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 | |||||
| (A)
THE INGALLS MEMORIAL HOSPITAL |
362170866 | Yes | 0 | 0 | ||
Total 1
|
0 | |||||
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.") . | ||||||
| 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: | 14000329 |
| Software Version: | 2014v1.0 |
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, Line 15a PROCESS TO ESTABLISH COMPENSATION OF TOP MANAGEMENT OFFICIAL | THE ORGANIZATION DOES NOT COMPENSATE THE ORGANIZATION'S TOP MANAGEMENT OFFICIAL. THEREFORE, THIS QUESTION HAS BEEN MARKED NO IN ACCORDANCE WITH IRS INSTRUCTIONS. THE INGALLS MEMORIAL HOSPITAL (IMH), A RELATED TAX-EXEMPT ORGANIZATION, IS RESPONSIBLE FOR DETERMINING AND ADMINISTERING COMPENSATION FOR ALL OFFICERS AND KEY EMPLOYEES OF EACH RESPECTIVE ENTITY WITHIN THE INGALLS HEALTH SYSTEM CORPORATE STRUCTURE. BELOW IS THE PROCESS USED TO ESTABLISH COMPENSATION FOR THE TOP MANAGEMENT OFFICIAL. TOP MANAGEMENT OFFICIAL: IN SETTING THE TOP MANAGEMENT OFFICIAL'S COMPENSATION, THE EXECUTIVE COMMITTEE RELIES ON RECENT COMPARABILITY STUDIES THAT PROVIDE COMPENSATION DATA FOR SIMILARLY QUALIFIED PERSONS IN COMPARABLE ORGANIZATIONS TO SUPPORT ITS DECISION-MAKING PROCESS. IN ADDITION, THE ORGANIZATION RECEIVED AN INDEPENDENT COMPENSATION REVIEW BY TOWERS WATSON IN THE FALL OF 2014. THE COMMITTEE ADEQUATELY DOCUMENTS ITS COMPENSATION DETERMINATIONS, DELIBERATIONS, AND APPROVAL OF THE TOP MANAGEMENT OFFICIAL'S COMPENSATION IN THE MEETING MINUTES. THE PROCESS FOR REVIEWING AND DETERMINING COMPENSATION FOR THE TOP MANAGEMENT OFFICIAL WAS LAST UNDERTAKEN IN THE FALL OF 2014. |
| Form 990, Part VI, Line 15b PROCESS TO ESTABLISH COMPENSATION OF OTHER EMPLOYEES | THE ORGANIZATION DOES NOT COMPENSATE THE ORGANIZATION'S OTHER OFFICERS OR KEY EMPLOYEES. THEREFORE, THIS QUESTION HAS BEEN MARKED NO IN ACCORDANCE WITH IRS INSTRUCTIONS. THE INGALLS MEMORIAL HOSPITAL (IMH), A RELATED TAX-EXEMPT ORGANIZATION, IS RESPONSIBLE FOR DETERMINING AND ADMINISTERING COMPENSATION FOR ALL OFFICERS AND KEY EMPLOYEES OF EACH RESPECTIVE ENTITY WITHIN THE INGALLS HEALTH SYSTEM CORPORATE STRUCTURE. BELOW IS THE PROCESS USED TO ESTABLISH COMPENSATION FOR OTHER OFFICERS AND KEY EMPLOYEES. OTHER OFFICERS AND KEY EMPLOYEES: AN OUTSIDE COMPENSATION CONSULTANT IS USED TO RENDER A REASONABLE OPINION AS TO WHAT PERCENTAGE OF INCREASE A VICE PRESIDENT SHOULD RECEIVE BY PERFORMING A MARKET COMPARISON FOR ALL VICE PRESIDENTS. THE PROCESS TO DETERMINE AN INCREASE IN COMPENSATION FOR VICE PRESIDENTS WAS PERFORMED IN THE PRIOR YEAR FOR THE CURRENT YEAR'S COMPENSATION. SALARY INCREASES ARE APPROVED ANNUALLY BY THE PRESIDENT AND EXECUTIVE COMMITTEE ONCE RECEIVED BY THE OUTSIDE CONSULTANT. DIRECTORS AND MANAGERS RECEIVE AN INCREASE IN COMPENSATION BASED ON WHETHER OR NOT PERFORMANCE GOALS HAVE BEEN REACHED. BEFORE A FISCAL YEAR STARTS PERFORMANCE GOALS ARE PUT TOGETHER BY THE DIRECTOR OR MANAGER AND SUBMITTED TO THE VICE PRESIDENT FOR APPROVAL. APPROVED GOALS ARE THEN REVIEWED BY ALL OTHER EXECUTIVES. ONCE APPROVED BY ALL, THESE ARE THE GOALS FOR THE YEAR. AFTER THE YEAR IS OVER THE PERFORMANCE GOALS ARE REVIEWED BY THE VP AND DIRECTOR OR MANAGER. MARKET ADJUSTMENTS ARE SET BY THE IMMEDIATE VP AND SENT TO ALL EXECUTIVES FOR THEIR APPROVAL. |
| Form 990, Part VI, Line 1a Delegate broad authority to a committee | EXECUTIVE COMMITTEE: The Board of Directors shall designate an Executive Committee, which shall consist of the Chairman, the President, the Secretary/Treasurer and such other Directors as shall be designated from time to time, which Executive Committee, to the extent provided by resolution of the Board of Directors, shall have and may exercise, except as to matters upon which the Board of Directors has acted, all of the powers of the Board of Directors. |
