Attach to Form 990 or Form 990-EZ.
Go to
www.irs.gov/Form990 for instructions and 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) 2016 | (b) 2017 | (c) 2018 | (d) 2019 | (e) 2020 | (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) 2016 | (b) 2017 | (c) 2018 | (d) 2019 | (e) 2020 | (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) 2016 | (b) 2017 | (c) 2018 | (d) 2019 | (e) 2020 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") . | 10,936 | 50,939 | 31,971 | 28,659 | 22,837 | 145,342 |
| 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 | 41,950,175 | 44,022,327 | 47,652,509 | 49,812,237 | 48,730,695 | 232,167,943 |
| 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 | 41,961,111 | 44,073,266 | 47,684,480 | 49,840,896 | 48,753,532 | 232,313,285 |
| 7a | Amounts included on lines 1, 2, and 3 received from disqualified persons | 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 | |||||
| c | Add lines 7a and 7b.. | 0 | |||||
| 8 | Public support. (Subtract line 7c from line 6.) | 232,313,285 | |||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2016 | (b) 2017 | (c) 2018 | (d) 2019 | (e) 2020 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | 41,961,111 | 44,073,266 | 47,684,480 | 49,840,896 | 48,753,532 | 232,313,285 |
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | 444 | 961 | 3,797 | 1,476 | 6,678 | |
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | ||||||
| c | Add lines 10a and 10b. | 444 | 961 | 3,797 | 1,476 | 6,678 | |
| 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.).. | 41,961,111 | 44,073,710 | 47,685,441 | 49,844,693 | 48,755,008 | 232,319,963 |
| 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) |
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| 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): |
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| 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 0.015 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 0.035 | 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 | 1 | |
|
2
Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity |
2 | |
| 3 Administrative expenses paid to accomplish exempt purposes of supported organizations | 3 | |
| 4 Amounts paid to acquire exempt-use assets | 4 | |
| 5 Qualified set-aside amounts (prior IRS approval required - provide details in Part VI) | 5 | |
| 6 Other distributions (describe in Part VI). See instructions | 6 | |
| 7Total annual distributions. Add lines 1 through 6. | 7 | |
|
8
Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions |
8 | |
| 9 Distributable amount for 2020 from Section C, line 6 | 9 | |
| 10 Line 8 amount divided by Line 9 amount | 10 | |
| Section E - Distribution Allocations (see instructions) |
(i) Excess Distributions |
(ii) Underdistributions Pre-2020 |
(iii) Distributable Amount for 2020 |
|
|---|---|---|---|---|
| 1 Distributable amount for 2020 from Section C, line 6 | ||||
|
2
Underdistributions, if any, for years prior to 2019 (reasonable cause required-- explain in Part VI). See instructions. |
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| 3 Excess distributions carryover, if any, to 2020: | ||||
| a From 2015....... | ||||
| b From 2016....... | ||||
| c From 2017....... | ||||
| d From 2018....... | ||||
| e From 2019....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2020 distributable amount | ||||
|
i
Carryover from 2015 not applied (see instructions) |
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| j Remainder. Subtract lines 3g, 3h, and 3i from line 3f. | ||||
| 4Distributions for 2020 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2020 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from line 4. | ||||
|
5
Remaining underdistributions for years prior to 2020, 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 2020. 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 2021. Add lines 3j and 4c. |
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| 8 Breakdown of line 7: | ||||
| a Excess from 2016..... | ||||
| b Excess from 2017..... | ||||
| c Excess from 2018..... | ||||
| d Excess from 2019..... | ||||
| e Excess from 2020..... | ||||
| Facts And Circumstances Test |
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| Return Reference | Explanation |
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| Software ID: | |
| Software Version: |
Attach to Form 990 or 990-EZ.
