2016-08-12T13:45:22-05:00 2015-09-30 930623286 AKT LLP 5665 SW MEADOWS RD SUITE 200 LAKE OSWEGO OR 97035 990 2014-10-01 237002687 SALEM HOSPITAL FOUNDATION SALE 5038141938 890 OAK STREET SE SALEM OR 97301 LEILANI SLAMA DIRECTOR OF DEVELOPMENT 5038141938 2016-08-09 1 JOYLYN M ANKENEY CPA P00366587 5036204489 2016-08-08 2014 2016-09-27 15:27:22Z LEILANI SLAMA 890 OAK STREET SE SALEM OR 97301 1909207 0 X WWW.SALEMHEALTH.ORG/FOUNDATION X 1968 OR DEDICATED TO RAISING, MANAGING AND DISTRIBUTING FUNDS TO HELP SALEM HOSPITAL ACHIEVE ITS MISSION OF IMPROVING THE HEALTH AND WELL-BEING OF THE PEOPLE AND COMMUNITY IT SERVES. 15 15 0 15 0 0 1326357 1356871 0 0 401835 472913 50633 55955 1778825 1885739 989064 953483 0 0 0 0 26109 13449 15004 778706 1373677 1793879 2340609 -15054 -454870 8511813 8085549 50213 576340 8461600 7509209 THE SALEM HOSPITAL FOUNDATION IS DEDICATED TO RAISING, MANAGING AND DISTRIBUTING FUNDS TO HELP SALEM HOSPITAL ACHIEVE ITS MISSION OF IMPROVING THE HEALTH AND WELL-BEING OF THE PEOPLE AND COMMUNITY IT SERVES. 0 0 168351 168351 SCHOLARSHIPS: NURSING, MEDICAL SCHOOL AND OTHER HEALTHCARE PROGRAMS. RECIPIENTS OF HEALTH CARE RELATED ACADEMIC SCHOLARSHIPS AND THE AMOUNTS OF THE AWARDS ARE DETERMINED BY ANALYSES OF THE CANDIDATES' QUALIFICATIONS, SCHOLARSHIP AWARDS ALREADY AWARDED TO THEM FOR THE YEAR BY OTHER ORGANIZATIONS, AND THE COSTS OF THE SPECIFIC SCHOOLS THE VARIOUS CANDIDATES WISH TO ATTEND. 677772 677772 PROPOSALS TO FUND CAPITAL EQUIPMENT AND MEDICALLY-RELATED ACTIVITIES AT SALEM HOSPITAL ARE RECEIVED AND REVIEWED BY THE FOUNDATION'S CHIEF DEVELOPMENT OFFICER. PROPOSALS ARE FORWARDED TO THE FOUNDATION'S BOARD OF DIRECTORS FOR FURTHER REVIEW AND APPROVAL IF THEY ARE CONSIDERED TO BE CONSISTENT WITH THE FOUNDATION'S ARTICLES OF INCORPORATION, STATING THAT ITS FUNDS ARE TO BE USED FOR HEALTH CARE, CHARITABLE, AND SCIENTIFIC PURPOSES, AND FOR MEDICAL AND SCIENTIFIC EDUCATION AND RESEARCH FOR THE USE AND BENEFIT OF SALEM HOSPITAL. 107360 107360 CERTAIN RESTRICTED FUNDS HAVE BEEN CREATED AND ARE USED FOR THE PURPOSE ASSISTING DIABETES AND CANCER PATIENTS WITH THE COSTS OF THEIR EDUCATIONAL, SUPPLY AND OTHER CARE-RELATED EXPENSES. IN ADDITION, FUNDS ARE DISTRIBUTED TO ASSIST LOW INCOME INDIVIDUALS MEDICAL REQUIREMENTS. 953483 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 7 0 1 0 0 0 0 0 0 0 0 0 0 0 X 15 15 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 OR X SALEM HOSPITAL 5038141938 890 OAK STREET SE SALEM OR 97301 ROBERT PONEC MD CHAIR 1.00 X X 0 0 0 LARRY GOODREAU VICE CHAIR 1.00 X X 0 0 0 KATHY GORDON SECRETARY/TREASURER 1.00 X X 0 0 0 MICHAEL DELK DIRECTOR 1.00 X 0 0 0 BARBARA FURER DIRECTOR 1.00 X 0 