2013-05-09T18:20:23-05:00 2012-06-30 861065772 Deloitte Tax LLP 111 South Wacker Drive Chicago IL 60606 990 2011-07-01 362170840 Copley Memorial Hospital Inc c/o Rush-Copley Medical Ctr COPL 6309786200 2000 Ogden Avenue Aurora IL 605044206 Brenda VanWyhe 6309786200 2013-05-09 1 Margaret Grinnell P00538660 3124861000 2011 2016-03-07 17:11:31Z Barry Finn 2000 Ogden Avenue Aurora IL 605044206 424299394 0 X www.rushcopley.com X 1886 IL To provide advanced medicine with quality outcomes and extraordinary care. 19 16 1854 300 0 0 1965618 1233078 267943666 259634483 3639156 9412271 703514 684692 274251954 270964524 24679 20545 0 0 109990657 116659646 0 0 0 136590734 117710952 246606070 234391143 27645884 36573381 311504046 367178403 172324068 213125243 139179978 154053160 X The mission of Rush-Copley is to provide advanced medicine with quality outcome and extraordinary care. 0 0 177920074 20545 259619994 Copley Memorial Hospital's mission is to provide advanced medicine with quality outcomes and extraordinary care. The focus on advanced medicine is concentrated in Copley Memorial Hospital's centers of excellence or "Institutes". Institutes represent the major service lines of the Medical Center: Cancer Care; Emergency Services; Heart & Vascular; Neuroscience; and Women's Health. The designation of Institutes allows the organization to prioritize among diverse opportunities and focus resources on these service lines. To that end, the medical center seeks to serve the community in ways that engage, educate and empower. In 2011, Copley Memorial Hospital proudly collaborated with dozens of civic and community groups to impact the knowledge, health and well being of the community. Copley Memorial Hospital offers free educational programs ranging from hand hygiene education aimed at preschool and primary grade school aged children to annual seminars educating adults about diabetes, heart health, cancer prevention, weight control, smoking cessation and more.A bimonthly newsletter is published and highlights health information and calendar of events info to 70,000+ households throughout the hospital service area. Free and reduced cost health screenings are regularly offered including free blood pressure monitoring on a walk-in basis.Highlighted Health Programming includes:During 2011, Copley Memorial Hospital (the "Hospital") sponsored, partnered or participated in nearly 600 community-based programs and events with special emphasis on improving the health and wellness of adults, children and underserved populations. Nutrition and Weight LossSeven programs aimed at providing sound nutrition advice and weight loss strategies were held during the year. Topics included healthy lunch preparation, women and weight loss, vegetarian cooking and grocery store tours. 54 people attended.Diabetes Presentations about diabetes and related screenings were conducted throughout the year at various community locations. Fasting glucose and blood pressure screenings were provided to 635 community members.Smoking CessationThe Freedom from Smoking class was offered four times with a total of 23 participants. This free eight-week program provides support and the skills needed to quit smoking.Cancer Awareness and InformationSeven classes and programs focusing on cancer were held in the community with over 400 participants. Topics ranged from prostate cancer to skin cancer as well as a course on survivorship. An ongoing yoga series is offered as well as a special celebration of National Cancer Survivors Day.Latina Talks (Platicas Para Mujeres)Latina Talks (Platicas Para Mujeres) is an educational series geared toward the healthcare needs of Latina women. Latina Talks is offered nine times a year from September through May targeting Latina women in the Fox Valley area. Topics presented by professional healthcare providers include From Girl to Young Woman, Menopause, Breast Health, Healthy Cooking demonstration, Discipline and Children and more. Typically, between thirty and fifty women attend the monthly sessions. In addition, Rush-Copley partners with Aurora University nursing students to provide daycare and blood pressure screenings to the women. Over 200 women have benefited from the presentations in the last year.Older Adult EducationEducational and interactive talks designed to provide seniors with health information