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.") . | ||||||
| 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) 2016 | (b) 2017 | (c) 2018 | (d) 2019 | (e) 2020 | (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 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, BOX B, AMENDED RETURN | THE ORGANIZATION MADE THE FOLLOWING AMENDMENTS TO THIS RETURN: 1. PART IV, LINE 26, CHECKED YES DUE TO CAP-EX (SPLIT DOLLAR LIFE INSURANCE ARRANGEMENT) 2. PART X, LINE 5, 15, DUE TO RECLASS OF CAP-EX (SPLIT DOLLAR LIFE INSURANCE ARRANGEMENT) 3. SCHEDULE J, PART III, INCLUDED CAP-EX (SPLIT DOLLAR LIFE INSURANCE ARRANGEMENT) NARRATIVE 4. SCHEDULE L, PART II, INCLUDED CAP-EX (SPLIT DOLLAR LIFE INSURANCE ARRANGEMENT) 5. SCHEDULE L, PART V, INCLUDED CAP-EX (SPLIT DOLLAR LIFE INSURANCE ARRANGEMENT) NARRATIVE |
| FORM 990, PART VI, SECTION A, LINE 4 | THE ORGANIZATION IS INCLUDED IN CONSOLIDATED BYLAWS FOR VALLEY HEALTH SYSTEM, INC., THE VALLEY HOSPITAL, INC., AND VALLEY PHYSICIAN SERVICES, INC. IN APRIL 2020, THE BYLAWS WERE AMENDED TO INCLUDE AN ARTICLE FOR CRISIS STANDARDS OF CARE (CSC) AND AMENDMENTS TO THE BYLAWS DURING CSC DUE TO A PERVASIVE OR CATASTROPHIC DISASTER (I.E. THE COVID-19 PANDEMIC). THE CRISIS STANDARD OF CARE BYLAWS PROVISIONS INCLUDE THE FOLLOWING DURING THE CSC: THE PERMITTED NUMBER OF TRUSTEES WAS AMENDED TO BE NO FEWER THAN NINE. THE EXECUTIVE COMMITTEE WAS ALLOWED TO ACT ON BEHALF OF THE FULL BOARD UNTIL THE BOARD IS ABLE TO ACT OR OTHERWISE EXERCISE ITS POWERS. THE BOARD DELEGATES FINAL APPROVAL OF MEDICAL STAFF PRIVILEGES TO THE PRESIDENT & CEO OF THE HOSPITAL. THE BOARD EMPOWERS MANAGEMENT TO CHANGE POLICIES AND PROCEDURES AS IT DEEMS NECESSARY. THE EXECUTIVE COMMITTEE OF THE MEDICAL STAFF DELEGATES APPROVAL OF MEDICAL STAFF PRIVILEGE CHANGES AND TEMPORARY PRIVILEGES TO THE PRESIDENT OF THE MEDICAL STAFF OR DESIGNEE. |
| FORM 990, PART VI, SECTION A, LINE 6 | THE ORGANIZATION'S SOLE MEMBER IS VALLEY HEALTH SYSTEM, INC. |
| FORM 990, PART VI, SECTION A, LINE 7A | THE ORGANIZATION'S SOLE MEMBER HAS THE RIGHT TO NOMINATE, ELECT, AND REMOVE THE MEMBERS OF THE ORGANIZATION'S GOVERNING BODY. |
| FORM 990, PART VI, SECTION A, LINE 7B | THE FOLLOWING DECISIONS OF THE ORGANIZATION ARE RESERVED TO THE ORGANIZATION'S SOLE MEMBER: TO DETERMINE THE NUMBER OF TRUSTEES ON THE BOARD TO AMEND, REVISE OR RESTATE THE CORPORATION'S CERTIFICATE OF INCORPORATION AND BYLAWS, AND TO APPROVE ALL AMENDMENTS OR REVISIONS TO THE CORPORATION'S CERTIFICATE OF INCORPORATION AND BYLAWS THAT MAY BE PROPOSED OR APPROVED BY THE BOARD BEFORE THEY BECOME EFFECTIVE; TO ADOPT OR CHANGE THE MISSION, PURPOSE, PHILOSOPHY OR OBJECTIVES OF THE CORPORATION; TO CHANGE