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 (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) 2011 | (b) 2012 | (c) 2013 | (d) 2014 | (e) 2015 | (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) 2011 | (b) 2012 | (c) 2013 | (d) 2014 | (e) 2015 | (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) 2011 | (b) 2012 | (c) 2013 | (d) 2014 | (e) 2015 | (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) 2011 | (b) 2012 | (c) 2013 | (d) 2014 | (e) 2015 | (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 | ||||
| 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 2015 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-2015 |
(iii) Distributable Amount for 2015 |
|
|---|---|---|---|---|
|
1
Distributable amount for 2015 from Section C, line 6 |
||||
|
2
Underdistributions, if any, for years prior to 2015 (reasonable cause required--see instructions) |
||||
| 3 Excess distributions carryover, if any, to 2015: | ||||
| a | ||||
| b | ||||
| c | ||||
| d From 2013....... | ||||
| e From 2014....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2015 distributable amount | ||||
|
i
Carryover from 2010 not applied (see instructions) |
||||
| j Remainder. Subtract lines 3g, 3h, and 3i from 3f. | ||||
| 4Distributions for 2015 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2015 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from 4. | ||||
|
5
Remaining underdistributions for years prior to 2015, if any. Subtract lines 3g and 4a from line 2 (if amount greater than zero, see instructions) |
||||
|
6
Remaining underdistributions for 2015. Subtract lines 3h and 4b from line 1 (if amount greater than zero, see instructions) |
||||
|
7 Excess distributions carryover to 2016. Add lines 3j and 4c. |
||||
| 8 Breakdown of line 7: | ||||
| a | ||||
| b | ||||
| c Excess from 2013....... | ||||
| d From 2014....... | ||||
| e From 2015....... | ||||
| 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 VI, SECTION A, LINE 6 | THE SOLE MEMBER OF ACNW IS ARKANSAS CHILDREN'S, INC., AN ARKANSAS NONPROFIT PUBLIC BENEFIT CORPORATION (THE "SOLE MEMBER"). |
| FORM 990, PART VI, SECTION A, LINE 7A | ARKANSAS CHILDREN'S, INC., ACNW'S SOLE MEMBER, HAS THE RESERVED POWER TO FIX THE SIZE OF THE BOARD OF DIRECTORS, AND THE GOVERNING BOARD OF ANY AFFILIATE CONTROLLED BY THE CORPORATION, AND APPOINT AND REMOVE, WITH OR WITHOUT CAUSE, THE DIRECTORS OF THE CORPORATION, AND MEMBERS OF THE GOVERNING BOARD OF ANY AFFILIATE CONTROLLED BY THE CORPORATION. |
