TY 2015 Form 990

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)
(1) AR Umans...................................................................... Director	1.0 ................. 5.0	X		0	0
(2) Abraham Morgan...................................................................... Director	1.0 ................. 5.0	X		0	0
(3) Aida Giachello...................................................................... Director	1.0 ................. 5.0	X		0	0
(4) Albert Grace...................................................................... Vice Chair	1.0 ................. 5.0	X	X	0	0
(5) Alex duBuclet...................................................................... Director	1.0 ................. 5.0	X		0	0
(6) Alex Pissios...................................................................... Director	1.0 ................. 5.0	X		0	0
(7) Anne Donnelly...................................................................... Director	1.0 ................. 5.0	X		0	0
(8) Bettylu Saltzman...................................................................... Director	1.0 ................. 5.0	X		0	0
(9) Bob Wolfberg...................................................................... Director	1.0 ................. 5.0	X		0	0
(10) Daniel Ash...................................................................... Director	1.0 ................. 5.0	X		0	0
(11) Daniel Katz MD...................................................................... Director	1.0 ................. 39.0	X		503,020	20,503
(12) Gary Keller...................................................................... Director	1.0 ................. 5.0	X		0	0
(13) Gary Niederpruem...................................................................... Director	1.0 ................. 5.0	X		0	0
(14) John Benevides...................................................................... Director	1.0 ................. 5.0	X		0	0
(15) John Danaher MD...................................................................... Director	1.0 ................. 5.0	X		0	0
(16) Jonathan Jonas...................................................................... Treasurer	1.0 ................. 5.0	X	X	0	0
(17) Karen Teitelbaum...................................................................... Ex-Officio	4.0 ................. 36.0	X	X	748,382	77,474

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)
(18) Keith Wakefield........................................................................ Director	1.0 .......................5.0	X				0	0	0
(19) Kenneth Luccioni........................................................................ Director	1.0 .......................5.0	X				0	0	0
(20) Laurie Hernandez........................................................................ Director	1.0 .......................5.0	X				0	0	0
(21) Leslie Davis........................................................................ Secretary	1.0 .......................5.0	X	X			0	0	0
(22) Mark Frisch........................................................................ Director	1.0 .......................5.0	X				0	0	0
(23) Rey Gonzalez........................................................................ Director	1.0 .......................5.0	X				0	0	0
(24) Robert Markin........................................................................ Chairman	1.0 .......................5.0	X	X			0	0	0
(25) Robert Shakno........................................................................ Director	1.0 .......................5.0	X				0	0	0
(26) Robert Steele........................................................................ Director	1.0 .......................5.0	X				0	0	0
(27) Sharon Rossmark........................................................................ Director	1.0 .......................5.0	X				0	0	0
(28) Sr Immacula Wendt........................................................................ Director	1.0 .......................5.0	X				0	0	0
(29) Steve Topel........................................................................ Director	1.0 .......................5.0	X				0	0	0
(30) Terry Wheat........................................................................ Director	1.0 .......................5.0	X				0	0	0
(31) Tom Nodine........................................................................ Director	1.0 .......................5.0	X				0	0	0
(32) Wayne Pierce........................................................................ Director	1.0 .......................5.0	X				0	0	0
(33) Loren Chandler........................................................................ Exec. VP & COO	6.0 .......................34.0		X			0	435,704	68,775
(34) Charles Weis Jr........................................................................ Exec. VP for Admin & CFO	6.0 .......................34.0		X			0	616,755	75,351
(35) James Wilson........................................................................ Vice President - Finance	8.0 .......................32.0		X			0	113,696	1,420
(36) Mark Multach........................................................................ Chief Medical Officer	8.0 .......................32.0		X			0	490,189	45,362
(37) Rachel Dvorken........................................................................ Exec. VP & Gen. Counsel	6.0 .......................34.0		X			0	405,602	47,882
(38) Aaron Austin........................................................................ Vice President-Human Resources	9.5 .......................30.5		X			0	295,403	44,048
(39) Roberta Rakove........................................................................ Exec. VP & Gen. Counsel	6.8 .......................33.2		X			0	240,619	10,041
(40) Justin Schneider........................................................................ Vice President - Operations	6.8 .......................33.2		X			0	182,290	9,121
(41) Joel Craig Frazier........................................................................ Vice President	6.8 .......................33.2		X			0	175,696	9,429
(42) Tanvir Mangat........................................................................ VP/Chief Strategy Officer	8.4 .......................31.6		X			0	285,338	35,811
(43) Lori Pacura........................................................................ President	40.0 .......................0.0		X			0	292,800	9,469
(44) Deborah Davisson........................................................................ CNO/VP -Patient Care Services	40.0 .......................0.0		X			210,207	0	3,293
(45) Dennis Ryan........................................................................ VP-Mission Effect &Ext Affairs	40.0 .......................0.0		X			177,688	0	9,274
(46) Donnica Austin........................................................................ Vice President - Operations	40.0 .......................0.0		X			135,865	0	3,579
(47) Elmer Escalon........................................................................ Registered Nurse	40.0 .......................0.0			X		177,129	0	2,396
(48) Kenneth Slawkowski........................................................................ Director - Information System	40.0 .......................0.0			X		135,587	0	17,865
(49) Donna Charles........................................................................ Director-Imaging Adminstration	40.0 .......................0.0			X		137,342	0	8,140
(50) Cheryl Bednarski........................................................................ Registered Nurse	40.0 .......................0.0			X		129,657	0	7,019
(51) Crystal Mobley........................................................................ Director-Nursng Administration	40.0 .......................0.0			X		128,693	0	8,868
(52) Suzette Mahneke........................................................................ Vice President Nursg Adm &CNO	0.0 .......................0.0				X	0	186,290	2,268

(A) Name and business address	(B) Description of services	(C) Compensation
SODEXO INC AFFILIATES, 9801 Washingtonian Blvd GAITHERSBURG,MD20878	OPERATIONAL SERVICES	1,948,365
PROFESSIONAL NURSING INC, 3300 West Peterson Ave Suite E CHICAGO,IL60659	TEMP EMPLOYMENT	1,169,651
SUPERIOR HEALTH LINENS LLC, 1160 Pierson Drive Suite 104 BATAVIA,IL60510	LAUNDRY SERVICES	768,864
TRANSCEND SERVICES INC, One Glenlake Parkway Suite 1325 ATLANTA,GA30328	TRANSCRIPTION SERVS.	515,839
EXECUTIVE HEALTH RESOURCESINC, 15 Campus Boulevard Suite 200 NEWTON SQUARE,PA19073	COMPLIANCE MGMT	452,023
2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization 12

- TIN:

SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

Complete if the organization is a section 501(c)(3) organization or a section 4947(a)(1) nonexempt charitable trust.
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Attach to Form 990 or Form 990-EZ.
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Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

Open to Public
Inspection

Name of the organization

Holy Cross Hospital

Employer identification number

36-2170133

Part I

Reason for Public Charity Status (All organizations must complete this part.) See instructions.

The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)

A church, convention of churches, or association of churches described in section 170(b)(1)(A)(i).

A school described in section 170(b)(1)(A)(ii). (Attach Schedule E (Form 990 or 990-EZ))

A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii).

A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the hospital's name, city, and state:

An organization operated for the benefit of a college or university owned or operated by a governmental unit described in section 170(b)(1)(A)(iv). (Complete Part II.)

A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v).

An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 170(b)(1)(A)(vi). (Complete Part II.)

A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.)

An organization that normally receives: (1) more than 331/3% of its support from contributions, membership fees, and gross receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)

An organization organized and operated exclusively to test for public safety. See section 509(a)(4).

An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box in lines 11a through 11d that describes the type of supporting organization and complete lines 11e, 11f, and 11g.

Type I. A supporting organization operated, supervised, or controlled by its supported organization(s), typically by giving the supported organization(s) the power to regularly appoint or elect a majority of the directors or trustees of the supporting organization. You must complete Part IV, Sections A and B.

Type II. A supporting organization supervised or controlled in connection with its supported organization(s), by having control or management of the supporting organization vested in the same persons that control or manage the supported organization(s). You must complete Part IV, Sections A and C.

Type III functionally integrated. A supporting organization operated in connection with, and functionally integrated with, its supported organization(s) (see instructions). You must complete Part IV, Sections A, D, and E.

Type III non-functionally integrated. A supporting organization operated in connection with its supported organization(s) that is not functionally integrated. The organization generally must satisfy a distribution requirement and an attentiveness requirement (see instructions). You must complete Part IV, Sections A and D, and Part V.

Check this box if the organization received a written determination from the IRS that it is a Type I, Type II, Type III functionally integrated, or Type III non-functionally integrated supporting organization.

Enter the number of supported organizations ..............

Provide the following information about the supported organization(s).

(i)Name of supported organization	(ii) EIN	(iv) Is the organization listed in your governing document?		(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)
(i)Name of supported organization	(ii) EIN	Yes	No	(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)


Total

For Paperwork Reduction Act Notice, see the Instructions for
Form 990 or 990-EZ.

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2015

Page 2

Part II

Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)

Section A. Public Support

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.

Section B. Total Support

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.

Gross receipts from related activities, etc. (see instructions) ..................

First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization, check this box and stop here........................................ right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2015 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2014 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2015. If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization ....................... right arrow

33 1/3% support test—2014. If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization ..................... right arrow

17a

10%-facts-and-circumstances test—2015. If the organization did not check a box on line 13, 16a, or 16b, and line 14
is 10% or more, and if the organization meets the facts-and-circumstances test, check this box and stop here. Explain
in Part VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization ..................................................... right arrow

10%-facts-and-circumstances test—2014. If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here.
Explain in Part VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly
supported organization ................................................ right arrow

Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions ..................................................... right arrow

Schedule A (Form 990 or 990-EZ) 2015

Page 3

Part III

Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)

Section A. Public Support

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.)

Section B. Total Support

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.)..

First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization,
check this box and stop here............................................. right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2015 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2014 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2015 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2014 Schedule A, Part III, line 17 .............

19a

331/3% support tests—2015. If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ....... right arrow

33 1/3% support tests—2014. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization .... right arrow

Private foundation. If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions .... right arrow

Schedule A (Form 990 or 990-EZ) 2015

Page 4

Part IV

Supporting Organizations

(Complete only if you checked a box on line 11 of Part I. If you checked 11a of Part I, complete Sections A and B. If you checked 11b of Part I, complete Sections A and C. If you checked 11c of Part I, complete Sections A, D, and E. If you checked 11d of Part I, complete Sections A and D, and complete Part V.)

Section A. All Supporting Organizations

Yes

Are all of the organization’s supported organizations listed by name in the organization’s governing documents?
If "No," describe in Part VI how the supported organizations are designated. If designated by class or purpose,
describe the designation. If historic and continuing relationship, explain.

Did the organization have any supported organization that does not have an IRS determination of status under section 509(a)(1) or (2)? If "Yes," explain in Part VI how the organization determined that the supported organization was described in section 509(a)(1) or (2).

Did the organization have a supported organization described in section 501(c)(4), (5), or (6)? If "Yes," answer (b) and (c) below.

Did the organization confirm that each supported organization qualified under section 501(c)(4), (5), or (6) and satisfied the public support tests under section 509(a)(2)? If "Yes," describe in Part VI when and how the organization made the determination.

Did the organization ensure that all support to such organizations was used exclusively for section 170(c)(2)(B) purposes? If "Yes," explain in Part VI what controls the organization put in place to ensure such use.