and education are presented regularly at the Beecher Community Center in Yorkville in collaboration with Kendall County Senior Services. This programming reaches over 400 seniors annually healthcare topics presented by healthcare providers followed by question and answer sessions. These sessions are offered to the senior community at large and take place at Sunnymere, an assisted living facility. Topics include Cholesterol Management, Bone and Joint Health and Acid Reflux Disease. Bi-monthly presentations are attended by annually by 120 seniors.Pregnancy and ChildbirthPrenatal education classes are offered to couples who are pregnant or considering having a baby. Class topics include New Advances in Infertility, Thinking About Having a Baby Healthy Pregnancy Healthy You, Bringing Home Baby and Child Safety. Tours of the Family Birth Center are also provided. Nearly 1,200 people participated in 2011.Physician Referral LineCopley Memorial Hospital offers a free physician and information referral telephone service to the community. This service allows community members to talk with a call advisor to match a person's health needs and preferences with the physician of their choice or link callers to services provided by the medical center. Over 27,000 people used this service in 2011.WebsiteCopley Memorial Hospital's website, rushcopley.com, with translation available into dozens of languages, offers access to free health information including interactive quizzes and assessments, a health encyclopedia, video library, guide to the body and its 12 systems, a symptom checker along with health and wellness tools to assess personal health conditions. In 2011, there were over 700,000 visitors to rushcopley.com.Copley Memorial Hospital provides a free speaker's bureau to community-based groups and routinely participates and sponsors health fairs aimed at minority populations including the yearly African American Health Fair and the annual Latina Health Festival.Together, these initiatives provided a positive influence for thousands of residents in the communities served by Copley Memorial Hospital.Charity Care - It is an inherent part of the Hospital's mission to provide necessary medical care free of charge, or at a discount, to individuals without insurance or other means of paying for such care. As the amounts determined to qualify for charity care are not pursued for collection, they are not reported as patient service revenue. The Hospital has an established charity care policy and maintains records to identify and monitor the level of charity care it provides. The Hospital provides free care to all patients who apply and support income and asset levels of less than 300% of the current-year poverty level and discounts balances under 600% of the poverty level. Interest-free payment plans are also provided. These charity care records include the estimated cost of unreimbursed services provided and supplies furnished under its charity care policy and the excess of cost over reimbursement for Medicaid patients. The Hospital also monitors the unreimbursed cost of patient bad debts. 177920074 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 0 1 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 109 0 1 1854 1 0 0 0 0 0 0 0 0 0 0 0 X 19 16 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 IL X Brenda VanWyhe 6309786200 2000 Ogden Avenue Aurora IL 60504 X Mark Metzger 1.00 X 0 0 0 William Skoglund 1.00 X 0 0 0 Trish Anen 1.00 X 0 0 0 Cati Cederoth start 1011 1.00 X 0 0 0 Bruce Dienst 1.00 X 0 0 0 Richard Edelman 1.00 X 0 0 0 Tom Fisher 1.00 X 0 0 0 Santosh Gill MD 40.00 X 566285 0 55749 Ronald Hem 1.00 X 0 0 0 Dennis Keane MD 1.00 X 13750 0 0 Herbert Knight 1.00 X 0 0 0 John Lies 1.00 X 0 0 0 Maryanne Locklin 1.00 X 0 0 0 Jack McEachern End 1011 1.00 X 0 0 0 Dave Mead 1.00 X 0 0 0 Avery Miller 1.00 X 0 0 0 Jerome Roberts 1.00 X 0 0 0 Christine Sobek 1.00 X 0 0 0 Suresh Velagapudi MD 1.00 X 0 0 0 Barry Finn 40.00 X X 1463800 0 373282 Brenda VanWyhe 40.00 X 320176 0 73383 Ryan Asmus 40.00 X 258280 0 67895 Lynn Scott 40.00 X 71874 0 18141 Steve Lowenthal MD 40.00 X 623868 0 45111 John Diederich 40.00 X 465776 0 159760 Diane Homan MD 40.00 X 437416 0 100716 Dennis DeMasie 40.00 X 329547 0 85568 Mary Shilkaitis 40.00 X 317738 0 81690 Gail Bumgarner 40.00 X 343586 0 63861 Barbara Graham 