2011-05-13T12:24:01-05:00 2010-06-30 Clark Nuber PS 10900 NE 4th Street Suite 1700 Bellevue WA 98004 990 2009-07-01 911538852 ST JOHN MEDICAL CENTER FOUNDATION STJO 3604147900 1615 Delaware Longview WA 98632 Cathy Barr 3604147900 2011-05-13 1 Sara Elizabeth J Hyre 4254544919 2009 2016-02-24 21:20:13Z Cathy Barr 1615 Delaware Longview WA 98632 1148699 0 X peacehealth.org/lowercolumbia/foundation X 1986 WA SUPPORT OF ST. JOHN MEDICAL CENTER BY BUILDING SOCIAL AND FINANCIAL RESOURCES. 27 21 0 85 0 0 758558 989924 0 120652 38944 -12425 -19376 866785 1009492 676903 1248951 0 0 17118 31700 142465 179960 819368 1446029 47417 -436537 6527971 6325030 1991839 1791279 4536132 4533751 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 373888 373888 THE EMERGENCY RENOVATION PROJECT: THIS COMPLETES THE TOWER RENOVATION CAMPAIGN TRANSFER OF FUNDS FROM THE PLEDGE PAYMENTS RECEIVED. 316332 316332 PATIENT TOWER RENOVATION PROJECT: THIS COMPLETES THE TOWER RENOVATION CAMPAIGN TRANSFER OF FUNDS FROM PLEDGE PAYMENTS RECEIVED. 170421 170421 MEDICAL & SURGICAL FLOORS RENOVATION PROJECT: THIS COMPLETED THE TOWER RENOVATION CAMPAIGN TRANSFER OF FUNDS FROM PLEDGE PAYMENTS RECEIVED. 388310 388310 ALL OTHER PROGRAM SERVICE ACCOMPLISHMENTS. 388310 388310 1248951 1 1 0 0 0 0 0 0 1 1 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 1 0 0 0 0 0 0 0 0 1 1 0 0 0 27 21 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 MICHAEL MCNELLIS MD 1.00 X X 0 200130 24035 MAILA CADD 1.00 X X 0 0 0 PAT SARI 1.00 X 0 0 0 BILL BOEHM 1.00 X X 0 0 0 PAULINE KIRCHNER 1.00 X X 0 0 0 JUDY ALLEN 1.00 X 0 0 0 JOHN BERWIND DDS 1.00 X 0 0 0 CHRIS SEARING 1.00 X 0 0 0 STEVEN CABRALES MD 1.00 X 0 294337 27964 FRANCENA DODD CSJP 1.00 X 0 0 0 LINDA DOERR 1.00 X 0 0 0 ROBERT EHRLICH MD 1.00 X 0 0 0 JACKIE EVANS 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 JULIE KENDALL 1.00 X 0 0 0 GWEN LARSON 1.00 X 0 0 0 VERONA LYNAM 1.00 X 0 0 0 JAMES NAKASHIMA MD 1.00 X 0 191841 33516 GEORGE OPSAHL JR 1.00 X 0 0 0 MARK PURCELL 1.00 X 0 0 0 TOM RENAUD 1.00 X 0 0 0 PAT RODMAN 1.00 X 0 0 0 SY JOHNSON 1.00 X 0 332996 39166 JUDIE WILSON 1.00 X 0 0 0 TOM HAYWOOD 1.00 X 0 214731 25410 CATHY BARR 40.00 X 0 99916 23728 0 1333951 173819 0 0 1 0 0 236110 753814 119426 989924 62671 62671 23727 -23727 -23727 -23727 96104 236110 115480 -19376 -19376 1009492 0 0 19568 1248951 1248951 37097 37097 17118 17118 9613 9613 6803 6803 80148 80148 10266 10266 BAD DEBT 21171 21171 INDIRECT FUNDRAISING EX 14582 14582 PROPERTY TAXES 280 280 1446029 1248951 165378 31700 97721 77476 281895 534284 457474 366171 2817333 2542277 2873548 2804822 6527971 6325030 100000 14120 10860 243865 236212 1633854 1544207 1991839 1791279 X 1051902 1399842 2549170 2178232 935060 955677 4536132 4533751 6527971 6325030 X 0 1 1 X 0 X 977571 858653 920488 758558 989924 4505194 977571 858653 920488 758558 989924 4505194 185436 4319758 140876 150011 152874 102481 62671 608913 5114107 0.84470 0.62430 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 