Was any supported organization not organized in the United States ("foreign supported organization")? If “Yes” and if you checked 11a or 11b in Part I, answer (b) and (c) below.

Did the organization have ultimate control and discretion in deciding whether to make grants to the foreign supported organization? If “Yes,” describe in Part VI how the organization had such control and discretion despite being controlled or supervised by or in connection with its supported organizations.

Did the organization support any foreign supported organization that does not have an IRS determination under sections 501(c)(3) and 509(a)(1) or (2)? If “Yes,” explain in Part VI what controls the organization used to ensure that all support to the foreign supported organization was used exclusively for section 170(c)(2)(B) purposes.

Did the organization add, substitute, or remove any supported organizations during the tax year? If “Yes,” answer (b) and (c) below (if applicable). Also, provide detail in Part VI, including (i) the names and EIN numbers of the supported organizations added, substituted, or removed; (ii) the reasons for each such action; (iii) the authority under the organization's organizing document authorizing such action; and (iv) how the action was accomplished (such as by amendment to the organizing document).

Type I or Type II only. Was any added or substituted supported organization part of a class already designated in the organization's organizing document?

Substitutions only. Was the substitution the result of an event beyond the organization's control?

Did the organization provide support (whether in the form of grants or the provision of services or facilities) to anyone other than (i) its supported organizations, (ii) individuals that are part of the charitable class benefited by one or more of its supported organizations, or (iii) other supporting organizations that also support or benefit one or more of the filing organization’s supported organizations? If “Yes,” provide detail in Part VI.

Did the organization provide a grant, loan, compensation, or other similar payment to a substantial contributor (defined in section 4958(c)(3)(C)), a family member of a substantial contributor, or a 35% controlled entity with regard to a substantial contributor? If “Yes,” complete Part I of Schedule L (Form 990 or 990-EZ) .

Did the organization make a loan to a disqualified person (as defined in section 4958) not described in line 7? If “Yes,” complete Part I of Schedule L (Form 990 or 990-EZ).

Was the organization controlled directly or indirectly at any time during the tax year by one or more disqualified persons as defined in section 4946 (other than foundation managers and organizations described in section 509(a)(1) or (2))? If “Yes,” provide detail in Part VI.

Did one or more disqualified persons (as defined in line 9a) hold a controlling interest in any entity in which the supporting organization had an interest? If “Yes,” provide detail in Part VI.

Did a disqualified person (as defined in line 9a) have an ownership interest in, or derive any personal benefit from, assets in which the supporting organization also had an interest? If “Yes,” provide detail in Part VI.

10a

Was the organization subject to the excess business holdings rules of section 4943 because of section 4943(f) (regarding certain Type II supporting organizations, and all Type III non-functionally integrated supporting organizations)? If “Yes,” answer line 10b below.

10a

Did the organization have any excess business holdings in the tax year? (Use Schedule C, Form 4720, to determine whether the organization had excess business holdings).

10b

Schedule A (Form 990 or 990-EZ) 2015

Page 5

Part IV

Supporting Organizations (continued)

Yes

Has the organization accepted a gift or contribution from any of the following persons?

A person who directly or indirectly controls, either alone or together with persons described in (b) and (c) below, the governing body of a supported organization?

11a

A family member of a person described in (a) above?

11b

A 35% controlled entity of a person described in (a) or (b) above? If “Yes” to a, b, or c, provide detail in Part VI.

11c

Section B. Type I Supporting Organizations

Yes

Did the directors, trustees, or membership of one or more supported organizations have the power to regularly appoint or elect at least a majority of the organization’s directors or trustees at all times during the tax year? If “No,” describe in Part VI how the supported organization(s) effectively operated, supervised, or controlled the organization’s activities. If the organization had more than one supported organization, describe how the powers to appoint and/or remove directors or trustees were allocated among the supported organizations and what conditions or restrictions, if any, applied to such powers during the tax year.

Did the organization operate for the benefit of any supported organization other than the supported organization(s) that operated, supervised, or controlled the supporting organization? If “Yes,” explain in Part VI how providing such benefit carried out the purposes of the supported organization(s) that operated, supervised or controlled the supporting organization.

Section C. Type II Supporting Organizations

Yes

Were a majority of the organization’s directors or trustees during the tax year also a majority of the directors or trustees of each of the organization’s supported organization(s)? If “No,” describe in Part VI how control or management of the supporting organization was vested in the same persons that controlled or managed the supported organization(s).

Section D. All Type III Supporting Organizations

Yes

Did the organization provide to each of its supported organizations, by the last day of the fifth month of the organization’s tax year, (i) a written notice describing the type and amount of support provided during the prior tax year, (ii) a copy of the Form 990 that was most recently filed as of the date of notification, and (iii) copies of the organization’s governing documents in effect on the date of notification, to the extent not previously provided?

Were any of the organization’s officers, directors, or trustees either (i) appointed or elected by the supported organization(s) or (ii) serving on the governing body of a supported organization? If "No," explain in Part VI how the organization maintained a close and continuous working relationship with the supported organization(s).

By reason of the relationship described in (2), did the organization’s supported organizations have a significant voice in the organization’s investment policies and in directing the use of the organization’s income or assets at all times during the tax year? If "Yes," describe in Part VI the role the organization’s supported organizations played in this regard.

Section E. Type III Functionally-Integrated Supporting Organizations

Check the box next to the method that the organization used to satisfy the Integral Part Test during the year (see instructions):

The organization satisfied the Activities Test. Complete line 2 below.

The organization is the parent of each of its supported organizations. Complete line 3 below.

The organization supported a governmental entity. Describe in Part VI how you supported a government entity (see instructions)

Activities Test. Answer (a) and (b) below.

Yes

Did substantially all of the organization’s activities during the tax year directly further the exempt purposes of the supported organization(s) to which the organization was responsive? If "Yes," then in Part VI identify those supported organizations and explain how these activities directly furthered their exempt purposes, how the organization was responsive to those supported organizations, and how the organization determined that these activities constituted substantially all of its activities.

Did the activities described in (a) constitute activities that, but for the organization’s involvement, one or more of the organization’s supported organization(s) would have been engaged in? If "Yes," explain in Part VI the reasons for the organization’s position that its supported organization(s) would have engaged in these activities but for the organization’s involvement.

Parent of Supported Organizations. Answer (a) and (b) below.

Did the organization have the power to regularly appoint or elect a majority of the officers, directors, or trustees of each of the supported organizations? Provide details in Part VI.

Did the organization exercise a substantial degree of direction over the policies, programs and activities of each of its supported organizations? If "Yes," describe in Part VI. the role played by the organization in this regard.

Schedule A (Form 990 or 990-EZ) 2015

Page 6

Part V

Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations

Check here if the organization satisfied the Integral Part Test as a qualifying trust on Nov. 20, 1970. See instructions. All other Type III non-functionally integrated supporting organizations must complete Sections A through E.

	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

Check here if the current year is the organization's first as a non-functionally-integrated Type III supporting organization (see instructions)

Schedule A (Form 990 or 990-EZ) 2015

Page 7

Part V

Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations (continued)

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.......

Schedule A (Form 990 or 990-EZ) (2015)

Schedule A (Form 990 or 990-EZ) 2015

Page 8

Part VI

Supplemental Information. Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; Part III, line 12; Part IV, Section A, lines 1, 2, 3b, 3c, 4b, 4c, 5a, 6, 9a, 9b, 9c, 11a, 11b, and 11c; Part IV, Section B, lines 1 and 2; Part IV, Section C, line 1; Part IV, Section D, lines 2 and 3; Part IV, Section E, lines 1c, 2a, 2b, 3a and 3b; Part V, line 1; Part V, Section B, line 1e; Part V Section D, lines 5, 6, and 8; and Part V, Section E, lines 2, 5, and 6. Also complete this part for any additional information. (See instructions).

Facts And Circumstances Test

Return Reference	Explanation

Schedule A (Form 990 or 990-EZ) 2015

Additional Data

Software ID:
Software Version:

- TIN:

Schedule B
(Form 990, 990-EZ,
or 990-PF)

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

Attach to Form 990, 990-EZ, or 990-PF.

Information about Schedule B (Form 990, 990-EZ, or 990-PF) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

Name of the organization

Holy Cross Hospital

Employer identification number

36-2170133

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

4947(a)(1) nonexempt charitable trust not treated as a private foundation

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

4947(a)(1) nonexempt charitable trust treated as a private foundation

501(c)(3) taxable private foundation

Check if your organization is covered by the General Rule or a Special Rule.
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.

General Rule

For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, contributions totaling $5,000 or more (in money or other property) from any one contributor. Complete Parts I and II. See instructions for determining a contributor's total contributions.

Special Rules

For an organization described in section 501(c)(3) filing Form 990 or 990-EZ that met the 33¹/3% support test of the regulations
under sections 509(a)(1) and 170(b)(1)(A)(vi), that checked Schedule A (Form 990 or 990-EZ), Part II, line 13, 16a, or 16b, and that received from any one contributor, during the year, total contributions of the greater of (1) $5,000 or (2) 2% of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1. Complete Parts I and II.

For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, total contributions of more than $1,000 exclusively for religious, charitable, scientific, literary, or educational purposes, or for the prevention of cruelty to children or animals. Complete Parts I, II, and III.

For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, contributions exclusively for religious, charitable, etc., purposes, but no such contributions totaled more than $1,000. If this box is checked, enter here the total contributions that were received during the year for an exclusively religious, charitable, etc., purpose. Do not complete any of the parts unless the General Rule applies to this organization because it received nonexclusively religious, charitable, etc., contributions totaling $5,000 or more during the year ......... Arrow Bullet

Caution. An organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2, of its Form 990; or check the box on line H of its
Form 990-EZ or on its Form 990PF, Part I, line 2, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).

For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.

Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2015)

Schedule B (Form 990, 990-EZ, or 990-PF) (2015) Page 2

Name of organization Holy Cross Hospital

Part I	Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
RESTRICTED	,	$ RESTRICTED	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2015)

Schedule B (Form 990, 990-EZ, or 990-PF) (2015)

Page 3

Name of organization Holy Cross Hospital		Employer identification number 36-2170133

Part II	Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
(a) No.from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No.from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No.from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No.from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No.from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No.from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
Schedule B (Form 990, 990-EZ, or 990-PF) (2015)

Schedule B (Form 990, 990-EZ, or 990-PF) (2015)

Page 4


Name of organization Holy Cross Hospital			Employer identification number 36-2170133
Part III Exclusively religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10) that total more than $1,000 for the year from any one contributor. Complete columns (a) through (e) and the following line entry. For organizations completing Part III, enter the total of exclusively religious, charitable, etc., contributions of $1,000 or less for the year. (Enter this information once. See instructions.) $ Use duplicate copies of Part III if additional space is needed.

(a)
No.from Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a)
No.from Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a)
No.from Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a)
No.from Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

Schedule B (Form 990, 990-EZ, or 990-PF) (2015)

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527
SchCMd Bullet

Complete if the organization is described below. SchCMd Bullet

Attach to Form 990 or Form 990-EZ.
SchCMd Bullet

Information about Schedule C (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

Open to Public
Inspection

If the organization answered "Yes" on Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet

Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet

Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet

Section 527 organizations: Complete Part I-A only.
If the organization answered "Yes" on Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet

Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)): Complete Part II-A. Do not complete Part II-B.
Round Bullet

Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered "Yes" on Form 990, Part IV, Line 5 (Proxy Tax) (see separate instructions) or Form 990-EZ, Part V, line 35c (Proxy Tax) (see separate instructions), then
Round Bullet

Section 501(c)(4), (5), or (6) organizations: Complete Part III.

