2012-08-10T12:13:33-05:00 2011-09-30 WIPFLI LLP 10000 INNOVATION DRIVE SUITE 250 MILWAUKEE WI 532264837 990 2010-10-01 370661230 PASSAVANT MEMORIAL AREA HOSPITAL ASSOC PASS 2172459541 1600 WEST WALNUT STREET JACKSONVILLE IL 62650 DAVID BOLEN 2172459541 2012-08-10 1 JAY ADKISSON CPA 4144319300 2012-08-09 2010 2016-02-24 21:20:13Z DAVID BOLEN 1600 WEST WALNUT STREET JACKSONVILLE IL 62650 86536504 0 X WWW.PASSAVANTHOSPITAL.COM X 1906 IL OUR MISSION IS TO PROVIDE EXCELLENT CARE WITH COMPASSION AND COMMITMENT. 16 13 968 228 169450 5432 1318678 209902 82875256 82649387 504757 1997283 1702660 1662265 86401351 86518837 71324 28770 0 0 46354758 43679570 0 0 15884 37505046 35084372 83931128 78792712 2470223 7726125 143981639 151532337 47503207 47837408 96478432 103694929 OUR MISSION IS TO PROVIDE EXCELLENT CARE WITH COMPASSION AND COMMITMENT. 0 0 62795693 28770 82649387 DELIVERY OF MEDICAL AND HOSPITAL SERVICES WITH APPROXIMATELY57,956 OUTPATIENT PROCEDURES PERFORMED, 3,412 INPATIENT ADMISSIONSAND 29,895 EMERGENCY DEPARTMENT VISITS. 62795693 1 1 0 1 0 0 0 0 1 1 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 0 0 0 1 87 0 1 968 1 1 1 0 0 0 0 0 0 0 0 0 X 16 13 0 0 0 0 0 1 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 IL X DAVID BOLEN 2172459541 1600 WEST WALNUT STREET JACKSONVILLE IL 62650 ERIC GIEBELHAUSEN 2.00 X 0 0 0 AMY JACKSON 2.00 X 0 0 0 LINDA STANDLEY 2.00 X 0 0 0 RICHARD JOHNSON 2.00 X 0 0 0 STEVEN LILLPOP 2.00 X 0 0 0 GREG MAY 2.00 X 0 0 0 KEITH BRADBURY 2.00 X 0 0 0 GINNY FANNING 2.00 X 0 0 0 ROGER HOUSTON 2.00 X 0 0 0 GILBERT JOEHL 2.00 X 0 0 0 PHYLLIS LAPE PHD 2.00 X 0 0 0 ANDY STAFFORD 2.00 X 0 0 0 JAN TERRY 2.00 X 0 0 0 NANCY SPANGENBERG 2.00 X 0 0 0 DONALD HEADEN 2.00 X 0 0 0 MICHAEL MOLYNEAUX MD 2.00 X 0 0 0 CHESTER A WYNN 50.00 X 240063 0 34102 DAVID A BOLEN 50.00 X 175446 0 17596 STEPHEN LEE 50.00 X 61651 49688 17868 RICHARD MOGLER 40.00 X 90279 0 16987 KAREN DAUM 50.00 X 117364 0 25422 REBECCA GOODMAN 50.00 X 83514 0 16540 RAYMOND HUGHES 40.00 X 347960 0 35067 MARY JONES 40.00 X 292850 0 22403 MARK RUFF 40.00 X 303480 0 33828 BRUCE SANDS 40.00 X 306695 0 42 MICHAEL WHITMORE 40.00 X 324658 0 18494 2343960 49688 238349 30 0 1 0 JOHN C DAILEY MDSC 1572 CONCORD ROAD JACKSONVILLE IL 62650 PHYSICIAN SERVICES 528806 SPRINGFIELD SERVICE CORPORATION 2960 PROFESSIONAL DRIVE SPRINGFIELD IL 62703 BILLING SERVICE 245158 WEATHERBY LOCUMS INC PO BOX 972633 DALLAS TX 75397 LOCUM TENENS SERVICE 224047 CENTURION INVESTIGATORS INC 1711 SOUTH WEST ST JACKSONVILLE IL 62650 SECURITY 178470 BKD LLP 211 N BROADWAY ST LOUIS