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) 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. | ||||||
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 | ||||||
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.) | ||||||
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.).. | ||||||
| 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 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 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. |
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| 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) |
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| 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. |
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|
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. |
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|
7 Excess distributions carryover to 2020. Add lines 3j and 4c. |
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| 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..... | ||||
| 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 V, LINE 1C: PAYMENTS TO VENDORS | PAYMENTS TO VENDORS FOR ENTITIES THAT ARE PART OF COMMONSPIRIT HEALTH (CSH) ARE MADE BY CSH, THEREFORE NO FORM 1099'S ARE ISSUED BY ALEGENT CREIGHTON CLINIC. CSH FILES THE FORM 1099'S AND COMPLIES WITH THE BACKUP WITHHOLDING RULES FOR REPORTABLE PAYMENTS TO VENDORS AND GAMING WINNINGS. THE 1099'S ISSUED BY CSH ON BEHALF OF ALEGENT CREIGHTON CLINIC ARE REPORTED TO THE IRS. |
| FORM 990, PART VI, SECTION A, LINE 6 | THE SOLE MEMBER OF ALEGENT CREIGHTON CLINIC IS ALEGENT CREIGHTON HEALTH. |
| FORM 990, PART VI, SECTION A, LINE 7A | THE BOARD OF DIRECTORS SHALL BE APPOINTED BY ALEGENT CREIGHTON HEALTH AND SHALL CONSIST OF NO MORE THAN EIGHTEEN (18) DIRECTORS. ALEGENT CREIGHTON HEALTH SHALL CONSIDER THE SLATE OF THE NOMINATIONS SUBMITTED TO IT BY ALEGENT CREIGHTON CLINIC'S BOARD OF DIRECTORS. ALEGENT CREIGHTON CLINIC'S BOARD OF DIRECTORS SHALL SOLICIT NOMINATIONS FROM ALEGENT CREIGHTON CLINIC'S PHYSICIAN EMPLOYEES. |
| FORM 990, PART VI, SECTION A, LINE 7B | ALEGENT CREIGHTON HEALTH SHALL HAVE, IN ADDITION TO ALL RIGHTS AND POWERS GRANTED BY LAW WITH RESPECT TO THE GOVERNANCE OF ALEGENT CREIGHTON CLINIC, THE RIGHT TO: A. INITIATE AND APPROVE ANY AMENDMENTS TO THE ARTICLES OF INCORPORATION OR BYLAWS; B. INITIATE AND APPROVE PHYSICIAN COMPENSATION AND BENEFITS AND RECRUITMENT INCENTIVES; C. INITIATE AND APPROVE JOINT VENTURES IN WHICH ALEGENT CREIGHTON CLINIC PROPOSES TO PARTICIPATE, PURSUANT TO GUIDELINES ESTABLISHED FROM TIME TO TIME BY ALEGENT CREIGHTON