Name of the organization

Holy Cross Hospital

Employer identification number

36-2170133

Part I-A

Complete if the organization is exempt under section 501(c) or is a section 527 organization.

Provide a description of the organization’s direct and indirect political campaign activities in Part IV.

Political expenditures ...................................................................................................................... SchCMd Bullet

Volunteer hours .............................................................................................................................

Part I-B

Complete if the organization is exempt under section 501(c)(3).

Enter the amount of any excise tax incurred by the organization under section 4955 ................................ SchCMd Bullet

Enter the amount of any excise tax incurred by organization managers under section 4955 ....................... SchCMd Bullet

If the organization incurred a section 4955 tax, did it file Form 4720 for this year? .........................................

Yes No

Was a correction made? ......................................................................................................................

Yes No

If "Yes," describe in Part IV.

Part I-C

Complete if the organization is exempt under section 501(c), except section 501(c)(3).

Enter the amount directly expended by the filing organization for section 527 exempt function activities ..... SchCMd Bullet

Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ............................................................................................................................ SchCMd Bullet

Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b........... SchCMd Bullet

Did the filing organization file Form 1120-POL for this year? ...................................................................

Yes No

Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.

(a) Name	(b) Address	(c) EIN	(d) Amount paid from filing organization's funds. If none, enter -0-.	(e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.
1
2
3
4
5
6

For Paperwork Reduction Act Notice, see the instructions for Form 990 or 990-EZ.

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2015

Page 2

Part II-A

Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).

A Check SchCMd Bullet

if the filing organization belongs to an affiliated group (and list in Part IV each affiliated group member's name, address, EIN, expenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet

if the filing organization checked box A and "limited control" provisions apply.

Limits on Lobbying Expenditures (The term "expenditures" means amounts paid or incurred.)		(b) Affiliated group totals
1a	Total lobbying expenditures to influence public opinion (grass roots lobbying) ...............................................
b	Total lobbying expenditures to influence a legislative body (direct lobbying) ...........................................
c	Total lobbying expenditures (add lines 1a and 1b) .......................................................................
d	Other exempt purpose expenditures .........................................................................................
e	Total exempt purpose expenditures (add lines 1c and 1d) ....................................................................
f	Lobbying nontaxable amount. Enter the amount from the following table in both columns.
	If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:
	Not over $500,00020% of the amount on line 1e.
	Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.
	Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.
	Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.
	Over $17,000,000$1,000,000.

g	Grassroots nontaxable amount (enter 25% of line 1f) ..........................................................................
h	Subtract line 1g from line 1a. If zero or less, enter -0-. ..........................................................................
i	Subtract line 1f from line 1c. If zero or less, enter -0-. ...........................................................................
j	If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting section 4911 tax for this year? ..............................................................................................................	Yes No

4-Year Averaging Period Under section 501(h) (Some organizations that made a section 501(h) election do not have to complete all of the five columns below. See the separate instructions for lines 2a through 2f.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2012	(b) 2013	(c) 2014	(d) 2015	(e) Total

2a	Lobbying nontaxable amount

b	Lobbying ceiling amount (150% of line 2a, column(e))

c	Total lobbying expenditures

d	Grassroots nontaxable amount

e	Grassroots ceiling amount (150% of line 2d, column (e))

f	Grassroots lobbying expenditures

Schedule C (Form 990 or 990-EZ) 2015

Page 3

Part II-B

Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).

For each "Yes" response on lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.

(a)

Yes

(b)

Amount

During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:

Volunteers? ...........................................................................................................

Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ........

Media advertisements? ...................................................................................................

Mailings to members, legislators, or the public? .............................................................................

Publications, or published or broadcast statements? ...........................................................

Grants to other organizations for lobbying purposes? ..........................................................

Direct contact with legislators, their staffs, government officials, or a legislative body? .......................

Yes

96,353

Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ..................

Other activities? ...................................................................................................................

Total. Add lines 1c through 1i ....................................................................................................

96,353

Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....

If "Yes," enter the amount of any tax incurred under section 4912 ...........................................

If "Yes," enter the amount of any tax incurred by organization managers under section 4912 ...................

If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? ........................

Part III-A

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).

Yes

Were substantially all (90% or more) dues received nondeductible by members? ...............................................

Did the organization make only in-house lobbying expenditures of $2,000 or less? ............................................

Did the organization agree to carry over lobbying and political expenditures from the prior year? .................................

Part III-B

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2, are answered "No" OR (b) Part III-A, line 3, is answered “Yes."

Dues, assessments and similar amounts from members ......................................................................

Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political expenses for which the section 527(f) tax was paid).

Current year .............................................................................................................................

Carryover from last year ............................................................................................................

Total ...........................................................................................................................................

Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .

If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ......................................................................................................................

Taxable amount of lobbying and political expenditures (see instructions) .........................................

Part IV

Supplemental Information

Provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, line 5; Part II-A (affiliated group list); Part II-A, lines 1 and 2 (see instructions), and Part ll-B, line 1. Also, complete this part for any additional information.

Return Reference	Explanation
FORM 990, SCHEDULE C	SUPPLEMENTAL INFORMATION SINAI HEALTH SYSTEM ENGAGES IN EDUCATION AND OTHER ACTIVITIES TO INFLUENCE LEGISLATORS REGARDING FEDERAL AND STATE POLICIES RELATED TO MEDICAID, SINAI'S MAJOR PAYER AND THE SAFETY NET OF MANY OF ITS PATIENTS. THE SYSTEM LOBBYING ACTIVITIES ARE COORDINATED THROUGH ROBERTA RAKOVE, SENIOR VICE PRESIDENT FOR SINAI HEALTH SYSTEM. LOBBYING IS CONDUCTED ON BEHALF OF THE ENTIRE SYSTEM, THEREFORE REGISTERED STATE LOBBYISTS ARE REGISTERED TO REPRESENT SINAI HEALTH SYSTEM. SOME EXPENSES ARE ALLOCATED TO MOUNT SINAI HOSPITAL AND HOLY CROSS HOSPITAL BUT THE EXPENSES ARE PAID BY SINAI HEALTH SYSTEM. AT THE FEDERAL LEVEL, SINAI HEALTH SYSTEM DOES NOT UTILIZE CONTRACT LOBBYISTS. SINAI HEALTH SYSTEM COLLABORATES WITH THE AMERICAN HOSPITAL ASSOCIATION, THE ILLINOIS HOSPITAL ASSOCIATION, THE PREMIER HOSPITAL ALLIANCE, AND THE JEWISH FEDERATION OF METROPOLITAN CHICAGO/JEWISH UNITED FUND. A PORTION OF DUES FROM THE AMERICAN HOSPITAL ASSOCIATION AND THE ILLINOIS HOSPITAL ASSOCIATION SUPPORT FEDERAL LOBBYING. AT THE STATE LEVEL, SINAI UTILIZES TWO OUTSIDE LOBBYING FIRMS.

Return Reference

Explanation

FORM 990, SCHEDULE C

SUPPLEMENTAL INFORMATION SINAI HEALTH SYSTEM ENGAGES IN EDUCATION AND OTHER ACTIVITIES TO INFLUENCE LEGISLATORS REGARDING FEDERAL AND STATE POLICIES RELATED TO MEDICAID, SINAI'S MAJOR PAYER AND THE SAFETY NET OF MANY OF ITS PATIENTS. THE SYSTEM LOBBYING ACTIVITIES ARE COORDINATED THROUGH ROBERTA RAKOVE, SENIOR VICE PRESIDENT FOR SINAI HEALTH SYSTEM. LOBBYING IS CONDUCTED ON BEHALF OF THE ENTIRE SYSTEM, THEREFORE REGISTERED STATE LOBBYISTS ARE REGISTERED TO REPRESENT SINAI HEALTH SYSTEM. SOME EXPENSES ARE ALLOCATED TO MOUNT SINAI HOSPITAL AND HOLY CROSS HOSPITAL BUT THE EXPENSES ARE PAID BY SINAI HEALTH SYSTEM. AT THE FEDERAL LEVEL, SINAI HEALTH SYSTEM DOES NOT UTILIZE CONTRACT LOBBYISTS. SINAI HEALTH SYSTEM COLLABORATES WITH THE AMERICAN HOSPITAL ASSOCIATION, THE ILLINOIS HOSPITAL ASSOCIATION, THE PREMIER HOSPITAL ALLIANCE, AND THE JEWISH FEDERATION OF METROPOLITAN CHICAGO/JEWISH UNITED FUND. A PORTION OF DUES FROM THE AMERICAN HOSPITAL ASSOCIATION AND THE ILLINOIS HOSPITAL ASSOCIATION SUPPORT FEDERAL LOBBYING. AT THE STATE LEVEL, SINAI UTILIZES TWO OUTSIDE LOBBYING FIRMS.

Schedule C (Form 990 or 990EZ) 2015

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

Complete if the organization answered "Yes," on Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b.
SchDMd Bullet

Attach to Form 990.
Information about Schedule D (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

Open to Public Inspection

Name of the organization

Holy Cross Hospital

Employer identification number

36-2170133

Part I

Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" on Form 990, Part IV, line 6.

			(a) Donor advised funds	(b) Funds and other accounts

1	Total number at end of year ....
2	Aggregate value of contributions to (during year)
3	Aggregate value of grants from (during year)
4	Aggregate value at end of year ....

Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ...........

Yes No

Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ............................

Yes No

Part II

Conservation Easements. Complete if the organization answered "Yes" on Form 990, Part IV, line 7.

Purpose(s) of conservation easements held by the organization (check all that apply).

Preservation of land for public use (e.g., recreation or education) Preservation of an historically important land area

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.


a	Total number of conservation easements ......................	2a
b	Total acreage restricted by conservation easements ....................	2b
c	Number of conservation easements on a certified historic structure included in (a) .....	2c
d	Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register ...	2d

Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during the
tax year SchDMd Bullet

Number of states where property subject to conservation easement is located SchDMd Bullet

Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and enforcement of the conservation easements it holds? ............

Yes No

Staff and volunteer hours devoted to monitoring, inspecting, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet

Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .............................

Yes No

In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" on Form 990, Part IV, line 8.

If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items.

If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts relating to these items:

(i)

Revenue included on Form 990, Part VIII, line 1 ......................... SchDMd Bullet

(ii)

Assets included in Form 990, Part X ............................... SchDMd Bullet

If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958) relating to these items:

Revenue included on Form 990, Part VIII, line 1 .......................... SchDMd Bullet

Assets included in Form 990, Part X ............................... SchDMd Bullet

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 52283D

Schedule D (Form 990) 2015

Page 2

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)

Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply):

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.

During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?...

Yes No

Part IV

Escrow and Custodial Arrangements. Complete if the organization answered "Yes" on Form 990, Part IV, line 9, or reported an amount on Form 990, Part X, line 21.

Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................

Yes No


b	If "Yes," explain the arrangement in Part XIII and complete the following table:		Amount
c	Beginning balance .............................	1c
d	Additions during the year ............................	1d
e	Distributions during the year ..........................	1e
f	Ending balance ................................	1f

Did the organization include an amount on Form 990, Part X, line 21, for escrow or custodial account liability?

Yes No

If "Yes," explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII ........

Part V

Endowment Funds. Complete if the organization answered "Yes" on Form 990, Part IV, line 10.

		(a)Current year	(b)Prior year	(c)Two years back	(d)Three years back	(e)Four years back

1a	Beginning of year balance ....
b	Contributions ...
c	Net investment earnings, gains, and losses
d	Grants or scholarships ...
e	Other expenditures for facilities and programs ...
f	Administrative expenses ....
g	End of year balance ......

Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Temporarily restricted endowment SchDMd Bullet

The percentages on lines 2a, 2b, and 2c should equal 100%.

Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes

(i) unrelated organizations .................

3a(i)

(ii) related organizations .................

3a(ii)

If "Yes" on 3a(ii), are the related organizations listed as required on Schedule R? .........

Describe in Part XIII the intended uses of the organization's endowment funds.

Part VI

Land, Buildings, and Equipment.
Complete if the organization answered 'Yes' on Form 990, Part IV, line 11a. See Form 990, Part X, line 10.

Description of property		(a) Cost or other basis (investment)	(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value

1a	Land ...	0	1,700,000		1,700,000
b	Buildings	0	83,549,231	12,278,545	71,270,686
c	Leasehold improvements	0	707,906	132,055	575,851
d	Equipment ...	0	28,508,829	14,432,440	14,076,389
e	Other ...	0	245,211		245,211
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..					87,868,137

Schedule D (Form 990) 2015

Page 3

Part VII

InvestmentsOther Securities. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11b. See Form 990, Part X, line 12.

(a) Description of security or category (including name of security)	(b)Book value	(c)Method of valuation: Cost or end-of-year market value
(1)Financial derivatives
(2)Closely-held equity interests
(3)Other (A) Northern Trust Agreement	11,415,476	F
(B) CD - Lakeside Bank	64,272	F
(B)
(C)
(D)
(E)
(F)
(G)
(H)
Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)	11,479,748

Part VIII

InvestmentsProgram Related. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11c. See Form 990, Part X, line 13.

(a) Description of investment	(b) Book value	(c) Method of valuation: Cost or end-of-year market value

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)

Part IX

Other Assets. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11d. See Form 990, Part X, line 15.

(a) Description				(b) Book value
(1) Due from Affiliates				12,397,915
(2) Due from third-party payors				4,264,958
(3) WORKERS COMPENSATION TRUST				1,287,757
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........				17,950,630

Part X

Other Liabilities. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11e or 11f. See Form 990, Part X, line 25.

1.(a) Description of liability	(b) Book value
(1) Federal income taxes	0
Pension and Post Retirement	365,972
Steward Fees	3,133,000
Professional Liability	11,598,950
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)	15,097,922
2. Liability for uncertain tax positions. In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII

Schedule D (Form 990) 2015

Page 4

Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
1	Total revenue, gains, and other support per audited financial statements .......		1
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains (losses) on investments ....	2a
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c
d	Other (Describe in Part XIII.) ............	2d
e	Add lines 2a through 2d .....................		2e
3	Subtract line 2e from line 1..................		3
4	Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b .	4a
b	Other (Describe in Part XIII.) ...........	4b
c	Add lines 4a and 4b....................		4c
5	Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ......		5

Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return. Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
1	Total expenses and losses per audited financial statements ...........		1
2	Amounts included on line 1 but not on Form 990, Part IX, line 25:
a	Donated services and use of facilities .........	2a
b	Prior year adjustments ............	2b
c	Other losses ................	2c
d	Other (Describe in Part XIII.) ............	2d
e	Add lines 2a through 2d....................		2e
3	Subtract line 2e from line 1...................		3
4	Amounts included on Form 990, Part IX, line 25, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b ..	4a
b	Other (Describe in Part XIII.) ............	4b
c	Add lines 4a and 4b.....................		4c
5	Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ......		5

Part XIII

Supplemental Information

Provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.

Return Reference

Explanation

Form 990, Schedule D, Part X, Line 2

FIN 48(ASC 740) Footnote Income taxes: Mount Sinai, Schwab, Holy Cross, SMG, and SCI are tax-exempt organizations under Internal Revenue Code Section 501(c)(3) and each, as required, files a form 990 (Return of Organization Exempt from Income Tax) annually. Progress health inc. files Federal and Illinois forms 1120 (U.S. Corporation Income Tax Return) annually. The Corporation adopted Financial Accounting Standards Board (FASB) issued guidance for uncertainty in income taxes. The guidance prescribes a recognition threshold and measurement attribute for the financial statement recognition and measurement of a tax position taken or expected to be taken in a tax return. Examples of tax positions common to health systems include such matters as the following: the tax-exempt status of each entity, the nature, characterization and taxability of joint venture income and various positions relative to potential sources of unrelated business taxable income (UBIT). UBIT is reported on Form 990T, as appropriate. The benefit of a tax position is recognized in the financial statements in the period during which, based on all available evidence, management believes that it is more likely than not that the position will be sustained upon examination, including the resolution of appeals or litigation processes, if any. Tax positions are not offset or aggregated with other positions. Tax positions that meet the "more likely than not" recognition threshold are measured as the largest amount of tax benefit that is more than 50 percent likely to be realized on settlement with the applicable taxing authority. The portion of the benefits associated with tax positions taken that exceeds the amount measured as described above is reflected as a liability for unrecognized tax benefits in the consolidated balance sheets along with any associated interest and penalties that would be payable to the taxing authorities upon examination. As of June 30, 2016 and 2015, there were no unrecognized tax benefits identified and recorded. Forms 990 and 1120 filed by the Corporation are subject to examination by the Internal Revenue Service (IRS) for up to three years from the extended due date of each return. Forms 990 and 1120 filed by the Corporation are no longer subject to examination for the years ended June 30, 2012 and prior.

Schedule D (Form 990) 2015

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H
(Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

Complete if the organization answered "Yes" on Form 990, Part IV, question 20.
MediumBullet

Attach to Form 990.
MediumBullet

Information about Schedule H (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

Open to Public Inspection

Name of the organization

Holy Cross Hospital

Employer identification number

36-2170133

Part I

Financial Assistance and Certain Other Community Benefits at Cost

Yes

Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a . . . .

Yes

If "Yes," was it a written policy? ......................

Yes

If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.

Applied uniformly to all hospital facilities Applied uniformly to most hospital facilities Generally tailored to individual hospital facilities

Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.

Did the organization use Federal Poverty Guidelines (FPG) as a factor in determining eligibility for providing free care?

If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:

Yes

100% 150% 200% Other 300 %

Did the organization use FPG as a factor in determining eligibility for providing discounted care? If "Yes," indicate

which of the following was the family income limit for eligibility for discounted care: . . . . . . . .

Yes

200% 250% 300% 350% 400% Other 600 %

If the organization used factors other than FPG in determining eligibility, describe in Part VI the criteria used for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, as a factor in determining eligibility for free or discounted care.

Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? . . . . . . . . . . . . .

Yes

Did the organization budget amounts for free or discounted care provided under its financial assistance policy during
the tax year? . . . . . . . . . . . . . . . . . . . . . . .

Yes

If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? . . . . . .

Yes

If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care? . . . . . . . . . . . . .

Did the organization prepare a community benefit report during the tax year? . . . . . . . . .

Yes

If "Yes," did the organization make it available to the public? . . . . . . . . . . . . .

Yes

Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance and Means-Tested Government Programs		(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a	Financial Assistance at cost (from Worksheet 1) . . .	6,276,476		6,276,476	5.240 %
b	Medicaid (from Worksheet 3, column a) . . . . .	17,049,723	81,712,894	-64,663,171
c	Costs of other means-tested government programs (from Worksheet 3, column b) . .
d	Total Financial Assistance and Means-Tested Government Programs . . . . .	23,326,199	81,712,894	-58,386,695	5.240 %
Other Benefits
e	Community health improvement services and community benefit operations (from Worksheet 4).	13,622		13,622	0.010 %
f	Health professions education (from Worksheet 5) . . .	5,950		5,950	0.010 %
g	Subsidized health services (from Worksheet 6) . . . .
h	Research (from Worksheet 7) .
i	Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .
j	Total. Other Benefits . .	19,572		19,572	0.020 %
k	Total. Add lines 7d and 7j .	23,345,771	81,712,894	-58,367,123	5.260 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2015

Schedule H (Form 990) 2015

Page

Part II

Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.

		(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community building expense	(d) Direct offsetting revenue	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development
3	Community support
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building
7	Community health improvement advocacy
8	Workforce development
9	Other
10	Total

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................

Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......

9,317,296

Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. ......

2,704,358

Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements.

Section B. Medicare

Enter total revenue received from Medicare (including DSH and IME).....

36,268,608

Enter Medicare allowable costs of care relating to payments on line 5.....

35,048,701

Subtract line 6 from line 5. This is the surplus (or shortfall)........

1,219,907

Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.Check the box that describes the method used:

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

Did the organization have a written debt collection policy during the tax year? ..........

Yes

If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year
contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI .........................

Yes

Part IV

Management Companies and Joint Ventures(owned 10% or more by officers, directors, trustees, key employees, and physicians—see instructions)

(a) Name of entity	(b) Description of primary activity of entity	(c) Organization's profit % or stock ownership %	(d) Officers, directors, trustees, or key employees' profit % or stock ownership %	(e) Physicians' profit % or stock ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13

Schedule H (Form 990) 2015

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest—see instructions) How many hospital facilities did the organization operate during the tax year?1 Name, address, primary website address, and state license number (and if a group return, the name and EIN of the subordinate hospital organization that operates the hospital facility)
1	Holy Cross Hospital 2701 West 68th Street Chicago,IL60629 www.holycrosshospital.org	X	X

Schedule H (Form 990) 2015

Page 4

Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)

	Holy Cross Hospital
Name of hospital facility or letter of facility reporting group

Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A):

Yes

Community Health Needs Assessment

Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?........................

Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C...............

During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 12......................

Yes

If "Yes," indicate what the CHNA report describes (check all that apply):

A definition of the community served by the hospital facility

Demographics of the community

Existing health care facilities and resources within the community that are available to respond to the health needs of the community

How data was obtained

The significant health needs of the community

Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups

The process for identifying and prioritizing community health needs and services to meet the community health needs

The process for consulting with persons representing the community’s interests

Information gaps that limit the hospital facility’s ability to assess the community’s health needs

Other (describe in Section C)

Indicate the tax year the hospital facility last conducted a CHNA: 20 15

In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted .................

Yes

6 a

Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C..................................

Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C. ............................

Did the hospital facility make its CHNA report widely available to the public?..............

Yes

If "Yes," indicate how the CHNA report was made widely available (check all that apply):

Hospital facility’s website (list url): www.sinai.org

Other website (list url):

Made a paper copy available for public inspection without charge at the hospital facility

Other (describe in Section C)

Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11. ..............

Yes

Indicate the tax year the hospital facility last adopted an implementation strategy: 20 15

Is the hospital facility's most recently adopted implementation strategy posted on a website?.........

Yes

If "Yes" (list url): www.sinai.org

If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ......

10b

Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.

12a

Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)?...............................

12a

If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........

12b

If "Yes" on line 12b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $

Schedule H (Form 990) 2015

Page 5

Part VFacility Information (continued)

Financial Assistance Policy (FAP)

	Holy Cross Hospital
Name of hospital facility or letter of facility reporting group

Yes

Did the hospital facility have in place during the tax year a written financial assistance policy that:

Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care?

Yes

If “Yes,” indicate the eligibility criteria explained in the FAP:

Federal poverty guidelines (FPG), with FPG family income limit for eligibility for free care of 300.% and FPG family income limit for eligibility for discounted care of 600.%

Income level other than FPG (describe in Section C)

Asset level

Medical indigency

Insurance status

Underinsurance discount

Residency

Other (describe in Section C)

Explained the basis for calculating amounts charged to patients?.................

Explained the method for applying for financial assistance?...................