243865 16551 8898 251518 1 1139166 11410 164123 40767 1273932 1403528 6452 -230851 39963 1139166 0.23000 0.77000 0.00000 0 0 0 INSURANCE 139340 SPLIT-INTEREST AGREEMENTS 2633887 REAL ESTATE 31595 2804822 SPLIT-INTEREST AGREEMENTS 1544207 1544207 1009492 1446029 -436537 256936 177220 434156 -2381 1920642 256936 421038 177220 855194 1065448 -55956 -55956 1009492 1923023 421038 55956 476994 1446029 0 1446029 Part IV, Line 2b: THE FOUNDATION HAS ENTERED INTO AGREEMENTS WHEREBY IT ACCEPTS ASSETS FROM A NONPROFIT ORGANIZATION AND AGREES TO TRANSFER THOSE ASSETS AND THE RETURN ON INVESTMENT OF THOSE ASSETS, BACK TO THE NONPROFIT ORGANIZATION AT SOME POINT IN THE FUTURE. THESE FUNDS ARE REPORTED ON THE BALANCE SHEET AS ASSETS WITH A MATCHING LIABILITY FOR THE PAYABLE TO THE OUTSIDE ORGANIZATIONS. Part V, Line 4: Description of Intended Use of Endowment Funds: 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: 177220. Part XII, Line 2d - Other Adjustments: SPLIT INTEREST VALUE CHANGE: 177220. Part XII, Line 4b - Other Adjustments: SPECIAL EVENT EXPENSES: -55956. NON-CASH CONTRIBUTION OF AUCTION ITEMS: 59524. AUCTION ITEM EXPENSE: -59524. Part XIII, Line 2d - Other Adjustments: SPECIAL EVENT EXPENSES RECORDED ON AUDITED STMT OF FUNC EXP: 55956. X X X X 1 PAT MARTIN GRANT WRITER 0 77854 17118 60736 77854 17118 60736 WA GOLF TOURNAMENT 159655 132156 27499 8873 560 5923 9245 DECEMBER EVENT 155608 92574 63034 11175 17758 300 53879 2 16951 11380 5571 844 1351 5572 332214 236110 96104 9717 13086 29253 300 63124 115480 -19376 1 ST JOHN MEDICAL CENTER PO BOX 3002 LONGVIEW WA 98632 910939479 501(c)(3) 72141 BASIC HEALTH PLAN ST JOHN MEDICAL CENTER PO BOX 3002 LONGVIEW WA 98632 910939479 501(c)(3) 28957 BIRTH CENTER RENOVATION ST JOHN MEDICAL CENTER PO BOX 3002 lONGVIEW WA 98632 910939479 501(c)(3) 147558 CCU RENOVATION ST JOHN MEDICAL CENTER PO BOX 3002 lONGVIEW WA 98632 910939479 501(c)(3) 24370 DIALYSIS ST JOHN MEDICAL CENTER PO BOX 3002 lONGVIEW WA 98632 910939479 501(c)(3) 373888 EMERGENCY DEPARTMENT RENOVATION. ST JOHN MEDICAL CENTER PO BOX 3002 lONGVIEW WA 98632 910939479 501(c)(3) 18249 LOWER COLUMBIA REGIONAL CANCER CENTER. ST JOHN MEDICAL CENTER PO BOX 3002 lONGVIEW WA 98632 910939479 501(c)(3) 6450 MAMMOGRAPHY ST JOHN MEDICAL CENTER PO BOX 3002 lONGVIEW WA 98632 910939479 501(c)(3) 170421 MEDICAL & SURGICAL RENOVATION. ST JOHN MEDICAL CENTER PO BOX 3002 lONGVIEW WA 98632 910939479 501(c)(3) 1095 PARISH NURSE ST JOHN MEDICAL CENTER PO BOX 3002 lONGVIEW WA 98632 910939479 501(c)(3) 316332 PATIENT TOWER RENOVATION ST JOHN MEDICAL CENTER PO BOX 3002 lONGVIEW WA 98632 910939479 501(c)(3) 273 SPIRITUAL CARE ST JOHN MEDICAL CENTER PO BOX 3002 LONGVIEW WA 98632 910939479 501(c)(3) 5014 INDIGENT CARE ENDOWMENT ST JOHN MEDICAL CENTER PO BOX 3002 LONGVIEW WA 98632 910939479 501(c)(3) 6435 TRAUMA PROGRAM ENDOWMENT ST JOHN MEDICAL CENTER PO BOX 3002 LONGVIEW WA 98632 910939479 501(c)(3) 29137 BOARD ENDOWMENTS ST JOHN MEDICAL CENTER PO BOX 3002 LONGVIEW