0 0 JIM GRIGGS DIRECTOR 1.00 X 0 0 0 BARBARA HALSEY DIRECTOR 1.00 X 0 0 0 BUD PIERCE MD DIRECTOR 1.00 X 0 0 0 MARI BAILEY DIRECTOR 1.00 X 0 0 0 GARTH BRANDAW DIRECTOR 1.00 X 0 0 0 ALEX CASEBEER DIRECTOR 1.00 X 0 0 0 ERIC FISKUM DIRECTOR 1.00 X 0 0 0 RAGHU KAMINENI MD DIRECTOR 1.00 X 0 0 0 CARL VISINTAINER DIRECTOR 1.00 X 0 0 0 THERESA WADE DIRECTOR 1.00 X 0 0 0 MARTIN MORRIS THRU 2615 VP/CHIEF DEVELOPMENT OFFICER 35.00 5.00 X 0 302823 57922 JAN MILLER 2915 - 9415 INTERIM FOUNDATION EXEC. DIRECTOR 20.00 20.00 X 0 187741 31919 LEILANI SLAMA AS OF 9715 DIR. OF DEVELOPMENT 20.00 20.00 X 0 115692 0 0 606256 89841 0 0 1 0 0 3450 1353421 1356871 133323 133323 339590 0 339590 339590 339590 79423 3450 23468 55955 55955 1885739 0 0 528868 677772 677772 275711 275711 716 716 20100 20100 13449 13449 27486 27486 9700 9700 1555 1555 3791 3791 28 28 131 131 545 545 ASSET IMPAIRMENT 725000 0 725000 0 MANAGEMENT SERVICES 548967 0 548967 0 MISCELLANEOUS 17111 0 17111 0 BANK FEES 8966 0 8966 0 9581 9581 2340609 953483 1372122 15004 300202 594537 685000 1410000 685000 6755470 6730513 40015 24487 6126 51012 8511813 8085549 6239 34790 43974 541550 50213 576340 X 2862391 1825020 3332541 3416521 2266668 2267668 8461600 7509209 8511813 8085549 -454870 -497521 0 X X 0 1 X 1 0 X 809178 956318 885907 1326357 1356871 5334631 809178 956318 885907 1326357 1356871 5334631 733600 4601031 61625 200330 130095 122991 133323 648364 5982995 0.76900 0.76110 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 2712832 52030 -16632 54604 2693626 2747398 1000 78662 114228 2712832 2752853 42410 281433 329298 2747398 2450432 79019 324539 101137 2752853 2498792 18333 -33888 32805 2450432 0.00000 0.84000 0.16000 0 0 685000 685000 685000 DUE TO SALEM HOSPITAL 541550 541550 X 924055 -497522 288324 -209198 1133253 27486 725000 752486 1885739 1611591 23468 23468 1588123 27486 725000 752486 2340609 PART V, LINE 4: SALEM HOSPITAL FOUNDATION HOLDS ENDOWMENT FUNDS FOR THE BENEFIT OF SALEM HOSPITAL AND FOR USE TOWARDS THE FOUNDATION'S MISSION. PART X, LINE 2: THE INTERNAL REVENUE SERVICE HAS RECOGNIZED THE FOUNDATION AS EXEMPT FROM TAX UNDER THE PROVISIONS OF SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE EXCEPT TO THE EXTENT OF UNRELATED BUSINESS INCOME UNDER SECTIONS 511 THROUGH 515. MANAGEMENT BELIEVES THAT UNRELATED BUSINESS INCOME TAX, IF ANY, IS IMMATERIAL,AND THEREFORE, NO TAX PROVISION HAS BEEN MADE IN ACCORDANCE WITH FASB ASC 740-10, ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES - AN INTERPRETATION OF FASB STATEMENT 109. PART XI, LINE 2D - OTHER ADJUSTMENTS: SPECIAL EVENT EXPENSES NETTED WITH REVENUE 23,468. ASSETS RELEASED FROM RESTRICTION INCLUDED IN