Yes

If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):

Described the information the hospital facility may require an individual to provide as part of his or her application

Described the supporting documentation the hospital facility may require an individual to submit as part of his or
her application

Provided the contact information of hospital facility staff who can provide an individual with information about the
FAP and FAP application process

Provided the contact information of nonprofit organizations or government agencies that may be sources of
assistance with FAP applications

Other (describe in Section C)

Included measures to publicize the policy within the community served by the hospital facility?........

Yes

If "Yes," indicate how the hospital facility publicized the policy (check all that apply):

The FAP was widely available on a website (list url):

www.sinai.org

The FAP application form was widely available on a website (list url):

www.sinai.org

A plain language summary of the FAP was widely available on a website (list url):
www.sinai.org

The FAP was available upon request and without charge (in public locations in the hospital facility and by mail)

The FAP application form was available upon request and without charge (in public locations in the hospital facility
and by mail)

A plain language summary of the FAP was available upon request and without charge (in public locations in the
hospital facility and by mail)

Notice of availability of the FAP was conspicuously displayed throughout the hospital facility

Notified members of the community who are most likely to require financial assistance about availability of the FAP

Other (describe in Section C)

Billing and Collections

Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained all of the actions the hospital facility or other authorized party may take upon non-payment?..................................

Yes

Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

None of these actions or other similar actions were permitted

Schedule H (Form 990) 2015

Page 6

Part VFacility Information (continued)

	Holy Cross Hospital
Name of hospital facility or letter of facility reporting group

Yes

Did the hospital facility or other authorized party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?............

If "Yes," check all actions in which the hospital facility or a third party engaged:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (check all that apply):

Notified individuals of the financial assistance policy on admission

Notified individuals of the financial assistance policy prior to discharge

Notified individuals of the financial assistance policy in communications with the individuals regarding the individuals’ bills

Documented its determination of whether individuals were eligible for financial assistance under the hospital facility’s financial assistance policy

Other (describe in Section C)

None of these efforts were made

Policy Relating to Emergency Medical Care

Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?..................

Yes

If "No," indicate why:

The hospital facility did not provide care for any emergency medical conditions

The hospital facility’s policy was not in writing

The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Section C)

Other (describe in Section C)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)

Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.

The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that
can be charged

The hospital facility used the average of its three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged

The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged

Other (describe in Section C)

During the tax year, did the hospital facility charge any FAP-eligible individual to whom the hospital facility provided emergency or other medically necessary services more than the amounts generally billed to individuals who had insurance covering such care? ...............................

If "Yes," explain in Section C.

During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual? ...........................

If "Yes," explain in Section C.

Schedule H (Form 990) 2015

Page 7

Part V

Facility Information (continued)

Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16i, 18d, 19d, 20e, 21c, 21d, 22d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A (“A, 1,” “A, 4,” “B, 2,” “B, 3,” etc.) and name of hospital facility.
Form and Line Reference	Explanation
Schedule H, Part V, Section B, Line 5	Holy Cross Hospital facilitated focus groups with community members to better understand the needs and assets of the community that makes up its primary service area. Focus group participants were selected to represent medically underserved, low income, marginalized and minority populations. The purpose of the focus groups were to gain insight on the most pressing health conditions affecting each community, the barriers to overcoming those conditions, and how a community hospital such as HCH might help improve the community's health. These groups were held in both English and Spanish, as appropriate. Many people contributed to the CHNA report, including the staff of the Sinai urban health institute. These are all people trained in public health (most are graduates of schools of public health with MPH or PhD degrees). We thus believe that the public health credentials of the authors of this report are substantial and notable. SCHEDULE H, PART V, SECTION B, LINE 11 Holy Cross Hospital is now using the implementation plan that was created as part of the 2016 CHNA. The CHNA identifies significant health needs and barriers faced by the communities served by HOLY CROSS HOSPITAL. HOLY CROSS HOSPITAL leaders developed an implementation plan and rollout strategy that aligns with the hospitals strategic plan and will be implemented over the course of three years. In the last iteration of the CHNA, we implemented projects such as providing community education around asthma, breast health, diabetes, maternal and child health, and violence prevention. In the hospital, we have conducted HIV screening programs, worked on a quality improvement project to address COPD readmissions, and assisted patients with social service needs. It is our goal to provide the best care possible to address the needs of our community. The CHNA and its implementation plan have assisted in guiding our work on how to address the needs of our community. Holy Cross Hospital completed its first implementation plan in June 2016 and is now working on implementing the strategies and actions as identified within the 2016 CHNA. Holy Cross Hospital remains fully engaged in implementing the strategies and expects to substantially complete the identified plans by the time of the next CHNA. Schedule H, Part V, Section B, Line 20 Holy Cross Hospital informs patients of the charity care policy through signage inthe hospital, written communication, statements and related corporation Sinai Health System website. Each hospital bill, invoice, or other summary of charges to an uninsured patient shall include with it, or on it, a prominent statement that an Uninsured Patient who meets certain income requirements may qualify for an Uninsured Discount along with information regarding how the patient may apply for financial assistance.

Schedule H (Form 990) 2015

Page 8

Part VFacility Information (continued)

Section D. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, from largest to smallest) How many non-hospital health care facilities did the organization operate during the tax year?
Name and address		Type of Facility (describe)
1
2
3
4
5
6
7
8
9
10

Schedule H (Form 990) 2015

Page 9

Part VI

Supplemental Information

Provide the following information.

1	Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b.
2	Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B.
3	Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4	Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5	Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6	Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7	State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.

Form and Line Reference	Explanation
Part I, Line 6a	Related Organization Community Benefit Report The community benefit report is prepared by parent corporation Sinai Health System (36-3166895). Part I, Line 7 Explanation of Costing Methodology The costing methodology utilized throughout this report is the cost to charge ratios based on the Medicare and Medcaid costs reports. Total cost per the Medicare Cost Report worksheet B, PT1 column 27 divided by total inpatient gross revenue. Part I, Line 7, Column F Explanation of Bad Debt Expense The bad debt expense was included on Form 990, Part IX, Line 25, column A but was subtracted from the total expenses for purpose of calculating the percentage in this column. The bad debt expense is $9,317,296.
Part III, Line 2	Methodology Used to Estimate Bad Debt Expense Holy Cross Hospital estimates bad debt expense based upon managements assessment of historical and expected net collections considering historical business and economic conditions, trends in health care coverage, and other collection indicators. Management assesses the allowance for uncollectible accounts based upon historical write-off experience. Part III, Line 3 Methodology Of Estimated Amount & Rationale For Including Community Benefit Holy Cross Hospital first determines if a patient qualifies for charity care. If a patient is classified as charity care they would not be included as bad debt. Some patients do not desire to complete the charity care applications and as such can be included in the bad debt amounts. One example of a patient population that does not complete charity care applications is undocumented workers. The corporation estimates bad debt expense based upon managements assessment of historical and expected net collections considering historical business and economic conditions, trends in health care coverage, and other collection indicators. Management assesses the allowance for uncollectible accounts based upon historical write-off experience. Part III, Line 4 Bad Debt Expense Per audited financial statements note 1 patient accounts receivable, the corporation maintains allowances for uncollectible accounts for estimated losses resulting from a payers inability to make payments on accounts. The corporation estimates the allowance for uncollectible accounts based upon management's assessment of historical and expected net collections considering historical business and economic conditions, trends in health care coverage, and other collection indicators. The corporation recognizes a significant amount of patient service revenue at the time services are rendered even though the corporation does not assess the patient's ability to pay at that time. As a result, the provision for bad debts is presented as a deduction from patient service revenue (net of contractual provisions and discounts). For uninsured patients that do not qualify for charity care, the corporation establishes an allowance to reduce the carrying value of such receivable to their accounts based upon historical write-off experience. After satisfaction of amounts due from insurance, the corporation follows established guidelines for placing certain past-due balances with collection agencies, subject to the term of certain restrictions on collection efforts as determined by the corporation. A significant portion of the corporation's provision for doubtful accounts relates to self-pay patients, as well as co-payments and deductibles owed to the corporation by patients with insurance. Part III, Line 8 Explanation of Shortfall as Community Benefit There was no shortfall this year. The costing methodology utilized throughout this report is the cost to charge ratios based on the Medicare and Medicaid cost reports. Total cost per the Medicare Cost Report worksheet B,PT1 column 27 divided by total inpatient and outpatient gross revenue. Part III, Line 9b Provisions on Collection practices for Qualified Patients Holy Cross Hospitals collection process includes both letter and call series built to inform patients of their outstanding balances and to explain available payment options. If the patient is uninsured a discount is applied to the patients account in accordance with the Illinois Patient Uninsured Act. In addition, resources are made available to patients throughout the collections process. These resources included a charity program targeted to low income individuals residing in Sinai Health System core service area, and non-interest bearing payment plans that start as low as $25 a month. The debt collection practices only apply to charity patients to the extent of the copayments or patient portion balances and not to amounts that have been approved as charity or financial assistance.
Part VI, Line 2	Needs Assessment Holy Cross Hospital uses various methods to assess the health care needs of the community it serves. Important information is gathered from the Census Updates, Illinois Department of Healthcare and Family Services, the Department of Public Health, Cook County Department of Public Health, City of Chicago Department of Public Health, University of Chicago Urban Health Initiatives, Churches, community organizations and advocacy groups Because of the Hospitals close relationship with leaders of the New Communities Program, the Hospital was instrumental in establishing the Healthy Chicago Lawn advocacy coalition Holy Cross Hospital has served as the host site and primary health resource for the majority of Healthy Chicago Lawn Coalitions planning, education and advocacy initiatives Healthy Chicago Lawn has prompted the development of many relational, educational and promotional health awareness activities in the Chicago Lawn community. As a result of the partnership with community organizations, Holy Cross Hospital has become more accessible to community groups and residents. There has been an increased awareness of the services provided by the Hospital which has resulted in positive health outcomes in the communities served by Holy Cross Hospital. The Hospital also assesses the needs of the community through the Parish Nurse program Community Outreach nurse attend church meetings where information is received about the sick parishioners at home and in nursing homes. There are three large Catholic churches in the community that have a formal HCH Parish Nurse program. The Hospital has designated a nurse to service these churches. The nurse conducts blood pressure screenings and health assessments for 100 regular parishioners. New parishioners, who are uninsured, are assisted with referrals Also, home visit arrangements are made for at risk seniors. The Hospital also has a volunteer team at churches to assist with health fairs and health education events, such as the MERCK Pharmaceuticals sponsored Diabetes Education program for the Latino community. Another source for assessing the health care needs of the community is through membership in 10 community organizations each of which is deeply invested in addressing one or more social determinants of health, such as housing, violence and youth services Community groups have requested the Hospital for health care professionals to join their boards and assist with the direction of their advocacy and policies unpaid Hospital staff have become members of board of these organizations, which has helped the Hospital identify the needs of the community and in turn communicate to the leadership of these organization the resources the Hospital has to serve them. Part VI, Line 3 Patient Education Of Eligibility For Assistance Holy Cross Hospital informs patients of the charity care policy through signage in the hospital, written communication, statements and related corporation Sinai Health System website. Each hospital bill, invoice, or other summary of charges to an uninsured patient shall include with it, or on it, a prominent statement that an uninsured patient who meets certain income requirements may qualify for an uninsured discount along with information regarding how the patient may apply for financial assistance. Part VI, Line 4 Community Information Holy Cross Hospital as a part of Sinai Health System and serves a population base of over one million people located on the west side of Chicago.
Part VI, Line 5	Promotion of Community health Holy Cross Hospital, as a part of Sinai Health System, has a board comprised of respected leaders in banking, finance, manufacturing, legal, health care and other industries. Holy Cross hospital extends medical staff privileges to all qualified physicians for all departments. Holy Cross Hospital invests any surplus funds into improving patient care. Holy Cross also participates in the following community benefit programs: Parish Nurse Program - Through the Hospitals Parish Nurse Program, the Hospital has dedicated a nurse to conduct blood pressure screenings and ongoing health assessments for approximately 100 regular parishioners. The nurse also attends church meetings where she receives information about the sick parishioners at home and in nursing homes. Arrangements are made to assist the sick parishioners. The hospital participates with seven catholic churches in conducting health education workshops and assist the uninsured with referrals Senior Groups, There are 30 senior groups that meet once a month for diagnostic testing, health assessments and health education. Most of these seniors are in their 80s and 90s and the Hospital assists them with having ongoing physician appointments and helping them with their medical needs, by ongoing health assessment and transition to assisted living or homemaker referrals. Vaccine for Children Program with CDPH - The Hospital works closely with grade school and high school nurses in the community. The purpose of this program is to assist children who are in need of recommended immunizations to remain in school. Vaccines are administered during school hours. Most of these children are on Medicaid or have no insurance. The vaccines are obtained from CDPH and the parents are not charged for administering the vaccines. The Hospital also documents in the state I CARE REGISTRY all immunizations given and assists the school nurses with medical immunizations by verifying the students immunizations found in the state system. Community Health Fairs - The Hospitals representatives attend community group events and fairs. The Hospital provides free health screenings and health education materials at these events. On average, there are approximately 40 events per year. Influenza Program - The Hospital administers flu immunizations during the year. These flu shots were administered at senior group meetings, churches and health fairs for community groups. We formed a Joint influenza program with Walgreens who provided free influenza vaccines to people with no insurance and ten area churches. Hospital Referrals for At Risk Seniors - Under this program, in certain situations, the Hospitals health care professional will make a home visit to assess an at risk seniors living situation after discharge from the Hospital. Participation in Community Health Speakers Bureau - The Hospitals health care professional participate in promoting healthy lifestyles by volunteering to be speakers whenever Community and civic groups ask for assistance in having a speaker for their events. Part VI, Line 6 Affiliated Health Care System Roles Holy Cross Hospital is part of the Sinai Health System. The Sinai Health System is a unique health care delivery system on the West and Southwest sides of Chicago. Mount Sinai Hospital was founded in 1919 to provide care to Eastern European Jewish immigrants in the area as well as to create a place for Jewish doctors to practice. The Sinai Health System now serves predominantly Black and Latino communities, but our mission has remained the same. This mission addresses our desire to make a difference in both the individuals and the communities we serve. As we develop innovative and effective ways to do this, we strive to become the national model for the delivery of urban health care. Along with Holy Cross Hospital, the system includes Mount Sinai Hospital, Schwab Rehabilitation Hospital, Sinai Childrens Hospital, Sinai Medical Group, the Sinai Community Institute, and the Sinai Urban Health Institute. For more information on the Sinai Health System, visit http://www.sinai.org/. Part VI, Line 7 States Where Community Benefit Report Filed Illinois

