2013-04-24T12:21:43-05:00 2012-06-30 911194016 CLARK NUBER PS 10900 NE 4TH STREET SUITE 1700 BELLEVUE WA 98004 990 2011-07-01 911538852 PEACEHEALTH ST JOHN MEDICAL CENTER FOUNDATION PEAC 3604147900 1615 DELAWARE LONGVIEW WA 98632 CATHY BARR 3604147900 2013-04-24 1 SARA ELIZABETH J HYRE P00235495 4254544919 2013-04-24 2011 2016-03-07 17:11:31Z CATHY BARR 1615 DELAWARE LONGVIEW WA 98632 1870295 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. 24 20 0 100 0 0 1472995 1615880 0 0 64426 36979 -13692 12823 1523729 1665682 1253827 825484 0 0 0 0 15445 17284 30450 193334 244296 1462606 1087064 61123 578618 7058706 7367301 2221402 2388362 4837304 4978939 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 169720 169720 UNRESTRICTED FUNDS - FUNDS RAISED WITH NO SPECIFIC PROJECT RESTRICTION ARE USED TO SUPPORT THE GENERAL OPERATING AND CAPITAL NEEDS OF THE HOSPITAL. 143490 143490 DIALYSIS - PROJECT TO RAISE FUNDS TO SUPPORT THE HOSPITAL'S DIALYSIS SERVICES TO THE COMMUNITY, BY SUPPORTING CAPITAL PROJECTS AND EQUIPMENT PURCHASES. 125238 125238 SPINE PROGRAM - PROJECT TO RAISE FUNDS FOR THE PURCHASE OF SPECIALIZED EQUIPMENT FOR THE HOSPITAL'S NEW SPINE PROGRAM, FOR USE BY THE HOSPITAL'S SPINE SURGEON DURING PROCEDURES. 387036 387036 THE ORGANIZATION HAS A VARIETY OF OTHER PROGRAM SERVICE ACCOMPLISHMENTS:NAME OF PROGRAM EXPENSES GRANTSJOINT REPLACEMENT FUND $111,291 $111,291OBSTETRICS $57,915 $57,915CRITICAL CARE FUND $47,877 $47,877ALL OTHER PROGRAM SERVICE $169,943 $169,943TOTAL $387,036 $387,036 387036 387036 825484 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 0 1 3 0 1 0 0 0 0 0 0 1 1 0 0 0 0 X 24 20 0 0 0 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 X X 0 0 0 STEVEN CABRALES MD 1.00 X X 0 368122 32810 CHRIS SEARING 1.00 X X 0 0 0 PAULINE KIRCHNER 1.00 X X 0 0 0 MICHAEL MCNELLIS MD 1.00 X 0 317295 36885 JOHN BERWIND 1.00 X 0 0 0 BILL BOEHM 1.00 X 0 0 0 DON CIANCI 1.00 X 0 0 0 SUZANNE CUSICK 1.00 X 0 0 0 LINDA DOERR 1.00 X 0 0 0 EARL FISHER 1.00 X 0 0 0 DENISE GABEL 1.00 X 0 0 0 GENE GUTTORMSEN 1.00 X 0 0 0 STEVE JABUSCH 1.00 X 0 0 0 JULIE KENDALL 1.00 X 0 0 0 GWEN LARSON 1.00 X 0 0 0 JAMES NAKASHIMA MD 1.00 X 0 207469 43077 ROSE MARIE NIGRO 1.00 X 0 0 0 MARK PURCELL 1.00 X 0 0 0 TOM RENAUD 1.00 X 0 0 0 PAT SARI 1.00 X 0 0 0 DOUGLAS STAFFORD 1.00 X 0 0 0 JUDIE WILSON 1.00 X 0 0 0 JOSIAH JOHNSON 1.00 X 0 385445 38279 CATHY BARR 40.00 X 0 116758 28692 0 1395089 179743 0 0 1 0 0 259626 1356254 498109 1615880 57665 57665 10800 0 10800 10800 10800 63903 84589 -20686 -20686 -20686 101674 259626 120024 -18350 -18350 13065 0 13065 13065 TAX REFUND 900099 7308 7308 7308 1665682 0 0 49802 825484 825484 47613 47613 17284 17284 11374 11374 5950 5950 94383 94383 18221 18221 REPAIR & MAINTENANCE 37305 37305 IND. FUNDRAISING EXP. 13166 13166 PROPERTY TAXES 10205 10205 BAD DEBT 6079 6079 1087064 825484 231130 30450 81362 81074 393688 660892 299388 149091 10194 12697 520684 0 284000 520684 2802948 2719108 3187126 3223755 7058706 