Attach to Form 990 or Form 990-EZ.
Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
| (i)Name of supported organization | (ii) EIN | (iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions)) | (iv) Is the organization listed in your governing document? | (v) Amount of monetary support (see instructions) | (vi) Amount of other support (see instructions) | |
|---|---|---|---|---|---|---|
| Yes | No | |||||
| Total | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .... | ||||||
| 2 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf....... | ||||||
| 3 | The value of services or facilities furnished by a governmental unit to the organization without charge.. | ||||||
| 4 | Total. Add lines 1 through 3 | ||||||
| 5 | The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f).. | ||||||
| 6 | Public support. Subtract line 5 from line 4. | ||||||
Calendar year
(or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 7 | Amounts from line 4.. | ||||||
| 8 | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources... | ||||||
| 9 | Net income from unrelated business activities, whether or not the business is regularly carried on.. | ||||||
| 10 | Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.).. | ||||||
| 11 | Total support Add lines 7 through 10. | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") . | 0 | 0 | 0 | 0 | 0 | 0 |
| 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...... | 11,237,638 | 13,464,319 | 24,701,957 | |||
| 3 | Gross receipts from activities that are not an unrelated trade or business under section 513.. | 0 | |||||
| 4 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf... | 0 | |||||
| 5 | The value of services or facilities furnished by a governmental unit to the organization without charge.. | 0 | |||||
| 6 | Total. Add lines 1 through 5. | 0 | 0 | 0 | 11,237,638 | 13,464,319 | 24,701,957 |
| 7a | Amounts included on lines 1, 2, and 3 received from disqualified persons... | 0 | |||||
| b | Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year. | 0 | |||||
| c | Add lines 7a and 7b.. | 0 | |||||
| 8 | Public support (Subtract line 7c from line 6.) | 24,701,957 | |||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | 0 | 0 | 0 | 11,237,638 | 13,464,319 | 24,701,957 |
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | 0 | |||||
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | 0 | |||||
| c | Add lines 10a and 10b. | 0 | |||||
| 11 | Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on. | 0 | |||||
| 12 | Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.) .. | 0 | |||||
| 13 | Total support. (Add lines 9, 10c, 11, and 12.).. | 0 | 0 | 0 | 11,237,638 | 13,464,319 | 24,701,957 |
| Section A - Adjusted Net Income | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Net short-term capital gain | 1 | ||||
| 2 | Recoveries of prior-year distributions | 2 | ||||
| 3 | Other gross income (see instructions) | 3 | ||||
| 4 | Add lines 1 through 3 | 4 | ||||
| 5 | Depreciation and depletion | 5 | ||||
| 6 | Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions) | 6 | ||||
| 7 | Other expenses (see instructions) | 7 | ||||
| 8 | Adjusted Net Income (subtract lines 5, 6 and 7 from line 4) | 8 | ||||
| Section B - Minimum Asset Amount | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year): | 1 | ||||
| a | Average monthly value of securities | 1a | ||||
| b | Average monthly cash balances | 1b | ||||
| c | Fair market value of other non-exempt-use assets | 1c | ||||
| d | Total (add lines 1a, 1b, and 1c) | 1d | ||||
| e | Discount claimed for blockage or other factors (explain in detail in Part VI): | |||||