Schedule H (Form 990) 2015

Additional Data

Software ID:
Software Version:

- TIN:

Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet

Complete if the organization answered "Yes" on Form 990, Part IV, line 23.
SchJMediumBullet

Attach to Form 990.
SchJMediumBullet

Information about Schedule J (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

Open to Public Inspection

Name of the organization

Holy Cross Hospital

Employer identification number

36-2170133

Part I

Questions Regarding Compensation

Yes

Check the appropiate box(es) if the organization provided any of the following to or for a person listed on Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.

First-class or charter travel Housing allowance or residence for personal use

Travel for companions Payments for business use of personal residence

Tax idemnification and gross-up payments Health or social club dues or initiation fees

Discretionary spending account Personal services (e.g., maid, chauffeur, chef)

If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain .........

Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
directors, trustees, officers, including the CEO/Executive Director, regarding the items checked in line 1a? ..

Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

Form 990 of other organizations Approval by the board or compensation committee

During the year, did any person listed on Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:

Receive a severance payment or change-of-control payment? ................

Yes

Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........

Yes

Participate in, or receive payment from, an equity-based compensation arrangement? .........

If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.

Only 501(c)(3), 501(c)(4), and 501(c)(29) organizations must complete lines 5-9.

For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:

The organization? ...........................

Any related organization?

If "Yes," on line 5a or 5b, describe in Part III.

For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:

The organization?

Any related organization? .........................

If "Yes," on line 6a or 6b, describe in Part III.

For persons listed on Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............

Were any amounts reported on Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................

If "Yes" on line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50053T

Schedule J (Form 990) 2015

Page 2

Part II

Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.

For each individual whose compensation must be reported on Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.

(A) Name and Title		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation in column(B) reported as deferred on prior Form 990
(A) Name and Title		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)
1Daniel Katz MDDirector	(i) (ii)	0 ------------- 503,020	0 ------------- 0	0 ------------- 0	0 ------------- 5,547	0 ------------- 14,956	0 ------------- 523,523	0 ------------- 0
2Karen TeitelbaumEx-Officio	(i) (ii)	0 ------------- 595,612	0 ------------- 99,456	0 ------------- 53,314	0 ------------- 68,634	0 ------------- 8,840	0 ------------- 825,856	0 ------------- 43,504
3Loren ChandlerExec. VP & COO	(i) (ii)	0 ------------- 372,704	0 ------------- 58,200	0 ------------- 4,800	0 ------------- 52,001	0 ------------- 16,774	0 ------------- 504,479	0 ------------- 0
4Charles Weis JrExec. VP for Admin & CFO	(i) (ii)	0 ------------- 471,326	0 ------------- 96,619	0 ------------- 48,810	0 ------------- 59,069	0 ------------- 16,282	0 ------------- 692,106	0 ------------- 44,596
5Mark MultachChief Medical Officer	(i) (ii)	0 ------------- 437,790	0 ------------- 52,399	0 ------------- 0	0 ------------- 31,108	0 ------------- 14,254	0 ------------- 535,551	0 ------------- 0
6Rachel DvorkenExec. VP & Gen. Counsel	(i) (ii)	0 ------------- 319,451	0 ------------- 46,502	0 ------------- 39,649	0 ------------- 45,557	0 ------------- 2,325	0 ------------- 453,484	0 ------------- 39,303
7Aaron AustinVice President-Human Resources	(i) (ii)	0 ------------- 252,979	0 ------------- 39,784	0 ------------- 2,640	0 ------------- 30,465	0 ------------- 13,583	0 ------------- 339,451	0 ------------- 0
8Roberta RakoveExec. VP & Gen. Counsel	(i) (ii)	0 ------------- 223,896	0 ------------- 16,723	0 ------------- 0	0 ------------- 4,297	0 ------------- 5,744	0 ------------- 250,660	0 ------------- 0
9Justin SchneiderVice President - Operations	(i) (ii)	0 ------------- 169,985	0 ------------- 12,305	0 ------------- 0	0 ------------- 3,463	0 ------------- 5,658	0 ------------- 191,411	0 ------------- 0
10Joel Craig FrazierVice President	(i) (ii)	0 ------------- 163,737	0 ------------- 11,959	0 ------------- 0	0 ------------- 3,278	0 ------------- 6,151	0 ------------- 185,125	0 ------------- 0
11Suzette MahnekeVice President Nursg Adm &CNO	(i) (ii)	0 ------------- 47,213	0 ------------- 0	0 ------------- 139,077	0 ------------- 0	0 ------------- 2,268	0 ------------- 188,558	0 ------------- 0
12Tanvir MangatVP/Chief Strategy Officer	(i) (ii)	0 ------------- 252,383	0 ------------- 32,955	0 ------------- 0	0 ------------- 35,675	0 ------------- 136	0 ------------- 321,149	0 ------------- 0
13Lori PacuraPresident	(i) (ii)	0 ------------- 252,281	0 ------------- 40,519	0 ------------- 0	0 ------------- 0	0 ------------- 9,469	0 ------------- 302,269	0 ------------- 0
14Deborah DavissonCNO/VP -Patient Care Services	(i) (ii)	196,283 ------------- 0	13,924 ------------- 0	0 ------------- 0	645 ------------- 0	2,648 ------------- 0	213,500 ------------- 0	0 ------------- 0
15Dennis RyanVP-Mission Effect &Ext Affairs	(i) (ii)	165,429 ------------- 0	12,259 ------------- 0	0 ------------- 0	3,362 ------------- 0	5,912 ------------- 0	186,962 ------------- 0	0 ------------- 0
16Elmer EscalonRegistered Nurse	(i) (ii)	177,129 ------------- 0	0 ------------- 0	0 ------------- 0	1,920 ------------- 0	476 ------------- 0	179,525 ------------- 0	0 ------------- 0
17Kenneth SlawkowskiDirector - Information System	(i) (ii)	130,613 ------------- 0	4,974 ------------- 0	0 ------------- 0	2,739 ------------- 0	15,126 ------------- 0	153,452 ------------- 0	0 ------------- 0

Schedule J (Form 990) 2015

Page 3

Part III

Supplemental Information

Provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II. Also complete this part for any additional information.