7367301 13360 12500 63894 2144148 2375862 2221402 2388362 X 1318393 1487352 2503994 2420432 1014917 1071155 4837304 4978939 7058706 7367301 X 578618 -436983 X 0 1 1 X 0 X 920488 758558 989924 1472995 1615880 5757845 920488 758558 989924 1472995 1615880 5757845 1020227 4737618 152874 102481 62671 61878 68465 448369 7308 7308 6213522 0.76250 0.83850 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 1525574 59885 -33723 34319 327052 1190365 1273932 33599 241023 22980 1525574 1139166 11410 164123 40767 1273932 1403528 6452 -230851 39963 1139166 0.89990 0.10010 0 0 520684 520684 520684 CASH VALUE OF LIFE INSURANCE 153704 SPLIT-INTEREST AGREEMENTS 3070051 3223755 SPLIT-INTEREST AGREEMENTS 2375862 2375862 1665682 1087064 578618 -118386 -318597 -436983 141635 1872222 -118386 581761 -318597 144778 1727444 -61762 -61762 1665682 1730587 581761 61762 643523 1087064 0 1087064 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 8 - OTHER ADJUSTMENTS: SPLIT INTEREST VALUE CHANGE -318,597. PART XII, LINE 2D - OTHER ADJUSTMENTS: SPLIT INTEREST VALUE CHANGE -318,597. PART XII, LINE 4B - OTHER ADJUSTMENTS: SPECIAL EVENT EXPENSES REPORTED ON AFS AS EXPENSES -61,762. PART XIII, LINE 2D - OTHER ADJUSTMENTS: SPECIAL EVENT EXPENSES REPORTED ON AFS AS EXPENSES 61,762. X X X X X 1 PAT MARTIN 2621 CASCADE WAY LONGVIEW WA 98632 GRANT WRITER 0 44500 17284 27216 44500 17284 27216 WA GOLF TOURNAMENT 154483 132270 22213 10194 1000 7354 9180 DECEMBER GALA 176714 110958 65756 11660 16217 200 51270 2 30103 16398 13705 2973 6629 1000 2347 361300 259626 101674 10194 15633 30200 1200 62797 120024 -18350 1 PEACEHEALTH ST JOHN MEDICAL CENTER 1615 DELAWARE STREET LONGVIEW WA 98632 910939479 501(C)(3) 825482 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 0 0 0 0 0 0 0 0 STEVEN CABRALES MD 0 368122 0 0 0 0 0 9809 0 23001 0 400932 0 0 MICHAEL MCNELLIS MD 0 317295 0 0 0 0 0 15335 0 21550 0 354180 0 0 JAMES NAKASHIMA MD 0 207469 0 0 0 0 0 13091 0 29986 0 250546 0 0 JOSIAH JOHNSON 0 385445 0 0 0 0 0 9809 0 28470 0 423724 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. CLARK NUBER PS GREATER THAN 5% SHAREHOLDER IS SISTER-IN-LAW OF BOARD MEMBER 47613 ACCOUNTING SERVICES 0 X 1 234198 FMV X AUCTION ITEMS 202 58262 FMV X GIFT ANNUITY PROPERTY 2 205649 FMV 0 0 1 0 METHOD FOR DETERMINING NUMBER OF CONTRIBUTORS: 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. 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. 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 & HOURS FOR RELATED ORGANIZATIONS: 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 $581,761 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 5: NET UNREALIZED LOSSES ON INVESTMENTS: -118,386. SPLIT INTEREST VALUE CHANGE -318,597. TOTAL TO FORM 990, PART XI, LINE 5: -436,983. PEACEHEALTH 1115 SE 164TH AVENUE VANCOUVER WA 98683 910939479 HOSPITAL WA 501(C)(3) 3 PEACEHEALTH 0 VISITING NURSE FOUNDATION 800 E CHESTNUT ST SUITE 1C 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 1 1 0 0 0 0