THE LEGAL STRUCTURE OF THE CORPORATION; TO COMMIT TO ADD OR THE ADDITION OF ANOTHER HOSPITAL OR HEALTH SYSTEM TO THE CORPORATION; TO DISSOLVE, DIVIDE, CONVERT OR LIQUIDATE THE CORPORATION, TO CONSOLIDATE OR MERGE THE CORPORATION WITH ANOTHER CORPORATION OR ENTITY, TO SELL ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF THE CORPORATION, TO CAUSE THE CORPORATION TO ACQUIRE SUBSTANTIALLY ALL OF THE ASSETS OF ANOTHER CORPORATION OR ENTITY, AND TO APPROVE ANY OF THE FOREGOING ACTIONS THAT ARE RECOMMENDED BY THE BOARD BEFORE SUCH ACTION BECOMES EFFECTIVE; TO APPROVE THE ANNUAL CAPITAL AND OPERATING BUDGETS OF THE CORPORATION AND ANY AMENDMENTS THERETO; TO INITIATE AND TO APPROVE THE INCURRENCE OF DEBT BY THE CORPORATION OR TO IMPLEMENT ANY FINANCING STRATEGY, INCLUDING WITHOUT LIMITATION IN CONNECTION WITH ANY DEBT ISSUANCE, CAPITAL OR OPERATING LEASING TRANSACTIONS, AND TAXABLE AND NONTAXABLE FINANCINGS; TO APPROVE THE INCURRENCE OF DEBT BY THE CORPORATION IN EXCESS OF THOSE THRESHOLDS ESTABLISHED BY THE BOARD, IF SUCH INCURRENCE OF DEBT IS NOT INCLUDED IN THE CORPORATION'S APPROVED BUDGETS, WHETHER IN A SINGLE TRANSACTION OR A SERIES OF RELATED TRANSACTIONS; TO CAUSE OR DIRECT THE CORPORATION TO PAY, LOAN OR OTHERWISE TRANSFER SUCH FUNDS AS ARE NECESSARY TO PAY ANY OUTSTANDING INDEBTEDNESS OBLIGATIONS, INCLUDING BUT NOT LIMITED TO BORROWINGS, GUARANTIES, NON-RECOURSE INDEBTEDNESS, LEASES, AND DERIVATIVE INSTRUMENTS, CREATED OR APPROVED BY THE CORPORATION; TO EXERCISE SUCH OVERSIGHT, INCLUDING INITIATING ACTION OR APPROVING ACTION BY THE CORPORATION, OVER THE MANAGEMENT, POLICIES, DISPOSITION OR ENCUMBRANCE OF ASSETS, INCLUDING REAL OR PERSONAL PROPERTY, OF THE CORPORATION TO CAUSE OR ENSURE COMPLIANCE WITH TERMS AND CONDITIONS OF INDEBTEDNESS OBLIGATIONS AND FINANCIAL RELATIONSHIPS RELATED IN ANY MANNER TO SUCH INDEBTEDNESS; TO APPROVE THE CAPITAL EXPENDITURES BY THE CORPORATION IN EXCESS OF THOSE THRESHOLDS ESTABLISHED BY THE BOARD, IF SUCH CAPITAL EXPENDITURES ARE NOT INCLUDED IN THE CORPORATION'S APPROVED BUDGETS, WHETHER IN A SINGLE TRANSACTION OR A SERIES OF RELATED TRANSACTIONS; TO APPROVE ANY DONATION OR ANY OTHER TRANSFER OF THE CORPORATION'S ASSETS, OTHER THAN TO AN AFFILIATED ENTITY, IN EXCESS OF AN AMOUNT EQUAL TO OR GREATER THAN THE THRESHOLDS ESTABLISHED BY THE BOARD FOR SUCH CORPORATION, UNLESS SPECIFICALLY AUTHORIZED IN THE CORPORATION'S APPROVED BUDGETS; TO SELECT AND APPOINT AUDITORS OF THE CORPORATION; TO INITIATE AND APPROVE STRATEGIC PLANS AND MISSION STATEMENTS OF THE CORPORATION; TO INITIATE AND APPROVE INVESTMENT POLICIES AND CAPITAL CAMPAIGNS OF THE CORPORATION; TO INITIATE AND APPROVE THE CLOSURE OR RELOCATION OF A