2015-05-07T13:28:43-05:00 2014-06-30 911194016 CLARK NUBER PS 10900 NE 4TH STREET SUITE 1700 BELLEVUE WA 98004 990 2013-07-01 911538852 PEACEHEALTH ST JOHN MEDICAL CENTER FOUNDATION PEAC 3604147900 1615 DELAWARE LONGVIEW WA 98632 CHRIS SEARING PRESIDENT 3604147900 2015-05-06 1 SARA ELIZABETH J HYRE P00235495 4254544919 2015-05-06 2013 2016-02-25 16:41:14Z CHRIS SEARING 1615 DELAWARE LONGVIEW WA 98632 1174834 0 X PEACEHEALTH.ORG/FOUNDATION/ST-JOHN/PAGES/DEFAULT X 1986 WA SUPPORT OF PEACEHEALTH ST. JOHN MEDICAL CENTER BY BUILDING SOCIAL AND FINANCIAL RESOURCES. 28 23 0 100 0 0 1187425 871834 0 0 142025 129196 -23636 -32438 1305814 968592 1146274 1238501 0 0 0 0 16063 14581 17611 173471 111623 1335808 1364705 -29994 -396113 7557886 7770219 2229861 2009227 5328025 5760992 X WE CULTIVATE THE UNDERSTANDING, INVOLVEMENT, COOPERATION AND PHILANTHROPIC SUPPORT OF ALL WHO WORK TOGETHER TO PROMOTE THE HEALTH AND WELL-BEING OF OUR COMMUNITY. BUILDING SOCIAL AND FINANCIAL RESOURCES FOR THE PRESENT AND FUTURE REFLECTS OUR COMMITMENT TO THE COMMUNITY AND TO EACH INDIVIDUAL'S HEALTH. 0 0 461091 461091 HOSPITAL SUPPORT - FUNDS RAISED WITH NO SPECIFIC PROJECT RESTRICTION ARE USED TO SUPPORT THE GENERAL OPERATING AND CAPITAL NEEDS OF THE HOSPITAL. 762410 762410 MAMMOGRAPHY - FUNDS RAISED TO SUPPORT THE NEEDS OF THE BREAST CENTER IN THE HOSPITAL. CURRENTLY FUNDS HAVE BEEN RAISED TOWARD A COMPLETE REMODEL OF THE BREAST CENTER IN 2014. 15000 15000 THE FUND IS TO SUPPORT THE NEEDS OF LOWER COLUMNBIA REGIONAL CANCER CENTER. 1238501 1 1 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 1 0 0 1 0 1 0 0 0 0 0 0 0 1 1 0 0 0 0 1 0 0 0 1 4 0 1 0 0 0 0 0 0 1 1 0 0 0 0 X 28 23 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 WA X LISA ANDERSON 3604142115 123 INTERNATIONAL WAY SPRINGFIELD OR 97477 X CHRIS SEARING PRESIDENT 1.00 0.00 X X 0 0 0 STEVEN CABRALES MD PRESIDENT (THRU 9/2013) 1.00 40.00 X X 0 396033 33663 BILL BOEHM VICE PRESIDENT 1.00 0.00 X X 0 0 0 MARK S PURCELL SECRETARY 1.00 0.00 X X 0 18308 0 CORI DOLAN CFO (THRU 9/2013) 1.00 40.00 X X 0 96128 8165 DENIS GABEL TREASURER 1.00 0.00 X X 0 0 0 KIRK RABOIN BOARD MEMBER 1.00 40.00 X 0 228059 23538 JOSIAH JOHNSON BOARD MEMBER 1.00 40.00 X 0 387433 34070 JAMES NAKASHIMA MD BOARD MEMBER (THRU 10/2013) 1.00 40.00 X 0 254098 37738 JOANNA ASPLUND BOARD MEMBER 1.00 40.00 X 0 59420 2487 MICHAEL MCNELLIS MD BOARD MEMBER 1.00 40.00 X 0 353049 31120 LILIAN STONEKING PA-C BOARD MEMBER 1.00 40.00 X 0 117914 15423 JOHN BERWIND DDS BOARD MEMBER 1.00 0.00 X 0 0 0 JACKIE EVANS BOARD MEMBER 1.00 0.00 X 0 0 0 EARL FISHER BOARD MEMBER 1.00 0.00 X 0 0 0 JULIE KENDALL BOARD MEMBER 1.00 0.00 X 0 0 0 PAULINE KIRCHNER BOARD MEMBER 1.00 0.00 X 0 0 0 TOM RENAUD BOARD MEMBER 1.00 0.00 X 0 0 0 JUDIE WILSON BOARD MEMBER 1.00 0.00 X 0 0 0 GERRIE BOOTH BOARD MEMBER 1.00 0.00 X 0 0 0 FRANCENA DODD BOARD MEMBER 1.00 0.00 X 0 0 0 