2015-08-12T15:21:38-05:00 2014-09-30 930623286 AKT LLP 5665 SW MEADOWS RD SUITE 200 LAKE OSWEGO OR 97035 990 2013-10-01 237002687 SALEM HOSPITAL FOUNDATION SALE 5035615576 890 OAK STREET SALEM OR 97301 JAMES PARR CHIEF FINANCIAL OFFICER 5035615527 2015-07-24 1 JOYLYN M ANKENEY CPA P00366587 5036204489 2015-07-24 2013 2016-02-25 16:41:14Z JAMES PARR 890 OAK STREET SALEM OR 97301 1928534 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. 14 14 0 14 0 0 894250 1326357 0 0 146436 401835 48637 50633 1089323 1778825 1317967 989064 0 0 0 0 20977 26109 29109 783492 778706 2122436 1793879 -1033113 -15054 8190828 8511813 40903 50213 8149925 8461600 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 181598 181598 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. 676389 676389 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. 131077 131077 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. 989064 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 1 0 0 0 1 1 0 0 0 1 6 0 1 0 0 0 0 0 0 0 0 0 0 0 X 14 14 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 OR X SALEM HOSPITAL 5035611200 890 OAK STREET SE SALEM OR 97301 KATHY GORDON CHAIR 1.00 X X 0 0 0 MARI BAILEY DIRECTOR 1.00 X 0 0 0 GARTH BRANDAW DIRECTOR 1.00 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 ROBERT PONEC MD VICE CHAIR 1.00 X X 0 0 0 ALEX CASEBEER DIRECTOR 1.00 X 0 0 0 LARRY GOODREAU SECRETARY/TREASURER 1.00 X 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 MARTIN MORRIS CHIEF DEVELOP OFFICER/VP C 40.00 X 0 296189 56175 0 296189 56175 0 0 1 0 0 5150 1321207 1326357 122991 122991 406166 127322 278844 278844 278844 73020 5150 22387 50633 50633 1778825 0 0 452468 676389 676389 312675 312675 6039 6039 19072 19072 26109 26109 1342 1342 3000 3000 4334 4334 1186 1186 MANAGEMENT SERVICES 712017 712017 MISCELLANEOUS 20867 20867 SOFTWARE/DATA PROCESS 5880 5880 BANK FEES 2957 2957 2012 2012 1793879 989064 775706 29109 306798 300202 1410000 1410000 1410000 6427248 6755470 46782 40015 0 6126 8190828 8511813 1000 6239 39903 43974 40903 50213 X 2975856 2862391 2908401 3332541 2265668 2266668 8149925 8461600 8190828 8511813 -15054 326729 0 X 0 1 X 1 0 X 1212534 809178 956318 885907 1326357 5190294 1212534 809178 956318 885907 1326357 5190294 807681 4382613 52561 61625 200330 130095 122991 567602 5757896 0.76110 0.69700 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 2747398 1000 78662 114228 2712832 2752853 42410 281433 329298 2747398 2450432 79019 324539 101137 2752853 2498792 18333 -33888 32805 2450432 2344770 19335 167208 32521 2498792 0.00000 0.84000 0.16000 0 0 1410000 1410000 1410000 DUE TO SALEM HOSPITAL 43974 43974 X 2442943 326729 337389 664118 1778825 0 1778825 1816266 22387 22387 1793879 0 1793879 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 22,387. ASSETS RELEASED FROM RESTRICTION INCLUDED IN REVENUE 315,002. PART XII, LINE 2D - OTHER ADJUSTMENTS: SPECIAL EVENT EXPENSES NETTED WITH REVENUE 22,387. X X X X 1 ADVANCED MARKETING 99 THIELMAN DRIVE BUFFALO NY 14206 DIRECT MAIL SOLICITATION 0 8287 11452 8287 8287 11452 8287 OR GOLF TOURNAMENT 78170 5150 73020 22387 78170 5150 73020 22387 22387 50633 SCHEDULE G, PART I, LINE 2B, COLUMN (V) PAYMENT WAS FOR A 33,734 PIECE DIRECT MAIL SOLICITATION. 111 DONATIONS RECEIVED AS A RESULT OF MAILING, TOTAL CONTRIBUTIONS ATTRIBUTED TO MAILING WERE $8,287. 1 SALEM HOSPITAL 890 OAK STREET SE SALEM OR 97301 930579722 503(C)(3) 676389 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) 102 181598 N/A SMALL ONE-TIME CASH GRANTS ($150-$300) TO INDIGENT PATIENTS FOR EMERGENT NEEDS SUCH AS MEDICATION, UTILITIES, TRANSPORTATION, RENT, ETC 43427 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. 87650 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 CHIEF DEVELOP OFFICER/VP C 0 258849 0 30188 0 7152 0 36162 0 20013 0 352364 0 0 SCHEDULE J, PART 1, LINE 3 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. 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 UNDER DEFERRED COMPENSATION. THE TOTAL NONQUALIFIED PORTION REPORTED IS $17,037. SCHEDULE J, PART II, LINE 1 COMPENSATION AND BENEFITS REPORTED FOR MARTIN MORRIS ON SCHEDULE J, LINE 1, (II) ARE PAID BY SALEM HOSPITAL. THE FOUNDATION HAS A MANAGEMENT AGREEMENT TO REIMBURSE SALEM HOSPITAL FOR A PORTION OF HIS COMPENSATION AND BENEFITS WHICH TOTALED $88,091. THIS AMOUNT IS INCLUDED ON FORM 990 PART IX; LINE 24A UNDER MANAGEMENT SERVICES. X 3 59082 AVERAGE MARKET VALUE 0 0 0 0 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. HAMPSHIRE PROPERTIES LLC 890 OAK STREET SE SALEM OR 97301 870804582 REAL ESTATE HOLDING OR 90 1450015 N/A SALEM HOSPITAL 890 OAK STREET SE SALEM OR 97301 930579722 HOSPITAL OR 501(C)(3) 3 SALEM HEALTH 0 SALEM HOSPITAL AUXILIARY 890 OAK STREET SE SALEM OR 97301 931081113 SUPPORTS SALEM HOSPITAL OR 501(C)(3) 9 N/A 0 SALEM HEALTH 890 OAK STREET SE SALEM OR 97301 930823471 LEASES LAND TO SALEM HOSPITAL OR 501(C)(3) 11 TYPE 1 N/A 0 WEST VALLEY HOSPITAL 525 SOUTHEAST WASHINGTON STREET DALLAS OR 97338 431960221 HOSPITAL OR 501(C)(3) 3 SALEM HEALTH 0 WEST VALLEY HOSPITAL FOUNDATION 525 SOUTHEAST WASHINGTON STREET DALLAS OR 97338 931298564 SUPPORTS WEST VALLEY HOSPITAL OR 501(C)(3) 11 TYPE 1 SALEM HEALTH 0 WILLAMETTE VALLEY INSURANCE COMPANY 745 FORT STREET HONOLULU HI 96813 201836190 CAPTIVE INSURANCE HI 501(C)(3) 11 TYPE 1 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) 3 SALEM HEALTH 0 0 1 1 0 0 0 0 0 0 0 0 1 0 1 1 0 0 0 0