2013-05-06T11:05:43-05:00 2012-06-30 861065772 Deloitte Tax LLP 50 South Sixth Street Ste 2800 Minneapolis MN 554021538 990 2011-07-01 420680391 Mercy Hospital Iowa City Iowa MERC 3193390300 500 East Market Street Iowa City IA 52245 Michael G Heinrich 3193390300 2013-04-29 1 Kristina Rasmussen P00143920 6123974000 2011 2016-02-25 16:41:14Z Michael G Heinrich 500 East Market Street Iowa City IA 52245 187795124 0 0928 X www.mercyiowacity.org X 1873 IA To heal and comfort the sick and improve the health of the community in the spirit of Jesus Christ. 13 12 1326 449 3648646 -584174 628872 577231 139782498 148788946 7219828 4442057 2053325 2136634 149684523 155944868 161366 158938 0 0 74776974 75245058 0 0 0 65664439 69585066 140602779 144989062 9081744 10955806 269627417 286076441 122320945 163143135 147306472 122933306 Mercy Iowa City ("Mercy") heals and comforts the sick and works to improve the health of the community in the spirit of Jesus Christ and the Catholic tradition of the Sisters of Mercy. 0 0 101451572 148922011 Hospital Services. In keeping with our mission of healing and comforting the sick, providing hospital medical services is at the heart of what we do. These services are provided in inpatient and outpatient settings in situations that may be emergent, acute, or chronic. Services include a 24-hour emergency unit, intensive care, cardiovascular care and the services of a cardiac cath lab, maternity unit and newborn nursery, surgical services, cancer care, orthopedic care, telemetry monitored care, medical care, stroke care, behavioral health care, and skilled nursing. 858728 195679 Education. The ongoing education of Mercy staff members is critical in the fast-changing field of health care and is necessary in many cases to meet regulation and certification. In addition to the efforts designed for staff members, Mercy provides a setting for many students who are considering or pursuing health care careers. For high school students, a health careers class is offered to give students insight into possible careers and options; it also prepares students for the certified nursing assistant exam. Mercy also works with students from Kirkwood Community College, and other local colleges, offering such options as a paid summer nursing internship program, a lab student rotation opportunity, and job shadow opportunity in anesthesiology. 2855782 158938 Community Benefit. Mercy's community benefits take many forms, beginning with traditional charity care of $.8 million, and the unpaid cost of Medicaid ($2 million). Other examples are varied; they include cash donations to community non-for-profits such as the Free Medical Clinic, free meeting space to valued community organizations, leadership time and skills that further the work of community non-for-profits, first aid booths provided at public events. These efforts are detailed in Mercy's community benefit report, prepared annually. As a trusted, longtime member of the community, Mercy plays an important role not only in furthering community health but the general community good. 105166082 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 67 0 1 1326 1 1 1 0 0 0 0 0 0 0 0 0 0 X 13 12 1 0 0 0 1 0 1 1 1 0 0 1 1 1 1 0 1 1 1 1 1 X Jean Berge 3193393238 500 East Market Street Iowa City IA 52245 X Robert Beckman MD Oct 11-June 12 1.00 X 0 0 0 Mark Danielson Oct 11-June 12 1.00 X 0 0 0 Geraldine Felton 1.00 X 0 0 0 Scott Fisher 1.00 X 0 0 0 Nyle Kauffman MD July 11-Oct 11 1.00 X 0 0 0 SR Sharon Kerrigan 1.00 X 0 0 0 Tim Krumm 1.00 X 0 0 0 Chuck McComas Oct 11-June 12 1.00 X 0 0 0 Tom McLaughlin 1.00 X 0 0 0 SR Patricia Murphy 1.00 X 0 0 0 Dick Oberman July 11-Oct 11 1.00 X 0 0 0 Mark Phillips 1.00 X 0 0 0 Cyndie Schmeiser 1.00 X 0 0 0 Mary Westabrook July 11-Oct 11 1.00 X 0 0 0 SR Margaret Wright 1.00 X 0 0 0 Ronald R Reed 40.00 X X 551156 0 68149 Jean M Berge 40.00 X 151685 0 43965 Michael G Heinrich 40.00 X 306601 0 56000 Cindy Penney 40.00 X 173651 0 45160 Andrew R Ashby MD 40.00 X 504149 0 38674 RJoe Ewing MD 40.00 X 654066 0 40791 Brian O'Meara MD 40.00 X 654925 0 24439 Thomas Shreves MD 40.00 X 647346 0 45412 Joseph Truszkowski MD 40.00 X 509799 0 44009 4153378 0 406599 67 