| 2 | Acquisition indebtedness applicable to non-exempt use assets | 2 | ||||
| 3 | Subtract line 2 from line 1d | 3 | ||||
| 4 | Cash deemed held for exempt use. Enter 1-1/2% of line 3 (for greater amount, see instructions). | 4 | ||||
| 5 | Net value of non-exempt-use assets (subtract line 4 from line 3) | 5 | ||||
| 6 | Multiply line 5 by .035 | 6 | ||||
| 7 | Recoveries of prior-year distributions | 7 | ||||
| 8 | Minimum Asset Amount (add line 7 to line 6) | 8 | ||||
| Section C - Distributable Amount | Current Year | |||||
| 1 | Adjusted net income for prior year (from Section A, line 8, Column A) | 1 | ||||
| 2 | Enter 85% of line 1 | 2 | ||||
| 3 | Minimum asset amount for prior year (from Section B, line 8, Column A) | 3 | ||||
| 4 | Enter greater of line 2 or line 3 | 4 | ||||
| 5 | Income tax imposed in prior year | 5 | ||||
| 6 | Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions) | 6 | ||||
| 7 | Check here if the current year is the organization's first as a non-functionally-integrated Type III supporting organization (see instructions) | |||||
| Section D - Distributions | Current Year | |
|---|---|---|
| 1 Amounts paid to supported organizations to accomplish exempt purposes | ||
|
2
Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity |
||
| 3 Administrative expenses paid to accomplish exempt purposes of supported organizations | ||
| 4 Amounts paid to acquire exempt-use assets | ||
| 5 Qualified set-aside amounts (prior IRS approval required) | ||
| 6 Other distributions (describe in Part VI). See instructions | ||
| 7Total annual distributions. Add lines 1 through 6. | ||
|
8
Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions |
||
| 9 Distributable amount for 2014 from Section C, line 6 | ||
| 10 Line 8 amount divided by Line 9 amount | ||
| Section E - Distribution Allocations (see instructions) |
(i) Excess Distributions |
(ii) Underdistributions Pre-2014 |
(iii) Distributable Amount for 2014 |
|
|---|---|---|---|---|
|
1
Distributable amount for 2014 from Section C, line 6 |
||||
|
2
Underdistributions, if any, for years prior to 2014 (reasonable cause required--see instructions) |
||||
| 3 Excess distributions carryover, if any, to 2014: | ||||
| a From 2009.......X | ||||
| b From 2010.......X | ||||
| c From 2011.......X | ||||
| d From 2012.......X | ||||
| e From 2013....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2014 distributable amount | ||||
|
i
Carryover from 2009 not applied (see instructions) |
||||
| j Remainder. Subtract lines 3g, 3h, and 3i from 3f. | ||||
| 4Distributions for 2014 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2014 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from 4. | ||||
|
5
Remaining underdistributions for years prior to 2014, if any. Subtract lines 3g and 4a from line 2 (if amount greater than zero, see instructions) |
||||
|
6
Remaining underdistributions for 2014. Subtract lines 3h and 4b from line 1 (if amount greater than zero, see instructions) |
||||
|
7 Excess distributions carryover to 2015. Add lines 3j and 4c. |
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| 8 Breakdown of line 7: | ||||
| a From 2010.......X | ||||
| b From 2011.......X | ||||
| c From 2012.......X | ||||
| d From 2013....... | ||||
| e From 2014....... | ||||
| Facts And Circumstances Test |
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| Return Reference | Explanation |
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| Software ID: | |
| Software Version: |