| FORM 990, PART VI, SECTION A, LINE 7B | ACNW'S ARTICLES OF INCORPORATION MAY BE AMENDED, AND THE BYLAWS MAY BE ALTERED, AMENDED, OR REPEALED AND NEW BYLAWS MAY BE ADOPTED: (I) UPON THE APPROVAL OF BOTH THE BOARD AND THE SOLE MEMBER, IF THE AMENDMENT DOES NOT RELATE TO THE NUMBER OF DIRECTORS, THE COMPOSITION OF THE BOARD, THE TERM OF OFFICE OF DIRECTORS, OR THE METHOD OR WAY IN WHICH DIRECTORS ARE ELECTED OR SELECTED; OR (II) BY THE MEMBER. |
| FORM 990, PART VI, SECTION B, LINE 11 | THE DRAFT FORM 990, WHICH IS RECONCILED TO THE ARKANSAS CHILDREN'S NORTHWEST (ACNW) INTERNAL FINANCIAL STATEMENTS AND THE ARKANSAS CHILDREN'S, INC. CONSOLIDATED AUDIT REPORT, IS INITIALLY REVIEWED IN DETAIL WITH ACNW'S VICE PRESIDENT. THE DRAFT IS ALWO REVIEWED IN DETAIL WITH BOTH THE SVP/CFO AND THE VP OF FINANCIAL OPERATIONS OF ARKANSAS CHILDREN'S, INC. IF THE REVIEW BY ACNW'S MANAGEMENT RESULTS IN REVISIONS TO THE DRAFT FORM 990, THOSE REVISIONS ARE MADE, AND THE FORM 990 TO BE FILED IS PROVIDED TO THE ACNW BOARD OF DIRECTORS PRIOR TO THE RETURN BEING FILED. IN ADDITION, THE FORM 990 IS PROVIDED TO BOTH THE CHAIRMAN OF THE BOARD AND THE TREASURER OF ARKANSAS CHILDREN'S, INC. |
| FORM 990, PART VI, SECTION B, LINE 12C | ARKANSAS CHILDREN'S, INC. (THE PARENT) MAINTAINS A CONFLICT OF INTEREST POLICY WHICH PERTAINS TO ALL ENTITIES WITHIN THE HEALTHCARE SYSTEM. FOLLOWING ARE THE DETAILS REGARDING MONITORING AND COMPLIANCE: A. CONSISTENT WITH THE ARKANSAS CHILDREN'S CODE OF CONDUCT, ALL EMPLOYEES OR THOSE SERVING ON ARKANSAS CHILDREN'S-RELATED COMMITTEES MUST DISCLOSE ANY EMPLOYMENT, TRANSACTION, OR OTHER ARRANGEMENT THAT MAY CAUSE A CONFLICT OF INTEREST. ALL PERSONS COVERED BY THIS POLICY MUST DISCLOSE POSSIBLE CONFLICTS OF INTEREST CAUSED BY THEIR WORK, OR A FAMILY MEMBER ASSOCIATED WITH ARKANSAS CHILDREN'S. ALL PARTIES MUST FURTHER AGREE TO MANAGE SUCH CONFLICTS IN ACCORDANCE WITH THIS POLICY AND ASSOCIATED PROCEDURES. B. EACH EMPLOYEE AND VOLUNTEER MUST COMPLETE THE CONFLICT OF INTEREST STATEMENT AT THE TIME OF THEIR ANNUAL EVALUATION. C. MEDICAL STAFF MEMBERS WILL COMPLETE AN INITIAL CONFLICT OF INTEREST STATEMENT DURING THE CREDENTIALING PROCESS AND THEN BI-ANNUALLY DURING THE REAPPOINTMENT APPLICATION PROCESS. THE MEDICAL STAFF OFFICE WILL FORWARD ANY STATEMENT THAT INCLUDES A CONFLICT TO THE COMPLIANCE OFFICER FOR REVIEW AND FURTHER ACTION, IF NEEDED. D. IT IS THE RESPONSIBILITY OF EACH INDIVIDUAL TO IMMEDIATELY NOTIFY THEIR SUPERVISOR OF ANY CONFLICT AND REMOVE THEMSELVES FROM ANY DISCUSSION, EVALUATION, DELIBERATION THAT INVOLVES THEIR CONFLICT OF INTEREST. E. THE COMPLIANCE OFFICER WILL REVIEW COMPLETED STATEMENTS AND IF NEEDED TAKE FURTHER ACTION, IN CONSULTATION WITH APPROPRIATE MANAGEMENT. F. UPON REQUEST, PATIENTS OR THEIR LEGAL REPRESENTATIVES WILL BE GIVEN INFORMATION REGARDING PHYSICIAN CONFLICTS OF INTEREST RELATED TO THE PATIENT'S CARE. THIS INFORMATION CAN BE REQUESTED FROM THE CORPORATE COMPLIANCE