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.") . | ||||||
| 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 V, Line 1a Form 1096 | The organization is filing for a short year for the period 1/1/15-6/30/15; as such, no calendar year ended within its tax year. Therefore, in accordance with the instructions, the organization has reported zero on this line. |
| Form 990, Part V, Line 2a Form W-3 | The organization is filing for a short year for the period 1/1/15-6/30/15; as such, no calendar year ended within its tax year. Therefore, in accordance with the instructions, the organization has reported zero on this line. |
| Form 990, Part VI, Line 15a PROCESS TO ESTABLISH COMPENSATION FOR TOP MANAGEMENT OFFICIAL | ROCKFORD HEALTH PHYSICIANS' TOP MANAGEMENT OFFICIAL IS THE PRESIDENT & CEO OF ROCKFORD HEALTH SYSTEMS (RHS), THE SOLE CORPORATE MEMBER. NOTE THAT NO COMPENSATION REVIEW WAS COMPLETED FOR THE SHORT PERIOD 1/1/15-6/30/15 FOR WHICH THIS RETURN IS BEING FILED. COMPENSATION FOR EXECUTIVES, INCLUDING THE TOP MANAGEMENT OFFICIAL, IS GOVERNED BY THE RHS BOARD OF DIRECTORS. THE RHS BOARD HAS ESTABLISHED A TOTAL COMPENSATION PHILOSOPHY THAT DIRECTS THE COMPENSATION PRACTICES FOR ALL EXECUTIVES FROM ALL RELATED ENTITIES (INCLUDING RHPH). THIS BOARD HAS ESTABLISHED A COMPENSATION COMMITTEE TO ESTABLISH AND REVIEW ALL EXECUTIVE COMPENSATION ANNUALLY BASED ON THE ESTABLISHED PHILOSOPHY. AN INDEPENDENT EXTERNAL EXECUTIVE COMPENSATION FIRM PROVIDES CONSULTING ON RHS (INCLUDING RHPH) SALARY RANGES AND COMPENSATION PHILOSOPHY. THE APPROPRIATE PEER GROUP FOR COMPENSATION COMPARISON PURPOSES IS OTHER NOT-FOR-PROFIT HEALTHCARE SYSTEMS SIMILAR IN SIZE AND COMPLEXITY. RHS GENERALLY CONDUCTS AN ANALYSIS OF TOTAL COMPENSATION EVERY THREE YEARS BUT MAY CHOOSE TO VARY FROM THIS SCHEDULE DETERMINED BY THE COMPENSATION COMMITTEE. THE RHPH BOARD OF DIRECTORS CONCEDES THE AUTHORITY TO SET COMPENSATION TO RHS. |
| Form 990, Part VI, Line 15b PROCESS TO ESTABLISH COMPENSATION FOR OTHER OFFICERS | NOTE THAT NO COMPENSATION REVIEW WAS COMPLETED FOR THE SHORT PERIOD 1/1/15-6/30/15 FOR WHICH THIS RETURN IS BEING FILED. COMPENSATION FOR EXECUTIVES, INCLUDING OTHER OFFICERS AND KEY EMPLOYEES, IS GOVERNED BY THE RHS BOARD OF DIRECTORS. THE RHS BOARD HAS ESTABLISHED A TOTAL COMPENSATION PHILOSOPHY THAT DIRECTS THE COMPENSATION PRACTICES FOR ALL EXECUTIVES FROM ALL RELATED ENTITIES (INCLUDING RHPH). THIS BOARD HAS ESTABLISHED A COMPENSATION COMMITTEE TO ESTABLISH AND REVIEW ALL EXECUTIVE COMPENSATION ANNUALLY BASED ON THE ESTABLISHED PHILOSOPHY. AN INDEPENDENT EXTERNAL EXECUTIVE COMPENSATION FIRM PROVIDES CONSULTING ON RHS (INCLUDING RHPH) SALARY RANGES AND COMPENSATION PHILOSOPHY. THE APPROPRIATE PEER GROUP FOR COMPENSATION COMPARISON PURPOSES IS OTHER NOT-FOR-PROFIT HEALTHCARE SYSTEMS SIMILAR IN SIZE AND COMPLEXITY. RHS GENERALLY CONDUCTS AN ANALYSIS OF TOTAL COMPENSATION EVERY THREE YEARS BUT MAY CHOOSE TO VARY FROM THIS SCHEDULE DETERMINED BY THE COMPENSATION COMMITTEE. THE RHPH BOARD OF DIRECTORS CONCEDES THE AUTHORITY TO SET COMPENSATION TO RHS. |
| Form 990, Part VI, Line 1a Delegate broad authority to a committee | THE VOTING MEMBERS OF THE EXECUTIVE COMMITTEE SHALL BE THE FOLLOWING INDIVIDUALS, EACH OF WHOM SHALL HAVE A VOTE: RHS CEO, CHAIRMAN, VICE-CHAIRMAN, IMMEDIATE PAST CHAIRMAN, TREASURER AND TWO ADDITIONAL DIRECTORS. AT LEAST ONE MEMBER OF THE EXECUTIVE COMMITTEE SHALL BE A PHYSICIAN. THE EXECUTIVE COMMITTEE SHALL BE COMPRISED OF AT LEAST 51% COMMUNITY MEMBERS. THE EXECUTIVE COMMITTEE SHALL REVIEW REPORTS FROM THE RHS CEO REGARDING THE PERFORMANCE OF EXECUTIVES OF THE CORPORATION AND AFFILIATED CORPORATIONS, MONITOR THE PERFORMANCE OF THE RHS CEO OF THE CORPORATION AGAINST ANNUAL OBJECTIVES, AND DETERMINE THE COMPENSATION LEVEL OF THE RHS CEO. IN ADDITION, WHEN THE BOARD OF DIRECTORS IS NOT IN SESSION, THE EXECUTIVE COMMITTEE SHALL HAVE ALL THE POWERS, DUTIES, RESPONSIBILITIES AND AUTHORITY OF THE BOARD, EXCEPT AS PROHIBITED BY LAW. |
| Form 990, Part VI, Line 6 Classes of members or stockholders | Rockford Health System (RHS) is the sole corporate member of Rockford Health Physicians (RHPH). The sole member shall have powers and voting rights to do the following: (a) Appoint all the directors of RHPH. (b) Nominate to RHPH's board of directors all candidates for selection as the RHPH president. (c) Approve expressly all amendments to RHPH's articles of incorporation and by-laws. (d) Approve annual budgets, and strategic, long-range and health manpower development plans of RHPH. (e) Approve all contracts (including contracts of indebtedness) effective for longer than eighteen months. (f) Approve all plans of merger or consolidation. (g) Approve the