TY 2017 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)	(F) Estimated amount of other compensation from the organization and related organizations
(1) MICHAEL EESLEY...................................................................... CHIEF EXECUTIVE OFFICER	0.0 ................. 40.0	X	X		2,316,338	46,299
(2) CHARIE ZANCK...................................................................... BOARD OF GOVERNORS	0.0 ................. 4.0	X			0	0
(3) CHARLES RUTH...................................................................... BOARD OF GOVERNORS	0.0 ................. 2.0	X			0	0
(4) CHRIS NEWKIRK...................................................................... BOARD OF GOVERNORS	0.0 ................. 1.0	X			0	0
(5) DAVE DOMEK...................................................................... BOARD OF GOVERNORS	0.0 ................. 3.0	X			0	0
(6) IRFAN HAFIZ...................................................................... BOARD OF GOVERNORS / SVP - CMO	0.0 ................. 40.0	X			420,299	1,976
(7) JIM THORPE...................................................................... BOARD OF GOVERNORS	1.0 ................. 2.0	X			0	0
(8) LISA GLOSSON MD...................................................................... BOARD OF GOVERNORS	0.0 ................. 40.0	X			256,745	30,698
(9) MICHAEL LUECHT...................................................................... BOARD OF GOVERNORS	0.0 ................. 4.0	X			0	0
(10) MIKE CURRAN...................................................................... BOARD OF GOVERNORS	0.0 ................. 1.0	X			0	0
(11) PAULA DORION GRAY...................................................................... BOARD OF GOVERNORS	1.0 ................. 2.0	X			0	0
(12) TERRANCE BUGNO...................................................................... BOARD OF GOVERNORS	0.0 ................. 2.0	X			0	0
(13) TOM CAREY...................................................................... Board of Directors	0.0 ................. 2.0	X			0	0
(14) WILLIAM BUSSE...................................................................... Board of Directors	0.0 ................. 2.0	X			0	0
(15) DAVID TOMLINSON...................................................................... EVP - CFO	0.0 ................. 40.0		X		1,044,771	63,657
(16) JASON SCIARRO...................................................................... PRESIDENT / COO- Termed 5/2018	0.0 ................. 40.0		X		785,924	59,571
(17) Kumar Nathan...................................................................... Pres. Insur. Svcs./Gen Counsel	0.0 ................. 40.0			X	571,084	62,277

(A) Name and business address	(B) Description of services	(C) Compensation
CARDINAL HEALTH - AURORA DIV, 7000 CARDINAL PL DUBLIN,OH43017	HEALTHCARE SERVICES	23,590,001
SODEXO INC AFFILIATES, PO BOX 352 BUFFALO,NY14240	HOUSEKEEPING	4,641,060
FFF ENTERPRISES, 41093 COUNTY CENTER DRIVE TEMECULA,CA92591	HEALTHCARE SERVICES	2,155,260
GE HEALTHCARE, 3000 N GRANDVIEW BLVD WAUKESHA,WI53188	HEALTHCARE SERVICES	1,940,791
ARUP LABORATORIES, PO BOX 27964 SALT LAKE CITY,UT84127	LABORATORY SERVICES	1,885,675
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 78

- 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.
right arrow

Attach to Form 990 or Form 990-EZ.
right arrow

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public
Inspection

Name of the organization

Northern Illinois Medical Center

Employer identification number

36-2338884

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 12, 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 agricultural research organization described in 170(b)(1)(A)(ix) operated in conjunction with a land-grant college or university or a non-land grant college of agriculture. See instructions. Enter the name, city, and state of the college or university:

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 12a through 12d that describes the type of supporting organization and complete lines 12e, 12f, and 12g.

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) 2019

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 failed to qualify under the tests listed below, please complete Part III.)

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2015	(b) 2016	(c) 2017	(d) 2018	(e) 2019	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") ..
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) 2015	(b) 2016	(c) 2017	(d) 2018	(e) 2019	(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 2019 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2018 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2019. 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—2018. 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—2019. 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—2018. 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) 2019

Page 3

Part III

Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 10 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) 2015	(b) 2016	(c) 2017	(d) 2018	(e) 2019	(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) 2015	(b) 2016	(c) 2017	(d) 2018	(e) 2019	(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 2019 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2018 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2019 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2018 Schedule A, Part III, line 17 .............

19a

331/3% support tests—2019. 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—2018. 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) 2019

Page 4

Part IV

Supporting Organizations

(Complete only if you checked a box on line 12 of Part I. If you checked 12a of Part I, complete Sections A and B. If you checked 12b of Part I, complete Sections A and C. If you checked 12c of Part I, complete Sections A, D, and E. If you checked 12d 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 12a or 12b 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) 2019

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) 2019

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 (explain in Part VI). 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) 2019

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 2019 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-2019	(iii) Distributable Amount for 2019
1 Distributable amount for 2019 from Section C, line 6
2 Underdistributions, if any, for years prior to 2019 (reasonable cause required-- explain in Part VI). See instructions.
3 Excess distributions carryover, if any, to 2019:
a From 2014.......
b From 2015.......
c From 2016.......
d From 2017.......
e From 2018.......
fTotal of lines 3a through e
g Applied to underdistributions of prior years
h Applied to 2019 distributable amount
i Carryover from 2014 not applied (see instructions)
j Remainder. Subtract lines 3g, 3h, and 3i from 3f.
4Distributions for 2019 from Section D, line 7:
$
a Applied to underdistributions of prior years
b Applied to 2019 distributable amount
c Remainder. Subtract lines 4a and 4b from 4.
5 Remaining underdistributions for years prior to 2019, if any. Subtract lines 3g and 4a from line 2. If the amount is greater than zero, explain in Part VI. See instructions.
6 Remaining underdistributions for 2019. Subtract lines 3h and 4b from line 1. If the amount is greater than zero, explain in Part VI. See instructions.
7 Excess distributions carryover to 2020. Add lines 3j and 4c.
8 Breakdown of line 7:
a Excess from 2015.....
b Excess from 2016.....
c Excess from 2017.....
d Excess from 2018.....
e Excess from 2019.....

Schedule A (Form 990 or 990-EZ) (2019)

Schedule A (Form 990 or 990-EZ) 2019

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) 2019

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.

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2019

Name of the organization

Northern Illinois Medical Center

Employer identification number

36-2338884

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. Don't 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 isn't covered by the General Rule and/or the Special Rules doesn't 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 doesn't 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) (2019)

Schedule B (Form 990, 990-EZ, or 990-PF) (2019) Page 2

Name of organization Northern Illinois Medical Center

Part I Contributors	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
		$	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) (2019)

Schedule B (Form 990, 990-EZ, or 990-PF) (2019)

Page 3

Name of organization Northern Illinois Medical Center		Employer identification number 36-2338884

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) (2019)

Schedule B (Form 990, 990-EZ, or 990-PF) (2019)

Page 4


Name of organization Northern Illinois Medical Center			Employer identification number 36-2338884
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) (2019)

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.
SchDMd Bullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public Inspection

Name of the organization

Northern Illinois Medical Center

Employer identification number

36-2338884

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 7/25/06, 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 FASB 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 FASB 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 FASB 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) 2019

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

Term 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 .....	116,338		116,338
b	Buildings ....	248,384,712	57,405,524	190,979,188
c	Leasehold improvements	15,562,587	1,965,343	13,597,244
d	Equipment ....	157,043,169	108,270,603	48,772,566
e	Other .....	9,988,716	533,649	9,455,067
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..				262,920,403

Schedule D (Form 990) 2019

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
(B)
(C)
(D)
(E)
(F)
(G)
(H)
(I)
Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)

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

(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
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)INTERCOMPANY RECEIVABLES				46,543,485
(2)OTHER RECEIVABLES				912,031
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........				47,455,516

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
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)	1,261,771
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) 2019

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 Sch D Part X Line 2

ASC Topic 740, Income Taxes, addresses the determination of how tax benefits claimed or expected to be claimed on a tax return should be recorded on the consolidated financial statements. Under ASC Topic 740, the Medical Center must recgonize the tax benefit from an uncertain tax position only if it is more likely than not that the tax position will be sustained on examination by the taxing authorities, based on the technical merits of the position. The tax benefits recognized in the consolidated financials statements from such a position are measured based on the largest benefit that has the greater than fifty percent likelihood of being realized upon ultimate settlement. ASC Topic 740 also provides guidance on derecognition, classification, interest and penalties on income taxes, and accounting in interim periods and requires increased disclosures. As of June 30, 2018 and 2017 the Health System does not have a liability for unrecognized tax benefits.

Schedule D (Form 990) 2019

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

Go to www.irs.gov/Form990EZ for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public Inspection

Name of the organization

Northern Illinois Medical Center

Employer identification number

36-2338884

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 %

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) . . .	5,900,429		5,900,429	1.280 %
b	Medicaid (from Worksheet 3, column a) . . . . .	43,255,916	23,711,748	19,544,168	4.220 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) . .
d	Total Financial Assistance and Means-Tested Government Programs . . . . .	49,156,345	23,711,748	25,444,597	5.500 %
Other Benefits
e	Community health improvement services and community benefit operations (from Worksheet 4).	286,396		286,396	0.060 %
f	Health professions education (from Worksheet 5) . . .	662,029		662,029	0.140 %
g	Subsidized health services (from Worksheet 6) . . . .	26,140		26,140	0.010 %
h	Research (from Worksheet 7) .
i	Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .
j	Total. Other Benefits . .	974,565		974,565	0.210 %
k	Total. Add lines 7d and 7j .	50,130,910	23,711,748	26,419,162	5.710 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2019

Schedule H (Form 990) 2019

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 Healthcare Financial Management Association Statement No. 15? ..........................

Yes

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

33,105,551

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. ......

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).....

156,041,612

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

190,986,298

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

-34,944,686

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 %
1ALGON RD SURGERT CTR	OUTPATIENT SURGICAL SERVICES	12.75 %
2ARSC REAL ESTATE	PROPERTY MANAGEMENT	25 %
3
4
5
6
7
8
9
10
11
12
13

Schedule H (Form 990) 2019

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?2Name, 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)						Other (describe)
1	NORTHERN ILLINOIS MEDICAL CENTER 385 MILLENNIUM DRIVE CRYSTAL LAKE,IL60012 3889	X	X	X	X	Cancer Center
2	CENTEGRA HOSPITAL-HUNTLEY 385 MILLENNIUM DRIVE CRYSTAL LAKE,IL60012 3889	X	X	X	X

Schedule H (Form 990) 2019

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)

	NORTHERN ILLINOIS MEDICAL CENTER
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

The impact of any actions taken to address the significant health needs identified in the hospital facility's prior CHNA(s)

Other (describe in Section C)

Indicate the tax year the hospital facility last conducted a CHNA: 20 17

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..................................

