Form990-PF

Department of the Treasury
Internal Revenue Service

Return of Private Foundation
or Section 4947(a)(1) Trust Treated as Private Foundation
bulletDo not enter social security numbers on this form as it may be made public.
bulletInformation about Form 990-PF and its instructions is at www.irs.gov/form990pf.
OMB No. 1545-0052
2015
Open to Public Inspection
For calendar year 2015, or tax year beginning 01-01-2015 , and ending 12-31-2015
Name of foundation
HEALTHCARE SERVICES GROUP CHARITABLE
FOUNDATION
% RICHARD ANDERSON
Number and street (or P.O. box number if mail is not delivered to street address)4700 COUNTRY CLUB DRIVE
  Room/suite
City or town, state or province, country, and ZIP or foreign postal code
JEFFERSON CITY, MO65109
A Employer identification number

46-1181892
B Telephone number (see instructions)

(573) 893-5300
C bullet
G Check all that apply:

D 1. bullet
2. bullet
E bullet
H Check type of organization:
F bullet
I Fair market value of all assets at end
of year (from Part II, col. (c),
line 16)bullet$1,239,508J Accounting method:
 
(Part I, column (d) must be on cash basis.)
Part I Analysis of Revenue and Expenses (The total of amounts in columns (b), (c), and (d) may not necessarily equal the amounts in column (a) (see instructions).) (a) Revenue and
expenses per
books 		(b) Net investment
income 		(c) Adjusted net
income 		(d) Disbursements
for charitable
purposes
(cash basis only)
Revenue 1 Contributions, gifts, grants, etc., received (attach schedule) 257,000
2 Check bullet Sch. B .............
3 Interest on savings and temporary cash investments 211 211  
4 Dividends and interest from securities... 40,412 40,412  
5a Gross rents............      
b Net rental income or (loss)  
6a Net gain or (loss) from sale of assets not on line 10 -5,024
b Gross sales price for all assets on line 6a 1,000,000
7 Capital gain net income (from Part IV, line 2)... 0
8 Net short-term capital gain.........  
9 Income modifications...........  
10a Gross sales less returns and allowances  
b Less: Cost of goods sold....  
c Gross profit or (loss) (attach schedule).....    
11 Other income (attach schedule).......      
12 Total. Add lines 1 through 11........ 292,599 40,623  
Operating and Administrative Expenses 13 Compensation of officers, directors, trustees, etc. 7,207      
14 Other employee salaries and wages......        
15 Pension plans, employee benefits.......        
16a Legal fees (attach schedule).........        
b Accounting fees (attach schedule)....... 1,300 0 0 0
c Other professional fees (attach schedule).... Click to see attachment 14,599      
17 Interest...............        
18 Taxes (attach schedule) (see instructions)... Click to see attachment 151      
19 Depreciation (attach schedule) and depletion...      
20 Occupancy..............        
21 Travel, conferences, and meetings.......        
22 Printing and publications..........        
23 Other expenses (attach schedule)....... Click to see attachment 2,100      
24 Total operating and administrative expenses.
Add lines 13 through 23.......... 25,357 0 0 0
25 Contributions, gifts, grants paid....... 165,482 165,482
26 Total expenses and disbursements. Add lines 24 and 25 190,839 0 0 165,482
27 Subtract line 26 from line 12:
a Excess of revenue over expenses and disbursements 101,760
b Net investment income (if negative, enter -0-) 40,623
c Adjusted net income (if negative, enter -0-)...  
For Paperwork Reduction Act Notice, see instructions.
Cat. No. 11289X Form 990-PF (2015)
Form 990-PF (2015)
Page 2
Part II Balance Sheets Attached schedules and amounts in the description column
should be for end-of-year amounts only. (See instructions.)		 Beginning of year End of year
(a) Book Value (b) Book Value (c) Fair Market Value
Assets 1 Cash—non-interest-bearing............. 4,630 71,253 71,253
2 Savings and temporary cash investments.........      
3 Accounts receivable bullet  
Less: allowance for doubtful accounts bullet        
4 Pledges receivable bullet  
Less: allowance for doubtful accounts bullet        
5 Grants receivable.................      
6 Receivables due from officers, directors, trustees, and other
disqualified persons (attach schedule) (see instructions).....      
7 Other notes and loans receivable (attach schedule) bullet  
Less: allowance for doubtful accounts bullet        
8 Inventories for sale or use..............      
9 Prepaid expenses and deferred charges.......... 100    
10a Investments—U.S. and state government obligations (attach schedule)      
b Investments—corporate stock (attach schedule)....... 1,110,078 1,168,255 1,168,255
c Investments—corporate bonds (attach schedule).......      
11 Investments—land, buildings, and equipment: basis bullet  
Less: accumulated depreciation (attach schedule) bullet        
12 Investments—mortgage loans.............      
13 Investments—other (attach schedule)..........      
14 Land, buildings, and equipment: basis bullet  
Less: accumulated depreciation (attach schedule) bullet        
15 Other assets (describe bullet)      
16 Total assets (to be completed by all filers—see the
instructions. Also, see page 1, item I) 1,114,808 1,239,508 1,239,508
Liabilities 17 Accounts payable and accrued expenses.......... 1,000 1,150
18 Grants payable..................    
19 Deferred revenue.................    
20 Loans from officers, directors, trustees, and other disqualified persons    
21 Mortgages and other notes payable (attach schedule)......    
22 Other liabilities (describe bullet)    
23 Total liabilities (add lines 17 through 22)......... 1,000 1,150
Net Assets or Fund Balances bullet
and complete lines 24 through 26 and lines 30 and 31.
24 Unrestricted..................    
25 Temporarily restricted...............    
26 Permanently restricted...............    
bullet
and complete lines 27 through 31.
27 Capital stock, trust principal, or current funds........    
28 Paid-in or capital surplus, or land, bldg., and equipment fund    
29 Retained earnings, accumulated income, endowment, or other funds 1,113,808 1,238,358
30 Total net assets or fund balances (see instructions)..... 1,113,808 1,238,358
31 Total liabilities and net assets/fund balances (see instructions). 1,114,808 1,239,508
Part III
Analysis of Changes in Net Assets or Fund Balances
1
Total net assets or fund balances at beginning of year—Part II, column (a), line 30 (must agree with end-of-year figure reported on prior year’s return) ...............
1
1,113,808
2
Enter amount from Part I, line 27a .....................
2
101,760
3
Other increases not included in line 2 (itemize) bulletClick to see attachment
3
22,790
4
Add lines 1, 2, and 3 ..........................
4
1,238,358
5
Decreases not included in line 2 (itemize) bullet
5
 
