2013-08-09T15:06:45-05:00 2012-09-30 930623286 AKT LLP 5665 SW MEADOWS RD SUITE 200 LAKE OSWEGO OR 97035 990 2011-10-01 237002687 SALEM HOSPITAL FOUNDATION SALE 5035615576 890 OAK STREET SE SALEM OR 97301 MARTIN A MORRIS 5035615576 2013-07-22 1 JOYLYN M ANKENEY CPA P00366587 5036204489 2011 2016-02-24 21:20:13Z MARTIN A MORRIS 890 OAK STREET SE SALEM OR 97301 4925909 0 X WWW.SALEMHOSPITAL.ORG/FOUNDATION X 1968 OR DEDICATED TO RAISING, MANAGING AND DISTRIBUTING FUNDS TO HELP SALEM HOSPITAL ACHIEVE ITS MISSION OF IMPROVING THE HEALTH AND WELL-BEING OF THE PEOPLE AND COMMUNITY IT SERVES. 14 14 0 14 0 0 840436 961218 0 0 587686 633227 53104 60618 1481226 1655063 1526082 1276377 0 0 0 0 21863 16908 33788 370170 377763 1918115 1671048 -436889 -15985 7964385 9036981 51455 551185 7912930 8485796 THE SALEM HOSPITAL FOUNDATION IS DEDICATED TO RAISING, MANAGING AND DISTRIBUTING FUNDS TO HELP SALEM HOSPITAL ACHIEVE ITS MISSION OF IMPROVING THE HEALTH AND WELL-BEING OF THE PEOPLE AND COMMUNITY IT SERVES. 0 0 158300 158300 SCHOLARSHIPS: NURSING, MEDICAL SCHOOL AND OTHER HEALTHCARE PROGRAMS. RECIPIENTS OF HEALTH CARE RELATED ACADEMIC SCHOLARSHIPS AND THE AMOUNTS OF THE AWARDS ARE DETERMINED BY ANALYSES OF THE CANDIDATES' QUALIFICATIONS, SCHOLARSHIP AWARDS ALREADY AWARDED TO THEM FOR THE YEAR BY OTHER ORGANIZATIONS, AND THE COSTS OF THE SPECIFIC SCHOOLS THE VARIOUS CANDIDATES WISH TO ATTEND. 1019770 1019770 PROPOSALS TO FUND CAPITAL EQUIPMENT AND MEDICALLY-RELATED ACTIVITIES AT SALEM HOSPITAL ARE RECEIVED AND REVIEWED BY THE FOUNDATION'S CHIEF DEVELOPMENT OFFICER. PROPOSALS ARE FORWARDED TO THE FOUNDATION'S BOARD OF DIRECTORS FOR FURTHER REVIEW AND APPROVAL IF THEY ARE CONSIDERED TO BE CONSISTENT WITH THE FOUNDATION'S ARTICLES OF INCORPORATION, STATING THAT ITS FUNDS ARE TO BE USED FOR HEALTH CARE, CHARITABLE, AND SCIENTIFIC PURPOSES, AND FOR MEDICAL AND SCIENTIFIC EDUCATION AND RESEARCH FOR THE USE AND BENEFIT OF SALEM HOSPITAL. 98307 98307 CERTAIN RESTRICTED FUNDS HAVE BEEN CREATED AND ARE USED FOR THE PURPOSE ASSISTING DIABETES AND CANCER PATIENTS WITH THE COSTS OF THEIR EDUCATIONAL, SUPPLY AND OTHER CARE-RELATED EXPENSES. IN ADDITION, FUNDS ARE DISTRIBUTED TO ASSIST LOW INCOME INDIVIDUALS MEDICAL REQUIREMENTS. 1276377 1 1 0 0 0 0 0 0 0 1 1 0 0 0 0 0 1 1 0 0 0 0 0 1 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 6 0 1 0 0 0 0 0 0 0 0 0 0 0 X 14 14 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 0 0 0 OR X SALEM HOSPITAL 5035611200 890 OAK STREET SE SALEM OR 97301 KELLY YUNKER 1.00 X X 0 0 0 KATHY GORDON 1.00 X X 0 0 0 MARI BAILEY 1.00 X X 0 0 0 GARTH BRANDAW 1.00 X 0 0 0 MICHAEL DELK 1.00 X 0 0 0 BARBARA FURER 1.00 X 0 0 0 JIM GRIGGS 1.00 X 0 0 0 BARBARA HALSEY 1.00 X 0 0 0 BUD PIERCE MD 1.00 X 0 0 0 ROBERT PONEC MD 1.00 X 0 0 0 JIM WASENMILLER MD 1.00 X 0 0 0 ALEX CASEBEER 1.00 X 0 0 0 LARRY GOODREAU 1.00 X 0 0 0 ERIC FISKUM 1.00 X 0 0 0 MARTIN MORRIS 40.00 X 0 283661 59289 0 283661 59289 0 0 1 0 0 4900 956318 961218 188310 188310 12020 0 12020 12020 12020 3689671 3244754 444917 444917 444917 74690 4900 26092 48598 48598 1655063 