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.") .... | 5,808,316 | 5,104,275 | 4,994,202 | 1,867,659 | 1,499,737 | 19,274,189 |
| 2 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf....... | 0 | |||||
| 3 | The value of services or facilities furnished by a governmental unit to the organization without charge.. | 0 | |||||
| 4 | Total. Add lines 1 through 3 | 5,808,316 | 5,104,275 | 4,994,202 | 1,867,659 | 1,499,737 | 19,274,189 |
| 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).. | 7,701,842 | |||||
| 6 | Public support. Subtract line 5 from line 4. | 11,572,347 | |||||
Calendar year
(or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 7 | Amounts from line 4.. | 5,808,316 | 5,104,275 | 4,994,202 | 1,867,659 | 1,499,737 | 19,274,189 |
| 8 | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources... | 221,990 | 201,438 | 46,102 | 45,565 | 164,668 | 679,763 |
| 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.).. | 0 | |||||
| 11 | Total support Add lines 7 through 10. | 19,953,952 | |||||
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.) | ||||||
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.).. | ||||||
| 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. |
||||
| 8 Breakdown of line 7: | ||||
| a From 2010.......X | ||||
| b From 2011.......X | ||||
| c From 2012.......X | ||||
| d From 2013....... | ||||
| e From 2014....... | ||||
| Facts And Circumstances Test |
|---|
| Return Reference | Explanation |
|---|
| 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 I, LINE 1 | ORGANIZATION'S MISSION THE ORGANIZATION'S PRIMARY EXEMPT PURPOSE IS TO ENGAGE IN CHARITABLE FUNDRAISING ACTIVITIES FOR AND TO OTHERWISE BENEFIT, PROMOTE AND CARRY OUT THE PURPOSES OF REHABILITATION HOSPITAL OF THE PACIFIC. |
| FORM 990, PART III, LINE 4A | PROGRAM SERVICE ACCOMPLISHMENTS THE REHABILITATION HOSPITAL OF THE PACIFIC FOUNDATION'S MISSION IS TO SUPPORT THE REHABILITATION HOSPITAL OF THE PACIFIC THROUGH PRIVATE GIFTS FROM INDIVIDUALS, FOUNDATIONS AND CORPORATIONS. THE FOUNDATION PROVIDES FUNDING FOR HOSPITAL RENOVATION, PATIENT CARE EQUIPMENT, CHARITY CARE, PATIENT ENRICHMENT PROGRAM AND STAFF EDUCATION AND TRAINING. IN FISCAL YEAR 2015, REHAB SERVED OVER 6,826 PATIENTS IN ITS INPATIENT AND OUTPATIENT PROGRAMS. THE FOLLOWING ARE DESCRIPTIONS OF PROGRAMS THAT BENEFITED FROM FOUNDATION GRANTS: HOSPITAL RENOVATION: CAPITAL CAMPAIGN FUNDS ARE USED TO REBUILD REHAB AS A STATE-OF-THE-ART HOSPITAL. INFRASTRUCTURE UPGRADES, CAPITAL EQUIPMENT AND NEW ADVANCEMENTS IN TECHNOLOGY WILL ENSURE THAT FUTURE GENERATIONS MAY RECEIVE THE CARE THEY NEED TO RECOVER RIGHT HERE IN HAWAII. IN FY2015, THE FOUNDATION PROVIDED $196,000 FOR HOSPITAL RENOVATIONS. PATIENT CARE EQUIPMENT: FOUNDATION PROVIDES FUNDS FOR NEW EQUIPMENT TO HELP PATIENTS REACH THEIR GREATEST POTENTIAL. IN FY2015, $242,000 WAS PROVIDED TO THE HOSPITAL FOR EQUIPMENT PURCHASES. PATIENT FINANCIAL ASSISTANCE: THE FOUNDATION SUPPLEMENTS THE HOSPITAL'S PROVISION OF SERVICES TO UNINSURED AND UNDERINSURED PATIENTS. BOTH INPATIENTS AND OUTPATIENTS IN NEED APPLY FOR FINANCIAL ASSISTANCE WITH THE HOSPITAL. APPLICATIONS MUST MEET SPECIFIC INCOME AND ASSET REQUIREMENTS. EQUIPMENT, SUPPLIES AND PRESCRIPTIONS DRUGS ARE ALSO PROVIDED TO PATIENTS IN NEED TO ENSURE A SAFE DISCHARGE HOME. FOUNDATION REIMBURSES THE HOSPITAL FOR PATIENT FINANCIAL ASSISTANCE PROVIDED DURING THE YEAR, AS DONATED FUNDS BECOME AVAILABLE UP TO A MAXIMUM LIMIT SET BY ITS BOARD OF DIRECTORS ANNUALLY. THE FOUNDATION REIMBURSED THE HOSPITAL $68,000 FOR FINANCIAL ASSISTANCE PROVIDED IN FY2015. PATIENT ENRICHMENT PROGRAM : CREATIVE ARTS PROGRAM HAS PROVIDED ART THERAPY FOR