2013-05-14T10:49:32-05:00 2012-06-30 410746749 CLIFTONLARSONALLEN LLP 101 N TRYON STREET SUITE 1000 CHARLOTTE NC 28246 990 2011-07-01 566052117 THE REX HEALTHCARE FOUNDATION INC REXH 9197844424 4420 LAKE BOONE TRAIL RALEIGH NC 27607 BERNADETTE SPONG 9197843100 2013-05-13 1 JOHN NORMAN P01506766 7049985200 2011 2016-02-24 21:20:13Z DAVID STRONG 4420 LAKE BOONE TRAIL RALEIGH NC 27607 6529889 0 X WWW.REXHEALTH.COM/FOUNDATION X 1958 NC TO PROVIDE OPPORTUNITIES FOR OUR COMMUNITY TO INVEST RESOURCES IN THE EXCELLENT WORK OF REX HEALTHCARE. 13 10 7 0 0 0 1243136 1643045 0 0 319099 78033 661108 652921 2223343 2373999 1225046 1291083 0 0 606149 653089 34683 65137 798146 231125 204265 2097003 2213574 126340 160425 5166927 5181495 159429 75914 5007498 5105581 TO PROVIDE OPPORTUNITIES FOR OUR COMMUNITY TO INVEST RESOURCES IN THE EXCELLENT WORK OF REX HEALTHCARE. 0 0 1291083 1291083 1643045 THE REX HEALTHCARE FOUNDATION SUPPORTS REX HOSPITAL THROUGH A VARIETY OF PATIENT ASSISTANCE PROGRAMS, ASSISTS IN UPGRADING FACILITIES AND ACQUIRING THE MEDICAL EQUIPMENT NECESSARY TO CONTINUE EXCELLENT HEALTHCARE SERVICES. THESE PROGRAMS INCLUDE A MOBILE MAMMOGRAPHY UNIT THAT TRAVELS THE REGION PROVIDING FREE MAMMOGRAPHY SCREENING SERVICES TO UNDERSERVED PATIENTS, PATIENT ASSISTANCE THROUGH THE REX CANCER CENTER ANGEL FUND, NURSING EDUCATION, BLANKET WARMERS, PATIENT TRANSPORTATION TO TREATMENT AND MORE. 1291083 1 1 0 0 0 0 0 0 0 1 1 0 1 0 0 1 0 1 0 0 0 0 0 1 1 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 7 1 0 0 0 0 0 0 0 0 0 0 X 13 10 0 0 0 0 0 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X BERNADETTE SPONG 9197843100 4420 LAKE BOONE TRAIL RALEIGH NC 27607 X A DALE JENKINS 5.00 X 0 0 0 VINCENT L HOELLERICH MD 2.00 X 0 0 0 JAMES B HYLER 2.00 X 0 0 0 DARLEEN M JOHNS 2.00 X 0 0 0 JEFFREY J LYASH 2.00 X 0 0 0 GARY L PARK 5.00 X 0 700383 222525 ORAGE QUARLES III 2.00 X 0 0 0 WILLIAM ROPER MD 5.00 X 0 748460 159639 MARK A STRIEBEL 2.00 X 0 0 0 ROBERT S THOMAS 2.00 X 0 0 0 TERESA ARTIS 2.00 X 0 0 0 DAVID STRONG 60.00 X X 0 1002936 243305 C HOWARD NYE 2.00 X 0 0 0 BERNADETTE SPONG 60.00 X 0 388036 47100 SYLVIA HACKETT 60.00 X 0 249885 47019 ROBERT B LIVERMAN JR 60.00 X 0 148109 33605 0 3237809 753193 0 0 1 0 0 678659 964386 1643045 176318 176318 3625033 3723318 -98285 -98285 -98285 1085493 432572 652921 652921 2373999 0 0 730954 1291083 1291083 537308 53731 483577 14946 1494 13452 64759 6476 58283 36076 3608 32468 8568 8568 65137 65137 34331 34331 70360 7036 63324 2847 285 2562 58503 5850 52653 7760 776 6984 12331 1233 11098 1397 140 1257 8168 817 7351 2213574 1291083 124345 798146 