40.00 X 217743 0 19419 Suzanne Sterchi 40.00 X 151514 0 31885 Sepehr Sani MD 40.00 X 1178320 0 25673 Todd Guynn MD 40.00 X 763010 0 59493 Teressa Alexander MD 40.00 X 563499 0 54705 Edward Lipman MD 40.00 X 532036 0 47512 Vijay Shah MD 40.00 X 515847 0 54816 9134065 0 1418659 165 0 1 0 Sodexho 4880 Paysphere Circle Chicago IL 60674 Food and Cleaning Service 3325656 Anthelio One Lincoln Center Suite 200 5400 Dallas TX 75240 Medical Records Management 875000 Advocate Medical Group 1875 Dempster Suite 325 Park Ridge IL 60068 Medical Services 864669 Fox Valley Acute Dialysis 1300 Waterford Drive Lower Level Aurora IL 60504 Dialysis 625524 Anderson Mikos Architects 1420 Kensington Road Suite 306 Oak Brook IL 60523 Architects 326259 14 655243 577835 1233078 Net Patient Revenue 621110 247647803 247647803 Medicaid Tax Revenue 621110 13466454 13466454 Other Program Revenue 900099 -1479774 -1479774 259634483 3199765 3199765 136796 136796 1764893 1399109 365784 365784 365784 157978137 33334 151935761 0 6042376 33334 6075710 6075710 Outside Service Rev. 621990 617976 617976 Gift Shop Revenue 453220 213434 213434 Cafeteria Revenue 621990 111335 111335 -623837 -632465 8628 318908 270964524 259619994 0 10111452 20545 20545 6932166 6932166 84140187 63115453 21024734 3467343 2600507 866836 14884935 11163701 3721234 7235015 5426261 1808754 4836976 3627732 1209244 627439 627439 165349 165349 117305 87979 29326 3357952 2518464 839488 1194742 1194742 53469284 40101963 13367321 9801435 7351076 2450359 4447766 3335824 1111942 113019 84764 28255 128787 96590 32197 7191469 7191469 16108420 16108420 7289879 5467409 1822470 Medicaid Provider Tax 7125302 7125302 Laundry 813487 813487 Consulting 524892 524892 397449 -36506 433955 234391143 177920074 56471069 0 24936230 32064640 38268349 44464193 4136968 4474935 2916629 9839546 316958825 180893548 136686624 136065277 97918642 115889739 6640604 24380073 311504046 367178403 74513594 108752898 91253999 90552297 6556475 13820048 172324068 213125243 X 135284712 149675080 3895266 4378080 0 139179978 154053160 311504046 367178403 X 36573381 -21700199 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 34525 34525 0 Part IV, Supplemental Information: Part II-B, Line 1i: Copley Memorial Hospital is a member of various organizations that advocate on legal and policy issues that affect healthcare. A portion of the annual membership dues paid by Copley Memorial Hospital to these organizations is attributable to lobbying activities. 10648390 1409175 364134 1290495 11131204 9770170 878220 1349773 1349773 10648390 9053445 716725 613671 613671 9770170 8795988 257457 -747024 -747024 9053445 0.62200 0.37800 0 1 1 16749318 16749318 191596683 99324069 92272614 108415544 81569479 26846065 197280 197280 136065277 Long Term Malpractice AR Gross-Up 20300417 Unamortized Financing Costs 2279228 Invest Riverwest Oncology 1774527 Invest Home Health 463483 Invest Rush Copley Cardiovascular -445582 Other 8000 24380073 Long Term Market Adjustment Swap Liability 10460170 Long Term SERP 3127714 Long Term Deferred Rent Obligation 232164 13820048 270964524 234391143 36573381 -6296956 -15403243 -21700199 14873182 267080727 -6296956 2413159 -3883797 270964524 0 270964524 242125276 7734133 7734133 234391143 0 234391143 Description of Intended Use of Endowment Funds: Part V, Line 4: Rush Copley Foundation holds the Voris (income for CMH Cancer Care), Kobisk (Board restricted income to CMH), Copley (income unrestricted) and Dobbins (income for CMH Women's Health) Endowments. These funds are held for the benefit of Copley Memorial Hospital. Part XI, Line 8 - Other Adjustments: Change in interest in net assets of Foundation 209,341. Swap value adjustment -5,320,974. Transfer of assets to affiliate-net -10,291,610. Total to Schedule D, Part XI, Line 8: -15,403,243. Part XII, Line 2d - Other Adjustments: RCCC revenue to reconcile to CMH corporate not consolidated 4,329,487. RCCC revenue elimination to reconcile to CMH corporate not consolidated 2,020,710. Rental expenses-2020 Ogden POB1 & 1100 W Veterans Pkwy Yorkville POB 1,383,936. Swap value adjustment -5,320,974. Part XIII, Line 2d - Other Adjustments: RCCC expenses to reconcile to CMH corporate not consolidated 6,350,197. Rental expenses-2020 Ogden POB1 & 1100 W Veterans Pkwy Yorkville POB 1,383,936. 1 1 1 X 300.000000000000 1 X 600.000000000000 1 1 1 0 1 1 8375614 8375614 0.03570 47506857 38087510 9419347 0.04020 55882471 38087510 17794961 0.07590 488817 488817 0.00210 2926480 622791 2303689 0.00980 20545 20545 0.00010 3435842 622791 2813051 0.01200 59318313 38710301 20608012 0.08790 1 23540541 2354054 68342536 80518219 -12175683 X 1 1 1 1 Copley Memorial Hospital