Yes

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. ............................

Yes

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): See Part V

Other website (list url): See Part V

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 17

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

Yes

If "Yes" (list url): See Part V

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) 2019

Page 5

Part VFacility Information (continued)

Financial Assistance Policy (FAP)

	NORTHERN ILLINOIS MEDICAL CENTER
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 200.%
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?.................

Yes

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)

Was widely publicized 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):

CENTEGRA.ORG/financial-assistance

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

CENTEGRA.ORG/financial-assistance

A plain language summary of the FAP was widely available on a website (list url):
SAME AS 16A & 16B

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)

Individuals were notified about the FAP by being offered a paper copy of the plain language summary of the FAP, by
receiving a conspicuous written notice about the FAP on their billing statements, and via conspicuous public displays or
other measures reasonably calculated to attract patients' attention

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

The FAP, FAP application form, and plain language summary of the FAP were translated into the primary language(s)
spoken by LEP populations

Other (describe in Section C)

Schedule H (Form 990) 2019

Page 6

Part VFacility Information (continued)

Billing and Collections

	NORTHERN ILLINOIS MEDICAL CENTER
Name of hospital facility or letter of facility reporting group

Yes

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 nonpayment?..................................

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

Deferring, denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP

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

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

Deferring , denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP

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):

Provided a written notice about upcoming ECAs (Extraordinary Collection Action) and a plain language summary of the
FAP at least 30 days before initiating those ECAs (if not, describe in Section C)

Made a reasonable effort to orally notify individuals about the FAP and FAP application process (if not, describe in
Section C)

Processed incomplete and complete FAP applications (if not, describe in Section C)

Made presumptive eligibility determinations (if not, describe in Section C)

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)

Schedule H (Form 990) 2019

Page 7

Part VFacility Information (continued)

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

	NORTHERN ILLINOIS MEDICAL CENTER
Name of hospital facility or letter of facility reporting group

Yes

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 a look-back method based on claims allowed by Medicare fee-for-service during a prior 12-month period

The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month period

The hospital facility used a look-back method based on claims allowed by Medicaid, either alone or in combination with
Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month
period

The hospital facility used a prospective Medicare or Medicaid method

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) 2019

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)

	Centegra Hospital-Huntley
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?........................

Yes

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

The impact of any actions taken to address the significant health needs identified in the hospital facility's prior CHNA(s)

Other (describe in Section C)

Indicate the tax year the hospital facility last conducted a CHNA: 20 17

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..................................

Yes

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. ............................

Yes

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): See Part V

Other website (list url): See Part V

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 17

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

Yes

If "Yes" (list url): See Part V

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

10b

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) 2019

Page 5

Part VFacility Information (continued)

Financial Assistance Policy (FAP)

	Centegra Hospital-Huntley
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 200.%
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?.................

Yes

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

Yes

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)

Was widely publicized 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):

CENTEGRA.ORG/financial-assistance

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

CENTEGRA.ORG/financial-assistance

A plain language summary of the FAP was widely available on a website (list url):
SAME AS 16A & 16B

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)

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

The FAP, FAP application form, and plain language summary of the FAP were translated into the primary language(s)
spoken by LEP populations

Other (describe in Section C)

Schedule H (Form 990) 2019

Page 6

Part VFacility Information (continued)

Billing and Collections

	Centegra Hospital-Huntley
Name of hospital facility or letter of facility reporting group

Yes

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Deferring, denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP

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

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

Deferring , denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP

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):

Provided a written notice about upcoming ECAs (Extraordinary Collection Action) and a plain language summary of the
FAP at least 30 days before initiating those ECAs (if not, describe in Section C)

Made a reasonable effort to orally notify individuals about the FAP and FAP application process (if not, describe in
Section C)

Processed incomplete and complete FAP applications (if not, describe in Section C)

Made presumptive eligibility determinations (if not, describe in Section C)

Other (describe in Section C)

None of these efforts were made

Policy Relating to Emergency Medical Care

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)

Schedule H (Form 990) 2019

Page 7

Part VFacility Information (continued)

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

	Centegra Hospital-Huntley
Name of hospital facility or letter of facility reporting group

Yes

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 a look-back method based on claims allowed by Medicare fee-for-service during a prior 12-month period

The hospital facility used a prospective Medicare or Medicaid method

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) 2019

Page 8

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, 16j, 18e, 19e, 20a, 20b, 20c, 20d, 20e, 21c, 21d, 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
FACILITY INFORMATION	Form Sch H Part V Line 2 CENTEGRA HOSPITAL - HUNTLEY WAS PLACED INTO SERVICE IN AUGUST 2016. CENTEGRA HOSPITAL - HUNTLEY IS A 128 BED HOSPITAL IN HUNTLEY, ILLINOIS. IT PROVIDES SOPHISTICATED TREATMENTS AND ADVANCED TECHNOLOGY TO ADDRESS THE MOST SERIOUS MEDICAL CONDITIONS. THESE INCLUDE - LEVEL II TRAUMA DEPARTMENT 8-BED INTENSIVE CARE UNIT FAMILY BIRTH CENTER CHEST PAIN CENTER CARDIAC CATHERIZATION AND CARDIOLOGY SERVICES A FULL RANGE OF DIAGNOSTIC IMAGING ACCOUNT INPUT FROM PERSON WHO REPRESENT THE COMMUNITY Form Sch H Part V Line 5 In pursuit of a healthier community, the 2017 McHenry County Healthy Community partners commissioned a set of studies to measure and monitor the overall health of the county. With the intent of identifying the most pressing needs, the six funding partners in conjunction with 25 additional community organizations, known collectively as the MAPP agencies, will use the studies' findings to assess multiple dimensions of life in McHenry County. Similar needs assessments were completed in 2006, 2010 and 2014. The MAPP (Mobilizing for Action through Partnerships and Planning) process has been used since 2010. Each of the three studies was designed to examine the health of McHenry County from a different perspective: The Community Survey targeted the county as a whole and was open to all persons 18 years and older who lived or worked in the county. Survey participants numbered 1,090 which included 774 electronic replies and 316 paper returns. Surpassing the 2014 survey response by 46.5%, the impressive volume of replies demonstrates the value of broad and multi-layer promotion about the survey. Focus groups sought information through discussion with target populations and community leaders. Target population focus groups included 1) persons with mental illness, substance abuse, disabilities, and their parents, 2) Hispanics/Latinos 3) veterans 4) low-income mothers. Total participants in the five target population focus groups numbered 59. For community leaders, three separate focus groups were conducted. Of the 50 community leaders invited to attend, 29 persons took part. Community leaders involved in the focus groups were comprised of: Claudia Aquilina, Office Coordinator Senior Services, Inc.; Susan Bauer, Executive Director, Harvard Area Community Health Center; Julie Biel Claussen, Executive Director, Harvard Area Community Health Center; Denise Bowman, Training and Community Development, McHenry County Mental Health Board; Terry Braune, Compliance and Operations Manager, McHenry County Mental Health Board; Robin Doeden, Executive Director, McHenry County Community Foundation; Michael Eesley, CEO, Centegra Health System; Jane Farmer, Executive Director, Turning Point; Laura Franz, Executive Director, Transitional Living Services; Bona Heinsohn, President, McHenry County Conservation District; Scott Hennings; Principal Transportation Planner, McHenry County Government; Michael Hill, Administrator, McHenry County Department of Health; Suzanne Hoban, Executive Director, Family Health Partnership Clinic; Aimee Knop, Sheriff's Deputy, McHenry County Sheriff's Office; Art Krzyzanowski, Program Director, Thresholds; Ashley Lach, Manager, American Cancer Society; Kim Larson, Executive Director, Family Alliance; Mary McCann, County Board Member, McHenry County; Scott Naydenoff, Deputy Chief of Field Operations, Cary Police Department; Steve Otten, Executive Director, United Way of Greater McHenry County; Walt Pesterfield, Director, Department of Probation and Court Services; Dennis Sandquist, Director, McHenry County Planning and Development; Gerald Schalk, Chaplain, Fox River Fire District; Nancy Schietzelt, President, McHenry County Environmental Defenders; Todd Schroll, Director of Behavioral Health Services, Centegra Health System; Rebecca Stiemke, Executive Director, Volunteer Center of McHenry County; Cindy Sullivan, Executive Director, Options and Advocacy; Toni Weaver, President, PFLAG; James Wiseman, Executive Director, Northern IL Special Recreation Association. The Community Analysis gathered secondary data about McHenry County. A description of McHenry County's demographic, social, economic and health characteristics using secondary sources of information that draws extensively on the U.S. Census and Centers for Disease Control and Prevention, National Center for Health Statistics products as well as numerous other sources.
CHNA CONDUCTED WITH OTHER HOSPITAL FACILITIES	Form Sch H Part V Line 6a Advocate Good Shepherd Hospital and Advocate Sherman Hospital
CHNA CONDUCTED WITH OTHER FACILITIES	Form Sch H Part V Line 6b The 2017 McHenry County Healthy Community Study was directed by six partners. They were: Advocate Health Care, Centegra Health System, McHenry County Department of Health, McHenry County Mental Health Board, McHenry County Substance Abuse Coalition, and United Way of Greater McHenry County. Form Sch H Part V Line 7a https://centegra.org/mchenry-county-healthy-community-study Form Sch H Part V Line 7b i. https://www.mchenrycountyil.gov/county-government/departments-a-i/ health-department/health-administration/strategic-planning ii. https://www.mchenrycountyil.gov/home/showdocument?id=71454 Form Sch H Part V Line 10a https://centegra.org/mchenry-county-healthy-community-study
HOW THE HOSPITAL IS ADDRESSING NEEDS AND NEEDS NOT ADDRESSED	Form Sch H Part V Line 11 Centegra Health System adopted an Implementation Strategy on behalf of its three hospitals, Centegra Hospital-McHenry, Centegra Hospital-Huntley and Centegra Hospital-Woodstock, to lay out the ways our teams will address our community's health needs through 2020. As Centegra Health System continues to grow and evolve, these strategies may be amended to most effectively utilize the system's capabilities. While this Implementation Strategy addresses the priorities identified in its 2017 Community Health Needs Assessment, Centegra will also continue to offer a wide range of other services to meet additional needs that have been identified by our health system. Centegra Health System and its hospitals also are an active member in McHenry County MAPP (Mobilizing for Action through Partnerships), which has workgroups focused around the following high-priority issues facing the County: Obesity, Cardiovascular health, Active Communities, and Behavioral Health. Centegra Health System has representation on each workgroup, which partners with area organizations including the McHenry County Department of Health to establish goals and strategies to improve the health of our community. There are certain needs identified in the CHNA that are not being addressed by Centegra Health System. These needs include areas of which Centegra Health System has no expertise, and falls outside the scope of care in which Centegra Health System provides to the community. Several of Centegra Health System's CHNA partner organizations are addressing these needs. Community Benefits Program Activity Highlights: Preventative Health (7/1/2017-6/30-2018) Big Latch On, Mommy Mingle Fair Centegra Health System takes part as a host site for the Big Latch On global initiative each August. The event welcomes breastfeeding mothers and babies to come and be counted in the Big Latch On a yearly total to promote and encourage breastfeeding. The Mommy Mingle Fair immediately follows the Big Latch On and includes vendors who promote services and products for health and wellness. McHenry County police officers and Safe Kids provide free car seat safety checks in the parking lot. In FY18, this initiative totaled 100 participants. Blood Pressure Screenings The Sun City residential community offers The Wellness Center at Sun City in partnership with Centegra Health System. This on-site service provides health education, screenings and healthcare support to residents while enabling easy access to experienced providers on staff. Walk-in blood pressure screenings are available every day. In FY18, this initiative totaled 104 participants. Know Your Numbers This event was held twice and included an 8- to 12-hour fasting finger-stick blood test for cholesterol, blood sugar, blood pressure and body mass index. Attendees received a one-on-one consultation to review their results with a physician, and had access to health experts in cardiology, oncology, sleep and neuro-rehabilitation. In FY18, this initiative totaled 68 participants. Concussion Screenings The Centegra Sports Concussion Program provides a cognitive baseline assessment and the necessary follow-up care for students and individuals in youth sports programs between the ages of 10-18. The full assessment is done using the ImPACT test: . An online testing program used to test cognitive ability with certified impact consultants. . The program measures multiple aspects of cognitive function in athletes including working memory, reaction time, speed and concentration. In FY18, this initiative totaled 8,000 participants. Freshstart Tobacco Cessation Program Freshstart is the American Cancer Society's 6-week, group-based, tobacco cessation, counseling program. The program is designed to help participants stop smoking by providing essential information, skills for coping with cravings and group support. In FY18, this initiative totaled 12 participants. Patient Transportation Free transportation is made available to or from a Centegra Health System facility for people who do not have a driver's license, who are being admitted or discharged from the hospital, who are undergoing treatment that prohibits driving, or for patients without any other means of transportation. In FY18, this initiative totaled 14,500 participants. Poison Prevention Education Poison prevention education and resources from the Illinois Poison Center are provided by Centegra Health System nurses to elementary students at the kindergarten level once a year. This program is intended to educate the kindergartener and their family on poison prevention and safety, and what to do if someone is exposed to a potentially poisonous item. The goal is to prevent accidental poisonings and introduce the Illinois Poison Center phone number to the community. In FY18, this initiative totaled 2,920 participants. Skin Cancer Screenings Monthly screenings are provided between May and September by a board-certified dermatologist or a certified physician assistant. A thorough examination of the skin is performed to detect suspicious lesions and any precancerous changes. In FY18, this initiative totaled 31 participants.
INCOME LEVEL OTHER THAN FPG	Form Sch H Part V Line 13B In addition to the documented 200% of FPG, we also provide a sliding scale discount of 80% for those who have FPG up to 350%. In addition we have presumption charity which allows for charity discounts/financial assistance to those who currently meet Medicaid eligibility or other state programs based on FPG who may not have had insurance coverage at the time of the service we provided.
OTHER FACTORS USED IN DETERMINING AMOUNTS CHARGED PATIENTS	Form Sch H Part V Line 13h All patients are charged the same for services rendered. Patients may qualify for free or discounted care as described in Part VI, Line 3. Eligibility for financial assistance depends on factors such as income level, asset level and medical indigency.