0 0 693845 1019770 1019770 256607 256607 2072 2072 17300 17300 16908 16908 8685 8685 16880 16880 5164 5164 50 50 1733 1733 MANAGEMENT SERVICES 299349 299349 MISCELLANEOUS 18233 18233 SOFTWARE/DATA PROCESS 4152 4152 BANK FEES 1877 1877 2268 2268 1671048 1276377 360883 33788 0 125573 743801 1410000 1410000 1410000 6371830 6833741 56982 49439 7964385 9036981 4569 125 46886 551060 51455 551185 X 3250366 3293704 2451896 2931424 2210668 2260668 7912930 8485796 7964385 9036981 X -15985 588851 X 0 1 0 X 0 X 2295581 934781 1212534 809178 956318 6208392 2295581 934781 1212534 809178 956318 6208392 1909779 4298613 293281 70592 52561 61625 43799 521858 6730250 0.63870 0.68110 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 2450432 79019 324539 101137 2752853 2498792 18333 -33888 32805 2450432 2344770 19335 167208 32521 2498792 2285949 31343 50166 22688 2344770 0.00000 0.82000 0.18000 0 0 1410000 1410000 1410000 DUE TO SALEM HOSPITAL 551060 551060 1655063 1671048 -15985 588851 588851 572866 2918263 588851 326787 347562 1263200 1655063 0 1655063 2345397 326787 347562 674349 1671048 0 1671048 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: SALEM HOSPITAL FOUNDATION HOLDS ENDOWMENT FUNDS FOR THE BENEFIT OF SALEM HOSPITAL AND FOR USE TOWARDS THE FOUNDATION'S MISSION. PART XII, LINE 2D - OTHER ADJUSTMENTS: SPECIAL EVENT EXPENSES NETTED WITH REVENUE 26,092. ASSETS RELEASED FROM RESTRICTION INCLUDED IN REVENUE 321,470. PART XIII, LINE 2D - OTHER ADJUSTMENTS: SPECIAL EVENT EXPENSES NETTED WITH REVENUE 26,092. ASSETS RELEASED FROM RESTRICTION INCLUDED IN EXPENDITURES 321,470. X X X X 1 ADVANCED MARKETING 99 THIELMAN DRIVE BUFFALO NY 14206 DIRECT MAIL SOLICITATION 0 0 16908 0 16908 OR GOLF TOURNAMENT 79590 4900 74690 300 979 17295 7518 79590 4900 74690 300 979 17295 7518 26092 48598 EXPLANATION OF FUNDRAISING PAYMENTS SCHEDULE G, PART I, LINE 2B, COLUMN (V) PAYMENT WAS FOR A 42,000 PIECE DIRECT MAIL SOLICITATION. 1 SALEM HOSPITAL 890 OAK STREET SE SALEM OR 97301 930579722 503(C)(3) 1019770 0 N/A N/A TO PAY FOR GENERAL EXPENSES AND CAPITAL EXPENDITURES. SCHOLARSHIPS FOR STUDENTS LIVING IN MARION/POLK OR YAMHILL COUNTY WHO ARE PURSUING A CAREER IN HEALTHCARE. PAYMENTS MADE DIRECTLY TO THE COLLEGE(S) 94 158300 N/A SMALL ONE-TIME CASH GRANTS ($150-$300) TO INDIGENT PATIENTS FOR EMERGENT NEEDS SUCH AS MEDICATION, UTILITIES, TRANSPORTATION, RENT, ETC 145 40250 N/A NON-CASH SUPPORT OF INDIGENT PATIENTS OF SALEM HOSPITAL AND/OR COMMUNITY MEMBERS INCLUDING PROVIDING MEDICATION, TRANSPORTATION, MEDICAL EQUIPMENT, CAR SEATS AND OTHER SUPPORT. 3361 56688 ACTUAL COST MEDICATIONS, TRANSPORTATION, DURABLE MEDICAL EQUIPMENT, NON-MEDICAL SAFETY/PREVENTION ITEMS (CAR SEATS, EMERGENCY CALL SYSTEM, ETC), REQUIRED HEALTH COUNSELING, EDUCATION. CASH SUPPORT FOR INJURY PREVENTION PROGRAM 200 1200 N/A PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: DECISIONS ON GRANTS TO SALEM HOSPITAL ARE MADE BY THE SALEM HOSPITAL FOUNDATION BOARD OF DIRECTORS. MINUTES OF THE MEETINGS OF THE FOUNDATION BOARD ARE SHARED WITH THE SALEM HEALTH BOARD OF TRUSTEES EACH