HEALTH; D. APPOINT AND REMOVE, WITH OR WITHOUT CAUSE, ALL MEMBERS OF THE GOVERNING BOARD; E. APPROVE THE INCURRENCE OF ANY DEBT BY ALEGENT CREIGHTON CLINIC THAT IS IN EXCESS OF A THRESHOLD ESTABLISHED FROM TIME TO TIME BY ALEGENT CREIGHTON HEALTH; F. INITIATE AND APPROVE PHYSICIAN FEE SCHEDULES; G. INITIATE AND APPROVE THE MERGER OR CONSOLIDATION OF ALEGENT CREIGHTON CLINIC INTO OR WITH ANY OTHER CORPORATION, ORGANIZATION, OR ASSOCIATION; H. INITIATE AND APPROVE THE DISSOLUTION OR LIQUIDATION OF ALEGENT CREIGHTON CLINIC; I. APPROVE THE INCORPORATION OR DISSOLUTION OF AFFILIATED ENTITIES, ORGANIZATIONS, OR ASSOCIATIONS; J. INITIATE AND APPROVE THE SALE, LEASE, EXCHANGE, TRANSFER, OR OTHER DISPOSITION OF ALL OR SUBSTANTIALLY ALL OF THE PROPERTY, OTHER THAN IN THE USUAL AND REGULAR COURSE OF BUSINESS; K. INITIATE AND APPROVE THE MORTGAGE, PLEDGE, DEDICATION TO REPAYMENT OF INDEBTEDNESS, OR OTHER ENCUMBRANCE OF ANY OR ALL OF ALEGENT CREIGHTON CLINIC'S PROPERTY; L. APPROVE ANNUAL CAPITAL AND OPERATING BUDGETS AND ANY DEVIATIONS IN EXCESS OF A THRESHOLD ESTABLISHED FROM TIME TO TIME BY ANY MEMBER; AND M. APPROVE THE PURCHASE OF A MEDICAL PRACTICE. |
| FORM 990, PART VI, SECTION B, LINE 11B | FOLLOWING THE PREPARATION OF THE FORM 990 BY TAX ANALYSTS OF COMMONSPIRIT HEALTH (CSH), A RELATED ORGANIZATION, THE RETURN IS REVIEWED BY THE CSH TAX DIRECTOR AND THE LOCAL CHIEF FINANCIAL OFFICER. ADDITIONALLY, THE BOARD OF DIRECTORS ARE PROVIDED THE FINAL FORM 990 AND RELATED SCHEDULES TO REVIEW AND ARE ABLE TO ASK THE CHIEF FINANCIAL OFFICER AND TAX DIRECTOR QUESTIONS PRIOR TO FILING WITH THE IRS. UPON CHIEF FINANCIAL OFFICER APPROVAL AND SIGNATURE, THE TAX ANALYST FILES THE FINAL FORM 990 AS PRESENTED TO THE BOARD AND FINANCE COMMITTEE, MAKING ANY NON-SUBSTANTIVE CHANGES NECESSARY IN ORDER TO EFFECT E-FILING. ANY SUCH CHANGES ARE NOT RE-SUBMITTED TO THE BOARD. |
| FORM 990, PART VI, SECTION B, LINE 12C | THE ORGANIZATION HAS A CONFLICTS OF INTEREST ("COI") POLICY (THE "POLICY") IN PLACE TO MAINTAIN THE INTEGRITY OF ITS ACTIVITIES. THE POLICY APPLIES TO THE FOLLOWING PERSONS ("COVERED PERSONS"): MEMBERS OF THE COMMONSPIRIT HEALTH ("COMMONSPIRIT") BOARD OF STEWARDSHIP TRUSTEES AND ITS COMMITTEES; COMMONSPIRIT HEALTH CORPORATE OFFICERS; MEMBERS OF THE DIGNITY HEALTH BOARD OF STEWARDSHIP TRUSTEES AND ITS COMMITTEES. IN ADDITION, THE POLICY APPLIES TO ORGANIZATIONS THAT WERE AFFILIATES AND SUBSIDIARIES OF COMMONSPIRIT HEALTH PRIOR TO ITS AFFILIATION WITH DIGNITY HEALTH ("CHI ENTITIES"). COVERED PERSONS OF CHI ENTITIES INCLUDE: MEMBERS OF ANY CHI ENTITY DIRECT AFFILIATE OR SUBSIDIARY BOARD AND THEIR