Go to www.irs.gov/Form990 for the latest information.
| Return Reference | Explanation |
|---|---|
| FORM 990, PART VI, SECTION A, LINE 6 | CHILDREN'S PHYSICIANS' HAS A SINGLE CORPORATE MEMBER, CHILDREN'S HOSPITAL & MEDICAL CENTER. |
| FORM 990, PART VI, SECTION A, LINE 7A | CHILDREN'S PHYSICIANS' HAS A SINGLE CORPORATE MEMBER, CHILDREN'S HOSPITAL & MEDICAL CENTER. |
| FORM 990, PART VI, SECTION A, LINE 7B | THE ACTIONS LISTED BELOW REQUIRE THE APPROVAL OF THE MEMBER: RESERVED POWERS OF MEMBER. NOTWITHSTANDING ANYTHING IN THESE BYLAWS TO THE CONTRARY, THE CONSENT OF THE MEMBER (ACTING BY AND THROUGH THE HOSPITAL DESIGNEE) SHALL BE REQUIRED TO APPROVE THE FOLLOWING ACTIONS OF THE BOARD OF DIRECTORS: A. APPROVAL OF AMENDMENTS. THE MEMBER SHALL HAVE THE POWER TO APPROVE OR REFUSE TO APPROVE ANY AMENDMENT TO THE CORPORATION'S ARTICLES OF INCORPORATION OR TO THESE BYLAWS. B. APPROVAL OF ITEMS REQUIRED BY NEBRASKA NONPROFIT CORPORATION ACT. THE MEMBER SHALL HAVE THE POWER TO APPROVE OR REFUSE TO APPROVE ANY MERGER, REORGANIZATION, OR CONSOLIDATION; ANY SALE, LEASE, OR TRANSFER OF ASSETS OUTSIDE OF THE ORDINARY COURSE; ANY DISSOLUTION; OR ANY OTHER ACTION REQUIRED TO BE SUBMITTED TO AND APPROVED BY THE VOTING MEMBERS OF A NONPROFIT CORPORATION PURSUANT TO THE NEBRASKA NONPROFIT CORPORATION ACT. C. ELECTION AND REMOVAL OF DIRECTORS. IN ACCORDANCE WITH THESE BYLAWS, THE MEMBER SHALL HAVE THE POWER TO APPOINT CERTAIN DIRECTORS OF THE CORPORATION UNDER ARTICLE III, SECTION 2, AND REMOVE CERTAIN DIRECTORS OF THE CORPORATION UNDER ARTICLE III, SECTION 11. D. APPROVAL OF OTHER CERTAIN ACTIONS. THE FOLLOWING ACTIONS OF THE CORPORATION ARE SUBJECT TO APPROVAL BY THE MEMBER: (1) ADOPTION AND ADJUSTMENT OF THE CORPORATION'S ANNUAL BUDGET, OPERATING PLAN, AND LONG-RANGE PLAN; (2) INCURRENCE OR ASSUMPTION OF DEBT (OTHER THAN TRADE PAYABLES); (3) ADOPTION OF COMPENSATION PLANS; (4) ANY DISTRIBUTIONS OF CAPITAL OR NET EARNINGS OF THE CORPORATION; (5) ESTABLISHMENT OF A SUBSIDIARY OR PARTICIPATION AS A SHAREHOLDER, PARTNER, MEMBER, OR OTHER PARTICIPANT OF ANY OTHER ENTITY OR JOINT VENTURE; AND (6) ADMISSION OF NEW MEMBERS. |
| FORM 990, PART VI, SECTION B, LINE 11B | THE FORM 990 WILL BE DISTRIBUTED ELECTRONICALLY TO CHILDREN'S PHYSICIANS' BOARD MEMBERS FOR REVIEW VIA DIRECTOR'S DESK PRIOR TO FILING WITH THE IRS. HOWEVER, SINCE ALL COMPENSATION INFORMATION WILL BE REDACTED FROM THE COPY SENT TO THE BOARD, THE TAXPAYER IS ANSWERING THE QUESTION ON PART VI, LINE 11A "NO". |