| Form 990, Part VI, Line 11b Review of form 990 by governing body | The full form 990, including supplemental schedules, was presented by the Chief Financial Officer to the Finance Committee at a committee meeting. The full board has granted to the Finance Committee authority to approve the Form 990. The full board will receive a report from the Finance committee, describing the Finance committee's review performed. The form 990 will be available at the organization's board meeting for each member's review. |
| Form 990, Part VI, Line 12c Conflict of interest policy | All officers, directors, board members, and key employees must avoid situations in which their personal interests may conflict, or appear to conflict, with the interest of Ingalls; and Ingalls reviews its own relationships with other care providers, educational institutions, and payers to determine if potential conflicts exist. Employees shall have the continuing affirmative duty to report to the President and Chief Executive Officer (CEO) of Ingalls any personal ownership interest or other relationship that might affect their ability to exercise impartial, ethical business judgments in the area of their responsibilities. Per the entity's conflict of interest policy, employees at management level will be required to complete a "Certification and Disclosure" form, on a schedule determined by the Corporate Compliance Officer. Completion of this form is a job requirement for all managerial employees, and may be required of non-management employees as determined by the President and Chief Executive Officer and the Corporate Compliance Officer. Employees also have a duty to report conflicts or potential conflicts of interest of which they may be aware involving other employees. Each situation reported shall be reviewed by the President and CEO, and Ingalls Corporate Compliance Officer, and a determination shall be made as to whether a conflict of interest exists or may arise from such a situation. The decision of the President and CEO and Corporate Compliance Officer regarding whether a conflict exists shall be final. The employee handbook mentions the entity's conflict of interest policy. Each employee is required to sign an acknowledgment of the handbook upon employment. |
| Form 990, Part VI, Line 19 Required documents available to the public | Financial statements, governing documents, and conflict of interest policies are not required disclosures pursuant to Internal Revenue Code (IRC) Section 6104. These documents are not available to the public at this time. |
| Form 990, Part VII, Section B, Line 1 Expenses for Ingalls Health System | Expenses of Ingalls Health System (IHS) and related entities (see Schedule R) are paid by IHS. IHS is responsible for issuing the 1099's to independent contractors, and subsequently allocates a percentage of the expense and receives reimbursement from the related entities. |
| Form 990, Part VIII, Line 7a Gross amount of sales of securities | The organization's investments are held in a pooled investment account managed by Northern Trust. Realized gains and losses are pooled and allocated to the participants. The Ingalls Memorial Hospital receives monthly information on the funds from Northern Trust and determines the total gain or loss amounts. However detail is not provided. |
| Software ID: | 14000329 |
| Software Version: | 2014v1.0 |