COMMITTEES; EMPLOYEES OF CHI ENTITIES; AND CHI ENTITY RESEARCHERS (AS DEFINED BY THE POLICY). DISCLOSURE, REVIEW AND MANAGEMENT OF PERCEIVED, POTENTIAL OR ACTUAL CONFLICTS OF INTEREST ARE ACCOMPLISHED THROUGH A DEFINED COI DISCLOSURE REVIEW PROCESS. ALL COVERED PERSONS ARE REQUIRED TO DISCLOSE ACTUAL OR POTENTIAL CONFLICTS AND MUST DISCLOSE THAT CONFLICT TO HIS/HER DIRECT MANAGER (OR OTHER PERSON AS IS APPROPRIATE PER POLICY). SUCH DISCLOSURE IS REQUIRED ON A TRANSACTIONAL BASIS AT THE TIME SUCH CONFLICTS ARISE, WHEN AN INDIVIDUAL BECOMES A COVERED PERSON (E.G. UPON HIRING OR BOARD APPOINTMENT), AND ANNUALLY THEREAFTER. DISCLOSURES OF PERCEIVED, POTENTIAL OR ACTUAL CONFLICTS ARE INITIALLY REVIEWED BY NATIONAL OR REGIONAL LEGAL OR CORPORATE RESPONSIBILITY TEAM MEMBERS TO DETERMINE WHETHER AN ACTUAL OR POTENTIAL CONFLICT MAY EXIST. IF IT IS DETERMINED THAT A POTENTIAL OR ACTUAL CONFLICT EXISTS, ISSUES ARE ELEVATED TO THE BOARD EXECUTIVE COMMITTEE OR BOARD CHAIR (FOR BOARD OR OFFICER CONFLICTS), OR THE CONFLICTS OF INTEREST REVIEW COMMITTEE (FOR ANY OTHER CONFLICT). THE PROCEDURES FOR ADDRESSING A CONFLICT RELATED TO A PROPOSED TRANSACTION IN THE CASE OF GOVERNING BODIES OR A CORPORATE OFFICER INCLUDE, BUT ARE NOT LIMITED TO 1) DISCLOSURE TO THE BOARD, 2) THE TRUSTEE OR CORPORATE OFFICER BEING EXCUSED FROM THE MEETING DURING DISCUSSION AND VOTE ON THE CONFLICT OF INTEREST (ALTHOUGH HE OR SHE MAY RESPOND TO PERTINENT QUESTIONS IF THE KNOWLEDGE IS RELEVANT), AND 3) BOARD APPROVAL OF THE TRANSACTION BY A MAJORITY OF DISINTERESTED MEMBERS. IN ADDITION, BOARDS CAREFULLY REVIEW AND SCRUTINIZE ANY NON-TRANSACTIONAL CONFLICTS OF INTEREST. IN SUCH CIRCUMSTANCES, BY A MAJORITY VOTE OF THE DISINTERESTED TRUSTEES, THE BOARD TAKES WHATEVER ACTION IS DEEMED APPROPRIATE. FOR CONFLICTS NOT INVOLVING A BOARD MEMBER OR OFFICER, THE CONFLICTS OF INTEREST REVIEW COMMITTEE ("C-CIRC") WILL FACILITATE A COI MANAGEMENT PLAN TO MITIGATE THE CONFLICT IF ADEQUATE CONTROLS AREN'T ALREADY IN PLACE. NOTWITHSTANDING THE FOREGOING, AT ITS SOLE DISCRETION, AN ENTITY MAY REJECT A PERSON'S REQUEST TO ENTER INTO THE RELATIONSHIP IN QUESTION, OR REQUIRE THE RELATIONSHIP BE SUFFICIENTLY ALTERED TO AVOID A POTENTIAL CONFLICT OF INTEREST. |
| FORM 990, PART VI, SECTION B, LINE 15B | SEE DISCLOSURE FOR FORM 990, PART VI, SECTION B, LINE 15A. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE ORGANIZATION'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE AVAILABLE TO THE PUBLIC UPON REQUEST. IN ADDITION, THE ARTICLES OF INCORPORATION ARE AVAILABLE ON THE NEBRASKA SECRETARY OF STATE WEBSITE AT HTTP://WWW.SOS.NE.GOV/BUSINESS. THE ORGANIZATION'S FINANCIAL STATEMENTS ARE INCLUDED IN COMMONSPIRIT HEALTH'S CONSOLIDATED AUDITED FINANCIAL STATEMENTS THAT ARE AVAILABLE AT WWW.COMMONSPIRIT.ORG. |