| FORM 990, PART VI, SECTION B, LINE 12C | THE CONFLICT OF INTEREST POLICY APPLIES TO ANY PERSON IN A POSITION TO EXERCISE INFLUENCE IN CONNECTION WITH ANY CONTRACT, TRANSACTION OR ARRANGEMENT PRESENTED TO THE BOARD OF DIRECTORS OR A BOARD COMMITTEE FOR APPROVAL (INTERESTED PERSON). THIS INCLUDES, BUT IS NOT LIMITED TO, ANY DIRECTOR, OFFICER, OR MEMBER OF A COMMITTEE WITH BOARD-DESIGNATED POWERS. EACH INTERESTED PERSON HAS THE OBLIGATION TO ANNUALLY SUBMIT A COMPLETED CONFLICTS OF INTEREST QUESTIONNAIRE AND HAS A CONTINUING OBLIGATION TO DISCLOSE ANY POTENTIAL CONFLICT OF INTEREST PROMPTLY. EACH INTERESTED PERSON SIGNS ANNUALLY AN ACKNOWLEDGMENT THAT STATES THAT THE INTERESTED PERSON HAS RECEIVED, READ AND UNDERSTANDS THE CONFLICT OF INTEREST POLICY, AGREES TO COMPLY WITH THE POLICY; UNDERSTANDS THAT THE POLICY APPLIES TO THE BOARD OF DIRECTORS AND COMMITTEES; UNDERSTANDS THAT CHILDREN'S PHYSICIANS IS A NOT-FOR-PROFIT ORGANIZATION THAT MUST ENGAGE PRIMARILY IN EXEMPT ACTIVITIES; AGREES TO REPORT TO THE COMPLIANCE OFFICER ANY CHANGE TO MATTERS PREVIOUSLY DISCLOSED ON THE CONFLICTS OF INTEREST QUESTIONNAIRE; STATES THAT THE INFORMATION PROVIDED IN THE CONFLICTS OF INTEREST QUESTIONNAIRE IS TRUE AND ACCURATE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF. THE GOVERNANCE COMMITTEE REVIEWS EACH COMPLETED CONFLICTS OF INTEREST QUESTIONNAIRE TO DETERMINE IF ANY FURTHER INVESTIGATION OF POTENTIAL CONFLICTS IS NECESSARY. WHEN A POTENTIAL CONFLICT IS VOLUNTARILY IDENTIFIED BY AN INTERESTED PERSON OR THROUGH DISCLOSURE BY ANOTHER PERSON, THE REMAINING BOARD/COMMITTEE MEMBERS REVIEW THE MATTER AND DETERMINE WHETHER A CONFLICT OF INTEREST EXISTS. ONLY DISINTERESTED BOARD/COMMITTEE MEMBERS MAY VOTE TO DETERMINE WHETHER A CONFLICT EXISTS. THE INTERESTED PERSON IN QUESTION CANNOT BE PRESENT DURING THE VOTE. IF A CONFLICT OF INTEREST EXISTS, THE DISINTERESTED BOARD/COMMITTEE MEMBERS DETERMINE WHETHER A MORE ADVANTAGEOUS CONTRACT, TRANSACTION OR ARRANGEMENT SHOULD BE OBTAINED. WHEN CONSIDERING WHETHER TO ENTER INTO THE PROPOSED CONTRACT, TRANSACTION, OR ARRANGEMENT, ONLY DISINTERESTED BOARD/COMMITTEE MEMBERS CAN VOTE TO DETERMINE IF IT IS IN THE BEST INTEREST OF CHILDREN'S PHYSICIANS AND FOR CHILDREN'S PHYSICIANS OWN BENEFIT. THE INTERESTED PERSON MAY BE REQUIRED TO LEAVE THE ROOM WHEN THE MATTER IS VOTED ON. ONLY DISINTERESTED BOARD/COMMITTEE MEMBERS MAY VOTE ON THE MATTER. FAILURE TO COMPLY WITH THE CONFLICT OF INTEREST POLICY MAY RESULT IN REMOVAL FROM THE BOARD. |
| FORM 990, PART VI, SECTION B, LINE 15 | EACH YEAR AN INDEPENDENT COMPANY (SULLIVAN COTTER) CONDUCTS A MARKET ANALYSIS OF THE EXECUTIVE COMPENSATION. THIS INFORMATION IS PRESENTED TO CHILDREN'S HOSPITAL & MEDICAL CENTER'S COMPENSATION COMMITTEE, WHICH IS A SUB-COMMITTEE OF THE BOARD OF DIRECTORS. SULLIVAN COTTER ISSUES AN ANNUAL REASONABLENESS OPINION LETTER REGARDING THE APPROPRIATENESS OF EXECUTIVE PAY LEVELS. THE COMPENSATION COMMITTEE REVIEWS BASE PAY CHANGES FOR CHILDREN'S PHYSICIANS' PRESIDENT. THE BOARD OF DIRECTORS RECEIVES A REPORT FROM THE COMMITTEE. |
| FORM 990, PART VI, SECTION C, LINE 19 | GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT AVAILABLE TO THE PUBLIC. CHILDREN'S HOSPITAL & MEDICAL CENTER AND AFFILIATES AUDITED FINANCIAL STATEMENTS CAN BE OBTAINED IN ADMINISTRATION. |
| Software ID: | |
| Software Version: |