Schedule H (Form 990) 2019

Page 9

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?28
Name and address		Type of Facility (describe)
1	CENTEGRA PHYSICIAN CARE 3707 DOTY RD MOB 2 STE C-E G H WOODSTOCK,IL60098	HOSPITAL OUTPATIENT DEPARTMENT
2	CENTEGRA CARDIACPULMONARY REHAB 4309 MEDICAL CENTER DR SUITE B104 MCHENRY,IL60050	Other health care facility
3	CENTEGRA GAVERS BREAST CENTER DIV 360 N TERRA COTTA RD CRYSTAL LAKE,IL60012	Other health care facility
4	CENTEGRA HEALTH CENTER 360 STATION DR CRYSTAL LAKE,IL60014	Other health care facility
5	CENTEGRA HEALTH CENTER 420 N IL ROUTE 31 CRYSTAL LAKE,IL60012	HOSPITAL BASED LOCATION
6	CENTEGRA HEALTH CENTER 10350 HALIGUS RD 100 HUNTLEY,IL60142	Other health care facility
7	CENTEGRA HEALTH CENTER-WEST DUNDEE 1925 HUNTLEY RD WEST DUNDEE,IL60118	HOSPITAL BASED LOCATION
8	CENTEGRA HEALTHY LIVING INSTITUTE 10350 HALIGUS RD 220 HUNTLEY,IL60142	Other health care facility
9	CENTEGRA HOSPITAL 10370 HALIGUS RD HUNTLEY,IL60142	HOSPITAL BASED
10	CENTEGRA HOSPITAL - HUNTLEY 10400 HALIGUS RD HUNTLEY,IL60142	PROVIDER-BASED REMOTE LOCATION
11	CENTEGRA HOSPITAL-MCHENRY 4309 W MEDICAL CENTER DR A200-B MCHENRY,IL60050	Other health care facility
12	CENTEGRA MILESTONES THERAPY CENTER 394 FEDERAL DR CRYSTAL LAKE,IL60014	Other health care facility
13	CENTEGRA NEURO REHABILITATION CENTER 500 COVENTRY LN 170 CRYSTAL LAKE,IL60014	Other health care facility
14	CENTEGRA PHYSICAN CARE 690 E TERRA COTTA AVE CRYSTAL LAKE,IL60014	Other health care facility
15	CENTEGRA PHYSICAN CARE 4309 W MEDICAL CENTER DR MCHENRY,IL60050	Other health care facility
16	CENTEGRA PHYSICIAN CARE 248 E GRAND AVE FOX LAKE,IL60020	Hospital Based Location
17	CENTEGRA PHYSICIAN CARE 1906 HOLIAN DR SPRING GROVE,IL60081	Other health care facility
18	CENTEGRA PHYSICIAN CARE 10350 HALIGUS RD 200 HUNTLEY,IL60142	Other health care facility
19	CENTEGRA PHYSICIAN CARE 750 E TERRA COTTA AVE CRYSTAL LAKE,IL60014	Other health care facility
20	CENTEGRA PHYSICIAN CARE 650 DAKOTA ST CRYSTAL LAKE,IL60012	Other health care facility
21	CENTEGRA PHYSICIAN CARE 1465 COMMERCE DR ALGONQUIN,IL60102	Other health care facility
22	CENTEGRA REHABILITATION & SPORTS MEDICIN 4305 MEDICAL CENTER DR 3 MCHENRY,IL60050	Other health care facility
23	CENTEGRA REHABILITATION & SPORTS MEDICIN 333 FRONT ST MCHENRY,IL60050	Other health care facility
24	CENTEGRA REHABILITATION & SPORTS MEDICIN 3703 DOTY RD 5 WOODSTOCK,IL60098	Other health care facility
25	CENTEGRA REHABILITATION & SPORTS MEDICIN 10450 ALGONQUIN RD HUNTLEY,IL60142	Other health care facility
26	CENTEGRA REHABILITATION & SPORTS MEDICIN 201 N THROOP ST WOODSTOCK,IL60098	Other health care facility
27	CENTEGRA REHABILITATION & SPORTS MEDICIN 200 E CONGRESS PKWY CRYSTAL LAKE,IL60014	Other health care facility
28	CENTEGRA SAGE CANCER CENTER DIV 4305 MEDICAL CENTER DR A MCHENRY,IL60050	Other health care facility