0 1 0 Rohrbach Associates PC 325 E Washington Iowa City IA 52244 Engineering/Architecture 1015935 Cross Medical Laboratories 2406 Towncrest Drive Iowa City IA 52244 Laboratory Services 368557 Deloitte & Touche LLP 50 South 6th Street Suite 2800 Minneapolis MN 55402 Auditing Services 159678 Phelan Tucker Mullen Walker Tucker & Gel Box 2150 Iowa City IA 52244 Legal Services 120848 4 568333 8898 577231 Patient Serv. Revenue 621400 87155647 87155647 Medicare/Medicaid 621400 53208909 53208909 Lab Outreach 621511 3648646 3648646 ASC Income 900099 3108017 3108017 Program Relat. Revenue 621400 833666 833666 834061 834061 148788946 2245408 2245408 2172424 1132042 1040382 1040382 1040382 32792062 122801 30688329 29885 2103733 92916 2196649 2196649 Cafeteria Income 722210 753841 753841 Access 621400 94343 94343 Miscellaneous revenue 900099 39226 39226 208842 195175 13667 1096252 155944868 145469044 3648646 6249947 141270 141270 17668 17668 1277542 561677 715865 56917160 43205337 13711823 4809715 3566404 1243311 8164868 6018664 2146204 4075773 3057771 1018002 188844 188844 153336 153336 30604 30604 4640825 3551496 1089329 769910 6800 763110 9678904 5017936 4660968 3228331 443085 2785246 2065644 56357 2009287 334499 217441 117058 2756874 1874766 882108 10946895 9453326 1493569 3761822 3761822 Medical Supplies 15032887 15031370 1517 0 Bad Debt Expense 6870033 6870033 0 0 Pharmacy Supplies 3015690 3015690 0 0 Food Expense 1043297 1043297 0 0 5066671 2015694 3050977 144989062 105166082 39822980 0 2831957 8409921 2379090 1597588 20402245 21282928 54373 60992 3969188 4062526 1968027 2201942 232227222 148181315 75209532 84045907 139357794 134034675 5800378 3446694 17654833 26933268 269627417 286076441 15358510 15383318 62073856 81955827 304211 734523 44584368 65069467 122320945 163143135 X 147306472 122933306 0 0 147306472 122933306 269627417 286076441 X 10955806 -35328972 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED X 0 0 0 0 1 0 1 0 1 30604 30604 0 Explanation of Lobbying Activities: Part II-B, Line 1: Mercy Hospital, Iowa City, Iowa is a member of the Iowa Hospital Association (IHA). A percentage of membership dues paid to IHA relate to lobbying activities. 12951892 165736 -117757 455752 12544119 10653690 451005 2031685 184488 12951892 9665745 140749 1003105 155909 10653690 12302591 36954 -2231983 441817 9665745 0.81000 0.19000 0.00000 0 1 1 6379393 6379393 118872579 74484017 44388562 614410 561109 53301 68048011 51930936 16117075 38312829 21205253 17107576 84045907 Beneficial Interest-Foundation 12960163 Due From Affiliates 2155895 Cash Value Life Insurance 368089 Deferred Financing Cost Other Assets 506432 Non-Compete Agreement Value 1190000 2011 Bond Fund 9752689 26933268 Pension Benefit Liability 62279484 Fair Value of Interst Rate SWAP 2789983 65069467 Description of Intended Use of Endowment Funds: Part V, Line 4: All Restricted Endowed Funds are used for the benefit of Mercy Hospital Iowa City - capital equipment, employee grants, scholarships, etc. Description of Uncertain Tax Positions Under FIN 48: Part X: Mercy adopted the provisions of FIN No. 48 in fiscal 2008. As a result of the implementation of FIN No. 48, and as of June 30, 2012, Mercy recorded no liabilities for unrecognized tax benefits. 1 1 1 X 1 X 1 1 0 1 1 806548 0 806548 0.00580 5741857 3702475 2039382 0.01480 22283 12431 9852 0.00010 6570688 3714906 2855782 0.02070 866413 9047 857366 0.00620 77787 20901 56886 0.00040 2008338 1408201 600137 0.00430 0.00000 574426 0 574426 0.00420 3526964 1438149 2088815 0.01510 10097652 5153055 4944597 0.03580 40737 40737 0.00030 37032 37032 0.00030 77769 77769 0.00060 0 2304896 68642 38992202 55938516 -16946314 X 1 1 1 Iowa City Ambulatory Surgery Center Outpatient Surgery Center 0.57500 0.42500 1 1 Mercy Hospital

500 East Market Street Iowa City IA 52245

X X X Skilled Nursing and Lab Outreach Mercy Hospital Iowa City Iowa 1 1 1 200.000000000000 1 200.000000000000 1 X X X X X X X 1 1 X X 1 0 1 X 0 0 1 Mercy Home Health Care

500 East Market Street Iowa City IA 52245