MONTH. SCHOLARSHIPS ARE GRANTED TO COLLEGE STUDENTS THAT RESIDE IN MARION, POLK OR YAMHILL COUNTIES AND ARE PURSUING A HEALTHCARE RELATED CAREER. A SCHOLARSHIP COMMITTEE REVIEWS INDIVIDUAL APPLICATIONS AND RECOMMENDS TO THE BOARD RECIPIENT AWARDS FOR APPROVAL. SCHOLARSHIPS AWARDED ARE PAID DIRECTLY TO THE EDUCATIONAL INSTITUTIONS FOR TUITION OR RELATED COSTS. X X X X 0 1 0 0 0 0 0 0 0 MARTIN MORRIS 0 243065 0 33936 0 6660 0 33204 0 26085 0 342950 0 0 PART I, LINE 4B MARTIN MORRIS RECEIVED DEFERRED COMPENSATION UNDER A 457(F) NONQUALIFIED PLAN. THIS COMPENSATION IS INCLUDED IN COMPENSATION REPORTED IN PART II UNDER DEFERRED COMPENSATION. THE TOTAL NONQUALIFIED PORTION REPORTED IS $15,855. SUPPLEMENTAL INFORMATION PART III COMPENSATION OF THE V.P. & CHIEF DEVELOPMENT OFFICER IS DETERMINED BY THE CEO OF SALEM HEALTH, IN CONJUNCTION WITH OTHER SALARY SURVEY OR PUBLIC INFORMATION AND INDEPENDENT CONSULTANTS TO ENSURE THE COMPENSATION IS COMPETITIVE IN THE MARKET FOR SIMILAR POSITIONS AT COMPARABLE ORGANIZATIONS. COMPENSATION AND BENEFITS REPORTED FOR MARTIN MORRIS ON SCHEDULE J, LINE 1, (II) ARE PAID BY SALEM HOSPITAL. THE FOUNDATION HAS A MANAGEMENT AGREEMENT TO REIMBURSE SALEM HOSPITAL FOR A PORTION OF HIS COMPENSATION AND BENEFITS WHICH TOTALED $78,981. THIS AMOUNT IS INCLUDED IN ON FORM 990 PART IX; LINE 24A UNDER MANAGEMENT SERVICES. FORM 990, PART VI, SECTION B, LINE 11 THE ORGANIZATION'S GOVERNING EXECUTIVE COMMITTEE REVIEWS THE IRS FORM 990 BEFORE FILING. FORM 990, PART VI, SECTION B, LINE 12C ON AN ANNUAL BASIS THE SECRETARY SHALL SEND TO EACH PERSON WHO IS A TRUSTEE, OFFICER, OR MEMBER OF A COMMITTEE A COPY OF THE POLICY REGARDING CONFLICTS OF INTEREST, TOGETHER WITH A QUESTIONNAIRE INQUIRING AS TO CONFLICTS, TO BE COMPLETED AND RETURNED TO THE SECRETARY BY THE TRUSTEE, OFFICER OR COMMITTEE MEMBER PRIOR TO THE BEGINNING OF EACH CALENDAR YEAR. FORM 990, PART VI, SECTION C, LINE 19 NO DOCUMENTS AVAILABLE TO THE PUBLIC. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 588,851. HAMPSHIRE PROPERTIES LLC 890 OAK STREET SE SALEM OR 97301 870804582 REAL ESTATE HOLDING OR 12020 1410000 N/A SALEM HOSPITAL 890 OAK STREET SE SALEM OR 97301 930579722 HOSPITAL OR 501(C)(3) 3 SALEM HEALTH 0 SALEM HOSPITAL AUXILIARY 890 OAK STREET SE SALEM OR 97301 931081113 SUPPORTS SALEM HOSPITAL OR 501(C)(3) 9 N/A 0 SALEM HEALTH 890 OAK STREET SE SALEM OR 97301 930823471 LEASES LAND TO SALEM HOSPITAL OR 501(C)(3) 11 TYPE 1 N/A 0 WEST VALLEY HOSPITAL 525 SOUTHEAST WASHINGTON STREET DALLAS OR 97338 431960221 HOSPITAL OR 501(C)(3) 3 SALEM HEALTH 0 WEST VALLEY HOSPITAL FOUNDATION 525 SOUTHEAST WASHINGTON STREET DALLAS OR 97338 931298564 SUPPORTS WEST VALLEY HOSPITAL OR 501(C)(3) 11 TYPE 1 SALEM HEALTH 0 WILLAMETTE VALLEY INSURANCE COMPANY 745 FORT STREET HONOLULU HI 96813 201836190 CAPITIVE INSURANCE HI 501(C)(3) 11 TYPE 1 SALEM HEALTH 0 WILLAMETTE VALLEY PROFESSIONAL SERVICES 890 OAK STREET SE SALEM OR 97301 753175249 BILLING SERVICE FOR SALEM HOSPITAL, WEST VALLEY HOSPITAL, & SALEM HEALTH OR 501(C)(3) 3 SALEM HEALTH 0 0 1 0 0 1 0 0 0 0 0 1 1 1 1 0 0 0 0