sale, lease, exchange, mortgage, pledge or other disposition of all or substantially all, the property and assets of RHPH. (h) Approve a voluntary dissolution of the RHPH. (i) Approve material amendments to RHPH's standard form of physician employment agreement. (j) Approve material amendments to the standard compensation system used by RHPH to establish individual physician compensation. (k) Require RHPH to take any action (including amending the articles of incorporation or by-laws), or to modify or rescind an action already taken, if RHS determines that failure to take the action, or to modify or rescind an action already taken, may result in the member's or RHPH's failure to obtain or maintain its exemption as an organization described in Section 501(c)(3) of the Code. |
| Form 990, Part VI, Line 7a Members or stockholders electing members of governing body | SEE NARRATIVE FOR PART VI, LINE 6 |
| Form 990, Part VI, Line 7b Decisions requiring approval by members or stockholders | SEE NARRATIVE FOR PART VI, LINE 6 |
| Form 990, Part VI, Line 11b Review of form 990 by governing body | The data was gathered by the accounting staff with input from the executive staff. The data was reviewed and the Form 990 prepared by the RHS staff. Once the Form 990 was completed, it was reviewed by an independent accounting firm and the organization's CFO. |
| Form 990, Part VI, Line 12c Conflict of interest policy | By written policy, RHS sends out, on an annual basis, the corporate Conflict and Duality of Interest policy to all Board members, corporate officers and other key individuals (those having responsibility and authority to make final decisions regarding the acquisition of products or services). Each recipient is required to complete a Financial Interest Disclosure Statement, which is submitted to the Vice President, Legal Services/General Counsel for review. With respect to physicians and managers who are key individuals, any potential conflict of interest is reviewed with the appropriate executive staff member for follow up with the disclosing party in order to review the matter in more detail. This includes emphasizing that the disclosing party is not permitted to participate in any negotiations for the purchase of any products or services where the conflict is deemed material, or authorize the subsequent purchase of related goods and services. The disclosing party is also required to identify each and every instance of a potential conflict as they may arise in the ordinary course of business. A similar process is followed for the Board of Directors, except that any potential conflict is reviewed by the Board's Governance Committee. Board members may comment on transactions where there is a potential conflict, but cannot vote on the related matter and may be required to leave any meeting where the potential conflict is reviewed by the Board or where the Board takes action to either approve or not approve the proposed transaction. A board member also has a continuing duty to report any conflicts as they may arise in the ordinary course of business. In the event that a potential conflict of interest is reported or discovered outside the established process, appropriate review and action would be taken. This process was last completed in 2015, when the questionnaires were sent to address any 2014 conflicts identified. RHS and RHPH have the same board, and therefore the RHS questionnaire is used to also address potential and actual conflicts for the filing organization. The RHS Conflict of Interest Policy is available upon request. |
| Form 990, Part VI, Line 19 Required documents available to the public | Financial statements are available through the Illinois Attorney General's office. Governing documents are available by request from Board Secretary. The conflict of interest policy is not published but is available upon request. |
| Form 990, Part VIII, Line 2f Other Program Service Revenue | Other Program Svc - Total Revenue: 275616, Related or Exempt Function Revenue: 275616, Unrelated Business Revenue: , Revenue Excluded from Tax Under Sections 512, 513, or 514: ; |
| Form 990, Part VIII, Line 11d Other Miscellaneous Revenue | PARTNERSHIP INCOME - Total Revenue: 13811, Related or Exempt Function Revenue: , Unrelated Business Revenue: , Revenue Excluded from Tax Under Sections 512, 513, or 514: 13811; |
| Form 990, Part XI, Line 9 Other changes in net assets or fund balances | PENSION-RELATED CHANGES OTHER THAN NET PERIODIC PENSION COST - 215700; POST-RETIREMENT MEDICAL BENEFIT-RELATED CHANGES OTHER THAN NET PERIODIC POST-RETIREMENT COST - 218751; TRANSFER TO/FROM AFFILIATES - 16246986; |
| Software ID: | 14000329 |
| Software Version: | 2014v1.0 |