......................0.0	X	117,761	0	7,795
(19) CATHERINE METESH........................................................................ PHARMACIST	40.0 .......................0.0	X	109,833	0	8,074
(20) ASHOKKUMAR PATEL........................................................................ PHARMACIST	40.0 .......................0.0	X	112,341	0	8,279

				(A) Total revenue	(B) Related or exempt function revenue	(C) Unrelated business revenue	(D) Revenue excluded from tax under sections 512-514
1a	Federated campaigns..1a
b	Membership dues....1b
c	Fundraising events....1c
d	Related organizations...1d		82,928
e	Government grants (contributions)1e

f	All other contributions, gifts, grants, and similar amounts not included above1f

g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			82,928
			Business Code
2a	PATIENT REVENUE		621110	66,629,279	66,629,279
b	MEDICAL RECORD REVENUE		561000	43,416	43,416
c	REFERENCE LAB REVENUE		621500	1,072,923		1,072,923
d
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			67,745,618
3	Investment income (including dividends, interest, and other similar amounts).......			924,825			924,825
4	Income from investment of tax-exempt bond proceeds..			0
5	Royalties...........			0
		(i) Real	(ii) Personal
6a	Gross rents	26,548
b	Less: rental expenses
c	Rental income or (loss)	26,548	0
d	Net rental income or (loss).......			26,548			26,548
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory	629,988	50,540
b	Less: cost or other basis and sales expenses		82,593
c	Gain or (loss)	629,988	-32,053
d	Net gain or (loss)..........			597,935			597,935
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ..
	a
b	Less: direct expenses ...b
c	Net income or (loss) from fundraising events..			0
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities...			0
10a	Gross sales of inventory, less returns and allowances .
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..			0
Miscellaneous Revenue			Business Code
11a	EHR FUNDS		900099	582,593	582,593
b	CAFETERIA REVENUE		722410	558,519			558,519
c	WELLNESS CENTER		621400	16,689			16,689
d	All other revenue ....			119,064			119,064
e	Total. Add lines 11a–11d ......			1,276,865
12	Total revenue. See Instructions......			70,654,719	67,255,288	1,072,923	2,243,580


				(A) Beginning of year		(B) End of year
1	Cash–non-interest-bearing .............			122,210	1	103,996
2	Savings and temporary cash investments .........			4,991,299	2	5,628,123
3	Pledges and grants receivable, net ...........			0	3	0
4	Accounts receivable, net .............			10,302,326	4	11,523,840
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
				0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
				0	6	0
7	Notes and loans receivable, net .............			0	7	0
8	Inventories for sale or use ..............			1,005,098	8	1,061,171
9	Prepaid expenses and deferred charges ..........			1,162,723	9	1,593,739
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	86,194,566
b	Less: accumulated depreciation .....	10b	63,045,763	24,203,715	10c	23,148,803
11	Investments—publicly traded securities ..........			25,053,928	11	25,108,752
12	Investments—other securities. See Part IV, line 11 .....			0	12	0
13	Investments—program-related. See Part IV, line 11 .....			0	13	0
14	Intangible assets ...............			0	14	0
15	Other assets. See Part IV, line 11 ...........			3,528,276	15	3,390,408
16	Total assets. Add lines 1 through 15 (must equal line 34)......			70,369,575	16	71,558,832
17	Accounts payable and accrued expenses .........			5,770,289	17	6,618,888
18	Grants payable .................			0	18	0
19	Deferred revenue ................			0	19	0
20	Tax-exempt bond liabilities .............			14,135,000	20	11,405,000
21	Escrow or custodial account liability. Complete Part IV of Schedule D..			0	21	0
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........			0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..			2,774,861	23	2,130,972
24	Unsecured notes and loans payable to unrelated third parties ....			0	24	0
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................			9,257,580	25	13,551,108
26	Total liabilities. Add lines 17 through 25.........			31,937,730	26	33,705,968
	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............			38,116,431	27	37,500,657
28	Temporarily restricted net assets ...........			315,414	28	352,207
29	Permanently restricted net assets ...........			0	29	0
	Organizations that do not follow SFAS 117 (ASC 958), check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds ........				30
31	Paid-in or capital surplus, or land, building or equipment fund .....				31
32	Retained earnings, endowment, accumulated income, or other funds				32
33	Total net assets or fund balances ...........			38,431,845	33	37,852,864
34	Total liabilities and net assets/fund balances ........			70,369,575	34	71,558,832