Attach to Form 990 or 990-EZ.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at| Return Reference | Explanation |
|---|---|
| FORM 990, PART VI, SECTION A, LINE 6 | MEMBERS OR STOCKHOLDERS: THE MEMBERS OF THE CORPORATION SHALL BE PENN STATE MILTON S. HERSHEY MEDICAL CENTER (HERSHEY) AND MOUNT NITTANY MEDICAL CENTER (MNMC), BOTH OF WHICH ARE PENNSYLVANIA NONPROFIT CORPORATIONS. |
| FORM 990, PART VI, SECTION A, LINE 7A | MEMBERS OR STOCKHOLDERS WHO CAN ELECT MEMBERS OF THE GOVERNING BODY: THE MEMBERS ARE RESPONSIBLE FOR THE APPOINTMENT OF EQUAL NUMBERS OF DIRECTORS OF THE CORPORATION AND THE REMOVAL OF SUCH DIRECTORS (SUCH REMOVAL POWER BEING RESERVED TO THE MEMBER WHO APPOINTED THE DIRECTOR) WITH OR WITHOUT CAUSE. |
| FORM 990, PART VI, SECTION A, LINE 7B | DECISIONS OF GOVERNING BODY SUBJECT TO APPROVAL BY MEMBERS: IN ADDITION TO THE APPOINTMENT AND REMOVAL OF DIRECTORS, THE MEMBERS HAVE THE FOLLOWING POWERS TO APPROVE RESERVED BEFORE THE CORPORATION SHALL TAKE ACTION: -THE ADOPTION, REVOCATION, OR RESTATEMENT OF THE ARTICLES OF INCORPORATION OR BYLAWS OF THE CORPORATION. -ANY MATERIAL CHANGE IN THE PURPOSES OF THE CORPORATION OR THE NATURE OR SCOPE OF THE BUSINESS CONDUCTED BY THE CORPORATION. -ANY FUNDAMENTAL CHANGE, INCLUDING: (I) THE MERGER OR CONSOLIDATION OF THE CORPORATION WITH OR INTO ANY OTHER ENTITY; (II) THE DIVISION OF THE CORPORATION; (III) THE EXCHANGE OF MEMBERSHIP INTERESTS IN THE CORPORATION FOR EQUITY INTERESTS OF ANY OTHER ENTITY; (IV) THE GRANT OF RESERVED POWERS OR ANY OTHER GOVERNANCE INTEREST TO A THIRD PARTY; OR (V) THE SALE OR LEASE OF ANY MATERIAL PORTION OF THE ASSETS OF THE CORPORATION OTHER THAN IN THE ORDINARY COURSE OF BUSINESS. -THE CORPORATION'S CREATION OF, OR PARTICIPATION BY THE CORPORATION IN, A SUBSIDIARY, JOINT VENTURE, PARTNERSHIP, LIMITED LIABILITY COMPANY OR OTHER SIMILAR ARRANGEMENT. -ANY MATERIAL CHANGE IN THE ACCOUNTING METHOD AFFECTING THE FINANCIAL STATEMENTS OR TAX RETURNS OF THE CORPORATION, OTHER THAN A CHANGE REQUIRED UNDER GENERALLY ACCEPTED ACCOUNTING PRINCIPLES. -ANY ISSUANCE OF ADDITIONAL, OR TRANSFER OF EXISTING, MEMBERSHIP INTERESTS IN THE CORPORATION (EXCEPT FOR TRANSFERS DESCRIBED IN SECTION 2.03). -ANY LOAN TO ANY PERSON OR ENTITY OTHER THAN FOR PAYABLES AND RECEIVABLES IN THE ORDINARY COURSE OF BUSINESS. -ANY DISTRIBUTIONS BY THE CORPORATION TO ITS MEMBERS, EXCEPT AS AUTHORIZED IN THE CORPORATE MEMBERSHIP AGREEMENT. -THE APPOINTMENT AND REMOVAL OF THE EXECUTIVE DIRECTOR OF THE CENTER. -THE EMPLOYMENT, CONTRACTING, OR LEASING OF A PHYSICIAN TO PROVIDE PROFESSIONAL OR ADMINISTRATIVE SERVICES AT THE CENTER; PROVIDED THAT MEMBER CONSENT SHALL NOT BE REQUIRED FOR LOCUM TENENS PHYSICIANS. -ANY MANDATORY CAPITAL CONTRIBUTIONS OF THE MEMBERS IN EXCESS OF CAPITAL CONTRIBUTIONS REQUIRED BY THE CORPORATE MEMBERSHIP AGREEMENT. -VOLUNTARY DECLARATION OF BANKRUPTCY OR SEEKING OF REORGANIZATION UNDER THE INSOLVENCY LAWS BY THE CORPORATION. -ANY OTHER MATERIAL TRANSACTION INVOLVING THE CORPORATION OR ITS BUSINESS NOT IN THE ORDINARY COURSE OF BUSINESS, EXCEPT THAT EITHER MEMBER AT ANY TIME MAY ELECT TO DISSOLVE THE CORPORATION PURSUANT TO SECTION 4 OF THE CORPORATE MEMBERSHIP AGREEMENT. -IN ADDITION TO THE FOREGOING, THE MEMBERS WILL APPROVE THE EXECUTION OF ANY THIRD PARTY PAYOR CONTRACT WHERE THERE IS DISAGREEMENT AMONG THE DIRECTORS. HOWEVER, WITH RESPECT TO ANY NON-MEDICARE, NON-MEDICAID THIRD PARTY PAYOR CONTRACT PROPOSED BY EITHER MEMBER OR THE DIRECTORS APPOINTED BY SUCH MEMBER, THE NON-PROPOSING MEMBER WILL NOT WITHHOLD OR DELAY APPROVAL UNLESS THE TERMS OF SUCH PROPOSED MANAGED CARE OR THIRD PARTY PAYOR CONTRACT ARE, IN THE AGGREGATE, LESS THAN 125% OF MEDICARE. |