Return Reference

Explanation

FORM 990, Part I, LIne 3 - Methods Used By Related Org to Establish CEO/Ex

THE ORGANIZATION PAYS OUT COMPENSATION BASED ON THE FOLLOWING PROCEDURES AND GUIDELINES: SINAI HEALTH SYSTEM HAS AN EXECUTIVE COMPENSATION COMMITTEE TO SUPPORT THE ORGANIZATION PERFORMANCE OF SINAI HEALTH SYSTEMS AND ITS RELATED ENTITIES THROUGH THE ALIGNMENT OF EXECUTIVE COMPENSATION WITH SYSTEM STRATEGIES AND PROGRAMS AND ENSURE COMPLIANCE WITH APPLICABLE LAW. THE VOTING MEMBERS OF THE COMMITTEE ARE INDEPENDENT MEMBERS OF THE BOARD OF DIRECTORS. THE COMMITTEE ESTABLISHES DETAILED GOALS ANNUALLY OR MORE FREQUENTLY AS CIRCUMSTANCES REQUIRE. THE COMMITTEE ESTABLISHES DETAILED GOALS ANNUALLY FOR THE PRESIDENT AND CEO AND OTHER EXECUTIVES, AND REVIEWS PERFORMANCE AGAINST THESE GOALS ON AN ANNUAL BASIS. THE COMMITTEE ANNUALLY ENGAGES AN OUTSIDE INDEPENDENT COMPENSATION CONSULTANT TO BENCHMARK THE SALARIES AND BENEFITS OF THE ORGANIZATION'S ASSISTANT VICE PRESIDENT AND ABOVE. COMPENSATION IS BASED ON: a) DETAILED WRITTEN PERFORMANCE OF THE PRESIDENT AND CEO; b) EACH ELEMENT OF COMPENSATION, DATA OF THE COMPENSATION PROGRAM IN EFFECT FOR CEOS OF COMPARABLE ORGANIZATIONS; AND c) ANNUAL REVIEW OF CEO PERFORMANCE IS CONDUCTED AGAINST MSH'S ESTABLISHED GOALS. THE COMMITTEE MAINTAINS WRITTEN MINUTES WHICH ARE MAINTAINED IN EXECUTIVE ADMINISTRATION. FORM 990, PART I, LINE 4A - SEVERANCE PAYMENTS THE ORGANIZATION PAID SEVERANCE IN THE FORM OF WAGE CONTINUATION TO SUZETTE MAHNEKE, VICE PRESIDENT NURSING ADM. & CNO, IN THE AMOUNT OF $139,076. THE TERMS AND CONDITIONS OF SEVERANCE AGREEMENTS VARY. FORM 990, PART I, LINE 4B - SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN MOUNT SINAI HOSPITAL'S SUPPLEMENTAL EARLY RETIREMENT PLAN (SERP) WAS ESTABLISHED AS A NON-QUALIFIED RETIREMENT PLAN FOR ITS KEY EMPLOYEES; SPECIFICALLY THE CHIEF EXECUTIVE STAFF. THIS PLAN PROVIDES ADDED BENEFITS THAT MAY BE ABOVE AND BEYOND THOSE THRESHOLDS COVERED IN OTHER TRADITIONAL RETIREMENT PLANS. UNLIKE NON-QUALIFIED PLANS, IN WHICH THE KEY EXECUTIVES ELECT TO DEFER THEIR COMPENSATION IN ORDER TO RECEIVE THAT COMPENSATION AT A LATER DATE, MOUNT SINAI HOSPITAL'S SUPPLEMENTAL EARLY RETIREMENT PLAN IS ENTIRELY FUNDED BY THE EMPLOYER (MOUNT SINAI HOSPITAL AND MEDICAL CENTER). THE MSH COMPENSATION COMMITTEE REVIEWS AND APPROVES ACCEPTANCE AND/OR MODIFICATIONS TO THE SERP PLAN. THE MSH'S SERP PLAN OUTLINES THE YEARLY EARNINGS PER THE INDIVIDUAL PARTICIPANTS AS WELL AS THE TIME FRAMES OF VESTMENT PER THOSE RESPECTIVE INDIVIDUALS. Aaron Austin $26,080 Charles Weis Jr. $49,966 Karen Teitelbaum $58,720 Loren Chandler $44,345 Mark Multach $31,108 Rachel Dvorkel $39,432 Tanvir Mangat $35,675 FORM 990, PART I LINE 7 - NON-FIXED PAYMENTS THE ORGANIZATION PAYS OUT BONUSES BASED ON THE FOLLOWING PROCEDURES AND GUIDELINES: SINAI HEALTH SYSTEM HAS AN EXECUTIVE COMPENSATION COMMITTEE TO SUPPORT THE ORGANIZATION PERFORMANCE OF SINAI HEALTH SYSTEMS AND ITS RELATED ENTITIES THROUGH THE ALIGNMENT OF EXECUTIVE COMPENSATION WITH SYSTEM STRATEGIES AND PROGRAMS AND ENSURE COMPLIANCE WITH APPLICABLE LAW. THE VOTING MEMBERS OF THE COMMITTEE ARE INDEPENDENT MEMBERS OF THE BOARD OF DIRECTORS. THE COMMITTEE ESTABLISHES DETAILED GOALS ANNUALLY OR MORE FREQUENTLY AS CIRCUMSTANCES REQUIRE. THE COMMITTEE ESTABLISHES DETAILED GOALS ANNUALLY FOR THE PRESIDENT AND CEO AND OTHER EXECUTIVES, AND REVIEWS PERFORMANCE AGAINST THESE GOALS ON AN ANNUAL BASIS. THE COMMITTEE ANNUALLY ENGAGES AN OUTSIDE INDEPENDENT COMPENSATION CONSULTANT TO BENCHMARK THE SALARIES AND BENEFITS OF THE ORGANIZATION'S ASSISTANT VICE PRESIDENT AND ABOVE. COMPENSATION IS BASED ON DETAILED WRITTEN PERFORMANCE OF THE PRESIDENT AND CEO, EACH ELEMENT OF COMPENSATION, DATA OF COMPENSATION PROGRAM IN EFFECT FOR CEOS OF COMPARABLE ORGANIZATIONS, AND CONDUCTS AN ANNUAL REVIEW OF CEO PERFORMANCE AGAINST ESTABLISHED GOALS. THE COMMITTEE MAINTAINS WRITTEN MINUTES WHICH ARE MAINTAINED IN EXECUTIVE ADMINISTRATION.

Schedule J (Form 990) 2015

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or 990-EZ or to provide any additional information.
MediumBullet

Attach to Form 990 or 990-EZ.
MediumBullet

Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.

OMB No. 1545-0047

2015

Open to Public
Inspection

Name of the organization

Holy Cross Hospital

Employer identification number

36-2170133

Return Reference	Explanation
Form 990, Part I, Line 1	MISSION STATEMENT As a member of Sinai Health System, Holy Cross Hospital's mission is to improve the health of the individuals and communities it serves by providing emergency, medical, surgical, and primary care services. The vision is to be a national model for the delivery of urban healthcare.
Form 990, Part VI, Line 1a	BOARD DELEGATING POWERS TO EXECUTIVE COMMITTEE The Executive Committee of Holy Cross Hospital consists of the board chairman, and at least 15 but no more than 17, members of the board of directors. The board chairman appoints the members of the Executive Committee. The Executive Committee has the power to transact regular business of the corporation during the period between meetings of the board, subject to limitations imposed by the board or law. When action is taken by the Executive Committee, it is reported to the board.
Form 990, Part VI, Line 6	DESCRIPTION OF CLASSES OF MEMBERS OR STOCKHOLDERS Sinai Health System (EIN 36-3166895) is sole corporate member of Holy Cross Hospital.
Form 990, Part VI, Line 7a	DESCRIPTION OF CLASSES OF PERSONS AND THE NATURE OF THEIR RIGHTS Board members are nominated by the Board Recruitment, Education, and Nominating Committee of the sole corporate member, Sinai Health System, and elected by the members from among those persons approved for appointment by the sole corporate member. FORM 990, PART VI, LINE 7B DESCR CLASSES OF PERSONS, DECISIONS REQUIRING APPR & TYPE OF VOTING The sole corporate member, Sinai Health System, has the following rights and powers: (a) To amend Holy Cross Hospitals Articles of Incorporation and corporate Bylaws. (b) To approve, interpret or amend the Mission Statement of Holy Cross Hospital. (c) To determine Holy Cross Hospitals compliance with Holy Cross Hospitals stated corporate purposes and Mission Statement. (d) To elect Holy Cross Hospitals Directors from among those persons nominated by the Board Recruitment, Education and Nominating Committee of the Sole Corporate Member. (e) To remove a Director by a two-thirds vote of the Sole Corporate Members Board of Directors at any time with or without cause. (f) To appoint the Chair, Vice Chair, President, Secretary and Treasurer of Holy Cross Hospital from among those nominated by the Board Recruitment, Education and Nominating Committee of the Sole Corporate Member, and to remove any such officers at any time with or without cause. (g) To approve all plans of merger, consolidation, joint venture or affiliation with Holy Cross Hospital. (h) To establish from time to time the "corporate limit" referred to in these reserved powers, which may be expressed either as a dollar amount or as a percentage of a budget. (i) To approve annual operating budgets and multi-year capital budgets and strategic plans of Holy Cross Hospital before expenditures pursuant to such budgets and plans may be made. Once the budgets are so approved, Holy Cross Hospitals Board of Directors may vary expenditures within the limits established from time to time by the Sole Corporate Member. (j) To approve the non-budgeted sale, lease (capitalized or otherwise), exchange, mortgage, pledge or other disposition of property and assets of Holy Cross Hospital in anyone fiscal year which is in excess of the corporate limit. (k) To approve all non-budgeted contracts obligating Holy Cross Hospital to expend or repay an amount in excess of the corporate limit. (l) To approve the creation or acquisition of majority-controlled or majority-owned subsidiaries or affiliates of Holy Cross Hospital. (m) To approve Holy Cross Hospitals non-budgeted incurring of long-term debt or obligating its assets in excess of the corporate limit. (n) To approve the appointment of independent certified public accountants for Holy Cross Hospital and its subsidiaries and affiliates. (o) To approve any voluntary dissolution and any liquidation of Holy Cross Hospitals assets. (p) To approve all executive compensation arrangements, including incentive compensation, for Holy Cross Hospital.
Form 990, Part VI, Line 11b	DESCRIBE THE PROCESS USED BY MANAGEMENT &/OR GOVENING BODY TO REVIEW 990 The Form 990 information was initially provided by the finance staff with multi-disciplinary input from Public Affairs, Corporate Integrity and other appropriate staff of the organization. The Form 990 was then prepared by Ernst & Young, LLP and reviewed by senior finance staff and other members of senior leadership. Prior to the filing, the Form 990 was made available to the full board of directors.
Form 990, Part VI, Line 12c	DESCRIBE THE PROCESS TO MONITOR TRANSACTIONS FOR CONFLICTS OF INTEREST The Conflict of Interest Disclosure Form is completed and signed annually by all board members, employed physicians, management personnel as well as other employees who are in a position to influence purchasing decisions, affiliations or referrals, hiring decisions or contracts. The form is completed on appointment to the board of directors of Sinai Health System or any one of its entities, upon hire for any relevant job category or at the time of appointment to the medical staff. In addition to the annual filing of the form, an update is required to be filed any time there has been a change. Conflicts disclosed on the Conflict of Interest Disclosure Form are taken into consideration when making board committee assignments. In addition, individuals who have a conflict of interest must abstain from participating in decisions affecting the interested parties and make it clear why they are abstaining. If the potential for conflict of interest exists, employees and physicians are required to discuss the situation with management. Board members of the Sinai Health System or any of its entities are required to report potential conflicts to the Chief Integrity Officer who will review potential conflicts with the Sinai Health System Chief Executive Officer and Chairman of the Board of Directors.
FORM 990, PART VI, LINE 15A & 15B	COMPENSATION REVIEW & APPROVAL PROCESS - OFFICERS & KEY EMPLOYEES Sinai Health Systems Executive Compensation Committee approves all executive compensation arrangements, including incentive compensation, for Holy Cross Hospital. Sinai Health System has an Executive Compensation Committee to support the organizational performance of Sinai Health System and its related entities through the alignment of executive compensation with system strategies and programs and ensure compliance with applicable law. The voting members of the Committee are independent members of the board of directors. The Committee meets twice annually or more frequently as circumstances require. The Committee establishes detailed goals annually for the President and CEO and other executives, and reviews performance against these goals on an annual basis. The Committee annually engages an outside, independent compensation consultant to benchmark the salaries and benefits of the organizations assistant vice presidents and above, as well as a few directors. Compensation is based on detailed written performance appraisals and external market data. In executive session, the Committee reviews the performance of the President and CEO, each element of compensation, data of compensation programs in effect for CEOs of comparable organizations, and conducts an annual review of CEO performance against established goals. The Committee maintains written minutes which are maintained in executive administration.
Form 990, Part VI, Line 19	THE ORGANIZATION MAKES ITS FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC Governing documents, conflict of interest and financial statements are made available upon request and after review by management.

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2015

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

Complete if the organization answered "Yes" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
MediumBullet

Attach to Form 990.
MediumBullet

Information about Schedule R (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2015

Open to Public Inspection

Name of the organization

Holy Cross Hospital

Employer identification number

36-2170133

Part I

Identification of Disregarded Entities Complete if the organization answered "Yes" on Form 990, Part IV, line 33.

