2014-04-25T11:48:13-05:00 2013-06-30 911194016 CLARK NUBER PS 10900 NE 4TH STREET SUITE 1700 BELLEVUE WA 98004 990 2012-07-01 911538852 PEACEHEALTH ST JOHN MEDICAL CENTER FOUNDATION PEAC 3604147900 1615 DELAWARE LONGVIEW WA 98632 CATHY BARR 3604147900 2014-04-24 1 SARA ELIZABETH J HYRE P00235495 4254544919 2014-04-11 2012 2015-11-30 17:44:51Z CATHY BARR 1615 DELAWARE LONGVIEW WA 98632 2252368 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. 29 22 0 100 0 0 1615880 1187425 0 0 36979 142025 12823 -23636 1665682 1305814 825484 1146274 0 0 0 0 17284 16063 37638 244296 173471 1087064 1335808 578618 -29994 7367301 7557886 2388362 2229861 4978939 5328025 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 349433 349433 UNRESTRICTED FUNDS - FUNDS RAISED WITH NO SPECIFIC PROJECT RESTRICTION ARE USED TO SUPPORT THE GENERAL OPERATING AND CAPITAL NEEDS OF THE HOSPITAL. 338849 338849 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 2013. 119724 119724 HEART - FUNDS RAISED TO SUPPORT THE NEEDS OF THE CARDIAC CATH LAB DEPARTMENT OF THE HOSPITAL, TO SUPPORT PURCHASE OF CAPITAL AND OPERATING NEEDS OF THE PROGRAM. 114700 114700 DAVID C. WRIGHT SUPPORTIVE CARE PROGRAM - FUNDS FOR USE IN THE PALLIATIVE CARE PROGRAM OF THE HOSPITAL, TO PROVIDE COMFORT AND END OF LIFE CARE. 38265 38265 CRITICAL CARE FUND 36405 36405 LOWER COLUMNBIA REGIONAL CANCER CENTER 22269 22269 RADIATION ONCOLOGY PROGRAM 17948 17948 DIALYSIS 15684 15684 OBSTETRICS 92997 92997 ALL OTHER PROGRAM SERVICES 338268 338268 1146274 1 1 0 0 0 0 0 0 0 1 1 0 0 1 1 0 1 0 0 0 0 0 0 1 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 29 22 0 0 1 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 WA X BRENDA MARSDEN 3604142115 PO BOX 3002 LONGVIEW WA 98632 X MAILA CADD 1.00 0.00 X X 0 0 0 STEVEN CABRALES MD 1.00 40.00 X X 0 371775 31842 CHRIS SEARING 1.00 0.00 X X 0 0 0 PAULINE KIRCHNER 1.00 0.00 X X 0 0 0 MICHAEL MCNELLIS MD 1.00 40.00 X 0 334775 30669 JOSIAH JOHNSON 1.00 40.00 X 0 401090 110621 GERT MARTINI 1.00 0.00 X 0 0 0 JOANNA ASPLUND 1.00 40.00 X 0 39110 5419 JOHN BERWIND DDS 1.00 0.00 X 0 0 0 JANICE CARTER 1.00 0.00 X 0 0 0 DON CIANCI 1.00 0.00 X 0 0 0 BILL CHESLOCK OD 1.00 0.00 X 0 0 0 SUZANNE CUSICK 1.00 0.00 X 0 0 0 EARL FISHER 1.00 0.00 X 0 0 0 DENISE GABEL 1.00 0.00 X 0 0 0 GENE GUTTORMSEN 1.00 0.00 X 0 0 0 STEVE JABUSCH 1.00 0.00 X 0 0 0 JULIE KENDALL 1.00 0.00 X 0 0 0 BILL MARCUM 1.00 0.00 X 0 0 0 JAMES NAKASHIMA MD 1.00 40.00 X 0 225575 39064 ROSE MARIE NIGRO CSJP 1.00 0.00 X 0 0 0 MARK PURCELL 1.00 0.00 X 0 0 0 TOM RENAUD 1.00 0.00 X 0 0 0 PAT SARI 1.00 0.00 X 0 0 0 DOUG STAFFORD 1.00 0.00 X 0 0 0 LILLIAN STONEKING PA 1.00 0.00 X 0 0 0 JUDIE WILSON 1.00 0.00 X 0 0 0 RONI ZIEGLER 1.00 0.00 X 0 0 0 BILL BOEHM 1.00 0.00 X 0 0 0 LINDA DOERR 1.00 0.00 X 0 0 0 GWEN LARSON 1.00 0.00 X 0 0 0 CORI DOLAN 1.00 40.00 X X 0 76803 6295 CATHY BARR 40.00 0.00 X 0 118145 19057 0 1567273 242967 0 0 1 0 0 X 343872 843553 65009 1187425 66668 66668 384417 509500 297876 520684 86541 -11184 75357 75357 94133 343872 127994 -33861 -33861 10225 0 10225 10225 1305814 0 0 118389 1146274 1146274 38341 38341 16063 16063 14099 14099 1895 1895 73590 73590 17064 17064 IND. FUNDRAISING EXP. 21575 21575 REPAIR & MAINTENANCE 2695 2695 BAD DEBT 2550 2550 PROPERTY TAXES 1662 1662 1335808 1146274 151896 37638 81074 80649 660892 865027 149091 141894 12697 1750 0 0 520684 0 2719108 3002781 3223755 3465785 7367301 7557886 0 27646 12500 12900 2375862 2189315 2388362 2229861 X 1487352 