Home Health & Private Duty Nursing Part I, Line 7: Amounts in the table were derived using a cost accounting system that addresses all patient segments. A cost to charge ratio derived from completing IRS worksheet 2 was used to determine the amounts in Part I, Line 7a, 7b, 7c, and 7g. Part I, L7 Col(f): Bad debt expense of $6,870,033 was subtracted for purposes of calculating the percentage in Schedule H, Part I, Line 7, column (f). Part II: Economic development:Mercy works with such groups as the Iowa City Area Chamber of Commerce and Iowa City Area Development Group to support the business community, welcome innovation to the area, and develop the workforce. Mercy's own growth benefits the community as well, particularly when Mercy's recruiting efforts attract new professionals to the area.Community support:Mercy has provided extensive support for many years to United Way of Johnson County. Mercy holds its own campaign for employees each autumn (typically raising more than $120,000) and provides much staff time and support to the local United Way organization. Environmental improvements:Mercy has been a good neighbor for its closest neighbors by maintaining its buildings and landscaping at a high level. Mercy also pursues extensive recycling (including newspapers, magazines, office paper, plastics, batteries, cooking oil, construction materials, and more) and programs that reduce energy consumption. Mercy regularly holds silent auctions open to employees to sell equipment that is no longer needed, rather than sending it into the trash stream. Mercy recently created a Sustainability Committee to further and standardize these efforts.Leadership development and training for community members:Mercy lends support to the Iowa City Area Chamber of Commerce annual Community Leadership Program. In this nine-month program, 24 members of the civic community receive an in-depth look at the workings of local government, public works, education system, health care, arts community, and more. This program gives participants a better understanding and appreciation of the entire community and develops fellowship among members from diverse backgrounds and settings.Coalition building:Mercy is involved in many ways with local citizens and groups that are working to afford all members of our community a good quality of life and to improve the overall quality of life. Mercy is a cosponsor of and provides leadership for the 20-year-old Johnson County Safe Kids Coalition, a grass-roots effort to reduce unintentional injuries to children from birth to age 14. Since its inception, the coalition has been active in promoting bike helmet use, bike safety, and safety education events. The coalition is particularly active in providing free car seat check clinics to parents.Community health improvement advocacy:Healthy Kids Community Care is a school-based clinic that provides health care to children who have no other access to it. Mercy made large cash donations over a period of five years to help launch this initiative and provided key leadership as the program developed. Mercy has also provided financial support to the Free Medical Clinic, which saw almost 2,300 unique patients in FY2012. Those who seek care of the Free Medical Clinic typically have no other access to health care services. Workforce development:Kirkwood Foundation, Workplace Learning Connection Part III, Line 4: We do not currently have a footnote to our financial statements that describes bad debt expense. The amount on line 2 was derived from taking actual bad debt write-offs and applying the cost to charge ratio of .3355 to that amount. Mercy Hospital does not include bad debt amounts as part of community benefit.An estimate of bad debt attributable to patients eligible for charity care has been estimated to be $68,642. This estimate was derived by using the outstanding patient balance of accounts recommended for presumptive charity at cost that were reviewed and denied. The presumptive charity program was implemented on October 1, 2010. Part III, Line 8: Mercy Hospital does not include Medicare shortfalls as part of it's community benefit. Total revenue was determined using charges per the CMS Provider Statistical Reimbursement System reports for Fee Reimbursed Services for the fiscal year ended 6/30/12. Costs calculated using the Cost to