MO 63102 AUDIT SERVICES 153731 7 209902 209902 PATIENT SERVICE REVENU 621110 82649387 82649387 82649387 1945582 1945582 645931 645931 645931 645931 66867 2501 17667 66867 -15166 51701 51701 CAFETERIA 722100 547875 547875 OTHER 900099 278063 -20946 299009 LIFE LINE 812900 190396 190396 1016334 86518837 82649387 169450 3490098 28770 28770 31812835 25462993 6349842 1527510 1222619 304891 8021675 6420549 1601126 2317550 1854967 462583 196249 196249 132367 132367 2509607 2008689 500918 288683 231062 57621 11528128 9227114 2301014 289409 231643 57766 1596980 1278223 318757 80766 64645 16121 1560999 1249424 311575 6137937 4912805 1225132 1054891 844335 210556 BAD DEBT EXPENSE 3789727 3033297 756430 REPAIRS AND MAINTENANCE 2559209 2048391 510818 MEDICAID TAXES 1099545 880076 219469 FOOD 979079 783655 195424 MISCELLANEOUS EXPENSE 518890 415320 103570 761906 597116 148906 15884 78792712 62795693 15981135 15884 6733 5679 6050439 7219733 11728463 13197978 10152618 14769284 658797 687856 1763504 1816047 126176888 75590860 52490238 50586028 43197779 44937260 565144 642227 1072376 16295548 17670245 143981639 151532337 15191060 18133283 32312147 29704125 47503207 47837408 X 80321684 86275019 770105 743592 15386643 16676318 96478432 103694929 143981639 151532337 X 7726125 -509628 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 28848 0 0 0 28848 0 58790267 1821901 1712704 58899464 66023041 50000 2714136 9996910 58790267 0.75000 0.23000 0.02000 0 0 356799 356799 83581480 48289538 35291942 36936292 24623730 12312562 5302317 2677592 2624725 50586028 BENEFICIAL INTERESTS IN TRUSTS 13909433 OTHER ASSETS 656202 FARMLAND 3104610 17670245 86518837 78792712 7726125 -1480215 970587 -509628 7216497 85043216 -1480215 4594 -1475621 86518837 0 86518837 78792712 0 78792712 0 78792712 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: CAPITAL PURCHASES, OPERATIONS, SCHOLARSHIPS, INDIGENT CARE. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THE ASSOCIATION DETERMINES WHETHER IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED UPON EXAMINATION ON THE TECHNICAL MERITS OF THE POSITION ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE-LIKELY-THAN-NOT RECOGNITION THRESHOLD, THE BENEFIT OF THAT POSITION IS NOT RECOGNIZED IN THE FINANCIAL STATEMENTS. THE ASSOCIATION RECORDED NO ASSETS OR LIABILITIES FOR UNCERTAIN TAX POSITIONS IN 2011 OR 2010 AS MANAGEMENT BELIEVES THE ASSOCIATION HAS NO MATERIAL UNRECOGNIZED INCOME TAX POSITIONS. FEDERAL TAX RETURNS FOR TAX YEARS 2007 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN BOND INTEREST RATE SWAP -295,933. CHANGE IN BENEFICIAL INTEREST IN PERPETUAL TRUSTS 1,289,675. NET ASSETS RELEASED FROM RESTRICTIONS -23,155. PART XII, LINE 2D - OTHER ADJUSTMENTS: TEMPORARILY RESTRICTED NET ASSETS 4,594. 