1628641 2420432 2625801 1071155 1073583 4978939 5328025 7367301 7557886 X -29994 117574 161089 100417 X 0 1 X 1 0 X 758558 989924 1472995 1615880 1187425 6024782 758558 989924 1472995 1615880 1187425 6024782 876743 5148039 102481 62671 61878 68465 66668 362163 7308 7308 6394253 0.80510 0.76250 X SCHEDULE A, PART IV, SUPPLEMENTAL INFORMATION: PART II LINE 10 FOR 2011: TAX REFUND: $7,308 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1190365 58717 119115 26536 70540 1271121 1525574 59885 -33723 34319 327052 1190365 1273932 33599 241023 22980 1525574 1139166 11410 164123 40767 1273932 1403528 6452 -230851 39963 1139166 0.84000 0.16000 0 0 0 CASH VALUE OF LIFE INSURANCE 159803 SPLIT-INTEREST AGREEMENTS 3305982 3465785 SPLIT-INTEREST AGREEMENTS 2189315 2189315 2119010 117574 527447 100417 745438 1373572 -67758 -67758 1305814 1931013 527447 67758 595205 1335808 0 1335808 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: 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 100,417. PART XI, LINE 4B - OTHER ADJUSTMENTS: SPECIAL EVENT EXPENSES REPORTED ON AFS AS EXPENSES -67,758. PART XII, LINE 2D - OTHER ADJUSTMENTS: SPECIAL EVENT EXPENSES REPORTED ON AFS AS EXPENSES 67,758. X X X X 0 PAT MARTIN 2621 CASCADE WAY LONGVIEW WA 98632 GRANT WRITER 0 5000 16063 -11063 5000 16063 -11063 WA GOLF TOURNAMENT 163385 143129 20256 9500 700 6341 12020 DECEMBER GALA 251215 186755 64460 13371 21848 48181 1 23405 13988 9417 3987 6433 2000 3613 438005 343872 94133 9500 18058 34622 2000 63814 127994 -33861 1 PEACEHEALTH ST JOHN MEDICAL CENTER 1615 DELAWARE STREET LONGVIEW WA 98632 910939479 501(C)(3) 1141081 4773 FMV GIFTS IN KIND FROM DONORS GENERAL SUPPORT FOR PEACEHEALTH ST. JOHN MEDICAL CENTER 1 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, 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 0 323936 0 47839 0 0 0 25596 0 6246 0 403617 0 0 MICHAEL MCNELLIS MD 0 334775 0 0 0 0 0 29250 0 1419 0 365444 0 0 JOSIAH JOHNSON 0 340350 0 50258 0 10482 0 109781 0 840 0 511711 0 0 JAMES NAKASHIMA MD 0 219110 0 6465 0 0 0 28523 0 10541 0 264639 0 0 SUPPLEMENTAL INFORMATION PART III 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. SUPPLEMENTAL INFORMATION PART III SCHEDULE J, PART I, LINE 4B: THE ORGANIZATION'S BOARD MEMBER JOSIAH JOHNSON, IS PEACEHEALTH'S CHIEF EXECUTIVE OFFICER 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 38341 ACCOUNTING SERVICES 0 X 18 1728 FMV X AUCTION ITEMS 105 60236 FMV X KIDS ITEMS 172 3045 FMV 0 0 1 0 METHOD FOR DETERMINING NUMBER OF CONTRIBUTIONS: 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 A, LINE 4 TERMS FOR BOARD MEMBERS CHANGED TO NO MORE THAN FOUR SUCCESSIVE THREE-YEAR TERMS. EMERITUS BOARD MEMBERS SHALL NOT HAVE A VOTE EXCEPT WHILE SERVING ON A FOUNDATION COMMITTEE. 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 HR AND THE ADMINISTRATIVE DIRECTOR OF HR. 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. COMPENSATION FROM RELATED ORGANIZATION: 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). IN-KIND CONTRIBUTIONS & EXPENSES: 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 $520,673 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. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: SPLIT INTEREST VALUE CHANGE 100,417. FORM 990, PART XI LINE 8: PRIOR PERIOD ADJUSTMENTS CHARITABLE GIFT ANNUITY LIABILITY RECALCULATED AND CORRECTED: $161,089 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 0 1 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0