OFFICE. REGARDING BOARD CONFLICTS, THE ACNW BOARD HAS ADOPTED, AND REQUIRES THE DIRECTORS, NON-DIRECTOR COMMITTEE MEMBERS, OFFICERS AND KEY EMPLOYEES OF THE CORPORATION TO ADHERE TO, A CONFLICT OF INTEREST POLICY THAT IS SUBSTANTIALLY CONSISTENT WITH THE PRINCIPLES AND STANDARDS ESTABLISHED FOR ADDRESSING CONFLICTS OF INTEREST BY APPLICABLE LAW, REGULATION OR ADMINISTRATIVE GUIDANCE AND WITH PREVAILING BEST PRACTICES FOR SECTION 501(C)(3) TAX-EXEMPT ORGANIZATIONS. A COPY OF SUCH CONFLICT OF INTEREST POLICY IS PROVIDED TO EACH NEWLY APPOINTED DIRECTOR AND TO ALL DIRECTORS ANNUALLY, TOGETHER WITH AN ANNUAL CONFLICT OF INTEREST DISCLOSURE STATEMENT. |
| FORM 990, PART VI, SECTION B, LINE 15 | COMPENSATION FOR ANY ACNW SENIOR OFFICER (PRESIDENT; SENIOR VICE PRESIDENT) WHO IS NOT A CONTRACTED UAMS EMPLOYEE IS REVIEWED BY THE ARKANSAS CHILDREN'S HUMAN RESOURCES AND COMPENSATION COMMITTEE WHICH IS ESTABLISHED THROUGH THE BYLAWS OF ARKANSAS CHILDREN'S, INC. THE HUMAN RESOURCES AND COMPENSATION COMMITTEE HAS THE FULL AUTHORITY AND SPECIFIC RESPONSIBILITY FOR REVIEWING AND APPROVING COMPENSATION POLICIES, BASE SALARY AND INCENTIVE COMPENSATION LEVELS, EXECUTIVE RETIREMENT AND OTHER EXECUTIVE BENEFIT PLANS FOR HEALTH SYSTEM SENIOR MANAGEMENT, INCLUDING OFFICERS OF THE CORPORATION AND AFFILIATES WHO ARE "DISQUALIFIED PERSONS" UNDER SECTION 4958 OF THE CODE. THE POLICIES AND PROGRAMS REVIEWED AND APPROVED BY THE HUMAN RESOURCES AND COMPENSATION COMMITTEE SHALL BE DESIGNED TO ENSURE THAT THE CORPORATION AND ITS AFFILIATES REMAIN COMPETITIVE AND REASONABLE RELATIVE TO THE COMPENSATION AND BENEFITS PRACTICES OF SIMILARLY SITUATED HEALTH SYSTEMS LOCALLY AND NATIONALLY, AND TO PERMIT THE CORPORATION AND SUCH AFFILIATES TO ATTRACT AND RETAIN SUPERIOR SENIOR MANAGEMENT, IN FURTHERANCE OF THE CORPORATION'S AND AFFILIATES PURPOSES. THE HUMAN RESOURCES AND COMPENSATION COMMITTEE SHALL HAVE, TO THE FULLEST EXTENT OF THE LAW, THE AUTHORITY TO APPROVE THE COMPENSATION PACKAGES FOR SENIOR MANAGEMENT OF THE CORPORATION AND THE AFFILIATES. |
| FORM 990, PART VI, SECTION C, LINE 18 | ARKANSAS CHILDREN'S NORTHWEST'S FORM 990 IS AVAILABLE TO THE PUBLIC UPON REQUEST. |
| FORM 990, PART VI, SECTION C, LINE 19 | ARKANSAS CHILDREN'S NORTHWEST'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST AS REQUIRED. |
| FORM 990, PART XI, LINE 9: | TRANSFER OF INITIAL FUNDS FROM ACH 20,000,000. |
| FORM 990 - SCHEDULE H | ARKANSAS CHILDREN'S NORTHWEST INC.'S HOSPITAL FACILITY IS CURRENTLY UNDER CONSTRUCTION. IT IS ANTICIPATED TO BE OPEN AND OPERATIONAL IN JANUARY 2018. SINCE THERE WAS NOT AN OPERATING HOSPITAL IN TAX YEAR 2015 (FY16), SCHEDULE H WAS NOT COMPLETED FOR THIS RETURN FILING. |
| Software ID: | |
| Software Version: |