6
Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 30 .
6
1,238,358
Form 990-PF (2015)
Form 990-PF (2015)
Page 3
Part IV
Capital Gains and Losses for Tax on Investment Income
(a) List and describe the kind(s) of property sold (e.g., real estate,
2-story brick warehouse; or common stock, 200 shs. MLC Co.) 		(b) How acquired
P—Purchase
D—Donation 		(c) Date acquired
(mo., day, yr.) 		(d) Date sold
(mo., day, yr.)
1 a SHORT TERM BOND LOSS D 2015-09-28 2015-12-31
b
c
d
e
(e) Gross sales price (f) Depreciation allowed
(or allowable) 		(g) Cost or other basis
plus expense of sale 		(h) Gain or (loss)
(e) plus (f) minus (g)
a 1,000,000   1,005,036 -5,024
b
c
d
e
Complete only for assets showing gain in column (h) and owned by the foundation on 12/31/69 (l) Gains (Col. (h) gain minus
col. (k), but not less than -0-) or
Losses (from col.(h))
(i) F.M.V. as of 12/31/69 (j) Adjusted basis
as of 12/31/69 		(k) Excess of col. (i)
over col. (j), if any
a       -5,036
b
c
d
e
2 Capital gain net income or (net capital loss) Bracket If gain, also enter in Part I, line 7
If (loss), enter -0- in Part I, line 7		 Bracket 2 -5,024
3 Net short-term capital gain or (loss) as defined in sections 1222(5) and (6):
If gain, also enter in Part I, line 8, column (c) (see instructions). If (loss), enter -0-
in Part I, line 8 ................... 		Bracket 3 -5,024
Part V
Qualification Under Section 4940(e) for Reduced Tax on Net Investment Income
(For optional use by domestic private foundations subject to the section 4940(a) tax on net investment income.)
If section 4940(d)(2) applies, leave this part blank.
Was the foundation liable for the section 4942 tax on the distributable amount of any year in the base period?
If "Yes," the foundation does not qualify under section 4940(e). Do not complete this part.
1 Enter the appropriate amount in each column for each year; see instructions before making any entries.
(a)
Base period years Calendar
year (or tax year beginning in) 		(b)
Adjusted qualifying distributions 		(c)
Net value of noncharitable-use assets 		(d)
Distribution ratio
(col. (b) divided by col. (c))
2014 140,406 0 0.0
2013 75,379 0 0.0
2012 0   0.0
2011      
2010      
2
Total of line 1, column (d) .....................
20.0
3
Average distribution ratio for the 5-year base period—divide the total on line 2 by 5, or by
the number of years the foundation has been in existence if less than 5 years . . .
3
0.0
4
Enter the net value of noncharitable-use assets for 2015 from Part X, line 5.....
4
0
5
Multiply line 4 by line 3......................
5
0
6
Enter 1% of net investment income (1% of Part I, line 27b)...........
6
406
7
Add lines 5 and 6........................
7
406
8
Enter qualifying distributions from Part XII, line 4.............
8
165,482
If line 8 is equal to or greater than line 7, check the box in Part VI, line 1b, and complete that part using a 1% tax rate. See the Part VI instructions.
Form 990-PF (2015)
Form 990-PF (2015)
Page 4
Part VI
Excise Tax Based on Investment Income (Section 4940(a), 4940(b), 4940(e), or 4948—see page 18 of the instructions)
1a Bullet and enter “N/A" on line 1. Bracket
Date of ruling or determination letter:   (attach copy of letter if necessary–see instructions)
b 1 406
hereBulletand enter 1% of Part I, line 27b...................
c All other domestic foundations enter 2% of line 27b. Exempt foreign organizations enter 4% of Part I, line 12, col. (b)
2 Tax under section 511 (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-) 2  
3 Add lines 1 and 2........................... 3 406
4 Subtitle A (income) tax (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-) 4  
5 Tax based on investment income. Subtract line 4 from line 3. If zero or less, enter -0- ..... 5 406
6 Credits/Payments:
a 2015 estimated tax payments and 2014 overpayment credited to 2015 6a  
b Exempt foreign organizations—tax withheld at source...... 6b
c Tax paid with application for extension of time to file (Form 8868)... 6c  
d Backup withholding erroneously withheld ........... 6d  
7 Total credits and payments. Add lines 6a through 6d.............. 7 0
8 Enter any penalty for underpayment of estimated tax. if Form 2220 is attached. 8  
9 Tax due. If the total of lines 5 and 8 is more than line 7, enter amount owed.......Bullet 9 406
10 Overpayment. If line 7 is more than the total of lines 5 and 8, enter the amount overpaid...Bullet 10  
11 Enter the amount of line 10 to be: Credited to 2015 estimated taxBullet   RefundedBullet 11  
Part VII-A
Statements Regarding Activities
1a
During the tax year, did the foundation attempt to influence any national, state, or local legislation or did
Yes
No
it participate or intervene in any political campaign? ....................
1a
 
No
b
Did it spend more than $100 during the year (either directly or indirectly) for political purposes (see Instructions
for definition)?.................................
1b
 
No
If the answer is "Yes" to 1a or 1b, attach a detailed description of the activities and copies of any materials
published or distributed by the foundation in connection with the activities.
c
Did the foundation file Form 1120-POL for this year?.....................
1c
 
No
d
Enter the amount (if any) of tax on political expenditures (section 4955) imposed during the year:
(1) On the foundation. bullet$   (2) On foundation managers.bullet$  
e
Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed
on foundation managers.bullet$  
2
Has the foundation engaged in any activities that have not previously been reported to the IRS?.......
2
 
No
If "Yes," attach a detailed description of the activities.
3
Has the foundation made any changes, not previously reported to the IRS, in its governing instrument, articles
of incorporation, or bylaws, or other similar instruments? If "Yes," attach a conformed copy of the changes....
3
 
No
4a
Did the foundation have unrelated business gross income of $1,000 or more during the year?........
4a
 
No
b
If "Yes," has it filed a tax return on Form 990-T for this year?...................
4b
 
 
5
Was there a liquidation, termination, dissolution, or substantial contraction during the year?.........
5
 
No
If "Yes," attach the statement required by General Instruction T.
6
Are the requirements of section 508(e) (relating to sections 4941 through 4945) satisfied either:
  • By language in the governing instrument, or
  • By state legislation that effectively amends the governing instrument so that no mandatory directions
    • that conflict with the state law remain in the governing instrument?................
    6
    Yes
     
    7
    Did the foundation have at least $5,000 in assets at any time during the year? If "Yes," complete Part II, col. (c),
    and Part XV..................................
    7
    Yes
     
    8a
    Enter the states to which the foundation reports or with which it is registered (see instructions)
    bulletMO
    b
    If the answer is "Yes" to line 7, has the foundation furnished a copy of Form 990-PF to the Attorney
    General (or designate) of each state as required by General Instruction G? If "No," attach explanation .
    8b
    Yes
     
    9
    Is the foundation claiming status as a private operating foundation within the meaning of section 4942(j)(3)
    or 4942(j)(5) for calendar year 2015 or the taxable year beginning in 2015 (see instructions for Part XIV)?
    If "Yes," complete Part XIV.............................
    9
    Yes
     
