Attach to Form 990 or Form 990-EZ.
Go to
www.irs.gov/Form990 for the latest information.
| (i) Name of supported organization | (ii) EIN | (iii) Type of organization (described on lines 1- 10 above (see instructions)) | (iv) Is the organization listed in your governing document? | (v) Amount of monetary support (see instructions) | (vi) Amount of other support (see instructions) | |
|---|---|---|---|---|---|---|
| Yes | No | |||||
|
Total |
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Calendar year (or fiscal year beginning in) ![]() |
(a) 2014 | (b) 2015 | (c) 2016 | (d) 2017 | (e) 2018 | (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. | ||||||
Calendar year
(or fiscal year beginning in) ![]() |
(a) 2014 | (b) 2015 | (c) 2016 | (d) 2017 | (e) 2018 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 7 | Amounts from line 4.. | ||||||
| 8 | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources... | ||||||
| 9 | Net income from unrelated business activities, whether or not the business is regularly carried on.. | ||||||
| 10 | Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.).. | ||||||
| 11 | Total support. Add lines 7 through 10 | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2014 | (b) 2015 | (c) 2016 | (d) 2017 | (e) 2018 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") . | 102,679 | 132,260 | 171,534 | 136,416 | 159,870 | 702,759 |
| 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 | 27,143,623 | 27,821,955 | 28,248,194 | 26,245,849 | 25,717,679 | 135,177,300 |
| 3 | Gross receipts from activities that are not an unrelated trade or business under section 513 ..... | 102,098 | 0 | 0 | 0 | 102,098 | |
| 4 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf... | 0 | |||||
| 5 | The value of services or facilities furnished by a governmental unit to the organization without charge | 0 | |||||
| 6 | Total. Add lines 1 through 5 | 27,348,400 | 27,954,215 | 28,419,728 | 26,382,265 | 25,877,549 | 135,982,157 |
| 7a | Amounts included on lines 1, 2, and 3 received from disqualified persons | 0 | 0 | 0 | 0 | 0 | 0 |
| 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. | 0 | 0 | 0 | 0 | 0 | 0 |
| c | Add lines 7a and 7b.. | 0 | 0 | 0 | 0 | 0 | 0 |
| 8 | Public support. (Subtract line 7c from line 6.) | 135,982,157 | |||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2014 | (b) 2015 | (c) 2016 | (d) 2017 | (e) 2018 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | 27,348,400 | 27,954,215 | 28,419,728 | 26,382,265 | 25,877,549 | 135,982,157 |
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | 169,349 | 232,476 | 217,215 | 195,533 | 206,877 | 1,021,450 |
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | 0 | |||||
| c | Add lines 10a and 10b. | 169,349 | 232,476 | 217,215 | 195,533 | 206,877 | 1,021,450 |
| 11 | Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on. | 0 | |||||
| 12 | Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.) .. | 0 | 0 | 0 | 0 | 0 | 0 |
| 13 | Total support. (Add lines 9, 10c, 11, and 12.).. | 27,517,749 | 28,186,691 | 28,636,943 | 26,577,798 | 26,084,426 | 137,003,607 |
| Section A - Adjusted Net Income | (A) Prior Year |
(B) Current Year (optional) |
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| 1 | Net short-term capital gain | 1 | ||||
| 2 | Recoveries of prior-year distributions | 2 | ||||
| 3 | Other gross income (see instructions) | 3 | ||||
| 4 | Add lines 1 through 3 | 4 | ||||
| 5 | Depreciation and depletion | 5 | ||||
| 6 | Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions) | 6 | ||||
| 7 | Other expenses (see instructions) | 7 | ||||
| 8 | Adjusted Net Income (subtract lines 5, 6 and 7 from line 4) | 8 | ||||
| Section B - Minimum Asset Amount | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year): | 1 | ||||
| a | Average monthly value of securities | 1a | ||||
| b | Average monthly cash balances | 1b | ||||
| c | Fair market value of other non-exempt-use assets | 1c | ||||
| d | Total (add lines 1a, 1b, and 1c) | 1d | ||||
| e |
Discount claimed for blockage or other factors (explain in detail in Part VI): |
|||||
| 2 | Acquisition indebtedness applicable to non-exempt use assets | 2 | ||||
| 3 | Subtract line 2 from line 1d | 3 | ||||
