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 | |||||
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Total |
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Calendar year
(or fiscal year beginning in)
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(a) 2019 | (b) 2020 | (c) 2021 | (d) 2022 | (e) 2023 | (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)
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(a) 2019 | (b) 2020 | (c) 2021 | (d) 2022 | (e) 2023 | (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) 2019 | (b) 2020 | (c) 2021 | (d) 2022 | (e) 2023 | (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)
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(a) 2019 | (b) 2020 | (c) 2021 | (d) 2022 | (e) 2023 | (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 on 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 2023 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-2023 |
(iii) Distributable Amount for 2023 |
|
|---|---|---|---|---|
| 1 Distributable amount for 2023 from Section C, line 6 | ||||
|
2
Underdistributions, if any, for years prior to 2023 (reasonable cause required-- explain in Part VI).
See instructions. |
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| 3 Excess distributions carryover, if any, to 2023: | ||||
| a From 2018....... | ||||
| b From 2019....... | ||||
| c From 2020....... | ||||
| d From 2021....... | ||||
| e From 2022....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2023 distributable amount | ||||
|
i
Carryover from 2018 not applied (see instructions) |
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| j Remainder. Subtract lines 3g, 3h, and 3i from line 3f. | ||||
| 4Distributions for 2023 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2023 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from line 4. | ||||
|
5
Remaining underdistributions for years prior to 2023, 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 2023. 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 2024. Add lines 3j and 4c. |
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| 8 Breakdown of line 7: | ||||
| a Excess from 2019..... | ||||
| b Excess from 2020..... | ||||
| c Excess from 2021..... | ||||
| d Excess from 2022..... | ||||
| e Excess from 2023..... | ||||
| Facts And Circumstances Test |
|---|
| Return Reference | Explanation |
|---|---|
| PART I LINE 3A: | NEBRASKA PEDIATRIC PRACTICE, INC. (NPP) HAS CHECKED LINE 3 ON THE SCHEDULE A AS THE IRS HAS RECOGNIZED NPP AS A TAX-EXEMPT HOSPITAL UNDER IRC SECTION 501(C)(3) AND AS A HOSPITAL UNDER IRC SECTION 170(B)(1)(A)(III). ALTHOUGH NPP HAS BEEN RECOGNIZED AS A HOSPITAL, IT DOES NOT OWN OR OPERATE A LICENSED HOSPITAL. THEREFORE, A SCHEDULE H HAS APPROPRIATELY NOT BEEN COMPLETED. |
| Software ID: | |
| Software Version: |
| Return Reference | Explanation |
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| FORM 990, PART VI, SECTION A, LINE 6 | THERE ARE TWO MEMBERS OF THE CORPORATION: (A) THE BOARD OF REGENTS OF THE UNIVERSITY OF NEBRASKA, A PUBLIC CORPORATE BODY, ACTING ON BEHALF OF THE UNIVERSITY OF NEBRASKA MEDICAL CENTER, COLLEGE OF MEDICINE (THE ACADEMIC MEMBER), AND (B) CHILDREN'S HOSPITAL AND MEDICAL CENTER, A NEBRASKA NONPROFIT CORPORATION (THE HOSPITAL MEMBER). THE MEMBERS RETAIN THE FOLLOWING POWERS, NOTWITHSTANDING ANYTHING IN THE BYLAWS TO THE CONTRARY: A. IN ACCORDANCE WITH THE BYLAWS, EACH MEMBER SHALL HAVE THE POWER TO APPOINT THREE CERTAIN DIRECTORS OF THE CORPORATION UNDER ARTICLE III, SECTION 2, AND REMOVE CERTAIN