    10
    Did any persons become substantial contributors during the tax year? If "Yes," attach a schedule listing their names
    and addresses. ...............................
    10
     
    No
    Form 990-PF (2015)
    Form 990-PF (2015)
    Page 5
    Part VII-A
    Statements Regarding Activities (continued)
    11
    At any time during the year, did the foundation, directly or indirectly, own a controlled entity within the
    meaning of section 512(b)(13)? If "Yes," attach schedule. (see instructions) .............
    11
     
    No
    12
    Did the foundation make a distribution to a donor advised fund over which the foundation or a disqualified person had
    advisory privileges? If "Yes," attach statement (see instructions).................
    12
     
    No
    13
    Did the foundation comply with the public inspection requirements for its annual returns and exemption application?
    13
    Yes
     
    Website addressbullet  
    14
    The books are in care ofbulletRICHARD ANDERSON Telephone no.bullet (573) 893-5300

    Located atbullet4700 COUNTRY CLUB DRIVEJefferson CityMO ZIP+4bullet65109
    15
    Section 4947(a)(1) nonexempt charitable trusts filing Form 990-PF in lieu of Form 1041.......bullet
    and enter the amount of tax-exempt interest received or accrued during the year ......bullet
    15  
    16 At any time during calendar year 2015, did the foundation have an interest in or a signature or other authority over YesNo
    a bank, securities, or other financial account in a foreign country?
    16   No
    See instructions for exceptions and filing requirements for FinCEN Form 114, Report of Foreign Bank and Financial Accounts (FBAR). If "Yes", enter the name of the foreign country bullet  
    Part VII-B
    Statements Regarding Activities for Which Form 4720 May Be Required
    File Form 4720 if any item is checked in the "Yes" column, unless an exception applies.
    Yes
    No
    1a
    During the year did the foundation (either directly or indirectly):
    (1) Engage in the sale or exchange, or leasing of property with a disqualified person?
    (2) Borrow money from, lend money to, or otherwise extend credit to (or accept it from)
    a disqualified person?......................
    (3) Furnish goods, services, or facilities to (or accept them from) a disqualified person?
    (4) Pay compensation to, or pay or reimburse the expenses of, a disqualified person?
    (5) Transfer any income or assets to a disqualified person (or make any of either available
    for the benefit or use of a disqualified person)?...............
    (6) Agree to pay money or property to a government official? (Exception. Check "No"
    if the foundation agreed to make a grant to or to employ the official for a period
    after termination of government service, if terminating within 90 days.).......
    b
    If any answer is "Yes" to 1a(1)–(6), did any of the acts fail to qualify under the exceptions described in Regulations
    section 53.4941(d)-3 or in a current notice regarding disaster assistance (see instructions)? ........
    1b
     
     
    ........bullet
    c
    Did the foundation engage in a prior year in any of the acts described in 1a, other than excepted acts,
    that were not corrected before the first day of the tax year beginning in 2015?.............
    1c
     
    No
    2
    Taxes on failure to distribute income (section 4942) (does not apply for years the foundation was a private
    operating foundation defined in section 4942(j)(3) or 4942(j)(5)):
    a
    At the end of tax year 2015, did the foundation have any undistributed income (lines 6d
    and 6e, Part XIII) for tax year(s) beginning before 2015?.............
    If "Yes," list the years bullet20, 20, 20, 20
    b
    Are there any years listed in 2a for which the foundation is not applying the provisions of section 4942(a)(2)
    (relating to incorrect valuation of assets) to the year’s undistributed income? (If applying section 4942(a)(2)
    to all years listed, answer "No" and attach statement—see instructions.) ..............
    2b
     
    No
    c
    If the provisions of section 4942(a)(2) are being applied to any of the years listed in 2a, list the years here.
    bullet20, 20, 20, 20
    3a
    Did the foundation hold more than a 2% direct or indirect interest in any business enterprise at
    any time during the year?......................
    b
    If "Yes," did it have excess business holdings in 2015 as a result of (1) any purchase by the foundation
    or disqualified persons after May 26, 1969; (2) the lapse of the 5-year period (or longer period approved
    by the Commissioner under section 4943(c)(7)) to dispose of holdings acquired by gift or bequest; or (3)
    the lapse of the 10-, 15-, or 20-year first phase holding period? (Use Schedule C, Form 4720, to determine
    if the foundation had excess business holdings in 2015.)..................
    3b
     
     
    4a
    Did the foundation invest during the year any amount in a manner that would jeopardize its charitable purposes?
    4a
     
    No
    b
    Did the foundation make any investment in a prior year (but after December 31, 1969) that could jeopardize its
    charitable purpose that had not been removed from jeopardy before the first day of the tax year beginning in 2015?
    4b
     
    No
    Form 990-PF (2015)
    Form 990-PF (2015)
    Page 6
    Part VII-B
    Statements Regarding Activities for Which Form 4720 May Be Required (Continued)
    5a
    During the year did the foundation pay or incur any amount to:
    (1) Carry on propaganda, or otherwise attempt to influence legislation (section 4945(e))?
    (2) Influence the outcome of any specific public election (see section 4955); or to carry
    on, directly or indirectly, any voter registration drive?.............
    (3) Provide a grant to an individual for travel, study, or other similar purposes?
    (4) Provide a grant to an organization other than a charitable, etc., organization described
    in section 4945(d)(4)(A)? (see instructions)................
    (5) Provide for any purpose other than religious, charitable, scientific, literary, or
    educational purposes, or for the prevention of cruelty to children or animals?.....
    b
    If any answer is "Yes" to 5a(1)–(5), did any of the transactions fail to qualify under the exceptions described in
    Regulations section 53.4945 or in a current notice regarding disaster assistance (see instructions)? ......
    5b
     
     
    .........bullet
    c
    If the answer is "Yes" to question 5a(4), does the foundation claim exemption from the
    tax because it maintained expenditure responsibility for the grant?..........
    If "Yes," attach the statement required by Regulations section 53.4945–5(d).
    6a
    Did the foundation, during the year, receive any funds, directly or indirectly, to pay premiums on
    a personal benefit contract?.....................
    b
    Did the foundation, during the year, pay premiums, directly or indirectly, on a personal benefit contract?....
    6b
     
    No
    If "Yes" to 6b, file Form 8870.
    7a
    At any time during the tax year, was the foundation a party to a prohibited tax shelter transaction?
    b
    If yes, did the foundation receive any proceeds or have any net income attributable to the transaction? ....
    7b
     
