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. |
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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 |
|---|---|
| PART V, LINE 1A | THE DISBURSEMENTS OF THE ORGANIZATION ARE PAID BY OF MISSION HEALTH SYSTEM, INC. ITS PARENT COMPANY. THE NUMBER REPORTED ON PART V LINE 1A IS 0 AND ANY 1099'S THAT WOULD OTHERWISE BE ASSOCIATED WITH THE ORGANIZATION ARE INCLUDED ON PART V LINE 1A OF MISSION HEALTH SYSTEM'S 990. |
| FORM 990, PART VI, SECTION A, LINE 1 | THE TERM OF OFFICE OF THE ELECTED MEMBER OF THE EXECUTIVE COMMITTEE SHALL BE ONE YEAR OR UNTIL A SUCCESSOR SHALL HAVE BEEN DULY ELECTED BY THE BOARD OF TRUSTEES. ANY VACANCY IN THE POSITION OF THE ELECTED MEMBER OF THE EXECUTIVE COMMITTEE SHALL BE FILLED AS SOON AS POSSIBLE AFTER THE OCCURRENCE OF THE VACANCY. THE EXECUTIVE COMMITTEE SHALL HAVE POWER TO TRANSACT ALL REGULAR BUSINESS OF THE HOSPITAL DURING THE PERIODS BETWEEN MEETINGS OF THE BOARD OF TRUSTEES SUBJECT TO ANY PRIOR LIMITATION IMPOSED BY THE BOARD OF TRUSTEES AND WITH THE UNDERSTANDING THAT ALL MATTERS OF MAJOR IMPORTANCE SHALL, EXCEPT IN EMERGENCY, BE REFERRED TO THE BOARD OF TRUSTEES. MINUTES OF THE EXECUTIVE COMMITTEE MEETINGS WILL BE SUBMITTED TO THE BOARD, AND ITS ACTIONS SHALL BE SUBJECT TO APPROVAL AT THE NEXT REGULAR BOARD MEETING. |
| FORM 990, PART VI, SECTION A, LINE 6 | THE HOSPITAL IS A MEMBERSHIP CORPORATION, OF WHICH THE SOLE MEMBER (THE "MEMBER") IS MISSION HEALTH SYSTEM, INC. |
| FORM 990, PART VI, SECTION A, LINE 7A | THE BOARD OF TRUSTEES WILL CONSIST OF NOT LESS THAN 11 AND NOT MORE THAN 16 VOTING MEMBERS. UP TO TWO TRUSTEES MAY BE APPOINTED BY MISSION AT ANY TIME (THE "MISSION TRUSTEES") AND IN ALL EVENTS, AT LEAST A MAJORITY OF THE TRUSTEES MUST BE COMMUNITY TRUSTEES. TRUSTEES OTHER THAN MISSION TRUSTEES ARE REFERRED TO HEREIN AS "COMMUNITY TRUSTEES." THERE WILL BE NOT LESS THAN NINE (9) AND NO MORE THAN THIRTEEN (13) COMMUNITY TRUSTEES. THE HOSPITAL SHALL EACH YEAR, NO LATER THAN THE MONTH OF AUGUST, SUBMIT FOR RATIFICATION TO THE MEMBER THE NAMES OF PERSONS TO FILL VACANCIES AMONG THE COMMUNITY TRUSTESS CAUSED BY THE EXPIRATION OF THE TERMS OF OFFICE OR OTHERWISE. THE RATIFICATION OF THE COMMUNITY TRUSTEES BY THE MEMBER SHALL TAKE PLACE BEFORE THE END OF SEPTEMBER. |
| FORM 990, PART VI, SECTION A, LINE 7B | FOR SO LONG AS IT IS THE MEMBER, MISSION HEALTH SYSTEM, NC. AND ITS SUCCESSORS AND ASSIGNS ("MISSION OR "MEMBER"), SHALL HAVE THE AUTHORITY TO APPROVE THE FOLLOWING REGARDING THE HOSPITAL WITHOUT ANY SEPARATE OR FURTHER ACTION B THE BOARD OF TRUSTEES OF THE HOSPITAL: (A) ANY AMENDMENT TO THE ARTICLES OF INCORPORATION OR BYLAWS; PROVIDED HOWEVER, THE TERMS OF SECTION III.3 OF THESE BYLAWS MAY NOT BE AMENDED AT ANY TIME WITHOUT THE