Charge Ratio for the appropriate services from the submitted Medicare Cost Report form 2552-96 for the fiscal year ended 6/30/12. Part III, Line 9b: Mercy Hospital has two policies related to debt collection. The Financial Assistance Policy provides guidelines for forgiving all or part of a patient's financial responsibility for healthcare services received at Mercy Hospital. Patients may be given a financial assistance application at the time of service, be offered financial assistance during the normal collection process or learn of the option on the Hospital website. All patients with no insurance are offered financial assistance via billing statements & follow up telephone calls. Any patient that is known to qualify for financial assistance is provided assistance. The payment plan policy enables those who qualify for partial financial assistance to establish payment plans of the remaining balance of their bill. Mercy Hospital, Iowa City, Iowa Part V, Section B, Line 13g: A copy of the Financial Assistance Policy Application is available on the Mercy Hospital website. The Financial Assistance Policy is available upon request. If a patient does not have insurance, the invoice states that financial assistance is available. Mercy Hospital, Iowa City, Iowa Part V, Section B, Line 19d: Mercy Hospital determines on an individual basis based on the patient's ability to pay for the maximum amounts that can be charged to FAP-Eligible individuals for emergency and other medically necessary care. Patients, who fall under the 200% Federal Poverty Guidelines, are eligible for free care. Mercy Hospital uses the following factors to determine the amount to charge FAP-eligible patients for individuals who earn more than 200% of the FPG: Income level, Asset level, medical indigency, insurance status, uninsured discount, Medicaid/Medicare. In addition to the financial assistance policy, all uninsured patients are eligible for discounts ranging from 30-10% based on timeliness of payment. Part VI, Line 2: Historically, community health needs assessment is conducted every 5-7 years. The most recent assessment was conducted in Fall 2012. The organization engaged Professional Research Consultants to conduct the assessment. The community health survey is a systematic, data-driven approach to determining the health status, behaviors and needs of residents in the communities the organization serves. The survey instrument used for the assessment is based largely on the Centers for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance System (BRFSS), as well as various other public health surveys and customized questions addressing gaps in indicator data relative to national health promotion and disease prevention objectives and other recognized health issues. The results of the survey will be used to improve health status, elevate overall quality of life, reduce health disparities, and increase accessibility to services for community residents. Part VI, Line 3: Evaluation for Medicaid, disability, and other types of coverage is provided for uninsured patients for inpatient stays as well as high dollar outpatient services. The evaluation is conducted during the patient stay or by a phone call to the patient's home.- Financial assistance is available for patients who meet Mercy assistance guidelines. Assistance may be available for uninsured, under-insured and catastrophic circumstances. Assistance may take the form of forgiving all or part of a bill and/or providing an extended payment option.- Meeting financial assistance guidelines involves evaluating family income and assets, using other sources of funds such as insurance or government programs, and other family or social support networks.- Financial assistance applications are available at the points of registration. Information and applications are also available at Mercy-affiliated clinics.- The first statement sent to patients who do not have insurance explains that financial assistance is available and provides information about further inquiry. Subsequent statements also contain information about who to contact for financial assistance. Financial assistance is offered to all patients with no insurance on the first telephone contact.