Schedule H (Form 990) 2019

Page 10

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
Financial Assistance and Community Benefits	Form Sch H Part I Line 7 Line 7a-7c amounts are calculated using the Medicare cost to charge ratio. Line 7e-7i dollars are calculated from community benefit reports that are submitted by the Hospital departments for various activities and support groups that benefit the community.
METHODOLOGY USED TO ESTIMATE BAD DEBT EXPENSE	Form Sch H Part III Line 2 In estimating allowances for doubtful accounts, the Health System analyzes past history, existing trends, and payer sources to determine the reserves needed.
BAD DEBT EXPENSE	Form Sch H Part III Line 4 In estimating allowances for doubtful accounts, the Health System analyzes past history, existing trends, and payer sources to determine the reserves needed. Please reference the notes to the audited financial statements for information on the allowances for doubtful accounts.
EXPLANATION OF SHORTFALL AS COMMUNITY BENEFIT	Form Sch H Part III Line 8 The amount shown in line 6 represents the actual costs incurred to treat Medicare patients and is calculated by applying the Medicare cost-to-charge ratio. Therefore, the entire amount of line 7 constitutes a community benefit.
PROVISIONS ON COLLECTION PRACTICES FOR QUALIFIED PATIENTS	Form Sch H Part III Line 9b Centegra provides patients with consistent information on payment expectations and assists them in meeting their financial obligations. A written explanation of the payment requirements categorized by type of payor is given prior to admission/registration or upon admission/registration of each Centegra health system (CHS) patient. Centegra will bill the patient's insurance carrier. Procedures will be implemented over time and by area to collect as much as possible of the time of service unless payor contracts require billing (i.e., no assignments). 1. Admission reservation/outpatient appointment made by physician/patient. Walk-in and emergency department patients present for service. 2. Perform the patient pre-registration for applicable scheduled registrations. 3. Patient verbal consent obtained and annotated except where prohibited by law. ""On (date) at about (time), (patient or representative) orally authorized (site name) to release information concerning the patient's medical care, treatment and diagnosis to employers, insurance companies, government agencies or third-party payors and their agents, for verification of benefits and pre-certification. I (the pre-registrar) did not obtain a written consent signed by the patient, due to the patient not being physically present and limited time constraints."" This statement would be signed and dated by the pre-registrar. Patient refusal to provide oral consent requires patient notification of potential penalties and places the burden on the patient to complete payor requirements. 4. Complete insurance verification and initiate pre-certification. 5. Estimate the approximate cost of services and advise the responsible party. Explanation of the cost will fluctuate based on services ordered by the physicians. 6. Discuss the financial requirements, including payment expectations with the patient/guarantor prior to admission/registration when applicable. 7. Interview conducted by financial counselor of patients who express difficulty in meeting Centegra's payment requirements. 8. Admission/registration of patient is completed. Patient/guarantor signature for the consent to release information obtained. 9. Collect the estimated patient share. The deductible and co-payments and any non-covered amounts quoted by the carrier are due from inpatients prior to discharge and where possible, for outpatients prior to or at the time of registration. 10. Self-pay accounts are to be paid in full or screened by the financial counselor for potential state or federal program, financial assistance application or payment plan. 11. Policy regarding non-compliance with respect to payment arrangements or plans: Self-pay: patients who have not completed arrangements for one of the payment options within 120 days of the billing date will be automatically turned over to a collection agency. Broken promise/defaults: patients with delinquent payments, 15 or more days late, will be turned over to a collection agency. After insurance: processing patients who have not made payments or enrolled in one of the payment options for co-insurance and deductible amounts within 120 days of insurance payment will be turned over to a collection agency.
NEEDS ASSESSMENT	Form Sch H Part VI Line 2 Centegra health system identifies community health care priorities and develops activities and strategies to meet the health care needs of at risk populations within its service area. These community benefit programs promote community wellness and disease prevention, enhance community health education, and improve the quality of clinical education. In 2016, centegra health system partnered with the mchenry county health department and other hospitals and organizations to conduct the 2017 mchenry county healthy community study. The intent of the needs assessment was to understand and address the county's most pressing needs, involving partners from diverse organizations, in order to improve the health of county residents. A thorough understanding of the county's health was measured using four assessments, each from a different perspective including residents, populations in need of services, community leaders, and descriptors using secondary data sources. Through the assessments, knowledge was gained about the current health status of county residents, demographic trends, social and economic indicators, health behaviors, and utilization of health services. The assessments also attempted to understand the perceptions of community strengths and weaknesses as well as answer questions about the health and human services delivery system, unmet needs, gaps, and barriers to care.
PATIENT EDUCATION OF ELIGIBILITY OF ASSISTANCE	Form Sch H Part VI Line 3 Uninsured patients arriving at our emergency department and/or direct admits are screened at time of service by either an emergency department financial counselor or the health system's in-patient financial counseling team, public aid representatives, and a medication assistance coordinator to identify eligibility guidelines for federal, state and local government programs, as well as charity care. CHS's self-pay process includes a screening which is completed by using hospital form c910050 03-09 prompting an interview offering payment options and eligibility guidelines. It is at this time that a patient becomes aware of the hospital uninsured patient discount act, Medicaid, medication assistance programs, crime victims, IBCCP, cash pay fee schedules, and other hospital discount incentives. Patients are advised of timeline for completing application processes at time of service in person. Appropriate scripting is followed by CHS associates. Discounts were established following the 200%, 350% and 600% federal poverty guidelines to assist in determining charity adjustments. Applications were designed by CHS self-pay committee in accordance to our financial policy (policy number 9850-2) identifying qualifications for the medically needy/catastrophic aid. Uninsured patients opting for elective services are contacted by phone prior to their date of service by the CHS outpatient financial counseling team. CHS'S self-pay process is followed and includes a screening for federal, state and local government programs as well as charity care. An interview offering payment options and eligibility guidelines using hospital form c910050 03/09 prompts a quick eligibility determination. It is at this time that a patient becomes aware of the uninsured patient discount act, Medicaid, medication assistance programs, crime victims, IBCCP, cash pay fee schedules, and other hospital discount incentives. Patients are advised of time line for completing application processes prior to their elective services via phone. Appropriate scripting is followed by CHS associates. Discounts were established following the 200%, 350% and 600% federal poverty guidelines to assist in determining charity adjustments. Applications were designed by CHS self-pay committee in accordance to our financial policy (policy number 9850-2) identifying qualifications for the medically needy/catastrophic aid. Our health system's website offers FAQ'S and answers as well as encourages patients to contact our customer service team when they are unable to pay for services. Our health system's statements also identify detailed account and billing information encouraging the patient to contact our customer service team and inquire about financial assistance options. Documentation is essential in effective communication. Follow up teams will then move forward in a timely manner with the appropriate actions to insure all necessary documents (if applicable) are received for eligibility determinations. CHS advertises a price line encouraging patients to inquire about estimated costs for future services. The price is manned by our outpatient financial counselors from 8:00am to 7:00pm. When calls are returned with estimated costs, a conversation ensues to identify a possible financial hardship. Our self-pay process is put into effect at this time. Site registrars will notify the CHS financial counseling team when a financial hardship is identified. Emergency department financial counseling positions have been created to meet the needs of our ED patients. In addition to these new roles, a full time financial counselor position was created to meet the special needs of our cancer patients. A financial assistance coordinator reviews all financial applications, gathers needed documents, determines financial assistance and prepares each patient file for leadership approval.
COMMUNITY INFORMATION	Form Sch H Part VI Line 4 Centegra Health System defines its primary service area as McHenry County, an area of approximately 603 square miles and approximately 309,122 residents in 2017. In 2017, the age distribution of the population was as follows: 29.5% ages 0-18, 56.5% ages 18-65, 14.0% ages 65 and older. McHenry County has relatively high socioeconomic status compared to the rest of Illinois. In 2013-2017 (in 2017 dollars), the median household income of the households in McHenry County was $82,230 compared to the Illinois state average of $61,229. The 2017 percentage of civilians in labor force ages 16+ was 70.8%, which was higher than the state of Illinois at 65.2%. The 2017 percentage of persons in poverty in McHenry County was lower than that of the state of Illinois, at 6.1% compared to 12.6%. In 2017, the percentage of the county's population holding a high school diploma or higher was 92.8%, while the percentage holding a bachelor's degree or higher was 33.2%. The McHenry County uninsured in 2017 was 5.5% compared to the state uninsured rate of 7.8%. The most recent data available was used in this description. Source: US Census Bureau
PROMOTION OF COMMUNITY HEALTH	Form Sch H Part VI Line 5 Please see Schedule O for a detailed description of the medical center's program service accomplishments.
AFFILIATED HEALTH CARE SYSTEM	Form Sch H Part VI Line 6 THE LEGAL ENTITY Northern Illinois Medical Center (NIMC) operates two hospitals - Centegra Hospital - McHenry and Centegra Hospital - Huntley. NIMC IS AFFILIATED with memorial medical center of Woodstock, IL. ALL THREE HOSPITALS are acute care facilities serving the greater Mchenry county area. Centegra health system is the parent of both northern Illinois medical center and memorial medical center. Northern Illinois medical center is affiliated with health bridge fitness centers in Crystal Lake, and the medical center provides outpatient physical rehabilitation services to the community from a clinic within that location. The centegra health system foundation supports hospital operations through fundraising activities. Please see schedule R for complete listing of all affiliated organizations.
STATE FILING OF COMMUNITY BENEFIT REPORT	Form Sch H Part VI Line 7 IL

Schedule H (Form 990) 2019

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

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public Inspection

Name of the organization

Northern Illinois Medical Center

Employer identification number

36-2338884

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 on 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 on 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 nonfixed
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) 2019

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)
1MICHAEL EESLEY CHIEF EXECUTIVE OFFICER	(i) (ii)	0 ------------- 886,518	0 ------------- 806,719	0 ------------- 623,101	0 ------------- 3,431	0 ------------- 42,868	0 ------------- 2,362,637	0 ------------- 453,073
2IRFAN HAFIZ BOARD OF GOVERNORS / SVP - CMO	(i) (ii)	0 ------------- 326,944	0 ------------- 69,096	0 ------------- 24,259	0 ------------- 1,907	0 ------------- 69	0 ------------- 422,275	0 ------------- 0
3LISA GLOSSON MD BOARD OF GOVERNORS	(i) (ii)	0 ------------- 209,423	0 ------------- 12,356	0 ------------- 34,966	0 ------------- 0	0 ------------- 30,698	0 ------------- 287,443	0 ------------- 10,600
4DAVID TOMLINSON EVP - CFO	(i) (ii)	0 ------------- 426,425	0 ------------- 323,400	0 ------------- 294,946	0 ------------- 3,450	0 ------------- 60,207	0 ------------- 1,108,428	0 ------------- 40,114
5JASON SCIARRO PRESIDENT / COO- Termed 5/2018	(i) (ii)	0 ------------- 96,396	0 ------------- 88,694	0 ------------- 600,834	0 ------------- 3,533	0 ------------- 56,038	0 ------------- 845,495	0 ------------- 0
6Kumar Nathan Pres. Insur. Svcs./Gen Counsel	(i) (ii)	0 ------------- 404,047	0 ------------- 90,300	0 ------------- 76,737	0 ------------- 3,042	0 ------------- 59,235	0 ------------- 633,361	0 ------------- 28,074
7RACHEL SEBASTIAN PRESIDENT - CHM	(i) (ii)	0 ------------- 312,880	0 ------------- 86,988	0 ------------- 67,872	0 ------------- 3,399	0 ------------- 35,442	0 ------------- 506,581	0 ------------- 24,853
8SHEILA SENN SVP - COO - CHH- Termed 3/2018	(i) (ii)	0 ------------- 271,793	0 ------------- 0	0 ------------- 23,545	0 ------------- 2,764	0 ------------- 35,890	0 ------------- 333,992	0 ------------- 0
9CONNIE SECOR DIRECT SURG/CARD- Termed 10/17	(i) (ii)	140,321 ------------- 0	0 ------------- 0	26,464 ------------- 0	3,153 ------------- 0	957 ------------- 0	170,895 ------------- 0	0 ------------- 0
10JOHN GEINOPOLOS MEDICAL PHYSICIST	(i) (ii)	161,796 -------------	0 -------------	26,670 -------------	0 -------------	59,194 -------------	247,660 -------------	0 -------------
11Lisa Evan PHARMD IP NGT	(i) (ii)	152,427 ------------- 0	0 ------------- 0	15,339 ------------- 0	1,852 ------------- 0	20,981 ------------- 0	190,599 ------------- 0	0 ------------- 0
12SUSAN CORCORAN CLINICAL STAFF PHARMACIST	(i) (ii)	158,223 -------------	2,110 -------------	18,301 -------------	2,479 -------------	58,124 -------------	239,237 -------------	0 -------------
13WEIHONG HE MEDICAL PHYSICIST	(i) (ii)	210,062 ------------- 0	0 ------------- 0	7,271 ------------- 0	0 ------------- 0	56,896 ------------- 0	274,229 ------------- 0	0 ------------- 0