608744 738424 128930 29188 14595 7990 15226 10929 5821 4297 4408837 4401596 5166927 5181495 159429 75914 159429 75914 X 5007498 5105581 5007498 5105581 5166927 5181495 X 160425 -62342 X X 0 1 1 X 0 X X X 0 0 0 REX HOSPITAL INC 561509260 3 1 1 1 1291083 1 1291083 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 332040 16338 25000 323378 330250 1790 332040 1.00000 0 0 15226 10929 4297 4297 INVESTMENTS 4401596 F 4401596 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE INTENDED USE OF THE ENDOWMENT FUNDS IS TO FURTHER THE MISSION OF REX HEALTHCARE FOUNDATION. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE FOLLOWING FOOTNOTE COMES FROM THE CONSOLIDATED FINANCIAL STATEMENTS OF REX HOSPITAL, INC. D/B/A REX HEALTHCARE. THE FOOTNOTE REFERENCES OTHER MEMBERS OF THE AUDIT CONSOLIDATED GROUP THAT ARE NOT PART OF THIS TAX RETURN: REX, THE HOSPITAL, THE FOUNDATION, AND HOME SERVICES ARE EXEMPT FROM FEDERAL INCOME TAX UNDER SECTION 501(A) AS ORGANIZATIONS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. ENTERPRISES IS A TAXABLE CORPORATION THAT PREVIOUSLY HAD NET OPERATING LOSS CARRYFORWARDS. AS OF JUNE 30, 2012, ENTERPRISES EXHAUSTED THEIR NET OPERATING LOSS CARRYFORWARDS. PHYSICIANS IS A SINGLE MEMBER LIMITED LIABILITY COMPANY THAT HAS ELECTED TO BE TAXED AS A FOR-PROFIT CORPORATION. PHYSICIANS HAD A NET OPERATING LOSS IN 2012 AND 2011. ACCORDINGLY, NO PROVISION FOR INCOME TAXES HAS BEEN REFLECTED IN THE COMBINED FINANCIAL STATEMENTS. X X X X X X 1 CAPITAL DEVELOPMENT SERVICES 633 WEST 4TH STREET SUITE 202 WINSTONSALEM NC 27101 CONSULTING 0 0 0 0 NC GOLF TOURNAMENT 604217 604217 184361 GALA 280395 280395 181333 4 200881 200881 66878 1085493 1085493 432572 432572 652921 EXPLANATION OF FUNDRAISING PAYMENTS SCHEDULE G, PART I, LINE 2B, COLUMN (V) PAID FOR CONSULTING 0 REX HOSPITAL INC 4420 LAKE BOONE TRAIL RALEIGH NC 27607 561509260 501(C)(3) 1291083 GENERAL SUPPORT 1 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: REX HEALTHCARE FOUNDATION'S SOLE RECIPIENT OF ASSISTANCE IS REX HOSPITAL, INC. THE TWO ORGANIZATIONS WORK CLOSELY TOGETHER, SO THEREFORE MONITORING IS REAL-TIME AND CONSISTENT. PART II, LINE 1, COLUMN A REX HOSPITAL, INC. 4420 LAKE BOONE TRAIL, RALEIGH, NC 27607 0 1 0 0 0 0 0 0 0 GARY L PARK 0 693051 0 0 0 7332 0 215595 0 6930 0 922908 0 0 WILLIAM ROPER MD 0 736460 0 0 0 12000 0 154709 0 4930 0 908099 0 0 DAVID STRONG 0 473828 0 189238 0 339870 0 230960 0 12345 0 1246241 0 308940 BERNADETTE SPONG 0 288082 0 78113 0 21841 0 31620 0 15480 0 435136 0 0 SYLVIA HACKETT 0 190383 0 52013 0 7489 0 37376 0 9643 0 296904 0 0 ROBERT B LIVERMAN JR 0 125027 