2000 Ogden Avenue Aurora IL 605044206

X X X X Copley Memorial Hospital 1 1 1 300.000000000000 1 600.000000000000 1 X X 1 1 X X 1 0 1 X 0 0 4 River West Radiation Center LLC

1221 N Highland Avenue Aurora IL 605044206

JV Oncology Community Alliance Home Health

4050 Healthway Drive Aurora IL 605044206

JV Home Health Rush-Copley Healthcare Center

1100 West Veterans Parkway Yorkville IL 60560

Convenient Care Rush-Copley Cardiovascular Consultants

2000 Ogden Avenue Aurora IL 605044206

Cardiovascular Services Part I, Line 7: A cost accounting system was used to calculate the amounts reported in the table and a cost to charge ratio was utilized. The cost accounting system addresses all patient segments (Inpatient, Outpatient, Emergency Room, Private Insurance, Medicaid, Medicare, Uninsured and Self-Pay. Part III, Line 4: Net patient service revenue is reported at the estimated net realizable amounts from third-party payors, patients, and others for services rendered. The Hospital has agreements with third-party payors that provide for payments at amounts different from established rates. Payment arrangements include prospectively determined rates per discharge, reimbursed costs, per diem payments, and discounted charges, including estimated retroactive settlements under payment agreements with third-party payors.The Hospital recognizes patient service revenue associated with services provided to patients who have third-party payor coverage on the basis of contractual rates for the services rendered. Provisions for adjustments to net patient service revenue are accrued on an estimated basis in the period the related services are rendered and adjusted in future periods as final settlements are determined. For uninsured patients that do not qualify for charity care, the Hospital recognizes revenue based on its discounted rates. On the basis of historical experience, a significant portion of the Hospital's uninsured patients will be unable or unwilling to pay for the services provided. Thus, the Hospital records a significant provision for uncollectible accounts related to uninsured patients in the period the services are provided. Patient service revenue, net of contractual allowances and discounts (but before the provision for uncollectible accounts), recognized in the period from these major payor sources, is as follows:Patient Service Revenue (Net of Contractual Allowances and Discounts) Third-Party PayorsFiscal year 2012 - $265,679Fiscal year 2011 - $254,246Self-PayFiscal year 2012 - $22,180Fiscal year 2011 - $16,757Total All PayorsFiscal year 2012 - $287,859Fiscal year 2011 - $271,003Patient accounts receivable are based on gross charges and stated at net realizable value. Accounts receivable are reduced by an allowance for contractual adjustments, based on expected payment rates from payors under current reimbursement methodologies, and also by an allowance for doubtful accounts. In evaluating the collectability of accounts receivable, the Hospital analyzes its past history and identifies trends for each of its major payor sources of revenue to estimate appropriate allowance for doubtful accounts and provision for uncollectible accounts based upon management's assessment of historical and expected net collections considering business and economic conditions, trends in health care coverage, and other collection indicators. Management regularly reviews data about these major payor sources of revenue in evaluating the sufficiency of the allowance for contractual adjustments and allowance for doubtful accounts.For receivables associated with services provided to patients who have third-party coverage, the Hospital analyzes contractually due amounts and provides an allowance for doubtful accounts and a provision for uncollectible accounts (for example, for expected uncollectible deductibles and copayments on accounts for which the third-party payor has not yet paid, or for payors who are known to be having financial difficulties that make the realization of