Schedule J (Form 990) 2019

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 Sch J Part I Line 4a

The following individuals received severance payments: JASON SCIARRO PRESIDENT / COO $555,916 SHEILA SENN SVP / COO - CHH $218,327 DAVID TOMLINSON EVP/CFO $162,657 CONNIE SECOR DIRECT. SURG./CARD $86,065

Form Sch J Part I Line 4b

Certain individuals listed in schedule J, Part II participate in a supplemental non-qualified retirement plan to which the hospital network makes annual contributions. The following individuals received distributions from a supplemental non-qualified retirement plan during 2017: Name Title Amount MICHAEL EESLEY CHIEF EXECUTIVE OFFICER $453,073 DAVID TOMLINSON EVP / CFO $40,144 RACHEL SEBASTIAN PRESIDENT - CHM $24,853 KUMAR NATHAN PRES. INSUR. SVCS./GEN COUNSEL $28,074 LISA GLOSSON BOARD OF GOVERNORS $10,600

Schedule J (Form 990) 2019

Additional Data

Software ID:
Software Version:

- TIN:

Schedule L
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Transactions with Interested Persons

Complete if the organization answered "Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c, or Form 990-EZ, Part V, line 38a or 40b.
MediumBullet

Attach to Form 990 or Form 990-EZ.
MediumBullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public Inspection

Name of the organization

Northern Illinois Medical Center

Employer identification number

36-2338884

Part I

Excess Benefit Transactions (section 501(c)(3), section 501(c)(4), and section 501(c)(29) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.

1(a) Name of disqualified person	(c) Description of transaction	(d) Corrected?
1(a) Name of disqualified person	(c) Description of transaction	Yes	No

Enter the amount of tax incurred by the organization managers or disqualified persons during the year under section 4958. ........................... Bullet Image

Enter the amount of tax, if any, on line 2, above, reimbursed by the organization ........ Bullet Image

Part II

Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990-EZ, Part V, line 38a, or Form 990, Part IV, line 26; or if the organization reported an amount on Form 990, Part X, line 5, 6, or 22

(a) Name of interested person	(b) Relationship with organization	(c) Purpose of loan	(d) Loan to or from the organization?		(e) Original principal amount	(f) Balance due	(g) In default?		(h) Approved by board or committee?		(i) Written agreement?
(a) Name of interested person	(b) Relationship with organization	(c) Purpose of loan	To	From	(e) Original principal amount	(f) Balance due	Yes	No	Yes	No	Yes	No






Total ............... $

Part III

Grants or Assistance Benefiting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.

(a) Name of interested person	(b) Relationship between interested person and the organization	(c) Amount of assistance	(d) Type of assistance	(e) Purpose of assistance

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

Cat. No. 50056A

Schedule L (Form 990 or 990-EZ) 2019

Page 2

Part IV

Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.

(a) Name of interested person	(b) Relationship between interested person and the organization	(c) Amount of transaction	(d) Description of transaction	(e) Sharing of organization's revenues?
(a) Name of interested person		(c) Amount of transaction	(d) Description of transaction	Yes	No
(1) RACHEL SEBASTIAN	FAMILY MEMBER	506,581	EMPLOYEE		No

Part V

Supplemental Information
Provide additional information for responses to questions on Schedule L (see instructions).

Return Reference	Explanation
BUSINESS TRANSACTIONS INVOLVING INTERESTED PERSONS	SCHEDULE L, PART IV ALL BUSINESS TRANSACTIONS ARE ARMS LENGTH TRANSACTIONS. SEE CONFLICT OF INTEREST DISCLOSURES IN SCHEDULE O FOR FORM 990, PART VI, LINE 2.