1 1 1 X 1 X 1 1 1 0 1 1 1209097 1209097 0.01530 1396711 7409033 -6012322 0.00000 2605808 7409033 -4803225 0.01530 65803 65803 0.00080 10186 10186 0.00010 75989 75989 0.00090 2681797 7409033 -4727236 0.01620 217970 217970 0.00280 3018 3018 0.00000 220988 220988 0.00280 1 1687826 14970 23409895 28773072 -5363177 X 1 1 1 1 PASSAVANT MEMORIAL AREA HOSPITAL

1600 WEST WALNUT ST JACKSONVILLE IL 62650

X X X X PASSAVANT MEMORIAL AREA HOSPITAL 1 1 1 200.000000000000 1 350.000000000000 0 0 1 X X X X X 1 X X X 1 X X X X X X X 1 X 0 1 PART I, L7 COL(F): THE ASSOCIATION REPORTS PATIENT ACCOUNTS RECEIVABLE FOR SERVICES RENDERED AT NET REALIZABLE AMOUNTS FROM THIRD-PARTY PAYERS, PATIENTS AND OTHERS. THE ASSOCIATION PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS BASED UPON A REVIEW OF OUTSTANDING RECEIVABLES, HISTORICAL COLLECTION INFORMATION AND EXISTING ECONOMIC CONDITIONS. AS A SERVICE TO THE PATIENT, THE ASSOCIATION BILLS THIRD-PARTY PAYERS DIRECTLY AND BILLS THE PATIENT WHEN THE PATIENT'S LIABILITY IS DETERMINED. PATIENT ACCOUNTS RECEIVABLE ARE DUE IN FULL WHEN BILLED. ACCOUNTS ARE CONSIDERED DELINQUENT AND SUBSEQUENTLY WRITTEN OFF AS BAD DEBTS BASED ON INDIVIDUAL CREDIT EVALUATION AND SPECIFIC CIRCUMSTANCES OF THE ACCOUNT PART II: PAH EXPANDED THE EMERGENCY DEPARTMENT TO SERVE AN INCREASING NUMBER OF PATIENTS. THE HOSPITAL'S PANDEMIC FLU COMMITTEE WORKS WITH THE COMMUNITY PANDEMIC TASK FORCE TO PUT A PLAN IN PLACE TO HANDLE H1N1 FLU. PAH HAS RECEIVED TRACTS OF FARM LAND, THE INCOME FROM WHICH ASSISTS WITH NURSING SCHOLARSHIPS AND WITH PATIENTS WHO CAN'T AFFORD TO PAY. WE FARM THE LAND AS THE DONORS HAVE REQUESTED. PAH IS ASSOCIATED WITH THE MORGAN-SCOTT VOLUNTEER HEALTH CLINIC IN AN EFFORT TO ASSIST THOSE WHO ARE UNINSURED. PAH OFFERS FREE MAMMOGRAM SCREENINGS AS PART OF ITS ASSOCIATION WITH THE MIA WARE FOUNDATION. THIS FOUNDATION ALSO DONATED FUNDS TOWARDS THE PURCHASE OF DIGITAL MAMMOGRAPHY EQUIPMENT AT PASSAVANT. REGARDLESS OF ABILITY TO PAY, NO ONE NEEDING PASSAVANT'S SERVICES IS TURNED AWAY. PAH DONATES OFFICE SPACE, LAB AND IMAGING SERVICES PLUS OTHER SERVICES AND CARE TO ELIGIBLE PERSONS THROUGH THE "FREE CLINIC" (MORGAN-SCOTT VOLUNTEER HEALTH CLINIC). HEALTH EDUCATION PROGRAMS AND FREE SCREENINGS ARE AVAILABLE TO THE COMMUNITIES THE HOSPITAL SERVES (I.E. PROSTRATE SCREENINGS, COLORECTAL SCREENINGS, DIABETES