     
    Form 990-PF (2015)
    Form 990-PF (2015)
    Page 7
    Part VIII
    Information About Officers, Directors, Trustees, Foundation Managers, Highly Paid Employees,
    and Contractors
    1 List all officers, directors, trustees, foundation managers and their compensation (see instructions).
    (a) Name and address (b) Title, and average
    hours per week
    devoted to position     		(c) Compensation
     (If not paid, enter
    -0-)     		(d) Contributions to employee benefit plans and deferred compensation (e) Expense account,
    other allowances
    John C GrossmeierClick to see attachment Director
    1.0     		0    
    PO Box 551 Highway 36 West
    Hannibal,MO63401
    Donald J BabbClick to see attachment Director
    1.0     		0    
    1500 North Oakland
    Bolivar,MO65613
    Gary D DuncanClick to see attachment Director
    1.0     		0    
    1437 Crestwood Drive
    Joplin,MO64801
    Judith K FeuquayClick to see attachment Director
    1.0     		0    
    800 South Ash Street
    Nevada,MO64772
    Herbert B KuhnClick to see attachment Director
    1.0     		0    
    4712 Country Club Drive
    Jefferson City,MO65109
    Diane L LightClick to see attachment Director
    1.0     		0    
    1125 Madison Suite C
    Jefferson City,MO65109
    Joseph B MoodyClick to see attachment President
    1.0     		12,000    
    4700 COUNTRY CLUB DRIVE
    JEFFERSON CITY,MO65109
    Dana L FreseClick to see attachment Vice President
    1.0     		12,000    
    4700 COUNTRY CLUB DRIVE
    JEFFERSON CITY,MO65109
    Richard G AndersonClick to see attachment Treasurer & Secretary
    1.0     		12,000    
    4700 COUNTRY CLUB DRIVE
    JEFFERSON CITY,MO65109
    Jennifer WilbersClick to see attachment Executive Director
    1.0     		12,000    
    4700 COUNTRY CLUB DRIVE
    JEFFERSON CITY,MO65109
    2 Compensation of five highest-paid employees (other than those included on line 1—see instructions). If none, enter “NONE."
    (a) Name and address of each employee paid more than $50,000 (b) Title, and average
    hours per week
    devoted to position     		(c) Compensation (d) Contributions to
    employee benefit
    plans and deferred
    compensation     		(e) Expense account,
    other allowances
     
    Total number of other employees paid over $50,000...................bullet  
    3 Five highest-paid independent contractors for professional services (see instructions). If none, enter "NONE".
    (a) Name and address of each person paid more than $50,000 (b) Type of service (c) Compensation
     
    Total number of others receiving over $50,000 for professional services.............bullet  
    Part IX-A
    Summary of Direct Charitable Activities
    List the foundation’s four largest direct charitable activities during the tax year. Include relevant statistical information such as the number of organizations and other beneficiaries served, conferences convened, research papers produced, etc. Expenses
    1 NONE 0
    2  
    3  
    4  
    Part IX-B
    Summary of Program-Related Investments (see instructions)
    Describe the two largest program-related investments made by the foundation during the tax year on lines 1 and 2. Amount
    1  
    2  
    All other program-related investments. See instructions.
    3  
    Total. Add lines 1 through 3.........................bullet  
    Form 990-PF (2015)
    Form 990-PF (2015)
    Page 8
    Part X
    Minimum Investment Return (All domestic foundations must complete this part. Foreign foundations,see instructions.)
    1
    Fair market value of assets not used (or held for use) directly in carrying out charitable, etc.,
    purposes:
    a
    Average monthly fair market value of securities...................
    1a
    0
    b
    Average of monthly cash balances.......................
    1b
    0
    c
    Fair market value of all other assets (see instructions)................
    1c
    0
    d
    Total (add lines 1a, b, and c).........................
    1d
    0
    e
    Reduction claimed for blockage or other factors reported on lines 1a and
    1c (attach detailed explanation) .............
    1e
     
    2
    Acquisition indebtedness applicable to line 1 assets..................
    2
    0
    3
    Subtract line 2 from line 1d.........................
    3
    0
    4
    Cash deemed held for charitable activities. Enter 1 1/2% of line 3 (for greater amount, see
    instructions) .............................
    4
    0
    5
    Net value of noncharitable-use assets. Subtract line 4 from line 3. Enter here and on Part V, line 4
    5
    0
    6
    Minimum investment return. Enter 5% of line 5..................
    6
    0
    Part XI
    Distributable Amount bullet
    1
    Minimum investment return from Part X, line 6....................
    1
     
    2a
    Tax on investment income for 2015 from Part VI, line 5......
    2a
     
    b
    Income tax for 2015. (This does not include the tax from Part VI.)...
    2b
     
    c
    Add lines 2a and 2b............................
    2c
     
    3
    Distributable amount before adjustments. Subtract line 2c from line 1............
    3
     
    4
    Recoveries of amounts treated as qualifying distributions................
    4
     
    5
    Add lines 3 and 4............................
    5
     
    6
    Deduction from distributable amount (see instructions).................
    6
     
    7
    Distributable amount as adjusted. Subtract line 6 from line 5. Enter here and on Part XIII, line 1 ...
    7
     
    Part XII
    Qualifying Distributions (see instructions)
    1
    Amounts paid (including administrative expenses) to accomplish charitable, etc., purposes:
    a
    Expenses, contributions, gifts, etc.—total from Part I, column (d), line 26 ..........
    1a
    165,482
    b
    Program-related investments—total from Part IX-B..................
    1b
    0
    2
    Amounts paid to acquire assets used (or held for use) directly in carrying out charitable, etc.,
    purposes...............................
    2
    0
    3
    Amounts set aside for specific charitable projects that satisfy the:
    a
    Suitability test (prior IRS approval required)....................
    3a
    0
    b
    Cash distribution test (attach the required schedule) .................
    3b
    0
    4
    Qualifying distributions. Add lines 1a through 3b. Enter here and on Part V, line 8, and Part XIII, line 4
    4
    165,482
    5
    Foundations that qualify under section 4940(e) for the reduced rate of tax on net investment
    income. Enter 1% of Part I, line 27b (see instructions).................
    5
    406
    6
    Adjusted qualifying distributions. Subtract line 5 from line 4..............
    6
    165,076
    Note: The amount on line 6 will be used in Part V, column (b), in subsequent years when calculating whether the foundation qualifies for
    the section 4940(e) reduction of tax in those years.
    Form 990-PF (2015)
    Form 990-PF (2015)
    Page 9
    Part XIII
    Undistributed Income (see instructions)
    (a)
    Corpus     		(b)
    Years prior to 2014     		(c)
    2014     		(d)
    2015
    1 Distributable amount for 2015 from Part XI, line 7 0
    2 Undistributed income, if any, as of the end of 2015:
    a Enter amount for 2014 only....... 0
    b Total for prior years:2013, 2012, 2011 0
    3 Excess distributions carryover, if any, to 2015:
    a From 2010......  
    b From 2011......  
    c From 2012...... 0
    d From 2013...... 75,480
    e From 2014...... 140,546
    fTotal of lines 3a through e........ 216,026
    4Qualifying distributions for 2015 from Part
    XII, line 4: bullet$ 165,482
    a Applied to 2014, but not more than line 2a 0
    b Applied to undistributed income of prior years
    (Election required—see instructions).....     		 
    c Treated as distributions out of corpus (Election
    required—see instructions)........     		 
    d Applied to 2015 distributable amount.....  
    e Remaining amount distributed out of corpus 165,482
    5 Excess distributions carryover applied to 2015.    
    (If an amount appears in column (d), the
    same amount must be shown in column (a).)
    6Enter the net total of each column as
    indicated below:
    a Corpus. Add lines 3f, 4c, and 4e. Subtract line 5 381,508
    b Prior years’ undistributed income. Subtract
    line 4b from line 2b ..........     		0
    c Enter the amount of prior years’ undistributed
    income for which a notice of deficiency has
    been issued, or on which the section 4942(a)
    tax has been previously assessed......     		 
    d Subtract line 6c from line 6b. Taxable amount
    —see instructions ...........     		0
    e Undistributed income for 2014. Subtract line
    4a from line 2a. Taxable amount—see
    instructions .............     		0
    f Undistributed income for 2016. Subtract
    lines 4d and 5 from line 1. This amount must
    be distributed in 2015 ..........     		0
    7 Amounts treated as distributions out of
    corpus to satisfy requirements imposed by
    section 170(b)(1)(F) or 4942(g)(3) (Election may
    be required - see instructions) .......     		 
    8Excess distributions carryover from 2010 not
    applied on line 5 or line 7 (see instructions) ...     		 
    9Excess distributions carryover to 2016.
    Subtract lines 7 and 8 from line 6a ......     		381,508
    10 Analysis of line 9:
    a Excess from 2011....  
    b Excess from 2012.... 0
    c Excess from 2013.... 75,480
    d Excess from 2014.... 140,546
    e Excess from 2015.... 165,482
    Form 990-PF (2015)
    Form 990-PF (2015)
    Page 10
    Part XIV
    Private Operating Foundations (see instructions and Part VII-A, question 9)
    1a If the foundation has received a ruling or determination letter that it is a private operating
    foundation, and the ruling is effective for 2015, enter the date of the ruling.......bullet
     