| FORM 990, PART VI, LINE 15A: TOP MANAGEMENT OFFICIAL COMPENSATION | THE ORGANIZATION'S TOP MANAGEMENT OFFICIAL'S COMPENSATION WAS PAID BY COMMONSPIRIT HEALTH, A RELATED ORGANIZATION. THE COMMONSPIRIT HEALTH BOARD OF STEWARDSHIP TRUSTEES APPOINTS A HUMAN RESOURCES AND COMPENSATION COMMITTEE, COMPRISED EXCLUSIVELY OF INDEPENDENT DIRECTORS, WHO ARE ACCOUNTABLE FOR APPROVING REASONABLE COMPENSATION PACKAGES FOR EACH OFFICER AND CERTAIN KEY EMPLOYEES (INCLUDING THE PRESIDENT/CEO). THE HUMAN RESOURCES AND COMPENSATION COMMITTEE APPROVES, CONSISTENT WITH THE ORGANIZATION'S PHILOSOPHY AND PRINCIPLES, THE ANNUAL PERFORMANCE GOALS AND CRITERIA TO BE USED IN DETERMINING MERIT INCREASES AND VARIABLE COMPENSATION CRITERIA FOR OFFICERS AND KEY EXECUTIVES. THE HUMAN RESOURCES AND COMPENSATION COMMITTEE ALSO ENGAGES OUTSIDE LEGAL COUNSEL AS NECESSARY AND QUALIFIED INDEPENDENT COMPENSATION AND BENEFITS SPECIALISTS (INDEPENDENT EXPERTS) TO REVIEW, ANALYZE AND PROVIDE BENCHMARKING DATA FOR THE TOTAL COMPENSATION AND BENEFITS PACKAGES OF OFFICERS AND KEY EXECUTIVES. APPROPRIATE COMPARABLE DATA IS OBTAINED FROM THE INDEPENDENT EXPERTS, (E.G., TOTAL ECONOMIC BENEFITS PAID BY SIMILARLY SITUATED ORGANIZATIONS, BOTH TAXABLE AND TAX-EXEMPT, FOR SIMILAR JOB RESPONSIBILITIES). KEY DELIBERATIONS OF THE COMMITTEE ARE DOCUMENTED IN MEETING MINUTES WHICH ARE APPROVED AT THE NEXT COMMITTEE MEETING AND PROVIDED TO THE BOARD OF STEWARDSHIP TRUSTEES. THE DOCUMENTATION OF THE DELIBERATIONS INCLUDES (A) THE TERMS OF THE AGREEMENT APPROVED AND THE DATE APPROVED; (B) THE MEMBERS OF THE COMMITTEE WHO WERE PRESENT DURING DISCUSSION OF THE APPROVED AGREEMENT AND THOSE WHO VOTED ON IT; AND (C) THE COMPARABILITY DATA OBTAINED AND RELIED UPON BY THE COMMITTEE AND HOW THE DATA WAS OBTAINED. FOR OTHER MEMBERS OF MANAGEMENT WHO WERE PAID UNDER ALEGENT CREIGHTON HEALTH FOR CALENDAR YEAR 2019, ALEGENT CREIGHTON HEALTH HUMAN RESOURCES COMPLETES A COMPENSATION MARKET STUDY TO DETERMINE SALARY. |
| FORM 990, PART XI, LINE 9: | ASC 842 ADJUSTMENT -192,384. OTHER CHANGES IN NET ASSETS -376. |
| SCHEDULE A, PART I, LINE 3: SCHEDULE H NOT REQUIRED | ALEGENT CREIGHTON CLINIC IS RECOGNIZED AS A HOSPITAL BY THE INTERNAL REVENUE SERVICE UNDER IRC SECTION 170(B)(1)(A)(III). HOWEVER, ALEGENT CREIGHTON CLINIC DOES NOT CURRENTLY OPERATE ANY LICENSED HOSPITAL FACILITIES; THEREFORE, NO SCHEDULE H IS REQUIRED. |
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