| FORM 990, PART VI, SECTION B, LINE 11B | 990 REVIEW PROCEDURES: THE FORM 990 IS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM BASED ON THE AUDITED FINANCIAL STATEMENTS AND INFORMATION PROVIDED BY THE ACCOUNTING DEPARTMENT OF THE ORGANIZATION. THE RETURN IS COMPLETED IN DRAFT FORM AND REVIEWED BY MANAGEMENT OF THE ORGANIZATION. THE COMPLETED 990 IS MADE AVAILABLE TO BOARD MEMBERS FOR REVIEW AND QUESTIONS PRIOR TO SUBMISSION. |
| FORM 990, PART VI, SECTION B, LINE 12C | CONFLICT OF INTEREST POLICY: THE ORGANIZATION HAS A CONFLICT OF INTEREST POLICY WHICH COVERS INTERESTED PERSONS. AN INTERESTED PERSON IS ANY PERSON IN A POSITION TO EXERCISE SUBSTANTIAL INFLUENCE OVER THE BUSINESS, OPERATIONS, ETHICAL, AND/OR COMPETITIVE POSITION. THIS INCLUDES, BUT IS NOT LIMITED TO, ANY DIRECTOR, EXECUTIVE, KEY EMPLOYEE, AND MEMBER OF THE MEDICAL STAFF. THE BOARD MAY ALSO DETERMINE THAT A PERSON OTHER THAN AN INTERESTED PERSON SHALL BE TREATED AS AN INTERESTED PERSON WITH RESPECT TO A PARTICULAR CONTRACT TRANSACTION, OR ARRANGEMENT. AN INTERESTED PERSON MUST DISCLOSE ALL MATERIAL FACTS RELATED TO THE EXISTENCE OF ANY ACTUAL, APPARENT, OR POTENTIAL CONFLICT OF INTEREST TO DIRECTORS CONSIDERING THE PROPOSED TRANSACTION, ARRANGEMENT, OR POLICY. DIRECTORS, EXECUTIVES, AND KEY EMPLOYEES COMPLETE AN ANNUAL DISCLOSURE STATEMENT. MEMBERS OF THE MEDICAL STAFF COMPLETE A DISCLOSURE STATEMENT EVERY OTHER YEAR, COINCIDING WITH THEIR APPLICATION FOR REAPPOINTMENT TO THE MEDICAL STAFF. THESE INDIVIDUALS ARE ALSO REQUIRED TO DISCLOSE ANY TRANSACTION OR RELATIONSHIP WHICH ARISES BETWEEN SUBMISSIONS OF THE DISCLOSURE STATEMENT. THE BOARD ANNUALLY REVIEWS AND EVALUATES THE DISCLOSURE STATEMENTS AND DETERMINES IF THERE ARE ANY CONFLICTS THAT ARE SO PERVASIVE AS TO RENDER ANY DIRECTOR INELIGIBLE FOR SERVICE. IF A POTENTIAL CONFLICT OF INTEREST ARISES AS A RESULT OF A CONTEMPLATED BOARD ACTION, THE PRESIDENT OR THE INTERESTED PERSON, OR ANY OTHER DIRECTOR, SHALL RAISE THE QUESTION OF THE INTERESTED PERSON'S CONFLICT OF INTEREST. THE BOARD WILL EVALUATE THE DISCLOSURE AND MATERIAL FACTS RELATED TO THE TRANSACTION AND WILL MAKE A DETERMINATION AS TO WHETHER THE INTERESTED PERSON HAS AN IMPERMISSIBLE CONFLICT OF INTEREST. BEFORE MAKING THIS DETERMINATION, AND DEPENDING UPON THE CIRCUMSTANCES, THE INTERESTED PERSON WILL BE ASKED TO LEAVE THE MEETING WHILE THE EVALUATION OF THE CONFLICT AND THE TRANSACTION IS DISCUSSED AND DECIDED UPON. IF THE DETERMINATION IS THAT A CONFLICT EXISTS, THE INTERESTED PERSON IS SO ADVISED. IF IT IS DETERMINED THAT A CONFLICT OF INTEREST EXISTS, THE INTERESTED PERSON MAY MAKE A PRESENTATION AT THE BOARD MEETING CONCERNING THE TRANSACTION OR ARRANGEMENT UNDER CONSIDERATION AND MAY BE ASKED TO REMAIN FOR QUESTIONS ON THIS PRESENTATION; HOWEVER, AFTER THE PRESENTATION AND QUESTION PERIOD, THE INTERESTED PERSON IS ASKED TO LEAVE THE MEETING DURING THE DISCUSSION OF, AND THE VOTE ON, THE TRANSACTION OR ARRANGEMENT INVOLVING THE CONFLICT OF INTEREST. IF AN INDIVIDUAL WHOSE COMPANY OR EMPLOYER HAS A BUSINESS RELATIONSHIP WITH THE ORGANIZATION, BUT THE INDIVIDUAL DOES NOT HAVE AN IMPERMISSIBLE CONFLICT OF INTEREST WITH RESPECT TO THIS BUSINESS RELATIONSHIP, THE INDIVIDUAL MAY NONETHELESS VOLUNTARILY RECUSE HIM/HERSELF FROM VOTING ON ANY MATTERS RELATED TO THIS RELATIONSHIP. |
| FORM 990, PART VI, SECTION C, LINE 19 | DOCUMENT DISCLOSURE: THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. |
| FORM 990, PART XI, LINE 9 | OTHER CHANGES IN NET ASSETS: $ 2,962,817 TRANSFERS FROM MEMBERS |
| Software ID: | |
| Software Version: |