LICENSED HEALTH CARE FACILITY OF THE CORPORATION; TO INITIATE AND APPROVE THE FORMATION OF SUBSIDIARIES OF THE CORPORATION; TO APPROVE THE CORPORATION'S ACQUISITION OF CONTROLLING INTERESTS IN ORGANIZATIONS OR BUSINESSES OUTSIDE OF THE CORPORATION'S APPROVED STRATEGIC PLAN; TO THE EXTENT NOT EXPRESSLY SET FORTH ABOVE, TO DIRECT OR REQUIRE THE CORPORATION TO TAKE ANY OTHER LAWFUL ACTS OR ACTIONS WITH RESPECT TO THE CORPORATION'S BUSINESS, AFFAIRS, MANAGEMENT, PROPERTIES OR ACTIVITIES THAT THE SOLE MEMBER MAY DIRECT. |
| FORM 990, PART VI, SECTION B, LINE 11B | THE VALLEY HOSPITAL HAS ITS FORM 990 PREPARED BY AN OUTSIDE ACCOUNTING FIRM AND HAS ESTABLISHED THE FOLLOWING REVIEW PROCESS TO ENSURE THAT THE INFORMATION REPORTED IS COMPLETE AND ACCURATE. WHEN THE FORM 990 IS PREPARED, IT IS SUBMITTED TO MANAGEMENT AND THE AUDIT COMMITTEE FOR REVIEW. ANY COMMENTS ARE SUMMARIZED AND PROVIDED TO THE DIRECTOR OF FINANCE. EACH ISSUE IS DOCUMENTED AND ADDRESSED UNTIL THE RETURN IS FINALIZED AND APPROVED BY THE AUDIT COMMITTEE FOR FILING WITH THE INTERNAL REVENUE SERVICE. BEFORE FILING, THE FORM 990 IS MADE AVAILABLE FOR THE BOARD'S REVIEW, BY HARD COPY AND OR ELECTRONIC COPY. |
| FORM 990, PART VI, SECTION B, LINE 15 | THE ORGANIZATION'S BOARD IS A SHARED BOARD WITH THE VALLEY HEALTH SYSTEM. THE VALLEY HEALTH SYSTEM HAS DEVELOPED A COMPENSATION PLAN, WHICH GOVERNS THE COMPENSATION FOR ALL EXECUTIVES, INCLUDING THE CEO AND VICE PRESIDENTS OF THE ORGANIZATION. THE PLAN WAS DEVELOPED IN CONJUNCTION WITH A CONSULTING FIRM, REVIEWED BY THE PHYSICIAN LEADERSHIP COUNCIL AND APPROVED BY THE BOARD OF TRUSTEES AND THE VALLEY HEALTH SYSTEM PHYSICIAN COMPENSATION COMMITTEE. ON AN ANNUAL BASIS, THE PLAN IS REVIEWED AND UPDATED AS NEEDED. THIS PROCESS WAS LAST UNDERTAKEN IN 2020. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE HOSPITAL MAKES ITS FORM 990 AVAILABLE FOR PUBLIC INSPECTION AS REQUIRED UNDER SECTION 6104 OF THE INTERNAL REVENUE CODE BY POSTING OF THE RETURN ON GUIDESTAR.ORG AND SIMILAR TYPES OF WEBSITES. IN ADDITION FORM 990 AS WELL AS THE FINANCIAL STATEMENTS AND CONFLICT OF INTEREST POLICY AND OTHER RELEVENT DOCUMENTS ARE AVAILABLE UPON REQUEST. |
| FORM 990, PART XI, LINE 9: | NET ASSETS RELEASED FOR OPERATING PURPOSES 85,858. CHANGE IN ASSETS HELD BY RELATED ORGANIZATION -4,268,460. CHANGE IN ACCRUED PENSION LIABILITY TO BE RECOGNIZED IN FUTURE PERIODS 81,344,105. NET LOSS ON DISPOSITION OF ASSETS -533,171. |
| FORM 990, PART XII, LINE 2C: | THE PROCESS FOR SELECTING AN INDEPENDENT ACCOUNTANT AND ESTABLISHING A COMMITTEE THAT ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT HAS NOT CHANGED FROM PRIOR YEARS. |
| Software ID: | |
| Software Version: |