REVENUE 264,856. PART XI, LINE 4B - OTHER ADJUSTMENTS: ASSET IMPAIRMENT 725,000. PART XII, LINE 2D - OTHER ADJUSTMENTS: SPECIAL EVENT EXPENSES NETTED WITH REVENUE 23,468. PART XII, LINE 4B - OTHER ADJUSTMENTS: ASSET IMPAIRMENT 725,000. X X X X 1 TIM THOMAS & ASSOCIATES 1590 BRATTLEBORO DRIVE WEBSTER NY 14580 DIRECT MAIL SOLICITATION 0 20119 10692 20119 20119 10692 20119 OR GOLF TOURNAMENT 82873 3450 79423 23468 82873 3450 79423 23468 23468 55955 SCHEDULE G, PART I, LINE 2B, COLUMN (V) PAYMENT WAS FOR A 37,511 PIECE DIRECT MAIL SOLICITATION. 139 DONATIONS RECEIVED AS A RESULT OF MAILING, TOTAL CONTRIBUTIONS ATTRIBUTED TO MAILING WERE $20,119. 1 SALEM HOSPITAL 890 OAK STREET SE SALEM OR 97301 930579722 501(C)(3) 677772 N/A N/A TO PAY FOR GENERAL EXPENSES AND CAPITAL EXPENDITURES. 1 SCHOLARSHIPS FOR STUDENTS LIVING IN MARION/POLK OR YAMHILL COUNTY WHO ARE PURSUING A CAREER IN HEALTHCARE. PAYMENTS MADE DIRECTLY TO THE COLLEGE(S) 88 168351 N/A SMALL ONE-TIME CASH GRANTS ($150-$300) TO INDIGENT PATIENTS FOR EMERGENT NEEDS SUCH AS MEDICATION, UTILITIES, TRANSPORTATION, RENT, ETC 228 42310 N/A NON-CASH SUPPORT OF INDIGENT PATIENTS OF SALEM HOSPITAL AND/OR COMMUNITY MEMBERS INCLUDING PROVIDING MEDICATION, TRANSPORTATION, MEDICAL EQUIPMENT, CAR SEATS AND OTHER SUPPORT. 65050 ACTUAL COST MEDICATIONS, TRANSPORTATION, DURABLE MEDICAL EQUIPMENT, NON-MEDICAL SAFETY/PREVENTION ITEMS (CAR SEATS, EMERGENCY CALL SYSTEM, ETC), REQUIRED HEALTH COUNSELING, EDUCATION. PART I, LINE 2: DECISIONS ON GRANTS TO SALEM HOSPITAL ARE MADE BY THE SALEM HOSPITAL FOUNDATION BOARD OF DIRECTORS. MINUTES OF THE MEETINGS OF THE FOUNDATION BOARD ARE SHARED WITH THE SALEM HEALTH BOARD OF TRUSTEES EACH MONTH. SCHOLARSHIPS ARE GRANTED TO COLLEGE STUDENTS THAT RESIDE IN MARION, POLK OR YAMHILL COUNTIES AND ARE PURSUING A HEALTHCARE RELATED CAREER. A SCHOLARSHIP COMMITTEE REVIEWS INDIVIDUAL APPLICATIONS AND RECOMMENDS TO THE BOARD RECIPIENT AWARDS FOR APPROVAL. SCHOLARSHIPS AWARDED ARE PAID DIRECTLY TO THE EDUCATIONAL INSTITUTIONS FOR TUITION OR RELATED COSTS. X X X X 0 1 0 0 0 0 0 0 0 MARTIN MORRIS THRU 2615 VP/CHIEF DEVELOPMENT OFFICER 0 256644 0 38847 0 7332 0 37027 0 20895 0 360745 0 0 JAN MILLER 2915 - 9415 INTERIM FOUNDATION EXEC. DIRECTOR 0 158540 0 28635 0 566 0 10625 0 21294 0 219660 0 0 SCHEDULE J, PART 1, LINE 3 COMPENSATION OF THE OFFICERS IS DETERMINED BY THE CEO OF SALEM HEALTH, IN CONJUNCTION WITH OTHER SALARY SURVEY OR PUBLIC INFORMATION AND INDEPENDENT CONSULTANTS TO ENSURE THE COMPENSATION IS COMPETITIVE IN THE MARKET FOR SIMILAR POSITIONS AT COMPARABLE ORGANIZATIONS. SCHEDULE J, PART 1, LINE 4B MARTIN MORRIS RECEIVED DEFERRED COMPENSATION UNDER A 457(F) NONQUALIFIED