| 4 | Cash deemed held for exempt use. Enter 1-1/2% of line 3 (for greater amount, see instructions). | 4 | ||||
| 5 | Net value of non-exempt-use assets (subtract line 4 from line 3) | 5 | ||||
| 6 | Multiply line 5 by .035 | 6 | ||||
| 7 | Recoveries of prior-year distributions | 7 | ||||
| 8 | Minimum Asset Amount (add line 7 to line 6) | 8 | ||||
| Section C - Distributable Amount | Current Year | |||||
| 1 | Adjusted net income for prior year (from Section A, line 8, Column A) | 1 | ||||
| 2 | Enter 85% of line 1 | 2 | ||||
| 3 | Minimum asset amount for prior year (from Section B, line 8, Column A) | 3 | ||||
| 4 | Enter greater of line 2 or line 3 | 4 | ||||
| 5 | Income tax imposed in prior year | 5 | ||||
| 6 | Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions) | 6 | ||||
| Section D - Distributions | Current Year | |
|---|---|---|
| 1 Amounts paid to supported organizations to accomplish exempt purposes | ||
|
2
Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity |
||
| 3 Administrative expenses paid to accomplish exempt purposes of supported organizations | ||
| 4 Amounts paid to acquire exempt-use assets | ||
| 5 Qualified set-aside amounts (prior IRS approval required) | ||
| 6 Other distributions (describe in Part VI). See instructions | ||
| 7Total annual distributions. Add lines 1 through 6. | ||
|
8
Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions |
||
| 9 Distributable amount for 2018 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-2018 |
(iii) Distributable Amount for 2018 |
|
|---|---|---|---|---|
|
1
Distributable amount for 2018 from Section C, line 6 |
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|
2
Underdistributions, if any, for years prior to 2018 (reasonable cause required-- explain in Part VI). See instructions. |
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| 3 Excess distributions carryover, if any, to 2018: | ||||
| a From 2013....... | ||||
| b From 2014....... | ||||
| c From 2015....... | ||||
| d From 2016....... | ||||
| e From 2017....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2018 distributable amount | ||||
|
i
Carryover from 2013 not applied (see instructions) |
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| j Remainder. Subtract lines 3g, 3h, and 3i from 3f. | ||||
| 4Distributions for 2018 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2018 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from 4. | ||||
|
5
Remaining underdistributions for years prior to 2018, if any. Subtract lines 3g and 4a from line 2. If the amount is greater than zero, explain in Part VI. See instructions. |
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|
6
Remaining underdistributions for 2018. Subtract lines 3h and 4b from line 1. If the amount is greater than zero, explain in Part VI. See instructions. |
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|
7 Excess distributions carryover to 2019. Add lines 3j and 4c. |
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| 8 Breakdown of line 7: | ||||
| a Excess from 2014...... | ||||
| b Excess from 2015..... | ||||
| c Excess from 2016..... | ||||
| d Excess from 2017..... | ||||
| e Excess from 2018..... | ||||
| Facts And Circumstances Test |
|---|
| Return Reference | Explanation |
|---|
| Software ID: | 18007697 |
| Software Version: | 2018v3.1 |
Attach to Form 990 or 990-EZ.
Go to www.irs.gov/Form990 for the latest information.
| Return Reference | Explanation |
|---|---|
| Form 990, Part V, Line 1a | ALL APPLICABLE 1099 AND 1096 IRS TAX FORMS ARE REPORTED AND FILED BY THE PARENT ORGANIZATION, SSM HEALTH CARE CORPORATION, EIN 46-6029223. |
| Form 990, Part VI, Line 4 Significant changes to organizational documents | THE ORGANIZATION AMENDED ITS BYLAWS TO REDUCE THE NUMBER OF SPONSORING HOSPITALS, ALLOW SSM HEALTH ST. MARY'S HOSPITAL - MADISON TO APPOINT THREE DIRECTORS, CHANGE THE NUMBER OF DIRECTORS OF THE ORGANIZATION, AND ADJUST THE CONTRIBUTION PERCENTAGES OF THE REMAINING TWO SPONSORING HOSPITALS. |