    b Check box to indicate whether the organization is a private operating foundation described in section or
    2a Enter the lesser of the adjusted net
    income from Part I or the minimum
    investment return from Part X for each
    year listed ..........     		Tax year Prior 3 years (e) Total
    (a) 2015 (b) 2014 (c) 2013 (d) 2012
    0 0 0 0 0
    b 85% of line 2a ......... 0 0 0 0 0
    c Qualifying distributions from Part XII,
    line 4 for each year listed .....     		165,482 140,546 75,480 0 381,508
    d Amounts included in line 2c not used directly
    for active conduct of exempt activities ..........     		         
    e Qualifying distributions made directly
    for active conduct of exempt activities.
    Subtract line 2d from line 2c ....     		165,482 140,546 75,480 0 381,508
    3 Complete 3a, b, or c for the
    alternative test relied upon:
    a “Assets" alternative test—enter:
    (1) Value of all assets ...... 1,239,508 1,114,808 914,357 500,000 3,768,673
    (2) Value of assets qualifying
    under section 4942(j)(3)(B)(i)    		         0
    b “Endowment" alternative test— enter 2/3
    of minimum investment return shown in
    Part X, line 6 for each year listed...     		         
    c “Support" alternative test—enter:
    (1) Total support other than gross
    investment income (interest,
    dividends, rents, payments
    on securities loans (section
    512(a)(5)), or royalties) ....     		        0
    (2) Support from general public
    and 5 or more exempt
    organizations as provided in
    section 4942(j)(3)(B)(iii)....     		        0
    (3) Largest amount of support
    from an exempt organization    		         0
    (4) Gross investment income         0
    Part XV
    Supplementary Information (Complete this part only if the organization had $5,000 or more in
    assets at any time during the year—see instructions.)
    1Information Regarding Foundation Managers:
    aList any managers of the foundation who have contributed more than 2% of the total contributions received by the foundation
    before the close of any tax year (but only if they have contributed more than $5,000). (See section 507(d)(2).)
    bList any managers of the foundation who own 10% or more of the stock of a corporation (or an equally large portion of the
    ownership of a partnership or other entity) of which the foundation has a 10% or greater interest.
    2Information Regarding Contribution, Grant, Gift, Loan, Scholarship, etc., Programs:
    Check here bullet
    aThe name, address, and telephone number or email address of the person to whom applications should be addressed:
    bThe form in which applications should be submitted and information and materials they should include:
    cAny submission deadlines:
    dAny restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other
    factors:
    Form 990-PF (2015)
    Form 990-PF (2015)
    Page 11
    Part XV
    Supplementary Information (continued)
    3 Grants and Contributions Paid During the Year or Approved for Future Payment
    Recipient If recipient is an individual,
    show any relationship to
    any foundation manager
    or substantial contributor
    		 Foundation
    status of
    recipient     		Purpose of grant or
    contribution     		Amount
    Name and address (home or business)
    aPaid during the year
    BJC HEALTHCARE
    8300 EAGER ROAD STE 600A
    ST LOUIS,MO63144     		  NC Scholarship 27,000
    BOTHWELL REGIONAL HEALTH CENTER
    601 EAST 14TH STREET
    SEDALIA,MO65301     		  NC Scholarship 2,500
    CAPITAL REGION MEDICAL CENTER
    1125 MADISON STREET
    JEFFERSON CITY,MO65101     		  NC Scholarship 2,041
    CARROLL COUNTY MEMORIAL HOSPITAL
    1502 NORTH JEFFERSON STREET
    CARROLLTON,MO64633     		  NC Scholarship 3,000
    CASS REGIONAL MEDICAL CENTER
    2800 EAST ROCK HAVEN ROAD
    HARRISIONVILLE,MO64701     		  NC Scholarship 3,000
    CEDAR COUNTY MEMORIAL HOSPITAL
    1401 SOUTH PARK STREET
    EL DORADO SPRINGS,MO64744     		  NC Scholarship 1,665
    FITZGIBBON HOSPITAL
    2305 SOUTH HIGHWAY 65
    MARSHALL,MO65340     		  NC Scholarship 3,000
    FREEMAN HEALTH SYSTEM
    1102 WEST 32ND STREET
    JOPLIN,MO64804     		  NC Scholarship 6,000
    HANNIBAL REGIONAL HEALTHCARE
    6000 HOSPITAL DRIVE
    HANNIBAL,MO63401     		  NC Scholarship 3,000
    HEARTLAND HEALTH
    5325 FARAON STREET
    ST JOSEPH,MO64506     		  NC Scholarship 3,000
    HERMANN AREA DISTRICT HOSPITAL
    509 WEST 18TH STREET
    HERMANN,MO65041     		  NC Scholarship 3,000
    MADISON MEMORIAL HOSPITAL
    611 WEST MAIN STREET
    FREDERICKTOWN,MO63645     		  NC Scholarship 3,000
    MISSOURI DELTA MEDICAL CENTER
    1008 NORTH MAIN STREET
    SIKESTON,MO63801     		  NC Scholarship 3,000
    NEVADA CITY HOSPITAL DBA
    800 SOUTH ASH STREET
    NEVADA,MO64773     		  NC Scholarship 3,000
    NORTHWEST MEDICAL CENTER ASSOCIATION INC
    705 NORTH COLLEGE STREET
    ALBANY,MO64402     		  NC Scholarship 3,000
    PERRY COUNTY MEMORIAL HOSPITAL
    434 NORTH WEST STREET
    PERRYVILLE,MO63775     		  NC Scholarship 3,000
    PUTNAM COUNTY MEMORIAL HOSPITAL
    1926 OAK STREET
    UNIONVILLE,MO63565     		  NC Scholarship 3,000
    SALEM MEMORIAL DISTRICT HOSPITAL
    35629 HIGHWAY 79
    SALEM,MO65560     		  NC Scholarship 1,100
    SAMARITAN MEMORIAL HOSPITAL
    1205 NORTH MISSOURI STREET
    MACON,MO63552     		  NC Scholarship 3,000
    SCOTLAND COUNTY MEMORIAL HOSPITAL
    450 EAST SIGLER AVENUE
    MEMPHIS,MO63555     		  NC Scholarship 3,000
    SOUTHEAST MISSOURI HOSPITAL ASSOCIATION
    1701 LACEY STREET
    CAPE GIRARDEAU,MO63701     		  NC Scholarship 12,000
    TEXAS COUNTY MEMORIAL HOSPITAL
    1333 SOUTH SAM HOUSTON BLVD
    HOUSTON,MO65483     		  NC Scholarship 3,000
    WASHINGTON COUNTY MEMORIAL HOSPITAL
    300 HEALTH WAY
    POTOSI,MO63664     		  NC Scholarship 3,000
    WESTERN MISSOURI MEDICAL CENTER
    403 BURKARTH ROAD
    WARRENSBURG,MO64093     		  NC Scholarship 3,000
    BARTON COUNTY MEMORIAL HOSPITAL
    29 NW 1st LANE
    LAMAR,MO64759     		  NC Scholarship 3,000
    CAMERON REG MED CENTER INC
    P O BOX 557
    CAMERON,MO64429     		  NC Scholarship 3,000
    GOLDEN VALLEY MEMORIAL HOSP
    1600 NORTH SECOND ST
    CLINTON,MO64735     		  NC Scholarship 3,000
    HARRISON COUNTY COMM HOSP DST
    P O BOX 428
    BETHANY,MO64424     		  NC Scholarship 1,000
    PERSHING MEMORIAL HOSPITAL
    130 EAST LOCKLING
    BROOKFIELD,MO64628     		  NC Scholarship 3,000
    SLHS - CRITTENTON CHILDREN'S
    10918 ELM AVE
    KANSAS CITY,MO64134     		  NC Scholarship 3,000