amounts due unlikely). For receivables associated with self-pay patients (which includes both patients without insurance and patients with deductible and copayment balances due for which third-party coverage exists for part of the bill), the Hospital records a significant provision for uncollectible accounts in the period of service on the basis of its past experience, which indicates that many patients are unable or unwilling to pay the portion of their bill for which they are financially responsible.The difference between the discounted rates and the amounts actually collected after all reasonable collection efforts have been exhausted is charged off against the allowance for doubtful accounts in the period they are determined uncollectible.The Hospital's allowance for doubtful accounts for self-pay patients increased from 33% of self-pay accounts receivable at June 30, 2011, to 34% of self-pay accounts receivable as of June 30, 2012. In addition, the Hospital's self-pay write-offs decreased by $5,006, from $29,597 for fiscal year 2011 to $24,591 for fiscal year 2012. The increase in percent of self-pay accounts was due to higher self-pay volumes. The decrease in self-pay write-offs was due to an increase in patients qualifying for charity. The Hospital does not maintain a material allowance for doubtful accounts from third-party payors, nor did it have significant write-offs from third-party payors.Bad debt amounts reported on Part III, Line 2 are reported at charges. Part III, Line 8: All of the shortfall reported in line 7 should be treated as community benefit because if we did not provide the service, the burden of the costs would fall on the government. Costs of treating Medicare patients are calculated using the IRS calculated percentage. Part III, Line 9b: It is our policy not to pursue collection practices against patients known to qualify for Charity Care or other financial assistance. In certain cases it may not be easily determined whether or not a patient qualifies for Charity Care or financial assistance. However, if after collection practices have begun, it later becomes known the patient qualifies, the collection efforts cease. Copley Memorial Hospital Part V, Section B, Line 13g: A summary of the FAP policy is available on the website and at the hospital emergency room and admissions areas. Copley Memorial Hospital Part V, Section B, Line 19d: Self Pay discount of 30% applied to the same total charges billed to all patients. Part VI, Line 2: Community need is assessed through review of community and hospital data, periodic assessments with physician and clinicians, and reporting of information from hospital committees. Further input from the community arises from the community based board of directors, various forms of patient input, and hospital involvement with government, health industry, and community agencies. The hospital also actively participates in formal needs assessments conducted by government and community agencies. Part VI, Line 3: At the time of service, Copley Memorial Hospital patients are given a billing brochure, which describes the financial assistance/charity program availability. This information is also posted at the registration check-in desks, in an inpatient guide, and on the Rush Copley website. Financial counselors are available to explain the program in detail to patients who are seen without insurance coverage. All patient billing statements advise the patients to call and inquire on the details as needed. Part VI, Line 4: Copley Memorial Hospital's primary service area is approximately Kane County and Kendall County, Illinois located 45 to 55 miles Southwest of Chicago. Kane County has a population of 512,000 people and is predominantly urban and suburban. Nearly 29% of the population is of Hispanic or Latino origin. Persons over the age of 65 comprise 8.6% of the population, and the poverty rate is 9.0%. Aurora, the second largest city in Illinois, dominates the county. Historically an industrial city, Aurora has experienced a considerable loss of manufacturing jobs and is transitioning its economy. Kendall County, to the south of Kane, has a population of 105,000. Persons over the age of 65 comprise 6.7% of the population and the poverty rate is 3.4%. The Northwest section of the county is suburban while the remainder is rural. Part