- During the collection process for insured patients, if the patient expresses concern about payment, he/she is offered financial assistance and/or payment plan options. Full or partial assistance is available. If partial assistance is received, the balance may be set up on a payment plan if needed.- The State of Iowa offers a statewide health insurance plan for uninsured children called hawk-i. Information about hawk-i is provided at registration points. Part VI, Line 4: Mercy Hospital is located in the community of Iowa City, Iowa, in Johnson County in the east central part of the state. The county's population in 2011 was approximately 133,000. From 2000 to 2008 Johnson County experienced strong population growth of 15.4 percent, compared to 2.6 percent for the entire state. Johnson County's population is projected to increase by another 9.5 percent by the year 2014.Mercy Hospital serves 10 counties in southeast Iowa, with the primary service area being Johnson County. The secondary service area includes Cedar, Iowa, Muscatine and Washington counties. The tertiary service area includes Henry, Jefferson, Keokuk, Lee and Louisa counties. The population of the service area is approximately 325,168.Iowa City is home to the University of Iowa, which has an enrollment of 31,498 for the 2012-2013 academic year. Johnson County is well-educated; of individuals 25 and older, 95.3 percent are high school graduates and 50.6 percent hold a bachelor's degree or higher.The University of Iowa also provides the foundation for an economy that has particular strengths in education, health care, services, technology, agribusiness, and manufacturing.According to the U.S. Census Bureau, 17.8 percent of the Johnson County population lived below the poverty line between 2007 and 2011, compared to 11.9 percent for the entire state. Part VI, Line 5: Mercy Iowa City is a faith-based institution that provides services based on the ethical and religious directives of the Catholic Church. An important part of Mercy's mission is to improve the health of the community. Mercy does so by: Ensuring that the medical staff is open to all qualified physicians; ensuring that the hospital is accredited and in good standing with The Joint Commission; ensuring that the board of directors is comprised of diverse, independent individuals, not employees of the hospital, representing the community and also providing necessary expertise; establishing and carrying out a conflict of interest policy; providing a site for clinical experience for a variety of health care professionals; providing charity care and financial assistance with medical bills as needed to community members; participating in such programs as Medicare, Medicaid, and hawk-i, an insurance program for needy Iowa children; absorbing unreimbursed costs for such government programs; ensuring that account collections are carried out in compliance with state and federal guidelines; providing emergency room services and working with local and state officials in community prepardness issues; treating emergency patients according to EMTALA guidelines and serving all patients regardless of their ability to pay; investing surplus funds in services, technology, and personnel that will further the benefit of the community. Reports Filed With States Part VI, Line 7 IA 1 Community Foundation of Johnson County 325 East Washington Street Iowa City IA 52240 421508117 501(c)(3) 100000 Healthy Kids Fund Iowa City Free Medical Clinic 2440 Towncrest Drive Iowa City IA 503402902 420960955 501(c)(3) 15500 General Support American Heart Association-Midwest Affiliate PO Box 4002902 Des Moines IA 503402902 135613797 501(c)(3) 12000 Iowa City Events Sponsor 3 0 Temporary Assistance Program 29 17668 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: All organizations Mercy provides assistance to are local organizations. Therefore, Mercy is in frequent contact with the organizations and is generally aware of their use of Mercy's assistance. However, there is no formal mechanism in place to track specific uses of the assistance. Mercy Hospital offers a Temporary Assistance Program (TAP) for