WA 98632 910939479 501(c)(3) 7626 GENERAL CARE ST JOHN MEDICAL CENTER PO BOX 3002 LONGVIEW WA 98632 910939479 501(c)(3) 3000 SR. FRANCENA DODD SCHOLARSHIP ST JOHN MEDICAL CENTER PO BOX 3002 LONGVIEW WA 98632 910939479 501(c)(3) 500 DOVE PANTRY EMPLOYEE COUNCIL ST JOHN MEDICAL CENTER PO BOX 3002 LONGVIEW WA 98632 910939479 501(c)(3) 17177 DAVID C. WRIGHT SUPPORTIVE CARE PROGRAM ST JOHN MEDICAL CENTER PO BOX 3002 LONGVIEW WA 98632 910939479 501(c)(3) 5000 RADIATION ONCOLOGY PATIENT ASSISTANCE. ST JOHN MEDICAL CENTER PO BOX 3002 LONGVIEW WA 98632 910939479 501(c)(3) 2000 FRIENDS CHAPEL ST JOHN MEDICAL CENTER PO BOX 3002 LONGVIEW WA 98632 910939479 501(c)(3) 8841 GUEST HOUSE. ST JOHN MEDICAL CENTER PO BOX 3002 LONGVIEW WA 98632 910939479 501(c)(3) 1406 OBSTETRICS ST JOHN MEDICAL CENTER PO BOX 3002 LONGVIEW WA 98632 910939479 501(c)(3) 3081 ONCOLOGY NURSE EDUCATION 1 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. X X 0 0 0 0 0 0 0 0 0 MICHAEL MCNELLIS MD 0 200130 0 0 0 0 0 13984 0 10051 0 224165 0 0 STEVEN CABRALES MD 0 294337 0 0 0 0 0 8604 0 19360 0 322301 0 0 JAMES NAKASHIMA MD 0 191841 0 0 0 0 0 15942 0 17574 0 225357 0 0 SY JOHNSON 0 332996 0 0 0 0 0 32770 0 6396 0 372162 0 0 TOM HAYWOOD 0 214731 0 0 0 0 0 15024 0 10386 0 240141 0 0 Clark Nuber PS Greater than 5% shareholder is sister-in-law of board member 34259 ACCOUNTING SERVICES 0 X 2 59902 FMV X AUCTION ITEMS 215 59524 FMV 0 1 0 Method for Determining Number of Contributors: Part I, Column (b): 2 CONTRIBUTIONS OF SECURITIES WERE RECEIVED, 215 AUCTION ITEMS WERE RECEIVED. 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. 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 HERSELF 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. FORM 990, PART I, LINE 6 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 VIII & IX IN-KIND CONTRIBUTIONS & EXPENSES 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 $421,038 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. COMPENSATION FROM RELATED ORGANIZATION THE BOARD MEMBERS THAT RECEIVE COMPENSATION FROM A RELATED ORGANIZATION ARE NOT BEING COMPENSATED FOR THEIR BOARD SERVICE. THE COMPENSATION RELATES TO SERVICES PROVIDED TO THE RELATED ORGANIZATION. PEACEHEALTH 14432 SE EASTGATE WAY SUITE 300 BELLEVUE WA 98007 910939479 HOSPITAL WA 501(c)(3) 3 PEACEHEALTH 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 KETCHIKAN GENERAL HOSPITAL FOUNDATION 3100 TONGASS AVE KETCHIKAN AK 99901 651225184 SUPPORT KETCHIKAN GENERAL HOSPITAL AK 501(c)(3) 7 PEACEHEALTH 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 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 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 ST JOSEPH HOSPITAL FOUNDATION 800 EAST CHESTNUT STREET SUITE LL1 BELLINGHAM WA 98225 721545902 SUPPORT ST. JOSEPH HOSPITAL WA 501(c)(3) 7 PEACEHEALTH HEALTH VENTURES PO BOX 10905 EUGENE OR 97440 911350776 HEALTHCARE JOINT VENTURES OR 501(C)(3) 7 PEACEHEALTH 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0