VI, Line 5: Copley Memorial Hospital's mission is to provide advanced medicine with quality outcomes and extraordinary care. To that end, the Medical Center seeks to serve the community in ways that engage, educate and empower. Copley Memorial Hospital serves all patients who present for care and serves the surrounding community along with a Board of Directors with a strong community base. The Board Members are independent community leaders and are selected based upon their expertise and experience in a variety of areas of benefit to the organization and their role as Board Members who direct and guide management in carrying out our mission. Board Members are not compensated for their service. As a charitable organization, all surplus funds are used to further our charitable purpose, mission and to serve the community. Some of our primary programs are: community health fairs, breastfeeding education classes, child care classes, etc. Copley Memorial Hospital provides access to physician, acute care, diagnostic, and rehabilitative services to people, regardless of ability to pay, through a number of facilities and services located throughout the service area. It provides programming relating to health education, prevention, and support targeted to specific populations. Medical education extends to clinical settings for nursing education and a family practice residency. Employees fill board and committee leadership positions for a number of economic development and social service agencies in communities throughout the service area. Part VI, Line 6: Copley Memorial Hospital has an affiliation with Rush University Medical Center that covers governance and other organizational relationships. Both organizations are parties to a master trust indenture that established an obligated group for purposes of issuing long-term debt. Reports Filed With States Part VI, Line 7 IL X X 1 0 X X X X X X 0 1 0 0 0 0 0 1 0 Santosh Gill MD 345497 0 157912 0 62876 0 13853 0 41896 0 622034 0 0 0 Barry Finn 563803 0 810624 0 89373 0 332445 0 40837 0 1837082 0 0 0 Brenda VanWyhe 219498 0 94275 0 6403 0 49870 0 23513 0 393559 0 0 0 Ryan Asmus 164243 0 86190 0 7847 0 35024 0 32871 0 326175 0 0 0 Steve Lowenthal MD 374699 0 192001 0 57168 0 13946 0 31165 0 668979 0 0 0 John Diederich 293278 0 146700 0 25798 0 125949 0 33811 0 625536 0 0 0 Diane Homan MD 267337 0 138493 0 31586 0 63544 0 37172 0 538132 0 0 0 Dennis DeMasie 207288 0 109512 0 12747 0 48329 0 37239 0 415115 0 0 0 Mary Shilkaitis 201743 0 105963 0 10032 0 46676 0 35014 0 399428 0 0 0 Gail Bumgarner 227630 0 101430 0 14526 0 49363 0 14498 0 407447 0 0 0 Barbara Graham 148234 0 62850 0 6659 0 6873 0 12546 0 237162 0 0 0 Suzanne Sterchi 146084 0 4750 0 680 0 7181 0 24704 0 183399 0 0 0 Sepehr Sani MD 630621 0 400000 0 147699 0 13946 0 11727 0 1203993 0 0 0 Todd Guynn MD 697950 0 0 0 65060 0 13946 0 45547 0 822503 0 0 0 Teressa Alexander MD 263229 0 272777 0 27493 0 13946 0 40759 0 618204 0 0 0 Edward Lipman MD 344247 0 179432 0 8357 0 13946 0 33566 0 579548 0 0 0 Vijay Shah MD 344247 0 148529 0 23071 0 13146 0 41670 0 570663 0 0 0 Part I, Line 1a Three officers, one director, seven key employees, one former key employee, and five highest compensated employees receive gross-up payments related to benefit plans. The gross-up payments made were in relation to a program that was discontinued in 2011. Such payments are no longer provided by the organization. The organization provides to all employees the use of an athletic facility that is owned and operated by a related tax exempt organization. Part I, Line 4b SERP PLAN of CMH (Accruals): Barry Finn $318,499, Mary Shilkaitis $35,250, John Diederich $112,003, Steve Lowenthal $0, Dennis DeMasie $36,412, Diane Homan $50,215, Brenda VanWyhe $37,323, Gail Bumgarner $37,117 and Ryan Asmus $27,620. Please note that these amounts are included in the amounts listed on Schedule J, Part II, Column C. There is no constructive receipt of these amounts by the individuals until they are paid out as they are subject to a substantial risk of forfeiture. Any individual payouts would be included as reportable compensation on the recipient's annual W2 form. There were no payouts in 2011. Part I, Line 7 Incentive bonus plan based on a series of approved strategic accomplishments. Supplemental Information Part III Part II, Column (B)(ii), Barry Finn Bonus & incentive compensation: A portion of this bonus payment was for performance provided over a five year time period, which was equivalent to $100,000 a year. Supplemental Information Part III Part II, Column (B)(ii), Physician Bonus & incentive compensation: Physician bonuses were paid based on individual productivity goals. Illinois Finance Authority 861091967 45200FHN2 2008-05-28 34772005 See Part VI 0 0 0 Illinois Finance Authority 861091967 45200FTZ2 2009-02-10 34075527 Construction of Replace Hosp & ICU addition 0 0 0 Illinois Finance Authority 861091967 45200FYT0 2009-07-29 25912180 New Construction Hospital Campus 0 0 0 34772005 3099542 540878 34231127 1 0 1 1 34075527 3413692 498260 32745950 2009 0 0 1 1 25912180 2585732 401472 22919490 2009 0 0 1 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 1 1 0 0.00000 0.00000 0.00000 1 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 1 Schedule K Supplental Information Schedule K, Part I, line A, column (e): Issue Price of bonds of $34,772,005 does not tie to Form 8038 Part III Line 21(b) of $98,278,724. This is because the $34,772,005 is Copley Memorial Hospital's 35.38% prorata share of the $98,278,724 Obligated Group amount issued. Schedule K, Part I, line A, column (f): The Series 2006B Fixed Rate bonds currently refunded (as a reissuance) the Series 2006B Auction Rate bonds issued 8/17/2006, which were issued to refund pre-2003 bond issues. Form 990, Part VI, Section A, line 2 Many of the persons listed on Part VII have a "business relationship" with each other by virtue of sitting on related Rush-Copley Medical Center entity boards. Barry Finn, CMH President & CEO/Director, and William Skoglund, CMH Vice Chairman of the Board/Director, have a business relationship. Barry Finn is a board member at Old Second National Bank and William Skoglund is the Chairman and CEO at Old Second National Bank. Mr. Skoglund does not serve on Copley Memorial Hospital's compensation committee and has recused himself from any discussions or votes that involve Mr. Finn's salary. Form 990, Part VI, Section A, line 6 Rush-Copley Medical Center, Inc. ("RCMC") is the sole corporate member of Copley Memorial Hospital, Inc. ("CMH"), Rush-Copley Medical Group, NFP ("RCMG"), Copley Ventures, Inc. ("CV"), and Rush-Copley Foundation ("RCF"). Form 990, Part VI, Section A, line 7a CMH's Board of Directors includes at least nine (9) individuals elected by the sole corporate member, RCMC. Each of these elected directors is also a member of the Governing Board of CMH's sole corporate member, RCMC. The election and re-election of all CMH directors is at the direction of RCMC at the annual Governing Board meeting. Vacancies on the CMH Board of Directors are filled by CMH's sole corporate member, RCMC. In accordance with certain procedural requirements stated in the bylaws, elected directors may be removed by the affirmative vote of two-thirds of the board of directors of CMH's sole corporate member, RCMC. Form 990, Part VI, Section A, line 7b The Board of Directors of CMH's sole corporate member, RCMC, has the following exclusive powers over CMH: (1) the borrowing of any sum, the principal of which exceeds $500,000.00, or which has a stated term of greater than one year, or which is secured by a mortgage of all or any portion of CMH's real property or the creation of a security interest in CMH's assets, including personal property and revenues, for the benefit of the lender, lessor or vendor, or the defeasance, advance payment or cancellation of any outstanding debt of the category described herein; (2) any voluntary dissolution, merger, consolidation, sale or transfer of any of CMH's assets which exceeds one percent (1%) of CMH's total assets or any creation of a subsidiary or affiliate of CMH; (3) application to the Illinois Health Facilities Planning Board or any successor for a permit or certificate of need for a proposed activity, whether or not involving a capital expenditure; (4) approval of all annual and long-term capital and operational budgets; (5) any amendment to the Articles of Incorporation or Bylaws of CMH; (6) any agreement or transaction, either of which is of a material nature, with another corporation controlled by or affiliated with CMH's sole corporate member, RCMC, or which is a subsidiary of RCMC; (7) approval