    SLHS - HEDRICK CHILLICOTHE
    2799 NORTH WASHINGTON STREET
    CHILLICOTHE,MO64601     		  NC Scholarship 3,000
    STE GENEVIEVE COUNTY MEM HOSP
    800 STE GENEVIEVE DR
    STE GENEVIEVE,MO63670     		  NC Scholarship 3,000
    CITIZENS MEMORIAL HOSP DIST
    1500 NORTH OAKLAND
    BOLIVAR,MO65613     		  NC Scholarship 3,000
    AMERICAN HEART ASSOCIATION
    460 NORTH LINDBERGH BLVD
    SAINT LOUIS,MO63141     		  NC Gift 700
    THE FOUNDATION FOR BARNES-JEWISH HOSPITAL
    1001 HIGHLANDS PLAZA DR WEST
    SUITE 140
    SAINT LOUIS,MO63110     		  NC Gift 1,000
    HANNIBAL REG HOSP FOUNDATION
    PO BOX 551
    HANNIBAL,MO63401     		  NC Gift 2,000
    HANNIBAL FREE CLINIC
    3145 HIGHWAY 61 NORTH
    HANNIBAL,MO63401     		  NC Gift 1,000
    HEARTLAND CHRISTIAN SCHOOL
    810 SOUTH CEDAR STREET
    BELTON,MO64012     		  NC Gift 75
    JEFFERSON CITY RAPE & ABUSE CRISIS SERVICE
    PO BOX 416
    JEFFERSON CITY,MO65102     		  NC Gift 385
    JEFFERSON CITY YMCA
    525 ELLIS BLVD
    JEFFERSON CITY,MO65101     		  NC Gift 250
    LAKE REGIONAL HEALTH SYSTEM
    54 HOSPITAL DRIVE
    OSAGE BEACH,MO650650187     		  NC Scholarship 3,000
    LEUKEMIA & LYMPHOMA SOCIETY - GATEWAY CHAPTERETY
    1972 INNERBELT BUSINESS CTR DRIVE
    SAINT LOUIS,MO63114     		  NC Gift 500
    MOSS HOUSE
    415 NORTH MAIN STREET
    NEVADA,MO64772     		  NC Gift 150
    NORTHWEST MED CTR ASSN INC
    DBA NORTHWEST MEDICAL CENTER
    705 NORTH COLLEGE
    ALBANY,MO64402     		  NC Gift 1,500
    THE SALVATION ARMY
    927 JEFFERSON STREET
    JEFFERSON CITY,MO65101     		  NC Gift 500
    SAMARITAN CENTER
    PO BOX 1687
    JEFFERSON CITY,MO65102     		  NC Gift 1,750
    SAMARITAN MEM HOSP FOUNDATION
    1205 NORTH MISSOURI
    MACON,MO63552     		  NC Gift 1,000
    EXCELSIOR SPRINGS HOSPITAL
    1700 RAINBOW BLVD
    EXCELSIOR SPRINGS,MO64024     		  NC Scholarship 3,000
    IRON COUNTY MEDICAL CENTER
    301 N HWY 21 PO BOX 548
    PILOT KNOB,MO63663     		  NC Scholarship 3,000
    RAY COUNTY MEMORIAL HOSPITAL
    904 WOLLARD BLVD
    RICHMOND,MO64085     		  NC Scholarship 2,111
    SULLIVAN COUNTY MEMORIAL HOSPITAL
    630 WEST THIRD STREET
    MILAN,MO63556     		  NC Scholarship 3,000
    CENTER FOR PATIENT SAFETY
    2410A HYDE PARK RD
    JEFFERSON CITY,MO65109     		  NC Gift 750
    COMMUNITY WELLNESS MISSION
    4700 COUNTRY CLUB DRIVE
    JEFFERSON CITY,MO65109     		  NC Gift 1,250
    CRITTENTON CHILDREN'S CENTER
    10918 ELM AVE
    KANSAS CITY,MO64134     		  NC Gift 55
    GOOD SHEPARD CENTER
    1117 E ADAMS ST
    LINN,MO65051     		  NC Gift 360
    MADISON COUNTY FOUNDATION FOR HEALTH
    806 W COLLEGE AVE
    FREDERICK,MO63645     		  NC Gift 500
    OSAGE COUNTY MISSOURI - FOOD PANTRY
    1117 ADAMS STREET
    LINN,MO65051     		  NC Gift 75
    SOUTHEAST MISSOURI FAMILY VIOLENCE COUNCIL
    PO BOX 465
    BONNE TERRE,MO63628     		  NC Gift 100
    SPECIAL EDUCATION ENRICHMENT FOUNDATION
    PO BOX 703
    LAFAYETTE,CA94549     		  NC Gift 200
    FOOD BANK OF CENTRAL & NE MISSOURI
    2010 VANDIVER DRIVE
    COLUMBIA,MO65202     		  NC Gift 120
    UNITED WAY
    910 N 11TH STREET
    SAINT LOUIS,MO63101     		  NC Gift 1,445
    PCHS CHILDREN'S HEALTHCARE FUND
    434 N WEST STREET
    PERRYVILLE,MO63775     		  NC Gift 300
    CAPITAL REGION MEDICAL CENTER
    1125 MADISON STREET
    JEFFERSON CITY,MO65101     		  NC Gift 1,000
    CARROLL COUNTY MEMORIAL HOSPITAL
    1502 NORTH JEFFERSON STREET
    CARROLLTON,MO64633     		  NC Gift 1,000
    FITZGIBBON HOSPITAL
    2305 SOUTH HIGHWAY 65
    MARSHALL,MS65340     		  NC Gift 1,100
    FREEMAN HEALTH SYSTEM
    1102 WEST 32ND STREET
    JOPLIN,MO63401     		  NC Gift 1,000
    HERMANN AREA DISTRICT HOSPITAL
    509 WEST 18TH STREET
    HERMANN,MO65041     		  NC Gift 1,000
    SCOTLAND COUNTY MEMORIAL HOSPITAL
    450 EAST SIGLER AVENUE
    MEMPHIS,MO63555     		  NC Gift 1,000
    STE GENEVIEVE COUNTY MEM HOSP
    800 STE GENEVIEVE DR
    STE GENEVIEVE,MO63670     		  NC Gift 1,000
    Total .................................bullet 3a 165,482
    bApproved for future payment
    Total .................................bullet 3b  
    Form 990-PF (2015)
    Form 990-PF (2015)
    Page 12
    Part XVI-A
    Analysis of Income-Producing Activities
    Enter gross amounts unless otherwise indicated. Unrelated business income Excluded by section 512, 513, or 514 (e)
    Related or exempt
    function income
    (See instructions.)
    1Program service revenue: (a)
    Business code     		(b)
    Amount     		(c)
    Exclusion code     		(d)
    Amount
    a
    b
    c
    d
    e
    f
    gFees and contracts from government agencies          
    2 Membership dues and assessments....          
    3
    Interest on savings and temporary cash investments ...........     		        211
    4 Dividends and interest from securities....         40,412
    5 Net rental income or (loss) from real estate:
    aDebt-financed property......          
    bNot debt-financed property.....          
    6
    Net rental income or (loss) from personal property     		         
    7 Other investment income.....          
    8
    Gain or (loss) from sales of assets other than inventory ............     		         
    9 Net income or (loss) from special events:          
    10 Gross profit or (loss) from sales of inventory..          
    11 Other revenue: a
    b
    c
    d
    e
    12 Subtotal. Add columns (b), (d), and (e)..     40,623
    13Total. Add line 12, columns (b), (d), and (e)..................
    1340,623
    (See worksheet in line 13 instructions to verify calculations.)
    Part XVI-B
    Relationship of Activities to the Accomplishment of Exempt Purposes
    Line No.
    DownArrow     		Explain below how each activity for which income is reported in column (e) of Part XVI-A contributed importantly to
    the accomplishment of the foundation’s exempt purposes (other than by providing funds for such purposes). (See
    instructions.)
    Form 990-PF (2015)
    Form 990-PF (2015)
    Page 13
    Part XVII
    Information Regarding Transfers To and Transactions and Relationships With Noncharitable Exempt Organizations
    1
    Did the organization directly or indirectly engage in any of the following with any other organization described in section 501(c) of the Code (other than section 501(c)(3) organizations) or in section 527, relating to political organizations?
    Yes
    No
    a
    Transfers from the reporting foundation to a noncharitable exempt organization of:
    (1) Cash...................................
    1a(1)
     