JOINT APPROVAL OF MISSION AND TRANSYLVANIA COMMUNITY HOSPITAL ("HOSPITAL") (B) THE MISSION, VISION AND VALUES STATEMENTS AND ANY AMENDMENTS THERETO. (C) THE SALE, LEASE OR OTHER TRANSFER OF A MATERIAL PORTION, SUBSTANTIALLY ALL OR ALL OF THE ASSETS OF THE HOSPITAL. (D) THE PLEDGE OF, OR GRANTING OF ANY LIEN OR ENCUMBRANCE ON, A MATERIAL PORTION, SUBSTANTIALLY ALL OR ALL OF THE ASSETS OF THE HOSPITAL TO SECURE THE OBLIGATIONS OF THE HOSPITAL OR ANY OF ITS SUBSIDIARIES. (E) THE PURCHASE, LEASE, PLEDGE OR SALE OF REAL OR PERSONAL PROPERTY OUTSIDE THE ORDINARY COURSE OF BUSINESS. (F) THE DISSOLUTION OR ANY MERGER, SALE, CONSOLIDATION OR OTHER BUSINESS COMBINATION. (G) THE FORMATION AND GOVERNING DOCUMENTS OF, AND INVESTMENT BY THE HOSPITAL IN, ANY NEW CORPORATION, PARTNERSHIP OR EQUITY OR CONTRACTUAL JOINT VENTURE IN WHICH THE HOSPITAL PROPOSES TO HAVE AN INTEREST THROUGH MEMBERSHIP, VOTING STOCK OR OTHER EQUITY PARTICIPATION. (H) THE REMOVAL OF THE PRESIDENT/CHIEF NURSING OFFICER OF THE HOSPITAL. (I) ANY DEBT ISSUANCE OR INCURRENCE, REFINANCING AND RETIREMENT OF DEBT, INCLUDING WITHOUT LIMITATION INDEBTEDNESS FOR BORROWED MONEY AND CAPITAL LEASES, INCLUDING ANY PROPOSALS AND RECOMMENDATIONS AS TO SAME BY THE BOARD OF TRUSTESS. (J) THE CAPITAL AND OPERATING BUDGETS (BASED ON RECOMMENDATIONS FROM THE BOARD OF TRUSTESS) AND ANY EXPENDITURES THAT WOULD CAUSE ANY LINE ITEM EXPENSE IN ANY APPROVED BUDGET TO EXCEED THE LIMITS ESTABLISHED FROM TIME TO TIME BY MISSION BASED ON RECOMMENDATIONS FROM THE BOARD OF TRUSTEES. (K) STRATEGIC AND FINANCIAL PLANS, INCLUDING ANY PROPOSALS AND RECOMMENDATIONS FOR REVISIONS TO SAME BY THE BOARD OF TRUSTEES. (L) THE SELECTION OF EXTERNAL AUDITORS AND LEGAL COUNSEL; PROVIDED HOWEVER, THE COMMUNITY DIRECTORS (AS DEFINED IN THE BYLAWS OF THE MEMBER) SHALL HAVE THE EXCLUSIVE RIGHT TO SELECT LEGAL COUNSEL TO ENFORCE THE HOSPITAL'S RIGHTS UNDER THE AFFILIATION AGREEMENT. |
| FORM 990, PART VI, SECTION B, LINE 11 | THE ORGANIZATION PROVIDES DATA TO THE SENIOR TREASURY ANALYST OF TAX SERVICES FOR MISSION HEALTH SYSTEM, INC. THE 990 IS PREPARED AND REVIEWED BY MANAGEMENT PRIOR TO THE REVIEW BY THE ORGANIZATION'S FINANCE COMMITTEE. AFTER REVIEW BY THE BOARD, AND REVISIONS FOR ANY CLARIFICATIONS OR CORRECTIONS, THE FULL COPY OF THE 990 IS PROVIDED TO THE BOARD PRIOR TO FILING THE 990. |
| FORM 990, PART VI, SECTION B, LINE 12C | THE ORGANIZATION'S CONFLICT OF INTEREST POLICY IS REVIEWED AND UPDATED ANNUALLY. EDUCATION ABOUT THE POLICY AND THE RESPONSIBILITIES OF A BOARD MEMBER OCCURS ANNUALLY AND FOR NEW BOARD MEMBERS DURING ORIENTATION. IF A CONFLICT OF INTEREST IS IDENTIFIED, THE MEMBER IS RECUSED FROM DISCUSSION AND A VOTE ON THE CONFLICTING MATTER, AND MAY BE EXCUSED. THE POLICY IS ADHERED TO DURING MEETINGS IN EXECUTIVE SESSION FOR CEO EVALUATION AND COMPENSATION DISCUSSION, AUDIT PLANNING, AND OTHER TIMES AS REQUIRED. |