(a) Name, address, and EIN (if applicable) of disregarded entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Total income	(e) End-of-year assets	(f) Direct controlling entity

Part II

Identification of Related Tax-Exempt Organizations Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1)SINAI HEALTH SYSTEM 15TH STREET CALIFORNIA AVE Chicago,IL60608 36-3166895	PARENT CORP	IL	501(C)(3)	11A TYPE 1	NA		No
(2)MT SINAI HOSPITAL MEDICAL CENTER 15TH STREET CALIFORNIA AVE Chicago,IL60608 36-1509000	HEALTHCARE	IL	501(c)(3)	3	SINAI HEALTH		No
(3)SCHWAB REHAB HOSPITAL & CARE NETWORK 1401 S CALIFORNIA AVENUE Chicago,IL60608 36-2179802	HEALTHCARE	IL	501(c)(3)	3	SINAI HEALTH		No
(4)SINAI COMMUNITY FOUNDATION 2760 W 15TH PL 7TH FLR Chicago,IL60608 36-3305449	HEALTHCARE	IL	501(c)(3)	11A TYPE 1	SINAI HEALTH		No
(5)SINAI COMMUNITY INSTITUTE 2653 WEST OGDEN AVE Chicago,IL60608 36-3932824	HEALTHCARE	IL	501(c)(3)	7	SINAI HEALTH		No

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50135Y

Schedule R (Form 990) 2015

Page 2

Part III

Identification of Related Organizations Taxable as a Partnership Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Part IV

Identification of Related Organizations Taxable as a Corporation or Trust Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(h) Percentage ownership	(i) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets		Yes	No
(1) PROGRESS HEALTH INC 2701 W 68TH STREET Chicago,IL60629 36-4109153	MGMT SERVICES	IL	NA	C CORP	322,263	1,675,228	100.000 %	Yes

Schedule R (Form 990) 2015

Page 3

Part V

Transactions With Related Organizations Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35b, or 36.

Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.

Yes

1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?

a Receipt of (i) interest, (ii) annuities, (iii) royalties, or (iv) rent from a controlled entity .....................

Yes

b Gift, grant, or capital contribution to related organization(s) ............................

c Gift, grant, or capital contribution from related organization(s) ............................

d Loans or loan guarantees to or for related organization(s) ............................

e Loans or loan guarantees by related organization(s) ............................

f Dividends from related organization(s) ............................

g Sale of assets to related organization(s) ............................

h Purchase of assets from related organization(s) ............................

i Exchange of assets with related organization(s) ............................

j Lease of facilities, equipment, or other assets to related organization(s) .......................

k Lease of facilities, equipment, or other assets from related organization(s) ......................

l Performance of services or membership or fundraising solicitations for related organization(s) .....................

m Performance of services or membership or fundraising solicitations by related organization(s) .................

Yes

n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) ...................

o Sharing of paid employees with related organization(s) ............................

p Reimbursement paid to related organization(s) for expenses ............................

Yes

q Reimbursement paid by related organization(s) for expenses ............................

r Other transfer of cash or property to related organization(s) ............................

s Other transfer of cash or property from related organization(s) ............................

If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.

(a) Name of related organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved
(1) SINAI HEALTH SYSTEM	p	6,791,425	COST
(2) MOUNT SINAI COMMUNITY FOUNDATION	m	4,731,720	COST
(3) MOUNT SINAI HOSPITAL	m	1,154,934	COST

Schedule R (Form 990) 2015

Page 4

Part VI

Unrelated Organizations Taxable as a Partnership Complete if the organization answered "Yes" on Form 990, Part IV, line 37.

Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.

(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(e) Are all partners section 501(c)(3) organizations?		(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	Yes	No	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Schedule R (Form 990) 2015

Page 5

Part VII

Supplemental Information

Provide additional information for responses to questions on Schedule R (see instructions).

Return Reference	Explanation

Schedule R (Form 990) 2015

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: SEE SCHEDULE O.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	32
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	30
5	Total number of individuals employed in calendar year 2015 (Part V, line 2a) ......	5	1,308
6	Total number of volunteers (estimate if necessary) .............	6	7
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	0
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b	0

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	6,088	237,520
9	Program service revenue (Part VIII, line 2g) .........	112,077,659	118,854,856
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	1,830,232	1,075,212
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	2,640,992	2,365,395
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)	116,554,971	122,532,983
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	0	0
14	Benefits paid to or for members (Part IX, column (A), line 4).....	0	0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	66,732,587	72,242,909
16a	Professional fundraising fees (Part IX, column (A), line 11e) .....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	52,027,937	56,865,091
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	118,760,524	129,108,000
19	Revenue less expenses. Subtract line 18 from line 12.......	-2,205,553	-6,575,017
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	166,667,983	157,417,259
21	Total liabilities (Part X, line 26).............	40,789,086	38,386,648
22	Net assets or fund balances. Subtract line 21 from line 20.....	125,878,897	119,030,611

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 118,213,048 including grants of $ ) (Revenue $ 120,875,310 )
	The Hospital is a not-for-profit Catholic hospital that serves a large area of Chicagos Southwest side. Located in Marquette Park, the Hospital provides emergency, medical/surgical, specialty, diagnostic and primary care services to communities that are home to mostly African American and Latino families. The emergency department sees an average of 50,000 patients per year and have more ambulance daily visits than any other Illinois hospital. The Hospital is a Disproportionate Share Hospital and is a vital safety net hospital.

4b	(Code: ) (Expenses $ including grants of $ ) (Revenue $ )












4c	(Code: ) (Expenses $ including grants of $ ) (Revenue $ )












4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses118,213,048

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)...........	1,232,168	4,971,784	517,388

1a	Federated campaigns..		1a
b	Membership dues..		1b
c	Fundraising events..		1c	0
d	Related organizations		1d
e	Government grants (contributions)		1e

f	All other contributions, gifts, grants, and similar amounts not included above		1f	237,520

g	Noncash contributions included in lines 1a-1f:$
h Total.Add lines 1a-1f.......		237,520

			Business Code
2a	Medicare/Medicaid	622110	68,369,394	68,369,394	0	0
b	PATIENT REVENUE	622110	50,324,748	50,324,748	0	0
c	Cafeteria	722514	61,851	61,851	0	0
d	Parking Garage	812930	98,863	98,863	0	0
e
f	All other program service revenue.
g Total.Add lines 2a–2f.....			118,854,856

3 Investment income (including dividends, interest, and othersimilar amounts) ..........			1,075,212			1,075,212
4 Income from investment of tax-exempt bond proceeds			0
5 Royalties...........			0
		(ii) Personal	(i) Real
6a	Gross rents		344,941
b	Less: rental expenses
c	Rental income or (loss)	0	344,941
d	Net rental income or (loss)......			344,941			344,941
		(ii) Other	(i) Securities
7a	Gross amount from sales of assets other than inventory
b	Less: cost or other basis and sales expenses
c	Gain or (loss)
d	Net gain or (loss).....			0
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ....
	a
b	Less: direct expenses ...b
c	Net income or (loss) from fundraising events..			0
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities..			0
10a	Gross sales of inventory, less returns and allowances ..
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..			0
Business Code			Miscellaneous Revenue
11a	E H R STIMULUS REVENUE		900099	942,278	942,278	0	0
b	CATALYST SCHOOL STEAM		900099	309,174	309,174	0	0
c	WALGREEN PHARMACY REBATE		900099	179,663	179,663	0	0
d	All other revenue ....			589,339	589,339	0	0
e	Total. Add lines 11a–11d ......			2,020,454
12	Total revenue. See Instructions......			122,532,983	120,875,310	0	1,420,153

1	Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21	0	0
2	Grants and other assistance to individuals in the United States. See Part IV, line 22	0	0
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16	0	0
4	Benefits paid to or for members	0	0
5	Compensation of current officers, directors, trustees, and key employees ....	552,352	0	552,352	0
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	0	0	0	0
7	Other salaries and wages	62,083,794	59,843,887	2,239,907	0
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	0	0	0	0
9	Other employee benefits .......	5,693,955	5,523,136	170,819	0
10	Payroll taxes ...........	3,912,808	3,795,424	117,384	0
11	Fees for services (non-employees):
a	Management ......	0	0	0	0
b	Legal .........	137,143	137,143	0	0
c	Accounting ...........	-77,121	-77,121	0	0
d	Lobbying ...........	96,353	0	96,353	0
e	Professional fundraising services. See Part IV, line 17	0			0
f	Investment management fees ......	0	0	0	0
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O)	10,260,413	7,229,811	3,030,602	0
12	Advertising and promotion ....	0	0	0	0
13	Office expenses .......	670,441	311,680	358,761	0
14	Information technology ......	4,121,016	0	4,121,016	0
15	Royalties ..	0	0	0	0
16	Occupancy ...........	1,543,574	1,543,574	0	0
17	Travel ............	35,543	35,471	72	0
18	Payments of travel or entertainment expenses for any federal, state, or local public officials .	0	0	0	0
19	Conferences, conventions, and meetings ....	7,639	7,639	0	0
20	Interest ...........	909,734	909,734	0	0
21	Payments to affiliates .......	0	0	0	0
22	Depreciation, depletion, and amortization ..	8,652,979	8,652,979	0	0
23	Insurance ...	-527,660	-735,346	207,686	0
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a	Medical Supplies	12,713,474	12,713,474	0	0
b	BAD DEBT	9,317,296	9,317,296	0	0
c	MEDICAL ASSESSMENT	6,403,051	6,403,051	0	0
d	EQUIPMENT REPAIR & MAITENANCE	699,909	699,909	0	0
e	All other expenses	1,901,307	1,901,307
25	Total functional expenses. Add lines 1 through 24e	129,108,000	118,213,048	10,894,952	0
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).	0	0	0	0

1	Cash–non-interest-bearing ........			5,210,002	1	-3,194
2	Savings and temporary cash investments .........			15,621,636	2	13,273,411
3	Pledges and grants receivable, net ......			65,163	3	29,280
4	Accounts receivable, net .............			16,536,618	4	19,098,821
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L
				0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
				0	6	0
7	Notes and loans receivable, net ....			0	7	0
8	Inventories for sale or use ........			1,982,209	8	2,097,026
9	Prepaid expenses and deferred charges ......			570,254	9	5,623,400
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	114,711,177
b	Less: accumulated depreciation	10b	26,843,040	95,121,686	10c	87,868,137
11	Investments—publicly traded securities .			0	11	0
12	Investments—other securities. See Part IV, line 11 .....			19,123,332	12	11,479,748
13	Investments—program-related. See Part IV, line 11 ..			0	13	0
14	Intangible assets ...............			0	14	0
15	Other assets. See Part IV, line 11 ...........			12,437,083	15	17,950,630
16	Total assets. Add lines 1 through 15 (must equal line 34)...			166,667,983	16	157,417,259

17	Accounts payable and accrued expenses .....	24,900,929	17	23,288,726
18	Grants payable ...	0	18	0
19	Deferred revenue .........	0	19	0
20	Tax-exempt bond liabilities .........	0	20	0
21	Escrow or custodial account liability. Complete Part IV of Schedule D	0	21	0
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..	0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..	0	23	0
24	Unsecured notes and loans payable to unrelated third parties ..	0	24	0
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D	15,888,157	25	15,097,922
26	Total liabilities. Add lines 17 through 25..	40,789,086	26	38,386,648

	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets	125,814,894	27	118,966,608
28	Temporarily restricted net assets ...........	64,003	28	64,003
29	Permanently restricted net assets	0	29	0
	Organizations that do not follow SFAS 117 (ASC 958), check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds .....		30
31	Paid-in or capital surplus, or land, building or equipment fund ...		31
32	Retained earnings, endowment, accumulated income, or other funds		32
33	Total net assets or fund balances ...........	125,878,897	33	119,030,611
34	Total liabilities and net assets/fund balances ........	166,667,983	34	157,417,259