| Form 990, Part VI, Line 6 Classes of members or stockholders | SSM HEALTH ST. CLARE HOSPITAL-BARABOO, BARABOO, WISCONSIN AND SSM HEALTH ST. MARY'S HOSPITAL-MADISON, MADISON, WISCONSIN ARE SPONSORING HOSPITALS OF THE ORGANIZATION AND HAVE THE RIGHT TO APPOINT MEMBERS OF THE GOVERNING BODY. FROM TIME TO TIME CONTRIBUTIONS OF CERTAIN ASSETS OF THE CORPORATION MAY BE MADE TO ITS SPONSORING HOSPITALS. UPON DISSOLUTION OF THE CORPORATION, ANY LIQUIDATING DISTRIBUTIONS OF THE CORPORATION'S ASSETS WILL BE MADE TO THE ORGANIZATION'S SPONSORING HOSPITALS. |
| Form 990, Part VI, Line 7a Members or stockholders electing members of governing body | THE BUSINESS AND AFFAIRS OF THE CORPORATION SHALL BE MANAGED BY ITS BOARD OF DIRECTORS. EACH OF THE SPONSORING HOSPITALS SHALL BE ENTITLED TO APPOINT ONE DIRECTOR EXCEPT ST. MARY'S HOSPITAL MEDICAL CENTER WHICH SHALL BE ENTITLED TO APPOINT TWO DIRECTORS. NOTICE OF THE NAME AND ADDRESS OF EACH APPOINTEE SHALL BE MADE BY THE SPONSORS TO THE SECRETARY OF THE ORGANIZATION. EACH DIRECTOR SERVES AT THE PLEASURE OF HIS OR HER APPOINTING SPONSOR AND MAY BE REMOVED AND REPLACED AT ANY TIME BY A WRITTEN NOTICE FROM THE APPOINTING SPONSOR TO THE SECRETARY OF THE CORPORATION. ONE POSITION ON THE BOARD OF DIRECTORS SHALL BE RESERVED FOR A VISITING NURSE SERVICE REPRESENTATIVE. ANY VACANCY IN THE REPRESENTATIVE POSITION SHALL BE FILLED BY THE BOARD IN THE FOLLOWING FASHION: THE SSM HEALTH AT HOME FOUNDATION OF WISCONSIN OR ANOTHER LOCAL NON-PROFIT ORGANIZATION SHALL PROPOSE A LIST OF THREE NOMINEES TO FILL THE VACANT POSITION. THE BOARD OF DIRECTORS SHALL SELECT A PERSON FROM THE LIST. |
| Form 990, Part VI, Line 8b Documentation of meetings held by committees of governing body | The organization does not have any committees with authority to act on behalf of the governing body. |
| Form 990, Part VI, Line 11b Review of form 990 by governing body | The Form 990 is prepared by the Tax Department of the parent organization, SSM Health Care Corporation (SSM). The Form 990 is reviewed by certain members of Senior Management. A copy of the Form 990 is provided to the Board of Directors prior to the filing of the Form 990 with the Internal Revenue Service. Any questions are addressed to the Tax Director of SSM prior to filing the Form 990 with the Internal Revenue Service. |
| Form 990, Part VI, Line 12c Conflict of interest policy | POTENTIAL CONFLICTS ARE MONITORED BASED BOTH ON RESPONSE AND ANNUALLY. ANY INDIVIDUAL WITH A PERCEIVED OR ACTUAL CONFLICT OF INTEREST WILL BE RECUSED FROM DISCUSSION AND VOTING ON THE SPECIFIC MATTER TO WHICH THE CONFLICT RELATES. |
| Form 990, Part VI, Line 15a Process to establish compensation of top management official | HOME HEALTH UNITED, HOME CARE UNITED, AND HHU XTRA CARE ARE ALL OPERATED BY A COMMON BOARD OF DIRECTORS AND MANAGEMENT. THE COMPENSATION OF THE PRESIDENT AND OTHER TOP MANAGEMENT PERSONNEL ARE DETERMINED BY MARKET ANALYSIS USING ORGANIZATIONS THAT COMPARE SALARY INFORMATION AMONG LIKE INDUSTRIES AND COMPARABLE SIZE. THE BOARD APPROVES THE PRESIDENT'S SALARY. |
| Form 990, Part VI, Line 15b Process to establish compensation of other employees | HOME HEALTH UNITED, HOME CARE UNITED, AND HHU XTRA CARE ARE ALL OPERATED BY A COMMON BOARD OF DIRECTORS AND MANAGEMENT. THE COMPENSATION OF THE PRESIDENT AND OTHER TOP MANAGEMENT PERSONNEL ARE DETERMINED BY MARKET ANALYSIS USING ORGANIZATIONS THAT COMPARE SALARY INFORMATION AMONG LIKE INDUSTRIES AND COMPARABLE SIZE. THE BOARD APPROVES THE PRESIDENT'S SALARY. |
| Form 990, Part VI, Line 19 Required documents available to the public | THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. |
| Form 990, Part VIII, Line 7d Realized gains/losses on Centralized Investment Program | Amounts reported on Form 990, Line 7d, include amounts allocated to the filing organization from a centralized investment program. |
| Form 990, Part X, Line 29 Adoption of ASC 958-205 | Effective for the 2018 calendar year, the organization has adopted ASC 958-205, which modifies how Not-for-Profit Entities present their net asset balances for Financial Statement reporting. The organization will report ending balances on Part X, Balance Sheet, in accordance with ASC 958-205 and include all amounts previous reported as temporarily restricted net assets and permanently restricted net assets on line 29. |
| Form 990, Part XI, Line 9 Other changes in net assets or fund balances | Change in beneficial interest of foundation - -140386; |
| Software ID: | 18007697 |
| Software Version: | 2018v3.1 |