STEVE JABUSCH BOARD MEMBER 1.00 0.00 X 0 0 0 BILL MARCUM BOARD MEMBER 1.00 0.00 X 0 0 0 ROSE MARIE NIGRO BOARD MEMBER 1.00 0.00 X 0 0 0 DON RODMAN BOARD MEMBER 1.00 0.00 X 0 0 0 BILL SARI BOARD MEMBER 1.00 0.00 X 0 0 0 RONI ZIEGLER BOARD MEMBER 1.00 0.00 X 0 0 0 WILLIAM CHESLOCK BOARD MEMBER 1.00 0.00 X 0 0 0 DON CIANCI BOARD MEMBER 1.00 0.00 X 0 0 0 GENE GUTTORMSEN BOARD MEMBER 1.00 0.00 X 0 0 0 DOUG STAFFORD BOARD MEMBER 1.00 0.00 X 0 0 0 JANICE CARTER BOARD MEMBER 1.00 0.00 X 0 0 0 BETH LAUFER BOARD MEMBER 1.00 0.00 X 0 0 0 GARY PARAFINCZUK BOARD MEMBER 1.00 0.00 X 0 0 0 JORI SCRUGGS-BROWN CFO (THRU 1/2014) 1.00 X 0 139405 12150 CATHY BARR EXECUTIVE DIRECTOR 40.00 0.00 X 0 122710 17997 0 2172557 216351 0 0 1 0 0 X 309427 562407 129978 871834 66875 66875 113024 50703 62321 62321 62321 110621 309427 155539 -44918 -44918 12480 0 12480 12480 968592 0 0 96758 1238501 1238501 34798 34798 14581 14581 12142 12142 100 100 47270 47270 11403 11403 FUNDRAISING EXP. 3030 3030 BAD DEBT 2880 2880 1364705 1238501 108593 17611 80649 18310 865027 494258 141894 31581 1750 3002781 3473969 3465785 3752101 7557886 7770219 27646 37 12900 10405 2189315 1998785 2229861 2009227 X 1628641 2114858 2625801 2550459 1073583 1095675 5328025 5760992 7557886 7770219 X -396113 347426 481654 X 0 1 X 1 0 X 989924 1472995 1615880 1187425 871834 6138058 989924 1472995 1615880 1187425 871834 6138058 840447 5297611 62671 61878 68465 66668 66875 326557 7308 7308 6471923 0.81860 0.80510 X PART II LINE 10 FOR 2011: TAX REFUND: $7,308 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1271121 730 214561 35271 1451141 1190365 58717 119115 26536 70540 1271121 1525574 59885 -33723 34319 327052 1190365 1273932 33599 241023 22980 1525574 1139166 11410 164123 40767 1273932 0.76000 0.24000 0 0 0 CASH VALUE OF LIFE INSURANCE 168856 SPLIT-INTEREST AGREEMENTS 3583245 3752101 SPLIT-INTEREST AGREEMENTS 1998785 1998785 2332857 347426 450223 481654 1279303 1053554 -84962 -84962 968592 1899890 450223 84962 535185 1364705 0 1364705 PART V, LINE 4: ENDOWMENT FUNDS ARE HELD FOR SPECIFIC PURPOSE AND GIVEN BASED ON OUR ENDOWMENT SPENDING POLICY AT THE DIRECTION OF OUR FINANCE COMMITTEE. PART XI, LINE 2D - OTHER ADJUSTMENTS: SPLIT INTEREST VALUE CHANGE 481,654. PART XI, LINE 4B - OTHER ADJUSTMENTS: SPECIAL EVENT EXPENSES REPORTED ON AFS AS EXPENSES -84,962. PART XII, LINE 2D - OTHER ADJUSTMENTS: SPECIAL EVENT EXPENSES REPORTED ON AFS AS EXPENSES 84,962. GOLF TOURNAMENT 169190 137715 31475 11200 6300 7229 12531 DECEMBER GALA 226115 153474 72641 38061 400 60978 1 24743 18238 6505 2352 5782 6188 4518 420048 309427 110621 11200 46713 13011 6588 78027 155539 -44918 1 PEACEHEALTH ST JOHN MEDICAL CENTER 1615 DELAWARE STREET LONGVIEW WA 98632 910939479 501(C)(3) 1181871 56630 FMV GIFTS IN KIND FROM DONORS GENERAL SUPPORT FOR PEACEHEALTH ST. JOHN MEDICAL CENTER 1 0 PART I, LINE 2: OUR FINANCE COMMITTEE AWARDS AND MONITORS THE DISTRIBUTION AND USE OF THE FUNDS ACCORDING TO DONOR INTENT. THE HOSPITAL'S FINANCE DEPARTMENT DISTRIBUTES FUNDS AFTER FOUNDATION APPROVAL AND ANY UNUSED FUNDS ARE RETURNED TO THE FOUNDATION. 