PLAN. THIS COMPENSATION IS INCLUDED IN COMPENSATION REPORTED IN PART II . THE TOTAL NONQUALIFIED PORTION REPORTED IS $36,847 ($21,319 INCLUDED IN OTHER REPORTABLE COMPENSATION AND $17,527 INCLUDED IN DEFERRED COMPENSATION). SCHEDULE J, PART II, LINE 1 COMPENSATION AND BENEFITS REPORTED FOR OFFICERS ON SCHEDULE J ARE PAID BY SALEM HOSPITAL. THE FOUNDATION HAS A MANAGEMENT AGREEMENT TO REIMBURSE SALEM HOSPITAL FOR A PORTION OF OFFICER COMPENSATION AND BENEFITS. THIS AMOUNT IS INCLUDED ON FORM 990 PART IX; LINE 24B UNDER MANAGEMENT SERVICES. FORM 990, PART VI, SECTION B, LINE 11 THE ORGANIZATION'S GOVERNING EXECUTIVE COMMITTEE REVIEWS THE IRS FORM 990 BEFORE FILING. FORM 990, PART VI, SECTION B, LINE 12C ON AN ANNUAL BASIS THE SECRETARY SHALL SEND TO EACH PERSON WHO IS A TRUSTEE, OFFICER, OR MEMBER OF A COMMITTEE A COPY OF THE POLICY REGARDING CONFLICTS OF INTEREST, TOGETHER WITH A QUESTIONNAIRE INQUIRING AS TO CONFLICTS, TO BE COMPLETED AND RETURNED TO THE SECRETARY BY THE TRUSTEE, OFFICER OR COMMITTEE MEMBER PRIOR TO THE BEGINNING OF EACH CALENDAR YEAR. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION OF THE V.P. & CHIEF DEVELOPMENT OFFICER IS DETERMINED BY THE CEO OF SALEM HEALTH, IN CONJUNCTION WITH OTHER SALARY SURVEY OR PUBLIC INFORMATION AND INDEPENDENT CONSULTANTS TO ENSURE THE COMPENSATION IS COMPETITIVE IN THE MARKET FOR SIMILAR POSITIONS AT COMPARABLE ORGANIZATIONS. FORM 990, PART VI, SECTION C, LINE 19 NO DOCUMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART XII, LINE 2C THERE HAVE NOT BEEN ANY CHANGES FROM THE PREVIOUS YEAR. HAMPSHIRE PROPERTIES LLC 890 OAK STREET SE SALEM OR 97301 870804582 REAL ESTATE HOLDING OR 90 709487 N/A SALEM HOSPITAL 890 OAK STREET SE SALEM OR 97301 930579722 HOSPITAL OR 501(C)(3) LINE 3 SALEM HEALTH 0 SALEM HOSPITAL AUXILIARY 890 OAK STREET SE SALEM OR 97301 931081113 SUPPORTS SALEM HOSPITAL OR 501(C)(3) LINE 9 N/A 0 SALEM HEALTH 890 OAK STREET SE SALEM OR 97301 930823471 LEASES LAND TO SALEM HOSPITAL OR 501(C)(3) LINE 11A, I N/A 0 WEST VALLEY HOSPITAL 525 SOUTHEAST WASHINGTON STREET DALLAS OR 97338 431960221 HOSPITAL OR 501(C)(3) LINE 3 SALEM HEALTH 0 WEST VALLEY HOSPITAL FOUNDATION 525 SOUTHEAST WASHINGTON STREET DALLAS OR 97338 931298564 SUPPORTS WEST VALLEY HOSPITAL OR 501(C)(3) LINE 11A, I SALEM HEALTH 0 WILLAMETTE VALLEY INSURANCE COMPANY 745 FORT STREET HONOLULU HI 96813 201836190 CAPTIVE INSURANCE HI 501(C)(3) LINE 11A, I SALEM HEALTH 0 WILLAMETTE VALLEY PROFESSIONAL SERVICES 890 OAK STREET SE SALEM OR 97301 753175249 BILLING SERVICE FOR SALEM HOSPITAL, WEST VALLEY HOSPITAL, & SALEM HEALTH OR 501(C)(3) LINE 3 SALEM HEALTH 0 0 1 1 0 0 0 0 0 0 0 0 1 0 1 1 0 0 0 0