emergency financial needs that employees may have. This confidential program offers crisis assistance and health benefit assistance. X 1 1 X X X X X X 0 1 0 0 0 0 0 1 0 Ronald R Reed 411388 0 0 0 139768 0 29220 0 38929 0 619305 0 116855 0 Jean M Berge 147005 0 0 0 4680 0 23989 0 19976 0 195650 0 0 0 Michael G Heinrich 274159 0 0 0 32442 0 14342 0 41658 0 362601 0 31302 0 Cindy Penney 163618 0 0 0 10033 0 11802 0 33358 0 218811 0 7888 0 Andrew R Ashby MD 359688 0 144096 0 365 0 0 0 38674 0 542823 0 0 0 RJoe Ewing MD 646825 0 6344 0 897 0 0 0 40791 0 694857 0 0 0 Brian O'Meara MD 648153 0 6242 0 530 0 0 0 24439 0 679364 0 0 0 Thomas Shreves MD 640399 0 6050 0 897 0 0 0 45412 0 692758 0 0 0 Joseph Truszkowski MD 503585 0 5786 0 428 0 0 0 44009 0 553808 0 0 0 Part I, Line 1a Health club membership dues were paid for Mercy's CEO, Ronald Reed in the amount of $898.80 and were included as taxable income on his W-2. Part I, Line 4b Mercy established an IRC Section 457(f) plan as a way of retaining executives, officers and select groups of highly compensated employees with supplemental retirement benefits. The following individuals participated in and received payments from the plan. - Michael Heinrich - $31,302 - Ronald Reed - $116,855 - Cindy Penney - $7,888 Part I, Line 7 Non-fixed payments were provided to physicians who met stated criteria that included meeting certain RVU (Relative Value Unit) productivity levels, specified CMS/JCAHO performance core indicators and certain patient satisfaction and/or nursing satisfaction survey scores. City of Hills Iowa 420920947 431669AA8 2008-04-29 39235000 Refund Bonds issued 10/19/2005 0 0 0 City of Hills Iowa 420920947 431669AW0 2011-11-30 44742571 Build and Equip Facility; Refund Bonds issued 7/16/1998 0 0 0 1660000 39235000 278380 96759 38859861 1 0 1 1 44743448 589874 10249535 24151438 9752601 1 0 0 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 1 0 0 0.00000 0.00000 0.00000 1 0 1 0 0 0 1 0 0 0 0 0 1 X Schedule K, Part II, Line 3: Differences between the issue price (Part I) and total proceeds (Part II, line 3) are due to investment earnings. Schedule K, Part II, Line 4: The amounts shown here consists solely of debt service fund deposits. Michael G Heinrich Split Dollar Life Insurance Policy X 18524 18524 0 0 0 Ronald R Reed Split Dollar Life Insurance Policy X 42468 42468 0 0 0 60992 Form 990, Part VI, Section A, line 2 Sister Sharon Kerrigan, board member; Sister Patricia Murphy, board member; and Sister Margaret Wright, board member are all members of the Sisters of Mercy of the Americas West Midwest Community. Form 990, Part VI, Section A, line 6 Mercy's sole member is the Sisters of Mercy of the Americas West Midwest Community, Inc. Form 990, Part VI, Section A, line 7b Mercy's sole member, Sisters of Mercy of the Americas West Midwest Community, Inc., maintains a number of "reserved powers" including but not limited to approval of annual budgets, approval of amendments to the articles of incorporation and bylaws, approval of real property transactions and approval of long term borrowing. Form 990, Part VI, Section B, line 11 The Form 990 is prepared and reviewed by Mercy Hospital management and is also reviewed by Deloitte Tax LLP. In addition, a board resolution was established that provides that each board member be (i) provided a copy of the Form 990 as it is intended to be filed, and (ii) given a reasonable opportunity before filing to provide to the Audit Committee any comments, corrections, concerns or other input on the proposed Form. The Audit Committee's review process shall be intended to reasonably verify that the Form 990 has been fully and accurately completed, including but not limited to, all inquiries therein relating to corporate governance. After completing its review, the Audit Committee, on the Board's behalf, shall have the authority to authorize the filing of the annual Form 990. Form 990, Part VI, Section B, line 12c A conflict of interest statement is signed at the beginning of Board members term and on an annual basis there after. Any abstention from a vote is recorded in Board minutes. After the fiscal year end a "look back" questionnaire is distributed