DIRECTORS OF THE CORPORATION UNDER ARTICLE II, SECTION 11. B. IN ACCORDANCE WITH THE BYLAWS, THE MEMBERS SHALL HAVE THE POWER TO APPROVE THE APPOINTMENT AND REMOVAL OF THE PERSON DESIGNATED BY THE BOARD OF DIRECTORS AS THE CORPORATION'S EXECUTIVE DIRECTOR. C. THE MEMBERS SHALL HAVE THE POWER TO APPROVE OR REFUSE TO APPROVE ANY AMENDMENT TO THE CORPORATION'S ARTICLES OF INCORPORATION OR THE BYLAWS, OR ANY ACTION REQUIRED TO BE SUBMITTED TO AND APPROVED BY VOTING MEMBERS OF A NONPROFIT CORPORATION UNDER THE NEBRASKA NONPROFIT CORPORATION ACT. D. THE FOLLOWING ACTIONS OF THE CORPORATION ARE SUBJECT TO APPROVAL BY THE MEMBERS: (I) ADOPTION AND ADJUSTMENT OF THE CORPORATIONS ANNUAL BUDGET, CAPITAL EXPENDITURES BUDGET, MISSION STATEMENT, OPERATING PLAN, AND LONG-RANGE PLAN; (II) INCURRENCE OF ASSUMPTION OF DEBT (OTHER THAN TRADE PAYABLES); (III) ADOPTION OF COMPENSATION PLANS; (IV) ASSESSMENTS AGAINST MEMBERS; (V) REORGANIZATION AND TRANSFER OF ASSETS OUTSIDE OF THE ORDINARY COURSE OF BUSINESS; (VI) ESTABLISHMENT OF A SUBSIDIARY OR PARTICIPATION AS A SHAREHOLDER, PARTNER, OR MEMBER OF ANY OTHER ENTITY; (VII) ANY DISTRIBUTION OF CAPITAL OR NET EARNINGS OF THE CORPORATION; (VIII) DISSOLUTION OF CORPORATION; AND (IX) ADMISSION OF NEW MEMBERS. THE AFFIRMATIVE APPROVAL OF BOTH MEMBERS IS NECESSARY FOR ANY ACTION OF THE MEMBERS. |
| FORM 990, PART VI, SECTION A, LINE 7A | SEE NARRATIVE ABOVE FOR FORM 990, PART VI, SECTION A, LINE 6. |
| FORM 990, PART VI, SECTION A, LINE 7B | SEE NARRATIVE ABOVE FOR FORM 990, PART VI, SECTION A, LINE 6. |
| FORM 990, PART VI, SECTION B, LINE 11B | THE FORM 990 WILL BE DISTRIBUTED VIA DIRECTOR'S DESK TO THE NEBRASKA PEDIATRIC PRACTICE BOARD MEMBERS FOR REVIEW 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 | AN OFFICER, DIRECTOR, COMMITTEE MEMBER (INCLUDING A MEMBER OF A BOARD-APPOINTED SUBCOMMITTEE), OR KEY EMPLOYEE SHALL BE DEEMED TO HAVE A POTENTIAL CONFLICT OF INTEREST IN A CONTRACT OR TRANSACTION IF HE OR SHE, OR A FAMILY MEMBER, IS A PARTY (OR ONE OF THE PARTIES) CONTRACTING OR DEALING WITH THE CORPORATION. ANY DUALITY OF INTEREST OR POTENTIAL CONFLICT OF INTEREST ON THE PART OF ANY OFFICER, DIRECTOR, COMMITTEE MEMBER, OR KEY EMPLOYEE SHOULD BE DISCLOSED TO THE GENERAL COUNSEL OR THE PRESIDENT OF THE PRACTICE PLAN, AND MADE A MATTER OF RECORD WHENEVER IT ARISES, OR WHENEVER IT INVOLVES A MATTER OF BOARD ACTION. ANY OFFICER, DIRECTOR, OR KEY EMPLOYEE HAVING A DUALITY OF INTEREST OR POSSIBLE CONFLICT OF INTEREST IN ANY MATTER SHOULD NOT VOTE OR USE HIS OR HER PERSONAL INFLUENCE ON THE MATTER. THE MAJORITY OF THE BOARD WHO HAVE NO CONFLICT OF INTEREST IN THE TRANSACTION COMPRISE A QUORUM FOR THE PURPOSE OF TAKING ACTION ON A CONFLICT TRANSACTION. IN CASES IN WHICH AN OFFICER, DIRECTOR, COMMITTEE MEMBER, OR KEY EMPLOYEE HAS A FINANCIAL INTEREST IN AN ARRANGEMENT OR TRANSACTION, THE FOLLOWING ADDITIONAL STEPS MAY BE TAKEN, AT THE DISCRETION OF THE BOARD: A. THE INTERESTED PERSON MAY BE REQUIRED TO LEAVE THE MEETING FOR THE GENERAL DISCUSSION OF THE MATTER AND THE BOARD VOTE; AND/OR B. A DISINTERESTED PERSON OR COMMITTEE MAY BE APPOINTED TO INVESTIGATE ALTERNATIVES TO THE PROPOSED AGREEMENT OR TRANSACTION. ALL OFFICERS, DIRECTORS, COMMITTEE MEMBERS, AND KEY EMPLOYEES SHALL REVIEW THE CONFLICT OF INTEREST POLICY AND COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE UPON INITIALLY AFFILIATING WITH THE CORPORATION. EACH YEAR AT AN ESTABLISHED TIME, A DESIGNATED PERSON WITHIN THE CORPORATION SHALL SEND DISCLOSURE QUESTIONNAIRES AND A COPY OF THE CONFLICT OF