Schedule L (Form 990 or 990-EZ) 2019

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

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2019

Open to Public
Inspection

Name of the organization

Northern Illinois Medical Center

Employer identification number

36-2338884

Return Reference	Explanation
PROGRAM SERVICE ACCOMPLISHMENTS	Form 990 Part III Line 4a Executive Summary Centegra Health System (Centegra) coordinates the delivery of health care services by assisting in the management of Centegra Hospital- McHenry, Centegra Hospital-Huntley (both facilities within Northern Illinois Medical Center), Centegra Hospital- Woodstock (Memorial Medical Center), (The Medical Centers), and Centegra Health System Foundation, Health Bridge Corporation and NIMED Corporation (Affiliates). Centegra's mission is to inspire and engage our community in their health and wellness. We provide quality health care services with innovative and responsible use of resources and promote wellness for the greater McHenry County area in Illinois. During its fiscal year 2018, Centegra Health System sponsored more than 230 community events. These events focused on the high priority issues facing the county: obesity, cardiovascular health, active communities and behavioral health. The Medical Centers provide optimum quality health care, delivered by competent hospital and medical center staff, to all who seek its services regardless of race, creed, sex, national origin, handicap, age, or ability to pay. The primary mission of the Medical Centers is to enhance the health of the community as the preferred health care organization providing outstanding service and value. It is the Medical Centers' objective to serve the community with respect to providing health care services and education. Although reimbursement for services rendered is critical to the operation and stability of the Medical Centers, it is recognized that not all individuals possess the ability to purchase essential medical services. Therefore, in keeping with the Medical Centers' commitment to serve all members of its community, free care and/or subsidized care will be considered where the need and/or an individual's inability to pay exist. Medical Services are provided in a dignified manner to Medicare, Medicaid and indigent patients. System-wide, community benefits included approximately $8.8 million of charity care, over $58.0 million of government sponsored indigent health care, approximately $4.5 million of other community benefits, and over 115,000 community benefit hours. The Medical Centers' services include, but are not limited to: Centegra Hospital-McHenry is a 179-bed facility located about 50 miles outside of Chicago. The hospital is the region's leading provider of advanced cardiovascular treatments through the Centegra Cardiovascular & Thoracic Center. It is also home to the Centegra Hip & Knee Replacement Center, the Centegra Sage Cancer Center and the Centegra Family Birth Center. As part of Centegra Health System, Centegra Hospital-McHenry achieved Magnet designation for nursing excellence. Centegra Hospital-McHenry provides sophisticated treatments and advanced technology to address the most serious medical conditions. These include: Open-heart surgery and heart catheterizations Joint replacement surgeries A Level II Trauma Center and on-site Flight for Life helicopter Certified chest pain and stroke centers Advanced cancer treatments including radiation oncology and infusion services Labor and delivery and on-site 24/7 obstetrics hospitalists and neonatologists Intensive care Medical-Surgical care and 24/7 hospitalist care Outpatient surgery Centegra Hospital - Huntley opened its doors in August 2016 as a 384,135 square-foot, 128 bed facility. Centegra Hospital- Huntley provides sophisticated treatments and advanced technology to address the most serious medical conditions. These include: Level II Trauma emergency department 8-bed intensive care unit Family Birth Center Chest Pain Center Cardiac Catheterization Laboratory and Cardiology Services A full range of diagnostic imaging including radiology, ultrasound, MRI scanning and nuclear medicine Helipad for transporting patients Centegra Hospital-Woodstock is a 106-bed facility located about 60 miles outside of Chicago. The hospital provides exceptional inpatient and outpatient care and has won top awards for patient safety and satisfaction. As part of Centegra Health System, Centegra Hospital-Woodstock achieved Magnet designation for nursing excellence. Centegra Hospital - Woodstock provides sophisticated treatments and advanced technology to address the most serious medical conditions, including: A Level II Trauma Center and on-site Flight for Life helicopter Certified chest pain and stroke centers Intensive care Medical-Surgical care and 24/7 hospitalist care Outpatient surgery Inpatient behavioral health services Weight-loss surgery through the Centegra Healthy Living Institute State-of-the-art medical imaging Centegra Health System Foundation provides fund-raising services for Centegra Health System in conjunction with the Medical Centers. The proceeds of these activities are used to purchase medical equipment and supplies, therefore enabling the Medical Centers to better serve the community. Health Bridge Corporation provides various rehabilitation services for the Medical Centers in conjunction with Centegra Health System, by providing a fitness center and pool that serves the community in various capacities and sponsors and hosts assorted educational programs. NIMED Corporation aids in the management of the Medical Centers and several satellite locations within the Centegra Health System organization. The Medical Centersthe Affiliates' program accomplishments are summarized below. SUPPORT GROUPS Centegra Health System, in conjunction with the Medical Centers and Affiliates, sponsors or hosts many support groups for its patients as well as the community. The following ongoing support groups are held at the Medical Centers, Affiliates or in the community. By supporting these groups, the Medical Centers and Affiliates are able to provide one or all of the following: Staff professionals who either act as facilitators of the group or function as Guest Speakers, Space offered free or at minimal charge, Free marketing to educate the community about these services. Programs sponsored by the Medical Centers and or Affiliates in conjunction with Centegra Health System include: Oncology Support Groups - Cancer Transitions focuses on the needs of cancer survivors who have finished treatment with the last two years. Caring for the Caregiver is a group for those offering care to anyone with a serious illness. The group provides an opportunity to connect with others who understand the unique experience of being a caregiver. Education and support are offered on relevant topics to assist successful management of the challenges of caregiving. Creating Expressions links artistic experience with the emotional benefits of cancer management. Growing Together Through Cancer Transitions is a monthly group for cancer survivors who have completed the Cancer Transitions program. Education and support is offered through the group experience to increase personal empowerment and wellness in body, mind and spirit toward the goal of long term cancer survivorship. Centegra STAR Program Guided Patient Services (GPS) where participants receive valuable information and resources that aid them before, during and after diagnosis and treatment. Members of the Survivorship Training and Rehabilitation (STAR) certified team are available to address questions and concerns while patients participate in assessments to help create a personalized plan of care. H.O.P.E.: High on Positive Energy is for women living with breast cancer Look Good Feel Better is a free program offered by the American Cancer Society and teaches beauty techniques to women who are currently undergoing cancer treatment. Partners in Cancer Transitions, a monthly support group for cancer survivors and their care partners. Pathfinders, a support group for men and women living with cancer and their care partners. Wig Boutique: This American Cancer Society program helps women with cancer select a free wig. Young Ribbons, a support group for those diagnosed with breast cancer younger than the age of 45. This support group helps participants connect with other breast cancer survivors to share, learn and support one another during and after treatment.
ADDITIONAL SUPPORT GROUPS AND SERVICES	A.W.A.K.E. (Alert, Well and Keeping Energetic) Support Group is a sleep disorder support group for patients and family members affected by sleep disordered breathing. The A.W.A.K.E. Support Group is part of the American Sleep Apnea Association. ADHD Parent Support Group a free support group for parents of children with Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD) this group provides opportunities for parents to share, collaborate and communicate about some of the challenges involved in raising children with ADD or ADHD. Breastfeeding Support groups are held to support all breastfeeding moms. Centegra Crisis Services in partnership with the McHenry County Mental Health Board offers 24-hour crisis line and 24-hour onsite response team. Diabetes Support Group is for individuals with diabetes and their families. Eating Disorder Support Group, a monthly eating disorder support group led by a mental health professional and a registered dietitian. Free Freshstart/Tobacco Cessation: Centegra has partnered with the American Cancer Society to empower participants towards quitting a tobacco habit. Freshstart provides information about effective strategies and helps motivate and prepare participants to make a successful quit attempt. Living with Grief, sponsored by Centegra Pastoral Care, offers support for adults grieving the loss of a loved one. Stroke Support Group. Weight-Loss Surgery Support Group for patients that have had weight-loss surgery. EDUCATION PROGRAMS The Medical Centers and Affiliates make a variety of educational programs designed to promote wellness available to all members of the community. The Medical Centers, in conjunction with Centegra Health System, work in cooperation with McHenry County College to provide a complete series of specialized training for those interested in developing their knowledge of emergency basics, or in pursuing a career in the emergency health care field. There are three levels of training available: First Responder, Emergency Medical Technician - Basic, Emergency Medical Technician - Paramedic. An Emergency Medical Dispatcher Course designed to prepare individuals for employment as dispatchers for a public service agency providing dispatch to law enforcement fire service, and/or Emergency Medical Service is also offered. The Medical Centers offer a variety of classes that can help people save lives. The Medical Centers, in conjunction with Centegra's Health Bridge Fitness Centers, offer Red Cross first aid classes that include First Aid and Cardio-Pulmonary Resuscitation (CPR). Classes help community members learn CPR prior to certification, or brush up on skills for re-certification. The Medical Centers also offer a CPR Instructor Course, International Trauma Life Support, Advanced Cardiac Life Support, and Pediatric Advanced Life Support training classes. Family health and wellness programs presented by the Medical Centers are designed to promote a healthier community. The Medical Centers offer low-cost education classes for expectant families including prenatal and cesarean birth classes, along with free hospital tours. Centegra's Healthy Living Institute offers a variety of education programs to support healthy habits toward weight loss or weight maintenance. Lipid screenings are offered periodically during the year. Integrative programs include mindful eating, understanding the healing potential of food, and journaling. Still more educational programs are offered to assist members of the community take charge of special needs in their lives, to change their lifestyles for healthier lives, as well as programs to inform the community about Advance Medical Directives, including living wills, durable power of attorney issues, organ donations, and Understanding Medicare. The Medical Centers sponsor several programs specializing in issues of concern for women including reduced fee mammograms, programs on osteoporosis, and programs on menopause. The annual Centegra Health Strong Woman Event is a program designed to give health information across a variety of topics to women in McHenry County and the surrounding area. Centegra Hospital - McHenry's Sage Cancer Center and Centegra Gavers Breast Center, together with the American Cancer Society, Gavers Community Cancer Foundation, and McHenry County College, sponsor various Cancer Awareness Programs. Centegra Health System offers colorectal cancer screenings, reduced fee mammograms, skin, oral, head and neck cancer screenings, and reduced fee prostrate (PSA) screenings. Cancer awareness also includes programs on reduction of risk for cancer through good nutrition and healthy lifestyle habits. Centegra Health System also sponsors celebrations of cancer survivorship. In addition, Centegra Health System is a learning center (clinical site) for students from a multitude of colleges and universities. Students have completed internships in programs such as nurse practitioner, nursing, nurse aide, physician assistant, social work, speech therapy, phlebotomy, diagnostic medical sonography, medical imaging, medical records, pharmacy, medical physics, surgical technology, professional counselor, substance abuse counselor, and medical assistant. Centegra Health System is also a learning site for 3rd and 4th year medical students from Rosalind Franklin University. OTHER COMMUNITY SERVICES The Medical Centers and Affiliates participate in various community events and initiatives including community health fairs and county business fairs in order to promote health and awareness in the community. Other community services are career shadowing opportunities for area students, Flight for Life Helicopter appearances, poison awareness programs, blood drives, and a variety of health screenings (blood pressure, diabetes, skin cancer, colorectal cancer, glaucoma, hearing, etc.) to promote health and awareness in the community. The Medical Centers and Affiliates also distribute thousands of informational brochures, service listings, and flyers at the request of area schools, churches, and organizations on an ongoing basis. The Referral Line (877-CENTEGRA) is a toll-free phone line sponsored by the Medical Centers. It offers free, computerized service to callers who require information or physician referrals. A trained counselor staffs the line. Several medical specialties are represented, and physicians are on staff for referrals. The line also gives information regarding physician's office hours, locations, insurance, and languages spoken. Additionally, counselors give information on Self-Help and Support Groups. The Medical Centers sponsor blood drives every year and are able to provide numerous pints of blood to those in need. The Medical Centers provide Patient Express! transportation services for individuals who require transportation to the Medical Centers. The Patient Express! van is provided and is frequently used by the disabled and elderly individuals of the community. The service is provided free of charge, although donations are accepted to defray the costs of the service. EXERCISE PROGRAMS The Medical Centers, in conjunction with Centegra Health System and Centegra Health Bridge Fitness Centers offer specialized exercise programs that help participants get moving and stay active for a healthier lifestyle. These programs include Aquatics, Individual and Group Fitness, Mind/Body including Pilates, Tai Chi, Yoga, Sports Performance, and Tennis Racquetball & Basketball.