    No
    (2) Other assets.................................
    1a(2)
     
    No
    b
    Other transactions:
    (1) Sales of assets to a noncharitable exempt organization....................
    1b(1)
     
    No
    (2) Purchases of assets from a noncharitable exempt organization..................
    1b(2)
     
    No
    (3) Rental of facilities, equipment, or other assets.......................
    1b(3)
     
    No
    (4) Reimbursement arrangements...........................
    1b(4)
     
    No
    (5) Loans or loan guarantees.............................
    1b(5)
     
    No
    (6) Performance of services or membership or fundraising solicitations................
    1b(6)
     
    No
    c
    Sharing of facilities, equipment, mailing lists, other assets, or paid employees..............
    1c
     
    No
    d
    If the answer to any of the above is "Yes," complete the following schedule. Column (b) should always show the fair market value
    of the goods, other assets, or services given by the reporting foundation. If the foundation received less than fair market value
    in any transaction or sharing arrangement, show in column (d) the value of the goods, other assets, or services received.

    (a) Line No. (b) Amount involved (c) Name of noncharitable exempt organization (d) Description of transfers, transactions, and sharing arrangements
    2a
    Is the foundation directly or indirectly affiliated with, or related to, one or more tax-exempt organizations
    described in section 501(c) of the Code (other than section 501(c)(3)) or in section 527?...........
    b
    If "Yes," complete the following schedule.

    (a) Name of organization (b) Type of organization (c) Description of relationship
    MO HOSPITAL PLAN 501(C)(4) AFFILIATE
    Sign Here
    Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
    Bullet Bullet
    May the IRS discuss this return
    with the preparer shown below
    (see instr.)?
    Signature of officer or trustee Date Title
    Paid Preparer Use Only Print/Type preparer's name Preparer's Signature Date PTIN
    Firm's name SmallBullet
    		 Firm's EIN SmallBullet
    Firm's address SmallBullet


    		 Phone no.
    Form 990-PF (2015)
    Additional Data


    Software ID:  
    Software Version:  


    Form 990PF - Special Condition Description:
    Special Condition Description
    Schedule B
    (Form 990, 990-EZ,
    or 990-PF)
    Department of the Treasury
    Internal Revenue Service
    Schedule of Contributors
    Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
    Arrow Bullet Information about Schedule B (Form 990, 990-EZ, or 990-PF) and its instructions is at www.irs.gov/form990.
    OMB No. 1545-0047
    2015
    Name of the organization
    HEALTHCARE SERVICES GROUP CHARITABLE
    FOUNDATION
    Employer identification number

    46-1181892
    Organization type (check one):
    Filers of:
    Section:
    Form 990 or 990-EZ