of any new or changes to existing long-term or master strategic plan; and (8) sale of any of CMH's real property or interest therein or purchases of any additional real estate. Form 990, Part VI, Section B, line 11 The Form 990 tax return is prepared by our external tax advisor with data provided by our organization. A draft of the Form 990 is provided to management for review and comment. The Board of Directors is provided with an approved copy of the Form 990 before it is filed. Form 990, Part VI, Section B, line 12c Annually, Officers, Directors, Key Employees, Management Team (Department Directors and Managers), and Billing Office personnel of Copley Memorial Hospital, Inc. are required to disclose interests that could give rise to conflicts. The conflict of interest statements are submitted and reviewed by the Chief Compliance Officer and the Audit and Corporate Integrity Committee of the Board. Those key personnel with conflicts are advised to recuse themselves from participating in decision-making related to the conflict. Form 990, Part VI, Section B, line 15 With respect to the CEO/VP's of the organization and key senior management, the organization follows a compensation approval procedure annually that involves approval of proposed and final compensation arragements by the organization's Compensation Committee and full board of Directors using comparability data, as well as contemporaneous documentation of compensation decisions in minutes. Form 990, Part VI, Section C, line 19 Form 990 available upon request. The organization does not make its governing documents or conflict of interest policy available to the public. Copies of the financial statements (whether or not audited) are provided upon reasonable request such as for a bank loan or to a bond rating agency. The financial statements are available on the Attorney General's website. Average hours devoted to related organizations: Form 990, Part VII, Section A: 1 hour per week devoted to related organization (Rush Copley Medical Center)- Barry Finn, Brenda VanWyhe, Ryan Asmus, Lynn Scott, Santosh Gill, M.D., Mark Metzger, William Skoglund, Trish Anen, Cati Cederoth, Bruce Dienst, Richard Edelman, Tom Fisher, Dennis Keane, Herbert Knight, Ronald Hem, John Lies, Maryanne Locklin, Dave Mead, Avery Miller, Jerome Roberts, Christine Sobek, Suresh Velagapudi. 1 hour per week devoted to related organization (Copley Ventures)- Barry Finn, Brenda VanWyhe, Ryan Asmus, Lynn Scott, John Diedrich. 1 hour per week devoted to related organization (Rush Copley Foundation)- Barry Finn, Brenda Vanwyhe, Ryan Asmus, Christine Weincek. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized losses on investments: -6,296,956. Change in interest in net assets of Foundation 209,341. Swap value adjustment -5,320,974. Transfer of assets to affiliate-net -10,291,610. Total to Form 990, Part XI, Line 5: -21,700,199. Rush Copley Medical Center Inc 2000 Ogden Avenue Aurora IL 60504 363193787 Parent Company IL 501(c)(3) 11A N/A 0 Rush Copley Health Care System Inc 2000 Ogden Avenue Aurora IL 60504 363584043 Bridge Board RCMC & RUMC IL 501(c)(3) 11A N/A 0 Rush-Copley Foundation 2000 Ogden Avenue Aurora IL 60504 363093877 Grants to Charitable Organizations IL 501(c)(3) 7 Rush-Copley Medical Center Inc 1 Copley Ventures Inc 2000 Ogden Avenue Aurora IL 60504 363370216 Rental Prop., Infirmary care, and Healthplex Fitness Center IL 501(c)(3) 3 Rush-Copley Medical Center Inc 1 Rush University Medical Center 1700 West Van Buren Street Chicago IL 60612 362174823 Hospitals IL 501(c)(3) 3 N/A 0 Yorkville Physical Therapy & Sports Medicine Center LLC 2000 Ogden Avenue Aurora IL 60504 364236345 Physical Therapy & Sports Medicine IL N/A Rush Copley Cardiovascular Consultants LLC 2000 Ogden Avenue Aurora IL 60504 273234201 Cardiovascular Medicine IL Copley Medical Center Inc Related -20202 3424233 0 0 1.00000 Rush Copley Medical Group NFP 2000 Ogden Avenue Aurora IL 60504 363235315 Physician Practices IL Rush-Copley Medical Center Inc C -4869291 6647800 1.00000 1 0 1 0 0 0 0 1 0 1 0 0 0 0 0 0 1 0 Rush Copley Medical Group NFP A 998329 Fair Market Value Rush Copley Foundation C 655243 Fair Market Value Rush Copley Medical Center Inc H 10291610 Fair Market Value Copley Ventures Inc J 569325 Fair Market Value Copley Ventures Inc Q 468000 Fair Market Value