to all Board members to disclose any conflicts of interest that may have taken place in the previous year. Form 990, Part VI, Section B, Line 13: Per IRS guidance, because the board had not formally adopted the whistleblower policy as of 6/30/12, the organization has answered "No" to this question. Mercy has an Administrative team "A Team" which is made up of Vice Presidents and the CEO that has been delegated by the board of directors to manage and approve policies. The A Team has approved the whistleblowers policy. Form 990, Part VI, Section B, line 15 Compensation for all executives and other key employees is determined based on national or regional market data for comparable positions at comparatively sized hospitals. The Executive Committee of the Board of Directors uses this market-based information to set the President and CEO's compensation. In turn, the CEO uses the same information to set compensation for officers and key employees, which is also approved by the board. Form 990, Part VI, Section C, line 19 An annual statement of "Financial Highlights" is published in Mercy's annual report. It provides annual Funds Available and Funds Applied in the form of percentages of Mercy's total budget. The annual report is produced in print form and appears on Mercy's Website, www.mercyiowacity.org, as a PDF. Mercy's governing documents and conflict of interest policy are not available to the public. Form 990, Part VII: The following individuals held positions at both Mercy Hospital and the Mercy Hospital, Iowa City, Iowa Self Insurance Plan and Trust. The hours listed on Part VII are the average hours per week these individuals devoted to the Hospital during the year. In addition, these individuals also devoted the following average hours per week to the Trust. - Ronald R. Reed - 1.0 hour - Michael Heinrich - 1.0 hour - Mark Phillips - 1.0 hour - Tim Krumm - 1.0 hour The following individuals held positions at both Mercy Hospital and Mercy Foundation. The hours listed on Part VII are the average hours per week these individuals devoted to the Hospital during the year. In addition, these individuals also devoted the following average hours per week to Mercy Foundation. - Ronald R. Reed - 2.0 hours - Michael Heinrich - 2.0 hours - Jean Berge - 1.0 hour - Scott Fisher - 1.0 hour - Robert Beckman - 1.0 hour - Mark Danielson - 1.0 hour Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized losses on investments: -3,460,572. Change in Unrecognized Pension Actuarial Loss -22,294,780. Change in Beneficial Interest in Foundation -394,677. Transfer to Mercy Hospital Self Insurance Plan & Trust -3,500,000. Change in Beneficial Interest in Services -4,741,795. Loss on Extinguishment of Debt -1,002,866. Other adjustment 65,718. Total to Form 990, Part XI, Line 5: -35,328,972. Mercy Foundation 500 East Market Street Iowa City IA 52245 237040506 Foundation/Fundraising IA 501(c)(3) 11-I Mercy Hospital 1 Mercy Hospital Iowa City Iowa Self Insurance Plan & Trust 500 East Market Street Iowa City IA 52245 426591803 Self Insurance IA 501(c)(3) 11-I Mercy Hospital 1 Sisters of Mercy of the Americas West Midwest Community Inc 7262 Mercy Road Omaha NE 68124 262400800 Religious Order NE 501(c)(3) N/A 0 Mercy Hospital Guild 500 East Market Street Iowa City IA 52245 426099912 Fundraising IA 501(c)(3) 11-III-FI N/A 0 Cancer Care of Iowa City LLC 613 East Bloomington Suite 100 Iowa City IA 52245 421460774 Oncology Services IA Mercy Hospital Related 160243 960752 0 0 0.58950 Iowa City Ambulatory Surgical Center LLC 2963 Northgate Drive Iowa City IA 52245 208503424 Outpatient Surgery IA Mercy Hospital Related 3619133 6201371 0 1 0.57500 Mercy Services Iowa City Inc 500 East Market Street Iowa City IA 52245 421241044 Medical Clinic Services IA Mercy Hospital C -4707223 7966521 1.00000 1 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 Mercy Services Iowa City A 955191 Cost Cancer Care of Iowa City A 124472 Cost Mercy Foundation C 568333 Cost Mercy Hospital Self Insurance Plan & Trust B 3500000 Cost Mercy Services Iowa City P 4290106 Cost Cancer Care of Iowa City P 1334544 Cost Mercy Foundation P 229799 Cost Mercy Services Iowa City B 4000000 Cost