INTEREST POLICY TO ALL OFFICERS, DIRECTORS, COMMITTEE MEMBERS, AND KEY EMPLOYEES OF THE CORPORATION. PERSONS RECEIVING QUESTIONNAIRES SHALL RESPOND WITH RESPECT TO POTENTIAL CONFLICTS OF INTEREST. PERSONS REQUIRED TO REPORT WHO HAVE NOT RETURNED QUESTIONNAIRES WILL BE CONTACTED AND FOLLOW-UP WILL CONTINUE ON A REGULAR BASIS UNTIL ALL QUESTIONNAIRES HAVE BEEN RETURNED. THE INFORMATION WILL BE USED TO IDENTIFY AND RESOLVE POTENTIAL CONFLICTS OF INTEREST. THE GENERAL COUNSEL OR THE PRESIDENT OF THE PRACTICE PLAN SHALL SERVE AS THE CONFLICT REVIEW COMMITTEE, UNLESS, IN ITS DISCRETION, IT CHOOSES TO APPOINT A COMMITTEE COMPOSED OF DIRECTORS OF THE BOARD TO ASSUME THE RESPONSIBILITY. WHEN QUESTIONNAIRES OR INTERIM DISCLOSURES OF ANY OF THE MEMBERS OF THE CONFLICT REVIEW COMMITTEE ARE BEING REVIEWED, THE MEMBER BEING REVIEWED SHALL BE EXCUSED FROM THE COMMITTEE'S DELIBERATIONS AND ACTION. THE CONFLICT COMMITTEE SHALL: 1. REVIEW ALL ANNUAL DISCLOSURE QUESTIONNAIRES AND INTERIM SUPPLEMENTAL DISCLOSURES FROM PERSONS SUBJECT TO THE POLICY. 2. IDENTIFY POTENTIAL CONFLICTS OF INTEREST DISCLOSED IN SUCH ANNUAL DISCLOSURE QUESTIONNAIRES OR INTERIM DISCLOSURES. 3. INVESTIGATE AND EVALUATE, AS NECESSARY, POTENTIAL CONFLICTS OF INTEREST, CONTAINED IN ANNUAL DISCLOSURE QUESTIONNAIRES OR INTERIM DISCLOSURES. 4. REPORT FINDINGS, CONCLUSION, AND RECOMMENDATION OF THE BOARD FOR DECISION AND ACTION. 5. IDENTIFY, BY POSITION OR CAPACITY, THE EMPLOYEES OR OTHER INDIVIDUALS TO BE DESIGNATED AS KEY EMPLOYEES SUBJECT TO DISCLOSURE REQUIREMENTS UNDER THE POLICY. 6. KEEP COMPLETE RECORDS OF ITS ACTIVITIES. 7. PERIODICALLY REVIEW THE POLICY AND ITS IMPLEMENTATION PROCEDURES TO DETERMINE WHETHER ANY CHANGES ARE REQUIRED. |
| FORM 990, PART VI, SECTION B, LINE 15 | EACH YEAR, AN INDEPENDENT COMPANY CONDUCTS A MARKET ANALYSIS OF COMPENSATION, TO SUBSTANTIATE THE COMPENSATION OF THE PRESIDENT OF THE CORPORATION AS WELL AS THE PHYSICIANS. THIS INFORMATION IS PRESENTED TO THE COMPENSATION COMMITTEE OF THE HOSPITAL MEMBER'S BOARD OF DIRECTORS. THE INDEPENDENT COMPANY ISSUES AN ANNUAL REASONABLENESS OPINION LETTER REGARDING THE APPROPRIATENESS OF EXECUTIVE AND PHYSICIAN PAY LEVELS. THE HOSPITAL MEMBER'S BOARD OF DIRECTORS RECEIVES A REPORT FROM THE COMMITTEE. |
| FORM 990, PART VI, SECTION C, LINE 19 | GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE NOT AVAILABLE TO THE PUBLIC. |
| FORM 990, PART IX, LINE 11G | STAFF SUPPORT: PROGRAM SERVICE EXPENSES 21,362,365. MANAGEMENT AND GENERAL EXPENSES 3,456,902. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 24,819,267. CONTRACT PROVIDERS: PROGRAM SERVICE EXPENSES 10,118,327. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 10,118,327. BILLING FEES: PROGRAM SERVICE EXPENSES 4,689,398. MANAGEMENT AND GENERAL EXPENSES 19. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,689,417. RECRUITMENT: PROGRAM SERVICE EXPENSES 207,260. MANAGEMENT AND GENERAL EXPENSES 10,710. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 217,970. CONSULTING: PROGRAM SERVICE EXPENSES 36,366. MANAGEMENT AND GENERAL EXPENSES 188,036. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 224,402. OTHER: PROGRAM SERVICE EXPENSES 295,986. MANAGEMENT AND GENERAL EXPENSES 394,108. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 690,094. |
| FORM 990, PART XI, LINE 9: | SUPPORT FROM HOSPITAL MEMBER 70,228,185. |
| FORM 990, PART XI, LINE 9 | SUPPORT FROM HOSPITAL MEMBER FOR CASH FLOW - REASON FOR NO FUND BALANCE AT END OF YEAR: $70,228,185. |
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