REHABILITATION / PHYSICAL THERAPY PROGRAMS	Through the Centegra Hospital - McHenry's acute inpatient rehabilitation/physical therapy programs, disabled individuals can practice and master the skills required for personal hygiene, home maintenance, financial management, mobility, and social interaction in the security and privacy of the rehabilitation department. Using distinctive environments such as, apartment, car, cafe & restaurant, and an ambulation course, therapists and clinical staff are able to assess and evaluate the progress of each patient using a unique form of individual care. When individual confidence and proficiency return, discharge planning and community re-entry training complete the rehabilitation program. The Medical Centers also provide extensive Cardiac Rehabilitation and Pulmonary Rehabilitation programs. Integrated into the Cardiac Rehabilitation Program is the Centegra WellBridge program. This is a wellness membership that promotes community health by providing patients who have completed Phase II or Phase III with a supervised exercise area at Centegra Health Bridge Fitness Centers at a very low cost. Outpatient rehabilitation care and Sports Medicine Clinics at Health Bridge Fitness Centers and other locations provide sports medicine, aquatics, outpatient physical and occupational therapy programs. The Centegra Industrial Rehabilitation programs help area employers with injured employees rebuild their strength and abilities for a safe and speedy return to work. The program includes work hardening, work conditioning, functional capacity evaluations, physical and occupational therapy. Worksite Services and Programs include ergonomic consultations and evaluations as well as other educational and safety programs. The Centegra Neuro-Rehabilitation Center serves individuals who have experienced traumatic brain injury and neurological impairments due to stroke, accident, or disease. It is a comprehensive program for patients requiring intensive, interdisciplinary services on an outpatient basis. The program facilitates the individual's function and independence in the home, work, school, and community with integrated and holistic treatment. Services include physical therapy, occupational therapy, speech therapy, neuropsychology, social work, nursing, vocational counseling, and recreational therapy. This program also has access to facilities at Centegra Health Bridge Fitness Center and may work in conjunction with the Centegra Industrial Rehabilitation Program. The Centegra Milestones Therapy Center provides outpatient therapy services for children from birth through age 21. Centegra Milestones Therapy Center provides individual therapy sessions with occupational, speech and physical therapists as well as a variety of playgroups where children learn and interact in a safe and stimulating environment. TAX-EXEMPT BONDS FORM 990 PART IV LINE 24A Northern Illinois Medical Center HOLDS A LIABILITY ON ITS BOOKS FOR TAX-EXEMPT BONDS, WHICH IS AN ALLOCATION FROM ITS SOLE CORPORATE MEMBER, CENTEGRA HEALTH SYSTEM. AS A RESULT, THE QUESTION WAS ANSWERED NO, AND SCHEDULE K WILL BE COMPLETED IN CENTEGRA HEALTH SYSTEM'S FORM 990. BUSINESS OR FAMILY RELATIONSHIP OF OFFICERS, DIRECTORS, ETC. Form 990 Part VI Line 2 Northern Illinois Medical Center, (NIMC), as part of Centegra Health System, has adopted specific conflict of interest policies for its governing and management staff. The policy includes, but is not limited to, when an individual, governor, committee member, officer, agent or employee believes that he or she, or a member of his or her immediate family might have or does have a real or apparent conflict, he or she should in addition to filing the disclosure notice required, abstain from making motions, voting, executing agreements, or taking any other similar direct action on behalf of the Medical Center. During fiscal year 2018, Northern Illinois Medical Center purchased certain goods, and or services from organizations with directors' affiliation. All transactions were competitively bid and were conducted at arms-length. The fees paid were at fair market value. During fiscal year 2018, Director Micheal Curran is an Officer / Director of Curran Contracting Company, supplier of excavation and asphalt pavement services. Director Charles Ruth is the Board Chairman of American Community Bank & Trust and Chief Executive Officer of Alliance Contractors. Director Tom Carey is Vice-President and majority owner, Carey Electric Contracting, Inc., supplier of electrical contracting services. Rachel Sebastian, President, Centegra Hospital - McHenry is the daughter of Chief Executive Officer, Michael Eesley. Rachel Sebastian reported to the Chief Executive Officer, Micheal Eesley. Matthew Eesley is the son of Chief Executive Officer, Michael Eesley. During fiscal year 2018, Matthew Eesley was the Director, Centegra Physician Care Outpatient Services, reporting to Mattias Carlen, Senior-Vice President - Ambulatory Services and CHW. EXPLANATION OF CLASSES OF MEMBERS OR SHAREHOLDER Form 990 Part VI Line 6 Centegra Health System is the sole member of NIMC. Centegra Health System has a single class of members.
HOW MEMBERS OR SHAREHOLDERS ELECT GOVERNING BODY	Form 990 Part VI Line 7a The powers and duties of the Centegra Health System members in fulfilling the purposes and objectives of the Corporation shall include, but not be limited to, the taking of action with respect to the following matters: The election of governors and the filling of vacancies on the Board of Governors, which shall be in accordance with the procedures set forth in the Bylaws. The Nominating Committee shall select one candidate for each position on the Board having a term to be voted upon for the office of governor at the next annual meeting of members. The Nominating Committee shall consider and approve a list of candidates and submit such list to the Board of Governors not less than 10 days prior to the date of the last meeting of the Board of Governors prior to the date on which notice of the annual meeting of members is to be sent, and the candidates set forth on such list shall be subject to approval by the Board of Governors. The names of the candidates so selected by the Nominating Committee and approved by the Board of Governors shall be included in the notice of the annual meeting of the members of the Corporation and shall be presented to the members of the Corporation at the annual meeting. The voting members of the Corporation may nominate candidates for the positions on the Board of Governors. Nominations by such members may be effected by means of written nomination signed by not less than 20 voting members in good standing, accompanied by a written statement of such nominee indicating a willingness to serve as a governor of the Corporation if elected. Any such nomination must be received by the Nominating Committee of the Corporation not less than 60 days prior to the annual meeting of members in order to be considered at such annual meeting. All elections shall be by secret ballot if there are more nominees than vacancies to be filled on the Board. All voting members present in person or by proxy at a meeting at which an election occurs shall be entitled to vote for governors. To be valid a ballot must not have more votes than there are vacancies. If there are more nominees than vacancies to be filled on the Board, those nominees who receive the most votes shall be elected to the Board of Governors. Members shall not be entitled to cumulate their votes in the election of governors.
REVIEW PROCESS	Form 990 Part VI Line 11b The review process for the Form 990 includes compilation by internal staff, detailed review by an outside tax preparer, and review by the Centegra Health System (CHS) Chief Financial Officer, prior to submission to the IRS. The tax return will be made available for the Board to review after submission to the IRS.
EXPLANATION OF MONITORING AND ENFORCEMENT OF CONFLICTS	Form 990 Part VI Line 12c As stated in Centegra's Bylaws, the Bylaws recognize that both real and apparent conflicts of interest sometimes naturally occur in the course of conducting daily affairs. Conflicts occur because the many persons associated with Centegra should be expected to have and do, in fact, generally have multiple interests and affiliations and various positions of responsibility within the community. The long-range interests of Centegra do not require the termination of all association with persons who may have real or apparent conflicts if a prescribed and effective method can render such conflicts harmless to all concerned. Centegra Health System has a conflict of interest policy that is intended to address such matters. 1. Duty to Disclose: In connection with any actual or possible conflicts of interest, an interested person or other person subject to this policy must disclose the existence and nature of his or her financial interest in writing to the President of Centegra or the Chief Corporate Responsibility Officer or designee, who shall provide such written disclosure to the Governors Affairs Committee of Centegra, which shall consider all conflicts of interest issues and, if appropriate, to the directors and members of committees with board-delegated powers considering the proposed transaction or arrangement. The disclosure must occur, at minimum, annually, with a Conflict of Interest Disclosure Statement being submitted no later than January 31st of each year. Copies of disclosure statements filed by Board members shall be distributed to the Board annually at the February Board meeting. 2. Determining Whether a Conflict of Interest Exists: When a conflict of interest is disclosed at meeting of the board or committee thereof, after disclosure of the financial interest, the interested person shall leave the board or committee meeting while the financial interest is discussed and voted upon. The remaining board or committee members shall decide if a conflict of interest exists. The interested person's leaving such meeting shall not affect whether a quorum exists at such meeting. 3. Procedures for Addressing the Transaction or Arrangement from Which the Conflict Arose: A. The chairperson of the board or committee shall, if appropriate, appoint a disinterested person or committee to investigate alternatives to the proposed transaction or arrangement. B. After exercising due diligence, the board or committee shall determine whether Centegra can obtain a more advantageous transaction or arrangement with reasonable efforts from a person or entity that would not give rise to a conflict of interest. C. If a more advantageous transaction or arrangement is not reasonably attainable under circumstances that would not give rise to a conflict of interest, the board or committee shall determine by a majority vote of the disinterested directors whether the transaction or arrangement is in Centegra's best interest and for its own benefit and whether the transaction is fair and reasonable to Centegra and shall make its decision as to whether to enter into the transaction or arrangement in conformity with such determination. 4. Violations of the Conflicts of Interest Policy: A. If the administration, the board, or a committee has a reasonable cause to believe that a member has failed to disclose actual or possible conflicts of interest, it shall inform the member of the basis for such belief and afford the member an opportunity to explain the alleged failure to disclose. B. If, after hearing the response of the member and making such further investigation as may be warranted in the circumstances, the board or committee determines that the member has, in fact, failed to disclose an actual or possible conflict of interest, it shall refer the matter to the Governors Affairs Committee for consideration, which shall subsequently recommend appropriate disciplinary and corrective action to such board or committee. 5. The minutes of the board and all committees with board-delegated powers shall contain the names of the persons who disclosed or otherwise were found to have a financial interest in connection with an actual or possible conflict of interest, the nature of the financial interest, any action taken to determine whether a conflict of interest was present, and the board's or committee's decision as to whether a conflict of interest, in fact, existed. The names of the persons who were present for discussion and votes relating to the transaction or arrangement, the content of the discussions, including any alternatives to the proposed transaction or arrangement, and a record of any votes taken in connection therewith. 6. A voting member of any committee whose jurisdiction includes compensation matters and who receives compensation, directly or indirectly, from Centegra for services is precluded from voting on matters pertaining to that member's compensation, physicians who receive compensation, directly or indirectly from Centegra, whether as employees or independent contractors, are precluded from membership on any committee whose jurisdiction includes compensation matters and in which such physician may have a direct or indirect interest. 7. Each director, principal officer, and member of a committee with board-delegated powers shall annually sign a statement which affirms that such person has received a copy of the conflicts of interest policy; has read and understands the policy; has agreed to comply with the policy; and understands that Centegra is a charitable organization and that in order to maintain its federal tax exemption, it must engage primarily in activities which accomplish one or more of its tax exempt purposes. 8. To ensure that Centegra operates in a matter consistent with its charitable purposes and that it does not engage in activities that could jeopardize its status as an organization exempt from federal income tax, periodic reviews shall, at a minimum, include the following subjects: whether acquisition of physician practices and other provider services result in inurement or impermissible private benefit. Whether joint venture arrangements and arrangements with management service organizations and physician hospital organizations conform to written policies, are properly recorded, reflect reasonable payment for goods and services, further Centegra's charitable purposes and do not result in inurement or impermissible private benefit. Whether agreements to provide healthcare and agreements with other healthcare providers, employees, and third party payors further Centegra's charitable purposes and do not result in inurement or impermissible private benefit. Whether business transactions on behalf of Centegra or an entity controlled by it are the result of arms-length dealing and are no less advantageous than competitively available goods and services of like grade and quality. 9. In conducting the periodic reviews provided for in article vii, Centegra may, but need not, use outside advisors. If outside experts are used, their use shall not relieve the board of its responsibility for ensuring that periodic reviews are conducted.
COMPENSATION REVIEW & APPROVAL PROCESS- OFFICERS & KEY EMPLOYEES	Form 990 Part VI Line 15a & 15b The Board of Governors of Centegra Health System, through the Compensation Committee comprised of independent members free of conflict, reviewed executive compensation levels and other features of the compensation plan in accordance with the organization's approved compensation philosophy and strategy: The Committee is comprised of members of the Board of Governors, who are independent of Centegra management, have no personal interest in the compensation arrangements, are not related to, or under the control of any individual whose compensation arrangement is being reviewed and have no material business relationship with Centegra. The C-Suite's compensation is determined by the Compensation Committee in relation to comparable peers or 990 market data. Compensation for other members of the executive staff is recommended by the CEO, reviewed by the Committee, and evaluated against market data based on comparable peers. The Committee approves all compensation decisions in advance of their implementation and documents its determinations and discussions. Its decisions and deliberations are thoroughly documented and meeting minutes are kept and distributed to the Committee members (for historical reference). The Compensation Committee uses a number of external resources and comparisons, and their review includes total compensation (cash compensation, plus benefits provided by Centegra) in relation to organizational performance and prevailing industry practices of comparably-sized organizations. They have engaged the services of a compensation consulting firm (Sullivan Cotter) specializing in the not-for-profit sector that has worked with Centegra and reports directly to the Compensation Committee. Reasonableness letters and documentation are provided to the organization after each review.
OTHER ORGANIZATION DOCUMENTS PUBLICLY AVAILABLE	Form 990 Part VI Line 19 The organization makes its governing documents, conflict of interest policy, and financial statements available to the public upon request.
RELATED COMPANY - CHS	Form 990 Part IX Line 24a It should be noted that the Related Company expenses in Form 990, Part IX, line 24a are allocated at 89% of total expense of the related company (Centegra Health System, FEIN 36-3196559). The allocation method is reviewed annually.
RECONCILIATION OF NET ASSETS	Form 990 Part XI Line 9 AFFILIATE TRANSFERS ($26,300,000) INTEREST IN FOUNDATION $1,381,062 NET ASSETS RELEASED FROM RESTRICTIONS ($156,043) ------------ ($25,074,981)