PERSONS WITH PHYSICAL AND COGNITIVE DISABILITIES. THE PROGRAM CURRICULUM EMPHASIZES ART AS THERAPY TO PROMOTE HEALING, FOSTER CREATIVITY AND IMPROVE SELF CONFIDENCE. APPROXIMATELY 40 PEOPLE PARTICIPATE ON A WEEKLY BASIS AND FOUNDATION FUNDED $194,000 FOR ART SUPPLIES AND INSTRUCTION IN FY2015. EDUCATION AND TRAINING PROGRAMS: THE FOUNDATION PROVIDES FUNDING FOR CONTINUING EDUCATION AND SCHOLARSHIP PROGRAMS FOR REHAB STAFF TO ENSURE THEY ARE TRAINED IN THE LATEST ADVANCEMENTS IN REHABILITATION MEDICINE AND FOR SCHOLARSHIPS FOR PHYSICAL THERAPY STUDENTS. IN FY2015 $137,000 WORTH OF EDUCATIONAL FUNDING AND SCHOLARSHIPS WERE AWARDED TO EMPLOYEES AND STUDENTS. |
| FORM 990, PART V, LINE 2 | THE ORGANIZATION DOES NOT FILE FORM W-3, THEREFORE, THERE ARE NO EMPLOYEES REPORTED ON FORM W-3. ALL EMPLOYEES OF THE ORGANIZATION ALSO PROVIDE CONCURRENT EMPLOYMENT SERVICES FOR A RELATED TAX EXEMPT ORGANIZATION REHABILITATION HOSPITAL OF THE PACIFIC (RHP), AND ARE REPORTED ON FORM W-3 OF RHP. THE ORGANIZATION FULLY REIMBURSES RHP FOR THE ORGANIZATION'S SHARE OF EMPLOYMENT RELATED COSTS OF EMPLOYEES IN QUESTION. |
| FORM 990, PART VI, LINE 1A | THE EXECUTIVE COMMITTEE CONSISTS OF OFFICERS OF THE BOARD OF DIRECTORS. THE EXECUTIVE COMMITTEE MEETS AT PLACES AND AT TIMES AS DETERMINED BY THE COMMITTEE. THE EXECUTIVE COMMITTEE SHALL POSSESS AND EXERCISE ALL POWERS OF THE BOARD OF DIRECTORS DURING THE INTERVALS BETWEEN BOARD MEETINGS WITH THE EXCEPTION OF THE FOLLOWING: - AUTHORIZE DISTRIBUTIONS; - APPROVE OR RECOMMEND TO THE MEMBERS DISSOLUTION, MERGER, OR THE SALE, PLEDGE OR TRANSFER OF ALL OR SUBSTANTIALLY ALL OF THE CORPORATION'S ASSETS; - ELECT, APPOINT OR REMOVE DIRECTORS OR FILL VACANCIES ON THE BOARD OR ON ANY OF ITS COMMITTEES; - ADOPT, AMEND OR REPEAL THE CHARTER OF INCORPORATION OR BYLAWS; - AUTHORIZE THE SALE, LEASE, EXCHANGE OR MORTGAGE OF ALL OR SUBSTANTIALLY ALL OF THE PROPERTY. |
| FORM 990, PART VI, LINE 6 | REHABILITATION HOSPITAL OF THE PACIFIC (RHP) IS THE SOLE MEMBER OF REHABILITATION HOSPITAL OF THE PACIFIC FOUNDATION (RHPF). |
| FORM 990, PART VI, LINE 7A & 7B | RHP, AS SOLE MEMBER, HAS THE POWER TO: - FIX THE NUMBER OF DIRECTORS OF THE BOARD OF RHPF FOR THE ENSUING YEAR; - ELECT THE DIRECTORS OF THE BOARD OF RHPF; - REMOVE ONE OR MORE DIRECTORS ELECTED BY RHP, WITH OR WITHOUT CAUSE. |
| FORM 990, PART VI, LINE 11B | PROCESS USED TO REVIEW THE FORM 990 THE ORGANIZATION HAS ESTABLISHED THE FOLLOWING PROCEDURES FOR THE REVIEW OF THE FORM 990: THE EXECUTIVE COMMITTEE OF THE BOARD IS GIVEN THE AUTHORITY BY THE FULL BOARD OF DIRECTORS TO REVIEW AND APPROVE THE FORM 990 PRIOR TO FILING. A COPY OF THE COMPLETE APPROVED FORM 990 IS PROVIDED TO EACH MEMBER OF THE BOARD PRIOR TO FILING. |
| FORM 990, PART VI, LINE 12C | CONFLICT OF INTEREST QUESTIONNAIRES ARE COMPLETED ANNUALLY BY BOARD MEMBERS AND MANAGEMENT. IF A BOARD MEMBER HAS A CONFLICT OF INTEREST, SUCH BOARD MEMBER WILL BE EXCUSED FROM VOTING. |
| FORM 990, PART VI, LINE 15A | THE HR COMMITTEE REVIEWS AND APPROVES COMPENSATION APPROVED BY THE FOUNDATION'S CHAIR AND VICE CHAIR OF THE ORGANIZATION'S EXECUTIVE DIRECTOR. THE EXECUTIVE COMMITTEE IS MADE UP OF INDEPENDENT BOARD MEMBERS. IN DETERMINING COMPENSATION, THE COMMITTEE REVIEWS APPROPRIATE COMPARABILITY DATA, AND CONTEMPORANEOUSLY DOCUMENTS ITS DELIBERATION AND DECISIONS. THE PROCESS WAS LAST COMPLETED IN NOVEMBER 2014. |
| FORM 990, PART VI, LINE 19 | UPON REQUEST, THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC. |
| FORM 990, PART XI, LINE 9 | CHANGE IN VALUE OF SPLIT-INTEREST AGREEMENTS ($5,732) CHANGE IN VALUE OF PLEDGES RECEIVABLE $8,915 -------- TOTAL $3,183 |
| Software ID: | |
| Software Version: |