0 1 0 0 0 0 0 0 0 STEVEN CABRALES MD PRESIDENT (THRU 9/2013) 0 314944 0 0 0 81089 0 26052 0 7611 0 429696 0 0 KIRK RABOIN BOARD MEMBER 0 226227 0 0 0 1832 0 22711 0 827 0 251597 0 0 JOSIAH JOHNSON BOARD MEMBER 0 381690 0 5000 0 743 0 26052 0 8018 0 421503 0 0 JAMES NAKASHIMA MD BOARD MEMBER (THRU 10/2013) 0 244860 0 6274 0 2964 0 31152 0 6586 0 291836 0 0 MICHAEL MCNELLIS MD BOARD MEMBER 0 351329 0 0 0 1720 0 30313 0 807 0 384169 0 0 JORI SCRUGGS-BROWN CFO (THRU 1/2014) 0 129422 0 9725 0 258 0 12150 0 0 0 151555 0 0 SCHEDULE J, PART I, LINE 3: THE COMPENSATION OF BOARD MEMBERS AND OFFICERS ARE PAID BY THE RELATED ORGANIZATION, PEACEHEALTH. PEACEHEALTH USES WRITTEN EMPLOYMENT CONTRACT AND COMPENSATION SURVEY/STUDY TO ESTABLISH THE COMPENSATION REPORTED IN SCHEDULE J PART II. SCHEDULE J, PART I, LINE 4B: THE ORGANIZATION'S BOARD MEMBER JOSIAH JOHNSON, IS PEACEHEALTH'S SENIOR VP AND ELIGIBLE TO PARTICIPATE IN PEACEHEALTH'S SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN. CONTRIBUTIONS TO THE PLAN ARE DISCLOSED ON SCHEDULE J AS DEFERRED COMPENSATION. CLARK NUBER PS GREATER THAN 5% SHAREHOLDER IS SISTER-IN-LAW OF BOARD MEMBER 34798 ACCOUNTING SERVICES 0 X 13 45074 FMV X 7 2070 FMV X AUCTION ITEMS 143 70577 FMV X KIDS ITEMS 28 7087 FMV X MISC. ITEMS 6 5170 FMV 0 0 1 0 PART I, COLUMN (B): THE NUMBER OF CONTRIBUTORS IS THE NUMBER OF ITEMS DONATED. FORM 990, PART I, LINE 6: VOLUNTEERS THE FOUNDATION HAS A DIVERSE GROUP OF VOLUNTEERS. SOME VOLUNTEERS SERVE AS FOUNDATION BOARD MEMBERS, WHILE OTHERS SERVE AT THE GALA AND GOLF TOURNAMENT FUNDRAISERS. FORM 990, PART VI, SECTION B, LINE 11 ONCE THE FORM 990 IS COMPLETED BY OUR INDEPENDENT ACCOUNTING FIRM IT IS REVIEWED BY THE GOVERNANCE COMMITTEE. EVERY MEMBER OF THE BOARD WILL RECEIVE A COPY OF THE FORM 990 BEFORE IT IS FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE GOVERNANCE COMMITTEE IN CONSULTATION WITH THE BOARD PRESIDENT AND EXECUTIVE DIRECTOR ARE RESPONSIBLE FOR ENSURING THAT ALL TOPICS BROUGHT BEFORE THE BOARD ARE FREE FROM CONFLICT. DETERMINATIONS OF WHETHER A CONFLICT EXISTS AND REVIEW OF ANY CONFLICTS ARE MADE AT THIS LEVEL. IF A CONFLICT ARISES, THE INDIVIDUAL AT RISK IS CONTACTED AND ASKED TO EXCUSE HIM OR HER FROM THE ROOM DURING DISCUSSION AND VOTING. ALL MEMBERS OF THE BOARD, AS WELL AS STAFF, ARE COVERED UNDER THE CONFLICT OF INTEREST POLICY. FORM 990, PART VI, SECTION B, LINE 15A THE FOUNDATION EXECUTIVE DIRECTOR IS COMPENSATED BY PEACEHEALTH (A RELATED ORGANIZATION) WHICH USES A MARKET BASED COMPENSATION PROGRAM UTILIZING SEVERAL INDEPENDENT THIRD PARTY COMPENSATION MARKET SURVEYS TO ESTABLISH PAY RANGES FOR THE POSITION. PEACEHEALTH THEN ESTABLISHES THE INDIVIDUAL RATE OF PAY WITHIN THE PAY RANGE BASED ON RELEVANT EXPERIENCE/SKILLS/COMPETENCE TO DO THE JOB. THIS RATE, OFFERED TO THE EXECUTIVE DIRECTOR AT TIME OF HIRE, WAS DETERMINED THROUGH A DISCUSSION BETWEEN THE REGIONAL CEO, REGIONAL DIRECTOR OF HUMAN RESOURCES AND THE ADMINISTRATIVE DIRECTOR OF HUMAN RESOURCES. THE RANGES AND RATE OF PAY ARE REVIEWED ON AN ANNUAL BASIS. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. THE FORM 990 IS AVAILABLE ONLINE THROUGH GUIDESTAR AND UPON REQUEST. FORM 990, PART VII, COLUMN B: THE BOARD MEMBERS THAT RECEIVE COMPENSATION FROM A RELATED ORGANIZATION (PEACEHEALTH ST. JOHN MEDICAL CENTER) ARE NOT BEING COMPENSATED FOR THEIR BOARD SERVICE. THE COMPENSATION RELATES TO SERVICES (ESTIMATED 40 HOURS/WEEK) PROVIDED TO THE RELATED ORGANIZATION (PEACEHEALTH ST. JOHN MEDICAL CENTER). FORM 990, PART VIII & IX THE FOUNDATION RECEIVES DONATED FACILITIES AND SERVICES FROM ST. JOHN MEDICAL CENTER AND PEACEHEALTH CORPORATION, WHICH INCLUDE SPACE RENTAL, THE USE OF PROPERTY AND EQUIPMENT, UTILITIES, AND EMPLOYEE SERVICES. THE ESTIMATED FAIR MARKET VALUE OF $447,453 OF SUCH ITEMS HAS BEEN REFLECTED IN THE FINANCIAL STATEMENTS AS A PART OF IN-KIND CONTRIBUTIONS AND EXPENSES, BUT HAS BEEN REMOVED FROM FORM 990, PARTS VIII AND IX, REVENUE AND EXPENSE, PER THE INSTRUCTIONS TO FORM 990. FORM 990, PART XI, LINE 9: SPLIT INTEREST VALUE CHANGE 481,654. PEACEHEALTH 1115 SE 164TH AVENUE VANCOUVER WA 98683 910939479 HOSPITAL WA 501(C)(3) 3 PEACEHEALTH 0 THE WHATCOM HOSPICE FOUNDATION 2901 SQUALICUM PARKWAY BELLINGHAM WA 98225 943146369 SUPPORT WHATCOM HOSPICE WA 501(C)(3) 11A - TYPE III-O PEACEHEALTH 0 KETCHIKAN GENERAL HOSPITAL FOUNDATION 3100 TONGASS AVE KETCHIKAN AK 99901 651225184 SUPPORT KETCHIKAN GENERAL HOSPITAL AK 501(C)(3) 7 PEACEHEALTH 0 COTTAGE GROVE COMMUNITY HOSPITAL FOUNDATION PO BOX 134 COTTAGE GROVE OR 97424 930688381 PROVIDE FINANCIAL AID TO COTTAGE GROVE COMMUNITY HOSPITAL OR 501(C)(3) 7 PEACEHEALTH 0 PEACE HARBOR HOSPITAL FOUNDATION 400 9TH STREET FLORENCE OR 97439 931084126 PROVIDE FINANCIAL AID TO PEACE HARBOR HOSPITAL OR 501(C)(3) 11A - TYPE I PEACEHEALTH 0 SACRED HEART MEDICAL CENTER FOUNDATION PO BOX 10905 EUGENE OR 97440 936026548 PROVIDE FINANCIAL AID TO SACRED HEART MEDICAL CENTER OR 501(C)(3) 11A - TYPE I PEACEHEALTH 0 PEACEHEALTH ST JOSEPH MEDICAL CENTER FOUNDATION 800 EAST CHESTNUT STREET SUITE LL1 BELLINGHAM WA 98225 721545902 SUPPORT ST. JOSEPH HOSPITAL WA 501(C)(3) 7 PEACEHEALTH 0 HEALTH VENTURES PO BOX 10905 EUGENE OR 97440 911350776 HEALTHCARE JOINT VENTURES OR 501(C)(3) 7 PEACEHEALTH 0 PEACEHEALTH SOUTHWEST MEDICAL CENTER PO BOX 1600 VANCOUVER WA 98668 911231436 HOSPITAL WA 501(C)(3) 3 PEACEHEALTH 0 PEACE ISLAND MEDICAL CENTER 1117 SPRING STREET FRIDAY HARBOR WA 98250 383868360 HOSPITAL WA 501(C)(3) 3 PEACEHEALTH 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0