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2019

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: TO PROVIDE QUALITY HEALTH CARE SERVICES WITH INNOVATIVE AND RESPONSIBLE USE OF RESOURCES AND PROMOTE WELLNESS FOR THE MCHENRY COUNTY AREA.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	14
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	11
5	Total number of individuals employed in calendar year 2019 (Part V, line 2a) ......	5	2,423
6	Total number of volunteers (estimate if necessary) .............	6	423
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	783,333
b	Net unrelated business taxable income from Form 990-T, line 39 .........	7b	-114,495

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	1,410,013	388,989
9	Program service revenue (Part VIII, line 2g) .........	399,424,106	473,231,902
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	3,688,685	4,061,670
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	7,229,649	5,280,535
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)	411,752,453	482,963,096
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)	137,698,531	156,078,913
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)....	281,693,243	306,582,029
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	419,391,774	462,660,942
19	Revenue less expenses. Subtract line 18 from line 12.......	-7,639,321	20,302,154
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	476,545,169	487,411,971
21	Total liabilities (Part X, line 26).............	326,804,205	342,098,023
22	Net assets or fund balances. Subtract line 21 from line 20.....	149,740,964	145,313,948

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 430,674,302 including grants of $ ) (Revenue $ 473,437,029 )
	See Schedule O

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 expenses430,674,302

(A) Name and title	(B) Average hours per week (list any hours for related organizations below dotted line)			(D) Reportable compensation from the organization (W-2/1099-MISC)	(E) Reportable compensation from related organizations (W-2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(A) Name and title
(18) RACHEL SEBASTIAN........................................................................ PRESIDENT - CHM	40.0 .......................0.0	X		0	467,740	38,841
(19) SHEILA SENN........................................................................ SVP - COO - CHH- Termed 3/2018	20.0 .......................20.0	X		0	295,338	38,654
(20) CONNIE SECOR........................................................................ DIRECT SURG/CARD- Termed 10/17	40.0 .......................0.0		X	166,785	0	4,110
(21) JOHN GEINOPOLOS........................................................................ MEDICAL PHYSICIST	40.0 .......................0.0		X	188,466	0	59,194
(22) Lisa Evan........................................................................ PHARMD IP NGT	40.0 .......................0.0		X	167,766	0	22,833
(23) SUSAN CORCORAN........................................................................ CLINICAL STAFF PHARMACIST	40.0 .......................0.0		X	178,634	0	60,603
(24) WEIHONG HE........................................................................ MEDICAL PHYSICIST	40.0 .......................0.0		X	217,333	0	56,896

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)...........	918,984	6,158,239	545,609

1a	Federated campaigns..		1a
b	Membership dues..		1b
c	Fundraising events..		1c
d	Related organizations		1d	293,547
e	Government grants (contributions)		1e	95,442

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

g	Noncash contributions included in lines 1a - 1f:$		1g

h Total. Add lines 1a-1f.......		388,989

		Business Code
2a	ANCILLARY OUTPATIENT SERVICES	621110	351,207,628	351,207,628
b	ANCILLARY INPATIENT SERVICES	621110	110,101,934	110,101,934
c	IDPA PROVIDER TAX REVENUE	621110	11,922,340	11,922,340
d
e
f	All other program service revenue.
g	Total. Add lines 2a–2f .....		473,231,902

3 Investment income (including dividends, interest, and othersimilar amounts) ......			4,588,848			4,588,848
4 Income from investment of tax-exempt bond proceeds			107			107
5 Royalties...........			0
		(ii) Personal	(i) Real
6a	Gross rents		11,518	6a
b	Less: rental expenses			6b
c	Rental income or (loss)	0	11,518	6c
d	Net rental income or (loss).......			11,518			11,518
		(ii) Other	(i) Securities
7a	Gross amount from sales of assets other than inventory		2,113,159	7a
b	Less: cost or other basis and sales expenses	200,549	2,439,895	7b
c	Gain or (loss)	-200,549	-326,736	7c
d	Net gain or (loss).........			-527,285			-527,285
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ....
			8a	0
b	Less: direct expenses ...		8b	0
c	Net income or (loss) from fundraising events..			0
9a	Gross income from gaming activities. See Part IV, line 19 ...
			9a	0
b	Less: direct expenses ...		9b	0
c	Net income or (loss) from gaming activities..			0
10a	Gross sales of inventory, less returns and allowances ..
			10a	0
b	Less: cost of goods sold ..		10b	0
c	Net income or (loss) from sales of inventory..			0
Business Code			Miscellaneous Revenue
11a	CHILD DAY CARE /RETAIL PHARMACY/LACTATION		624410	2,546,538		783,333	1,763,205
b	CAFETERIA SERVICES/EDUCATION		900099	1,751,535			1,751,535
c	RELATED COMPANY REVENUE		900099	205,127	205,127
d	All other revenue ....			765,817			765,817
e	Total. Add lines 11a–11d ......			5,269,017
12	Total revenue. See instructions.....			482,963,096	473,437,029	783,333	8,353,745

1	Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21 ....	0
2	Grants and other assistance to domestic individuals. See Part IV, line 22 ...........	0
3	Grants and other assistance to foreign organizations, foreign governments, and foreign individuals. See Part IV, lines 15 and 16. .............	0
4	Benefits paid to or for members .......	0
5	Compensation of current officers, directors, trustees, and key employees ...........	1,321,893		1,321,893
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
7	Other salaries and wages........	126,516,485	115,075,174	11,441,311
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	-864,378	-786,584	-77,794
9	Other employee benefits .......	20,712,136	18,848,044	1,864,092
10	Payroll taxes ...........	8,392,777	7,637,427	755,350
11	Fees for services (non-employees):
a	Management ......	1,362,716		1,362,716
b	Legal .........	5,402		5,402
c	Accounting ...........	0
d	Lobbying ...........	0
e	Professional fundraising services. See Part IV, line 17	0
f	Investment management fees ......	0
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O)	21,478,849	19,740,944	1,737,905
12	Advertising and promotion ....	4,381	4,381
13	Office expenses .......	96,492,565	95,895,219	597,346
14	Information technology ......	16,674	15,899	775
15	Royalties ..	0
16	Occupancy ...........	7,834,478	6,817,507	1,016,971
17	Travel ............	134,133	92,818	41,315
18	Payments of travel or entertainment expenses for any federal, state, or local public officials .	0
19	Conferences, conventions, and meetings ....	133,804	102,620	31,184
20	Interest ...........	12,024,094	10,941,925	1,082,169
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization ..	19,394,122	17,648,652	1,745,470
23	Insurance ...	2,437,007	2,217,675	219,332
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	RELATED COMPANY - CHS	78,510,624	71,444,668	7,065,956
b	BAD DEBT	33,105,551	33,105,551
c	RELATED COMPANY - CMS	15,303,139	15,303,139
d	IDA PROVIDER TAX	8,880,655	8,880,655
e	All other expenses	9,463,835	7,688,588	1,775,247
25	Total functional expenses. Add lines 1 through 24e	462,660,942	430,674,302	31,986,640	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).

1	Cash–non-interest-bearing ........			92,587	1	-120,074
2	Savings and temporary cash investments .........			42,550,177	2	20,034,601
3	Pledges and grants receivable, net ......			0	3	0
4	Accounts receivable, net .............			59,004,288	4	60,920,449
5	Loans and other payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .......
				0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), and persons described in section 4958(c)(3)(B) ...
				0	6	0
7	Notes and loans receivable, net ...........			0	7	0
8	Inventories for sale or use ............			8,897,834	8	9,874,673
9	Prepaid expenses and deferred charges ......			1,802,900	9	1,735,314
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	431,095,522
b	Less: accumulated depreciation	10b	168,175,119	276,571,875	10c	262,920,403
11	Investments—publicly traded securities .			74,832,266	11	78,144,435
12	Investments—other securities. See Part IV, line 11 .....			0	12	0
13	Investments—program-related. See Part IV, line 11 ..			6,623,112	13	6,446,654
14	Intangible assets ...............			0	14	0
15	Other assets. See Part IV, line 11 ...........			6,170,130	15	47,455,516
16	Total assets. Add lines 1 through 15 (must equal line 33)...			476,545,169	16	487,411,971

17	Accounts payable and accrued expenses .....	217,184,003	17	231,688,605
18	Grants payable ...	0	18	0
19	Deferred revenue .........	0	19	0
20	Tax-exempt bond liabilities .........	108,489,024	20	109,147,647
21	Escrow or custodial account liability. Complete Part IV of Schedule D	0	21	0
22	Loans and other payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .........
		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	1,131,178	25	1,261,771
26	Total liabilities. Add lines 17 through 25..	326,804,205	26	342,098,023

	Organizations that follow FASB ASC 958, check here and complete lines 27, 28, 32, and 33.
27	Net assets without donor restrictions ..........		27
28	Net assets with donor restrictions ...........		28
	Organizations that do not follow FASB ASC 958, check here and complete lines 29 through 33.
29	Capital stock or trust principal, or current funds .....		29
30	Paid-in or capital surplus, or land, building or equipment fund ...		30
31	Retained earnings, endowment, accumulated income, or other funds		31
32	Total net assets or fund balances ...........	149,740,964	32	145,313,948
33	Total liabilities and net assets/fund balances ........	476,545,169	33	487,411,971

(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)Centegra Health System 541 N FAIRBANKS CT STE 1630 CHICAGO,IL606113309 36-3196559	Health System	IL	501(c)(3)	10	NA		No
(2)Centegra Health System Foundation 541 N FAIRBANKS CT STE 1630 CHICAGO,IL606113309 36-3196560	Fundraising	IL	501(c)(3)	7	Centegra HS		No
(3)NIMED Corporation 541 N FAIRBANKS CT STE 1630 CHICAGO,IL606113309 36-3119911	Property Mgmt	IL	501(c)(3)	12B	Centegra HS		No
(4)Health Bridge Corporation 541 N FAIRBANKS CT STE 1630 CHICAGO,IL606113309 36-3196550	Health FT CTR	IL	501(c)(3)	10	Centegra HS		No
(5)Centegra Hospital Huntley Holdings 541 N FAIRBANKS CT STE 1630 CHICAGO,IL606113309 45-3449737	Support Org	IL	501(c)(3)	12C	NIMC	Yes
(6)Memorial Medical Center 541 N FAIRBANKS CT STE 1630 CHICAGO,IL606113309 36-2179764	Hospital	IL	501(c)(3)	3	Centegra HS		No

(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

(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