CLASSES, THE KIDNEY MOBILE, "WALKING FOR WELLNESS" PROGRAM, "COMMUNITY HEALTH CHECK", PROGRAMS ON HEART DISEASE, STROKES, BREAST CANCER, ETC.) PAH, THE MIA WARE FOUNDATION AND THE JACKSONVILLE CHAMBER OF COMMERCE SPONSOR A COMMUNITY HEALTH FAIR EACH YEAR CALLED "THE BE AWARE WELLNESS FAIR." THIS FAIR TAKES PLACE AT COMMUNITY PARK AND PROVIDES PREVENTATIVE HEALTH INFORMATION FOR ALL AGES AND ALSO EMPHASIZES BREAST CANCER AWARENESS. IT'S AN EVENT FOR EVERYONE IN THE FAMILY. PART III, LINE 8: THE AMOUNT ON LINE 2 WAS DETERMINED BY APPLYING THE OVERALL COST TO CHARGE RATIO TO THE BAD DEBT EXPENSE RECORDED FOR FINANCIAL STATEMENT PURPOSES. THE AMOUNT REPORTED ON LINE 6 WAS OBTAINED FOR THE MEDICARE COST REPORT FILED BY THE ORGANIZATION. ALTHOUGH THE AMOUNT ON LINE 7 HAS NOT BEEN INCLUDED IN PART I, LINE 7, THE AMOUNT SHOULD BE TREATED AS A COMMUNITY BENEFIT BECAUSE IT REPRESENTS CARE TO MEMBERS OF THE COMMUNITY WHICH HAS NOT BEEN REIMBURSED TO THE ORGANIZATION. PART III, LINE 9B: OUR COLLECTION POLICY STATES "HOSPITAL MAY PURSUE COLLECTION ACTIVITY ONLY AFTER THE HOSPITAL HAS GIVEN THE PATIENT THE OPPORTUNITY TO APPLY FOR FINANCIAL ASSISTANCE". OUR FINANCIAL ASSISTANCE POLICY STATES "THERE ARE INSTANCES WHEN A PATIENT MAY APPEAR ELIGIBLE FOR CHARITY CARE DISCOUNTS, BUT THERE IS NO FINANCIAL ASSISTANCE FORM ON FILE DUE TO LACK OF SUPPORTING DOCUMENTATION. OFTEN THERE IS ADEQUATE INFORMATION PROVIDED BY THE PATIENT OR THROUGH OTHER SOURCES, WHICH SHOWS SUFFICIENT EVIDENCE TO PROVIDE THE PATIENT WITH CHARITY CARE ASSISTANCE. IF THERE IS NO EVIDENCE TO SUPPORT A PATIENT'S ELIGIBILITY FOR CHARITY CARE, THE HOSPITAL CAN USE OUTSIDE AGENCIES IN DETERMINING ESTIMATED INCOME AMOUNTS FOR THE BASIS OF DETERMINING CHARITY CARE ELIGIBILITY AND POTENTIAL DISCOUNT AMOUNTS. ONCE DETERMINED, DUE TO THE INHERENT NATURE OF THE PRESUMPTIVE CIRCUMSTANCES, THE ONLY DISCOUNT THAT CAN BE GRANTED IS A 100% WRITE OFF OF THE ACCOUNT BALANCE. PRESUMPTIVE ELIGIBILITY MAY BE DETERMINED ON THE BASIS OF INDIVIDUAL LIFE CIRCUMSTANCES THAT MAY INCLUDE 1) STATE-FUNDED PRESCRIPTION PROGRAMS; 2) HOMELESS OR RECEIVED CARE FROM A HOMELESS CLINIC; 3) PARTICIPATION IN WOMEN, INFANTS AND CHILDREN'S PROGRAMS (WIC); 4) FOOD STAMP ELIGIBILITY; 5) SUBSIDIZED SCHOOL LUNCH PROGRAM ELIGIBILITY; 6) ELIGIBILITY FOR OTHER STATE OR LOCAL ASSISTANCE PROGRAMS THAT ARE UNFUNDED (E.G., MEDICAID SPEND-DOWN); 7) LOW INCOME/SUBSIDIZED HOUSING IS PROVIDED AS A VALID ADDRESS; AND 8) PATIENT IS DECEASED WITH NO KNOWN ESTATE." PASSAVANT MEMORIAL AREA HOSPITAL PART V, SECTION B, LINE 15E: WAGE GARNISHMENTS PASSAVANT MEMORIAL AREA HOSPITAL PART V, SECTION B, LINE 16E: WAGE GARNISHMENTS PASSAVANT MEMORIAL AREA HOSPITAL PART V, SECTION B, LINE 19D: HOSPITAL IS NOTIFIED OF THE AMOUNT TO BILL BY THE ATTORNEY GENERAL'S OFFICE, WHICH BASES THAT FIGURE ON OUR COST REPORT. PASSAVANT MEMORIAL AREA HOSPITAL PART V, SECTION B, LINE 21: ALL PATIENTS HAVE TO COMPLETE AN APPLICATION TO PROVE THEY ARE ELIGIBLE FOR ASSISTANCE. THE HOSPITAL FOLLOWS STATE GUIDELINES. PART VI, LINE 2: PASSAVANT AREA HOSPITAL ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITIES IT SERVES IN MANY DIFFERENT MANNERS. THE HOSPITAL WORKS WITH THE MORGAN COUNTY HEALTH DEPARTMENT IN DEVELOPING THE MORGAN COUNTY HEALTH PLAN. THE HOSPITAL THEN USES THE RESULTS OF THE HEALTH PLAN TO DETERMINE WHAT PROGRAMS AND SERVICES NEED TO BE OFFERED. ANOTHER SOURCE OF INFORMATION ON HEALTH CARE NEEDS IS THE MEDICAL STAFF. MEMBERS OF THE HOSPITAL'S ADMINISTRATIVE TEAM MEET REGULARLY WITH THE PHYSICIANS TO DETERMINE WHAT NEW SERVICES SHOULD BE IMPLEMENTED. THE SIXTEEN MEMBERS OF THE BOARD OF DIRECTORS, WHO REPRESENT THE DIFFERENT GEOGRAPHIC AREAS SERVED BY THE HOSPITAL, ALSO PROVIDE INPUT ON HEALTH CARE NEEDS, ALONG WITH THE VOLUNTEERS AND THE HOSPITAL'S EMPLOYEES. LASTLY, THE HOSPITAL ASKS THE PUBLIC ABOUT SERVICES THROUGH PATIENT SURVEYS AND FOCUS GROUPS. PART VI, LINE 3: THERE ARE SIGNS IN THE REGISTRATION AREAS (IN ENGLISH & SPANISH)WHICH INDICATE THE HOSPITAL TREATS PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. GUIDELINES FOR PAYMENTS ON PATIENT ACCOUNTS BROCHURES ARE AT EACH REGISTRATION BOOTH FOR PATIENTS AND THE GENERAL PUBLIC. THESE BROCHURES PROVIDE PAYMENT AND FINANCIAL ASSISTANCE INFORMATION (ENGLISH & SPANISH). OUR GENERAL CONSENT FOR TREATMENT HAS A SECTION ABOUT OUR FINANCIAL ASSISTANCE PROGRAM (ENGLISH & SPANISH). THERE IS INFORMATION AVAILABLE ON THE HOSPITAL WEBSITE ABOUT OUR FINANCIAL ASSISTANCE PROGRAM. INFORMATION ABOUT BILLING AND FINANCIAL ASSISTANCE IS AVAILABLE AT BEDSIDE FOR OVERNIGHT AND SURGERY PATIENTS. PATIENT BILLING STATEMENTS ADVISE OF OUR FINANCIAL ASSISTANCE PROGRAMS AND HOW TO CONTACT US TO APPLY. SELF-PAY OVERNIGHT PATIENTS ARE CONTACTED BY SOCIAL SERVICES AND/OR PFS STAFF AND PROVIDED WITH INFORMATION ON FINANCIAL ASSISTANCE PROGRAMS. STAFF RECEIVED EDUCATION TO DIRECT PATIENT TO SOCIAL SERVICE OR PATIENT FINANCIAL SERVICE IF A PATIENT INDICATES THEY NEED ASSISTANCE WITH A BILL. PART VI, LINE 4: THE MAIN COUNTIES THAT PAH SERVES ARE CASS, MORGAN, SCOTT, MACOUPIN AND GREENE COUNTIES (PAH HAS AT LEAST 25% OF THE MARKET