| FORM 990, PART VI, SECTION B, LINE 15 | A RELATED ORGANIZATION DRAWS WAGE COMPARISON DATA FROM OUTSIDE EXECUTIVE COMPENSATION CONSULTANTS TO ENSURE COMPENSATION LEVELS ARE AT FAIR MARKET VALUE THE HUMAN RESOURCES AND COMPENSATION COMMITTEE OF THE RELATED ORGANIZATION(COMMITTEE) REVIEWS THIS DATA AND RECOMMENDS TO THE BOARD OF THE RELATED ORGANIZATION ANY REVISIONS TO THE OVERALL PHILOSOPHY AND POLICY TO GUIDE THE DETERMINATION OF COMPENSATION AND BENEFIT PACKAGES FOR EXECUTIVES WHICH INCLUDES THE PRESIDENT & CNO, THE CFO, AS WELL AS ALL OTHER EXECUTIVES, WHICH WOULD INCLUDE ALL KEY EMPLOYEES. THE COMMITTEE KEEPS AND DISTRIBUTES MINUTES OF ALL ITS MEETINGS TO ITS MEMBERS. ITEMS OF A SENSITIVE NATURE ARE REFERENCED IN THE MINUTES WITH DETAILED, SUPPORTING DOCUMENTATION RETAINED ON FILE. THE COMMITTEE ALSO DISCLOSES ANY POTENTIAL CONFLICTS OF INTEREST SITUATIONS TO THE COMMITTEE CHAIRMAN THAT MAY AFFECT THEIR INDEPENDENT DIRECTORS' STATUS AS SOON AS THEY ARISE, AND MAINTAINS COMPLETE DOCUMENTATION OF ALL MATTERS DISCUSSED BY THE COMMITTEE. THE COMMITTEE OBTAINS EDUCATION AND TRAINING TO EXERCISE ALL RESPONSIBILITIES EFFECTIVELY AND KEEPS ABREAST OF SIGNIFICANT DEVELOPMENTS IN EXECUTIVE COMPENSATION PRACTICES AND REGULATIONS, AND ENSURES THAT ALL ASPECTS OF MISSION HEALTH SYSTEM AND HOSPITAL EXECUTIVE COMPENSATION ADHERE TO ALL RELEVANT REGULATORY REQUIREMENTS, AND REVIEWS THE COMMITTEE CHARTER ANNUALLY REVISING AS APPROPRIATE AND CONDUCTS AN ANNUAL EVALUATION OF THE COMMITTEE'S PERFORMANCE. |
| FORM 990, PART VI, SECTION C, LINE 18 | PHOTOCOPIES OF RECENT FILINGS OF THE FORM 990 ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. |
| FORM 990, PART VI, SECTION C, LINE 19 | PHOTOCOPIES OF THE ORGANIZATION'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. AN ANNUAL REPORT OF THE ORGANIZATION'S FINANCIAL STATEMENTS IS AVAILABLE ON THE ORGANIZATION'S WEBSITE AND IS PUBLISHED ANNUALLY IN THE LOCAL NEWSPAPER. |
| FORM 990, PART IX, LINE 11G | MEDICAL FEES: PROGRAM SERVICE EXPENSES 3,778,051. MANAGEMENT AND GENERAL EXPENSES 257,100. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,035,151. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 1,935,557. MANAGEMENT AND GENERAL EXPENSES 131,716. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,067,273. OTHER FEES: PROGRAM SERVICE EXPENSES 1,831,455. MANAGEMENT AND GENERAL EXPENSES 124,632. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,956,087. |
| FORM 990, PART XI, LINE 9: | OTHER CHANGES IN NET ASSETS 822. OTHER |
| FORM 990, PART XII, LINE 2C: | THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. |
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