    Form 990-PF




    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
    Special Rules
    ......... 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) (2015)
    Schedule B (Form 990, 990-EZ, or 990-PF) (2015) Page 2
    Name of organization
    HEALTHCARE SERVICES GROUP CHARITABLE
    FOUNDATION         		Employer identification number
    46-1181892
    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
    1
     
     

    Healthcare Services Association  
    4700 Country Club Drive PO Box 14
     
    Jefferson City, MO65102

    		$ 257,000


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
     
     
     

       
     
     

    		$  


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
     
     
     

       
     
     

    		$  


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
     
     
     

       
     
     

    		$  


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
     
     
     

       
     
     

    		$  


    (Complete Part II for noncash contributions.)
    (a)
    No.    		 (b)
    Name, address, and ZIP + 4    		 (c)
    Total contributions    		 (d)
    Type of contribution
     
     
     

       
     
     

    		$  


    (Complete Part II for noncash contributions.)
    Schedule B (Form 990, 990-EZ, or 990-PF) (2015)
    Schedule B (Form 990, 990-EZ, or 990-PF) (2015)
    Page 3
    Name of organization
    HEALTHCARE SERVICES GROUP CHARITABLE
    FOUNDATION         		Employer identification number

    46-1181892
    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) (2015)
    Schedule B (Form 990, 990-EZ, or 990-PF) (2015)
    Page 4
    Name of organization
    HEALTHCARE SERVICES GROUP CHARITABLE
    FOUNDATION         		Employer identification number

    46-1181892
    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 (c) Use 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 (c) Use 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 (c) Use 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 (c) Use 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) (2015)

    Additional Data


    Software ID:  
    Software Version:  

    TY 2015 CompensationExplanation
    Name:
    HEALTHCARE SERVICES GROUP CHARITABLE
     
    FOUNDATION
    EIN:
    46-1181892
    Person Name Explanation
    Joseph B Moody HOSPITAL SERVICES GROUP, INC. ("HSG") PROVIDES MANAGEMENT SERVICES TO HEALTHCARE SERVICES GROUP CHARITABLE FOUNDATION UNDER A CONTRACT SIGNED JANUARY 1, 2014 AND EFFECTIVE UNTIL THE CONTRACT IS CANCELLED OR AMENDED BY EITHER PARTY. UNDER SAID CONTRACT, HSG WAS PAID $12,000 DURING THE YEAR ENDED 12/31/2015. OFFICERS JOSEPH B. MOODY, RICHARD G. ANDERSON, DANA FRESE, AND EXECUTIVE DIRECTOR JENNIFER WILBERS WERE PAID THROUGH HSG FOR THEIR SERVICES PROVIDED TO HEALTHCARE SERVICES GROUP CHARITABLE FOUNDATION.
    Dana L Frese HOSPITAL SERVICES GROUP, INC. ("HSG") PROVIDES MANAGEMENT SERVICES TO HEALTHCARE SERVICES GROUP CHARITABLE FOUNDATION UNDER A CONTRACT SIGNED JANUARY 1, 2014 AND EFFECTIVE UNTIL THE CONTRACT IS CANCELLED OR AMENDED BY EITHER PARTY. UNDER SAID CONTRACT, HSG WAS PAID $12,000 DURING THE YEAR ENDED 12/31/2015. OFFICERS JOSEPH B. MOODY, RICHARD G. ANDERSON, DANA FRESE, AND EXECUTIVE DIRECTOR JENNIFER WILBERS WERE PAID THROUGH HSG FOR THEIR SERVICES PROVIDED TO HEALTHCARE SERVICES GROUP CHARITABLE FOUNDATION.
    Richard G Anderson HOSPITAL SERVICES GROUP, INC. ("HSG") PROVIDES MANAGEMENT SERVICES TO HEALTHCARE SERVICES GROUP CHARITABLE FOUNDATION UNDER A CONTRACT SIGNED JANUARY 1, 2014 AND EFFECTIVE UNTIL THE CONTRACT IS CANCELLED OR AMENDED BY EITHER PARTY. UNDER SAID CONTRACT, HSG WAS PAID $12,000 DURING THE YEAR ENDED 12/31/2015. OFFICERS JOSEPH B. MOODY, RICHARD G. ANDERSON, DANA FRESE, AND EXECUTIVE DIRECTOR JENNIFER WILBERS WERE PAID THROUGH HSG FOR THEIR SERVICES PROVIDED TO HEALTHCARE SERVICES GROUP CHARITABLE FOUNDATION.
    Jennifer Wilbers HOSPITAL SERVICES GROUP, INC. ("HSG") PROVIDES MANAGEMENT SERVICES TO HEALTHCARE SERVICES GROUP CHARITABLE FOUNDATION UNDER A CONTRACT SIGNED JANUARY 1, 2014 AND EFFECTIVE UNTIL THE CONTRACT IS CANCELLED OR AMENDED BY EITHER PARTY. UNDER SAID CONTRACT, HSG WAS PAID $12,000 DURING THE YEAR ENDED 12/31/2015. OFFICERS JOSEPH B. MOODY, RICHARD G. ANDERSON, DANA FRESE, AND EXECUTIVE DIRECTOR JENNIFER WILBERS WERE PAID THROUGH HSG FOR THEIR SERVICES PROVIDED TO HEALTHCARE SERVICES GROUP CHARITABLE FOUNDATION.

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    TY 2015 DepreciationSchedule
    Name:
    HEALTHCARE SERVICES GROUP CHARITABLE
     
    FOUNDATION
    EIN:
    46-1181892
    Description of Property Date Acquired Cost or Other Basis Prior Years' Depreciation Computation Method Rate /
    Life (# of years)    		 Current Year's Depreciation Expense Net Investment Income Adjusted Net Income Cost of Goods Sold Not Included

    TY 2015 OtherExpensesSchedule
    Name:
    HEALTHCARE SERVICES GROUP CHARITABLE
     
    FOUNDATION
    EIN:
    46-1181892
    Description Revenue and Expenses per Books Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    ADVERTISING 2,100      


    TY 2015 OtherIncreasesSchedule
    Name:
    HEALTHCARE SERVICES GROUP CHARITABLE
     
    FOUNDATION
    EIN:
    46-1181892
    Description Amount
    UNREALIZED GAIN 22,790


    TY 2015 OtherProfessionalFeesSchedule
    Name:
    HEALTHCARE SERVICES GROUP CHARITABLE
     
    FOUNDATION
    EIN:
    46-1181892
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    HSG MANAGEMENT FEES 12,000      
    PROFESSIONAL FEES 2,599      


    TY 2015 TaxesSchedule
    Name:
    HEALTHCARE SERVICES GROUP CHARITABLE
     
    FOUNDATION
    EIN:
    46-1181892
    Category Amount Net Investment Income Adjusted Net Income Disbursements for Charitable Purposes
    TAXES AND LICENSES 11      
    INCOME TAX 140