IN THESE ZIP CODES). THERE IS A SMALLER, SECONDARY MARKET WHERE PAH HAS AT LEAST 5%, BUT LESS THAN 25% OF THE MARKET. THE SECONDARY MARKET INCLUDES ZIP CODES IN BROWN, SCHUYLER, FULTON, PIKE, AND CALHOUN COUNTIES. OVER 90% OF CASES COMES FROM THE PRIMARY MARKET. PART VI, LINE 6: PAH EMPLOYEES ARE VOLUNTEERS IN NON-PROFIT ORGANIZATIONS, SUCH AS ROTARY CLUB, KIWANIS, CHAMBER OF COMMERCE, HABITAT FOR HUMANITY, ETC. THEY ALSO SUPPORT THE UNITED WAY AND PARTICIPATE IN THE AMERICAN CANCER SOCIETY'S RELAY FOR LIFE. PAH PROVIDES CASH AND IN-KIND DONATIONS TO AREA NON-PROFIT ORGANIZATIONS AND TO AREA SCHOOLS' POST-PROM PARTIES. PAH ALSO PROVIDES DISEASE-RELATED SUPPORT GROUPS, FREE COMMUNITY HEALTH PROGRAMS AND SCREENINGS, USE OF MEETING ROOMS, CHAPLAINCY SERVICES AND LANGUAGE ASSISTANCE SERVICES. WITH THE SUPPORT GROUPS, PAH STAFF FACILITATES SOME OF THOSE GROUPS. PAH PROVIDES FREE MEDICARE CONSULTING SERVICES TO SENIORS. PAH PROMOTES AND SUPPORTS THE JACKSONVILLE AREA SENIOR CENTER, WHICH OFFERS MANY ACTIVITIES FOR SENIORS. PASSAVANT PROVIDES SPEAKERS, SCREENINGS AND HEALTH FAIRS FOR FREE AT THE CENTER. IT ALSO CONDUCTS A "COMMUNITY HEALTH CHECK" AT THE CENTER THE FIRST WEDNESDAY OF EACH MONTH. IN FISCAL YEAR 2011, PAH PROVIDED $16.3 MILLION IN CHARITY CARE AND BAD DEBT CHARGES PLUS $1.3 MILLION OF FREE CHARGES AT THE VOLUNTEER HEALTH CLINIC (TOTALING $17.6 MILLION) 1 ILLINOIS HOSPITAL RESEARCH AND EDUCATIONAL ASSOCIATION 1151 EAST WARRENVILLE ROAD NAPERVILLE IL 60566 237421930 501(C)(3) 28770 TO ADDRESS THE DISPARATE AND NEGATIVE EFFECTS OF THE ILLINOIS MEDICAID PROGRAM EXPERIENCED BY HOSPITALS AND HEALTHCARE SYSTEMS IN ILLINOIS. 1 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: GRANTS PAID TO ILLINOIS HOSPITAL RESEARCH AND EDUCATIONAL ASSOCIATION ARE PAID AS PART OF A VOLUNTARY STATE MEDICAID REALLOCATION PROGRAM KNOWN AS THE HOSPITAL MUTUAL ASSISTANCE PROGRAM. NO FORMAL POLICY EXISTS TO MONITOR THE USE OF THESE GRANTS. X X X 0 0 0 0 0 0 0 0 0 CHESTER A WYNN 240063 0 0 0 0 0 14534 0 19568 0 274165 0 0 0 DAVID A BOLEN 175446 0 0 0 0 0 0 0 17596 0 193042 0 0 0 RAYMOND HUGHES 347960 0 0 0 0 0 15629 0 19438 0 383027 0 0 0 MARY JONES 292850 0 0 0 0 0 14509 0 7894 0 315253 0 0 0 MARK RUFF 303480 0 0 0 0 0 14330 0 19498 0 337308 0 0 0 BRUCE SANDS 306695 0 0 0 0 0 0 0 42 0 306737 0 0 0 MICHAEL WHITMORE 324658 0 0 0 0 0 10500 0 7994 0 343152 0 0 0 CITY OF JACKSONVILLE IL 469590AA1 2006-12-01 19905000 ADVANCE REFUNDING AND DEFEASANCE OF PREVIOUS BORROWINGS 1 0 0 CITY OF JACKSONVILLE IL 469590AB9 2006-12-01 12485000 FUNDING FOR