0 11735 0 11347 0 25852 0 7753 0 181714 0 0 PART I, LINE 1A THE ORGANIZATION OFFERS COMPLIMENTARY MEMBERSHIPS TO REX WELLNESS CENTERS FOR THE EXECUTIVE STAFF, BOTH ACTIVE AND RETIRED BOARD MEMBERS AND MEDICAL DIRECTORS. ALL MEMBERS RECEIVING COMPLIMENTARY MEMBERSHIPS ARE REQUIRED TO COMPLETE THE SAME APPLICATION AND TESTING PROCEDURES AS OTHER MEMBERS. CURRENTLY, THERE ARE 11 INDIVIDUALS LISTED THAT RECEIVE COMPLIMENTARY MEMBERSHIPS. THE VALUE OF THE COMPLIMENTARY MEMBERSHIPS IS TREATED AS TAXABLE COMPENSATION AND IS REPORTED ON THE INDIVIDUAL'S W-2. PART I, LINE 4B PART I, LINE 4B, DURING CALENDAR YEAR 2011, DAVID STRONG PARTICIPATED IN A NON QUALIFIED SUPPLEMENTAL RETIREMENT PLAN AND RECEIVED AMOUNTS TOTALING $308,940. HE ALSO EARNED COMPENSATION UNDER THIS PLAN TOTALING $207,533. THE CURRENT YEAR EARNINGS ARE PAYABLE IN THE FUTURE. PART I, LINE 5 EMPLOYEES IN MANAGERIAL ROLES PARTICIPATE IN AN ANNUAL INCENTIVE COMPENSATION PLAN. THE COMPENSATION EARNED UNDER THIS PLAN IS BASED PARTLY ON THE COMBINED EARNINGS OF REX HEALTHCARE, INC. AND ITS SUBSIDIARIES. ADDITIONALLY, THE INCENTIVE COMPENSATION OF THE PRESIDENT AND CFO IS BASED PARTLY ON THE EARNINGS OF THE UNC HEALTH CARE SYSTEM. OTHER PERFORMANCE MEASURES USED TO DETERMINE INCENTIVE COMPENSATION ARE PHYSICIAN SATISFACTION, PATIENT CARE QUALITY OUTCOMES, EFFECTIVE USE OF TECHNOLOGY AND INDIVIDUAL GOALS. FORM 990, PART VI, SECTION A, LINE 7A THE UNIVERSITY OF NORTH CAROLINA HEALTH CARE SYSTEM APPOINTS ALL OF THE THIRTEEN SEATS ON THE ORGANIZATION'S BOARD OF TRUSTEES. FORM 990, PART VI, SECTION A, LINE 7B THE ORGANIZATION'S BOARD REQUIRES PRIOR APPROVAL OF THE UNIVERSITY OF NORTH CAROLINA HEALTH CARE SYSTEM FOR CERTAIN POWERS, INCLUDING BUT NOT LIMITED TO ADDITION OR DELETION OF A HEALTH CARE SERVICE, PARTICIPATION, DIRECTLY OR INDIRECTLY, IN A JOINT VENTURE, INDEBTEDNESS AND CAPITAL BUDGETS, OPERATING BUDGETS AND NON-BUDGETED MATERIAL EXPENDITURES. FORM 990, PART VI, SECTION B, LINE 11 THE ORGANIZATION'S EXECUTIVE TEAM DISCUSSES AND REVIEWS THE FORM 990 AND ALL ASSOCIATED SCHEDULES THROUGHOUT THE INFORMATION GATHERING STAGE. THE FORM 990 AND ASSOCIATED SCHEDULES ARE THEN REVIEWED AND APPROVED BY THE BOARD AS A WHOLE. A COPY OF THE APPROVED FORM 990 ALONG WITH THE ASSOCIATED SCHEDULES IS PROVIDED TO ALL BOARD MEMBERS PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION REGULARLY AND CONSISTENTLY MONITORS AND ENFORCES COMPLIANCE WITH THE CONFLICT OF INTEREST POLICY BY REQUIRING ALL BOARD MEMBERS TO ANNUALLY COMPLETE AND SIGN A QUESTIONNAIRE DOCUMENTING ANY AREA OF CONFLICT OF INTEREST. THE BOARD MEMBERS ARE REQUIRED TO REPORT AND DOCUMENT ANY NEW AREAS OF CONFLICT OF INTEREST AS THEY ARISE. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATION USES AN INDEPENDENT CONSULTANT TO MEASURE FAIR VALUE OF COMPENSATION FOR THE ORGANIZATION'S PRESIDENT AND OTHER TOP MANAGEMENT. THE ORGANIZATION'S BOARD REVIEWS AND APPROVES THE COMPENSATION FOR ALL OFFICERS EXCEPT THE ASSISTANT TREASURER AND ASSISTANT SECRETARY. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S FORM 990 IS AVAILABLE UPON REQUEST AND ON GUIDESTAR'S WEBSITE AND THE FINANCIAL STATEMENTS ARE AVAILABLE ON MUNICIPAL SECURITIES RULEMAKING BOARD'S WEBSITE. THE ORGANIZATION DOES NOT MAKE OTHER GOVERNING DOCUMENTS AND THE CONFLICT OF INTEREST POLICY AVAILABLE TO THE PUBLIC. PART VII, SECTION A, COLUMN B DUE TO THE TREMENDOUS OVERLAP OF DIRECTORS BETWEEN THE ORGANIZATION AND ALL RELATED ORGANIZATIONS, THE RELATED ORGANIZATIONS' HOURS ARE INCLUDED IN THE HOURS LISTED. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -62,342. PART XII, LINE 2C: THE AUDIT COMMITTEE'S PROCESS FOR OVERSIGHT OF THE AUDIT AND SELECTION OF INDEPENDENT ACCOUNTANTS HAS NOT CHANGED FROM THE PRIOR YEAR. REX HEALTHCARE INC 4420 LAKE BOONE TRAIL RALEIGH NC 27607 561509129 HEALTHCARE NC 501(C)(3) LINE 11A, I UNC HEALTHCARE 0 REX HOME SERVICES INC 4420 LAKE BOONE TRAIL RALEIGH NC 27607 561636242 HEALTHCARE NC 501(C)(3) LINE 11A, I REX HOSPITAL 0 UNC HEALTH CARE SYSTEM 101 MANNING DRIVE CHAPEL HILL NC 27514 562206970 HEALTHCARE NC 501(C)(3) LINE 3 UNC HEALTHCARE 0 REX HOSPITAL INC 4420 LAKE BOONE TRAIL RALEIGH NC 27607 561509260 HOSPITAL NC 501(C)(3) LINE 3 REX HEALTHCARE 0 REX SURGERY CENTER OF CARY LLC 4420 LAKE BOONE TRAIL RALEIGH NC 27607 273684056 ASC NC REX HOSPITAL INC RELATED 0 0 JRH VENTURES LLC 4420 LAKE BOONE TRAIL RALEIGH NC 27607 274092967 MED CAMPUS DVLT NC REX HOSPITAL INC RELATED 0 0 REX HEALTH VENTURES GPI LLC 4420 LAKE BOONE TRAIL RALEIGH NC 27607 VENTURE CAPITAL INVESTMENT NC RELATED 0 0 REX ENTERPRISES COMPANY INC 4420 LAKE BOONE TRAIL RALEIGH NC 27607 561553957 OPERATIONS SUPPORT NC REX HEALTHCARE C REX PHYSICIANS LLC 4420 LAKE BOONE TRAIL RALEIGH NC 27607 264594963 HEALTHCARE NC REX HOLDINGS C 0 1 0 0 0 0 0 0 0 1 0 0 1 1 1 0 0 0 REX HOSPITAL INC B 1291083 FMV REX HOSPITAL INC J 7760 FMV REX HOSPITAL INC O 678659 FMV PART V, LINE 1 M&N: REX HOSPITAL, INC. PERSONNEL PROVIDES ADMINISTRATIVE SUPPORT, SUCH AS EXECUTIVE MANAGEMENT, LEGAL, ACCOUNTING, HUMAN RESOURCES, PURCHASING AND IT FUNCTIONS UTILIZING REX HOSPITAL FACILITIES AND OTHER ASSETS. ESTIMATING THE VALUE OF THESE SHARED PERSONNEL AND ASSETS CANNOT BE READILY DETERMINED.