CONSTRUCTION AND DEVELOPMENT 0 0 0 18778988 276018 43940 806055 0 1 1 1 173127 27560 12284313 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 1 LEHMAN BROTHERS 0 0 0 0 0 0 0 1 LEHMAN BROTHERS 0 0 0 0 0 LINDA STANDLEY DIRECTOR 55018 LINDA STANDLEY IS CEO OF ILMO PRODUCTS COMPANY. PASSAVANT MEMORIAL AREA HOSPITAL PURCHASED VARIOUS GASES FROM THE COMPANY FOR USE IN VARIOUS DEPARTMENTS IN THE HOSPITAL. 0 FORM 990, PART VI, SECTION A, LINE 7A REPRESENTATIVES OF 139 CHURCHES IN THE PASSAVANT SERVICE AREA MAKE UP THE BOARD OF GOVERNORS. THE BOARD OF DIRECTORS IS ELECTED BY THE BOARD OF GOVERNORS AT THE GOVERNORS' ANNUAL MEETING. FORM 990, PART VI, SECTION B, LINE 11 A COPY OF THE FORM 990 IS REVIEWED BY THE CEO AND THE CFO PRIOR TO FILING. A COPY OF THE FORM 990 IS PROVIDED TO THE BOARD FOR REVIEW PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C BOARD MEMBERS AND KEY EMPLOYEES ARE REQUIRED TO DISCLOSE CONFLICTS OF INTERESTS BY FILING SIGNED STATEMENTS WITH THE ORGANIZATION. THE BOARD MEMBERS COMPLETE THE CONFLICT OF INTEREST POLICY ON A YEARLY BASIS. THEY ARE REQUIRED TO DISCLOSE ANY CONFLICTS WHEN INFORMATION IS GATHERED TO PREPARE FORM 990. IF THEY HAVE A CONFLICT, THE BOARD MEMBERS EXCUSE THEMSELVES FROM ANY APPLICABLE VOTES. IF THERE IS A QUESTION OF WHETHER OR NOT THEY HAVE A CONFLICT, EITHER THE CEO OR THE CFO WILL INVESTIGATE THE ISSUE AND CONSULT WITH THE BOARD CHAIR, WHO WILL MAKE THE FINAL DETERMINATION. EMPLOYEES SIGN A CODE OF CONDUCT STATEMENT ANNUALLY, WHICH INCLUDES A SECTION ON CONFLICT OF INTEREST. EMPLOYEES ARE ALSO REQUIRED TO DISCLOSE ANY POTENTIAL CONFLICTS OF INTEREST. IF THEY HAVE A CONFLICT, THEY CANNOT HAVE ANY DECISION-MAKING POWERS REGARDING ANY OF THEIR AREAS OF CONFLICT. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATION PARTICIPATES IN SEVERAL NATIONAL AND REGIONAL SURVEYS WHERE DATA IS OBTAINED ON VARIOUS POSITIONS SUCH AS CEO, CFO, CNO, ETC. THIS INFORMATION IS THEN PROVIDED TO THE BOARD EXECUTIVE COMMITTEE FOR REVIEW AND APPROVAL. FOR OTHER OFFICERS AND KEY EMPLOYEES, A CUSTOMIZED SURVEY CONDUCTED BY INTEGRATED HEALTHCARE STRATEGIES COMPARES THE COMPENSTION DATA PROVIDED BY THE ORGANIZATION TO THE STATISTICAL INFORMATION THEY HAVE. INTEGRATED HEALTHCARE STRATEGIES GENERATES A TRUE MARKET AVERAGE REPORT THAT COMPARES THE ORGANIZATION'S SALARY FOR A POSITION AND ASSOCIATED MINIMUM, 1ST QUARTILE, MIDPOINT, 3RD QUARTILE AND MAXIMUM SALARY POINTS. THE KEY EMPLOYEE DATA IS REVIEWED BY OUR CEO, CFO AND HR DIRECTOR AND MARKET COMPARATIVE SALARY ADJUSTMENTS ARE MADE AS NECESSARY. FORM 990, PART VI, SECTION C, LINE 19 COPIES OF THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE UPON INDIVIDUAL REQUEST. THE AUDITED FINANCIAL STATEMENTS ARE POSTED ON THE HOSPITAL'S WEBSITE. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -1,480,215. CHANGE IN BOND INTEREST RATE SWAP -295,933. CHANGE IN BENEFICIAL INTEREST IN PERPETUAL TRUSTS 1,289,675. NET ASSETS RELEASED FROM RESTRICTIONS -23,155. TOTAL TO FORM 990, PART XI, LINE 5: -509,628. JACKSONVILLE CRNA'S INC 1600 WEST WALNUT STREET JACKSONVILLE IL 62650 273083265 CRNA SERVICES IL 501(C)(3) LINE 11C, III-FI 0 PASSAVANT MEMORIAL AREA AUXILIARY 1600 WEST WALNUT STREET JACKSONVILLE IL 62650 370890067 SUPPORTING THE HOSPITAL IL 501(C)(3) LINE 11C, III-FI 0 JACKSONVILLE JOINT VENTURE 644 N 2ND STRRET SPRINGFIELD IL 62702 364180270 MEDICAL EQUIPMENT IL N/A RELATED 77083 652161 0 0 0.50000 PASSAVANT PHYSICIAN ASSOCIATION 1600 WEST WALNUT STREET JACKSONVILLE IL 62650 261200566 PHYSICIAN SERVICES IL C 3902373 919002 1.00000 LELAND CAPPS CO US BANK NA 205 S FIFTH STREET SPRINGFIELD IL 62701 376023527 INVESTMENT IL T -8733 158837 1.00000 IRMA BARSNES CO FARMERS STATE BANK & TRUST 205 S FIFTH STREET SPRINGFIELD IL 62701 376026493 INVESTMENT IL T 1731 128431 0.80000 BEILSCHMIDT FARM FBO BEREA CHURCH 200 W STATE STREET JACKSONVILLE IL 62651 376365758 INVESTMENT IL T 82353 1620560 1.00000 BEILSCHMIDT FARM FBO PASSAVANT HOSPITAL 200 W STATE STREET JACKSONVILLE IL 62651 376365760 INVESTMENT IL T 12119 1297712 1.00000 FRANCES CORRINGTON CO US BANK NA 205 S FIFTH STREET SPRINGFIELD IL 62701 376135460 INVESTMENT IL T -15381 2128649 1.00000 MILDRED DINWIDDIE CO US BANK NA 205 S FIFTH STREET SPRINGFIELD IL 62701 376227814 INVESTMENT IL T -37061 2120773 1.00000 ELIZABETH SHEKELTON CO US BANK NA 205 S FIFTH STREET SPRINGFIELD IL 62701 376124484 INVESTMENT IL T -3874 898861 1.00000 THOMAS TISSINGTON FARM CO FARMERS STATE BANK & TRUST 200 W STATE STREET JACKSONVILLE IL 62651 376022909 INVESTMENT IL T -10755 2478811 1.00000 TISSINGTON CLAUSE XIX CO FARMERS STATE BANK & TRUST 200 W STATE STREET JACKSONVILLE IL 62651 376022909 INVESTMENT IL T 96 16652 1.00000 FRED VANBEBBER CO FARMERS STATE BANK & TRUST 200 W STATE STREET JACKSONVILLE IL 62651 376118658 INVESTMENT IL T -3921 439666 1.00000 JANE H WILSON CO US BANK NA 205 S FIFTH STREET SPRINGFIELD IL 62701 900513371 INVESTMENT IL T -49040 368053 1.00000 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 1 0 1 PASSAVANT PHYSICIAN ASSOCIATION D 12672333 FMV JACKSONVILLE CRNA'S INC P 1492298 FMV JACKSONVILLE CRNA'S INC R 1075000 FMV